Remote interviews and virtual campus tours seemed like quick, easy fixes for medical students looking to successfully match with a residency program during the pandemic. And, the process worked – but, now the same method presents what some in academic medicine are dubbing a “clear and present danger” to students and programs alike.

In an opinion piece published Oct. 12 in the 

Journal of the American College of Radiology

 a multi-institutional team led by Anna Rozenshtein, M.D., MPH, associate professor of radiology at New York Medical College and director of thoracic and cardiac imaging at Westchester Medical Center

 outlined the potential new playing field for residency programs. It is possible, they said, that many programs will see a significant uptick in applicants – an increase that does not necessarily equate to a vested interest a residency spot, but that could leave other medical students shut out of a coveted place.

Re-Thinking the Radiology Residency Interview: The COVID-19 Guidebook

“In the coming match season, residency administrators should keep in mind that a rise in the number of applications and a higher interview acceptance rate from highly qualified applicants do not mean greater interest in either their program or radiology as a specialty,” the team wrote.

As interview season ramps up, the pandemic is lingering and -- in many locations – getting worse. This means residency interviews will occur online, eliminating the need and cost for traveling to see a program first-hand. In the past, 41 percent of medical students reported foregoing an application for financial reasons. With this obstacle removed, it will be much easier for applicants to expand the number of programs to which they apply.

“In the nearly costless scenario, medical students lose nothing from every additional encounter while improving their interviewing skills. Because the most desirable students are usually invited first, we foresee that the competitive cohort is likely to displace other qualified applicants who would have been granted an interview in prior years,” Rozenshtein’s team explained. “If this comes to pass, programs will interview the same applicants, resulting in a smaller rank pool and increase in the number of unfilled positions and unmatched applicants.”

This phenomenon could have a serious impact on radiology, they said, because the specialty is frequently viewed by many applicants as a “back-up” option. It is possible that medical students who do not have a genuine, deep interest in a radiology residency program could see their application as a chance to sharpen their interview skills with no real intent of committing to the institution.

Online applications are not new to The Match. In 2001, the Electronic Residency Application Service (ERAS) made it easy for medical students to apply to multiple residency programs with a single click. Since then, for radiology, the number of applications per medical school senior has more than doubled, and the number of applications per training programs has more than tripled.

To address this problem and alleviate the impact on radiology residencies, the team offered a solution – a “early action” period, possibly two weeks, at the launch of interview season where ERAS could let medical students apply to a small number of programs, such as 10, in which they had a particular interest. Even though more than 75 percent of radiology residency program directors expressed their interest in the program, ERAS and its parent program, the Association of American Medical Colleges (AAMC) shut down the idea.

This is where medical students stepped in and took matters into their own hands. They created SingleToken, the Residency Application Preference Signaling Platform, and the website is functional now. Through this avenue, medical students pay $25 to profess their interest in the 12 programs of their choice, and residency programs can participate at no cost.

While it is not yet clear if the platform will be able to enroll enough Match participants to make a dent in the increased application congestion for this interview season, the program has potential, the team said.

“If it succeeds, it is likely to do much good,” they wrote. “Since remote residency interviews, like remote work, telemedicine, and online instruction are likely to stay in some form, at the very least Signal and other novel solutions would send a message to the AAMC, ERAS, and [National Residency Matching Program] that ‘business as usual’ cannot continue and urgent reform must take place.”

Still, the team advised, residency programs that opt not to participate in SingleToken or any other congestion solution should focus on increasing their number of interviewed applicants to ensure they fill all positions on Match Day.

This year, they said, radiology residencies “cannot be complacent.”

Articles

A new platform could give medical students a greater likelihood of matching with their preferred residency program during a time when some programs are seeing record applications.


Medical Students Take the Match into Their Own Hands

From the detection of a bulging blood vessel to a blocked artery to a suspicious mass, the advancements in modern medical imaging save lives. However, there are many times when medical imaging tests are being performed for one reason, and the radiologist detects an unexpected anomaly that is completely unrelated. In those cases, the radiologist usually recommends additional imaging.

Unfortunately, the number of the recommendations that actually translate into additional imaging (RAIs) tests being performed is low. This non-compliance can cause poor outcomes for patients, and it could have negative downstream effects for a practice, as well. In some cases, a patient could file a malpractice lawsuit, resulting in the radiology practice or department being found legally liable for some of a patient's damages.

New Research Indicates Adherence to Recommendations for Additional Imaging is Low

New research gathered during a six-month study shows that whether the follow-up exams a radiologist recommends are performed depends greatly on the type of provider who receives the recommendation and the care setting in which that provider treats the patient.

The Goal of This Study: Determining Why RAI Adherence is Low

The only way to increase the number of providers adhering to the recommendations for additional imaging is to discover the factors affecting adherence rates.

Factors Affecting Adherence to Recommendations for Additional Imaging of Incidental Findings in Radiology Reports

. Conducted by doctors at the University of California’s Davis Medical Center, this study focused on the reasons why providers disregard RAIs. To answer this question, researchers reviewed 539 reports of computed axial tomography scans that, due to incidental findings, had recommendations for additional imaging. Since these reports were studied retrospectively, the researchers used the patients’ medical charts to determine if providers adhered to the RAIs.

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Study results indicate that outpatient sites and primary care providers (PCP) were most likely to follow additional imaging recommendations. However, according to study researcher Shan S. Hansra, M.D., from the Sacramento, California, institution, it is the referring physician who is usually responsible for managing radiology report recommendations.

Nevertheless, if the referring physician neglects to follow-up on the incidental findings, the consequences are likely to trickle down, detrimentally affecting the radiology practice or department.

Factors Affecting Recommendations for Additional Imaging Adherence Rates

Ascertaining adherence rates and, then, recognizing the factors that affect these rates can help determine the reasons that RAIs are not being addressed.

Overall, the recommendations for additional imaging were performed in 39.1 percent of the 539 cases. However, when the patient’s primary care provider was at the institution where the CT scan was performed, the compliance rate increased substantially to 56.8 percent.

Adherence Rates Based on the Type of Patient Being Treated When the PCP is at the Same Location

The adherence rate when the patient is seen as:

A patient in the emergency department, 46 percent.

Adherence rates based on the part of the body that requires additional imaging tests:

At 3.5 percent, chest imaging had the highest rate of adherence. After chest imaging, providers adhered to 3.1 percent of the RAIs for the neck, abdomen and pelvis.

The lowest adherence rates involved an extremity (0.3 percent), the spine (0.8 percent), the head (0.1 percent) and the face (0.1 percent).

For outpatients, the specialty of the provider ordering the CT scan made a difference in the percentage of providers following up, as well:

PCPs adhered to the recommendations 67 percent of the time.

Surgeons followed up 37.7 percent of the time.

Internal medicine subspecialists adhered to the RAIs 50 percent of the time.

Noncompliance to RAIs is Mainly Due to a Lapse in Communication

According to the authors of this study, lapses in communication serve as the main reason for the failure to follow-up on RAIs. While documenting the need for follow-up imaging in the discharge summary does boost adherence rates, these details are often absent from the patient's discharge summary. In addition, many times, the patient only receives the test results once they are released.

There are numerous gaps that must be addressed to make sure that there is a good line of communication between the radiologist, the ordering physician, the PCP, and the patient.

Neglecting to follow-up on a recommendation for additional imaging can result in diagnosis and treatment delays, which may lead to poor patient outcomes. Poor patient outcomes due to this negligence can lead to a malpractice lawsuit, resulting in the practice’s or department’s legal liability. 

Numerous examples demonstrate where incidental findings go unnoticed due to a gap in communication and lack of patient tracking – these mishaps can lead to patient fatalities and lawsuits. A recent settlement in Illinois makes it clear how important good communication is.

In November 2017, Mark James had a CT scan for potential venous stenosis in one of his kidneys. This scan was performed on James' pelvis and abdomen. While the radiologist was reading the scan, he found a mass on James’ lung. The radiologist gave a recommendation for additional imaging; however, this information was not shared with James.

In May 2019, James began experiencing inflammation and pain in his chest and shoulder. He had another CT scan – it revealed that the mass found in 2017, which he was never informed about, had metastasized. James passed away in July of 2019.

Due to the delayed cancer diagnosis, James’ family received a $7.5 million settlement from the University of Illinois Hospital.

Patients who miss their follow-up appointments or choose another provider for their care are vulnerable. Often, incidental findings and recommendations are altogether missed by the referring provider. It is essential that patient contact information and preferences on how to be contacted are captured accurately to ensure the continuity of care. Otherwise, the patient may never know there is a recommendation for additional imaging. Consider implementing the practice of informing the patient how important his or her follow-up visit is. Doing so may increase the likelihood that the patient keeps this appointment.

Texas Radiology Associates, a group of 150 radiologists based in Plano, Texas, also has a unique solution to combat the lack of follow-ups through technological advancements.

John Kim, M.D., managing partner of Texas Radiology Associates explains how technology has helped them better communicate.

“We have deployed technology that identifies studies that require follow-ups based on the patient’s case. This technology can also ensure the same information has been relayed and received by the referring physician, and creates an alerting mechanism to take action should the particular patient not have the recommended study, such as following up with the patient, or the referring physician to inform them of a recommendation not being adhered to,” he said. “This has resulted into a significant decrease in missed recommendations.” 

Texas Radiology Associates also allows patients to have access to their radiology reports, thereby allowing them to play a critical role in their continuity of care. In the healthcare space, innovative technology can address several gaps and is ever-growing and evolving.

The American College of Radiology is Addressing Gaps in Care

Currently, a consensus for guiding classification of the incidental findings discovered on imaging tests is nonexistent. However, the American College of Radiology (ACR) is in the process of creating a quality measure for addressing these potentially dangerous gaps in care.

Recently, the ACR received a grant in the amount of $341,000 for work that was previously done with a large group of radiologists. Now, the researchers are requesting that physicians give questionnaires to patients and their families with the goal of attaining additional information related to incidental findings. Furthermore, the American College of Emergency Physicians is working in conjunction with the ACR to create guidance related to following up on anomalies found during emergency situations.

Once a coordinated process is implemented to prevent gaps in care, patient morbidity and mortality rates should drop. Consequently, the likelihood of litigation due to poor communication related to CT scans and other imaging test results will drop.

Collaborative Imaging’s Dhruv Chopra, MBA, takes a deeper look into how many follow-up recommendations are ignored and what can be done to reverse the trend, leading to better patient care.

Communication Critical to Providers Adhering to Follow-Up Recommendations

The U.S. Food & Drug Administration, on Oct. 12, awarded GE Healthcare 510(k) clearance for the Ultra Edition package for its Vivid cardiovascular ultrasound system.

Ultra Edition features on this new system, company officials said, can deliver repeatable exam assessments, helping providers identify whether patients have improved or whether their disease is progressing. Vivid Ultra Edition uses the AI Auto Measure-2D feature to increase scanning process efficiencies for reduced exam times with up to 80 percent fewer clicks and 99 percent accuracy by using the View Recognition feature. The AI Auto Measure-2D feature also allows for less inter-operator variability. This advance is critical, they said, because currently capturing heart function assessments is tedious and time-consuming.

According to a company statement, the Vivid Ultra Edition, which is driven by cSound, GE’s unique software-based ultrasound beam-forming platform, includes three neural network-based algorithms driven by artificial intelligence (AI) that can more quickly produce repeatable measurements in 2D echo imaging:

 By semi-automatically detecting the appropriate spectral Doppler imaging measurement, this feature allows the system to accelerate the path from scanning to measurement while maintaining 98-percent accuracy and 100-percent reproducibility.

This feature detects relevant image points that can reveal key left ventricle measurements. The 100-percent reproducibility performance is comparable to human users.

With 99-percent accuracy and 100-percent reproducibility, this feature can automatically detect which standard 2D scan plan has been acquired and can store the label in the imaging file. GE’s auto AFI package uses this data to automatically select views that can be used for strain analysis, streamlining workflow, and increasing efficiency.

Using this system has already resulted in time-savings for one system user, the company said.

“We use AI Auto Measure-2D, AI Auto Measure-Spectrum Recognition, and Auto AFI together with Auto EF. We also use Scan Assist Pro, 4D biplane and 4D triplane,” said Rebecca Perry, Ph.D., cardiac sonography program stream coordinator at the University of South Australia. “All of this in combination has saved us 7-to-10 minutes per scan, which is fantastic, so we really do have more time to spend with the patient.”

Additionally, said Dagfinn Saetre, general manager of cardiovascular ultrasound at GE, the Vivid Ultra Edition also offers new image quality, advanced visualization, and navigation capabilities:

 To enhance 3D perception, this feature presents anatomy and jet via shadowing, reflections, and transparency.

 Providers can capture photorealistic images that improve how they see moving structures, as well as their depth perception of tissues. 

This product characteristic offers high-quality 2D and 4D imaging for pediatric patients ranging from newborns to teen-agers.

“With the Vivid Ultra Editions, we offer AI capabilities that hlep address healthcare providers’ to key challenges in echo exams – how time consuming the exam is and the degree of variability that exists in the quantitative results,” Saetre said. “This package supports our vision of where we need to go with cardiovascular ultrasound: tools to support less variability and improved productivity.”

New system incorporates artificial intelligence features intended to truncate exam time and create more consistently repeatable exams.

GE Healthcare Secures FDA Clearance for Faster, More Consistent Cardiovascular Ultrasound

Here's what is coming soon to Diagnostic Imaging:

 is launching a new feature, bringing you a preview of what to expect from our weekly coverage. This week on 

, you can expect to see coverage of a number of hot topics:

October is Breast Cancer Awareness month, and 

 is devoting a great deal of attention to bringing you the latest news in breast imaging. Look for our interview later this week with Christoph Lee, M.D., MS, MBA, a professor of radiology at the University of Washington School of Medicine and provider with Seattle Cancer Care Alliance. Lee shared with us the latest advancements in breast imaging, as well as his insights on how artificial intelligence can enhance breast cancer screening.

To check out some of our other video interviews for Breast Cancer Awareness month, 

Breast imaging radiologist Svati Singla Long, M.D., with Raleigh Radiology in North Carolina, will also share details about the downturn of breast imaging during the COVID-19 pandemic, the impacts of this drop, as well as the multi-disciplinary solutions to treating breast cancer during this outbreak. Look for her article later this week. 

To check out our latest coverage of breast cancer screening and shortfalls, 

 “The Reading Room,” our podcast series, offers in-depth conversations with some of the industry’s leading experts on clinical topics of wide-spread interest. Recently, Anupam Basu, M.D., a diagnostic radiologist with Cook County Health in Chicago sat down with us to talk about his work into lung cancer screening guidelines and African-American patients. In this week’s upcoming podcast episode, listen as he shares insights about why the current benchmark for when to begin CT scans for lung cancer screening is likely too late for this patient population.

To check out other episodes from “The Reading Room,” 

What to expect this week on Diagnostic Imaging.

Diagnostic Imaging: A Look Ahead

Imagine being several hours into your shift, focusing on a particularly heavy, time-sensitive case load. Perhaps you’re searching for a pneumothorax, or maybe you’re examining an intracranial bleed, trying to meet a requested turn-around time.

Suddenly, your system freezes. You can’t access images, and you can’t write reports. Your reading room has gone dark in a frightening way. You and your facility are victims of a cyberattack.

Whether your facility has fallen victim, fended off an attempt, or been left unscathed, chances are you’re familiar with the ever-growing threat of widespread digital warfare throughout the healthcare industry. And, as medicine’s most data-rich, technology-driven specialty, radiology must be particularly careful to safeguard its tools and patient information.

“Not a week goes by that you don’t hear about a hospital system that’s been impacted by a malicious software attack,” said James Whitfill, M.D., chief transformation officer and vice president of Honor Health and clinical associate professor of internal medicine and bioinformatics at the University of Arizona College of Medicine. “Our radiology departments and practices, in general, need to have a heightened sense of awareness.” 

According to security firm RedTeam Security, healthcare is the second-most targeted industry for cyberattacks. Overwhelmingly, these attempts seek patient information for sale. According to Black Book Research, in 2019 alone, healthcare data breaches cost more than $4 billion.

For radiologists, these cyberattacks mean a significant loss of workflow and work product, said Suresh Narayan, director for service life cycle and install base with Canon Medical Systems.

“When attacks hit an imaging device, the device shuts down,” he said. “So, the radiologist loses their image, and it takes time and effort and a principled way of figuring out how to restore the services of the imaging device.”

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But, the dangers of cyberattacks is also expanding, said Andreas Ehrlund, product manager cross-enterprise solutions and senior security architect for Sectra Imaging IT Solutions, and the coming wave of activity could be even more damaging.

“The next horizon is integrity attacks – those that slowly introduce errors into a system instead of shutting it down,” he said. “This type of attack could change blood types for groups of patients, jumble around reports, and introduce lesions into medical images that would cause not only distrust of the data that doctors work with and a huge problem in providing healthcare, but it would also cause distrust in a government’s ability to protect its healthcare system.”

Consequently, it’s critical for radiology to do its part in safeguarding patient information. Knowing the threats and identifying your weak points is vital, and selecting a strong cybersecurity solution is fundamental.

Currently, there are several issues that pose an immediate threat to radiology’s cybersecurity and one that has been theoretically produced. Understanding what could happen can play a significant role in picking an effective cybersecurity solution.

 Currently, these attacks are the most common. After infiltrating your system, an attacker encrypts your data, eventually grinding your equipment and programs to a halt, and unless you pay a fee – a ransom – your system remains locked. Typically, Whitfill said, it takes roughly 10 days to reclaim your functionality, but only about 92 percent of data is recovered on average.

 Within radiology, there is growing awareness about the significant number of unprotected DICOM archives that are openly available on the Internet. These files are sitting ducks, Whitfill said, and the specialty has an obligation to protect the data.

“This is a uniquely radiology-related issue. That’s patient-health information, and people might try to sell it on the black market,” he warned. “They might not care specifically about the images, but the potential identify theft from that medical information creates a market that we need to be worried about.”

 Though most attention has been given to the security of wearable medical devices, including insulin pumps or implants, dangers also exist for radiation-dosing devices, such as CT scanners, Whitfill said. In many cases these products have between 5-to-10 software algorithms running, and they frequently aren’t getting patched or updated on a regular basis, potentially putting all patients imaged on a compromised machine at risk.

“If a CT scanner or any other radiation-emitting device is compromised, at least, in theory, someone could change the dose. And, that’s frightening,” he said. “From a radiologist and industry perspective, we must make sure our radiation-dosing devices are protected or they could deliver a dose that could be lethal.”

 This threat has only been produced in the lab so far, but the fact that it’s possible reveals a significant vulnerability that can harm patient care. Last summer, researchers in Israel successfully changed images captured on a CT scanner before they were uploaded into a PACS system. Manipulating an image before it is reviewed could fundamentally change any radiologist-rendered diagnosis and proposed treatment.

“With this type of attack, someone can intercept a CT scan from a normal person and introduce things like lung cancer tumors, prompting the radiologist to determine the patient has widespread disease,” Whitfill said. “Or, you could do the opposite, removing evidence of the tumors, in essence preventing the patient from receiving critical medical care.”

As these cybersecurity threats continue to evolve, it’s imperative that you examine your facility or department for areas of weakness that could serve as entry points for an attack, Ehrlund said. Unfortunately, the root of these problems largely stems from a source you can’t control with a technological solution – people.

 Historically, healthcare environments, including radiology departments, have trusted their digital security to an in-house IT department staffed with employees who they know and who are well acquainted with how the systems and modalities work together. But, with mergers and acquisitions making multi-site health systems more commonplace, relying on the same group of people no longer offers you the same level of protection.

IT departments are largely understaffed, Ehrlund said, making it harder for them to keep all equipment and software up-to-date. Ensuring the connectivity and security of multiple modalities spread across several facilities can be an overwhelming task.

“Hospital IT systems are integrating to a much larger degree than before, and interoperability is huge,” Erhlund said. “It’s hard to take care of the system. It’s too much pressure for Bob in the basement. He can’t handle it – it’s not humanly possible. That provides a very nice target for a cybercriminal who wants an easy and quick payout.”

 Fake emails and websites that steal usernames and passwords are known entities, but organizations still struggle with helping staff avoid the pitfalls, Ehrlund said. Healthcare systems that have done a good job of training employees will suffer a 10-percent click rate in a phishing email – and an organization with excellent training will likely witness 2-to-5 percent.

“An attacker only needs one sucker,” he said. “There has to be an in-depth conversation about security and how you can side-step problems. You can’t just put a ring wall around a system and expect it to be strong in the future.”

Whitfill agreed, suggesting facilities and departments regularly test their employees to see how many are clicking on links that open the door to a cyberattack. After these tests, he cautioned, employees should be educated on better digital hygiene rather than punished for their mistakes.

To help radiology departments and practices maximize their cybersecurity efforts, Canon and Sectra are among the industry vendors who offer product solutions.

Launched during RSNA in November, Canon offers its Gateway Platinum solution, an optional service available to customers on top of their existing modality contract. The system offers cybersecurity through a three-prong system, and requires no training for the end user responsible for collecting and processing diagnostic images.

First, a Barracuda NextGen Firewall protects the imaging device, keeping it isolated from the rest of the hospital system. In addition to stopping any infiltration attempt, such as ransomware or a denial of service attack, Narayan said, the firewall can identify the type of threat before reporting it. Security data is continuously sent to the healthcare system’s security personnel, and attack alerts are sent out to notify both the system and Canon Risk Management of the threat.

Second, Gateway Platinum includes InnerVision® Plus, a remote diagnostic solution that runs Windows 10. This feature keeps the health system in constant contact with Canon’s service engineers, he explained, allowing Canon engineers access to work on any problems. For example, they can remotely view the screen of a CT console and access files and images to determine the problem, as well as identify how to fix it.

Lastly, Narayan said, a secure, constant VPN connection with multi-factor authentication between the healthcare system and Canon ensures the highest level of encrypted data transfers.

For Sectra, cybersecurity solutions focus on providing easy access to images while ensuring they’re not exposed on the Internet, Ehrlund said.

“In the earlier days of the Sectra workstation and zero footprint viewers, a lot of people wanted to expose things on the Internet. We said no,” he said. “It’s slowly turning out, years later, that we were right.”

Sectra’s PACS system offers easy access and image sharing through a secure connection so you can reach out to colleagues to discuss scans, he said. In addition, the company conducts regular penetration tests on its web-based viewer, Univiewer™, with a third-party firm to validate its security. Included with the system, they also offer training so you and your staff can use the system to maximize your online safety.

“We provide guidance to customers so their abilities to use the security products are on the same level of what the products are capable of doing,” he explained. “Otherwise, they’re more likely to fail. It can be the most secure product in the world, but if someone opens the wrong port on the customer side, things can go very badly.”

Not every cybersecurity vendor will be the right fit for every organization. Identifying which one is best for you can require an intense interview and testing process. Doing so can be critical to future success and safety, said Christopher Roth, M.D., associate professor of radiology and director of imaging informatics strategy at Duke Health.

“You need to know your partners – to know who you’re in bed with,” he said. “This can be something that’s easy to forget when you’re trying to find the right solution quickly. But, remember any problems can roll up stream.”

Roth presented on cybersecurity during the RSNA annual meeting in November.

To help in this endeavor, last fall, the Medical Imaging and Technology Alliance published its Manufacturer Disclosure Statement for Medical Device Security, called the MDS2, in an effort to give healthcare organizations crucial information about medical device cybersecurity features. The MDS2 can be very helpful, but this is where the Request for Proposal (RFP) fits in, Ehrlund added. And, in recent years, inquiries from customers about cybersecurity – whether they’re specific to a piece of equipment or for a holistic solution – have increased.

“It’s really important to poke vendors in the ribs and really ask the difficult questions,” Ehrlund said. “You don’t need to a huge amount of questions, but you need hard-hitting ones that will put vendors on the edge of their seats – ones where their answers will let you know whether they know what they’re talking about.”

, he outlined seven questions that can help practices and hospitals best determine which potential cybersecurity provider will best be able to meet their needs for protecting not only patient data, but also employee information.

For facilities searching for the right vendor partner, he suggested posing these questions:

Is the application, particularly those facing public networks, penetration tested by accredited third-party firms?

Is the vendor willing to share the results of those penetration tests? (Anticipate being asked to sign a non-disclosure agreement.)

Is the application capable of PKI-based authentication? (This can be important during application integrations, such as URL launch integration.)

Does the vendor regularly conduct its own internal security reviews, assessments, or penetration tests?

Do any software components contain hard-coded passwords or other credentials?

Is the vendor amenable to allowing customers to penetration test products, systems, or services?

Does the vendor provide regular product security patches?

Overall, successfully defending your practice or department from a cyberattack will require a collaborative partnership not only between your providers, but your business and IT leaders, as well, Whitfill said. You must work together to find solutions that are effective and practical – ones that fulfill security needs without hampering your ability to provide clinical care. And, it’s paramount for providers to embrace cybersecurity measures and tools rather than view them as just one more compliance requirement.

“We are moving away from the era where cybersecurity is a compliance issue. We have to be worried about our patient’s health,” he said. The only way we’re going to combat this problem is with a combined, mutually-supportive partnership of all vested parties.”

At the end of the day, Roth said, cybersecurity will continue to be a consistent and growing priority for radiology practices and departments no matter how big or small. Always be preemptive and take threats seriously.

“Never think it can’t happen to you. Be careful where you click, only browse and work on devices you trust, and back up all your data,” he advised. “Be skeptical of requests for sensitive information, monitor your systems for sketchy activity. Update your software early, have a firewall, and encrypt everything.”

As the price tag of cyberattacks on healthcare continues to rise, radiology looks to bolster its defenses.

 Cybersecurity and Your Images: Taking Safety Beyond Passwords and Home-Grown Protections

Diagnostic imaging powers the heart of every hospital. The presence of medical imaging resources has a tremendous impact on the quality of care patients receive, and, unfortunately, the deficiency of these resources can have a profound impact on patient outcomes. The scarcity of medical imaging widens the healthcare disparities we see around the world. Although this is evident worldwide, its absence is particularly impactful in the developing world. Could we creatively apply new technologies to address some of the difficult-to-solve disparities in healthcare?

At the University of Pennsylvania School of Medicine, we have had a long-standing legacy to not just strive to lead healthcare innovation, but also to build collaborations with healthcare partners to address the problems in healthcare disparities. This is seen at both of our major clinical sites, including the Hospital of the University of Pennsylvania, as well as the Children’s Hospital of Philadelphia, among all medical departments, but particularly within the department of radiology. Some of the prior work accomplished by the University of Pennsylvania Department of Radiology is profiled 

To continue to foster the spirit of global health, the authors, who are all radiology resident physicians, along with Saurabh Jha, M.D., an associate professor of radiology, wanted to highlight some of the work being done while also building the groundwork for continued collaboration in the future. There could be no better avenue than the annual meeting of the Radiological Society of North America (RSNA), in Chicago, where more than 60,000 leaders in industry, radiology, and non-governmental organizations converge for more than a week. One of the largest professional society gatherings in the world, people from all over come together to learn, share, and collaborate in order to move the field forward. The RSNA 2019 meeting held an ever-increasing focus on the role of artificial intelligence (AI) in radiology. Where many questioned and feared how this could disrupt the current practice of radiology, we, at Penn Radiology, wondered how we could bring it to global health.

To catalyze the combined intelligence, we organized a panel featuring some of the key voices in industry, academic radiology, and global health to discuss the role of medical imaging technology in limited resource settings, specifically AI and radiology in developing countries. The event was sponsored by Penn Radiology, RAD-AID International, as well as the major corporate sponsor TeraRecon. TeraRecon, led by Jeff Sorenson and Lindsay Fleming, worked with members of Penn Radiology to make this event a reality. Additional sponsors included Densitas, Infervision, Riverain, Imbio, VIDA, and Image Biopsy Lab. Our main goal was to bring together leaders in academia, like Penn Radiology, and industry, like TeraRecon, to create avenues for collaboration for global health.

While we were expecting a warm response, the event was more successful even beyond what we had hoped.

While the event achieved what we set out for it to attain at RSNA, the success continued beyond the conference. RAD-AID International, a non-profit organization that increases and improves radiology for low-resource regions in the world, and Densitas, a global leader in AI for digital mammography, announced a new partnership to “advance personalized breast screening” and to “establish an AI-based decision support program for breast health in medically underserved regions.” We reached out to Mo Abdolell, founder and chief executive officer (CEO) of Densitas, and Dan Mollura, M.D, founder and CEO of RAD-AID, to discuss the inspiration for and challenges presented by this collaboration.

“We were inspired by the spirit of volunteerism that RAD-AID has tapped into,” Abdolell responded, when asked about the origin of this partnership.

The spirit he mentions is captured in the thousands of volunteers and scores of industry partners that dedicate their time and resources to the RAD-AID mission of bringing radiology services to those who need it most. Mollura encapsulated the heart of that partnership by simply stating, “We learn by doing and by doing so together.”

Although there is nothing we cannot accomplish when we bring together passionate and brilliant minds to tackle some of the most challenging problems in global health and radiology, we start by identifying obstacles to implementing new technologies in settings with limited resources.

We should begin by determining the disease processes in which AI can be used to make a significant impact in the global health setting. The most elegant algorithm in the world would mean little if we are unable to see improvement in patient outcomes on a population scale. It is critical to use AI to address problems that hinder physician performance in population medicine. For example, AI revolutionizes how we screen patients for diseases, such as breast cancer—especially when we consider the rising incidence and prevalence of breast cancer coupled with limited screening in low-and-middle income countries. However, it is challenging enough to create these products and implement them within the workflow of high resource settings, that problem may be magnified when taken to environments where support for such products are limited.

Mollura said the most important question in deploying AI in limited resource settings is determining the mode of distribution for AI to reach hospitals. He lists four possibilities: hardware, desktops, cloud, or Picture Archiving Communication System (PACS).

Each scenario presents unique problems that will not always be addressed in the same way, depending on the hospital. For example, if AI is integrated within the hardware of diagnostic imaging, such as digital radiography, the success of the product is predicated on that particular digital radiography equipment to remain in working order. That, in itself, is no easy feat and is highly reliant on the accessibility of vendor support and repair. In each scenario, obstacles are readily identifiable which demands flexibility and collaboration if such endeavors are to truly be successful.

In addition to the question of where such products are implemented, whether it be hardware or cloud, data sharing and privacy rules are not constant and are different even within hospital systems in the same city. Abdolell is not disheartened by this.

“We didn’t get into this to collect data,” he said. “We’re in it to help patients.”

He further emphasized that comprehensive data sharing and privacy rules are essential to protect patients. Ultimately, companies like Densitas will be the stewards of the important information that comes from these new solutions, and that information belongs to the people.

It is essential for industry leaders looking to implement AI in the global health setting to partner with organizations like RSNA and RAD-AID International. RAD-AID has a proven track record for collaborating successfully with hospitals in varied environments to devise solutions unique to their locales. In addition to determining where to integrate AI, we need to ensure the long-term success of such projects by understanding the needs of each hospital as it pertains to the delivery of that product. We have to address the gaps hospitals say need to be closed - from training physicians and technologists to assisting with administrative issues, such as negotiating service contracts for hardware - in order for such endeavors to succeed.

Although it takes complex solutions to address such multifactorial public health problems, augmenting the workflow of physicians with AI will undoubtedly improve performance, and we hope, patient outcomes. Densitas and RAD-AID are creating a roadmap for others to follow. We, at Penn Radiology, are honored to be a part of the journey.

Abass Noor M.D., and Victor Babatunde, M.D., are diagnostic radiology residents at The Hospital of the University of Pennsylvania. Ajay Kohli, M.D., is an MSK radiology fellow and assistant radiology instructor at UTSouthwestern Medical Center and is a graduate of the Hospital of University of Pennsylvania radiology residency program.

Penn Medicine is dedicated to improving artificial intelligence to address radiology needs in individual institutions worldwide, both improving performance and patient outcomes.

Radiology and AI for the Developing World

In my relatively new Twitter account, I’ve referenced some intellectual interests that have graced my life in recent months: the skills of persuasion and negotiation, underpinned by cognitive science. My undergrad degree being in psych, it’s not exactly surprising that this stuff would resonate.

I’ve found myself viewing much of daily life through these new-to-me lenses. Even when remembering events of years gone by, I see new angles to them. One episode harks back to my residency…I might have referenced it in a previous column.

Our hospital had given control of its radiology department to a local private-practice group, and while most of our attendings had opted to stay on as its employees, some of the group’s members were new faces in our corridors. Even the group’s leader would occasionally put in an appearance.

His first encounter with one of the junior residents was in the non-interventional fluoro area. The leader-guy marched into the room, eyeballed the day’s schedule (which never had more than half a dozen assorted barium exams, spread out over the morning and early afternoon), and told the resident, “I want all of these studies done by ten o’clock.”

The resident was a good, likeable guy, easy to get along with but not afraid to be blunt. Surprised and irked by the demand, his bluntness was on full display as he informed the leader that there was no way the edict could be fulfilled. The leader, perhaps unaccustomed to being challenged by a subordinate, seemed somewhat horrified and left the scene. Fluoro cases proceeded with no more alacrity than they ever had, that day or any subsequent.

Until now, I’ve regarded the exchange in the same way I did as a resident, and, indeed, the way the junior did that day: the leader was being imperious and demanding. His first day in the place, he struts around, and tells folks who have been working there that they’re going to abruptly do everything differently on his say-so? Whether or not logistically possible?

I have no way of knowing what the leader’s goal was in that exchange. Maybe he genuinely did want the fluoro service to run more efficiently…or maybe he just wanted to impress the resident and nearby rad-techs that he was a take-change, watch-me-improve-everything kind of guy.

Whatever his motives, he could have gone about them more effectively. Rather than barking out demands and, then, retreating when they were not well-received, he would have been far better served by gathering information and recruiting the resident and techs to his cause.

For instance, instead of “I want all of these cases done by ten o’clock,” he might have taken a thoughtful look at the schedule and, then, started asking questions about it:

“Is this a typical daily case-load?” “How frequently do cases get added on?” “How long do these cases tend to take? Are they difficult?” “What else do you have to do, that doesn’t show up on the schedule?”

He would have done well to not only listen to the verbal responses, but also note tone of voice, posture, gestures, etc., accompanying them. The techs and the resident might have had valuable information or insights that could, then, be teased out with follow-up questions.

For instance, had the leader invited the staff to help him understand the situation, any one of them might have pointed out that the limiting reagent was not their desire or ability to get cases done…but, rather, the incredibly balky and inefficient system that got patients down from their rooms to the radiology department. Nurses on the wards and patient-transporters had plenty of other demands on their time, and/or weren’t particularly motivated to maximize throughput for imaging studies. You could go ahead and schedule two or three times as many fluoro studies each day, but all that would happen would be patients showing up hours after they were supposed to be there, and, then, sitting around even longer waiting to be brought back to their rooms.

Armed with such information, the leader might have understood that the problem he needed to attack was not his own staff in the rad department. He might have taken things up with hospital administration. Perhaps gotten a patient-transporter or three specifically assigned to radiology. Gotten dispensation for one or more rad-techs to go and fetch patients themselves, when feasible.

And, in his first interaction with the resident and rad-techs, he would have come off not as a haughty Grand Poobah, doing a drive-by on his high horse…but, a down-to-earth new guy, wanting to learn the ins-and-outs of the place just like anybody else. Except with the clout to maybe make some things better.

I did say, however, he only “mostly” botched this. What did he get right -- aside maybe from establishing that he was in charge and comfortable making demands?

One item is that he expressed what he wanted. Not everybody does that, and at some point in every negotiation you need to plainly communicate what you want to the people who can give it to you.

And, maybe he didn’t really want all of the cases done by 10:00 a.m. Maybe all he was after was moving the needle, getting cases done sooner in the day. In a negotiation, your first “ask” shouldn’t be the same thing as what you’re ultimately willing to settle for. So, if fluoro cases ordinarily got done by mid-afternoon, maybe an initial demand for 10 a.m. would ultimately lead to having things done by lunchtime. Turning fluoro from a full-day schedule into a half-day, after which your personnel can be allocated elsewhere? That’s a “win” for efficiency.

Believe it or not, this is just the tip of the iceberg. Tempted as I was to make this a marathon column delving into the various other ways this rad-group leader could have done better, let’s give your eyes a rest, shall we? Come on by my Twitter page and we can discuss the rest!

Taking time to ask questions – instead of announcing mandates – can be far more effective.

A Mostly Botched Attempt at Leadership

A quality improvement study conducted at a large New Jersey tertiary care COVID-19 referral center showed that following strict prevention and disinfection protocols can be effective in keeping facilities free of the virus.

Based on the analysis of 128 environmental samples collected from a variety of services throughout the radiation oncology department at Rutgers Cancer Institute of New Jersey, a team of investigators determined their clinic had zero traces of the SARS-CoV-2 virus.

“The results of this study suggest that following strict prevention protocols and routine cleaning and disinfecting seem adequate for limiting surface contamination with SARS-CoV-2,” said the team by Bruce G. Haffty, M.D., chair of radiation oncology and associate vice chancellor for cancer programs.

Being able to demonstrate that radiation oncology centers can successfully keep the virus out is critical, he said, because many patients are making substantial decisions about needed medical care based on their fears of the virus. In fact, he pointed out, many patients have deferred or canceled scheduled follow-up appointments, leading numerous radiation oncology clinics to see a significant drop-off in patient volume during the pandemic.

Surfaces Swabbed for SARS-CoV-2 Virus RNA in Radiation Oncology Clinic

“Although re-scheduling follow-up visits or converting selected follow-up visits and consultations to telemedicine is good practice during the pandemic, some patients or clinicians may delay or decline important cancer therapies that can substantially affect quality of life and cancer outcomes,” Haffty said. “We believe that appropriate patient care should not be delayed because of the pandemic.”

In an effort to assuage patient fears, Haffty’s team tested their facility during the height of the pandemic in New Jersey. They collected samples every Monday, Wednesday, and Friday for a total of six days between May 1, 2020, and May 13, 2020. Samples fells into three categories: patient areas (80 swabs), staff areas (19 swabs), and department equipment (29 swabs). Of all the samples, 15 were taken from objects touched by patients who were positive for infection.

Their swabbing efforts, which focused on surfaces that were at high risk for contamination due to patient contact and frequent use, followed World Health Organization protocols, and samples were collected at 4:30 p.m. prior to the 5 p.m.-scheduled disinfection and cleaning services. The team also went a step further and tested the immobilization mask of a COVID-19-positive patient – with RT-PCR analysis – daily for five radiation treatments.

According to their analysis, none of the samples came back positive for any SARS-CoV-2 RNA.

Haffty’s team did acknowledge that their study had some limitations, however.

In addition to not collecting air samples, the team was unable to test 100 percent of surfaces. Consequently, they said, their study could have reduced sensitivity, pointing to the need for additional surface and air studies in varied environments that could improve the overall understanding of the role of environment factors in spreading COVID-19.

Zero evidence of SARS-CoV-2 virus in a radiation oncology clinic shows disinfection policies are working.


Clean to the Touch: No COVID-19 in Radiation Oncology Clinic

Partnerships between emergency radiology and emergency medicine are critical to proper patient care.

In a session during the American Society of Emergency Radiology (ASER) 2020 annual meeting, Summer Kaplan, M.D., a pediatric radiologist at the Children's Hospital of Philadelphia, discussed methods and strategies emergency radiologists can implement to launch quality improvement projects.

And, in outlining the overall importance of quality improvement partnerships between emergency medicine and emergency radiology, Kaplan also discussed some challenges that providers should keep in mind. 

Dr. Summer Kaplan discusses strategies to design quality improvements projects in emergency radiology and the challenges that exist to proper implementation. She shared her insights during the American Society of Emergency Radiology 2020 annual meeting.