Radiologists' productivity in the interpretation of CT scans: a comparison of PACS with conventional film

Full Radiology Report through Patient Web Portal: A Literature Review

The aim of this study discusses the gap between the patient web portal and providing a full radiology report. A literature review was conducted to examine radiologists, physicians, and patients’ opinions and preferences of providing patients with online access radiology reports. The databases searched were Pubmed and Google Scholar and the initial search included 927 studies. After review, 47 studies were included in the study. We identified several themes, including patients’ understanding of radiology reports and radiological images, as well as the need for decreasing the turnaround time for reports availability. The existing radiology reports written for physicians are not suited for patients. Further studies are needed to guide and inform the design of patient friendly radiology reports. One of the ways that can be used to fill the gap between patients and radiology reports is using social media sites.

A General Framework for Monitoring Image Acquisition Workflow in the Radiology Environment: Timeliness for Acute Stroke CT Imaging

Many facets of an image acquisition workflow leave a digital footprint, making workflow analysis amenable to an informatics-based solution. This paper describes a detailed framework for analyzing workflow and uses acute stroke response timeliness in CT as a practical demonstration. We review methods for accessing the digital footprints resulting from common technologist/device interactions. This overview lays a foundation for obtaining data for workflow analysis. We demonstrate the method by analyzing CT imaging efficiency in the setting of acute stroke. We successfully used digital footprints of CT technologists to analyze their workflow. We presented an overview of other digital footprints including but not limited to contrast administration, patient positioning, billing, reformat creation, and scheduling. A framework for analyzing image acquisition workflow was presented. This framework is transferable to any modality, as the key steps of image acquisition, image reconstruction, image post processing, and image transfer to PACS are common to any imaging modality in diagnostic radiology.

Needs Assessment Using a Structured Prioritization Schema: An Open Letter to PACS Vendors

PURPOSE

The aim of this work was to prioritize in a quaternary academic environment necessary elements of a replacement PACS.

METHODS

This quality improvement work was conducted at one academic medical center and was "not regulated" by the institutional review board. Three workgroups (10-15 members each) with unique resident, fellow, and attending radiologists; IT specialists; and departmental leaders convened in 2018 to prioritize elements for a PACS replacement project, including integrated IT tools. Each workgroup met two or three times and represented one of three missions (clinical, research, and education). Six elements assigned the highest priority were distilled from each workgroup. The resulting 18 elements were condensed into survey format and distributed to all department residents, fellows, and faculty members for 5-point Likert-type prioritization stratified by mission. Data were collected over 2 weeks.

RESULTS

The survey response rate was 37% (71 of 192; 17 of 44 residents, 3 of 27 fellows, and 51 of 121 faculty members). Self-reported work effort was 63 ± 26% clinical, 14 ± 11% education, 15 ± 21% research, and 8 ± 14% administration. Aggregate priority ratings across all domains were highest for "stable system with predictable behavior" (mean, 4.51), "minimizes repetitive non-value-added work" (mean, 4.40), "interoperability" (mean, 4.12), and "near-instantaneous load times" (mean, 4.07). Clinical-specific ratings for these elements were even higher (means, 4.85-4.90). The lowest aggregate scores were mobile device compatibility (mean, 3.03), connectivity to nonaffiliated sites (mean, 3.01), and integrated instant messaging (mean, 2.87).

CONCLUSIONS

The department prioritized a stable and interoperable system that minimized non-value-added work. In other words, participants wanted a functioning PACS. PACS vendors should prioritize a reliable experience over niche add-ons.

Workflow Dynamics and the Imaging Value Chain: Quantifying the Effect of Designating a Nonimage-Interpretive Task Workflow

PURPOSE

To assess the impact of separate non-image interpretive task and image-interpretive task workflows in an academic neuroradiology practice.

MATERIALS AND METHODS

A prospective, randomized, observational investigation of a centralized academic neuroradiology reading room was performed. The primary reading room fellow was observed over a one-month period using a time-and-motion methodology, recording frequency and duration of tasks performed. Tasks were categorized into separate image interpretive and non-image interpretive workflows. Post-intervention observation of the primary fellow was repeated following the implementation of a consult assistant responsible for non-image interpretive tasks. Pre- and post-intervention data were compared.

RESULTS

Following separation of image-interpretive and non-image interpretive workflows, time spent on image-interpretive tasks by the primary fellow increased from 53.8% to 73.2% while non-image interpretive tasks decreased from 20.4% to 4.4%. Mean time duration of image interpretation nearly doubled, from 05:44 to 11:01 (p = 0.002). Decreases in specific non-image interpretive tasks, including phone calls/paging (2.86/hr versus 0.80/hr), in-room consultations (1.36/hr versus 0.80/hr), and protocoling (0.99/hr versus 0.10/hr), were observed. The consult assistant experienced 29.4 task switching events per hour. Rates of specific non-image interpretive tasks for the CA were 6.41/hr for phone calls/paging, 3.60/hr for in-room consultations, and 3.83/hr for protocoling.

CONCLUSION

Separating responsibilities into NIT and IIT workflows substantially increased image interpretation time and decreased TSEs for the primary fellow. Consolidation of NITs into a separate workflow may allow for more efficient task completion.

Image Sharing Technologies and Reduction of Imaging Utilization: A Systematic Review and Meta-analysis

INTRODUCTION

Image sharing technologies may reduce unneeded imaging by improving provider access to imaging information. A systematic review and meta-analysis were conducted to summarize the impact of image sharing technologies on patient imaging utilization.

METHODS

Quantitative evaluations of the effects of PACS, regional image exchange networks, interoperable electronic heath records, tools for importing physical media, and health information exchange systems on utilization were identified through a systematic review of the published and gray English-language literature (2004-2014). Outcomes, standard effect sizes (ESs), settings, technology, populations, and risk of bias were abstracted from each study. The impact of image sharing technologies was summarized with random-effects meta-analysis and meta-regression models.

RESULTS

A total of 17 articles were included in the review, with a total of 42 different studies. Image sharing technology was associated with a significant decrease in repeat imaging (pooled effect size [ES] = -0.17; 95% confidence interval [CI] = [-0.25, -0.09]; P < .001). However, image sharing technology was associated with a significant increase in any imaging utilization (pooled ES = 0.20; 95% CI = [0.07, 0.32]; P = .002). For all outcomes combined, image sharing technology was not associated with utilization. Most studies were at risk for bias.

CONCLUSIONS

Image sharing technology was associated with reductions in repeat and unnecessary imaging, in both the overall literature and the most-rigorous studies. Stronger evidence is needed to further explore the role of specific technologies and their potential impact on various modalities, patient populations, and settings.

ADR--Anatomy-Driven Reformation

Dedicated visualization methods are among the most important tools of modern computer-aided medical applications. Reformation methods such as Multiplanar Reformation or Curved Planar Reformation have evolved as useful tools that facilitate diagnostic and therapeutic work. In this paper, we present a novel approach that can be seen as a generalization of Multiplanar Reformation to curved surfaces. The main concept is to generate reformatted medical volumes driven by the individual anatomical geometry of a specific patient. This process generates flat views of anatomical structures that facilitate many tasks such as diagnosis, navigation and annotation. Our reformation framework is based on a non-linear as-rigid-as-possible volumetric deformation scheme that uses generic triangular surface meshes as input. To manage inevitable distortions during reformation, we introduce importance maps which allow controlling the error distribution and improving the overall visual quality in areas of elevated interest. Our method seamlessly integrates with well-established concepts such as the slice-based inspection of medical datasets and we believe it can improve the overall efficiency of many medical workflows. To demonstrate this, we additionally present an integrated visualization system and discuss several use cases that substantiate its benefits.

Digitization of medicine: how radiology can take advantage of the digital revolution

In the era of medical cost containment, radiologists must continually maintain their actual and perceived value to patients, payers, and referring providers. Exploitation of current and future digital technologies may be the key to defining and promoting radiology's "brand" and assure our continued relevance in providing predictive, preventive, personalized, and participatory medicine. The Association of University of Radiologists Radiology Research Alliance Digitization of Medicine Task Force was formed to explore the opportunities and challenges of the digitization of medicine that are relevant to radiologists, which include the reporting paradigm, computational biology, and imaging informatics. In addition to discussing these opportunities and challenges, we consider how change occurs in medicine, and how change may be effected in medical imaging community. This review article is a summary of the research of the task force and hopefully can be used as a stimulus for further discussions and development of action plans by radiology leaders.

Ultrasound imaging on picture archiving and communication systems: are radiologists satisfied?

OBJECTIVES

To evaluate whether picture archiving and communication systems (PACS) adequately satisfy radiologists' needs in ultrasound (US) imaging and which PACS functions may be inadequately implemented for handling US diagnosis.

METHODS

An electronic survey was sent to the membership of the Society of Radiologists in Ultrasound asking them to rate their PACS experience for different modalities, judge the quality of various PACS functions having an impact on US practice and diagnosis, indicate if they felt a need for US-related PACS functions to be implemented or improved, and rate PACS-related improvements for different components of their US practice.

RESULTS

Of the 161 respondents, 112 (70%) used a general radiology PACS. Of these respondents, only 53.2% gave a high rating to the US experience in PACS, significantly lower (P < .0001) than for computed tomography (85.2%), magnetic resonance imaging (84.4%), and radiography (83.2%). The functionality of US-specific display, image-processing, and data management PACS processes were graded significantly lower than basic PACS display functions. Only 0.9% of respondents highly rated PACS handling of 3-dimensional US volume data, whereas 92% highly rated the quality of the black-and-white US image display (P < .0001). Most respondents would like most of these US-specific functions implemented or improved, and most respondents stated that PACS has improved their US practice in different ways, although the contribution in more complex image analysis is lagging.

CONCLUSIONS

Radiologists with a special interest in US believe that the PACS experience for US is lacking. This research helps identify those specific tasks that may further improve work efficiency and diagnostic confidence.

Assessing task-technology fit in a PACS upgrade: do users' and developers' appraisals converge?

The purpose of this study was to measure users' perceived benefits of a picture archiving and communication system (PACS) upgrade, and compare their responses to those predicted by developers. The Task-Technology Fit (TTF) model served as the theoretical framework to study the relation between TTF, utilization, and perceived benefits. A self-administered survey was distributed to radiologists working in a university hospital undergoing a PACS upgrade. Four variables were measured: impact, utilization, TTF, and perceived net benefits. The radiologists were divided into subgroups according to their utilization profiles. Analysis of variance was performed and the hypotheses were tested with regression analysis. Interviews were conducted with developers involved in the PACS upgrade who were asked to predict impact and TTF. Users identified only a moderate fit between the PACS enhancements and their tasks, while developers predicted a high level of TTF. The combination of a moderate fit and an underestimation of the potential impact of changes in the PACS led to a low score for perceived net benefits. Results varied significantly among user subgroups. Globally, the data support the hypotheses that TTF predicts utilization and perceived net benefits, but not that utilization predicts perceived net benefits. TTF is a valid tool to assess perceived benefits, but it is important to take into account the characteristics of users. In the context of a technology that is rapidly evolving, there needs to be an alignment of what users perceive as a good fit and the functionality developers incorporate into their products.

Optimal presentation modes for detecting brain tumor progression

BACKGROUND AND PURPOSE

A common task in radiology interpretation is visual comparison of images. The purpose of this study was to compare traditional side-by-side and in-place (flicker) image presentation modes with advanced methods for detecting primary brain tumors on MR imaging.

MATERIALS AND METHODS

We identified 66 patients with gliomas and 3 consecutive brain MR imaging examinations (a "triplet"). A display application that presented images in side-by-side mode with or without flicker display as well as display of image subtraction or automated change detection information (also with and without flicker display) was used by 3 board-certified neuroradiologists. They identified regions of brain tumor progression by using this display application. Each case was reviewed using all modes (side-by-side presentation with and without flicker, subtraction with and without flicker, and change detection with and without flicker), with results compared via a panel rating.

RESULTS

Automated change detection with or without flicker (P < .0027) as well as subtraction with or without flicker (P < .0027) were more sensitive to tumor progression than side-by-side presentation in cases where all 3 raters agreed. Change detection afforded the highest interrater agreement, followed by subtraction. Clinically determined time to progression was longer for cases rated as nonprogressing by using subtraction images and change-detection images both with and without flicker display mode compared with side-by-side presentation.

CONCLUSIONS

Automated change detection and image subtraction, with and without flicker display mode, are superior to side-by-side image comparison.

Channelized Hotelling observers for the assessment of volumetric imaging data sets

Current clinical practice is rapidly moving in the direction of volumetric imaging. For two-dimensional (2D) images, task-based medical image quality is often assessed using numerical model observers. For three-dimensional (3D) images, however, these models have been little explored so far. In this work, first, two novel designs of a multislice channelized Hotelling observer (CHO) are proposed for the task of detecting 3D signals in 3D images. The novel designs are then compared and evaluated in a simulation study with five different CHO designs: a single-slice model, three multislice models, and a volumetric model. Four different random background statistics are considered, both gaussian (noncorrelated and correlated gaussian noise) and non-gaussian (lumpy and clustered lumpy backgrounds). Overall, the results show that the volumetric model outperforms the others, while the disparity between the models decreases for greater complexity of the detection task. Among the multislice models, the second proposed CHO could most closely approach the volumetric model, whereas the first new CHO seems to be least affected by the number of training samples.

Does improved access to diagnostic imaging results reduce hospital length of stay? A retrospective study

BACKGROUND

One year after the introduction of Information and Communication Technology (ICT) to support diagnostic imaging at our hospital, clinicians had faster and better access to radiology reports and images; direct access to Computed Tomography (CT) reports in the Electronic Medical Record (EMR) was particularly popular. The objective of this study was to determine whether improvements in radiology reporting and clinical access to diagnostic imaging information one year after the ICT introduction were associated with a reduction in the length of patients' hospital stays (LOS).

METHODS

Data describing hospital stays and diagnostic imaging were collected retrospectively from the EMR during periods of equal duration before and one year after the introduction of ICT. The post-ICT period was chosen because of the documented improvement in clinical access to radiology results during that period. The data set was randomly split into an exploratory part used to establish the hypotheses, and a confirmatory part. The data was used to compare the pre-ICT and post-ICT status, but also to compare differences between groups.

RESULTS

There was no general reduction in LOS one year after ICT introduction. However, there was a 25% reduction for one group - patients with CT scans. This group was heterogeneous, covering 445 different primary discharge diagnoses. Analyses of subgroups were performed to reduce the impact of this divergence.

CONCLUSION

Our results did not indicate that improved access to radiology results reduced the patients' LOS. There was, however, a significant reduction in LOS for patients undergoing CT scans. Given the clinicians' interest in CT reports and the results of the subgroup analyses, it is likely that improved access to CT reports contributed to this reduction.

[PACS: acceptance by orthopedic surgeons]

PURPOSE

The goal of the study was to evaluate the acceptance of a web-based picture archiving and communication system (PACS) by orthopedic surgeons 1 year after implementation.

MATERIALS AND METHODS

One year after the implementation of a web-based PACS all physicians were surveyed with a standardized questionnaire. Questions included: speed of PACS, quality of clinicoradiological meetings, quality of monitors, PACS training, and performance. Data were evaluated separately for the Department of Orthopedic Surgery and the reference group of all other physicians.

RESULTS

Among the respondents, 92% of the orthopedic surgeons stated there was a reduction of time required to receive images, and 64% concluded that patient care was faster. Archived images were received in less than 5 min in 82% after PACS and in 8% before PACS. The clinicoradiological meetings improved with PACS in 100% due to beamer presentation. All would recommend a PACS. The equipment to view images in the operating theater was assessed as being good or very good by 83%; monitor quality was judged better for the outpatient clinics (100% good or very good). Conventional radiograms were missed at the ward rounds by 56%. Training for PACS was considered sufficient by 67%, and 15% asked for refresher courses. In the reference group 60% asked for refresher courses. In the comparison of orthopedic surgeons with the reference group PACS was judged better especially concerning the viewing software and quality of monitors.

CONCLUSION

There is an over all acceptance of PACS by physicians outside the radiology department. The availability of images was not only facilitated it was faster as well. However, the quality of monitors in the operating theater should be improved. To achieve sustained success of PACS consistent training on PACS and its features is necessary. Conventional radiograms were often missed at the ward rounds.

Digital imaging data on CD-R: a time trap for orthopaedic surgeons in outpatient clinics

PURPOSE

X-rays are presented on CD-Rs in a digital format with increasing frequency. This technique is potentially more time-consuming for the clinician compared to conventional pictures.

METHODS

Ten sets of six X-rays for each case were prepared in both the conventional way and in digital format on CD-R. The order was randomised. Time in seconds was measured for six experienced orthopaedic residents to present the most recent a.p. view out of a given set. As a precondition, the computer was turned on and the same viewing software was used for all digital sets. The results were compared using a non-linked Student's t-test (significance level P = 0.05).

RESULTS

The presentation of conventional X-rays required 21 s (+/-7.5 s) and of digital X-rays 90 s (+/-27 s), respectively (P < 0.001).

CONCLUSION

In spite of ideal conditions, digital X-rays on CD-R need significantly more time in the orthopaedic clinic. In major centres, patients present with different software and software in other languages, which increase the required time even further. This latter problem will be assessed in another study. This increase of preparation time required by a highly qualified staff member has implications on the economics and logistics and has a negative impact on daily clinical practice. One of the solutions might be that the CD-Rs be given to the registration desk and the data being already prepared when the patient sees the doctor. This can also include it being implemented in the digital system used in the inpatient part of the hospital and, therefore, making any other consultations or second opinions easily accessible.

High-resolution esophageal manometry: a time motion study

INTRODUCTION

High-resolution manometry (HRM) of the esophagus is a new technique that provides a more precise assessment of esophageal motility than conventional techniques. Because HRM measures pressure events along the entire length of the esophagus simultaneously, clinical procedure time should be shorter because less catheter manipulation is required. According to manufacturer advertising, the new HRM system is more accurate and up to 50% faster than conventional methods.

OBJECTIVE

To test the hypothesis that clinical testing with HRM requires less procedural time than a standard water perfusion (WP) method.

METHODS

Forty-one consecutive patients were studied (20 underwent WP and 21 underwent HRM). Using time-motion analysis, the start and end times for each task associated with performing the study were recorded. Patient discomfort and study quality were also assessed by using five- and four-point qualitative scales, respectively.

RESULTS

Total procedure time was reduced on average by 25.6% in the HRM group (from 41.8 minutes with WP to 30.7 minutes with HRM, P<0.05). There was no significant difference in the discomfort scores reported by the study subjects and no difference in study quality.

CONCLUSIONS

HRM requires less time to complete than conventional manometry and should therefore shorten the wait-times of patients scheduled for esophageal manometry and have a significant impact on the cost of performing this commonly used clinical investigation.

Is targeted reconstruction necessary for evaluating contrast-enhanced chest computed tomography using a liquid crystal display monitor?

PURPOSE

The aim of this study was to examine whether 20-cm field-of-view (FOV) targeted reconstruction (TR) on contrast-enhanced (CE) chest computed tomography (CT) might improve the diagnostic value compared with simple zooming (SZ) from whole-thorax FOV images using a 2 million (2M)-pixel liquid crystal display (LCD) monitor.

MATERIALS AND METHODS

We prospectively evaluated 44 patients. SZ images were magnified from a FOV of 26-34 cm (mean 29.7 cm). Parameters were 512 x 512 matrix and 3 mm thickness and interval. Images were reconstructed using a soft-tissue kernel. Three radiologists evaluated contour, spiculation, notch, pleural tag, invasion, and internal characteristics of the lesions using 5-scale scores. We also performed a phantom study to evaluate the spatial resolution of images.

RESULTS

The diagnostic value of the TR images was similar to that of the SZ images, with the findings identified in 88%-100% of the cases. Artifacts from high-density structures deteriorated the image quality in six (14%), and the SZ images were judged to be preferable in five of them. In the phantom study, there was little difference in spatial resolution between the two images.

CONCLUSION

The SZ images from whole-thorax FOV on CE chest CT were similar in quality to TR images using a 2M-pixel LCD monitor.

Comparison of navigation techniques for large digital images

Medical images are examined on computer screens in a variety of contexts. Frequently, these images are larger than computer screens, and computer applications support different paradigms for user navigation of large images. The paper reports on a systematic investigation of what interaction techniques are the most effective for navigating images larger than the screen size for the purpose of detecting small image features. An experiment compares five different types of geometrically zoomable interaction techniques, each at two speeds (fast and slow update rates) for the task of finding a known feature in the image. There were statistically significant performance differences between several groupings of the techniques. The fast versions of the ArrowKey, Pointer, and ScrollBar performed the best. In general, techniques that enable both intuitive and systematic searching performed the best at the fast speed, while techniques that minimize the number of interactions with the image were more effective at the slow speed. Additionally, based on a postexperiment questionnaire and qualitative comparison, users expressed a clear preference for the Pointer technique, which allowed them to more freely and naturally interact with the image.

Image browsing in slow medical liquid crystal displays

RATIONALE AND OBJECTIVES

Statistics show that radiologists are reading more studies than ever before, creating the challenge of interpreting an increasing number of images without compromising diagnostic performance. Stack-mode image display has the potential to allow radiologists to browse large three-dimensional (3D) datasets at refresh rates as high as 30 images/second. In this framework, the slow temporal response of liquid crystal displays (LCDs) can compromise the image quality when the images are browsed in a fast sequence.

MATERIALS AND METHODS

In this article, we report on the effect of the LCD response time at different image browsing speeds based on the performance of a contrast-sensitive channelized-hoteling observer. A stack of simulated 3D clustered lumpy background images with a designer nodule to be detected is used. The effect of different browsing speeds is calculated with LCD temporal response measurements from our previous work. The image set is then analyzed by the model observer, which has been shown to predict human detection performance in Gaussian and non-Gaussian lumpy backgrounds. This methodology allows us to quantify the effect of slow temporal response of medical liquid crystal displays on the performance of the anthropomorphic observers.

RESULTS

We find that the slow temporal response of the display device greatly affects lesion contrast and observer performance. A detectability decrease of more than 40% could be caused by the slow response of the display.

CONCLUSIONS

After validation with human observers, this methodology can be applied to more realistic background data with the goal of providing recommendations for the browsing speed of large volumetric image datasets (from computed tomography, magnetic resonance, or tomosynthesis) when read in stack-mode.

Picture, archiving and communication system in the Italian NHS: a primer on diffusion and evaluation analysis

This contribution focuses on picture archiving and communication systems (PACS) in the Italian National Healthcare System (NHS). It finally aims to test the Chiefs Radiology Department's perceptions about PACS along the main evaluation dimensions emerging from the literature. First, a brief review of the main literature concerning PACS evaluation leads the authors to classify the different approaches undertaken and highlight the main variables of investigation. Second, the evidence emerging from a survey is presented and discussed in the light of the literature review. The survey aims to: (a) map out the degree of PACSs diffusion and their main features in the Italian NHS; (b) verify whether and how PACS impact the dimensions analyzed in many evaluation studies carried out to date; (c) test the relationship between some measured impacts and specific PACS features.

Ergonomics evaluation of Picture Archiving and Communication System implementations in two X-ray departments

Two large X-ray departments in the County of Stockholm have changed from traditional analogue technology to digital imaging, including the implementation of Picture Archiving and Communication Systems (PACS). One of the departments was moved to a completely new purpose-built building and equipped with the latest technology, but for the other one the change merely meant rebuilding and adaptation of existing rooms on the premises. The objectives of the present study were to evaluate the ergonomics effects of the new technique in the two X-ray departments and to find out whether the implementation of digital imaging technique came up to expectations of improved ergonomics and work environment. Another purpose was to compare the outcomes for the two departments, in order to learn about the importance of the different implementation approaches. Questionnaires were sent out to the two departments both before the implementation of PACS and after the transition. The questionnaires covered several aspects of work conditions, such as working time, the physical and psychosocial environment, physical work load and musculoskeletal complaints, expectations from the digital technology, etc. The changeover went better than expected and even high expectations were fulfilled and surpassed. However, there were also some unexpected and distressing results; for example, a substantial increase in headaches and musculoskeletal symptoms as well as the use of pain killers among the radiologists of one of the X-ray departments.

Optimizing physicians' instruction of PACS through e-learning: cognitive load theory applied

This article outlines the strategy used by our hospital to maximize the knowledge transfer to referring physicians on using a picture archiving and communication system (PACS). We developed an e-learning platform underpinned by the cognitive load theory (CLT) so that in depth knowledge of PACS' abilities becomes attainable regardless of the user's prior experience with computers. The application of the techniques proposed by CLT optimizes the learning of the new actions necessary to obtain and manipulate radiological images. The application of cognitive load reducing techniques is explained with several examples. We discuss the need to safeguard the physicians' main mental processes to keep the patient's interests in focus. A holistic adoption of CLT techniques both in teaching and in configuration of information systems could be adopted to attain this goal. An overview of the advantages of this instruction method is given both on the individual and organizational level.

Display considerations for quantitative radiology

The early prediction of the response to treatment using quantitative imaging holds great promise for streamlining the development, assessment, approval and personalization of new therapies. However, to realize this potential, quantitative radiology needs to develop an understanding of several limitations that might hinder the application of quantitation tools and techniques. Among these limitations, the fidelity of the display device used to interpret the image data is a significant factor that affects the accuracy and precision of quantitative visual tasks, particularly those involving large, volumetric, multi-dimensional and multi-modality image sets. This paper reviews several aspects of display performance and display image quality that are likely to contribute negatively to the robustness of quantitative imaging methods. Display characteristics that will be addressed include the grayscale and color performance of different classes of display devices, the angular distribution of the emissions of liquid crystal technologies, and the temporal response for stack mode viewing. The paper will also summarize current efforts for the metrology, standardization and image quality assessment methods for display devices.:

Impact of PACS on dictation turnaround time and productivity

This study was conducted to measure the impact of PACS on dictation turnaround time and productivity. The radiology information system (RIS) database was interrogated to calculate the time interval between image production and dictation for every exam performed during three 90-day periods (the 3 months preceding PACS implementation, the 3 months immediately following PACS deployment, and a 3-month period 1 year after PACS implementation). Data were obtained for three exam types: chest radiographs, abdominal CT, and spine MRI. The mean dictation turnaround times obtained during the different pre- and post-PACS periods were compared using analysis of variance (ANOVA). Productivity was also determined for each period and for each exam type, and was expressed as the number of studies interpreted per full-time equivalent (FTE) radiologist. In the immediate post-PACS period, dictation turnaround time decreased 20% (p < 0.001) for radiography, but increased 13% (ns) for CT and 28% (p < 0.001) for MRI. One year after PACS was implemented, dictation turnaround time decreased 45% (p < 0.001) for radiography and 36% (p < 0.001) for MRI. For CT, 1 year post-PACS, turnaround times returned to pre-PACS levels. Productivity in the immediate post-PACS period increased 3% and 38% for radiography and CT, respectively, whereas a 6% decrease was observed for MRI. One year after implementation, productivity increased 27%, 98%, and 19% in radiography, CT, and MRI, respectively. PACS benefits, namely, shortened dictation turnaround time and increased productivity, are evident 1 year after PACS implementation. In the immediate post-PACS period, results vary with the different imaging modalities.

Development and validation of queries using structured query language (SQL) to determine the utilization of comparison imaging in radiology reports stored on PACS

The purpose of this research was to develop queries that quantify the utilization of comparison imaging in free-text radiology reports. The queries searched for common phrases that indicate whether comparison imaging was utilized, not available, or not mentioned. The queries were iteratively refined and tested on random samples of 100 reports with human review as a reference standard until the precision and recall of the queries did not improve significantly between iterations. Then, query accuracy was assessed on a new random sample of 200 reports. Overall accuracy of the queries was 95.6%. The queries were then applied to a database of 1.8 million reports. Comparisons were made to prior images in 38.69% of the reports (693,955/1,793,754), were unavailable in 18.79% (337,028/1,793,754), and were not mentioned in 42.52% (762,771/1,793,754). The results show that queries of text reports can achieve greater than 95% accuracy in determining the utilization of prior images.

Impact of PACS deployment strategy on dictation turnaround time of chest radiographs

RATIONALE AND OBJECTIVES

The aim of the study is to measure the impact of a picture archive and communication system (PACS) on dictation turnaround time of chest radiographs in a multisite hospital and relate variations across sites to local factors and implementation strategy.

MATERIALS AND METHODS

The multisite hospital is composed of three sites. Dictation turnaround time was calculated by using data obtained from the radiology information system for examinations performed during three 90-day periods (immediately before PACS implementation, immediately after PACS implementation, and 1 year after implementation). Productivity, expressed as number of examinations dictated per full-time-equivalent radiologist, also was calculated. For each 3-month period, average interval delay was calculated. Values for average interval delay obtained during the different pre- and post-PACS periods were compared by using analysis of variance. This was done for each hospital.

RESULTS

In the immediate post-PACS period at site 1, dictation turnaround time decreased 5% (P < .05), whereas productivity decreased 16.5%. The implementation strategy was revised for the next two sites, and dictation turnaround time decreased 21% (P < .001) in both sites in the immediate post-PACS period. Productivity increased 2% and 3% in these sites. One year after implementation, decreases in turnaround ranged from 28% to 55% (P < .001) in the three sites.

CONCLUSION

Our experience suggests that PACSs cannot be isolated from their contexts; therefore, implementation strategy matters in the realization of projected benefits. In addition, regardless of differences in film-based environments before PACS, all three sites benefited from conversion to filmless operation, with the greatest benefits seen in the site that was least efficient before implementation.

The academic radiologist's clinical productivity: an update

RATIONALE AND OBJECTIVES

The purpose of this project was to further understand the academic radiologist's clinical workload with comparison to the prior studies in the past decade. This updated data is very important in determining faculty staffing requirements.

MATERIALS AND METHODS

A survey performed by the Society of Chairmen of Academic Radiology Departments (SCARD) collected data in 2003 for radiologists in 23 departments. This data included Current Procedure Terminology (CPT) codes by radiologist. The CPT codes were converted into relative value units (RVUs) per full-time equivalent (FTE) faculty. By grouping the CPT codes into similar examination categories, adjustment factors were created for the RVU values for each CPT in order to compensate for workload variations. These adjustment factors are identical to the adjustments made in 2001 except for a new factor for nuclear medicine.

RESULTS

Overall, the average clinical workload in 2003 was 5,872 RVU/FTE, a 32% increase compared to 4,458 RVU/FTE in 1998 and 55% increase compared to 3,790 RVU/FTE in 1996. The average number of examinations per FTE had a smaller (17%) increase since 1998. The adjustment factors remain very similar to those presented in 2001. The only change was a new adjustment factor of 1.3 for nuclear medicine.

CONCLUSIONS

Clinical workload as measured by RVU/FTE and adjusted RVU/FTE are very useful for determining optimal staffing in subspecialty sections and in the department as a whole. The workload continues to increase, but more in examination complexity than in numbers of procedures overall.

Ergonomics of digital imaging

There has been an increase in the use of digital imaging in recent years and radiologists have almost universally accepted the use of computers in their day-to-day work. Completely filmless radiology departments, with all reporting being done on visual display terminals and picture archiving and communications systems (PACS) around the department, are already a reality in many places in the UK and other parts of the world. There is a constant need of computers for literature searches on the web, e-mails, communication and preparing lectures and presentations. With this explosive increase in the use of computers in the hospital, it is imperative that the use of computer monitor screens for medical use is optimized in order to avoid eyestrain and fatigue. This is especially important as tired eyes and brains may be more likely to commit errors. We have reviewed the current literature to elaborate a few useful measures that can be taken to minimize the effect of excessive computer use in a soft-copy radiology reporting area on the eyes and the musculoskeletal system. We recommend that optimal placement of computer monitors with user-friendly PACS terminal interfaces will ensure greater acceptability and improve reporting efficiency and accuracy. Good work practices to ensure reduction of reporting errors are highlighted.

Multislice CT of the abdomen

Major advances have been made in CT technology since its introduction 30 years ago. Examination time has been markedly reduced and it is possible to cover considerably larger scan ranges. Multidetector technology now allows near isotopic imaging with the ability to perform high quality multiplanar reconstructions. It is also now possible to image in well defined vascular phases. In this article we share our experience in the use of multislice CT and detail protocols used in imaging of the abdomen.

Picture Archiving and Communication System Introduced to a New Japanese Cancer Center Hospital

Picture archiving and communication systems (PACS) have been widely introduced as a credible alternative to the traditional film-based radiological service. Shizuoka Cancer Center Hospital (SCCH) introduced PACS and hospital information systems as an alternative to the film- and traditional paper-based hospital system at the opening of the hospital. Using PACS, whole images and their reports can be available at any nearby terminal. Users can select the display format for monitor viewing on the bases of individual preference and navigate through cases by buttons and rollerballs on the mouse with easy handling and quick response. Most clinicians in SCCH evaluated such medical circumstances well. Filmless image management systems will become popular in all hospitals in the near feature. All staff in each hospital should investigate the merits and demerits of this system and how to introduce it effectively.

Multi-detector computed tomography and 3-dimensional imaging in a multi-vendor picture archiving and communications systems (PACS) environment

RATIONALE AND OBJECTIVES

To show the impact of the introduction of multi-detector computed tomography (CT) on radiologic workflow and to demonstrate how this reflects on picture archiving and communications systems (PACS) requirements.

MATERIALS AND METHODS

Production measurements were obtained from different CT scanners (first two single-slice CT scanners; from December 2001 single and 4-slice CT; from April 2002 single and 16-slice CT) in number of patients from the radiologic information system. Implications on our PACS were recorded in terms of images and studies stored. Furthermore, our PACS design was made so that optimal use of 3-dimensional imaging within the radiologic workflow was possible. Finally, the number of non-diagnosed studies were recorded every day since the start of the transition to a filmless radiology department.

RESULTS

This PACS design achieved a high level of integration between simple viewing and advanced 3-dimensional imaging and is optimized for handling large amounts of data. Overall increase of patients scanned with CT from January 2002-December 2003 was 54%. The number of series increased by 286% from December 2001-April 2003 and by 130% from April 2002-December 2003. From January 2002-February 2003, the number of images per patient increased from 175 to 450 (157%). Non-diagnosed studies decreased from about 100-120 before to practically zero after PACS implementation.

CONCLUSION

PACS significantly increases productivity because of availability of the images and elimination of certain manual tasks. These results show that although the amount of examinations increases significantly with the introduction of MDCT, simultaneous introduction of PACS and filmless operation allows radiologists to handle the growth in workload.

Importance and Effects of Altered Workplace Ergonomics in Modern Radiology Suites

The transition from a film-based to a filmless soft-copy picture archiving and communication system (PACS)-based environment has resulted in improved work flow as well as increased productivity, diagnostic accuracy, and job satisfaction. Adapting to this filmless environment in an efficient manner requires seamless integration of various components such as PACS workstations, the Internet and hospital intranet, speech recognition software, paperless electronic hospital medical records, e-mail, office software, and telecommunications. However, the importance of optimizing workplace ergonomics has received little attention. Factors such as the position of the work chair, workstation table, keyboard, mouse, and monitors, along with monitor refresh rates and ambient room lighting, have become secondary considerations. Paying close attention to the basics of workplace ergonomics can go a long way in increasing productivity and reducing fatigue, thus allowing full realization of the potential benefits of a PACS. Optimization of workplace ergonomics should be considered in the basic design of any modern radiology suite.

PACS adoption

Once the decision has been made to adopt PACS instead of a film-based radiology practice, there are a number of hurdles to jump. Users need to be aware of the impact the change will make on end users and be prepared to address issues that arise before they become problems. Someone who understands the technology of PACS must be identified to help make an informed decision about vendor selection, network architecture, workstation functionality, and archives. A PACS administrator should have the tools available to avoid problems with the system after implementation and should be able to repair the inevitable mistakes that will happen. Hopefully, this article can serve as a starting point for a potential new PACS adoption.

Evolution of the digital revolution: a radiologist perspective

The transformation from film-based to filmless operation has become more and more challenging, as imaging studies expand in size and complexity. To adapt to these changes, radiologists must proactively develop new workflow strategies to compensate for increasing work demands and the existing workforce shortage. This article addresses the evolutionary changes underway in the radiology interpretation process and reviews changes that have occurred in the past decade. These include a number of developments in soft-copy interpretation, which is migrating from a relatively static process, duplicating film-based interpretation, to a dynamic process, using multi-planar reconstructions, volumetric navigation, and electronic decision support tools. The result is optimization of the human-computer interface with improved productivity, diagnostic confidence, and interpretation accuracy.

Usefulness of coronal reformations in the diagnostic evaluation of infiltrative lung disease

PURPOSE

To evaluate the diagnostic accuracy of coronal thin sections as an alternative to transverse high-resolution computed tomography (HRCT) scans in the diagnostic approach to infiltrative lung disease (ILD) with multislice computed tomography (MSCT).

MATERIALS AND METHODS

Fifty consecutive patients referred for suspicion of ILD underwent MSCT (collimation: 4 mm x 1 mm; pitch: 1.75; scan time: 0.5 seconds; 80 mA per slice) of the entire thorax. Two sets of lung images were systematically reconstructed: 1-mm thick transverse computed tomography (CT) scans (i.e., HRCT scans) (group 1) and 1-mm thick coronal images (group 2). Both series of images were obtained at 10-mm intervals and reconstructed with a high-spatial frequency algorithm. Two observers independently analyzed the overall image quality, the presence and distribution of CT features of ILD, and the diagnostic value of group 1 and group 2 lung images.

RESULTS

Group 1 and group 2 images were coded as interpretable, with minimal respiratory artifacts in the lower lung zones in two cases (4%). Presence of abnormal lung infiltration was found in 38 patients in group 2 with concordant interpretation of group 1 images. No significant difference was found in the identification of CT features of ILD between group 2 and group 1 (nodules: 32% vs. 30%; lines: 14% vs. 16%; increased attenuation: 24% vs. 26%; fibrosis: 48% vs. 50%; distortion: 46% vs. 50%; and abnormal interfaces: 16% in both groups). Distribution of lung abnormalities in central, peripheral, anterior, and/or posterior lung zones was similarly recognized in group 2 and group 1. In patients with extensive lung infiltration, the vertical predominance of lung changes was more precisely assessed in group 2 (n = 12) than in group 1 (n = 4). For a mean coverage of 260 mm in this study group, the mean number of sections to be interpreted was significantly lower in group 2 (19 sections) than in group 1 (28 sections) (P < 0.01).

CONCLUSION

Coronal sections allow a diagnostic approach to ILD as precise as that provided with HRCT scans, based on the interpretation of a significantly reduced number of images.

Effect of filmless imaging on utilization of radiologic services with a two-stage, hospital-wide implementation of a picture archiving and communication system: initial experience of a fee-for-service model

A medium-sized general hospital using a fee-for-service model implemented a hospital-wide picture archiving and communication system (PACS) in two stages. This study evaluated the reporting time with filmless operation and the effect of filmless imaging on referring physicians' use of the radiologic service before and after completion of the second stage of PACS implementation. The relationship between the total number of hospital patients and the number of radiologic department patients was also evaluated. All sample images were retrieved from the PACS. All corresponding reports except for one for a computerized tomography study were available. The median reporting time for different studies performed during working hours was less than 2 hours. There was a significantly positive and linear relationship (p < 0.01) between the total number of hospital patients and the number of radiologic department patients after hospital-wide implementation of PACS. We conclude that the fee-for-service model had no negative impact on referring physicians' use of radiologic services in a filmless hospital.