- Email: [email protected]
Authors’ Reply
Leonard Berlin, MD Skokie Hospital 9600 Gross Point Road Skokie, IL 60076 e-mail: [email protected] The author has no conflicts of interest related to the material discussed in this article.
REFERENCES 1. Mezrich JL, Siegel EL. Legal ramifications of computer-aided detection in mammography. J Am Coll Radiol 2015;12:572-4. 2. Jones v Chidester, 610 A 2d964 (Supr Ct 1992). 3. Levine v Rosen, 616 A 2d (PA Supr Ct 1992). 4. Berlin L. Mammographic CAD markings: archive or discard? AJR Am J Roentgenol 2011;196:W659. http://dx.doi.org/10.1016/j.jacr.2015.07.034 S1546-1440(15)00580-3
n
Authors’ Reply We were pleased to see that Leonard Berlin, MD, was asked respond to our report. Dr Berlin has served as an extraordinary resource on legal aspects of imaging to the radiology community for many years and has, in fact, served as an inspiration for our own research and publications on medicolegal aspects of imaging informatics. Dr Berlin shared his opinion about mammographic computer-aided detection (CAD) markings in an online piece in the American Journal of Roentgenology, stating his belief that “radiologists should discard them” [1]. In this particular case, however, we disagree with Dr Berlin. In both his piece in the American Journal of Roentgenology and his letter to JACR, he essentially makes two salient points. He states that it “has never been established that CAD markings constitute a medical record, and there is no indication that they ever will” and points out in his online reply that “neither the American College of Radiology nor the Society of Breast Imaging has issued any recommendations about this.” He goes on to state, “I do not see how saving a CAD marking that a radiologist judged to be a false-positive can help the radiologist in a courtroom in a lawsuit alleging the missing of
a cancer on a mammogram, but it may well weaken the radiologist’s defense” [1]. Dr Berlin’s position is similar to those of many nonradiologist specialties: why save image data that could hurt you in court if your society hasn’t come out with this recommendation, which seems, prima facie, to make great common sense. However, we believe that on the basis of current trends in the evolution of the electronic medical record and evolving software used for quantitative analysis and visualization, Dr Berlin’s approach and recommendation may be difficult to defend, and, more important, it is probably not sound medical practice. The definition of the electronic medical record is evolving rapidly and will likely encompass not only radiologic images and reports but also other types of medical images, such as those obtained by dermatologists, pathologists, cardiologists, and gastroenterologists. Importantly, lawyers at our hospital and those across the country are suggesting that outside images and any other data used to help arrive at a diagnosis should be retained. This has been the case for images reviewed in uncompressed format as well as outside studies. Upon review in court, CAD markings would likely be considered akin to measurements made in a 3-D laboratory or by individual radiologists using an advanced workstation. There is a Current Procedural Terminology code for these advanced visualization procedures, technical and professional fees, and the expectation that the results of 3-D rendering be not only mentioned in the report but saved as a PACS image. It would be difficult to convince a judge and jury that mammographic CAD markings should be treated differently. In his letter to JACR, Dr Berlin further opines that although the “mammography report itself is of course a medical record; however, an informal consultation with a radiology colleague, or a CAD marking, that assists a radiologist in making his or her interpretation is not, and therefore neither is subject to the spoliation law.” We believe that it would be erroneous and legally difficult to
Journal of the American College of Radiology Letters to the Editor
equate CAD markings with an informal consultation with a colleague. Radiologists do not bill patients for informal consultations, but they do bill for CAD. Informal consultations do not result in any documentation, whereas CAD markings do. The use of CAD is more akin to a formal consultation with a bill sent to a patient for the consultation. Although there is no specific recommendation from the ACR or the Society of Breast Imaging about these formal billable second opinions, we would expect that a radiologist obtaining a consultation would feel uncomfortable discarding a written consult and that it would not serve the patient’s best interests. From the perspective of optimal patient care, retention of CAD markings offers similar advantages to those offered by retention of 3-D and advanced visualization images and measurements. Radiologists reviewing follow-up studies in the future, for example, can review the CAD markings on a study and reexamine areas selected by the computer as suspicious for tumor as well as areas marked as suspicious microcalcifications. Retention of CAD markings in the system would allow future technological development of CAD software that could use previous markings as a baseline for assessment of change, which would make CAD a more useful and powerful tool. Along the lines of technological advances anticipated in CAD for mammography, new research in CAD is certain to result in improvements in the detection and diagnosis of breast cancer. Unlike Dr Berlin, we can very much conceive of a future in which a state-of-the-art CAD system could be summoned by a plaintiff’s lawyer in the analysis of a case in addition to expert human witnesses. This was our rationale for suggesting that the version of software should be automatically saved with the CAD markings if needed to provide perspective on what the original CAD system presented to the radiologist. We agree with Dr Berlin that it isn’t necessarily true that the use 1135
of CAD has actually become the standard of care. However, we recommend that the ACR consider a guideline about whether its use is a best practice given that a judge and jury might interpret the high proportion of radiologists who use CAD as establishing a standard of care. An ACR guideline could similarly address the specific issue of whether radiologists should indeed retain CAD markings and mention CAD results in their reports.
We also wholeheartedly agree with our friend and colleague Dr Berlin that readers of this letter should draw their own conclusions and act accordingly. Jonathan L. Mezrich, MD, JD MBA, LLM Department of Diagnostic Radiology Yale University School of Medicine 333 Cedar Street, TE2 New Haven, CT 06520 e-mail: [email protected]
Eliot Siegel, MD University of Maryland School of Medicine The authors have no conflicts of interest related to the material discussed in this article.
REFERENCE 1. Berlin L. Mammographic CAD markings: archive or discard? AJR Am J Roentgenol 2011;196:W659. http://dx.doi.org/10.1016/j.jacr.2015.07.034 S1546-1440(15)00733-4
n
SPEAKING OF LANGUAGE
Avoiding Abbreviations in Radiology Reports Samuel J. Kuzminski, MD Abbreviations have become commonplace in the English language, thanks largely to social media and texting. Terms such as LOL, FYI, and OMG have insinuated themselves into everyday usage to the point that all three appear in the Oxford English Dictionary. Abbreviations are no less commonplace in medicine. Many radiologists have experienced the frustration of attempting to glean some clinical data from the medical record, only to encounter a jumble of nonsense abbreviations. We too often return the favor by offering up in our reports obtuse abbreviations of our own. The list of abbreviations radiologists commonly use in their reports is extensive and may even be institution specific [1]. With ever increasing patient access to electronic medical records,
radiologists must be aware that their audience is now more naive about these abbreviations. If a clinician with years of medical training cannot decipher the meaning of an abbreviation in a report, then a patient has no hope of doing so. Abbreviations have a place in medicine. “Standard” abbreviations, such as MRI and CT, save time and can potentially enhance report readability. The difficulty is deciding which ones qualify as “standards,” as there are no set guidelines. If a term is commonly used in ordinary conversation, inclusion in a report is acceptable. There are some entities with long names that are more widely known by their abbreviations, HIV for example. One way to deal with an unwieldy term that will be used multiple times
in a report is to include the full name the first time it is used, with the abbreviation in parenthesis, then use the shortened form on repeated use. The key point is that although a keen eye and extensive medical knowledge are paramount for a radiologist, the ability to clearly communicate is just as essential. Clinicians and patients value clear and understandable reports, and the misuse of abbreviations is likely to result in misunderstandings and frustration.
REFERENCE 1. Hunter TB, Taljanovic MS. Glossary of medical devices and procedures: abbreviations, acronyms, and definitions. Radiographics 2003;23:195-213. http://dx.doi.org/10.1016/j.jacr.2015.07.027 S1546-1440(15)00726-7
n
The author has no conflicts of interest related to the material discussed in this article. Samuel J. Kuzminski, MD: 2301 Erwin Rd, Box 3808, Durham, NC 27710; e-mail: [email protected].
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Journal of the American College of Radiology Volume 12 n Number 11 n November 2015
REFERENCES 1. Mezrich JL, Siegel EL. Legal ramifications of computer-aided detection in mammography. J Am Coll Radiol 2015;12:572-4. 2. Jones v Chidester, 610 A 2d964 (Supr Ct 1992). 3. Levine v Rosen, 616 A 2d (PA Supr Ct 1992). 4. Berlin L. Mammographic CAD markings: archive or discard? AJR Am J Roentgenol 2011;196:W659. http://dx.doi.org/10.1016/j.jacr.2015.07.034 S1546-1440(15)00580-3
n
Authors’ Reply We were pleased to see that Leonard Berlin, MD, was asked respond to our report. Dr Berlin has served as an extraordinary resource on legal aspects of imaging to the radiology community for many years and has, in fact, served as an inspiration for our own research and publications on medicolegal aspects of imaging informatics. Dr Berlin shared his opinion about mammographic computer-aided detection (CAD) markings in an online piece in the American Journal of Roentgenology, stating his belief that “radiologists should discard them” [1]. In this particular case, however, we disagree with Dr Berlin. In both his piece in the American Journal of Roentgenology and his letter to JACR, he essentially makes two salient points. He states that it “has never been established that CAD markings constitute a medical record, and there is no indication that they ever will” and points out in his online reply that “neither the American College of Radiology nor the Society of Breast Imaging has issued any recommendations about this.” He goes on to state, “I do not see how saving a CAD marking that a radiologist judged to be a false-positive can help the radiologist in a courtroom in a lawsuit alleging the missing of
a cancer on a mammogram, but it may well weaken the radiologist’s defense” [1]. Dr Berlin’s position is similar to those of many nonradiologist specialties: why save image data that could hurt you in court if your society hasn’t come out with this recommendation, which seems, prima facie, to make great common sense. However, we believe that on the basis of current trends in the evolution of the electronic medical record and evolving software used for quantitative analysis and visualization, Dr Berlin’s approach and recommendation may be difficult to defend, and, more important, it is probably not sound medical practice. The definition of the electronic medical record is evolving rapidly and will likely encompass not only radiologic images and reports but also other types of medical images, such as those obtained by dermatologists, pathologists, cardiologists, and gastroenterologists. Importantly, lawyers at our hospital and those across the country are suggesting that outside images and any other data used to help arrive at a diagnosis should be retained. This has been the case for images reviewed in uncompressed format as well as outside studies. Upon review in court, CAD markings would likely be considered akin to measurements made in a 3-D laboratory or by individual radiologists using an advanced workstation. There is a Current Procedural Terminology code for these advanced visualization procedures, technical and professional fees, and the expectation that the results of 3-D rendering be not only mentioned in the report but saved as a PACS image. It would be difficult to convince a judge and jury that mammographic CAD markings should be treated differently. In his letter to JACR, Dr Berlin further opines that although the “mammography report itself is of course a medical record; however, an informal consultation with a radiology colleague, or a CAD marking, that assists a radiologist in making his or her interpretation is not, and therefore neither is subject to the spoliation law.” We believe that it would be erroneous and legally difficult to
Journal of the American College of Radiology Letters to the Editor
equate CAD markings with an informal consultation with a colleague. Radiologists do not bill patients for informal consultations, but they do bill for CAD. Informal consultations do not result in any documentation, whereas CAD markings do. The use of CAD is more akin to a formal consultation with a bill sent to a patient for the consultation. Although there is no specific recommendation from the ACR or the Society of Breast Imaging about these formal billable second opinions, we would expect that a radiologist obtaining a consultation would feel uncomfortable discarding a written consult and that it would not serve the patient’s best interests. From the perspective of optimal patient care, retention of CAD markings offers similar advantages to those offered by retention of 3-D and advanced visualization images and measurements. Radiologists reviewing follow-up studies in the future, for example, can review the CAD markings on a study and reexamine areas selected by the computer as suspicious for tumor as well as areas marked as suspicious microcalcifications. Retention of CAD markings in the system would allow future technological development of CAD software that could use previous markings as a baseline for assessment of change, which would make CAD a more useful and powerful tool. Along the lines of technological advances anticipated in CAD for mammography, new research in CAD is certain to result in improvements in the detection and diagnosis of breast cancer. Unlike Dr Berlin, we can very much conceive of a future in which a state-of-the-art CAD system could be summoned by a plaintiff’s lawyer in the analysis of a case in addition to expert human witnesses. This was our rationale for suggesting that the version of software should be automatically saved with the CAD markings if needed to provide perspective on what the original CAD system presented to the radiologist. We agree with Dr Berlin that it isn’t necessarily true that the use 1135
of CAD has actually become the standard of care. However, we recommend that the ACR consider a guideline about whether its use is a best practice given that a judge and jury might interpret the high proportion of radiologists who use CAD as establishing a standard of care. An ACR guideline could similarly address the specific issue of whether radiologists should indeed retain CAD markings and mention CAD results in their reports.
We also wholeheartedly agree with our friend and colleague Dr Berlin that readers of this letter should draw their own conclusions and act accordingly. Jonathan L. Mezrich, MD, JD MBA, LLM Department of Diagnostic Radiology Yale University School of Medicine 333 Cedar Street, TE2 New Haven, CT 06520 e-mail: [email protected]
Eliot Siegel, MD University of Maryland School of Medicine The authors have no conflicts of interest related to the material discussed in this article.
REFERENCE 1. Berlin L. Mammographic CAD markings: archive or discard? AJR Am J Roentgenol 2011;196:W659. http://dx.doi.org/10.1016/j.jacr.2015.07.034 S1546-1440(15)00733-4
n
SPEAKING OF LANGUAGE
Avoiding Abbreviations in Radiology Reports Samuel J. Kuzminski, MD Abbreviations have become commonplace in the English language, thanks largely to social media and texting. Terms such as LOL, FYI, and OMG have insinuated themselves into everyday usage to the point that all three appear in the Oxford English Dictionary. Abbreviations are no less commonplace in medicine. Many radiologists have experienced the frustration of attempting to glean some clinical data from the medical record, only to encounter a jumble of nonsense abbreviations. We too often return the favor by offering up in our reports obtuse abbreviations of our own. The list of abbreviations radiologists commonly use in their reports is extensive and may even be institution specific [1]. With ever increasing patient access to electronic medical records,
radiologists must be aware that their audience is now more naive about these abbreviations. If a clinician with years of medical training cannot decipher the meaning of an abbreviation in a report, then a patient has no hope of doing so. Abbreviations have a place in medicine. “Standard” abbreviations, such as MRI and CT, save time and can potentially enhance report readability. The difficulty is deciding which ones qualify as “standards,” as there are no set guidelines. If a term is commonly used in ordinary conversation, inclusion in a report is acceptable. There are some entities with long names that are more widely known by their abbreviations, HIV for example. One way to deal with an unwieldy term that will be used multiple times
in a report is to include the full name the first time it is used, with the abbreviation in parenthesis, then use the shortened form on repeated use. The key point is that although a keen eye and extensive medical knowledge are paramount for a radiologist, the ability to clearly communicate is just as essential. Clinicians and patients value clear and understandable reports, and the misuse of abbreviations is likely to result in misunderstandings and frustration.
REFERENCE 1. Hunter TB, Taljanovic MS. Glossary of medical devices and procedures: abbreviations, acronyms, and definitions. Radiographics 2003;23:195-213. http://dx.doi.org/10.1016/j.jacr.2015.07.027 S1546-1440(15)00726-7
n
The author has no conflicts of interest related to the material discussed in this article. Samuel J. Kuzminski, MD: 2301 Erwin Rd, Box 3808, Durham, NC 27710; e-mail: [email protected].
1136
Journal of the American College of Radiology Volume 12 n Number 11 n November 2015