Radiology, historically, has been the medical specialty leading the edge of technological advancement. It abandoned a paper-based work system first. Its machines are the most advanced. And, the tests available for patient diagnosis have grown dramatically within the past 30 years.
Consequently, it’s no surprise that the industry is ahead of the curve with new tools designed to improve workflow, bolster patient care, and streamline performance. In some cases, adoption has been slow, but interest is growing, putting radiology on the fast-track, once again.
Benefits and Challenges
But, having new ways to implement diagnostic and workflow changes impacting every day practice provides benefits and offers challenges.
Overall, according to Staten Island University Hospital’s Director of Radiology Informatics David Hirschorn, MD, these tools make image capture and manipulation easier, prompting greater clinical success. Garnered data can be used to draft more accurate and actionable reports. Simultaneously, clinical reports can be standardized, meaning they are readable and functional in almost every facility.
There will be stumbling blocks, however.
• Interoperability: The biggest hurdle will be interoperability now that electronic health records (EHR) are more prevalent. For decades, many larger institutions have relied on their own ingenuity to build information systems that give providers facility-wide data-sharing capabilities.
Under Meaningful Use requirements, vendor-produced EHR systems must fulfill government requirements intended to help providers achieve the highest possible level of care. Initially designed to connect and improve communication between various hospital departments, they’re now advancing to link different facilities, sometimes cross-country. And, the pivot can be an adjustment, Hirschorn said.
“If you’re at a cutting edge institution, you’ve been doing this for 20 years already,” he said. “But, now, places are starting to go to vendor-based solutions, and it’s a shift.”
Interoperability is so important Congress enacted penalties for any vendor attempting to block information and prevent free data flow between entities.
• Digital Mandate: The second challenge will be the Affordable Care Act requirement that facilities shift from mainly paper-based systems to digital ones. It’s a significant time and capital investment that could tax smaller institutions’ resources. When achieved, though, it gives radiologists something they haven’t had in a decade – access to a patient’s chart.
“In the past, we had to read a scan and not know what’s going on other than a few words scribbled like ‘pain’ or ‘trauma.’ How can we really know what’s wrong if that’s all we have?” he said. “Now, there’s a chart for the first time that radiologists can have access to.”
• Longstanding Practices: The viewpoint of many older radiologists will be the third sticking point, Hirschorn said. Many have practiced for 30-plus years and are reluctant to deviate from their daily practices.
“Some radiologists learn about these tools, and they’re all over it like a dog on a bone. Now they can’t live without it,” he said. “Some radiologists don’t want to because it takes more time to learn.”
Changing their minds will require younger providers to voice their opinions and assume greater leadership roles within groups and practices, he said.
• Data Collection: Once these new diagnostic and workflow tools are populated with patient information and appropriateness guidelines, they’ll simplify day-to-day work for radiologists, Hirschorn said. The hard part will be identifying the data providers need to best do their jobs. For example, he said, radiologists could benefit from seeing nurses’ notes, but they might not be helped by lab reports.
Impacting the Patient
Radiologists, referring physicians, and facilities aren’t the only beneficiaries of a technologically-advanced industry. Patients will be among the biggest winners, Hirschorn said.
“I see more radiologic findings being caught because of better interoperative tools,” he said. “We’ll miss fewer findings, and we’ll economically find more of what we’re looking for.”
As more hospitals, groups, and practices adopt diagnostic and workflow tools, patient care will improve, he said. Not only will they enable radiologists to read more cases and move through them faster, but they will also improve the accuracy of diagnosis. Increased clinical precision means fewer patients will forego needed follow-up care, and there will also be a decrease in unnecessary follow-up care or inappropriate imaging.
Overall, Hirschorn said, care costs will begin to decrease.
Institutional Data Exchange: In today’s medical environment, data must be mobile, and referring physicians and radiologists must be able to easily exchange information across institutions.
Systems like eMedApp’s Care Connectivity Platform make that possible by optimizing workflow and data transmission without regard to data storage location, file format, or vendor-specific architecture, meaning data follows patients throughout their care. These tools are effective in ambulatory and group settings with in-house imaging.
“The key is the link between clinical record systems and PACS architecture to make data transmission smooth for all recipients,” said Vik Sheshadri, eMedApps vice president of product development. “It creates an environment where providers can order tests easily and provide pertinent clinical data for radiologists to use in the PACS.”
Additionally, integrated systems promote medical device interoperability and augmented workflow as images and other patient data are housed together. The system informs radiologists and physicians when tests are ready to read and when they’re completed, respectively. Recorded reports are also available. The platform also handles professional component billing, making it easier for providers to receive reimbursement.
Ordering and Finances: Within radiology, two areas where accuracy counts the most – outside of diagnosis – are physician ordering and finances. One tool from Toronto-based clinical decision support (CDS) vendor MedCurrent, called MedCurrent CDS, integrates these capabilities into existing EHRs.
“We wanted to help physicians stay abreast of the most current knowledge,” said Stephen Herman, MD, MedCurrent founder and chief executive officer. “It’s a system they can use the knowledge from in a single fashion.”
Not only does MedCurrent CDS integrate a clinical physician order entry (CPOE) system with a facility’s EHR, but it draws upon a patient’s individualized medical history, allowing referring physicians to further customize image ordering. The system also maintains analytics records so facilities can monitor ordering habits and spot-check to ensure referring providers use existing appropriateness criteria.
MedCurrent CDS also affects imaging dollars spent. Referring physicians can show patients whether a requested test is warranted, potentially avoiding an unreimbursable study. But that doesn’t mean imaging volume will necessarily drop.
“There will be an imaging volume shift,” he said. “Fewer CTs might be performed, but there will be more ultrasounds or MRIs. Every hospital’s unique ordering patterns will change.”
Hospitals with a better idea of how their modalities are used can make more informed decisions about equipment purchases and technologist staffing.
Volume Matching Registration
Although each diagnostic study captures nearly 1,000 images, no radiologist can read them all. Volume matching registration, unavailable less than a decade ago, uses a subset to help create 3D images of a structure, such as the head. Representations give radiologists a better view through slices, and the technology can be used to compare prior and new imaging.
“Volume matching registration can be extremely helpful in something like brain surgery,” Hirschorn said. “It can be invaluable in helping position a patient correctly for preoperative planning.”
3D Volume Technology
For the past decade, 3D imaging technology has coexisted with PACS systems, but in recent years, PACS vendors have slowly begun incorporating 3D features, Hirschorn said. Although 3D technology is effective as a stand-alone tool, it’s far more effective when housed within a PACS.
This technology, including ImageGrid PACS, gives a radiologist the opportunity to view the images and, through multi-planar reconstruction, piece together a 3D representation within the same system, saving time and effort.
“The truth is, to the radiologist, it’s not just a matter of one less piece of software to worry about,” he said. “It makes a huge difference in usability.”
Although ACR Assist, the American College of Radiology’s CDS system, isn’t new, it’s still gaining widespread traction. The goal: offering structured clinical guidance in ways that easily fuse with an everyday radiology workflow.
Clinical data are encoded in vendor-neutral ways, making it accessible to a wide range of commercial applications, Hirschorn said. The clinical components include various reporting taxonomies, such as LI-RADS, PI-RADS, and Lung-RADS care pathways and algorithms, and classification and communication needs for actionable findings.
Using this data, the ACR created guidelines governing how radiologists and referring physicians should proceed when faced with clinical findings. For example, based on the size, location, and other known risk factors of a lung nodule, ACR Assist offers standardized guidance on a 6-to-12 month course of treatment, including follow-up care.
The tool is finding its way into more PACS systems, he said.
“This technology has tentacles that it’s taking on. The dendrites are its connections into the PACS systems,” Hirschorn said. “Radiologists want to be able to communicate information that is critical, and they want to know when the time comes to follow-up with a patient, someone will actually know about it.”
At every step, he said, these new tools and others like them are setting the industry up for greater efficiency and efficacy while highlighting the benefits radiology brings to the health care table.