Integration of a Zero-footprint Cloud-based Picture Archiving and Communication System with Customizable Forms for Radiology Research and Education

Error Management Training and Adaptive Expertise in Learning Computed Tomography Interpretation: A Randomized Clinical Trial

Importance

Adaptive expertise helps physicians apply their skills to novel clinical cases and reduce preventable errors. Error management training (EMT) has been shown to improve adaptive expertise with procedural skills; however, its application to cognitive skills in medical education is unclear.

Objective

To evaluate whether EMT improves adaptive expertise when learning the cognitive skill of head computed tomography (CT) interpretation.

Design, Setting, and Participants

This 3-arm randomized clinical trial was conducted from July 8, 2022, to March 30, 2023, in 7 geographically diverse emergency medicine residency programs. Participants were postgraduate year 1 through 4 emergency medicine residents masked to the hypothesis.

Interventions

Participants were randomized 1:1:1 to a difficult EMT, easy EMT, or error avoidance training (EAT) control learning strategy for completing an online head CT curriculum. Both EMT cohorts received no didactic instruction before scrolling through head CT cases, whereas the EAT group did. The difficult EMT cohort answered difficult questions about the teaching cases, leading to errors, whereas the easy EMT cohort answered easy questions, leading to fewer errors. All 3 cohorts used the same cases.

Main Outcomes and Measures

The primary outcome was a difference in adaptive expertise among the 3 cohorts, as measured using a head CT posttest. Secondary outcomes were (1) differences in routine expertise, (2) whether the quantity of errors during training mediated differences in adaptive expertise, and (3) the interaction between prior residency training and the learning strategies.

Results

Among 212 randomized participants (mean [SD] age, 28.8 [2.0] years; 107 men [50.5%]), 70 were allocated to the difficult EMT, 71 to the easy EMT, and 71 to the EAT control cohorts; 150 participants (70.8%) completed the posttest. The difficult EMT cohort outperformed both the easy EMT and EAT cohorts on adaptive expertise cases (60.6% [95% CI, 56.1%-65.1%] vs 45.2% [95% CI, 39.9%-50.6%], vs 40.9% [95% CI, 36.0%-45.7%], respectively; P < .001), with a large effect size (η2 = 0.19). There was no significant difference in routine expertise. The difficult EMT cohort made more errors during training than the easy EMT cohort. Mediation analysis showed that the number of errors during training explained 87.2% of the difficult EMT learning strategy's effect on improving adaptive expertise (P = .01). The difficult EMT learning strategy was more effective in improving adaptive expertise for residents earlier in training, with a large effect size (η2 = 0.25; P = .002).

Conclusions and Relevance

In this randomized clinical trial, the findings show that EMT is an effective method to develop physicians' adaptive expertise with cognitive skills.

Trial Registration

ClinicalTrials.gov Identifier: NCT05284838.

Reporting of Facet Joint Inflammation in Lumbar Spine MRI Studies in Patients With Low Back Pain

STUDY DESIGN

Retrospective.

OBJECTIVE

We aimed to assess the frequency of facet joint inflammatory features noted in routine radiology reports of lumbar spine magnetic resonance imaging (MRI) studies among patients with chronic low back pain.

SUMMARY OF BACKGROUND DATA

Facet joint arthropathy is one of the most common causes of chronic low back pain. It may encompass various inflammatory imaging characteristics, such as facet joint effusion, bone marrow edema, and soft tissue edema. The extent to which radiology reports mention inflammatory features of the lumbar facet joints and the accuracy of these reports have not been investigated.

MATERIALS AND METHODS

The authors performed a chart review on 49 subjects with previous facet-related interventions ( i.e . medial branch blocks or intra-articular facet joint injection) and MRI available in the medical record. One senior musculoskeletal radiologist and a musculoskeletal radiology fellow graded the inflammatory features using a published facet joint inflammation grading system [Gold Standard (GS)]. The authors identified the inflammatory markers mentioned in the radiology reports and calculated the sensitivity and positive predictive value of the radiology reports compared with GS readings.

RESULTS

Compared with the GS, the sensitivity of radiology reports for facet joint effusion, bone marrow, and soft tissue edema ranged from 6% to 22%, and the positive predictive value ranged from 25% to 100%. L4/5 had the highest number of cases with inflammatory features noted on the reports.

CONCLUSION

Inflammatory findings, such as facet joint effusion, bone marrow edema, and soft tissue edema, are not commonly identified in radiology reports. Further investigations are needed to determine the clinical importance of MRI-detected lumbar facet joint inflammatory features as a potential mechanism of nociception and as a predictor of outcomes following injections or other therapies.

Comprehensive Grading System of Inflammatory Features of the Lumbar Facet Joints on Magnetic Resonance Imaging

STUDY DESIGN

Retrospective.

OBJECTIVE

We aimed to describe a magnetic resonance imaging (MRI)-based grading system of inflammatory features of the lumbar facet joints using an atlas and assess its reliability.

SUMMARY OF BACKGROUND DATA

Chronic low back pain is often caused by facet joint arthropathy. Inflammatory features are often evident on MRI. While several grading systems of facet arthropathy have been described, there is scant data on the reliability of these systems, and none focus exclusively on inflammatory features.

MATERIALS AND METHODS

We describe a grading system that assesses facet joint effusion, bone marrow edema, and soft tissue edema. Each feature was graded from 0 to 3 (facet edema) or 0 to 2 (bone marrow edema intensity and extent, soft tissue edema intensity and extent). Four spine experts graded MRIs of 50 subjects at the bilateral L3/4, L4/5, and L5/S1 levels. All subjects had symptomatic facet arthropathy and received therapeutic facet joint injections. We assessed the intra-reader and inter-reader reliability of each feature at each joint and summarized across all six joints.

RESULTS

The mean age of subjects was 56 years (SD = 17), and 48% were female. The injections occurred at the L3/4 level in 12% of cases, at L4/5 in 88%, and at L5/S1 in 80% of cases. The intra-reader reliability kappa's for each feature ranged from 0.42 to 0.81. In contrast, the inter-reader reliability kappa values for each feature ranged from 0.37 to 0.54.

CONCLUSION

MRI inflammatory features of the lumbar facet joints are often noted in patients with low back pain. The proposed grading system is reliable and could serve as a research tool for studies assessing the clinical relevance and prognostic value of these features.

Rethinking Radiology: An Active Learning Curriculum for Head Computed Tomography Interpretation

Introduction: Head computed tomography (CT) interpretation is a vital skill for emergency physicians. Existing literature shows poor concordance between emergency physicians and radiologists in head CT interpretation. Prior studies have used passive learning methods to address this knowledge gap. We created an active learning curriculum for teaching head CT interpretation to emergency medicine (EM) residents and compared its effectiveness to a passive learning strategy. Methods: We conducted a prospective, randomized controlled study of EM residents at a single institution. Three educational sessions were delivered over a three-month period via video conference. The active learning cohort (ALC) scrolled through head CT teaching cases we designed on Pascbin, a web-based radiology picture archiving and communication system. The passive learning cohort (PLC) watched instructional videos that scrolled through the same cases. Both cohorts were given equal time to review the cases and ask an instructor questions. Residents took pre-intervention and post-intervention tests on head CT interpretation. We analyzed scores using paired and unpaired t-tests. Results: Forty-two residents took the pre-intervention test. Mean pre- and post-test scores for the ALC were 43.8% and 59.0% (P <0.001), and for the PLC were 41.7% and 45.3% (P = 0.29). The difference in ALC and PLC post-test scores was statistically significant (P = 0.009) with a large effect size (Cohen’s d = 1.34). Conclusion: Our active learning head CT curriculum using Pacsbin showed superior learning outcomes when compared to a passive learning strategy and required no additional time or resources. This intervention offers a more effective and learner-centric method for implementing radiology curricula in EM residency programs.

Standardized Classification of Lumbar Spine Degeneration on Magnetic Resonance Imaging Reduces Intra- and Inter-subspecialty Variability

BACKGROUND AND PURPOSE

To determine the efficacy of standardized definitions of degenerative change in reducing variability in interpretation of lumbar spine magnetic resonance imaging within and between groups of subspecialty-trained neuroradiologists (NR) and musculoskeletal radiologists (MSK).

MATERIALS AND METHODS

Six radiologists, three from both NR and MSK groups were trained on a standardized classification system of degenerative change. After an 11-month washout period, they independently re-interpreted fifty exams at the L4-L5 and L5-S1 levels. Responses were converted to a six-point ordinal scale for the assessment of neural foraminal stenosis and spinal canal stenosis (SCS), three-point scale for lateral recess stenosis, and four-point scale for facet osteoarthritis (FO). Intra-subspecialty and inter-subspecialty analysis was performed using the weighted Cohen's kappa with a binary matrix of all reader pairs.

RESULTS

Inter-subspecialty agreement improved from k=0.527 (moderate) to k=0.602 (substantial) for neural foraminal stenosis, from k=0.540 (moderate) to k=0.652 (substantial) for SCS, from k=0.0818 (slight) to k=0.337 (fair) for lateral recess stenosis, and from k=0.176 (slight) to k=0.495 (moderate) for FO. The NR group demonstrated improved intra-subspecialty agreement for the assessment of SCS, from k=0.368 (fair) to k=0.638 (substantial). The MSK group demonstrated improved intra-subspecialty agreement for the assessment of FO, from k=0.134 (slight) to k=0.413 (moderate). Intra-subspecialty agreement was similar for other parameters before and after training.

CONCLUSIONS

As result of the standardized definitions training, the NR and MSK groups each improved in one of the four parameters, while inter-subspecialty variability improved in all four parameters. These definitions may be useful in clinical practice across radiology subspecialties.

Simplified Universal Grading of Lumbar Spine MRI Degenerative Findings: Inter-Reader Agreement of Non-Radiologist Spine Experts

OBJECTIVE

1) To describe a simplified multidisciplinary grading system for the most clinically relevant lumbar spine degenerative changes. 2) To measure the inter-reader variability among non-radiologist spine experts in their use of the classification system for interpretation of a consecutive series of lumbar spine magnetic resonance imaging (MRI) examinations.

METHODS

ATS multidisciplinary and collaborative standardized grading of spinal stenosis, foraminal stenosis, lateral recess stenosis, and facet arthropathy was developed. Our institution's picture archiving and communication system was searched for 50 consecutive patients who underwent non-contrast MRI of the lumbar spine for chronic back pain, radiculopathy, or symptoms of spinal stenosis. Three fellowship-trained spine subspecialists from neurosurgery, orthopedic surgery, and physiatry interpreted the 50 exams using the classification at the L4-L5 and L5-S1 levels. Inter-reader agreement was assessed with Cohen's kappa coefficient.

RESULTS

For spinal stenosis, the readers demonstrated substantial agreement (κ = 0.702). For foraminal stenosis and facet arthropathy, the three readers demonstrated moderate agreement (κ = 0.544, and 0.557, respectively). For lateral recess stenosis, there was fair agreement (κ = 0.323).

CONCLUSIONS

A simplified universal grading system of lumbar spine MRI degenerative findings is newly described. Use of this multidisciplinary grading system in the assessment of clinically relevant degenerative changes revealed moderate to substantial agreement among non-radiologist spine physicians. This standardized grading system could serve as a foundation for interdisciplinary communication.

Blockchain Technology: Principles and Applications in Medical Imaging

Blockchain is an immutable, encrypted, distributed ledger technology. While initially devised for and most commonly referenced with cryptocurrencies, there are an increasing number of applications outside finance, many of which are relevant to medical imaging. In this paper, the concepts and principles underlying the technology and applications relevant to medical imaging are discussed, in addition to potential challenges with implementations such as public versus private key access, distributed ledger size constraints, speed, complexity, and security pitfalls. Potential use cases for blockchain specifically relevant to medical imaging include image sharing including direct patient ownership of images, tracking of implanted medical devices, research, teleradiology, and artificial intelligence. While blockchain offers exciting ways to facilitate the storage and distribution of medical images, similar to the advent of picture archiving and communication systems decades ago, it does have several key limitations of which healthcare providers of medical imaging and imaging informatics professionals should be aware.

Open Health Imaging Foundation Viewer: An Extensible Open-Source Framework for Building Web-Based Imaging Applications to Support Cancer Research

PURPOSE

Zero-footprint Web architecture enables imaging applications to be deployed on premise or in the cloud without requiring installation of custom software on the user's computer. Benefits include decreased costs and information technology support requirements, as well as improved accessibility across sites. The Open Health Imaging Foundation (OHIF) Viewer is an extensible platform developed to leverage these benefits and address the demand for open-source Web-based imaging applications. The platform can be modified to support site-specific workflows and accommodate evolving research requirements.

MATERIALS AND METHODS

The OHIF Viewer provides basic image review functionality (eg, image manipulation and measurement) as well as advanced visualization (eg, multiplanar reformatting). It is written as a client-only, single-page Web application that can easily be embedded into third-party applications or hosted as a standalone Web site. The platform provides extension points for software developers to include custom tools and adapt the system for their workflows. It is standards compliant and relies on DICOMweb for data exchange and OpenID Connect for authentication, but it can be configured to use any data source or authentication flow. Additionally, the user interface components are provided in a standalone component library so that developers can create custom extensions.

RESULTS

The OHIF Viewer and its underlying components have been widely adopted and integrated into multiple clinical research platforms (e,g Precision Imaging Metrics, XNAT, LabCAS, ISB-CGC) and commercial applications (eg, Osirix). It has also been used to build custom imaging applications (eg, ProstateCancer.ai, Crowds Cure Cancer [presented as a case study]).

CONCLUSION

The OHIF Viewer provides a flexible framework for building applications to support imaging research. Its adoption could reduce redundancies in software development for National Cancer Institute-funded projects, including Informatics Technology for Cancer Research and the Quantitative Imaging Network.

Tibial bone stress injury: diagnostic performance and inter-reader agreement of an abbreviated 5-min magnetic resonance protocol

OBJECTIVE

To compare the diagnostic performance and inter-reader agreement of an abbreviated (5 min) MR protocol compared to a complete (25 min) protocol, for evaluation of suspected tibial bone stress injury.

MATERIALS AND METHODS

This IRB-approved retrospective study consisted of 95 consecutive MR examinations in 88 patients with suspected tibial bone stress injury. Three musculoskeletal radiologists independently classified all examinations utilizing both an abbreviated protocol consisting only of axial T2-weighted images with fat suppression, and after a washout period again classified the complete examinations. Accuracy was calculated as proportion of cases classified exactly, within 1 grade, within 2 grades, and also utilizing a simplified "clinically relevant" classification combining grades 2, 3, and 4A into a single group. Significance testing was performed with the chi-test, and a post-hoc power analysis was performed. Inter-reader agreement was calculated with Kendall's coefficient of concordance, with significance testing performed utilizing the z-test after bootstrapping to obtain the standard error.

RESULTS AND CONCLUSIONS

There was no significant difference in accuracy of grading tibial bone stress injuries between complete and abbreviated examinations. For complete exams, pooled exact accuracy was 47.8%; accuracy within 1 grade was 82.8%; and accuracy within 2 grades was 96.1%. For the abbreviated protocol, corresponding accuracies were 50.2, 82.0, and 93.9%. With the "clinically relevant" simplified classification, accuracy was 58.6% for complete exams and 64.2% for abbreviated exams. There was no significant difference in inter-reader agreement, with substantial agreement demonstrated for both complete (Kendall coefficient of concordance 0.805) and abbreviated examinations (coefficient of 0.767).

Intra- and Intersubspecialty Variability in Lumbar Spine MRI Interpretation: A Multireader Study Comparing Musculoskeletal Radiologists and Neuroradiologists

BACKGROUND AND PURPOSE

The purpose of this study is to assess the differences in degenerative spine MRI reporting between subspecialty-trained attending neuroradiologists and musculoskeletal radiologists (MSK) at a single institution, academic medical center.

MATERIALS AND METHODS

Fifty consecutive outpatient noncontrast lumbar spine examinations were selected from the Picture Archiving and Communication System. Three MSK and 3 neuroradiologists (NR) independently reviewed and interpreted the exams at the L4-L5 and L5-S1 levels in the same manner as in clinical practice. The assessment of neural foraminal stenosis (NFS) and spinal canal stenosis (SCS) was converted to a 5-point ordinal scale. The assessment of lateral recess stenosis (LRS) and facet osteoarthritis (FO) was recorded as present/absent. Intersubspecialty and intrasubspecialty analysis was performed using Cohen's kappa coefficient with a binary matrix of all reader pairs.

RESULTS

There was moderate intersubspecialty agreement (k = 0.527) for NFS and SCS (k = 0.540). Intersubspecialty agreement was slight for LRS (k = 0.0818) and FO (k = 0.176). The MSK group demonstrated greater intrasubspecialty agreement in assessment of NFS and SCS compared to the NR group, with nonoverlapping confidence intervals. The NR group demonstrated greater nominal intrasubspecialty agreement in the assessment of both LRS and FO, although with nonoverlapping confidence intervals.

CONCLUSION

There is moderate intersubspecialty agreement between MSK radiologists and neuroradiologists in reporting the severity of NFS and SCS, although MSK radiologists demonstrated greater intrasubspecialty agreement. There is slight intersubspecialty agreement for LRS and FO. The demonstration of differences in inter-reader agreement is a crucial first step to attempt to ameliorate these variabilities.

Spaced radiology: encouraging durable memory using spaced testing in pediatric radiology

Applied memory research in the field of cognitive and educational psychology has generated a large body of data to support the use of spacing and testing to promote long-term or durable memory. Despite the consensus of this scientific community, most learners, including radiology residents, do not utilize these tools for learning new information. We present a discussion of these parallel and synergistic learning techniques and their incorporation into a software platform, called Spaced Radiology, which we created for teaching radiology residents. Specifically, this software uses these evidence-based strategies to teach pediatric radiology through a flashcard deck system.

Rethinking the Meaning of Cloud Computing for Health Care: A Taxonomic Perspective and Future Research Directions

BACKGROUND

Cloud computing is an innovative paradigm that provides users with on-demand access to a shared pool of configurable computing resources such as servers, storage, and applications. Researchers claim that information technology (IT) services delivered via the cloud computing paradigm (ie, cloud computing services) provide major benefits for health care. However, due to a mismatch between our conceptual understanding of cloud computing for health care and the actual phenomenon in practice, the meaningful use of it for the health care industry cannot always be ensured. Although some studies have tried to conceptualize cloud computing or interpret this phenomenon for health care settings, they have mainly relied on its interpretation in a common context or have been heavily based on a general understanding of traditional health IT artifacts, leading to an insufficient or unspecific conceptual understanding of cloud computing for health care.

OBJECTIVE

We aim to generate insights into the concept of cloud computing for health IT research. We propose a taxonomy that can serve as a fundamental mechanism for organizing knowledge about cloud computing services in health care organizations to gain a deepened, specific understanding of cloud computing in health care. With the taxonomy, we focus on conceptualizing the relevant properties of cloud computing for service delivery to health care organizations and highlighting their specific meanings for health care.

METHODS

We employed a 2-stage approach in developing a taxonomy of cloud computing services for health care organizations. We conducted a structured literature review and 24 semistructured expert interviews in stage 1, drawing on data from theory and practice. In stage 2, we applied a systematic approach and relied on data from stage 1 to develop and evaluate the taxonomy using 14 iterations.

RESULTS

Our taxonomy is composed of 8 dimensions and 28 characteristics that are relevant for cloud computing services in health care organizations. By applying the taxonomy to classify existing cloud computing services identified from the literature and expert interviews, which also serves as a part of the taxonomy, we identified 7 specificities of cloud computing in health care. These specificities challenge what we have learned about cloud computing in general contexts or in traditional health IT from the previous literature. The summarized specificities suggest research opportunities and exemplary research questions for future health IT research on cloud computing.

CONCLUSIONS

By relying on perspectives from a taxonomy for cloud computing services for health care organizations, this study provides a solid conceptual cornerstone for cloud computing in health care. Moreover, the identified specificities of cloud computing and the related future research opportunities will serve as a valuable roadmap to facilitate more research into cloud computing in health care.