Imaging Informatics to Prevent Harm

John F Kalafut PhD

Disclosure

• Employee of GE Healthcare (Imaging IT)

• Inventor on numerous patents assigned to MEDRAD
Inc covering certain topics discussed within
Primum non nocere

(first do no harm) 

Wellcome Library, London

Copyrighted work available under
Creative Commons Attribution
only licence
Learning Obejctives

• How and where in the imaging value chain

informatics solutions can:
– Improve quality AND outcomes while ensuring
patient safety
• Review and discuss applications and examples
of Imaging IT
– Emphasis on contrast and radiation dose issues

Informaticists can and should play an important role in

improving quality and safety in imaging
Great Poets Steal….
• “Quality is the extent to which the right procedure is done in the
right way, at the right time, and the correct interpretation is
accurately and quickly communicated to the patient and referring
clinician.”

Hillman BJ, Amis ES, Neiman HL Journal American

College Radiology, 2004;1(1):33-39
Radiology IS the Patient
The Imperative of Informatics for imaging’s
survival
• …“the collective radiology product is a sum total of multiple steps, performed
by multiple individuals, using multiple technologies.”
• “…each individual step in the collective imaging chain create the ability to use
medical informatics to objectively analyze performance deliverables and
differentiate medical imaging service providers in data-driven qualitative and
quantitative terms.”

“This data-driven, quality-oriented

analysis is crucial to the long-term
survival of medical imaging.”

Reiner and Siegel. The Clinical Imperative of Medical Imaging Informatics. Journal Digital Imaging, May 2009.

7
 The Imaging Value Chain

Scheduling Protocoling Acquisition Processing Reporting

• Review • Review previous • IV Access • Reproducibility • Automated,

previous contrast and • Contrast protocol by application of complete and
contrast and radiation parameter appropriate accurate procedure
radiation exposures and optimization settings specifics
exposures parameters • Scanning • Appropriate • Automated,
• Appropriate • Set personalized protocol noise vs. appropriate
and right-sized scan and parameter diagnostic radiation exposure
approaches injection protocol optimization tradeoffs • Quality assurance
settings • Patient and improvement
management

8
So…
What happens when a study is suboptimal due to
methodological, protocoling or other issues?
– Repeat the study – may result in increased contrast and radiation
exposure for the patient
– OR you deal with incomplete information to make a diagnosis
– An incomplete, or indeterminate diagnosis may result in additional
testing and costs
•Does this really happen?

Oh yeah.
9
Sub-diagnostic CT Pulmonary Angiography – Jones,
Wittram*

• Over a 2 year window, 237/3612 (6.5%) CTPAs were deemed

indeterminate for diagnosis
• Of those indeterminate exams, 40% were due to a poor contrast bolus
or timing
• Conclusion: The two major causes of indeterminism are motion artifacts
and poor contrast enhancement

“A similar reduction in the second leading cause, poor

bolus enhancement, could be accomplished with
increased attention to detail during contrast
administration. Optimal timing for contrast
administration could be determined by using [..] a
small test bolus [..].”

*Jones SE, Wittram C. The Indeterminate CT Pulmonary Angiogram: Imaging Characteristics

and Patient Clinical Outcome. Radiology 2005, 237: 329-337.
10
Ozawa et al.
Journal of Thoracic Imaging, June 2010,
The Frequency of Insufficient Contrast Enhancement of the Pulmonary
Artery in Routine Contrast –Enhanced Chest CT and Its Improvement with
an Increased Injection Rate
•Ozawa .Y., Hara M., Yuta S.

“The frequency of insufficient Contrast Enhancement of

the Pulmonary Artery was 7.3% (21/288) and 3.2% (9/278)
in the 2 ml/s and 3 ml/s protocols, respectively (as defined
as enhancement > 180 HU in the PA)”
A really non-diagnostic CTPA

*440 lb male, contrast protocol – 4 ml/s, 100 ml, 350 mgI/ml contrast
c/o: J Lacomis MD, UPMC
Does it really matter?

Weininger et al, AJR 2011

 “Lean” in Imaging

• Waste is any activity that consumes time,

resources, or space but does not add any
value to the product or service.

*Good Ref: see Flug and Nagy, June 2011 JACR “The Lean Concept of Waste in Radiology”
“”Lean” in Radiology

Waste is any activity that consumes time, resources, or

space but does not add any value to the product or
service.

The complex environment that is the

imaging suite necessitates data
analysis tools, methods and
approaches to minimize repeat studies
and poor outcomes.

*Good reference: Flug and Nagy. The Lean Concept of Waste in Radiology. JACR. June 2011.

15
 Informatics: Quality Enabler and
Barrier?

RadioGraphics. 2011; 31 (6): 1511-27 

Errors
Near-Misses

Thornton et al, AJR 2011

Near-Misses

Thornton et al, AJR 2011

“Designing a Safer Radiology Dept”

Johnson et al, AJR Feb 2012

 “Designing a Safer Radiology Dept”

Johnson et al, AJR Feb 2012

 “Designing a Safer Radiology Dept”

Johnson et al, AJR Feb 2012

 Dose (Radiation and
Contrast) Management
Joint Commission
 Personalized Contrast Delivery

You could do
it like this..
Time Series Example Contrast Delivery

Note: Flow Rate x 10 to aid

visualization. Actual flow
rate = 2 ml/s

Kalafut et al, RSNA 2009

More Examples
Kalafut et al, RSNA 09
 Non-diagnostic 3p liver CT

Arterial phase Arterial phase delayed phase

85 ± 21.5 HU 100.7 ± 22.4 HU 85 ± 21.5 HU

c/o: L Mitsumori MD, Univ Washington

 “Designing a Safer Radiology Dept”

Johnson et al, AJR Feb 2012

ACR – ICE Registry; M.O.C Oppty

“Qualified by the American Society of Radiology in

meeting the criteria for practice quality improvement
(PQI) and toward the purpose of fulfiling
requirements in the ABR Maintenance of Certification
Program”
The Dose Management Solution Space

POS* parameter
Appropriate
QC and protocol Protocoling
Orders
personalization
Tech, Physicist
Rad, Physicist Rad, Referring MD
Tech, Rad

Image
Dose analytics
enhancement/IR
Rad, Physicist

It takes a team managing

Performance
the appropriate usage of metrics (KPI & BI)
contrast and radiation.
Rad, Physicist, RSO,
*POS: Point of Scanning
Admin, Provider

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Contrast Media IT Management

• Manual methods
Data entry into RIS
Paper
• Vendor Solutions
–Standards Update – DICOM Supplement 164
From the Literature..
Radiation Dose Management

• Manual methods
Data entry into RIS
• Scanner Outputs (Secondary Capture)
–Static data stuck in the PACS
• Open Source tools
–Extract Data from static data and DICOM metadata
–RADIANCE, GROK,
Vendor Solutions
Radiation Exposure Saftey
• Image Gently
Example State Regs: Texas
Managing Dose for the Patient—
it’s not just iterative reconstruction!

QC

POC Parameter
Image
and Protocol
Enhancement/IR
Personalization

Protocoling

Dose analytics: Performance Metrics (KPI and PI)

41
 Critical Factors At CT Protocoling

Scanner parameters: Contrast parameters: Patient Factors:

•kVP •Types of contrast •Habitus
•Scan coverage •Flow rate •Age
•mAs (TCM) •Volume •Renal status
•Acquisition mode •IV access •Consent?
•Timing method •Pressure limits •Cardiac function
•Recon options •Delays •Order

Protocol

Page 42 • Total Dose Management • November 2012

 Critical Factors

Protocol

Prior Exam Data Prior Exam Data

(Trapped or hard to get) (Easier to get)
•Scan and contrast parameters •Prior reports
•Effective dose estimates •Number of visits
•Detailed clinical context •Some clinical context
•Quality of study

Page 43 • Total Dose Management • November 2012

 MultiFactorial Issue

Prior Exam Data

Contrast
Clinical Context Scanning

Patient Factors Protocol

IT solutions needed to facilitate and optimize this process!!

Page 44
 ACR Practice Guidelines

http://www.acr.org/accreditation/computed/qc_forms/image_guide.aspx
Bigger Data Paradigm for Imaging

*Rascovsky et al, Radiographics 2012

Checklists – low tech?
Checklisting as UX Construct

Kalafut et al RSNA 2011ility.

In compliance with HIPAA regulations. Patient information listed on GUI are
examples only and do not contain any actual patient information
48
Interventional Rad Checklist – Oppty
• Lewis et al. [4], a complication rate requiring vascular surgical intervention
was found in 0.2% of 24,033 cardiac and vascular radiological procedures.[..]
, and 40 patients had complications requiring vascular surgical
procedures resulting from peripheral vascular intervention.
Mining Your Data

• Open Source Solutions (Apache Lucene,

etc)
• Vendor Solutions
Unstructured structuredness

Your Reports as a
source of
Continuous Quality
Improvement
Conclusion

• Managing information and processes in

imaging with IT solutions enables
improvements in patient safety and
quality
• As informaticists, think beyond just the
image