Imaging Features of Intraosseous Schwannoma: A Case Series and Review of the Literature.

To characterize the imaging features of patients with pathologically confirmed intraosseous schwannoma (IOS), institutional pathology and imaging databases were searched for IOS cases over a period of 17 years. A musculoskeletal radiologist evaluated all imaging studies. Additionally, a literature search was performed to identify IOS cases that had imaging findings of at least two modalities. Six patients (one female, five males, mean age of 50 ± 14 years) with IOS were identified, with all lesions localized to the lumbosacral region. Radiographic imaging was available in four patients, while all patients underwent CT and MR imaging. Radiographs depicted lytic lesions, and CT depicted heterogeneous expansile lesions with centrally hypodense areas and peripheral sclerosis. All cases involved extra-osseous extension, producing a mass effect on adjacent soft tissues and nerve roots. On MRI, the neoplasms displayed iso- to- slightly- low signal intensity on T1-weighted images and hyperintense signal intensity on T2-weighted images with heterogeneous enhancement. The literature review resulted in 102 IOS cases, which to the best of our knowledge, is the largest review on IOS, and the imaging findings of the previously published cases were the same as our cases. IOSs are rare benign neoplasms that should be considered in the differential diagnosis of well-defined expansile lytic lesions with sclerotic borders. This is particularly important in middle-aged adults with mandibular, sacral, or vertebral body mass.

Proximal fibular physeal stress injury: a known entity in an unusual location.

In the skeletally immature patient, physeal stress injury is a common diagnosis in repetitive stress injury; in this case, we present an atypical location of physeal stress injury of the bilateral proximal fibulae. There are multiple well-documented diagnoses of physeal stress injury involving the shoulder, elbow, wrist and tibia, often considered when patients present with the typical history of intensive sports training and pain exacerbated by repetitive movements. However, isolated proximal fibular physeal stress injury is either unusual or under-recognized and underreported. Although less common, proximal fibular physeal stress injury should be among the diagnostic considerations in active adolescents complaining of lower extremity pain as failure to identify this entity can lead to delayed care and preventable potential long-term musculoskeletal effects.

Interactive Multimedia Reporting Technical Considerations: HIMSS-SIIM Collaborative White Paper.

Despite technological advances in the analysis of digital images for medical consultations, many health information systems lack the ability to correlate textual descriptions of image findings linked to the actual images. Images and reports often reside in separate silos in the medical record throughout the process of image viewing, report authoring, and report consumption. Forward-thinking centers and early adopters have created interactive reports with multimedia elements and embedded hyperlinks in reports that connect the narrative text with the related source images and measurements. Most of these solutions rely on proprietary single-vendor systems for viewing and reporting in the absence of any encompassing industry standards to facilitate interoperability with the electronic health record (EHR) and other systems. International standards have enabled the digitization of image acquisition, storage, viewing, and structured reporting. These provide the foundation to discuss enhanced reporting. Lessons learned in the digital transformation of radiology and pathology can serve as a basis for interactive multimedia reporting (IMR) across image-centric medical specialties. This paper describes the standard-based infrastructure and communications to fulfill recently defined clinical requirements through a consensus from an international workgroup of multidisciplinary medical specialists, informaticists, and industry participants. These efforts have led toward the development of an Integrating the Healthcare Enterprise (IHE) profile that will serve as a foundation for interoperable interactive multimedia reporting.

TeleResidents: Exploring the use of Resident Home Workstations During the COVID Pandemic.

RATIONALE AND OBJECTIVES: Since the beginning of the COVID-19 pandemic, numerous strategies have been proposed to allow for continued resident education while following social distancing guidelines. Diagnostic radiology is largely electronic work, allowing for relatively easy transition to telehealth. Our institution deployed home workstations to interested upper level radiology residents and fellows in order to maintain high volume workload and education, while complying with CDC social distancing and quarantine guidelines. MATERIALS AND METHODS: We deployed 28 home workstations with integrated PACS, electronic health record, and reporting system, supporting workflow that matched our on-site processes and allowing residents to work from home while on diagnostic rotations. Two months into the pilot, surveys were sent to trainees and faculty to assess satisfaction related to education, productivity, and wellness. A retrospective study count was performed for a sample of residents in order to assess productivity. RESULTS: Residents perceived their remote productivity as unchanged or better than at the hospital, while faculty were more likely to perceive it as decreased, however, objective results showed no difference. Education was largely considered worse or unchanged with very few regarding it as improved. Those utilizing shared-screen signout platforms rated education better than those utilizing voice/telephone communications only. Trainees expressed improvement in wellness and quality of life. CONCLUSION: Home workstations for trainees represent a feasible solution for implementing social distancing or even quarantine while maintaining operational productivity. There is the added benefit of scheduling flexibility, option to overcome space constraints, and improved quality of life.

Retrospective Evaluation of Artificial Intelligence Leveraging Free-Text Imaging Order Entry to Facilitate Federally Required Clinical Decision Support.

OBJECTIVE: The Protecting Access to Medicare Act mandates clinical decision support (CDS) at imaging order entry, necessitating the use of structured indications to map CDS scores. We evaluated the performance of a commercially available artificial intelligence (AI) tool leveraging free-text order entry to facilitate provider selection of the necessary structured indications. METHODS: Our institution implemented an AI tool offering predicted structured indications based upon the ordering provider's entry of a free-text reason for examination. Providers remained able to order via the traditional direct search for structured indications. Alternatively, they could take the new free-text-AI approach allowing them to select from AI-predicted indications, perform additional direct searches, indicate no matching indication, or exit CDS workflow. We hypothesized the free-text-AI approach would be elected more often and the AI tool would be successful in facilitating selection of structured indications. We reviewed advanced imaging orders (n = 40,053) for the first 3 months (February to May 2020) since implementation. RESULTS: Providers were more likely (P < .001) to choose the free-text-AI approach (23,580; 58.9%) to order entry over direct search for structured indications (16,473; 41.1%). The AI tool yielded alerts with predicted indications in 91.7% (n = 21,631) of orders with free text. Ultimately, providers chose AI-predicted indications in 57.7% (n = 12,490) of cases in which they were offered by the tool. DISCUSSION: Providers significantly more often elected the new free-text-AI approach to order entry for CDS, suggesting provider preference over the traditional approach. The AI tool commonly predicted indications acceptable to ordering providers.

Multispecialty Enterprise Imaging Workgroup Consensus on Interactive Multimedia Reporting Current State and Road to the Future: HIMSS-SIIM Collaborative White Paper.

Diagnostic and evidential static image, video clip, and sound multimedia are captured during routine clinical care in cardiology, dermatology, ophthalmology, pathology, physiatry, radiation oncology, radiology, endoscopic procedural specialties, and other medical disciplines. Providers typically describe the multimedia findings in contemporaneous electronic health record clinical notes or associate a textual interpretative report. Visual communication aids commonly used to connect, synthesize, and supplement multimedia and descriptive text outside medicine remain technically challenging to integrate into patient care. Such beneficial interactive elements may include hyperlinks between text, multimedia elements, alphanumeric and geometric annotations, tables, graphs, timelines, diagrams, anatomic maps, and hyperlinks to external educational references that patients or provider consumers may find valuable. This HIMSS-SIIM Enterprise Imaging Community workgroup white paper outlines the current and desired clinical future state of interactive multimedia reporting (IMR). The workgroup adopted a consensus definition of IMR as "interactive medical documentation that combines clinical images, videos, sound, imaging metadata, and/or image annotations with text, typographic emphases, tables, graphs, event timelines, anatomic maps, hyperlinks, and/or educational resources to optimize communication between medical professionals, and between medical professionals and their patients." This white paper also serves as a precursor for future efforts toward solving technical issues impeding routine interactive multimedia report creation and ingestion into electronic health records.

Use of a Commercially Available Clinical Decision Support Tool to Expedite Prior Authorization in Partnership With a Private Payer.

PURPOSE: The aim of this study was to determine if a clinical decision support (CDS) tool could be used in partnership with a private payer to successfully expedite the prior authorization process for advanced (ie, MRI, CT, PET, nuclear medicine) imaging requests. METHODS: A single academic institution integrated a commercially available CDS tool utilizing the ACR Appropriateness Criteria into the ordering process for outpatient advanced imaging tests within the electronic health record. Ordering providers could elect to use the CDS tool or ignore the available technology. In partnership with a health care insurance company and a contracted radiology benefits management company, orders deemed as "usually indicated" by the CDS tool underwent expedited prior authorization in a pilot program from June 2018 to October 2019. RESULTS: Providers used the CDS tool for 15% (1,453 of 9,640) of outpatient advanced imaging orders. Of these orders with elective CDS scores, 69% (n = 997) qualified for an expedited prior authorization process. CONCLUSIONS: Under specific circumstances, a commercially available CDS tool was used in partnership with a private payer and a radiology benefits management company to expedite prior authorization of outpatient advanced imaging examination orders deemed likely to be appropriate by multispecialty professional guidelines.

Radiologist Adoption of Interactive Multimedia Reporting Technology.

PURPOSE: To determine if radiologists find enough value in available interactive multimedia reporting technology to routinely adopt it into clinical practice. MATERIALS AND METHODS: Our institution's reporting application (Vue Reporting, Carestream Health) allows the incorporation of multimedia elements, including active hyperlinks, into clinical reports, but would radiologists find enough value in this technique to change their practice? We retrospectively reviewed 559,841 diagnostic reports issued July 2016 to February 2018 for the presence of text hyperlinks that interactively connect to imaging findings in the PACS. Results were subdivided by modality, reporting radiologist role (ie, resident, fellow, attending physician), and subspecialty. Average percentages over the final 6 months were chosen to represent established adoption rates. RESULTS: For each modality, the 6-month average percentages of reports containing hyperlinks to imaging findings subdivided by the role of the radiologist who created the report were found to be as follows: CT: residents = 27.6%, fellows = 19.5%, attending physicians = 26.0%; MRI: residents = 26.6%, fellows = 8.7%, attending physicians = 5.1%; and PET/CT: residents = 53.3%, fellows = 46.7%, attending physicians = 19.4%. Rates were 0% to 4% among ultrasound, radiography, and nuclear medicine reports, regardless of radiologist role. The 6-month average percentages of CT and MRI reports with hyperlinks to imaging findings varied by subspecialty from 5.4% to 57.1%. CONCLUSION: Our radiologists found enough value in available interactive multimedia reporting technology to adopt it into their clinical practice, commonly inserting hyperlinks into their CT, PET/CT, and MRI reports to create interactive connections to key imaging findings in the PACS.

Impact of a Commercially Available Clinical Decision Support Program on Provider Ordering Habits.

PURPOSE: Clinical decision support (CDS) software designed around the ACR Appropriateness Criteria assists health care providers in choosing appropriate imaging studies at the time of order entry. The goal of this study was to determine the impact of commercially available CDS on the ordering habits of inpatient and emergency providers. METHODS: In 2014, ACR Select was integrated into our electronic health record, though without displaying appropriateness scores in a "silent" mode for 6 months. Then, feedback regarding examination appropriateness was "turned on" at order entry for adult patients in the emergency and inpatient settings for 24 months. We retrospectively compared the appropriateness scores of imaging tests before and after displaying feedback at order entry and evaluated these data by modality and attending versus trainee status. RESULTS: The commercially available CDS-generated scores for 34% and 20.4% of pre- and postintervention studies, respectively. After feedback, the relative frequency of low utility studies decreased to 5.4% from 11%, and the relative frequency of indicated studies increased to 82% from 64.5%. This was most pronounced in trainees for whom the percentage of low utility studies decreased from 10.8% (95% confidence interval [CI]: 10.0%, 11.7%) to 4.8% (95% CI: 4.4%, 5.2%) and the percentage of indicated studies increased from 65.6% (95% CI: 64.3%, 66.9%) to 83.7% (83.0%, 84.3%). CONCLUSIONS: After implementation of a commercially available decision support tool integrated into the electronic health record, there was a significant improvement in imaging study appropriateness scores, more pronounced in studies ordered by trainees.

Developing an Interactive Data Visualization Tool to Assess the Impact of Decision Support on Clinical Operations.

Due to mandates from recent legislation, clinical decision support (CDS) software is being adopted by radiology practices across the country. This software provides imaging study decision support for referring providers at the point of order entry. CDS systems produce a large volume of data, providing opportunities for research and quality improvement. In order to better visualize and analyze trends in this data, an interactive data visualization dashboard was created using a commercially available data visualization platform. Following the integration of a commercially available clinical decision support product into the electronic health record, a dashboard was created using a commercially available data visualization platform (Tableau, Seattle, WA). Data generated by the CDS were exported from the data warehouse, where they were stored, into the platform. This allowed for real-time visualization of the data generated by the decision support software. The creation of the dashboard allowed the output from the CDS platform to be more easily analyzed and facilitated hypothesis generation. Integrating data visualization tools into clinical decision support tools allows for easier data analysis and can streamline research and quality improvement efforts.

Skeletal development of the hand and wrist: digital bone age companion-a suitable alternative to the Greulich and Pyle atlas for bone age assessment?

PURPOSE: To assess reader performance and subjective workflow experience when reporting bone age studies with a digital bone age reference as compared to the Greulich and Pyle atlas (G&P). We hypothesized that pediatric radiologists would achieve equivalent results with each method while digital workflow would improve speed, experience, and reporting quality. MATERIALS AND METHODS: IRB approval was obtained for this HIPAA-compliant study. Two pediatric radiologists performed research interpretations of bone age studies randomized to either the digital (Digital Bone Age Companion, Oxford University Press) or G&P method, generating reports to mimic clinical workflow. Bone age standard selection, interpretation-reporting time, and user preferences were recorded. Reports were reviewed for typographical or speech recognition errors. Comparisons of agreement were conducted by way of Fisher's exact tests. Interpretation-reporting times were analyzed on the natural logarithmic scale via a linear mixed model and transformed to the geometric mean. Subjective workflow experience was compared with an exact binomial test. Report errors were compared via a paired random permutation test. RESULTS: There was no difference in bone age determination between atlases (p = 0.495). The interpretation-reporting time (p < 0.001) was significantly faster with the digital method. The faculty indicated preference for the digital atlas (p < 0.001). Signed reports had fewer errors with the digital atlas (p < 0.001). CONCLUSIONS: Bone age study interpretations performed with the digital method were similar to those performed with the Greulich and Pyle atlas. The digital atlas saved time, improved workflow experience, and reduced reporting errors relative to the Greulich and Pyle atlas when integrated into electronic workflow.

Revision Anterior Cruciate Ligament Reconstruction: Results of a Single-stage Approach Using Allograft Dowel Bone Grafting for Femoral Defects.

INTRODUCTION: The purpose of this study was to present results of single-stage revision anterior cruciate ligament (ACL) reconstruction using an allograft bone dowel for isolated femoral bony deficiency. METHODS: Sixteen patients underwent single-stage revision ACL reconstruction using an allograft bone dowel for isolated femoral bony deficiency between 2007 and 2012. Twelve patients (75%) completed study visits, which included CT scans as well as completion of validated outcomes measures. RESULTS: The average KT-1000 side-to-side difference was 1.0 mm ± 2.9 mm. The average International Knee Documentation Committee score was 70.2 ± 17.8, the Tegner score was 4.8 ± 2.8, and the visual analog scale pain score was 2.8 ± 2.4. An analysis of CT scans showed that all 12 dowels had excellent (>75%) incorporation. CONCLUSIONS: A single-stage approach for revision ACL reconstruction using allograft dowels for isolated femoral bony deficiency yields objective and subjective outcomes comparable to those reported in the literature for two-stage and other single-stage techniques, with good incorporation of the dowels. LEVEL OF EVIDENCE: Retrospective case series, level IV.

Prospective Evaluation of Agreement and Accuracy in the Diagnosis of Meniscal Tears: MR Arthrography a Short Time After Injection Versus CT Arthrography After a Moderate Delay.

OBJECTIVE: The purpose of this study was to compare the performance of direct CT arthrography performed after a moderate injection delay with that of MR arthrography performed soon after injection in the diagnosis of meniscal tears. SUBJECTS AND METHODS: Twenty-five patients underwent direct MR arthrography followed by same-day CT arthrography of the knee. Two blinded musculoskeletal radiologists independently reviewed the MR and CT arthrographic images for the presence of medial or lateral meniscal tears in the anterior horn, body, and posterior horn. Their readings were compared with a reference standard reading, which was based on post-MRI arthroscopic findings (n = 11) or the consensus opinion of two other musculoskeletal radiologists who simultaneously reviewed the paired CT and MR arthrographic examinations using all available clinical, surgical, and imaging information. The individual and combined radiologist agreements with the reference standard were calculated for each modality. RESULTS: Interreader agreement was 91% for MR arthrography and 85% for CT arthrography. The overall combined radiologist agreement with the reference standard was 91% for MR arthrography and 86% for CT arthrography (p = 0.03). For the two readers, the overall accuracy rates for diagnosing a meniscal tear were 82% and 88% with MR arthrography and 74% and 76% with CT arthrography. Only 50% (3/6) of surgically proven tears imbibed gadolinium. CONCLUSION: Although MR arthrography performed soon after the contrast injection had higher interreader agreement and greater accuracy, CT arthrography performed after a mean postinjection delay of 100 minutes was moderately accurate in the diagnosis of meniscal tears and can be used as an alternative procedure when MR arthrography cannot be completed.

Prevalence of asymptomatic chondrocalcinosis in the pelvis.

OBJECTIVE: To determine trends in incidentally detected age- and gender-associated chondrocalcinosis on pelvic CT. MATERIALS AND METHODS: Twenty patients of each gender at the center of each decade of life who underwent a CT scan of the pelvis performed 2009-2013 were identified and selected for a total of 400 pelvic CTs. Images were reviewed independently by two radiologists for the presence or absence of chondrocalcinosis within the pelvis. Patients with hip or low back pain, known CPPD arthropathy or any known predisposing condition, prior hip arthroplasty, or articular fracture were excluded. Logistic regression was used to predict the presence/absence of chondrocalcinosis as a function of patient age and gender. RESULTS: The presence/absence of chondrocalcinosis was found to be associated with patient age (p = 0.016) but not patient gender (p = 0.929). In the pelvis, chondrocalcinosis was most frequently identified at the pubic symphysis. Incidental chondrocalcinosis was not identified in any patients under 50 years of age. Chondrocalcinosis increased in frequency from 12.5 at 55 years of age to 27.5 % of patients 95 years of age. CONCLUSIONS: Chondrocalcinosis is common and more prevalent in late adulthood, occurs without a gender predilection, and is infrequently identified in patients younger than 50 years of age.

Impact of a Reading Priority Scoring System on the Prioritization of Examination Interpretations.

OBJECTIVE: Our institution implemented a read priority scoring system to combat the known limitations of traditional methods for the prioritization of examination interpretations by radiologists. We aimed to determine the impact on report turnaround time (RTAT) and RTAT variability. MATERIALS AND METHODS: On examination completion, technologists entered a read priority score (1-9) using provided definitions. We retrospectively reviewed the median RTAT and RTAT variability (i.e., interquartile range length) for radiology examinations (n = 615,541; 2011-2014). We used Spearman correlation coefficients to determine the relationships between read priority scores and the median RTAT and the RTAT variability by year. We compared median RTAT and RTAT variability between early (2011) versus late (2012-2014) adoption phases using distribution-free random permutation tests. RESULTS: Ranked correlations showed yearly improvement, leading to a near-perfect ranking of median RTAT (r = 0.98, p < 0.001) and a perfect ranking of RTAT variability (r = 1.00, p < 0.001) by nine levels of priority. Eight of the nine priority levels showed a reduction in median RTAT between the early and late phases, and the three most urgent levels--that is, 1, 2, and 3--improved by 23%, 5%, and 70% (all, p < 0.001), respectively. Only one priority level (4, defined as outpatient urgent [8% of studies]) showed significant worsening by 15% (p < 0.001). The three most urgent levels of priority also showed improvements in RTAT variability (61%, 17%, 71%, respectively; all, p < 0.01). Only the lowest level of priority (9) exhibited a significant worsening in RTAT variability by 9% (p < 0.01). CONCLUSION: A reading priority scoring system with defined clinical scenarios yielded desirable prioritization of examination interpretations by radiologists as evidenced by appropriate and improved stratification of RTATs and RTAT variability.

Early Experience With Implementation of a Commercial Decision-Support Product for Imaging Order Entry.

Clinical decision support platforms for imaging order entry have recently been mandated by the federal government. Little data exists outside of the convener sites on how to go about the implementation process. As an early adopter of a commercially available clinical decision support program for imaging order entry, we present our initial experience.

Electronic Health Record-Driven Workflow for Diagnostic Radiologists.

In most settings, radiologists maintain a high-throughput practice in which efficiency is crucial. The conversion from film-based to digital study interpretation and data storage launched the era of PACS-driven workflow, leading to significant gains in speed. The advent of electronic health records improved radiologists' access to patient data; however, many still find this aspect of workflow to be relatively cumbersome. Nevertheless, the ability to guide a diagnostic interpretation with clinical information, beyond that provided in the examination indication, can add significantly to the specificity of a radiologist's interpretation. Responsibilities of the radiologist include, but are not limited to, protocoling examinations, interpreting studies, chart review, peer review, writing notes, placing orders, and communicating with referring providers. Most of the aforementioned activities are not PACS-centric and require a login to one or more additional applications. Consolidation of these tasks for completion through a single interface can simplify workflow, save time, and potentially reduce the incidence of errors. Here, the authors describe diagnostic radiology workflow that leverages the electronic health record to significantly add to a radiologist's ability to be part of the health care team, provide relevant interpretations, and improve efficiency and quality.

Impact of a Four-Point Order-Priority Score on Imaging Examination Performance Times.

BACKGROUND: Many hospitals use a traditional categoric system (eg, STAT, ASAP [as soon as possible], routine) to prioritize orders for imaging examination performance. If left undefined, these categories contain ambiguity, which contributes to errant or misused categorizations, and ultimately, lost opportunity to optimally direct resources toward timely patient care. Our hospital implemented ordinal order-priority categories with specific definitions. We sought to determine the impact of this prioritization method on examination performance time and consistency. METHODS: A four-level numeric priority system with clinical definitions for each category was implemented in 2011 to replace a traditional model for hospital imaging orders. Retrospective analysis was performed on imaging orders for three years (2011-2013) after implementation, to assess the order-to-performance time (OTPT), defined as the time between order placement by the provider and examination completion by the technologist. Consistency was measured by the length of the interquartile range for the OTPT distribution. Comparison was made to orders from the preimplementation year (2010), as a control. RESULTS: The OTPT and OTPT consistency for performed examinations were both predictably stratified by order-priority level. Relative to control, we observed a reduction in the percentage of prioritized examinations, as well as modest general improvements in OTPT and OTPT consistency. CONCLUSIONS: A revised order-priority system with ordinal categorizations and clinical definitions accompanying each priority level at order entry yielded desirable prioritization of imaging examination performance by technologists, as evidenced by appropriate stratification of turnaround times and consistency by level of priority.