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Abstract Structured reporting in radiology continues to hold substantial potential to improve the quality of service provided to patients and referring physicians. Despite many physicians’ preference for structured reports and various efforts by radiological societies and some vendors, structured reporting has still not been widely adopted in clinical routine. While in many countries national radiological societies have launched initiatives to further promote structured reporting, cross-institutional applications of report templates and incentives for usage of structured reporting are lacking. Various legislative measures have been taken in the USA and the European Union to promote interoperable data formats such as Fast Healthcare Interoperability Resources (FHIR) in the context of the EU Health Data Space (EHDS) which will certainly be relevant for the future of structured reporting. Lastly, recent advances in artificial intelligence and large language models may provide innovative and efficient approaches to integrate structured reporting more seamlessly into the radiologists’ workflow. The ESR will remain committed to advancing structured reporting as a key component towards more value-based radiology. Practical solutions for structured reporting need to be provided by vendors. Policy makers should incentivize the usage of structured radiological reporting, especially in cross-institutional setting. Critical relevance statement Over the past years, the benefits of structured reporting in radiology have been widely discussed and agreed upon; however, implementation in clinical routine is lacking due—policy makers should incentivize the usage of structured radiological reporting, especially in cross-institutional setting. Key points 1. Various national societies have established initiatives for structured reporting in radiology. 2. Almost no monetary or structural incentives exist that favor structured reporting. 3. A consensus on technical standards for structured reporting is still missing. 4. The application of large language models may help structuring radiological reports. 5. Policy makers should incentivize the usage of structured radiological reporting. Graphical Abstract

Abstract Entrustable professional activity (EPA) is a tool for comprehensively evaluating the level of confidence in resident performances across various competencies in medicine. The application of and attitudes towards EPAs in radiology across the European Society of Radiology (ESR) national institutional member societies is still to be determined. An online survey was conducted among ESR national institutional member societies to assess the current use of EPAs and other resident assessment forms among different countries. Although the primary focus was on the use of EPAs, additional questions also addressed the adherence of training programs to the European Training Curriculum (ETC), other methods of continuous assessment, and examinations. A total of 65 responses were received from 38 countries (81% response rate among national institutional member societies). EPAs were being used in radiology in 21% of countries and planned to be used in 26%. Most responders considered EPAs suitable for radiology and, regarding the future, preferred European-level guidelines on EPAs over national or institutional levels. The majority (63%) of national training programs were reported to be similar to or following the content of the ETC, and the majority (95%) of countries rated the requirements of the European Training Curriculum (ETC) to be adequate. In conclusion, EPAs are beginning to be used in radiology resident training programs across Europe, and their use is expected to increase. There seems to be a positive attitude toward using EPAs in radiology and toward a common European framework. Critical relevance statement As a result of this survey, we found positive attitudes towards using entrustable professional activities (EPA) in radiology among the institutional member societies of the European Society of Radiology (ESR). Key points • Twenty-one percent of national member societies use entrustable professional activities (EPA) in radiology. • There is a positive attitude toward using EPAs in radiology. • Majority of respondents preferred a common European framework for EPAs. • Majority of radiology training curricula adhere to the European Training Curriculum (ETC). Graphical Abstract

Key points 1. Survey findings indicate improvements have been made in the last decade in radiologists’ involvement in undergraduate radiology education. 2. Undergraduate radiology education is curriculum-based in over 90% of ESR-affiliated European countries surveyed. 3. Teaching is now delivered by radiologists across all years of medical training through lectures, workshops, radiology department placements, online resources and simulation.

Key points Multidisciplinary approach to patients is vital for providing balanced and comprehensive health care. Radiology is an integral and indispensable part of all multidisciplinary teams in diagnosing and treating patients. Radiologists need to collaborate with colleagues from other disciplines and increase their visibility. Despite numerous benefits, multidisciplinarity also creates new challenges for radiologists that need to be considered. Multidisciplinarity and building bridges between professions is the way forward as only this approach can ensure that patients will receive the best possible care.

Abstract A survey among the members of European Society of Radiology (ESR) was conducted regarding the current practical clinical experience of radiologists with Artificial Intelligence (AI)-powered tools. 690 radiologists completed the survey. Among these were 276 radiologists from 229 institutions in 32 countries who had practical clinical experience with an AI-based algorithm and formed the basis of this study. The respondents with clinical AI experience included 143 radiologists (52%) from academic institutions, 102 radiologists (37%) from regional hospitals, and 31 radiologists (11%) from private practice. The use case scenarios of the AI algorithm were mainly related to diagnostic interpretation, image post-processing, and prioritisation of workflow. Technical difficulties with integration of AI-based tools into the workflow were experienced by only 49 respondents (17.8%). Of 185 radiologists who used AI-based algorithms for diagnostic purposes, 140 (75.7%) considered the results of the algorithms generally reliable. The use of a diagnostic algorithm was mentioned in the report by 64 respondents (34.6%) and disclosed to patients by 32 (17.3%). Only 42 (22.7%) experienced a significant reduction of their workload, whereas 129 (69.8%) found that there was no such effect. Of 111 respondents who used AI-based algorithms for clinical workflow prioritisation, 26 (23.4%) considered algorithms to be very helpful for reducing the workload of the medical staff whereas the others found them only moderately helpful (62.2%) or not helpful at all (14.4%). Only 92 (13.3%) of the total 690 respondents indicated that they had intentions to acquire AI tools. In summary, although the assistance of AI algorithms was found to be reliable for different use case scenarios, the majority of radiologists experienced no reduction of practical clinical workload.

Abstract Radiology as a specialty has been enormously successful since its beginnings, moving over time from an adjunct to clinical decision-making to a crucial component of multidisciplinary patient care. However, this increased centrality of radiology and reliance on our services carries within it dangers, prominent among them being the danger of our being viewed as deliverers of a commodity, and the risk of our becoming overwhelmed by increasing workload, unable to interact sufficiently with patients and referrers due to pressure of work. With this White Paper, the Board of Directors of the European Society of Radiology (ESR) seeks to briefly explain the position of the radiologist in the modern healthcare environment, considering our duties and contributions as doctors, protectors, communicators, innovators, scientists and teachers. This statement is intended to serve as a summary of the breadth of our responsibilities and roles, and to assist radiologists in countering misunderstanding of who we are and what we do.

Abstract With demand increasing each year for diagnostic imaging and imaging guided interventions, it is important for the radiology workforce to expand in line with need. National and international societies such as the European Society of Radiology have an important role to play in showcasing the diversity of radiology, and highlighting the key role radiologists have in patient care and clinical decision-making to attract the next generation of radiologists. Medical students are an important group to engage with early. Meaningful exposure of undergraduates to radiology with an integrated programme and clinical placements in radiology is essential. Elective courses and dedicated 1-year Bachelor or Masters imaging programmes provide medical students with an opportunity for more in-depth study of radiology practice. Undergraduate radiology societies improve opportunities for engagement and mentorship. Innovations in imaging such as augmented-reality simulation and artificial intelligence and image-guided intervention also offer exciting training opportunities. Through these opportunities, students can gain insight into the wide variety of career opportunities in radiology.

Abstract The ESR International Forum at the ECR 2021 discussed effects of artificial intelligence on the future of radiology and the need for increased visibility of radiologists. The participating societies were invited to submit written reports detailing the current situation in their country or region. The European Society of Radiology (ESR) established the ESR International Forum in order to discuss hot topics in the profession of radiology with non-European radiological partner societies. At the ESR International Forum 2021, different strategies, initiatives and ideas were presented with regard to radiology community’s response to the changes caused by the emerging AI technology.

Abstract The Patient Advisory Group (PAG) of the European Society of Radiology aims to highlight, in this short paper, patients’ expectations from the radiological community and support workers, throughout the patient’s medical imaging journey for completion of diagnostic or interventional examinations. In order to maintain constant awareness of patients’ expectations, key expectations have been summarised in an easy-to-remember mnemonic: PATIENTS CARERS AIMS. Due to disparate healthcare systems and medical imaging services in Europe, not all patient expectations can be systematically met, but healthcare providers should be mindful, when setting up new operational procedures, of the need to focus on patient-centred needs and care. At times when new or improved technology is being introduced, such as artificial intelligence applications, telemedicine, robotisation of interventional procedures and digitised records, the impact on radiologist–patient communication and interactions should be considered.

Abstract Background The ongoing COVID-19 pandemic has significantly affected radiology services around the globe. The impact of the crisis on radiology education in Europe has yet to be determined, in order to identify measures to achieve optimal training of radiologists during pandemics. The aim of this survey was to evaluate the impact of the pandemic on young radiologist members of the European Society of Radiology (ESR). Methods A survey consisting of 28 questions was developed and distributed using SurveyMonkey to all ESR European radiologist members in training. The survey sought to collect information on three main themes, ‘demographics’, ‘training level’ and ‘effects of COVID-19’. The responses were statistically analysed with the use of R programming using descriptive statistics. Results A total of 249 responses from 34 countries were collected. Specific training on COVID-19 was not offered to 52.2% (130) of the participants. A total of 196 participants were not redeployed to other specialities but only 46.2% of institutions allowed residents to work from home. E-learning was offered at 43% of the departments and most participants (86.2%) were not allowed to switch from clinical work to research. A minority (n = 13) were suspended with (30.8%) or without salary (38.5%) or were forced to take vacation/yearly holiday leave (7.7%) or sick leave (23%). Almost half of the participants did not have access to personal protective equipment and a minority of them had their financial status affected. Conclusions The ongoing SARS-CoV-2 outbreak has significantly affected all aspects of postgraduate radiology training across the ESR member countries.

Abstract The recently implemented European Council Basic Safety Standards Directive (BSSD), 2013/59/Euratom lays down core radiation protection standards for European radiology departments, including a mandatory requirement for supporting processes of clinical audit. A repeat survey on behalf of the European Society of Radiology (ESR) was undertaken in February 2021, involving the ESR EuroSafe Imaging Star department network, to re-assess compliance with selected key BSSD requirements following an initial survey in 2018 where variable compliance was demonstrated. 61% (78/128) of eligible departments participated and overall the survey results revealed a mixed picture in terms of implementation of BSSD requirements when compared to the 2018 survey with both improvement and deterioration observed. This pattern was seen also in relation to supporting processes of regulatory audit and re-audit. Higher levels of “skipping” of responses were also observed in 2021. These findings were unexpected in light of the interventions in relation to audit (clinical and regulatory) and radiation protection undertaken by the ESR and other organisations in recent years, but can reasonably be explained by the onset of the COVID-19 pandemic, with consequent significant disruption of radiology services. The 2021 survey results do serve to highlight again the need for co-ordinated intervention involving relevant European bodies, organisations and governmental agencies to address the important issues raised by this survey. The European Commission clinical audit and radiation protection initiatives, QuADRANT, led by the ESR, and SAMIRA will act as important drivers for improvement in patient safety, experience and outcomes across Europe.

Abstract Value-based radiology (VBR) is rapidly gaining ground as a means of considering the input of radiology practice into individual and societal healthcare, and represents a welcome move away from older metrics focused on counting studies performed, without consideration of whether these studies contributed positively to patient management or to society as a whole. Intrinsic to the process of considering whether radiology activity confers value is recognising the breadth of involvement of radiology in healthcare delivery; previous ESR and multi-society publications have explored this, and have sought to highlight the many ways in which our specialty contributes to patient welfare. This paper is intended to highlight some current ESR activities which already contribute substantially to value creation and delivery, and to outline a selection of practical steps which could be taken by the ESR in the future to enhance value. Patient summary Value-based radiology (VBR) is a conceptual means of looking at the benefits conferred on patients and on society as a whole by provision of radiology services, as opposed to older means of counting numbers of radiology studies performed, without consideration of whether or not those studies contributed overall value. VBR will become increasingly important in the future as a means of determining resources. The ESR has been a leader in advancing VBR concepts and educating radiologists about this novel way of looking at what we do. This paper is designed to highlight current ESR activities which contribute value to healthcare, and to consider other ways in which the ESR could potentially support value enhancement in the future.

Abstract This statement summarises basic settings in lung ultrasonography and best practice recommendations for lung ultrasonography in COVID-19, representing the agreed consensus of experts from the Ultrasound Subcommittee of the European Society of Radiology (ESR). Standard lung settings and artefacts in lung ultrasonography are explained for education and training, equipment settings, documentation and self-protection.

Abstract Blockchain can be thought of as a distributed database allowing tracing of the origin of data, and who has manipulated a given data set in the past. Medical applications of blockchain technology are emerging. Blockchain has many potential applications in medical imaging, typically making use of the tracking of radiological or clinical data. Clinical applications of blockchain technology include the documentation of the contribution of different “authors” including AI algorithms to multipart reports, the documentation of the use of AI algorithms towards the diagnosis, the possibility to enhance the accessibility of relevant information in electronic medical records, and a better control of users over their personal health records. Applications of blockchain in research include a better traceability of image data within clinical trials, a better traceability of the contributions of image and annotation data for the training of AI algorithms, thus enhancing privacy and fairness, and potentially make imaging data for AI available in larger quantities. Blockchain also allows for dynamic consenting and has the potential to empower patients and giving them a better control who has accessed their health data. There are also many potential applications of blockchain technology for administrative purposes, like keeping track of learning achievements or the surveillance of medical devices. This article gives a brief introduction in the basic technology and terminology of blockchain technology and concentrates on the potential applications of blockchain in medical imaging.

Abstract The ESR International Forum at the ECR 2020 discussed the current situation, activities and measures undertaken by radiologists around the world in their fight against the global COVID-19 pandemic. The participating societies were invited to submit written reports detailing the current situation in their countries or regions. The European Society of Radiology (ESR) established the ESR International Forum in order to discuss hot topics in the profession of radiology with non-European radiological partner societies. At the ESR International Forum 2020, different strategies, initiatives, and ideas were presented with regard to facing this unprecedented challenge together.

Abstract Rationale and methodology A survey of patients was carried out between January and June 2019, to better understand how patients interpret value in relation to radiology as a means to refining the concept of Value-Based Radiology (VBR) in Europe, ensure radiology’s value is properly weighted in Value-Based Health Care (VBH) metrics, and maximise the value of radiological services to patients. The survey was disseminated via various heads of radiology departments, ESR officers, patient organisations, and ESR website and social media channels. Results Responses were received from 400 patients from 22 countries. Whilst most expressed general satisfaction with the radiological services they received, certain aspects of the radiological services they received left room for improvement. Thirty-six percent of respondents reported that they were not satisfied with the information provided about the risks and benefits of procedures, and thirty-three percent reported not being satisfied with the availability of radiologists for consultation, potentially suggesting that some patients lack sufficient information to participate fully in treatment decisions. Patients were often unaware of what information they were entitled to receive. Over eighty percent of respondents were unfamiliar with the concepts of Value-Based Radiology and/or Value-Based Health Care. Conclusion In addition to procedural correctness (correct diagnosis, appropriate procedures performed), patients highly value information and communication with their radiologist (information provided about procedures, explanation of results, personal consultation). Lack of communication was found to be a cause of dissatisfaction in many cases. This could suggest a means of improving patient outcomes as measured by Value-Based Health Care metrics.

Abstract Background Radiologists undertake a wide variety of functions which have altered as technologies have evolved. The aim of this survey was to explore radiologists’ opinions concerning their role and identity in 2020. Methods The survey included 124 questions on training, daily work, interaction with colleagues and patients, involvement in teaching, research and management and task delegation. An initial draft was amended following responses from the Presidents of the 48 ESR’s national institutional member societies. The final on-line survey was available to individual ESR full members between January and March 2020. 1344 responses from radiologists in 49 European countries were obtained. Findings 80% (1049/1317) of radiologists considered a period of non-radiology clinical training mandatory and 92% (1192/1291) felt that sub-specialty expertise was important and improved the visibility of radiologists. 76% (961/1262) of radiologists regularly communicate directly with patients. Only 25% (314/1238) had undergone formal communications training although 82% (1020/1238) felt that this would be beneficial. Radiologists highly value their positive interaction with colleagues, including within multi-disciplinary team meetings, despite limited resources. Difficulties identified included high workload, especially the need to cover general work in parallel with the need to offer subspecialty expertise. 66% (837/1262) felt that lack of visibility to patients is a risk to radiology and professional visibility could be improved by radiology-led research and teaching. Conclusions ESR activities should aim to (1) support radiologists with sub-specialty training and maintenance of competencies; (2) develop recommendations for patient communications training and multi-disciplinary working with strong clinical integration; (3) enhance radiologists’ visibility by harnessing opportunities for radiology-led research and education.

Abstract In 2013, the new European Basic Safety Standards Directive 2013/59/Euratom (BSS Directive), which defines the new legal framework for the use of ionising radiation in medical imaging and radiotherapy, was published. In 2014, the ESR EuroSafe Imaging Initiative was founded with a goal in mind “to support and strengthen medical radiation protection across Europe following a holistic, inclusive approach”. To support radiology departments in developing a programme of clinical audit, the ESR developed a Guide to Clinical Audit and an accompanying audit tool in 2017, with an expanded second edition released in 2019 and published under the name of Esperanto – ESR Guide to Clinical Audit in Radiology and the ESR Clinical Audit Tool, 2019. Audits represent specific aspects at a certain point in time, usually with retrospective evaluation of data. Key performance indicators (KPIs), on the other hand, are intended to enable continuous monitoring of relevant parameters, for example to provide warnings or a dashboard. KPIs, which can, for example, be recorded automatically and visualised in dashboards, are suitable for this purpose. This paper will discuss a selection of indicators covering different areas and include suggestions for their implementation.

Abstract This document summarises best practice recommendations for medical imaging use of ultrasound in Europe, representing the agreed consensus of experts from the Ultrasound Subcommittee of the European Society of Radiology (ESR), the European Union of Medical Specialists (UEMS) Section of Radiology, and the European Federation of Societies for Ultrasound in Medicine and Biology. Recommendations are given for education and training, equipment and its maintenance, documentation, hygiene and infection prevention, and medico-legal issues.

Abstract Medical imaging capable of generating imaging biomarkers, specifically radiology and nuclear medicine image acquisition and analysis processes, differs from frequently used comparators like blood or urine biomarkers. This difference arises from the sample acquisition methodology. While different analysis methodologies and equipment provide slightly different results in any analytical domain, unlike blood or urine analysis where the samples are obtained by simple extraction or excretion, in radiology the acquisition of the sample is heterogeneous by design, since complex equipment from different vendors is used. Therefore, with this additional degree of freedom in medical imaging, there is still risk of persistent heterogeneity of image quality through time, due to different technological implementations across vendors and protocols used in different centres. Quantitative imaging biomarkers have yet to demonstrate an impact on clinical practice due to this lack of comprehensive standardisation in terms of technical aspects of image acquisition, analysis algorithms, processes and clinical validation. The aim is establishing a standard methodology based on metrology for the validation of image acquisition and analysis methods used in the extraction of biomarkers and radiomics data. The appropriate implementation of the guidelines herein proposed by radiology departments, research institutes and industry will allow for a significant reduction in inter-vendor & inter-centre variability in imaging biomarkers and determine the measurement error obtained, enabling them to be used in imaging-based criteria for diagnosis, prognosis or treatment response, ultimately improving clinical workflows and patient care. The validation of developed analytical methods must be based on a technical performance validation and clinical validation.

Abstract Clinical audit “according to national procedures” is a legal requirement as defined within the recently implemented European Council Basic Safety Standards Directive (BSSD), 2013/59/Euratom. A survey was undertaken in 2019 to assess the current status of clinical audit in European radiology departments and for feedback on the recently published “ESR Guide to Clinical Audit in Radiology” and the “ESR Clinical Audit Tool (Esperanto)”. The survey was distributed within the European Society of Radiology (ESR) EuroSafe Imaging Star network and also to European national radiological societies which are institutional members of the ESR. A total of 47/116 (41%) EuroSafe Imaging Star departments responded, and responses were received from 43 radiology departments from 16/48 national radiological societies. Survey findings demonstrated a low awareness of recent key ESR audit-related publications (Esperanto), a lack of clinical audit infrastructure for BSSD compliance and by inference a poorly developed local/national communication and audit infrastructure in many cases. Key stakeholders, including the ESR and the European national radiological societies, will need to continue to work with other bodies to further promote, integrate and to encourage resourcing of clinical audit at all levels, facilitating BSSD compliance and improving patient care.

Abstract The ESR International Forum at the ECR 2019 discussed strategies for engaging the young generation. The future of radiology is a crucial topic that goes hand in hand with tomorrow’s radiologists. The European Society of Radiology (ESR) established the ESR International Forum in order to discuss hot topics in the profession of radiology with non-European radiological partner societies. At the ESR International Forum 2019, different strategies, initiatives and ideas were presented by the different societies with regard to engaging young doctors into radiology.

Abstract Medical education is evolving and electronic learning (e-Learning) strategies have now become an essential asset in radiology education. Radiology education is a significant part of the undergraduate medical curriculum and the use of e-Learning in radiology teaching in medical schools is on the rise. If coupled with clinical decision support systems, e-Learning can be a practical way of teaching students clinical decision making, such as selecting the diagnostic imaging tests that are best suited in certain clinical scenarios. The innovative concept of flipped classroom learning encourages students to work independently and maximises the application of learnt contents in interactive classroom sessions. For integrated curricula with their student-centred, problem-based, and community-based design, an approach to systematically integrate radiology may be to define diagnostic reasoning as one of the core goals. Radiologists as teachers and scholars may understand themselves as experts in diagnostic reasoning and in mentoring how to make medical decisions. Computer programs simulating the routine work are available and can be used to teach the recognition of anatomical structures and pathological patterns, and also to teach ultrasonography and interventional radiology, maximising patient safety.

Abstract We report the results of a survey conducted among ESR members in November and December 2018, asking for expectations about artificial intelligence (AI) in 5–10 years. Of 24,000 ESR members contacted, 675 (2.8%) completed the survey, 454 males (67%), 555 (82%) working at academic/public hospitals. AI impact was mostly expected (≥ 30% of responders) on breast, oncologic, thoracic, and neuro imaging, mainly involving mammography, computed tomography, and magnetic resonance. Responders foresee AI impact on: job opportunities (375/675, 56%), 218/375 (58%) expecting increase, 157/375 (42%) reduction; reporting workload (504/675, 75%), 256/504 (51%) expecting reduction, 248/504 (49%) increase; radiologist’s profile, becoming more clinical (364/675, 54%) and more subspecialised (283/675, 42%). For 374/675 responders (55%) AI-only reports would be not accepted by patients, for 79/675 (12%) accepted, for 222/675 (33%) it is too early to answer. For 275/675 responders (41%) AI will make the radiologist-patient relation more interactive, for 140/675 (21%) more impersonal, for 259/675 (38%) unchanged. If AI allows time saving, radiologists should interact more with clinicians (437/675, 65%) and/or patients (322/675, 48%). For all responders, involvement in AI-projects is welcome, with different roles: supervision (434/675, 64%), task definition (359/675, 53%), image labelling (197/675, 29%). Of 675 responders, 321 (48%) do not currently use AI, 138 (20%) use AI, 205 (30%) are planning to do it. According to 277/675 responders (41%), radiologists will take responsibility for AI outcome, while 277/675 (41%) suggest shared responsibility with other professionals. To summarise, responders showed a general favourable attitude towards AI.

Abstract The use of portable ultrasound (US) devices has increased in recent years and the market has been flourishing. Portable US devices can be subdivided into three groups: laptop-associated devices, hand-carried US, and handheld US devices. Almost all companies we investigated offer at least one portable US device. Portable US can also be associated with the use of different US techniques such as colour Doppler US and pulse wave (PW)-Doppler. Laptop systems will also be available with contrast-enhanced US and high-end cardiac functionality. Portable US devices are effective in the hands of experienced examiners. Imaging quality is predictably inferior to so-called high-end devices. The present paper is focused on portable US devices and clinical applications describing their possible use in different organs and clinical settings, keeping in mind that patient safety must never be compromised. Hence, portable devices must undergo the same decontamination assessment and protocols as the standard equipment, especially smartphones and tablets.

Abstract The importance of clinical audit in radiological practice is increasingly recognised and undertaking clinical audit “in accordance with national procedures” is mandatory for radiology departments within the European Union following implementation of the Basic Safety Standard Directive (BSSD), 2013/59/Euratom in 2018. This survey, sent to all National Radiological Societies in Europe in 2018, evaluated the current status of clinical audit at national level and supporting infrastructure, and explored the potential for wider co-operation and collaboration in developing and evaluating clinical audit processes. Responses were received from 36/47 (76.6%) National Societies. Broadly responses indicated an increasing awareness of the importance of clinical audit, but highlighted deficiencies in necessary infrastructure and resources required for enhancement and development of existing clinical audit systems. National Societies are well placed, in the context of appropriate and prioritised resource allocation, to collaborate with other European bodies, in particular the European Society of Radiology (ESR), to help lead on these important changes, with the potential to provide external direction.

Abstract The recently implemented European Council Basic Safety and Standards Directive (BSSD), 2013/59/Euratom lays down core radiation protection standards for European radiology departments, with a mandatory requirement for supporting clinical audit processes. A survey on behalf of the European Society of Radiology (ESR) was undertaken in November 2018 involving the ESR EuroSafe Imaging Star department network to assess compliance with selected key BSSD requirements, with emphasis also on clinical audit/re-audit. 64% of invited departments participated and the survey results revealed a lack of compliance with BSSD requirements even when allowing for work in progress within departments. Justification processes showed the lowest rates of compliance overall, with varying results relating to dose limits, patient information and significant accidental exposure notification. Questions around implementation of diagnostic reference levels (DRLs) revealed generally far higher compliance with requirements. The survey findings confirm a lack of compliance with key BSSD radiation protection indicators and also a lack of supporting clinical audit structures. These findings are likely to be representative of the wider radiological community in Europe. There is a need for a co-ordinated response, involving relevant European agencies, national bodies and societies and also individual radiology departments to address these issues. ESR publications on clinical audit (Esperanto) and the 2018 EuroSafe Imaging Call for Action will be important components of this response.

Abstract The fundamental professional roles of radiographers and radiologists are focused on providing benefit to patients with our skills, while maintaining their safety at all times. There are numerous patient safety issues in radiology which must be considered. These encompass: protection from direct harm arising from the techniques and technologies we use; ensuring physical and psychological well-being of patients while under our care; maintaining the highest possible quality of service provision; and protecting the staff to ensure they can deliver safe services. This paper summarises the key categories of safety issues in the provision of radiology services, from the joint perspectives of radiographers and radiologists, and provides references for further reading in all major relevant areas. This is a joint statement of the European Society of Radiology (ESR) and the European Federation of Radiographer Societies (EFRS), published simultaneously in Insights into Imaging [DOI:10.1186/s13244-019-0721-y] and Radiography (DOI: 10.1016/j.radi.2019.01.009).

Abstract This paper aims to provide a review of the basis for application of AI in radiology, to discuss the immediate ethical and professional impact in radiology, and to consider possible future evolution. Even if AI does add significant value to image interpretation, there are implications outside the traditional radiology activities of lesion detection and characterisation. In radiomics, AI can foster the analysis of the features and help in the correlation with other omics data. Imaging biobanks would become a necessary infrastructure to organise and share the image data from which AI models can be trained. AI can be used as an optimising tool to assist the technologist and radiologist in choosing a personalised patient’s protocol, tracking the patient’s dose parameters, providing an estimate of the radiation risks. AI can also aid the reporting workflow and help the linking between words, images, and quantitative data. Finally, AI coupled with CDS can improve the decision process and thereby optimise clinical and radiological workflow.

Abstract The European Society of Radiology (ESR) considers the use of evidence-based referral guidelines in clinical practice essential to ensure the appropriate utilisation of medical imaging for patients. Since 2014, the ESR has been working with the American College of Radiology (ACR) to develop referral guidelines for Europe, based on the ACR Appropriateness Criteria (AC) and appropriate use criteria developed by the ACR Rapid Response Committee. This paper sets out the methodology used by the ESR’s Referral Guidelines Subcommittee to adapt the ACR criteria for use in the European clinical decision support (CDS) platform ESR iGuide. The ESR adheres to the ACR’s original methodology as far as applicable, and has established additional methodological guidance for its experts, establishing several key principles:Any changes to existing recommendations, and any additional guidelines, should be based on evidence as far as possibleExpert opinion, judgement, European practice standards, should only function as a supplement when necessaryAppropriateness recommendations should give no consideration to national or institutional circumstances, costs, or availability of equipment. The cooperation between the ACR and ESR on appropriate use criteria and imaging referral guidelines provides added value to both societies as European studies and guidelines from European subspecialty societies of radiology are fed into the process and the exchange of views among the experts makes the guideline development and review process more robust. The ESR’s aim is to ensure referrers and patients benefit from the best possible guidance for appropriate imaging.

Abstract The International Forum, established by the European Society of Radiology (ESR), aims to discuss important topics in the field of radiology with radiological partner societies from outside Europe. Value-based healthcare is currently a hot topic around the world and has been addressed in many papers. The ESR chose the topic “value-based radiology” for the ESR International Forum at ECR 2018 to discuss the trend within radiology to move from volume-based to value-based practice. The value-based healthcare (VBH) concept defined “value” as health outcomes achieved for patients relative to the costs of achieving them (European Society of Radiology (ESR) 2017, Insights Imaging 8: 566). Value should increase the health outcome and decrease the cost of delivering the outcomes. Radiology is simply counted as a cost and therefore, it is important that the radiologists themselves have an active role in the transition to be recognised as clinicians taking care of the patients.

Abstract Objectives To gather information from radiological departments in Europe about the organization and practice of interventional radiology (IR). Methods The European Society of Radiology (ESR) and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) developed an online survey with questions that addressed the organization of IR within radiology departments. The survey was sent to 1180 addresses of department heads throughout Europe. Results There were 98 answers (response rate 8.3%) from many European nations, reflecting the situation of IR in Europe. Conclusions Five points of action can be suggested based on the survey results. There is a need to assure 24-h service of IR in all radiological departments; networking can be the solution in case staffing problems arise. To attract students, IR needs to be recognized early as a possible career option. Although IR is included in the ESR Curriculum for Undergraduate Radiological Education, this is not the case everywhere, and it must be. There is a “gender issue” in IR since the majority of specialists are male. The lack of role models is probably the main reason why women do not pursue an interventional career. It is, therefore, necessary to increase the number of women in faculty and chair positions to provide a well-balanced leadership team. The field of radiology should work towards recognition of the full clinical role of IR, making efforts to also take into account the “administrative” responsibility throughout the entire process of care for each patient treated by interventional radiologists. Additionally, those radiologists who perform only diagnostic tasks must take an active role in IR. When a situation is encountered which could be amenable to therapy with IR, the radiological report should suggest this form of therapy and the patient should be referred to colleagues in IR.

Abstract The Digital Imaging Adoption Model (DIAM), a joint project established in 2016 by the European Society of Radiology (ESR) and the Healthcare Information and Management Systems Society (HIMSS), is designed to assist imaging institutions in implementing increasingly integrated IT systems and improving patient care. The model provides a framework through which existing capacities can be assessed and strategy for future institutional development elaborated. DIAM has already been adopted by 58 leading institutions in 18 countries. This article will first provide an overview of the DIAM framework; subsequently, it will consider what its adoption has revealed so far, both through the analysis of global data and through specific case studies; finally, it will outline the future potential and goals of the project.

Abstract Since February 2018, the Directive 2013/59/EURATOM (EU-BSS) requires all EU member states to implement a system for recording and analysis of all accidental or unintended medical exposures (Article 63). An ESR questionnaire in May 2018 among ESR member countries including all EU member states (MS) revealed a very heterogeneous and unsatisfactory situation in transposition of the EU-BSS. Some MS just translated this part of the directive, others used effective dose as reporting criteria and others used physical dose parameters from the modalities. This white paper will help national scientific organisations advice their national regulators and authorities on how to provide a simple and practicable implementation of the directive. ESR recommends notification and reporting criteria for significant events based on physical quantities and units and not on effective dose or text-based criteria like “significantly different” (EU-BSS, Article 4 (99)).

Abstract Fusion imaging allows exploitation of the strengths of all imaging modalities simultaneously, eliminating or minimizing the weaknesses of every single modality. Ultrasound (US) fusion imaging provides benefits in real time from both the dynamic information and spatial resolution of the normal US and the high-contrast resolution and wider field of view of the other imaging methods. US fusion imaging can also be associated with the use of different ultrasound techniques such as color Doppler US, elastography, and contrast-enhanced US (CEUS), for better localization and characterization of lesions. The present paper is focused on US fusion imaging technologies and clinical applications describing the possible use of this promising imaging technique in the liver, kidney, and pancreatic pathologies.

Abstract Objectives The Radiology Trainees Forum (RTF) of the European Society of Radiology (ESR) conducted a survey among radiologists in training to gather and evaluate data on workplace satisfaction, ESR educational initiatives, mobility of professionals and stress levels. Methods A questionnaire was forwarded to radiologists in training across Europe. The subject of the questionnaire was related to: (1) the working place, (2) safety of the working environment, (3) satisfaction at the working place, (4) familiarity with educational initiatives within the ESR and (5) reasons and motivation for mobility. Results were obtained and analysed. Results Invitations to participate were sent by the ESR office to radiologists in training across Europe. A total of 1045 radiologists responded to the questionnaire; 77.8% were trainees and 22.2% were certified radiologists. Of the responders 65.3% considered the working place safe. Only 25.7% considered themselves involved in management, 43.9% would consider working in another country, and 52.3% were moderately satisfied with their working place. Of the responders 46.8% did not have any teaching responsibilities; 59.7% knew the European Diploma in Radiology (EDiR) and 69.7% were not aware of the content of the ESR European Training Curriculum (ETC). Conclusion The level of training in aspects related to management safety and quality is low among trainees. The level of satisfaction at work is adequate but not sufficient. The degree of responsibility in training tasks is scarce. A small percentage is familiar with the ESR educational initiatives. As for the mobility the main reservation is lack of confidence in the training acquired. Main Messages • For satisfaction levels to improve, it is vital to include more creative aspects of the profession, such as research and teaching, in balance with the routine aspects of radiology. • Furthermore, a greater involvement of radiologists in patient care is also essential in radiology training. • To facilitate mobility, it is important to standardise training across European countries through universal programmes and training controls such as the EDiR and the ETC.

Abstract Clinical audit is a powerful tool to improve patient care, experience and outcome. It consists of measuring a clinical outcome or procedure against predefined standards, identifying differences between current practice and the standards, and changing practice where necessary to facilitate meeting the standards, followed by re-audit (the audit cycle). The recently implemented European Council Basic Safety & Standards (BSS) Directive (2013/59/Euratom) emphasises that carrying out clinical audit is compulsory in the EU “in accordance with national requirements”. In 2017, the ESR published a Clinical Audit Tool booklet (Esperanto), consisting of an explanation of clinical audit, guidance on how to start a program in a radiology department, and 17 sample audit templates which could guide departments through the process of performing audits. A sample of key audits from these templates was performed by participating EuroSafe Imaging Star departments as a pilot project, with participants providing feedback on the audit process, and their experience of using the templates. Responses showed that the chosen topics were relevant, the audit process and templates were straightforward and easy to use, and that the audit process was time-efficient. Following this successful pilot, the Audit Tool has been made available for all potential users through the ESR website. Key Points • Clinical audit is the process of assessing one’s practice against defined standards, altering practice if necessary to meet standards, and re-assessing following changes to confirm improvement • Clinical audit should be part of practice in all radiology departments • Under European Council Directive 2013/59/Euratom, clinical audit is compulsory in the EU “in accordance with national requirements” • The ESR has developed a Clinical Audit Tool (Esperanto) to explain the process and guide departments through sample audit templates • This Clinical Audit Tool was successfully piloted in 2017, and is now available to all users on the ESR website

Abstract Mobile devices (smartphones, tablets, etc.) have become key methods of communication, data access and data sharing for the population in the past decade. The technological capabilities of these devices have expanded very rapidly; for example, their in-built cameras have largely replaced conventional cameras. Their processing power is often sufficient to handle the large data sets of radiology studies and to manipulate images and studies directly on hand-held devices. Thus, they can be used to transmit and view radiology studies, often in locations remote from the source of the imaging data. They are not recommended for primary interpretation of radiology studies, but they facilitate sharing of studies for second opinions, viewing of studies and reports by clinicians at the bedside, etc. Other potential applications include remote participation in educational activity (e.g. webinars) and consultation of online educational content, e-books, journals and reference sources. Social-networking applications can be used for exchanging professional information and teaching. Users of mobile device must be aware of the vulnerabilities and dangers of their use, in particular regarding the potential for inappropriate sharing of confidential patient information, and must take appropriate steps to protect confidential data. Key Points • Mobile devices have revolutionized communication in the past decade, and are now ubiquitous. • Mobile devices have sufficient processing power to manipulate and display large data sets of radiological images. • Mobile devices allow transmission & sharing of radiologic studies for purposes of second opinions, bedside review of images, teaching, etc. • Mobile devices are currently not recommended as tools for primary interpretation of radiologic studies. • The use of mobile devices for image and data transmission carries risks, especially regarding confidentiality, which must be considered.

Abstract Structured reporting is emerging as a key element of optimising radiology’s contribution to patient outcomes and ensuring the value of radiologists’ work. It is being developed and supported by many national and international radiology societies, based on the recognised need to use uniform language and structure to accurately describe radiology findings. Standardisation of report structures ensures that all relevant areas are addressed. Standardisation of terminology prevents ambiguity in reports and facilitates comparability of reports. The use of key data elements and quantified parameters in structured reports (“radiomics”) permits automatic functions (e.g. TNM staging), potential integration with other clinical parameters (e.g. laboratory results), data sharing (e.g. registries, biobanks) and data mining for research, teaching and other purposes. This article outlines the requirements for a successful structured reporting strategy (definition of content and structure, standard terminologies, tools and protocols). A potential implementation strategy is outlined. Moving from conventional prose reports to structured reporting is endorsed as a positive development, and must be an international effort, with international design and adoption of structured reporting templates that can be translated and adapted in local environments as needed. Industry involvement is key to success, based on international data standards and guidelines. Key Points • Standardisation of radiology report structure ensures completeness and comparability of reports. • Use of standardised language in reports minimises ambiguity. • Structured reporting facilitates automatic functions, integration with other clinical parameters and data sharing. • International and inter-society cooperation is key to developing successful structured report templates. • Integration with industry providers of radiology-reporting software is also crucial.

Abstract The International Forum is held once a year by the ESR and its international radiological partner societies with the aim to address and discuss selected topics of global relevance in radiology. In 2017, the issue of the position of interventional radiology (IR) within radiology was analysed. IR is expanding because of the increased patient demand for minimally invasive therapies performed under imaging guidance, and its success in improving patient outcomes, reducing in-hospital stays, reducing morbidity and mortality of treatment in many organs and organ-systems. Despite the many successes of IR, public awareness about it is quite low. IR requires specific training and, in most countries, the majority of interventional radiologists do not dedicate their time completely to IR but perform diagnostic radiology investigations as well. Turf battles in IR are common in many countries. To preserve and keep IR within radiology, it is necessary to focus more on direct and longitudinal patient care. Having beds dedicated to IR within radiology departments is very important to increase clinical involvement of interventional radiologists. IR procedures fit perfectly within “value-based healthcare”, but the metrics have to be developed. Main messages • IR should stay a prominent subspecialty within radiology. • Dedicated IR training pathways are mandatory. • Measures to increase recruitment of young doctors to IR and to increase public awareness of IR are needed. • Beds dedicated to IR within radiology departments are important in order to increase clinical involvement of interventional radiologists.

Abstract The European Society of Radiology (ESR) established a Working Group on Value-Based Imaging (VBI WG) in August 2016 in response to developments in European healthcare systems in general, and the trend within radiology to move from volume- to value-based practice in particular. The value-based healthcare (VBH) concept defines “value” as health outcomes achieved for patients relative to the costs of achieving them. Within this framework, value measurements start at the beginning of therapy; the whole diagnostic process is disregarded, and is considered only if it is the cause of errors or complications. Making the case for a new, multidisciplinary organisation of healthcare delivery centred on the patient, this paper establishes the diagnosis of disease as a first outcome in the interrelated activities of the healthcare chain. Metrics are proposed for measuring the quality of radiologists’ diagnoses and the various ways in which radiologists provide value to patients, other medical specialists and healthcare systems at large. The ESR strongly believes value-based radiology (VBR) is a necessary complement to existing VBH concepts. The Society is determined to establish a holistic VBR programme to help European radiologists deal with changes in the evolution from volume- to value-based evaluation of radiological activities. Main Messages • Value-based healthcare defines value as patient’s outcome over costs. • The VBH framework disregards the diagnosis as an outcome. • VBH considers diagnosis only if wrong or a cause of complications. • A correct diagnosis is the first outcome that matters to patients. • Metrics to measure radiologists’ impacts on patient outcomes are key. • The value provided by radiology is multifaceted, going beyond exam volumes.

Abstract The European Society of Radiology (ESR) informs its membership and its associated Institutional Members about the new General Data Protection Regulation (GDPR) of the European Union (EU,) which will apply from 25 May 2018. Radiologists and radiology departments should be prepared to comply with several new rules for the protection of imaging data. Although the new GDPR applies to all domains of the public and private sectors, some specific derogations are defined for data concerning health, aiming at protecting the rights of data subjects and confidentiality of their personal health data, whilst preserving the benefits of processing data, including digital images for research and public health purposes. Specific new obligations which healthcare providers (including radiologists/radiology departments) should prepare for include data access for patients, rules for data processing including explicit consent of the data subject in the absence of derogations, or technical and organisational safeguards. National health authorities can define exceptions and derogations from certain obligations by means of national law. They will also define sanctions in the form of penalties or fines that may be applicable for organisations of the public and private sector that fail to comply with the rules of the GDPR. Main messages • Explicit consent prior to data processing will be necessary. • Explicit consent prior to communication of imaging data will be necessary. • Providing patient access to their personal data, including portability, will be required. • Certain derogations and exceptions exist for healthcare and research. • Additional specific rules may be defined by national law.