Integrating and Adopting AI in the Radiology Workflow: A Primer for Standards and Integrating the Healthcare Enterprise (IHE) Profiles.

The deployment of artificial intelligence (AI) solutions in radiology practice creates new demands on existing imaging workflow. Accommodating custom integrations creates a substantial operational and maintenance burden. These custom integrations also increase the likelihood of unanticipated problems. Standards-based interoperability facilitates AI integration with systems from different vendors into a single environment by enabling seamless exchange between information systems in the radiology workflow. Integrating the Healthcare Enterprise (IHE) is an initiative to improve how computer systems share information across health care domains, including radiology. IHE integrates existing standards-such as Digital Imaging and Communications in Medicine, Health Level Seven, and health care lexicons and ontologies (ie, LOINC, RadLex, SNOMED Clinical Terms)-by mapping data elements from one standard to another. IHE Radiology manages profiles (standards-based implementation guides) for departmental workflow and information sharing across care sites, including profiles for scaling AI processing traffic and integrating AI results. This review focuses on the need for standards-based interoperability to scale AI integration in radiology, including a brief review of recent IHE profiles that provide a framework for AI integration. This review also discusses challenges and additional considerations for AI integration, including technical, clinical, and policy perspectives.

From Bench to Bedside With Large Language Models: AJR Expert Panel Narrative Review.

Large language models (LLMs) hold immense potential to revolutionize radiology. However, their integration into practice requires careful consideration. Artificial intelligence (AI) chatbots and general-purpose LLMs have potential pitfalls related to privacy, transparency, and accuracy, limiting their current clinical readiness. Thus, LLM-based tools must be optimized for radiology practice to overcome these limitations. While research and validation for radiology applications remain in their infancy, commercial products incorporating LLMs are becoming available alongside promises of transforming practice. To help radiologists navigate this landscape, this AJR Expert Panel Narrative Review provides a multidimensional perspective on LLMs, encompassing considerations from bench (development and optimization) to bedside (use in practice). At present, LLMs are not autonomous entities that can replace expert decision-making, and radiologists remain responsible for the content of their reports. Patient-facing tools, particularly medical AI chatbots, require additional guardrails to ensure safety and prevent misuse. Still, if responsibly implemented, LLMs are well-positioned to transform efficiency and quality in radiology. Radiologists must be well-informed and proactively involved in guiding the implementation of LLMs in practice to mitigate risks and maximize benefits to patient care.

Environmental Sustainability and AI in Radiology: A Double-Edged Sword.

According to the World Health Organization, climate change is the single biggest health threat facing humanity. The global health care system, including medical imaging, must manage the health effects of climate change while at the same time addressing the large amount of greenhouse gas (GHG) emissions generated in the delivery of care. Data centers and computational efforts are increasingly large contributors to GHG emissions in radiology. This is due to the explosive increase in big data and artificial intelligence (AI) applications that have resulted in large energy requirements for developing and deploying AI models. However, AI also has the potential to improve environmental sustainability in medical imaging. For example, use of AI can shorten MRI scan times with accelerated acquisition times, improve the scheduling efficiency of scanners, and optimize the use of decision-support tools to reduce low-value imaging. The purpose of this Radiology in Focus article is to discuss this duality at the intersection of environmental sustainability and AI in radiology. Further discussed are strategies and opportunities to decrease AI-related emissions and to leverage AI to improve sustainability in radiology, with a focus on health equity. Co-benefits of these strategies are explored, including lower cost and improved patient outcomes. Finally, knowledge gaps and areas for future research are highlighted.

Value Creation Through Artificial Intelligence and Cardiovascular Imaging: A Scientific Statement From the American Heart Association.

Multiple applications for machine learning and artificial intelligence (AI) in cardiovascular imaging are being proposed and developed. However, the processes involved in implementing AI in cardiovascular imaging are highly diverse, varying by imaging modality, patient subtype, features to be extracted and analyzed, and clinical application. This article establishes a framework that defines value from an organizational perspective, followed by value chain analysis to identify the activities in which AI might produce the greatest incremental value creation. The various perspectives that should be considered are highlighted, including clinicians, imagers, hospitals, patients, and payers. Integrating the perspectives of all health care stakeholders is critical for creating value and ensuring the successful deployment of AI tools in a real-world setting. Different AI tools are summarized, along with the unique aspects of AI applications to various cardiac imaging modalities, including cardiac computed tomography, magnetic resonance imaging, and positron emission tomography. AI is applicable and has the potential to add value to cardiovascular imaging at every step along the patient journey, from selecting the more appropriate test to optimizing image acquisition and analysis, interpreting the results for classification and diagnosis, and predicting the risk for major adverse cardiac events.

Efficient healthcare with large language models: optimizing clinical workflow and enhancing patient care.

PURPOSE: This article explores the potential of large language models (LLMs) to automate administrative tasks in healthcare, alleviating the burden on clinicians caused by electronic medical records. POTENTIAL: LLMs offer opportunities in clinical documentation, prior authorization, patient education, and access to care. They can personalize patient scheduling, improve documentation accuracy, streamline insurance prior authorization, increase patient engagement, and address barriers to healthcare access. CAUTION: However, integrating LLMs requires careful attention to security and privacy concerns, protecting patient data, and complying with regulations like the Health Insurance Portability and Accountability Act (HIPAA). It is crucial to acknowledge that LLMs should supplement, not replace, the human connection and care provided by healthcare professionals. CONCLUSION: By prudently utilizing LLMs alongside human expertise, healthcare organizations can improve patient care and outcomes. Implementation should be approached with caution and consideration to ensure the safe and effective use of LLMs in the clinical setting.

A randomized trial of mailed outreach with behavioral economic interventions to improve liver cancer surveillance.

BACKGROUND: Surveillance rates for HCC remain limited in patients with cirrhosis. We evaluated whether opt-out mailed outreach increased uptake with or without a $20 unconditional incentive. METHODS: This was a pragmatic randomized controlled trial in an urban academic health system including adult patients with cirrhosis or advanced fibrosis, at least 1 visit to a specialty practice in the past 2 years and no surveillance in the last 7 months. Patients were randomized in a 1:2:2 ratio to (1) usual care, (2) a mailed letter with a signed order for an ultrasound, or (3) a mailed letter with an order and a $20 unconditional incentive. The main outcome was the proportion with completion of ultrasound within 6 months. RESULTS: Among the 562 patients included, the mean age was 62.1 (SD 11.1); 56.8% were male, 51.1% had Medicare, and 40.6% were Black. At 6 months, 27.6% (95% CI: 19.5-35.7) completed ultrasound in the Usual care arm, 54.5% (95% CI: 47.9-61.0) in the Letter + Order arm, and 54.1% (95% CI: 47.5-60.6) in the Letter + Order + Incentive arm. There was a significant increase in the Letter + Order arm compared to Usual care (absolute difference of 26.9%; 95% CI: 16.5-37.3; p<0.001), but no significant increase in the Letter + Order + Incentive arm compared to Letter + Order (absolute difference of -0.4; 95% CI: -9.7 to 8.8; p=0.93). CONCLUSIONS: There was an increase in HCC surveillance from mailed outreach with opt-out framing and a signed order slip, but no increase in response to the financial incentive.

Quality Improvement Report: Design and Implementation of a Radiology E-Consult Service.

Electronic consultations (e-consults) mediated through an electronic health record system or web-based platform allow synchronous or asynchronous physician-to-physician communication. E-consults have been explored in various clinical specialties, but relatively few instances in the literature describe e-consults to connect health care providers directly with radiologists.The authors outline how a radiology department can implement an e-consult service and review the development of such a service in a large academic health system. They describe the logistics, workflow, turnaround time expectations, stakeholder management, and pilot implementation and highlight challenges and lessons learned.

Striving to be of Value: Building a Virtual Radiology Consult Service for Patients.

PURPOSE: Direct interactions between patients and diagnostic radiologists are uncommon, but recent medicolegal developments in the United States may increase patient interest in communicating directly with radiologists. Patient participation rates in prior attempts at direct radiology consultation vary widely in the literature. Our objective was to design and build a virtual radiology consult service for a subset of patients undergoing lung cancer screening CTs to enable communication between patients and radiologists regarding imaging results and radiology recommendations. METHODS: Patients scheduled for lung cancer screening CTs were identified using a custom scheduling system and offered via text message a free 15-minute consultation with a radiologist to discuss the results. RESULTS: Of 38 patients texted, 10 (26.3%) responded. Nine (90%) scheduled a consultation, but 5 (55.5%) subsequently cancelled. Of the remaining four, 3 (75%) attended their appointments, with an overall 3/38 (7.9%) text-to-consult conversation rate. The 3 consults averaged 18 (±8.2) minutes. CONCLUSION: The recruitment rate for our virtual service was between the low rate of a prior phone consult line study and the high rate in consults integrated into another physician visit. Further research is needed to identify patients most interested in a radiology consultation and optimize consultation modality by patient population.

Population Health Management in Radiology: Economic Considerations.

There is a growing emphasis on population health management (PHM) in the United States, in part because it has the worst health outcomes indices among high-income countries despite spending by far the most on health care. Successful PHM is expected to lead to a healthier population with reduced health care utilization and cost. The role of radiology in PHM is increasingly being recognized, including efforts in care coordination, secondary prevention, and appropriate imaging utilization, among others. To further discuss economic considerations for PHM, we must understand the evolving health care payer environment, which combines fee-for-service and increasingly, an alternative payment model framework developed by the Health Care Payment Learning and Action Network. In considering the term "value-based care," perceived value needs to accrue to those who ultimately pay for care, which is more commonly employers and the government. This perspective drives the design of alternative payment models and thus should be taken into consideration to ensure sustainable practice models.

Exploring the Clinical Translation of Generative Models Like ChatGPT: Promise and Pitfalls in Radiology, From Patients to Population Health.

Generative artificial intelligence (AI) tools such as GPT-4, and the chatbot interface ChatGPT, show promise for a variety of applications in radiology and health care. However, like other AI tools, ChatGPT has limitations and potential pitfalls that must be considered before adopting it for teaching, clinical practice, and beyond. We summarize five major emerging use cases for ChatGPT and generative AI in radiology across the levels of increasing data complexity, along with pitfalls associated with each. As the use of AI in health care continues to grow, it is crucial for radiologists (and all physicians) to stay informed and ensure the safe translation of these new technologies.

Management of spontaneous coronary artery dissection: Trends over time.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome. Guidance regarding the optimal management of patients with SCAD has been published over the past 10 years, but the impact on clinical practice has not been evaluated. The present study aims to examine if approaches to invasive management, medical therapy, and vascular imaging have changed over time. METHODS: This is a retrospective cohort study of 157 patients treated for SCAD between 2005 and 2019 at an academic health system in Philadelphia, Pennsylvania. We aimed to examine change in management over time, including rates of coronary revascularization, discharge medications, and vascular imaging. RESULTS: Conservative management of SCAD increased over time from 35% before 2013 to 89% in 2019, p < 0.001. Revascularization was associated with younger age, pregnancy-associated SCAD, and lesions of the left main artery, left anterior descending artery, and multiple vessels, p < 0.05 for all. Partial imaging for extracoronary vascular abnormalities ranged from 33% before 2013 to 71% in 2018, p = 0.146. The rate of comprehensive vascular imaging (cross-sectional head to pelvis imaging) remained low in all time categories (10-18%) and did not change over time. Patients who underwent comprehensive imaging were more likely to be diagnosed with fibromuscular dysplasia (FMD) compared to those with partial imaging (63% vs 15%, p < 0.001). CONCLUSION: Management of spontaneous coronary artery dissection has changed over time. More patients are being managed conservatively and undergo screening for extracoronary vascular abnormalities such as FMD. Future efforts should focus on improving rates of comprehensive vascular screening.

Changes in Radiology Due to Artificial Intelligence That Can Attract Medical Students to the Specialty.

The role of artificial intelligence (AI) in radiology has grown exponentially in the recent years. One of the primary worries by medical students is that AI will cause the roles of a radiologist to become automated and thus obsolete. Therefore, there is a greater hesitancy by medical students to choose radiology as a specialty. However, it is in this time of change that the specialty needs new thinkers and leaders. In this succinct viewpoint, 2 medical students involved in AI and 2 radiologists specializing in AI or clinical informatics posit that not only are these fears false, but the field of radiology will be transformed in such a way due to AI that there will be novel reasons to choose radiology. These new factors include greater impact on patient care, new space for innovation, interdisciplinary collaboration, increased patient contact, becoming master diagnosticians, and greater opportunity for global health initiatives, among others. Finally, since medical students view mentorship as a critical resource when deciding their career path, medical educators must also be cognizant of these changes and not give much credence to the prevalent fearmongering. As the field and practice of radiology continue to undergo significant change due to AI, it is urgent and necessary for the conversation to expand from expert to expert to expert to student. Medical students should be encouraged to choose radiology specifically because of the changes brought on by AI rather than being deterred by it.

Improved Fine-Tuning of In-Domain Transformer Model for Inferring COVID-19 Presence in Multi-Institutional Radiology Reports.

Building a document-level classifier for COVID-19 on radiology reports could help assist providers in their daily clinical routine, as well as create large numbers of labels for computer vision models. We have developed such a classifier by fine-tuning a BERT-like model initialized from RadBERT, its continuous pre-training on radiology reports that can be used on all radiology-related tasks. RadBERT outperforms all biomedical pre-trainings on this COVID-19 task (P<0.01) and helps our fine-tuned model achieve an 88.9 macro-averaged F1-score, when evaluated on both X-ray and CT reports. To build this model, we rely on a multi-institutional dataset re-sampled and enriched with concurrent lung diseases, helping the model to resist to distribution shifts. In addition, we explore a variety of fine-tuning and hyperparameter optimization techniques that accelerate fine-tuning convergence, stabilize performance, and improve accuracy, especially when data or computational resources are limited. Finally, we provide a set of visualization tools and explainability methods to better understand the performance of the model, and support its practical use in the clinical setting. Our approach offers a ready-to-use COVID-19 classifier and can be applied similarly to other radiology report classification tasks.

Automated deidentification of radiology reports combining transformer and "hide in plain sight" rule-based methods.

OBJECTIVE: To develop an automated deidentification pipeline for radiology reports that detect protected health information (PHI) entities and replaces them with realistic surrogates "hiding in plain sight." MATERIALS AND METHODS: In this retrospective study, 999 chest X-ray and CT reports collected between November 2019 and November 2020 were annotated for PHI at the token level and combined with 3001 X-rays and 2193 medical notes previously labeled, forming a large multi-institutional and cross-domain dataset of 6193 documents. Two radiology test sets, from a known and a new institution, as well as i2b2 2006 and 2014 test sets, served as an evaluation set to estimate model performance and to compare it with previously released deidentification tools. Several PHI detection models were developed based on different training datasets, fine-tuning approaches and data augmentation techniques, and a synthetic PHI generation algorithm. These models were compared using metrics such as precision, recall and F1 score, as well as paired samples Wilcoxon tests. RESULTS: Our best PHI detection model achieves 97.9 F1 score on radiology reports from a known institution, 99.6 from a new institution, 99.5 on i2b2 2006, and 98.9 on i2b2 2014. On reports from a known institution, it achieves 99.1 recall of detecting the core of each PHI span. DISCUSSION: Our model outperforms all deidentifiers it was compared to on all test sets as well as human labelers on i2b2 2014 data. It enables accurate and automatic deidentification of radiology reports. CONCLUSIONS: A transformer-based deidentification pipeline can achieve state-of-the-art performance for deidentifying radiology reports and other medical documents.

Imaging Informatics Fellowship Curriculum: Building Consensus on the Most Critical Topics and the Future of the Informatics Fellowship.

The existing fellowship imaging informatics curriculum, established in 2004, has not undergone formal revision since its inception and inaccurately reflects present-day radiology infrastructure. It insufficiently equips trainees for today's informatics challenges as current practices require an understanding of advanced informatics processes and more complex system integration. We sought to address this issue by surveying imaging informatics fellowship program directors across the country to determine the components and cutline for essential topics in a standardized imaging informatics curriculum, the consensus on essential versus supplementary knowledge, and the factors individual programs may use to determine if a newly developed topic is an essential topic. We further identified typical program structural elements and sought fellowship director consensus on offering official graduate trainee certification to imaging informatics fellows. Here, we aim to provide an imaging informatics fellowship director consensus on topics considered essential while still providing a framework for informatics fellowship programs to customize their individual curricula.