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Year of Publication
1.  Changes to Stage 1 Meaningful Use in 2014: Impact on Radiologists 
Journal of Digital Imaging  2014;27(3):292-296.
The goal of this work is to provide radiologists an update regarding changes to stage 1 of meaningful use in 2014. These changes were promulgated in the final rulemaking released by the Centers for Medicare and Medicaid Services and the Office of the National Coordinator for Health Information Technology in September 2012. Under the new rules, radiologists are exempt from meaningful use penalties provided that they are listed as radiologists under the Provider Enrollment, Chain and Ownership System (PECOS). A major caveat is that this exemption can be removed at any time. Additional concerns are discussed in the main text. Additional changes discussed include software editions independent of meaningful use stage (i.e., 2011 edition versus 2014 edition), changes to the definition of certified electronic health record technology (CEHRT), and changes to specific measures and exemptions to those measures. The new changes regarding stage 1 add complexity to an already complex program, but overall make achieving meaningful use a win-win situation for radiologists. There are no penalties for failure and incentive payments for success. The cost of upgrading to CEHRT may be much less than the incentive payments, adding a potential new source of revenue. Additional benefits may be realized if the radiology department can build upon a modern electronic health record to improve their practice and billing patterns. Meaningful use and electronic health records represent an important evolutionary step in US healthcare, and it is imperative that radiologists are active participants in the process.
doi:10.1007/s10278-014-9673-4
PMCID: PMC4026469  PMID: 24682743
Meaningful Use; Stage 2; 2014 Base EHR; Certified electronic health record; Complete EHR; Electronic health records; Meaningful Use in radiology
2.  Building Blocks for a Clinical Imaging Informatics Environment 
Journal of Digital Imaging  2013;27(2):174-181.
Over the past 20 years, imaging informatics has been driven by the widespread adoption of radiology information and picture archiving and communication and speech recognition systems. These three clinical information systems are commonplace and are intuitive to most radiologists as they replicate familiar paper and film workflow. So what is next? There is a surge of innovation in imaging informatics around advanced workflow, search, electronic medical record aggregation, dashboarding, and analytics tools for quality measures (Nance et al., AJR Am J Roentgenol 200:1064–1070, 2013). The challenge lies in not having to rebuild the technological wheel for each of these new applications but instead attempt to share common components through open standards and modern development techniques. The next generation of applications will be built with moving parts that work together to satisfy advanced use cases without replicating databases and without requiring fragile, intense synchronization from clinical systems. The purpose of this paper is to identify building blocks that can position a practice to be able to quickly innovate when addressing clinical, educational, and research-related problems. This paper is the result of identifying common components in the construction of over two dozen clinical informatics projects developed at the University of Maryland Radiology Informatics Research Laboratory. The systems outlined are intended as a mere foundation rather than an exhaustive list of possible extensions.
doi:10.1007/s10278-013-9645-0
PMCID: PMC3948933  PMID: 24248276
Software reuse; HL7; DICOM; Mirth; Open-source; Imaging informatics; Informatics
4.  The IIP Examination: an Analysis of Group Performance 2009–2011 
Journal of Digital Imaging  2013;26(3):378-382.
This report summarizes the performance of the Imaging Informatics Professional (IIP) examination from 2009 to 2011 (six exam administrations). Results show that the IIP exam is a reliable measuring instrument that is functioning well to consistently classify candidates as passing or failing. An analysis of the section scores revealed that content in the Image Management, Systems Management, and Clinical Engineering sections of the exam were somewhat more difficult than the content in the other sections. The authors discuss how future candidates may use this information to help hone their study strategies. By all indications, the IIP examination appears to be statistically functioning as a high-quality certification measuring instrument.
doi:10.1007/s10278-012-9508-0
PMCID: PMC3649059  PMID: 23299633
ABII; IIP; Certification; Examination; Statistics
5.  Certification of Imaging Informatics Professionals (CIIP): 2010 Survey of Diplomates 
Journal of Digital Imaging  2012;25(5):678-681.
The Certification for Imaging Informatics Professionals (CIIP) program is sponsored by the Society of Imaging Informatics in Medicine and the American Registry of Radiologic Technologists through the American Board of Imaging Informatics. In 2005, a survey was conducted of radiologists, technologists, information technology specialists, corporate information officers, and radiology administrators to identify the competencies and skill set that would define a successful PACS administrator. The CIIP examination was created in 2007 in response to the need for an objective way to test for such competencies, and there have been 767 professionals who have been certified through this program to date. The validity of the psychometric integrity of the examination has been previously established. In order to further understand the impact and future direction of the CIIP certification on diplomats, a survey was conducted in 2010. This paper will discuss the results of the survey.
doi:10.1007/s10278-012-9486-2
PMCID: PMC3447087  PMID: 22565602
PACS administration; Informatics training; Medical informatics applications
6.  Leveraging Internet Technologies with DICOM WADO 
Journal of Digital Imaging  2012;25(5):646-652.
The digital imaging and communications in medicine (DICOM) 3.0 standard was first officially ratified by the national electrical manufacturers association in 1993. The success of the DICOM open standard cannot be overstated in its ability to enable an explosion of innovation in the best of breed picture archiving and communication systems (PACS) industry. At the heart of the success of allowing interoperability between disparate systems have been three fundamental DICOM operations: C-MOVE, C-FIND, and C-STORE. DICOM C-MOVE oversees the transfer of DICOM Objects between two systems using C-STORE. DICOM C-FIND negotiates the ability to discover DICOM objects on another node. This paper will discuss the efforts within the DICOM standard to adapt this core functionality to Internet standards. These newer DICOM standards look to address the next generation of PACS challenges including highly distributed mobile acquisition systems and viewing platforms.
doi:10.1007/s10278-012-9469-3
PMCID: PMC3447090  PMID: 22411061
Web technology; Wide area network (WAN); Systems integration; PACS integration; Image distribution; Integrating healthcare enterprise (IHE); Internet technology; Enterprise PACS; Digital imaging and communications in medicine (DICOM)
7.  B6eGFPChAT mice overexpressing the vesicular acetylcholine transporter exhibit spontaneous hypoactivity and enhanced exploration in novel environments 
Brain and Behavior  2013;3(4):367-383.
Cholinergic innervation is extensive throughout the central and peripheral nervous systems. Among its many roles, the neurotransmitter acetylcholine (ACh) contributes to the regulation of motor function, locomotion, and exploration. Cholinergic deficits and replacement strategies have been investigated in neurodegenerative disorders, particularly in cases of Alzheimer's disease (AD). Focus has been on blocking acetylcholinesterase (AChE) and enhancing ACh synthesis to improve cholinergic neurotransmission. As a first step in evaluating the physiological effects of enhanced cholinergic function through the upregulation of the vesicular acetylcholine transporter (VAChT), we used the hypercholinergic B6eGFPChAT congenic mouse model that has been shown to contain multiple VAChT gene copies. Analysis of biochemical and behavioral paradigms suggest that modest increases in VAChT expression can have a significant effect on spontaneous locomotion, reaction to novel stimuli, and the adaptation to novel environments. These observations support the potential of VAChT as a therapeutic target to enhance cholinergic tone, thereby decreasing spontaneous hyperactivity and increasing exploration in novel environments.
doi:10.1002/brb3.139
PMCID: PMC3869679  PMID: 24381809
Choline acetyltransferase; cholinergic; eGFP-ChAT; exploration; locomotion; VAChT
8.  Unbiased Review of Digital Diagnostic Images in Practice: Informatics Prototype and Pilot Study 
Academic radiology  2012;20(2):238-242.
Rationale and Objectives
Clinical and contextual information associated with images may influence how radiologists draw diagnostic inferences, highlighting the need to control multiple sources of bias in the methodological design of investigations involving radiological interpretation. In the past, manual control methods to mask review films presented in practice have been used to reduce potential interpretive bias associated with differences between viewing images for patient care versus reviewing images for purposes of research, education, and quality improvement. These manual precedents from the film era raise the question whether similar methods to reduce bias can be implemented in the modern digital environment.
Materials and Methods
We built prototype “CreateAPatient” information technology for masking review case presentations within our institution’s production Radiology Information and Picture Archiving and Reporting Systems (RIS and PACS). To test whether CreateAPatient could be used to mask review images presented in practice, six board-certified radiologists participated in a pilot study. During pilot testing, seven digital chest radiographs, known to contain lung nodules and associated with fictitious patient identifiers, were mixed into the routine workload of the participating radiologists while they covered general evening call shifts. We tested whether it was possible to mask the presentation of these review cases, both by probing the interpreting radiologists to report detection and by conducting a forced-choice experiment on a separate cohort of 20 radiologists and information technology professionals.
Results
None of the participating radiologists reported awareness of review activity, and forced-choice detection was less than predicted at chance, suggesting radiologists were effectively blinded. In addition, we identified no evidence of review reports unsafely propagating beyond their intended scope or otherwise interfering with patient care, despite integration of these records within production electronic workflow systems.
Conclusion
Information technology can facilitate the design of unbiased methods involving professional review of digital diagnostic images.
doi:10.1016/j.acra.2012.09.016
PMCID: PMC3580150  PMID: 23103185
true screening; in-service monitoring; blind review; objective determination; unannounced standardized patients
9.  Five Levels of PACS Modularity: Integrating 3D and Other Advanced Visualization Tools 
Journal of Digital Imaging  2011;24(6):1096-1102.
The current array of PACS products and 3D visualization tools presents a wide range of options for applying advanced visualization methods in clinical radiology. The emergence of server-based rendering techniques creates new opportunities for raising the level of clinical image review. However, best-of-breed implementations of core PACS technology, volumetric image navigation, and application-specific 3D packages will, in general, be supplied by different vendors. Integration issues should be carefully considered before deploying such systems. This work presents a classification scheme describing five tiers of PACS modularity and integration with advanced visualization tools, with the goals of characterizing current options for such integration, providing an approach for evaluating such systems, and discussing possible future architectures. These five levels of increasing PACS modularity begin with what was until recently the dominant model for integrating advanced visualization into the clinical radiologist's workflow, consisting of a dedicated stand-alone post-processing workstation in the reading room. Introduction of context-sharing, thin clients using server-based rendering, archive integration, and user-level application hosting at successive levels of the hierarchy lead to a modularized imaging architecture, which promotes user interface integration, resource efficiency, system performance, supportability, and flexibility. These technical factors and system metrics are discussed in the context of the proposed five-level classification scheme.
doi:10.1007/s10278-011-9366-1
PMCID: PMC3222550  PMID: 21301923
PACS; 3D imaging (imaging, three-dimensional); Computer systems; Advanced visualization; Server-based rendering; Application hosting
10.  Online Social Networking: A Primer for Radiology 
Journal of Digital Imaging  2011;24(5):908-912.
Online social networking is an immature, but rapidly evolving industry of web-based technologies that allow individuals to develop online relationships. News stories populate the headlines about various websites which can facilitate patient and doctor interaction. There remain questions about protecting patient confidentiality and defining etiquette in order to preserve the doctor/patient relationship and protect physicians. How much social networking-based communication or other forms of E-communication is effective? What are the potential benefits and pitfalls of this form of communication? Physicians are exploring how social networking might provide a forum for interacting with their patients, and advance collaborative patient care. Several organizations and institutions have set forth policies to address these questions and more. Though still in its infancy, this form of media has the power to revolutionize the way physicians interact with their patients and fellow health care workers. In the end, physicians must ask what value is added by engaging patients or other health care providers in a social networking format. Social networks may flourish in health care as a means of distributing information to patients or serve mainly as support groups among patients. Physicians must tread a narrow path to bring value to interactions in these networks while limiting their exposure to unwanted liability.
doi:10.1007/s10278-011-9371-4
PMCID: PMC3180534  PMID: 21360214
E-communication; Doctor patient relationship; Facebook; Sermo
11.  Should Post-Processing Be Performed by the Radiologist? 
Journal of Digital Imaging  2011;24(3):378-381.
Post-processing of volumetric data sets lands in a fuzzy boundary between the technologist and the radiologist. Is this the role of the technologist as part of image preparation? Or is it the beginning of the diagnostic process by the radiologist? Technology advances in real-time server side rendering platforms is challenging the traditional role of expensive dedicated advanced visualizations workstations with dedicated personnel. Will this also challenge the role of a dedicated 3D post-processing technologist?
doi:10.1007/s10278-011-9370-5
PMCID: PMC3092043  PMID: 21380573
3D reconstruction; Web technology; Volume rendering; Image visualization
12.  Will the Next Generation of PACS Be Sitting on a Cloud? 
Journal of Digital Imaging  2010;24(2):179-183.
Cloud computing has gathered significant attention from information technology (IT) vendors in providing massively scalable applications as well as highly managed remote services. What is cloud computing and how will it impact the medical IT market? Will the next generation of picture archiving and communication systems be leveraging cloud technology?
doi:10.1007/s10278-010-9331-4
PMCID: PMC3056983  PMID: 20734101
distributed computing; enterprise PACS; grid computing; information storage and retrieval; cloud computing
13.  Tracking Delays in Report Availability Caused by Incorrect Exam Status with Web-Based Issue Tracking: A Quality Initiative 
Journal of Digital Imaging  2010;24(2):300-307.
Many radiology information systems (RIS) cannot accept a final report from a dictation reporting system before the exam has been completed in the RIS by a technologist. A radiologist can still render a report in a reporting system once images are available, but the RIS and ancillary systems may not get the results because of the study’s uncompleted status. This delay in completing the study caused an alarming number of delayed reports and was undetected by conventional RIS reporting techniques. We developed a Web-based reporting tool to monitor uncompleted exams and automatically page section supervisors when a report was being delayed by its incomplete status in the RIS. Institutional Review Board exemption was obtained. At four imaging centers, a Python script was developed to poll the dictation system every 10 min for exams in five different modalities that were signed by the radiologist but could not be sent to the RIS. This script logged the exams into an existing Web-based tracking tool using PHP and a MySQL database. The script also text-paged the modality supervisor. The script logged the time at which the report was finally sent, and statistics were aggregated onto a separate Web-based reporting tool. Over a 1-year period, the average number of uncompleted exams per month and time to problem resolution decreased at every imaging center and in almost every imaging modality. Automated feedback provides a vital link in improving technologist performance and patient care without assigning a human resource to manage report queues.
doi:10.1007/s10278-010-9330-5
PMCID: PMC3056982  PMID: 20798973
Quality control; quality assurance; turnaround time; human error; communication
14.  Has the Picture Archiving and Communication System (PACS) Become a Commodity? 
Journal of Digital Imaging  2010;24(1):6-10.
The Picture Archiving and Communication System (PACS) market has been transformed by disruptive innovations from the information technology industry. The cost of storage alone has dropped by a factor of 100 within the past 10 years. Improvements in display, processing, and networking have likewise enabled PACS to be a capable replacement for film. The maturity of PACS has permeated the US healthcare industry from large academic hospitals to small outpatient imaging centers. Can PACS continue to be a platform for innovation or has it become a commodity?
doi:10.1007/s10278-010-9299-0
PMCID: PMC3046786  PMID: 20419387
PACS; cost analysis; computer hardware
15.  Computer Input Devices: Neutral Party or Source of Significant Error in Manual Lesion Segmentation? 
Journal of Digital Imaging  2010;24(1):135-141.
Lesion segmentation involves outlining the contour of an abnormality on an image to distinguish boundaries between normal and abnormal tissue and is essential to track malignant and benign disease in medical imaging for clinical, research, and treatment purposes. A laser optical mouse and a graphics tablet were used by radiologists to segment 12 simulated reference lesions per subject in two groups (one group comprised three lesion morphologies in two sizes, one for each input device for each device two sets of six, composed of three morphologies in two sizes each). Time for segmentation was recorded. Subjects completed an opinion survey following segmentation. Error in contour segmentation was calculated using root mean square error. Error in area of segmentation was calculated compared to the reference lesion. 11 radiologists segmented a total of 132 simulated lesions. Overall error in contour segmentation was less with the graphics tablet than with the mouse (P < 0.0001). Error in area of segmentation was not significantly different between the tablet and the mouse (P = 0.62). Time for segmentation was less with the tablet than the mouse (P = 0.011). All subjects preferred the graphics tablet for future segmentation (P = 0.011) and felt subjectively that the tablet was faster, easier, and more accurate (P = 0.0005). For purposes in which accuracy in contour of lesion segmentation is of the greater importance, the graphics tablet is superior to the mouse in accuracy with a small speed benefit. For purposes in which accuracy of area of lesion segmentation is of greater importance, the graphics tablet and mouse are equally accurate.
doi:10.1007/s10278-009-9258-9
PMCID: PMC3046792  PMID: 20049624
Image segmentation; user-computer interface; computer assisted detection; computer hardware; data collection; human computer interaction; evaluation research; segmentation
16.  Use of a Wiki as a Radiology Departmental Knowledge Management System 
Information technology teams in health care are tasked with maintaining a variety of information systems with complex support requirements. In radiology, this includes picture archive and communication systems, radiology information systems, speech recognition systems, and other ancillary systems. Hospital information technology (IT) departments are required to provide 24 × 7 support for these mission-critical systems that directly support patient care in emergency and other critical care departments. The practical know-how to keep these systems operational and diagnose problems promptly is difficult to maintain around the clock. Specific details on infrequent failure modes or advanced troubleshooting strategies may reside with only a few senior staff members. Our goal was to reduce diagnosis and recovery times for issues with our mission-critical systems. We created a knowledge base for building and quickly disseminating technical expertise to our entire support staff. We used an open source, wiki-based, collaborative authoring system internally within our IT department to improve our ability to deliver a high level of service to our customers. In this paper, we describe our evaluation of the wiki and the ways in which we used it to organize our support knowledge. We found the wiki to be an effective tool for knowledge management and for improving our ability to provide mission-critical support for health care IT systems.
doi:10.1007/s10278-009-9180-1
PMCID: PMC3043765  PMID: 19184221
Wiki; PACS; knowledge management; informatics
18.  Should Medical Schools Incorporate Formal Training in Informatics? 
Are we preparing future generations of physicians with the skills to practice in the information age? Has the health care IT industry matured to the stage that we can standardize training physicians in how to search and synthesize massive databases of clinical information and tease out complex diagnoses based upon scant information? Will literacy in information technology become a differentiator between physicians’ abilities? For the proposition of changing existing curriculum in medical schools to incorporate formal informatics training is Michael Chen, a second year medical student at the University of Maryland School of Medicine. Taking the opposing position is Nabile Safdar, M.D., assistant professor of radiology at the University of Maryland School of Medicines.
doi:10.1007/s10278-009-9249-x
PMCID: PMC3025106  PMID: 19908095
Education; medical; clinical information systems; continuing medical education
19.  Should Medical Schools Incorporate Formal Training in Informatics? 
Journal of Digital Imaging  2009;24(1):1-5.
Are we preparing future generations of physicians with the skills to practice in the information age? Has the health care IT industry matured to the stage that we can standardize training physicians in how to search and synthesize massive databases of clinical information and tease out complex diagnoses based upon scant information? Will literacy in information technology become a differentiator between physicians’ abilities? For the proposition of changing existing curriculum in medical schools to incorporate formal informatics training is Michael Chen, a second year medical student at the University of Maryland School of Medicine. Taking the opposing position is Nabile Safdar, M.D., assistant professor of radiology at the University of Maryland School of Medicines.
doi:10.1007/s10278-009-9249-x
PMCID: PMC3025106  PMID: 19908095
Education; medical; clinical information systems; continuing medical education
20.  Is Android or iPhone the Platform for Innovation in Imaging Informatics 
Journal of Digital Imaging  2009;23(1):2-7.
It is clear that ubiquitous mobile computing platforms will be a disruptive technology in the delivery of healthcare in the near future. While radiologists are fairly sedentary, their customers, the referring physicians, and the patients are not. The need for closer collaboration and interaction with referring physicians is seen as a key to maintaining relationships and integrating tightly with the patient management team. While today, patients have to settle for their images on a CD, in short time, they will be taking them home on their cell phone. As PACS vendors are moving ever outward in the enterprise, they are already actively developing clients on mobile platforms. Two major contenders are the Apple’s iPhone and the Android platform developed by Google. These two designs represent two entirely different architectures and business models.
doi:10.1007/s10278-009-9242-4
PMCID: PMC2809941  PMID: 19789925
Infrastructure; enterprise PACS; web technology; mobile platforms
21.  Is Android or iPhone the Platform for Innovation in Imaging Informatics 
It is clear that ubiquitous mobile computing platforms will be a disruptive technology in the delivery of healthcare in the near future. While radiologists are fairly sedentary, their customers, the referring physicians, and the patients are not. The need for closer collaboration and interaction with referring physicians is seen as a key to maintaining relationships and integrating tightly with the patient management team. While today, patients have to settle for their images on a CD, in short time, they will be taking them home on their cell phone. As PACS vendors are moving ever outward in the enterprise, they are already actively developing clients on mobile platforms. Two major contenders are the Apple’s iPhone and the Android platform developed by Google. These two designs represent two entirely different architectures and business models.
doi:10.1007/s10278-009-9242-4
PMCID: PMC2809941  PMID: 19789925
Infrastructure; enterprise PACS; web technology; mobile platforms
22.  Developing and Verifying the Psychometric Integrity of the Certification Examination for Imaging Informatics Professionals 
Journal of Digital Imaging  2009;23(3):241-245.
The American Board of Imaging Informatics (ABII) was founded in 2005 by the Society of Imaging Informatics in Medicine (SIIM) and the American Registry of Radiologic Technologists (ARRT). ABII’s mission is to enhance patient care, professionalism, and competence in imaging informatics. This is accomplished primarily through the development and administration of a certification examination. The creation of the exam has been an exercise in open community involvement with SIIM providing access to the PACS community and ARRT providing skilled psychometric support to ensure a balanced and comprehensive examination. The process to generate the exam required several years and the efforts of dozens of subject matter experts active who volunteered to submit and validate questions for the examination. This article describes the organizational and statistical processes used to generate test items, assemble test forms, set performance standards, and validate test scores.
doi:10.1007/s10278-009-9241-5
PMCID: PMC2865641  PMID: 19777309
PACS administration; statistic analysis; PACS training; education; medical
23.  Developing and Verifying the Psychometric Integrity of the Certification Examination for Imaging Informatics Professionals 
Journal of Digital Imaging  2009;23(3):241-245.
The American Board of Imaging Informatics (ABII) was founded in 2005 by the Society of Imaging Informatics in Medicine (SIIM) and the American Registry of Radiologic Technologists (ARRT). ABII’s mission is to enhance patient care, professionalism, and competence in imaging informatics. This is accomplished primarily through the development and administration of a certification examination. The creation of the exam has been an exercise in open community involvement with SIIM providing access to the PACS community and ARRT providing skilled psychometric support to ensure a balanced and comprehensive examination. The process to generate the exam required several years and the efforts of dozens of subject matter experts active who volunteered to submit and validate questions for the examination. This article describes the organizational and statistical processes used to generate test items, assemble test forms, set performance standards, and validate test scores.
doi:10.1007/s10278-009-9241-5
PMCID: PMC2865641  PMID: 19777309
PACS administration; statistic analysis; PACS training; education; medical
24.  Should Radiology IT be Owned by the Chief Information Officer? 
Considerable debate within the medical community has focused on the optimal location of information technology (IT) support groups on the organizational chart. The challenge has been to marry local accountability and physician acceptance of IT with the benefits gained by the economies of scale achieved by centralized knowledge and system best practices. In the picture archiving and communication systems (PACS) industry, a slight shift has recently occurred toward centralized control. Radiology departments, however, have begun to realize that no physicians in any other discipline are as dependent on IT as radiologists are on their PACS. The potential strengths and weaknesses of centralized control of the PACS is the topic of discussion for this month’s Point/Counterpoint.
doi:10.1007/s10278-009-9196-6
PMCID: PMC3043688  PMID: 19387740
Hospital Information Systems (HIS); information management; PACS; PACS management; radiology department; hospital

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