"D/C the CC (Carbon Copy)" - Improving the EHR Signal-to-Noise Ratio for Clinicians by Selective Feature De-Implementation.

De-implementation of a 10-year EHR configuration resulted in over 50% decrease in the volume of the most-common InBasket message type received by PCPs. Pro-actively seeking out ways to not only (a) implement helpful new EHR features but (b) de-implement detrimental ones offers an opportunity to accelerate improvement in the S/N ratio and reduce clinician frustration and dissatisfaction with the EHR. Balancing governance decision agendas with de-implementation opportunities can enhance the clinician experience.

User stories as lightweight requirements for agile clinical decision support development.

OBJECTIVE: We sought to demonstrate applicability of user stories, progressively elaborated by testable acceptance criteria, as lightweight requirements for agile development of clinical decision support (CDS). MATERIALS AND METHODS: User stories employed the template: As a [type of user], I want [some goal] so that [some reason]. From the "so that" section, CDS benefit measures were derived. Detailed acceptance criteria were elaborated through ensuing conversations. We estimated user story size with "story points," and depicted multiple user stories with a use case diagram or feature breakdown structure. Large user stories were split to fit into 2-week iterations. RESULTS: One example user story was: As a rheumatologist, I want to be advised if my patient with rheumatoid arthritis is not on a disease-modifying anti-rheumatic drug (DMARD), so that they receive optimal therapy and can experience symptom improvement. This yielded a process measure (DMARD use), and an outcome measure (Clinical Disease Activity Index). Following implementation, the DMARD nonuse rate decreased from 3.7% to 1.4%. Patients with a high Clinical Disease Activity Index improved from 13.7% to 7%. For a thromboembolism prevention CDS project, diagrams organized multiple user stories. DISCUSSION: User stories written in the clinician's voice aid CDS governance and lead naturally to measures of CDS effectiveness. Estimation of relative story size helps plan CDS delivery dates. User stories prove to be practical even on larger projects. CONCLUSIONS: User stories concisely communicate the who, what, and why of a CDS request, and serve as lightweight requirements for agile development to meet the demand for increasingly diverse CDS.

Acute pulmonary embolism: endovascular therapy.

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Agile Co-Development for Clinical Adoption and Adaptation of Innovative Technologies.

Even the most innovative healthcare technologies provide patient benefits only when adopted by clinicians and/or patients in actual practice. Yet realizing optimal positive impact from a new technology for the widest range of individuals who would benefit remains elusive. In software and new product development, iterative rapid-cycle "agile" methods more rapidly provide value, mitigate failure risks, and adapt to customer feedback. Co-development between builders and customers is a key agile principle. But how does one accomplish co-development with busy clinicians? In this paper, we discuss four practical agile co-development practices found helpful clinically: (1) User stories for lightweight requirements; (2) Time-boxed development for collaborative design and prompt course correction; (3) Automated acceptance test driven development, with clinician-vetted specifications; and (4) Monitoring of clinician interactions after release, for rapid-cycle product adaptation and evolution. In the coming wave of innovation in healthcare apps ushered in by open APIs to EHRs, learning rapidly what new product features work well for clinicians and patients will become even more crucial.

CT angiography of lower extremity vascular bypass grafts.

Over the past several years computed tomography (CT) technology has advanced to such a degree that CT angiography (CTA) has become the study of choice at our institution for imaging lower extremity vascular bypass grafts. CTA quickly provides anatomic information about the state of the graft and identifies virtually all forms of bypass graft failure and related complications. Furthermore, detailed vascular anatomy is seen beyond the graft and affords sufficient anatomic detail for surgical revision without the need for other angiographic studies. Although catheter angiography, duplex-ultrasound, magnetic resonance angiography, and nuclear medicine studies all continue to play some role in the evaluation of vascular grafts, they are more often used as problem solving modalities when CTA findings are equivocal. Whereas it was once essential to catheterize directly through a failing bypass graft or pass catheters into the graft from a distant arterial puncture to obtain an angiogram of a failing bypass graft, CTA produces arteriograms with only intravenous contrast administration, a brief visit to the CT scanner, and return to daily activities without catheterization, discomfort, or risk to the bypass conduit.

Approaching the Practice Quality Improvement Project in Interventional Radiology.

An important component of maintenance of certification and quality improvement in radiology is the practice quality improvement (PQI) project. In this article, the authors describe several methodologies for initiating and completing PQI projects. Furthermore, the authors illustrate several tools that are vital in compiling, analyzing, and presenting data in an easily understandable and reproducible manner. Last, they describe two PQI projects performed in an interventional radiology division that have successfully improved the quality of care for patients. Using the DMAIC (define, measure, analyze, improve, control) quality improvement framework, interventional radiology throughput has been increased, to lessen mediport wait times from 43 to 8 days, and mediport infection rates have decreased from more than 2% to less than 0.4%.

Rare hepatic arterial anatomic variants in patients requiring pancreatoduodenectomy and review of the literature.

Normal hepatic arterial anatomy occurs in approximately 50-80% of cases; for the remaining cases, multiple variations have been described. Knowledge of these anomalies is especially important in hepatobiliary and pancreatic surgery in order to avoid unnecessary complications. We describe two cases of patients undergoing pancreatoduodenectomy for abnormalities in the head of the pancreas. Preoperative contrast-enhanced cross-sectional imaging demonstrated relevant, rare hepatic arterial variants: (1) a completely replaced hepatic arterial system with a gastroduodenal artery (GDA) arising directly from the celiac axis and (2) a replaced right hepatic artery originating from the superior mesenteric artery and traveling anterior to the pancreatic uncinate process and head. These findings were confirmed during pancreatoduodenectomy. Both of these variants have been rarely described with an incidence of <1.0%. In the present paper, we describe the hepatic arterial anomalies commonly encountered and clarify the important details associated with these variants as they pertain to pancreatoduodenectomy.

Myelography: a primer.

Despite recent trends toward evaluation of back and neck pain with magnetic resonance imaging, myelography and postmyelography computed tomography continue to play an important role in the workup of many patients with spinal pathology. We present techniques for the safe and efficient performance of myelography, lumbar, and cervical puncture, which remain important skills to be mastered by radiology residents and fellows.

Predictors of early versus late timing of pulmonary embolus after traumatic injury.

OBJECTIVE: To identify risk factors predictive of pulmonary embolus (PE) timing after a traumatic injury. METHODS: One hundred eight traumatic injury patients with a confirmed diagnosis of PE were classified as early PE (≤4 days, n = 54) or late PE (>4 days, n = 54). Independent predictors of early versus late PE were identified using multivariate logistic regression. RESULTS: Half the PEs were diagnosed ≤4 days of injury. Only long bone fractures independently predicted early PE (odds ratio 2.8; 95% confidence interval, 1.1-7.1). Severe head injuries were associated with late PE (odds ratio 11.1; 95% confidence interval, 3.9-31). Established risk factors such as age did not affect timing. CONCLUSIONS: Half the PEs were diagnosed ≤4 days after injury. The risk of early PE appeared highest in patients with long bone fractures, and the benefits of immediate prophylaxis may outweigh risks. Patients with severe head injuries appear to have later PE events. Prospective interventional trials in these injury populations are needed.