- Diagnostic Radiology
Professor - Med Center Line, Radiology - Pediatric Radiology
Associate Dean, Maternal and Child Health (Quality and Safety), Stanford University School of Medicine (2018 - Present)
Christopher G. Dawes Endowed Director of Quality, Lucile Packard Children's Hospital / Stanford Children's Health (2018 - Present)
Chief Quality Officer, Lucile Packard Children's Hospital at Stanford (2017 - Present)
Professor, Stanford University School of Medicine (2017 - Present)
Board Certification: Diagnostic Radiology, American Board of Radiology (1994)
Board Certification: Pediatric Radiology, American Board of Radiology (1996)
Fellowship:Cincinnati Children's Hospital Medical Center (1995) OH
Residency:University of Cincinnati College of Medicine (1994) OH
Medical Education:University of Cincinnati College of Medicine (1990) OH
Pediatric Radiology, Cincinnati Children's Hospital Medical Center, Pediatric Radiology (1995)
Radiology, University of Cincinnati, Radiology (1994)
MD, University of Cincinnati College of Medicine, Medicine (1990)
BS, Ohio State University, Biology (1986)
- Author's Reply. Journal of the American College of Radiology : JACR 2019; 16 (1): 6–7
Gauging potential risk for patients in pediatric radiology by review of over 2,000 incident reports
2018; 48 (13): 1867–74
Incident reporting can be used to inform imaging departments about adverse events and near misses.To study incident reports submitted during a 5-year period at a large pediatric imaging system to evaluate which imaging modalities and other factors were associated with a greater rate of filed incident reports.All incident reports filed between 2013 and 2017 were reviewed and categorized by modality, patient type (inpatient, outpatient or emergency center) and use of sedation/anesthesia. The number of incident reports was compared to the number of imaging studies performed during that time period to calculate an incident report rate for each factor. Statistical analysis of whether there were differences in these rates between factors was performed.During the study period, there were 2,009 incident reports filed and 1,071,809 imaging studies performed for an incident report rate of 0.19%. The differences in rates by modality were statistically significant (P=0.0001). There was a greater rate of incident reports in interventional radiology (1.54%) (P=0.0001) and in magnetic resonance imaging (MRI) (0.62%) (P=0.001) as compared to other imaging modalities. There was a higher incident report rate for inpatients (0.34%) as compared to outpatient (0.1%) or emergency center (0.14%) (P=0.0001). There was a higher rate of incident reports for patients under sedation (1.27%) as compared to non-sedated (0.12%) (P=0.0001).Using incident report rates as a proxy for potential patient harm, the areas of our pediatric radiology service that are associated with the greatest potential for issues are interventional radiology, sedated patients, and inpatients. The areas associated with the least risk are ultrasound (US) and radiography. Safety improvement efforts should be focused on the high-risk areas.
View details for DOI 10.1007/s00247-018-4238-1
View details for Web of Science ID 000452082100005
View details for PubMedID 30159593
- Impact on Quality When Pediatric Urgent Care Centers Are Staffed With Radiology Technologists JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY 2018; 15 (12): 1717–22
The American Board of Radiology B. Leonard Holman Research Pathway to Initial Certification: Opportunities Lost for Diagnostic Radiology.
AJR. American journal of roentgenology
OBJECTIVE: In 1998, the American Board of Radiology introduced the B. Leonard Holman Research Pathway (HRP) to initial certification for trainees in diagnostic radiology (DR) and radiation oncology (RO) motivated to pursue research-oriented careers in academic DR and RO.CONCLUSION: The HRP Committee anticipated that there would be a relatively even distribution between DR and RO participants, but with 18 years of experience that has not been the case. This article focuses on the HRP and DR.
View details for DOI 10.2214/AJR.18.20163
View details for PubMedID 30476455
Using a Natural Language Processing and Machine Learning Algorithm Program to Analyze Inter-Radiologist Report Style Variation and Compare Variation Between Radiologists When Using Highly Structured Versus More Free Text Reporting.
Current problems in diagnostic radiology
PURPOSE: To use a natural language processing and machine learning algorithm to evaluate inter-radiologist report variation and compare variation between radiologists using highly structured versus more free text reporting.MATERIALS AND METHODS: 28,615 radiology reports were analyzed for 4 metrics: verbosity, observational terms only, unwarranted negative findings, and repeated language in different sections. Radiology reports for two imaging examinations were analyzed and compared - one which was more templated (ultrasound - appendicitis) and one which relied on more free text (chest radiograph - single view). For each metric, the mean and standard deviation for defined outlier results for all dictations (individual and group mean) was calculated. The mean number of outlier metrics per reader per study was calculated and compared between radiologists and between the two report types. Wilcoxon rank test and paired Wilcoxon signed rank test were applied. The radiologists were also ranked based on the number of outlier metrics identified per study.RESULTS: There was great variability in radiologist dictation styles - outlier metrics per report varied greatly between radiologists with the maximum 10 times higher than the minimum score. Metric values were greater (P < 0.0001) on the standardized reports using free text than the more structured reports.CONCLUSIONS: The algorithm successfully evaluated metrics showing variability in reporting profiles particularly when there is free text. This variability can be an obstacle to providing effective communication and reliability of care.
View details for DOI 10.1067/j.cpradiol.2018.09.005
View details for PubMedID 30391224
Radiographic appearance and clinical significance of fidget spinner ingestions
2018; 48 (11): 1584–92
According to anecdotal press reports, there have been medically significant ingestions of fidget spinner toys, including ingestions that required endoscopic intervention. Fidget spinners have been marketed to improve attention and have been suggested as a therapeutic alternative to medications in children with attention deficit hyperactivity disorder (ADHD).To describe the radiographic appearance and features of ingested fidget spinner components. To evaluate clinical significance via rates of endoscopic intervention, incidence in patients on ADHD medications, and mean age compared to other accidental foreign body ingestions.A nested retrospective case control study analyzed pediatric accidental foreign body ingestions identified via electronic medical record search between March 1, 2017, and Feb. 28, 2018. Radiographic identifiability, component type and maximum diameter of ingested fidget spinner components were described. A nested cohort of non-fidget spinner ingestions between May 1 and Aug. 31, 2017, was compared with the fidget spinner ingestions for rates of endoscopic intervention (a), concomitant use of ADHD medication (b) and mean age (c) using the Fisher exact test (a and b) and independent samples t-test (c).There were 1,095 unintentional foreign body ingestions. Ten were ingested fidget spinner component ingestions. Eight of the 10 ingested components were radiographically identifiable. Compared with the nested cohort of non-fidget spinner ingestions, fidget spinner ingestions were more likely to undergo endoscopic intervention (P=0.009, 5/10 fidget spinner ingestions vs. 54/383 other ingestions). Fidget spinner patients were more likely to be on ADHD medication (P=0.011, 2/10 fidget spinners vs. 5/383 other). Fidget spinner mean patient age was significantly older than other ingestions (P=0.015, mean: 7.1 years fidget spinner ingestions vs. 4.0 years for other ingestions).Compared with other foreign body ingestions, patients who ingested fidget spinner components were more likely to undergo endoscopic intervention, had a higher rate of ADHD medication use and were older. Familiarity with the radiographic appearance of ingested fidget spinner components is important for patient management.
View details for DOI 10.1007/s00247-018-4179-8
View details for Web of Science ID 000444838000006
View details for PubMedID 29955903
Optimizing Performance by Preventing Disruptive Behavior in Radiology.
Radiographics : a review publication of the Radiological Society of North America, Inc
2018; 38 (6): 1639–50
Disruptive behaviors impede delivery of high-value health care by negatively impacting patient outcomes and increasing costs. Health care is brimming with potential triggers of disruptive behavior. Given omnipresent environmental and cultural factors such as constrained resources, stressful environments, commercialization, fatigue, unrealistic expectation of perfectionism, and burdensome documentation, a burnout epidemic is raging, and medical providers are understandably at tremendous risk to succumb and manifest these unprofessional behaviors. Each medical specialty has its own unique challenges. Radiology is not exempt; these issues do not respect specialty or professional boundaries. Unfortunately, preventive measures are too frequently overlooked, provider support programs rarely exist, and often organizations either tolerate or ineffectively manage the downstream disruptive behaviors. This review summarizes the background, key definitions, contributing factors, impact, prevention, and management of disruptive behavior. Every member of the health care team can gain from an improved understanding and awareness of the contributing factors and preventive measures. Application of these principles can foster a just culture of understanding, trust, support, respect, and teamwork balanced with accountability. The authors discuss these general topics along with specific issues for radiologists in the current medical environment. Patients, providers, health care organizations, and society all stand to benefit from better prevention of these behaviors. There is a strong moral, ethical, and business case to address this issue head-on. ©RSNA, 2018.
View details for DOI 10.1148/rg.2018180019
View details for PubMedID 30303780
Costs of Quality and Safety in Radiology.
Radiographics : a review publication of the Radiological Society of North America, Inc
2018; 38 (6): 1682–87
With the movement toward at-risk population health management-related payment models, a core factor for the success and survival of health care organizations has become understanding and decreasing costs. In medical specialties such as radiology, understanding models for procedure-based costing will become increasingly important. Using bottom-up models for procedure-based costing, such as time-driven activity-based costing, is more advantageous than using the inaccurate ratio of costs to charges approach; however, these approaches are more resource intensive when compared to top-down approaches. Understanding the costs of quality is also important for creating an accounting and budgeting process that reflects the total cost of quality. The costs of quality are divided into two main categories: the cost of control (also referred to as the costs of conformance) and the costs of failure of control (also referred to as the costs of nonconformance). The costs of control are the expenditures that occur to ensure quality. The costs of noncontrol are the expenses that arise from the lack of quality and safety. The cost of control has two subcategories: prevention costs and appraisal costs. The cost of noncontrol also has two subcategories: internal failure costs and external failure costs. Adopting a mind-set that takes into account the costs of control, or the costs to ensure high-quality care, and the costs of noncontrol, or the hidden costs of poor-quality care, will be essential for successful health care organizations in the future. ©RSNA, 2018.
View details for DOI 10.1148/rg.2018180020
View details for PubMedID 30303806
Practical Application of the International Neuroblastoma Risk Group Staging System: A Pictorial Review.
Current problems in diagnostic radiology
Because of issues with the previous staging system, the International Neuroblastoma Risk Group Staging System (INRG-SS) was created in 2009. The INRG-SS is based on preoperative imaging, rather than surgical, staging and emphasizes Imaging-Defined Risk Factors as the determining factors between L1 and L2 stages. Like with the introduction of any new tool, based on the authors' experience, there has been a time-lag related to adoption of the INRG-SS staging system by radiologists. This pictorial essay offers a practical approach to learning and utilizing the INRG system, emphasizing use of the descriptive terms which determine the presence or absence of imaging-defined risk factors.
View details for DOI 10.1067/j.cpradiol.2018.08.008
View details for PubMedID 30268582
Magnetic resonance imaging of obstructive sleep apnea in children
2018; 48 (9): 1223–33
Sleep-disordered breathing has a spectrum of severity that spans from snoring and partial airway collapse with increased upper airway resistance, to complete upper airway obstruction with obstructive sleep apnea during sleeping. While snoring occurs in up to 20% of children, obstructive sleep apnea affects approximately 1-5% of children. The obstruction that occurs in obstructive sleep apnea is the result of the airway collapsing during sleep, which causes arousal and impairs restful sleep. Adenotonsillectomy is the first-line treatment of obstructive sleep apnea and is usually effective in otherwise healthy nonsyndromic children. However, there are subgroups in which this surgery is less effective. These subgroups include children with obesity, severe obstructive sleep apnea preoperatively, Down syndrome, craniofacial anomalies and polycystic ovarian disease. Continuous positive airway pressure (CPAP) is the first-line therapy for persistent obstructive sleep apnea despite previous adenotonsillectomy, but it is often poorly tolerated by children. When CPAP is not tolerated or preferred by the family, surgical options beyond adenotonsillectomy are discussed with the parent and child. Dynamic MRI of the airway provides a means to identify and localize the site or sites of obstruction for these children. In this review the authors address clinical indications for imaging, ideal team members to involve in an effective multidisciplinary program, basic anesthesia requirements, MRI protocol techniques and interpretation of the findings on MRI that help guide surgery.
View details for DOI 10.1007/s00247-018-4180-2
View details for Web of Science ID 000440818200005
View details for PubMedID 30078047
Practical Suggestions on How to Move From Peer Review to Peer Learning
AMERICAN JOURNAL OF ROENTGENOLOGY
2018; 210 (3): 578–82
The purpose of this article is to outline practical steps that a department can take to transition to a peer learning model.The 2015 Institute of Medicine report on improving diagnosis emphasized that organizations and industries that embrace error as an opportunity to learn tend to outperform those that do not. To meet this charge, radiology must transition from a peer review to a peer learning approach.
View details for DOI 10.2214/AJR.17.18660
View details for Web of Science ID 000426017600028
View details for PubMedID 29323555
Comparison Between Manual Auditing and a Natural Language Process With Machine Learning Algorithm to Evaluate Faculty Use of Standardized Reports in Radiology
JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY
2018; 15 (3): 550–53
When implementing or monitoring department-sanctioned standardized radiology reports, feedback about individual faculty performance has been shown to be a useful driver of faculty compliance. Most commonly, these data are derived from manual audit, which can be both time-consuming and subject to sampling error. The purpose of this study was to evaluate whether a software program using natural language processing and machine learning could accurately audit radiologist compliance with the use of standardized reports compared with performed manual audits.Radiology reports from a 1-month period were loaded into such a software program, and faculty compliance with use of standardized reports was calculated. For that same period, manual audits were performed (25 reports audited for each of 42 faculty members). The mean compliance rates calculated by automated auditing were then compared with the confidence interval of the mean rate by manual audit.The mean compliance rate for use of standardized reports as determined by manual audit was 91.2% with a confidence interval between 89.3% and 92.8%. The mean compliance rate calculated by automated auditing was 92.0%, within that confidence interval.This study shows that by use of natural language processing and machine learning algorithms, an automated analysis can accurately define whether reports are compliant with use of standardized report templates and language, compared with manual audits. This may avoid significant labor costs related to conducting the manual auditing process.
View details for DOI 10.1016/j.jacr.2017.10.042
View details for Web of Science ID 000427667000012
View details for PubMedID 29269244
The Daily Operational Brief: Fostering Daily Readiness, Care Coordination, and Problem-Solving Accountability in a Large Pediatric Health Care System
JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY
2018; 44 (1): 43–51
At a pediatric health system, the Daily Operational Brief (DOB) was updated in 2015 after three years of operation. Quality and safety metrics, the patient volume and staffing assessment, and the readiness assessment are all presented. In addition, in the problem-solving accountability system, problematic issues are categorized as Quick Hits or Complex Issues. Walk-the-Wall, a biweekly meeting attended by hospital senior administrative leadership and quality and safety leaders, is conducted to chart current progress on Complex Issues. The DOB provides a daily standardized approach to evaluate readiness to provide care to current patients and improvement in the care to be provided for future patients.
View details for DOI 10.1016/j.jcjq.2017.04.010
View details for Web of Science ID 000418892600006
View details for PubMedID 29290246