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Purpose: The aim of this study was to assess appropriateness scoring and structured order entry after the implementation of an artificial intelligence (AI) tool for analysis of free-text indications., Methods: Advanced outpatient imaging orders in a multicenter health care system were recorded 7 months before (March 1, 2020, to September 21, 2020) and after (October 20, 2020, to May 13, 2021) the implementation of an AI tool targeting free-text indications. Clinical decision support score (not appropriate, may be appropriate, appropriate, or unscored) and indication type (structured, free-text, both, or none) were assessed. The χ 2 and multivariate logistic regression adjusting for covariables with bootstrapping were used., Results: In total, 115,079 orders before and 150,950 orders after AI tool deployment were analyzed. The mean patient age was 59.3 ± 15.5 years, and 146,035 (54.9%) were women; 49.9% of orders were for CT, 38.8% for MR, 5.9% for nuclear medicine, and 5.4% for PET. After deployment, scored orders increased to 52% from 30% (P < .001). Orders with structured indications increased to 67.3% from 34.6% (P < .001). On multivariate analysis, orders were more likely to be scored after tool deployment (odds ratio [OR], 2.7, 95% CI, 2.63-2.78; P < .001). Compared with physicians, orders placed by nonphysician providers were less likely to be scored (OR, 0.80; 95% CI, 0.78-0.83; P < .001). MR (OR, 0.84; 95% CI, 0.82-0.87) and PET (OR, 0.12; 95% CI, 0.10-0.13) were less likely to be scored than CT (; P < .001). After AI tool deployment, 72,083 orders (47.8%) remained unscored, 45,186 (62.7%) with free-text-only indications., Conclusions: Embedding AI assistance within imaging clinical decision support was associated with increased structured indication orders and independently predicted a higher likelihood of scored orders. However, 48% of orders remained unscored, driven by both provider behavior and infrastructure-related barriers., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Quality patient care and advancements in medical education, investigation, and innovation require effective teamwork. High-functioning teams navigate stressful environments, learning openly from failures and leveraging successes to fuel future initiatives. The authors review foundational concepts for implementing and sustaining successful teams, including emotional intelligence, trust, inclusivity, clear communication, and accountability. Focus is given to real-world examples and actionable, practical solutions., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to scale structured report templates categorizing actionable renal findings across health systems and create a centralized registry of patient and report data., Methods: In January 2017, three academic radiology departments agreed to prospectively include identical structured templates categorizing the malignant likelihood of renal findings in ≥90% of all adult ultrasound, MRI, and CT reports, a new approach for two sites. Between November 20, 2017, and September 30, 2019, deidentified HL7 report data were transmitted to a centralized ACR registry. An automated algorithm extracted categories. Radiologists were requested to addend reports with missing or incomplete templates after the first month. Separately, each site submitted patient sociodemographic and clinical data 12 months before and at least 3 months after enrollment., Results: A total of 164,982 eligible radiology reports were transmitted to the registry; 4,159 (2.5%) were excluded because of missing categories or radiologist names. The final cohort included 160,823 examinations on 102,619 unique patients. Mean template use before and after addendum requests was 99.3% and 99.9% at SITE1, 86.5% and 94.6% at SITE2, and 91.4% and 96.0% at SITE3. Matching patient sociodemographic and clinical data were obtained on 96.9% of reports from SITE1, 94.2% from SITE2, and 96.0% from SITE3. Regulatory, cultural, and technology barriers to the creation of a multisite registry were identified., Conclusions: Barriers to the adoption of unified structured report templates for actionable kidney findings can be addressed. Deidentified report and patient data can be securely transmitted to an external registry. These data can facilitate the collection of diverse evidence-based population imaging outcomes., (Published by Elsevier Inc.)

Purpose: The aim of this study was to evaluate the effect of Pennsylvania Act 112 notification reading level and presentation on patient understanding and anxiety., Methods: Four notifications were developed by alternating 12th grade and 6th grade reading level Act 112 language with letters or infographics. Using Amazon Mechanical Turk, 909 US adult volunteers were randomly assigned to one notification followed by a survey. Participants who answered all 12 survey questions on understanding, anxiety, and sociodemographics were paid $0.10. Chi-square analysis and multivariate regression were used to determine the impact of notification type and sociodemographic data on understanding of communicated information and anxiety., Results: Sixty percent of participants (489 of 821) correctly understood all three questions directly answered within notifications regarding Act 112 subject, next steps, and process for obtaining reports. Approximately half of respondents understood that notifications indirectly conveyed "definitely" or "possibly" abnormal test results (344 of 821 [42%] and 99 of 821 [12%], respectively). Compared with the 12th grade letter, correct understanding of all directly communicated information was lower with the 12th grade infographic after adjustment (odds ratio, 0.61; 95% confidence interval, 0.39-0.95; P = .028) and equivalent with the 6th grade infographic and letter (P = .744 and P = .316). Correct indirect understanding of abnormal test results was not associated with notification type after adjustment but was associated with higher anxiety (odds ratio, 2.86; 95% confidence interval, 0.57-1.35; P < .001)., Conclusions: Layperson understanding of information directly and indirectly communicated in Pennsylvania Act 112 is suboptimal, regardless of reading level or presentation. New Act 112 language is needed to improve patient understanding, which would ideally be coproduced with Pennsylvania patients, policymakers, and other relevant stakeholders., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: The Protecting Access to Medicare Act of 2014 requires clinicians to consult Appropriate Use Criteria (AUC) when ordering advanced imaging procedures. Free-text order indications are available when there is no applicable structured indication but are unscored by the AUC. We determined the proportion of free-text indications among all advanced imaging orders and the proportion of free-text indications that could be mapped to a single structured indication., Methods: All outpatient advanced diagnostic imaging orders placed in a large multisite health system were recorded after initial AUC deployment (November 20, 2017, to December 19, 2017). Clinicians were prompted upon order entry to select a structured indication or enter a free-text indication. We manually reviewed the two imaging examinations with the highest rate of free-text indications: enhanced CT abdomen/pelvis and unenhanced CT head. Regression analysis examined differences in patient-, imaging-, context-, and provider-level characteristics between scored and unscored examinations., Results: Among all 39,533 orders for advanced imaging procedures, 59% (23,267 of 39,533) were unscored by the system. The regression model c-statistic (0.50-0.55) demonstrated poor model fit to evaluate for differences between scored and unscored examinations. Free-text indications were found in 71% (16,440 of 23,267) of unscored examinations and 42% (16,440 of 39,533) of all examinations. Manual review of all 1,693 CT abdomen/pelvis and 1,527 CT head examinations with free-text indications revealed that 3,132 free-text indications (97%) could be mapped to a single existing structured indication., Discussion: Of all initially placed outpatient advanced imaging procedure orders, 42% included free-text indications and 97% of manually reviewed free-text indications could be mapped to a single structured indication., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Objective: Pennsylvania Act 112 requires diagnostic imaging facilities to directly notify outpatients about significant imaging abnormalities that require follow-up care within 3 months. The effects of Act 112 on patient care are unclear. We sought to characterize follow-up discussions and care received by outpatients with significant imaging abnormalities as defined by Act 112., Methods: We evaluated findings flagged for patient notification under Act 112 at our institution over a 1-month period. We analyzed findings for radiologic reporting, follow-up discussions between patients and ordering providers, and follow-up medical care provided., Results: Follow-up discussions were documented for 87% of findings (n = 205 of 235) and occurred on average 6.0 days after imaging examinations were performed. Follow-up discussions directly attributable to the Act 112 letter occurred in 0.4% of findings. Follow-up care was provided for 74% of findings on average 31.3 days after imaging examinations were performed. Provider-initiated follow-up discussions occurred earlier and were associated with shorter time to follow-up care when compared with patient-initiated discussions. Direct contact of ordering provider by interpreting radiologist was a significant predictor of occurrence of follow-up discussions and length of time to follow-up care., Discussion: Act 112 had a small impact at our institution on improving completed follow-up for abnormal imaging findings. Our results also imply that health systems should encourage timeliness of patient-provider discussions of abnormal imaging findings and facilitate direct radiologist communication with ordering providers. Future studies should evaluate the impact of Act 112 in different practice settings to understand its broader impact on follow-up care., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the relationship between patient location at time of imaging and completion of relevant imaging follow-up for findings with indeterminate malignant potential., Methods: We used a mandatory hospital-wide standardized assessment categorization system to analyze all ultrasound, CT, and MRI examinations performed over a 7-month period. Multivariate logistic regression, adjusted for imaging modality, characteristics of patients, ordering clinicians, and interpreting radiologists, was used to evaluate the relationship between patient location (outpatient, inpatient, or emergency department) at the time of index examination and completion of relevant outpatient imaging follow-up., Results: Relevant follow-up occurred in 49% of index examinations, with a greater percentage among those performed in the outpatient setting compared with those performed in the inpatient or emergency department settings (62% versus 18% versus 17%, respectively). Compared with examinations obtained in the outpatient setting, examinations performed in the emergency department (adjusted odds ratio [aOR] 0.07; 95% confidence interval [CI], 0.03-0.19) and inpatient (aOR 0.14; 95% CI, 0.09-0.23) settings were less likely to be followed up. Black patients and those residing in lower-income neighborhoods were also less likely to receive relevant follow-up. Few lesions progressed to more suspicious lesions (4.6%)., Conclusions: Patient location at time of imaging is associated with the likelihood of completing relevant follow-up imaging for lesions with indeterminate malignant potential. Future work should evaluate health system-level care processes related to care setting, as well as their effects on appropriate follow-up imaging. Doing so would support efforts to improve appropriate follow-up imaging and reduce health care disparities., (Copyright © 2018 American College of Radiology. All rights reserved.)

Purpose: The aims of this study were to examine the association between radiologist-initiated verbal communication for abdominal imaging findings indeterminate for malignancy and receipt of relevant outpatient follow-up imaging and to evaluate the proportion of findings that progress from indeterminate to suspicious for malignancy., Methods: Using a mandatory standardized assessment coding system, 727 eligible outpatient abdominal CT, MRI, and ultrasound studies performed between July 1, 2013, and January 31, 2014, were identified. Multivariate logistic regression was used to evaluate the association between radiologist-initiated verbal communication and receipt of relevant outpatient imaging follow-up, adjusted for patient, ordering physician, interpreting radiologist, and imaging variables., Results: Sixty-two percent of patients (451 of 727) with imaging findings indeterminate for malignancy received relevant outpatient imaging follow-up. Radiologist-initiated verbal communication occurred in 4.8% of cases (35 of 727). Radiologist-initiated verbal communication (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.02-5.87) and existing cancer diagnosis (OR, 3.00; 95% CI, 2.11-4.26) were associated with a higher likelihood of receiving relevant imaging follow-up. Compared with those whose imaging studies were ordered by clinicians in a medical specialty, patients with studies ordered by clinicians in surgical (OR, 0.70; 95% CI, 0.49-0.99) or other (OR, 0.44; 95% CI, 20.24-0.83) specialties were less likely to receive relevant imaging follow-up. Progression of findings from indeterminate to suspicious for malignancy occurred in 5.4% of cases and was not associated with radiologist-initiated verbal communication., Conclusions: Radiologist-initiated verbal communication increases the likelihood that patients receive outpatient imaging follow-up for abdominal findings indeterminate for malignancy. Progression of these findings is relatively infrequent., (Copyright © 2018 American College of Radiology. All rights reserved.)

Purpose: To explore quantitative differences between genders in morphologic colonic metrics and determine metric reproducibility., Methods: Quantitative colonic metrics from 20 male and 20 female CTC datasets were evaluated twice by two readers; all exams were performed after incomplete optical colonoscopy. Intra-/inter-reader reliability was measured with intraclass correlation coefficient (ICC) and concordance correlation coefficient (CCC)., Results: Women had overall decreased colonic volume, increased tortuosity and compactness and lower sigmoid apex height on CTC compared to men (p<0.0001,all). Quantitative measurements in colonic metrics were highly reproducible (ICC=0.9989 and 0.9970; CCC=0.9945)., Conclusion: Quantitative morphologic differences between genders can be reproducibility measured., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Surveillance PET after curative-intent treatment of non-small-cell lung cancer (NSCLC) or colorectal cancer (CRC) is not clearly supported by available evidence or the Choosing Wisely campaign. However, the frequency of PET imaging during the surveillance period is relatively unknown., Methods: Using Surveillance, Epidemiology, and End Results-Medicare data, 65,748 patients aged 66 years or older who were diagnosed with stage I to IIIA NSCLC or stage I to III CRC from 2001 through 2009 and who underwent surgical resection were identified. Trends in "any PET" or "PET-only" use 6 to 18 months postoperatively were assessed., Results: Any PET use more than doubled over the study period. Eleven percent of patients with NSCLC and 4% of those with CRC diagnosed in 2001 received any PET, compared with 25% of patients with NSCLC and 13% of those with CRC in 2009 (P < .001 for both). Higher stage disease was correlated with higher PET utilization and faster growth in use over the study period. PET-only use also increased over the study period, especially in higher stage disease. Fewer than 2% of patients diagnosed with stage IIIA NSCLC in 2001 received PET only, compared with 15% of patients diagnosed in 2009 (P = .014). Similarly, 1% of patients diagnosed with stage III CRC in 2001 received PET only, compared with 8% of patients diagnosed in 2009 (P < .001)., Conclusions: PET utilization during the surveillance period increased between 2001 and 2009. Further research is needed to determine the factors driving use of surveillance PET and to examine relationships between PET and patient outcomes., (Published by Elsevier Inc.)

Imaging clinical decision support (CDS) systems provide evidence for or against imaging procedures ordered within a computerized physician order entry system at the time of the image order. Depending on the pertinent clinical history provided by the ordering clinician, CDS systems can optimize imaging by educating providers on appropriate image order entry and by alerting providers to the results of prior, potentially relevant imaging procedures, thereby reducing redundant imaging. The American Recovery and Reinvestment Act (ARRA) has expedited the adoption of computerized physician order entry and CDS systems in health care through the creation of financial incentives and penalties to promote the "meaningful use" of health IT. Meaningful use represents the latest logical next step in a long chain of legislation promoting the areas of appropriate imaging utilization, accurate reporting, and IT. It is uncertain if large-scale implementation of imaging CDS will lead to improved health care quality, as seen in smaller settings, or to improved patient outcomes. However, imaging CDS enables the correlation of existing imaging evidence with outcome measures, including morbidity, mortality, and short-term imaging-relevant management outcomes (eg, biopsy, chemotherapy). The purposes of this article are to review the legislative sequence relevant to imaging CDS and to give guidance to radiology practices focused on quality and financial performance improvement during this time of accelerating regulatory change., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)