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Artificial Intelligence (AI) carries the potential for unprecedented disruption in radiology, with possible positive and negative consequences. The integration of AI in radiology holds the potential to revolutionize healthcare practices by advancing diagnosis, quantification, and management of multiple medical conditions. Nevertheless, the ever-growing availability of AI tools in radiology highlights an increasing need to critically evaluate claims for its utility and to differentiate safe product offerings from potentially harmful, or fundamentally unhelpful ones.This multi-society paper, presenting the views of Radiology Societies in the USA, Canada, Europe, Australia, and New Zealand, defines the potential practical problems and ethical issues surrounding the incorporation of AI into radiological practice. In addition to delineating the main points of concern that developers, regulators, and purchasers of AI tools should consider prior to their introduction into clinical practice, this statement also suggests methods to monitor their stability and safety in clinical use, and their suitability for possible autonomous function. This statement is intended to serve as a useful summary of the practical issues which should be considered by all parties involved in the development of radiology AI resources, and their implementation as clinical tools.Key points • The incorporation of artificial intelligence (AI) in radiological practice demands increased monitoring of its utility and safety.• Cooperation between developers, clinicians, and regulators will allow all involved to address ethical issues and monitor AI performance.• AI can fulfil its promise to advance patient well-being if all steps from development to integration in healthcare are rigorously evaluated.

The urgency for climate action is recognised by international government and healthcare organisations, including the United Nations (UN) and World Health Organisation (WHO). Climate change, biodiversity loss, and pollution negatively impact all life on earth. All populations are impacted but not equally; the most vulnerable are at highest risk, an inequity further exacerbated by differences in access to healthcare globally. The delivery of healthcare exacerbates the planetary health crisis through greenhouse gas emissions, largely due to combustion of fossil fuels for medical equipment production and operation, creation of medical and non-medical waste, and contamination of water supplies. As representatives of radiology societies from across the globe who work closely with industry, and both governmental and non-governmental leaders in multiple capacities, we advocate together for urgent, impactful, and measurable changes to the way we deliver care by further engaging our members, policymakers, industry partners, and our patients. Simultaneous challenges including global health disparities, resource allocation, and access to care must inform these efforts. Climate literacy should be increasingly added to radiology training programmes. More research is required to understand and measure the environmental impact of radiological services and inform mitigation, adaptation and monitoring efforts. Deeper collaboration with industry partners is necessary to support innovations in the supply chain, energy utilization, and circular economy. Many solutions have been proposed and are already available, but we must understand and address barriers to implementation of current and future sustainable innovations. Finally, there is a compelling need to partner with patients, to ensure that trust in the excellence of clinical care is maintained during the transition to sustainable radiology. By fostering a culture of global cooperation and rapid sharing of solutions amongst the broader imaging community, we can transform radiological practice to mitigate its environmental impact, adapt and develop resilience to current and future climate and environmental threats, and simultaneously improve access to care.

In January 2015, Secretary of Health and Human Services Sylvia Burwell described the administration’s priority of transitioning volume-based care to a system providing greater value,6 7 and a whole new industry was formed to manage this transition.8 9 Throughout this period, a legion of other regulatory issues was confronting healthcare practitioners, ranging from ICD-10 implementation to meaningful use.10 One such perennial issue was the need to implement a fix to prevent enormous cuts to Medicare payments resulting from the sustainable growth rate formula for Part B services.11 12 In April 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was passed, permanently ending the sustainable growth rate.13 14 However, MACRA, which has been described in numerous dedicated reviews,15 16 introduced an array of new challenges for providers, beneficiaries, and payers alike.17 18 It is generally agreed that there are challenges to the continued vitality of the ACA. Healthcare quickly became the priority.20 A previous review in JNIS detailed the intricacies of the initial ACA repeal legislation passed by the House—namely, the American Healthcare Act (AHCA).21 Using the timeline format established by the UCSF/UC Hastings Consortium on Law, Science and Health Policy, that manuscript will be updated here.22 The 2017 timeline On 12 January in the Senate and then on 13 January in the House, Republicans casted votes that would allow subsequent legislation to use the budget reconciliation process to remove large elements of the ACA.23 On 20 January, just hours after being sworn into office, President Trump signed the Executive Order Minimizing the Economic Burden of the Patient Protection and ACA Pending Repeal that weakened regulations designed to enforce that law.24 On 7 March the AHCA was introduced into the House of Representatives through the two standing committees with jurisdiction for healthcare: the House Energy and Commerce Committee and the House Ways and Means Committee. [...]on 2 August, Republican Senator Alexander from Tennessee released a statement that the Senate would hold bipartisan hearings to stabilize the individual market.38 The present day At the time of writing, September 2017 looks to be a very busy month for Congress with hard deadlines in place for increasing the federal debt ceiling, passing a budget bill to avoid a looming federal shutdown, and avoiding expiration of the Children’s Health Insurance Programme. [...]President Trump has repeatedly suggested that the federal government might curtail its subsidies for Obamacare era insurance products. [...]the groups propose raising the threshold on the requirement for employers to provide insurance to employees to businesses of 500 employees or more and repeal the medical device tax.42 Discussion The ACA established the Center for Medicare and Medicaid Innovation (CMMI).43 44 As described previously, at least two initiatives of the CMMI had meaningful potential to directly impact neurointerventional specialists: the Medicare Shared Savings Programme (MSSP), which implemented accountable care organizations (ACOs), and the Bundled Payments for Care Improvement (BPCI).9 45 However, per CMS, MSSP has been a net drain on Medicare ($216 million through 2015).46 In addition, BPCI Model 2 has demonstrated limited savings for cardiology and orthopedic surgeons, and its attempts to bundle spinal surgery have led to increased costs. [...]the results of existing alternative payment models are mixed.47 Moreover, on 15 August, CMS cancelled two separate bundled payment models and dramatically cut the number of providers required to participate in a third.48 Collectively, these developments call into question the long-term impact of the CMMI in implementing effective value-driven accountable care.

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 subjects of global relevance in radiology. In 2016, the issue of implementing imaging referral guidelines in clinical routine was analysed. The legal environment in the USA requires that after January 1, 2017, physicians must consult government-approved, evidence-based appropriate-use criteria through a clinical decision support system when ordering advanced diagnostic imaging exams. The ESR and the National Decision Support Company are developing “ESR iGuide“, a clinical decision support system for European imaging referral guidelines using ESR imaging referral guidelines based on ACR Appropriateness Criteria. In many regions of the world, the situation is different and quite diverse, depending on the specific features of health care systems in different countries, but there are, unlike in the USA and EU, no legal obligations to implement imaging referral guidelines into the clinical practice. Imaging referral guidelines and clinical decision support implementation is a complex issue everywhere and the legal environment surrounding it even more so; how they will be implemented into the clinical practice in different areas of the world needs yet to be decided. Main messages • Implementation of imaging referral guidelines in clinical routine is needed . • Potential benefits are improved appropriateness in referrals and reduction of unnecessary radiation exposure . • The educational benefits include new insights through data collection and reporting . • The system will potentially highlight the lack in quality or availability of equipment .

The urgency for climate action is recognised by international government and healthcare organisations, including the United Nations (UN) and World Health Organisation (WHO). Climate change, biodiversity loss, and pollution negatively impact all life on earth. All populations are impacted but not equally; the most vulnerable are at highest risk, an inequity further exacerbated by differences in access to healthcare globally. The delivery of healthcare exacerbates the planetary health crisis through greenhouse gas emissions, largely due to combustion of fossil fuels for medical equipment production and operation, creation of medical and non-medical waste, and contamination of water supplies. As representatives of radiology societies from across the globe who work closely with industry, and both governmental and non-governmental leaders in multiple capacities, we advocate together for urgent, impactful, and measurable changes to the way we deliver care by further engaging our members, policymakers, industry partners, and our patients. Simultaneous challenges including global health disparities, resource allocation, and access to care must inform these efforts. Climate literacy should be increasingly added to radiology training programmes. More research is required to understand and measure the environmental impact of radiological services and inform mitigation, adaptation and monitoring efforts. Deeper collaboration with industry partners is necessary to support innovations in the supply chain, energy utilization, and circular economy. Many solutions have been proposed and are already available, but we must understand and address barriers to implementation of current and future sustainable innovations. Finally, there is a compelling need to partner with patients, to ensure that trust in the excellence of clinical care is maintained during the transition to sustainable radiology. By fostering a culture of global cooperation and rapid sharing of solutions amongst the broader imaging community, we can transform radiological practice to mitigate its environmental impact, adapt and develop resilience to current and future climate and environmental threats, and simultaneously improve access to care.

Although Section 21 of the 1992 Rehabilitation Act Amendments describes patterns of inequitable treatment of African Americans with disabilities in state vocational rehabilitation agencies, most of the empirical investigations related to this phenomenon have utilized state-wide data. The present study, which also found state-wide differences, extended the investigation to the district level, and in some cases, to the counties that comprise the districts. The differences in the district and county findings indicate that this may be a useful approach for vocational rehabilitation agencies and may assist the agencies in determining appropriate interventions that can be used to eliminate the inequitable treatment of African Americans with disabilities in the state-federal rehabilitation system.