Second-opinion Interpretations Research Articles

Value of Second-Opinion Interpretation of Outside-Facility Breast Imaging Studies to a Radiology Department and Cancer Center.

The aim of this study was to estimate the physician work effort for formal written breast radiology second-opinion reports of imaging performed at outside facilities, to compare this effort with a per-report credit system, and to estimate the downstream value of subsequent services provided by the radiology department and institution at a National Comprehensive Cancer Network-designated comprehensive cancer center. A retrospective review was conducted of consecutive reports for "outside film review" from July 1, 2015, to June 30, 2018. The number and types of breast imaging studies reinterpreted for each individual patient request were tabulated for requests for a 3-month sample from each year. Physician effort was estimated on the basis of the primary interpretation CMS fee schedule for work relative value units (wRVUs) for the study-specific Current Procedural Terminology (CPT) code and study type. This effort was compared with the interpreting radiologist credit of 0.44 wRVUs per report. Subsequent imaging and evaluation and management encounters generated by these second-opinion patient requests were tracked through June 30,2019. For the 3-year period reviewed, 2,513 unique patient requests were identified, averaging 837 per fiscal year. For January to March of 2016, 2017, and 2018, 645 unique patient reports were identified. For these reports, 2,216 studies were reinterpreted, with an estimated physician effort of 2,660 wRVUs compared with 284 wRVUs on the basis of per-report credit. The range of annualized wRVUs for all outside studies interpreted and credited per specific CPT code was 3,135 to 3,804 (mean, 3,547). However, the institutional relative value unit credit received for fiscal years 2015, 2016, and 2017, on the basis of the number of patient requests, was only 385, 375, and 345 wRVUs, respectively. This study demonstrates the substantial work effort necessary to provide formal second-opinion interpretations for breast imaging studies at a National Comprehensive Cancer Network cancer center. The authors believe that these data support billing for the study-specific CPT code and crediting the radiologist with the full wRVUs for each study reinterpreted.

Clinical importance of second-opinion interpretations of abdominal imaging studies in a cancer hospital and its impact on patient management

PurposeThe purpose of this retrospective study was to evaluate the quality of outside hospital imaging and associated reports submitted to us for reinterpretation related to clinical care at our tertiary cancer center. We compared the initial study interpretations to that of interpretations performed by subspecialty-trained abdominal radiologists at our center and whether this resulted in a change in inpatient treatment. Materials and methodsWe performed an institutional review board-approved retrospective single-institution study of 915 consecutive outside computed tomography (CT) and magnetic resonance (MR) abdominal imaging studies that had been submitted to our institution between August 1, 2020 and November 30, 2020. The assessed parameters included the quality and accuracy of the report, the technical quality of the imaging compared to that at our institution, the appropriateness of the imaging for staging or restaging, usage of oral and IV contrast, and CT slice thickness. Clinical notes, pathologic findings, and subsequent imaging were used to establish an accurate diagnosis and determine the effect on clinical treatment. Discrepancies between the initial and secondary interpretations were identified independently by a panel of radiologists to assess changes in treatment. The impact of discrepancies on treatment was evaluated based on current treatment guidelines. ResultsOf 744 CT (81%) and 171 MR (19%) outside imaging studies, 65% had suboptimal quality compared to the images at our institution, and 31% were inappropriate for oncological care purposes. Only 21% of CT studies had optimal slice thickness of <3 mm. Of 375 (41%) outside reports, 131 (34%) had discrepancies between secondary and initial interpretations. Of the 88 confirmed discrepant studies, 42 patients (48%) had a change in treatment based on the secondary interpretation. ConclusionsImaging studies from outside institutions have variable image quality and are often inadequate for oncologic imaging. The secondary interpretations by subspecialty-trained radiologists resulted in treatment change.

Automated Deep Learning of COVID-19 and Pneumonia Detection Using Google AutoML

Coronavirus (COVID-19) is a pandemic disease classified by the World Health Organization. This virus triggers several coughing problems (e.g., flu) that include symptoms of fever, cough, and pneumonia, in extreme cases. The human sputum or blood samples are used to detect this virus, and the result is normally available within a few hours or at most days. In this research, we suggest the implementation of automated deep learning without require handcrafted expertise of data scientist. The model developed aims to give radiologists a second-opinion interpretation and to minimize clinicians’ workload substantially and help them diagnose correctly. We employed automated deep learning via Google AutoML for COVID-19 X-ray detection to provide an automated and faster diagnosis. The model is employed on X-ray images to detect COVID-19 based on several binary and multi-class cases. It consists of three scenarios of binary classification categorized as healthy, pneumonia, and COVID-19. The multi-classification model based on these three labels is employed to differentiate between them directly. An investigational review of 1125 chest X-rays indicates the efficiency of the proposed method. AutoML enables binary and multi-classification tasks to be performed with an accuracy up to 98.41%.

Providing second-opinion interpretations of pediatric imaging: embracing the call for value-added medicine.

The value of obtaining second-opinion interpretations by specialty radiologists has been established. In pediatric radiology, this has primarily been explored in general terms, comparing tertiary pediatric radiologists' interpretations to referral reads. In adults, second reads by subspecialty radiologists have been shown to yield changes in patient management, including in neuroradiology, musculoskeletal radiology and oncological radiology. Here, we examine second-opinion reads by pediatric radiologists by reviewing the pediatric and adult subspecialty literature. We also present our experience in providing subspecialty outside reads, summarizing lessons learned in implementing a system for outside interpretations into a pediatric radiology practice.

Musculoskeletal Outside Interpretation (MOI-RADS): an automated quality assurance tool to prospectively track discrepancies in second-opinion interpretations in musculoskeletal imaging.

To implement an automated quality assurance tool to prospectively track discrepancies in musculoskeletal (MSK) exams submitted for second-opinion radiology interpretation at a tertiary center. From 2013 to 2020, a standardized template was included in re-interpretation MSK reports, and a concordance assessment compared with primary interpretation was assigned. Analysis of standardized template implementation and discordance rates was performed. Of the re-interpretations that demonstrated likely clinically relevant discordance, a sample was randomly selected and the EMR was reviewed to evaluate the impact on patient care and change in medical management. A total of 1052 re-interpretations were identified using the standardized template. Services with higher requests for second-opinion interpretation were oncology (n = 351, 33%) and orthopedic surgery (n = 255, 24%). Overall utilization rate of the template was 65% with marked decreased during the last year (22% rate). In comparison to the primary report, there was a 30% discordance rate (n = 309) with 18% (n = 184) classified as likely clinically relevant. From the subset of discrepancies that could be clinically relevant, there was a change in management in 63% of the cases (19/30) with the re-interpretation ultimately proving correct in 80% of the cases (24/30). Implementation of a quality assurance tool embedded in the radiology workflow of second-opinion interpretations can facilitate the analysis of patient care impact; however, stricter implementation is necessary. Oncologic studies were the most common indication for re-interpretations. Although the primary and second interpretations in the majority of cases were in agreement, subspecialty MSK radiology interpretation was shown to be more accurate than primary interpretations and impacted clinical management in cases of discrepancy.

Subspecialty Second-Opinion in Multiple Myeloma CT: Emphasis on Clinically Significant Lytic Lesions.

Background and objectives: In order to increase the accuracy of lytic lesion detection in multiple myeloma, a dedicated second-opinion interpretation of medical images performed by subspecialty musculoskeletal radiologists could increase accuracy. Therefore, the purpose of this study is to evaluate the added value (increased accuracy) of subspecialty second-opinion (SSO) consultations for Computed Tomography (CT) examinations in Multiple Myeloma (MM) patients undergoing stem cell transplantation on standard computed tomography with a focus on focal lesion detection. Materials and Methods: Approval from the institutional review board was obtained. This retrospective study included 70 MM consecutive patients (mean age, 62 years ± 11.3 (standard deviation); range, 35–88 years) admitted in the last six years. Pre-transplant total-body CT (reported by general radiologists) was the only inclusion criteria. Each of these CT examinations had a second-opinion interpretation by two experienced subspecialty musculoskeletal (MSK) radiologists (13 years of experience and 6 years of experience, mean: 9.5 years), experts in musculoskeletal radiology and bone image interpretation with a focus on lytic lesions. Results: Per lesion intra- and inter-observer agreement between the two radiologists was calculated with K statistics and the results were good (K = 0.67: Confidence Inteval (CI) 95%: 0.61–0.78). When the initial CT reports were compared with the re-interpretation reports, 46 (65%) of the 70 cases (95% CI: 37–75%) had no discrepancy. There was a discrepancy in detecting a clinically unimportant abnormality in 10/70 (14%) patients (95% CI: 7–25%) unlikely to alter patient care or irrelevant to further clinical management. A discrepancy in interpreting a clinically important abnormality was registered in 14/70 (21%) patients for focal lesions. The mean diameter of focal lesions was: 23 mm (95% CI: 5–57 mm). The mean number of focal lesions per patient was 3.4 (95% CI). Conclusions: subspecialty second-opinion consultations in multiple myeloma CT is more accurate to identify lesions, especially lytic lesions, amenable to influence patients’ care.

Second-Opinion Reads in Interstitial Lung Disease Imaging: Added Value of Subspecialty Interpretation.

The purpose of this study was to determine how often a second-opinion interpretation of interstitial lung disease (ILD) by an academic cardiothoracic radiologist is discordant with the initial interpretation by a nonacademic radiologists and how often the clinical diagnosis determined by multidisciplinary consensus agrees with the initial and second-opinion interpretations. This retrospective study included 364 consecutive second-opinion CT examination reports of imaging from nonacademic radiology practices from July 2014 to May 2016. The second-opinion interpretations, provided by seven fellowship-trained cardiothoracic radiologists, were compared with the initial interpretations and the clinical diagnoses determined by multidisciplinary consensus. Two hundred ninety-six consecutive reports met the inclusion criteria, and two hundred had findings of ILD. The initial interpretations lacked specific diagnoses in 41% of reports, but the second-opinion reports lacked specific diagnoses in only 7%. When a diagnosis was provided, the second-opinion diagnosis disagreed with the initial interpretation in 25% of cases. The clinical-consensus diagnosis was concordant with that of the academic radiologists 85% of the time but concordant with the initial interpretation only 44% of the time. The academic radiologists' diagnostic sensitivity was higher than that of the initial radiologists for the four most common diagnoses: usual interstitial pneumonitis (0.91 versus 0.4), sarcoidosis (0.94 versus 0.60), hypersensitivity pneumonitis (0.79 versus 0.17), and nonspecific interstitial pneumonitis (0.72 versus 0.14). Academic cardiothoracic radiologists were more likely to provide specific diagnoses for ILD, and these diagnoses were more likely to be concordant with the multidisciplinary consensus.

Detection of recurrent pancreatic cancer: value of second-opinion interpretations of cross-sectional images by subspecialized radiologists.

To investigate the value of second-opinion interpretation of cross-sectional images by subspecialized radiologists to diagnose recurrent pancreatic cancer after surgery. The IRB approved and issued a waiver of informed consent for this retrospective study. Initial and second-opinion interpretations of 69 consecutive submitted MRI or CT follow-up after pancreatic cancer resection between January 1, 2009 and December 31, 2013 were evaluated by one oncologic imaging radiologist, who was blinded to patient's clinical details and histopathologic data. The reviewer was asked to classify each interpretation in reference of the diagnosis of PDAC recurrence. It was also recorded if the radiologic interpretation recommended additional imaging studies to confirm recurrence. The diagnosis of recurrence was determined by pathology when available, otherwise by imaging follow-up, clinical, or laboratory assessments. Cohen's kappa statistic was used to assess agreement between initial and second-opinion interpretations. The differences between the initial and second-opinion interpretations were examined using McNemar test or Bowker's test of symmetry. Disagreement on recurrence between the initial report and the second-opinion interpretation was observed in 32% of cases (22/69; k = 0.44). Second-opinion interpretations had a higher sensitivity and a higher specificity on recurrence compared to the initial interpretations (0.93 vs. 0.75 and 0.90 vs. 0.68, respectively), and the difference in specificity was significant (p = 0.016). Additional imaging studies were recommended more frequently in the initial interpretation (22% vs. 6%, p = 0.006). Our study shows the second-opinion interpretation by subspecialized radiologists improves the detection of pancreatic cancer recurrence after surgical resection.

The Impact of Patient-Initiated Subspecialty Review on Patient Care

PurposeTo determine the effect of subspecialty review of breast imaging on patients without a diagnosis of breast cancer who self-referred for a second opinion. MethodsInstitutional review board–approved retrospective review was performed of 415 breast imaging studies submitted to our cancer center for second-opinion review by 245 patients in 2014, excluding cases without follow-up or change in original BI-RADS 0 assessment. One hundred forty-seven patients with 176 lesions were included. Original and second-opinion interpretations and recommendations were compared with histopathology or follow-up imaging. ResultsNinety-six of 176 (55%) lesions were reported as suspicious in the original interpretation. Second-opinion review was discordant with the original interpretation in 82 of 176 (47%) lesions. Second-opinion review downgraded 24 of 96 (25%) lesions originally reported as suspicious to benign or probably benign, averting biopsy of these lesions. Second-opinion review upgraded 31 of 80 (39%) lesions originally reported as benign or probably benign to suspicious. A total of 87 lesions were biopsied yielding malignancy in 23 (26%) biopsies. Twenty-eight of 87 (32%) biopsies performed were recommended after second-opinion review, with 8 of 28 (29%) of these biopsies yielding cancer. Eight of 23 (35%) cancers detected represented malignancy not initially detected in the original interpretation. ConclusionSecond-opinion review is valuable in patients pursuing a breast imaging specialist’s opinion, even before they are diagnosed with breast cancer. Second-opinion review disagreed with the original interpretation for 47% of lesions, averted 25% of originally recommended biopsies, and detected cancer in 29% of additional biopsies recommended. Thirty-five percent of cancers diagnosed after second-opinion review were not initially detected in the original interpretation.

Impact of Second-Opinion Interpretation of Breast Imaging Studies in Patients Not Currently Diagnosed With Breast Cancer

PurposeTo study the impact of second-opinion interpretation of breast imaging studies submitted from outside facilities to a tertiary cancer center. Materials and MethodsA retrospective database review was conducted of second-opinion interpretations rendered at our institution from January 1, 2010, to June 30, 2014, on studies from patients who did not have a concurrent breast cancer diagnosis. A total of 2,253 patients were included. ResultsIn 800 of 2,253 patients (35.5%), the BI-RADS categories assigned at our institution and at outside facilities were discordant. Of 973 patients assigned BI-RADS category 4 or 5 at outside facilities, 278 (28.6%) were assigned BI-RADS category 1 to 3 (no biopsy necessary) at our institution. Of 923 patients assigned BI-RADS category 1 to 3 at outside facilities, 191 (20.7%) were assigned BI-RADS category 4 or 5 at our institution, and 189 of these had biopsies, which revealed 23 cancers, 15 high-risk lesions, and 151 benign lesions. One high-risk lesion at core biopsy was upgraded to invasive ductal carcinoma and ductal carcinoma in situ (DCIS) on excision, resulting in 24 cancers. Of these, 18 reflected true additional breast cancers detected as a result of second-opinion interpretation: 12 invasive carcinomas and 6 cases of DCIS. These results translate into a 9.4% (18/191) positive predictive value for the number of cancers diagnosed among all biopsies recommended and a 9.5% (18/189) positive predictive value for the number of cancers diagnosed among all biopsies recommended and actually performed. ConclusionsThese findings demonstrate the positive clinical impact of second-opinion interpretation at a tertiary cancer center of outside-facility breast imaging studies in patients without a breast cancer diagnosis.

Clinical importance of second-opinion interpretations by radiologists specializing in gynecologic oncology at a tertiary cancer center: magnetic resonance imaging for endometrial cancer staging.

ObjectiveTo determine whether there are substantive differences between the initial interpretations of magnetic resonance imaging (MRI) scans acquired at outside facilities and the second-opinion interpretations of radiologists specializing in gynecologic oncology at a tertiary cancer center, among patients referred for endometrial cancer staging.Materials and MethodsThis was a retrospective, comparative analysis of 153 initial and second-opinion MRI reports for endometrial cancer staging officially submitted for review by radiologists specializing in gynecologic oncology. For each case, the relationship between the initial and second-opinion reports, regarding the suggested diagnosis and the clinically relevant MRI findings reported, was categorized as "agreement" or "disagreement". Histopathology was used in order to establish the definitive diagnosis.ResultsDisagreement was found in 58 (37.9%) of the 153 cases. Second-opinion interpretations reported findings that affected the preoperative cancer staging and could have led to a change in treatment in 38 cases (24.8%); that did not affect the preoperative staging but provided information that was more accurate in 8 (5.2%); and that suggested a new cancer diagnosis in 12 (7.8%). In 37 cases (24.2%), there was a potential for changes in patient care. Among the 58 cases of disagreement, a definitive (histopathological) diagnosis was made in 41 (70.7%). In 31 (75.6%) of those 41 cases, the second-opinion report was more accurate than was the initial report.ConclusionDiscordant interpretations of MRI examinations, which can have a substantial effect on the clinical management of patients, appear to be common.

Second-Opinion Review of Breast Imaging at a Cancer Center: Is It Worthwhile?

Second-opinion review of breast imaging studies can be a time-consuming and labor-intensive process. The purpose of this investigation was to determine whether reinterpretation of studies obtained at institutions outside a cancer center influences clinical management, specifically by revealing additional cancer and preventing unnecessary biopsy. A review was conducted of breast imaging studies of 200 patients who underwent ultrasound and MRI at community facilities and had the images submitted for second opinions at a cancer center between January and April 2014. Each case was evaluated for concordance between the original report and the second-opinion interpretation. Second-opinion review resulting in the recommendation and performance of new biopsies was further subdivided into benign, high-risk, and malignant categories based on the histopathologic results obtained at the cancer center. Second-opinion review of the 200 cases showed a change in interpretation in 55 cases (28%; 95% CI, 21-34%). Overall, 26 recommendations (13%; 95% CI, 9-18%) led to a major change in management. Twenty new biopsies were performed, yielding 10 malignancies (5%; 95% CI, 2-9%) and four high-risk lesions (2%; 95% CI, 1-5%). Surgical management was changed to mastectomy for 6 of 10 patients (60%) with new sites of biopsy-proven malignancy. Eight biopsies were averted (4%; 95% CI, 2-8%) on the basis of benign interpretation of the imaging findings, and no disease was found at 1-year follow-up evaluation. Reinterpretation of studies obtained outside a cancer center resulted in a change in interpretation in more than one-fourth of submitted studies. Additional cancer was detected in 5% of patients, and biopsy was averted for 4%. The practice of second-opinion review influences clinical management and adds value to patient care.

Second-opinion interpretations of neuroimaging studies by oncologic neuroradiologists can help reduce errors in cancer care.

The purpose of this study was to investigate the utility and clinical impact of second-opinion interpretations of outside neuroimaging studies by oncologic neuroradiologists at a National Cancer Institute-designated cancer center. We performed a retrospective analysis of initial outside and second-opinion radiology reports from 300 computed tomography and magnetic resonance imaging studies and identified cases with discrepancies between the two reports. An adult neuro-oncologist, pediatric neuro-oncologist, and head and neck surgeon reviewed each pair of discrepant reports based on their area of expertise, patient age, and the type of study performed. The clinicians were blinded to the origin of each report and recorded whether the differences in the reports would have led to a change in patient management and/or disease staging. Histopathologic analysis, clinical assessment, and/or minimum 3-month imaging follow-up served as the reference standards to establish which of the 2 reports was correct. Among the 283 cases that met our study criteria, there were 55 neuroimaging studies with disagreements (19%) between the initial outside report and second-opinion interpretation. Patient management and/or disease stage would have been altered in 42 of 283 cases (15%) based on report differences as determined by the 2 neuro-oncologists and the surgeon participating in the study. Sufficient follow-up was available in 35 of 42 cases (83%). The second-opinion interpretation was correct 100% of the time (35/35). Second-opinion interpretations of neuroimaging studies by subspecialized oncologic neuroradiologists provide added value by reducing error and optimizing the care of cancer patients. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2708-2714. © 2016 American Cancer Society.

Second-Opinion Interpretations of Gynecologic Oncologic MRI Examinations by Sub-Specialized Radiologists Influence Patient Care.

To determine if second-opinion review of gynaecologic oncologic (GynOnc) magnetic resonance imaging (MRI) by sub-specialized radiologists impacts patient care. 469 second-opinion MRI interpretations rendered by GynOnc radiologists were retrospectively compared to the initial outside reports. Two gynaecologic surgeons, blinded to the reports' origins, reviewed all cases with discrepancies between initial and second-opinion MRI reports and recorded whether these discrepancies would have led to a change in patient management defined as a change in treatment approach, counselling, or referral. Histopathology or minimum 6-month imaging follow-up were used to establish the diagnosis. Second-opinion review of GynOnc MRIs would theoretically have affected management in 94/469 (20%) and 101/469 (21.5%) patients for surgeons 1 and 2, respectively. Specifically, second-opinion review would have theoretically altered treatment approach in 71/469 (15.1%) and 60/469 (12.8%) patients for surgeons 1 and 2, respectively. According to surgeons 1 and 2, these treatment changes would have prevented unnecessary surgery in 35 (7.5%) and 31 (6.6%) patients, respectively, and changed surgical procedure type/extent in 19 (4.1%) and 12 (2.5%) patients, respectively. Second-opinion interpretations were correct in 103 (83%) of 124 cases with clinically relevant discrepancies between initial and second-opinion reports. Expert second-opinion review of GynOnc MRI influences patient care. • Outside gynaecologic oncologic MRI examinations are often submitted for a second-opinion review. • One-fifth of MRIs had important discrepancies between initial and second-opinion interpretations. • Second-opinion review of gynaecologic oncologic MRI is a valuable clinical service.

Diagnosis of Extracapsular Extension of Prostate Cancer on Prostate MRI: Impact of Second-Opinion Readings by Subspecialized Genitourinary Oncologic Radiologists

The purpose of this article is to investigate the added value of second-opinion evaluation of prostate MRI by subspecialized genitourinary oncologic radiologists for the assessment of extracapsular extension (ECE) of prostate cancer. We performed a retrospective evaluation of initial and second-opinion radiology reports of 76 patients who underwent MRI of the prostate before prostatectomy for histologically proven prostate cancer. Initial outside reports and second-opinion reports were unpaired and reviewed in random order by a urologist who was blinded to patients' clinical details and histopathologic data. Histopathologic analysis of the prostatectomy specimen served as the reference standard. Among cases with diagnostic-quality images available (71/76; 93%), disagreement between the initial report and the second-opinion report was observed in 30% of cases (21/71; κ = 0.35); in 18 of these 21 cases (86%), histopathologic analysis proved that the second-opinion report was correct. The second-opinion interpretations had statistically significantly higher sensitivity (66% vs 24%; p < 0.0001) than did the initial reports, whereas there was no statistically significant difference in specificity (87% vs 93%; p = 0.317). On ROC curve analysis, the second-opinion reports yielded a statistically significantly higher AUC for the detection of ECE (0.80 vs 0.65; p = 0.004). The reinterpretation of prostate MRI examinations by subspecialized genitourinary oncologic radiologists improved the detection of ECE of prostate cancer.

Formal reporting of second-opinion CT interpretation: experience and reimbursement in the emergency department setting

The purpose of this study is to describe a system for formally reporting second-opinion interpretations of CT imaging exams accompanying patients transferred emergently to a tertiary care center. Second-opinion interpretations of cross-sectional imaging exams rendered in the emergency department setting over 6 months spanning 22 September 2009 to 22 March 2010 were reviewed and tallied by two radiologists and a research assistant, with a focus on professional fee reimbursement rates. A more in depth review was performed of those exams for which a clinical referral request form was available, detailing such information as the clinical history, content and source of available initial interpretation, and congruity of the initial interpretation with clinical data. Discrepancies between outside and second-opinion interpretations were also assessed. This quality assurance exercise was reviewed by our institutional review board, which waived formal informed consent. Formal second-opinion interpretation was rendered for 370 exams on 198 patients (mean age, 53.5 years; 45.1% female), received from 50 referring facilities. Head CT was the most common imaging exam referred for second opinion. Forty-one of 370 exams (11%) were submitted for self-pay, and 43 (12%) were written off as free care. The remaining 286 exams (77%) were submitted for reimbursement of the professional fee only. Ultimately, of the 286 exams submitted, 260 (91%) were reimbursed for professional fees, 199 (70%) on the initial submission. Of 29 health plans contracted with our facility, 22 ultimately approved all claims made. Three plans denied all claims submitted. The largest payer was Medicare, which reimbursed 88 of 90 submitted claims. Clinical intake forms were available for 184 exams on 107 patients (mean age, 52.7 years, 43.0% female). Trauma was the most common indication, or history, provided (55% of 184 exams, 40% of 107 patients). An outside report of some form was available for 112 of the 184 exams (61%), although only 18 were formal, signed radiology reports from the referring facility. Discrepancies between available outside reports and second-opinion interpretations were noted for 17 out of 112 exams. Need for reimaging was substantially curtailed, with only ten exams repeated within 24 h. A formal process for issuing second-opinion interpretations of cross-sectional exams performed at outside institutions is feasible in the emergency department setting. In the majority of cases, reimbursement for full professional fees can be obtained.