Collaborative Development of a PACS-Integrated Quality Control Dashboard: a Single Institutional Experience.

Regular communication between technologists and radiologists is necessary for maintaining optimal diagnostic image quality throughout a radiology practice. In a large hospital system with multiple sites, this task becomes increasingly difficult without simultaneously causing significant disruptions in the clinical workflow and decreased throughput. Thus, establishing a system for quality control reporting that enables effective communication in a seamless and convenient manner is imperative. In this report, we describe the development of a new integrated system, in collaboration with our PACS vendor, with tools that allow for instant reporting of quality errors and dashboards providing real-time up-to-date quality data across our hospital system, directly accessible from PACS. To date, 8,167 quality reports have been logged in our new system with roughly 355 submissions per month. Early user engagement and consensus feedback among radiologists and technologists have been positive suggesting an overall improvement from prior systems. We hope this report can help inform other radiology enterprises seeking to improve quality control reporting within their clinical practice.

Magnetic resonance fingerprinting: an overview.

Magnetic resonance fingerprinting (MRF) is an evolving quantitative MRI framework consisting of unique data acquisition, processing, visualization, and interpretation steps. MRF is capable of simultaneously producing multiple high-resolution property maps including T1, T2, M0, ADC, and T2* measurements. While a relatively new technology, MRF has undergone rapid development for a variety of clinical applications from brain tumor characterization and epilepsy imaging to characterization of prostate cancer, cardiac imaging, among others. This paper will provide a brief overview of current state of MRF technology including highlights of technical and clinical advances. We will conclude with a brief discussion of the challenges that need to be overcome to establish MRF as a quantitative imaging biomarker.

Quantifying the decrease in emergency department imaging utilization during the COVID-19 pandemic at a multicenter healthcare system in Ohio.

PURPOSE: To illustrate the change in emergency department (ED) imaging utilization at a multicenter health system in the state of Ohio during the COVID-19 pandemic. METHODS: A retrospective observational study was conducted assessing ED imaging volumes between March 1, 2020, and May 11, 2020, during the COVID-19 crisis. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization in the ED was compared with new COVID-19 cases in our region. Utilization was first categorized by modality and then by plain films and computed tomography (CT) scans grouped by body part. CT imaging of the chest was specifically investigated by assessing both CT chest only exams and CT chest, abdomen, and pelvis (C/A/P) exams. Ultimately, matching pair-wise statistical analysis of exam volumes was performed to assess significance of volume change. RESULTS: Our multicenter health system experienced a 46% drop in imaging utilization (p < 0.0001) during the pandemic. Matching pair-wise analysis showed a statistically significant volume decrease by each modality and body part. The exceptions were non-contrast chest CT, which increased (p = 0.0053), and non-trauma C/A/P CT, which did not show a statistically significant volume change (p = 0.0633). CONCLUSION: ED imaging utilization trends revealed through actual health system data will help inform evidence-based decisions for more accurate volume predictions and therefore institutional preparedness for current and future pandemics.

Magnetic resonance fingerprinting.

Magnetic resonance is an exceptionally powerful and versatile measurement technique. The basic structure of a magnetic resonance experiment has remained largely unchanged for almost 50 years, being mainly restricted to the qualitative probing of only a limited set of the properties that can in principle be accessed by this technique. Here we introduce an approach to data acquisition, post-processing and visualization--which we term 'magnetic resonance fingerprinting' (MRF)--that permits the simultaneous non-invasive quantification of multiple important properties of a material or tissue. MRF thus provides an alternative way to quantitatively detect and analyse complex changes that can represent physical alterations of a substance or early indicators of disease. MRF can also be used to identify the presence of a specific target material or tissue, which will increase the sensitivity, specificity and speed of a magnetic resonance study, and potentially lead to new diagnostic testing methodologies. When paired with an appropriate pattern-recognition algorithm, MRF inherently suppresses measurement errors and can thus improve measurement accuracy.

Implementation and Benefits of a Vendor-Neutral Archive and Enterprise-Imaging Management System in an Integrated Delivery Network.

The use of digital imaging has substantially grown in recent decades, in traditional services, new specialties, and departments. The need to share these data among departments and caregivers necessitated central archiving systems that are able to communicate with various viewing applications and electronic medical records. This promoted the development of modern vendor neutral archive (VNA) systems. The need to aggregate and share imaging data from various departments promoted the development of enterprise-imaging (EI) solutions that replace departmental silos of data with central healthcare enterprise databases. To describe the implementation process of a VNA-EI solution in a large health system and its outcomes. We review the background of VNA and EI solutions development and describe the characteristics and advantages of such systems. We then describe our experience in implementation of these solutions in a large integrated healthcare delivery network in northeast Ohio. We then present the process, challenges, costs, advantages, and outcomes of such implementation. The VNA and EI solution was launched in December 2015 and is still ongoing. It currently includes 54 radiology and 26 cardiology sites affiliated with the University Hospitals health system. This process was associated with more than 10% cost savings, 30% reduction in storage costs, superior support for disaster recovery, and 80% decrease in unscheduled outages. All these were achieved despite a 120% increase in archive retrieval needs and a 40% growth in image production. Implementation of a VNA and EI solution was successful and resulted in numerous measurable and qualitative improvements in a large and growing health system.

Radiologists' Variation of Time to Read Across Different Procedure Types.

The workload of US radiologists has increased over the past two decades as measured through total annual relative value units (RVUs). This increase in RVUs generated suggests that radiologists' productivity has increased. However, true productivity (output unit per input unit; RVU per time) is at large unknown since actual time required to interpret and report a case is rarely recorded. In this study, we analyzed how the time to read a case varies between radiologists over a set of different procedure types by retrospectively extracting reading times from PACS usage logs. Specifically, we tested two hypotheses that; i) relative variation in time to read per procedure type increases as the median time to read a procedure type increases, and ii) relative rankings in terms of median reading speed for individual radiologists are consistent across different procedure types. The results that, i) a correlation of -0.25 between the coefficient of variation and median time to read and ii) that only 12 out of 46 radiologists had consistent rankings in terms of time to read across different procedure types, show both hypotheses to be without support. The results show that workload distribution will not follow any general rule for a radiologist across all procedures or a general rule for a specific procedure across many readers. Rather the findings suggest that improved overall practice efficiency can be achieved only by taking into account radiologists' individual productivity per procedure type when distributing unread cases.

Detection and Labeling of Vertebrae in MR Images Using Deep Learning with Clinical Annotations as Training Data.

The purpose of this study was to investigate the potential of using clinically provided spine label annotations stored in a single institution image archive as training data for deep learning-based vertebral detection and labeling pipelines. Lumbar and cervical magnetic resonance imaging cases with annotated spine labels were identified and exported from an image archive. Two separate pipelines were configured and trained for lumbar and cervical cases respectively, using the same setup with convolutional neural networks for detection and parts-based graphical models to label the vertebrae. The detection sensitivity, precision and accuracy rates ranged between 99.1-99.8, 99.6-100, and 98.8-99.8% respectively, the average localization error ranges were 1.18-1.24 and 2.38-2.60 mm for cervical and lumbar cases respectively, and with a labeling accuracy of 96.0-97.0%. Failed labeling results typically involved failed S1 detections or missed vertebrae that were not fully visible on the image. These results show that clinically annotated image data from one image archive is sufficient to train a deep learning-based pipeline for accurate detection and labeling of MR images depicting the spine. Further, these results support using deep learning to assist radiologists in their work by providing highly accurate labels that only require rapid confirmation.

Factors Affecting Radiologist's PACS Usage.

The purpose of this study was to determine if any of the factors radiologist, examination category, time of week, and week effect PACS usage, with PACS usage defined as the sequential order of computer commands issued by a radiologist in a PACS during interpretation and dictation. We initially hypothesized that only radiologist and examination category would have significant effects on PACS usage. Command logs covering 8 weeks of PACS usage were analyzed. For each command trace (describing performed activities of an attending radiologist interpreting a single examination), the PACS usage variables number of commands, number of command classes, bigram repetitiveness, and time to read were extracted. Generalized linear models were used to determine the significance of the factors on the PACS usage variables. The statistical results confirmed the initial hypothesis that radiologist and examination category affect PACS usage and that the factors week and time of week to a large extent have no significant effect. As such, this work provides direction for continued efforts to analyze system data to better understand PACS utilization, which in turn can provide input to enable optimal utilization and configuration of corresponding systems. These continued efforts were, in this work, exemplified by a more detailed analysis using PACS usage profiles, which revealed insights directly applicable to improve PACS utilization through modified system configuration.

Online Error Reporting for Managing Quality Control Within Radiology.

Information technology systems within health care, such as picture archiving and communication system (PACS) in radiology, can have a positive impact on production but can also risk compromising quality. The widespread use of PACS has removed the previous feedback loop between radiologists and technologists. Instead of direct communication of quality discrepancies found for an examination, the radiologist submitted a paper-based quality-control report. A web-based issue-reporting tool can help restore some of the feedback loop and also provide possibilities for more detailed analysis of submitted errors. The purpose of this study was to evaluate the hypothesis that data from use of an online error reporting software for quality control can focus our efforts within our department. For the 372,258 radiologic examinations conducted during the 6-month period study, 930 errors (390 exam protocol, 390 exam validation, and 150 exam technique) were submitted, corresponding to an error rate of 0.25 %. Within the category exam protocol, technologist documentation had the highest number of submitted errors in ultrasonography (77 errors [44 %]), while imaging protocol errors were the highest subtype error for computed tomography modality (35 errors [18 %]). Positioning and incorrect accession had the highest errors in the exam technique and exam validation error category, respectively, for nearly all of the modalities. An error rate less than 1 % could signify a system with a very high quality; however, a more likely explanation is that not all errors were detected or reported. Furthermore, staff reception of the error reporting system could also affect the reporting rate.

Analyzing PACS Usage Patterns by Means of Process Mining: Steps Toward a More Detailed Workflow Analysis in Radiology.

In this paper, statistical analysis and techniques from process mining are employed to analyze interaction patterns originating from radiologists reading medical images in a picture archiving and communication system (PACS). Event logs from 1 week of data, corresponding to 567 cases of single-view chest radiographs read by 14 radiologists, were analyzed. Statistical analysis showed that the numbers of commands and command types used by the radiologists per case only have a slightly positive correlation with the time to read a case (0.31 and 0.55, respectively). Further, one way ANOVA showed that the factors time of day, radiologist and specialty were significant for the number of commands per case, whereas radiologist was also significant for the number of command types, but with no significance of any of the factors on time to read. Applying process mining to the event logs of all users showed that a seemingly "simple" examination (single-view chest radiographs) can be associated with a highly complex interaction process. However, repeating the process discovery on each individual radiologist revealed that the initially discovered complex interaction process consists of one group of radiologists with individually well-structured interaction processes and a second smaller group of users with progressively more complex usage patterns. Future research will focus on metrics to describe derived interaction processes in order to investigate if one set of interaction patterns can be considered as more efficient than another set when reading radiological images in a PACS.

Device localization and dynamic scan plane selection using a wireless magnetic resonance imaging detector array.

PURPOSE: A prototype wireless guidance device using single sideband amplitude modulation (SSB) is presented for a 1.5T magnetic resonance imaging system. METHODS: The device contained three fiducial markers each mounted to an independent receiver coil equipped with wireless SSB technology. Acquiring orthogonal projections of these markers determined the position and orientation of the device, which was used to define the scan plane for a subsequent image acquisition. Device localization and scan plane update required approximately 30 ms, so it could be interleaved with high temporal resolution imaging. Since the wireless device is used for localization and does not require full imaging capability, the design of the SSB wireless system was simplified by allowing an asynchronous clock between the transmitter and receiver. RESULTS: When coupled to a high readout bandwidth, the error caused by the lack of a shared frequency reference was quantified to be less than one pixel (0.78 mm) in the projection acquisitions. Image guidance with the prototype was demonstrated with a phantom where a needle was successfully guided to a target and contrast was delivered. CONCLUSION: The feasibility of active tracking with a wireless detector array is demonstrated. Wireless arrays could be incorporated into devices to assist in image-guided procedures.

Design and implementation of disaster recovery and business continuity solution for radiology PACS.

In the digital era of radiology, picture archiving and communication system (PACS) has a pivotal role in retrieving and storing the images. Integration of PACS with all the health care information systems e.g., health information system, radiology information system, and electronic medical record has greatly improved access to patient data at anytime and anywhere throughout the entire enterprise. In such an integrated setting, seamless operation depends critically on maintaining data integrity and continuous access for all. Any failure in hardware or software could interrupt the workflow or data and consequently, would risk serious impact to patient care. Thus, any large-scale PACS now have an indispensable requirement to include deployment of a disaster recovery plan to ensure secure sources of data. This paper presents our experience with designing and implementing a disaster recovery and business continuity plan. The selected architecture with two servers in each site (local and disaster recovery (DR) site) provides four different scenarios to continue running and maintain end user service. The implemented DR at University Hospitals Health System now permits continuous access to the PACS application and its contained images for radiologists, other clinicians, and patients alike.

Rapid time-resolved magnetic resonance angiography via a multiecho radial trajectory and GraDeS reconstruction.

Contrast-enhanced magnetic resonance angiography is challenging due to the need for both high spatial and temporal resolution. A multishot trajectory composed of pseudo-random rotations of a single multiecho radial readout was developed. The trajectory is designed to give incoherent aliasing artifacts and a relatively uniform distribution of projections over all time scales. A field map (computed from the same data set) is used to avoid signal dropout in regions of substantial field inhomogeneity. A compressed sensing reconstruction using the GraDeS algorithm was used. Whole brain angiograms were reconstructed at 1-mm isotropic resolution and a 1.1-s frame rate (corresponding to an acceleration factor > 100). The only parameter which must be chosen is the number of iterations of the GraDeS algorithm. A larger number of iterations improves the temporal behavior at cost of decreased image signal-to-noise ratio. The resulting images provide a good depiction of the cerebral vasculature and have excellent arterial/venous separation.

Resolution enhanced T1-insensitive steady-state imaging.

Resolution enhanced T(1)-insensitive steady-state imaging (RE-TOSSI) is a new MRI pulse sequence for the generation of rapid T(2) contrast with high spatial resolution. TOSSI provides T(2) contrast by using nonequally spaced inversion pulses throughout a balanced steady-state free precession (SSFP) acquisition. In RE-TOSSI, these energy and time intensive adiabatic inversion pulses and associated magnetization preparation are removed from TOSSI after acquisition of the data around the center of k-space. Magnetization evolution simulations demonstrate T(2) contrast in TOSSI as well as reduction in the widening of the point spread function width (by up to a factor of 4) to a near ideal case for RE-TOSSI. Phantom experimentation is used to characterize and compare the contrast and spatial resolution properties of TOSSI, RE-TOSSI, balanced SSFP, Half-Fourier Acquisition Single-Shot Turbo Spin Echo (HASTE), and turbo spin echo and to optimize the fraction of k-space acquired using TOSSI. Comparison images in the abdomen and brain demonstrate similar contrast and improved spatial resolution in RE-TOSSI compared with TOSSI; comparison balanced SSFP, HASTE, and turbo spin echo images are provided. RE-TOSSI is capable of providing high spatial resolution T(2)-weighted images in 1 s or less per image.

Advanced neuroimaging to guide acute stroke therapy.

Traditionally non-contrast CT has been considered the first choice imaging modality for acute stroke. Acute ischemic stroke patients presenting to the hospital within 3-hours from symptom onset and without any visible hemorrhages or large lesions on CT images are considered optimum reperfusion therapy candidates. However, non-contrast CT alone has been unable to identify best reperfusion therapy candidates outside this window. New advanced imaging techniques are now being used successfully for this purpose. Non-invasive CT or MR angiography images can be obtained during initial imaging evaluation for identification and characterization of vascular lesions, including occlusions, aneurysms, and malformations. Either CT-based perfusion imaging or MRI-based diffusion and perfusion imaging performed immediately upon arrival of a patient to the hospital helps estimate the extent of fixed core and penumbra in ischemic lesions. Patients having occlusive lesions with small fixed cores and large penumbra are preferred reperfusion therapy candidates.

Characterization and reduction of saturation banding in multiplanar coherent and incoherent steady-state imaging.

Hypointense band artifacts occur at intersections of nonparallel imaging planes in rapidly acquired MR images; quantitative or numerical analysis of these bands and strategies to mitigate their appearance have largely gone unexplored. The magnetization evolution in the different regions of multiplanar images was simulated for three common rapid steady-state techniques (spoiled gradient echo, steady state free precession, balanced steady state free precession). Saturation banding was found to be highly dependent on the pulse sequence, acquisition time, and phase-encoding order. Encoding the center of k-space at the end of the acquisition of each slice (i.e., reverse centric phase encoding) is demonstrated to be a simple and robust method for significantly reducing the relative saturation in all imaging planes. View ordering and resolution dependence were confirmed in multiplanar abdominal images. The added importance of reducing the artifact in accelerated acquisition techniques (e.g., parallel imaging) is particularly notable in multiplanar balanced steady state free precession images in the brain.

COVID-19 Pandemic Impact on Decreased Imaging Utilization: A Single Institutional Experience.

RATIONALE AND OBJECTIVES: Predictive models and anecdotal articles suggest radiology practices were losing 50%-70% of their normal imaging volume during the COVID-19 pandemic. Using actual institutional data, we investigated the change in imaging utilization and revenue during this public health crisis. MATERIALS AND METHODS: Imaging performed within the 8-week span between March 8 and April 30, 2020 was categorized into the COVID-19 healthcare crisis timeframe. The first week of this date range and the 10 weeks prior were used to derive the normal practice expected volume. A rolling 7-day total value was used for volume tracking and comparison. Total imaging utilization was derived and organized by patient setting (outpatient, inpatient, emergency) and imaging modality (X-ray, CT, Mammography, MRI, Nuclear Medicine/PET, US). The three highest volume hospitals were analyzed. Revenue information was collected from the hospital billing system. RESULTS: System-wide imaging volume decreased by 55% between April 7 and 13, 2020. Outpatient exams decreased by 68% relative to normal practice. Emergency exams decreased by 48% and inpatient exams declined by 31%. Mammograms and nuclear medicine scans were the most affected modalities, decreasing by 93% and 61%, respectively. The main campus hospital experienced less relative imaging volume loss compared to the other smaller and outpatient-driven hospitals. At its lowest point, the technical component revenue from main campus imaging services demonstrated a 49% negative variance from normal practice. CONCLUSION: The trends and magnitude of the actual imaging utilization data presented will help inform evidence-based decisions for more accurate volume predictions, policy changes, and institutional preparedness for current and future pandemics.

Comparison of combined venous and arterial thrombolysis with primary arterial therapy using recombinant tissue plasminogen activator in acute ischemic stroke.

OBJECTIVE: We sought to compare the safety and efficacy of combined intravenous (IV) and intra-arterial (IA) thrombolysis with primary IA therapy using tissue plasminogen activator for acute ischemic stroke presenting within 6 hours of symptom onset. METHODS: We performed quasirandomization of a single institution's prospectively collected stroke database, comparing IV/IA (0.6 mg/kg IV < or = 60 mg, followed by 0.3 mg/kg IA < or = 30 mg) versus primary IA. Outcome measures include 90-day modified Rankin scale score, mortality, symptomatic intracerebral hemorrhage, and recanalization rates. Statistical analysis was performed using bivariate and propensity score methods. RESULTS: Of 1057 patients, 41 patients were treated with IV/IA, and 55 with IA. There was significant difference in time to treatment (mean of 151 minutes for the combined group and 261 minutes for the IA, P < .0001) and arterial tissue plasminogen activator dose (17.5 mg for IV/IA v 22.8 mg for IA only, P = .05). Propensity score matching yielded 25 patients in each group. Symptomatic intracerebral hemorrhage rate was 12% in each group. Mortality was 20% in the IV/IA group versus 16% in the IA group (relative risk 1.3 [0.4-4.1], P = .7). More patients in IV/IA group had modified Rankin scale score less than or equal to 2 (odds ratio 1.6 [0.5-5.8], P = .3). Recanalization was 64% with IV/IA versus 48% with IA (odds ratio 1.9 [0.5-7.0], P = .3). CONCLUSION: This study demonstrates that both combined IV/IA and primary IA recombinant tissue plasminogen activator therapy is feasible and safe in the treatment of acute ischemic stroke. Combined IV/IA therapy may be associated with an improvement in clinical outcome without a significant increase in the risk of symptomatic intracerebral hemorrhage and mortality compared with IA therapy.

Older age does not increase risk of hemorrhagic complications after intravenous and/or intra-arterial thrombolysis for acute stroke.

BACKGROUND: The elderly have significantly higher incidence of ischemic stroke and have higher mortality and morbidity compared with younger patients. Intracranial hemorrhage (ICH) after thrombolysis is one of the causes of unfavorable outcome. However, it is unclear whether age over 80 years is a predictor for hemorrhagic transformation after intravenous, intra-arterial, or a combination of both thrombolytic therapies. METHODS: A database of 488 consecutive patients with ischemic stroke who received thrombolytic therapy was analyzed using logistic regression model to determine whether factors such as age over 80 years, demographic characteristics, onset to treatment time, severity of neurologic deficits, route of administration, blood glucose, or mean arterial pressure were associated with symptomatic ICH. RESULTS: The rates of symptomatic hemorrhage were 12.82% and 10.4% in older and younger groups, respectively. The odds of symptomatic hemorrhage after thrombolytic therapy for patients over 80 years of age after adjusting for route of administration, National Institutes of Health Stroke Scale score, mean arterial pressure, and glucose was not significantly different from that of the younger age group (odds ratio [OR] = 1.64; 95% confidence interval [CI]: 0.729-3.66). Hyperglycemia (>150 mg/dL) was associated with increased odds of symptomatic ICH (OR = 2.32; 95% CI: 1.09-4.93). Patients older than 80 years had similar rates of recanalization (OR = 0.8; 95% CI: 0.4-1.8) and rates of asymptomatic ICH (OR = 2.40; 95% CI: 0.89-6.5). CONCLUSIONS: Risks of ICH after thrombolysis for acute ischemic stroke are similar in patients over and under 80 years of age. Our data suggest that the decision to provide thrombolytic therapy should not be solely based on patient's age.

Decreased functional connectivity in the fronto-parietal network in children with mood disorders compared to children with dyslexia during rest: An fMRI study.

Background: The DSM-5 separates the diagnostic criteria for mood and behavioral disorders. Both types of disorders share neurocognitive deficits of executive function and reading difficulties in childhood. Children with dyslexia also have executive function deficits, revealing a role of executive function circuitry in reading. The aim of the current study is to determine whether there is a significant relationship of functional connectivity within the fronto-parietal and cingulo-opercular cognitive control networks to reading measures for children with mood disorders, behavioral disorders, dyslexia, and healthy controls (HC). Method: Behavioral reading measures of phonological awareness, decoding, and orthography were collected. Resting state fMRI data were collected, preprocessed, and then analyzed for functional connectivity. Differences in the reading measures were tested for significance among the groups. Global efficiency (GE) measures were also tested for correlation with reading measures in 40 children with various disorders and 17 HCs. Results: Significant differences were found between the four groups on all reading measures. Relative to HCs and children with mood disorders or behavior disorders, children with dyslexia as a primary diagnosis scored significantly lower on all three reading measures. Children with mood disorders scored significantly lower than controls on a test of phonological awareness. Phonological awareness deficits correlated with reduced resting state functional connectivity MRI (rsfcMRI) in the cingulo-opercular network for children with dyslexia. A significant difference was also found in fronto-parietal global efficiency in children with mood disorders relative to the other three groups. We also found a significant difference in cingulo-opercular global efficiency in children with mood disorders relative to the Dyslexia and Control groups. However, none of these differences correlate significantly with reading measures. Conclusions/significance: Reading difficulties involve abnormalities in different cognitive control networks in children with dyslexia compared to children with mood disorders. Findings of the current study suggest increased functional connectivity of one cognitive control network may compensate for reduced functional connectivity in the other network in children with mood disorders. These findings provide guidance to clinical professionals for design of interventions tailored for children suffering from reading difficulties originating from different pathologies.