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Integrating AP and radiology, inch by inch

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Kevin B. O’Reilly

September 2015—Two major specialties serve all of health care as the foundation for diagnosis. Now efforts to align pathology and radiology again appear to be picking up steam. As payment shifts to so-called value-based care and as medical record systems may challenge successful test interpretation, many experts seek a clear integration of these two specialties.

Moreover, an Institute of Medicine report on diagnostic errors due this fall is expected to add pressure on everyone within U.S. health care to redouble their efforts to improve diagnostic accuracy.

Richard C. Friedberg, MD, PhD, pathology chair at Baystate Health System, sees the need for integrated diagnostics extending beyond cancer or other life-threatening illnesses. U.S. health care’s growing reliance on nurse practitioners and physician assistants to provide primary care, he believes, will increase the importance of the role of diagnostic specialists.

“We’ve seen this in Massachusetts over the last eight years, where we have long experience with ‘Romneycare.’ There are more people, who have less scientific background and less experience, taking care of more patients,” says Dr. Friedberg, the CAP’s president-elect. “We see ordering practices going bizarre because they don’t have the history and tradition of how to work up this process or that process, or may not know the nuances of this test versus that test.”

Bruce A. Friedman, MD, active emeritus professor of pathology at the University of Michigan Medical School, is a longtime advocate of the integrated approach to diagnostics, which he believes is essential for the specialties of pathology and radiology to assert their central place within health care organizations and dramatically improve diagnostic efficiency. He detailed his vision for diagnostic integration at a December 2014 Chicago meeting of the International Society for Strategic Studies in Radiology.

Dr. Friedman

Dr. Friedman

We are living in a “golden age of diagnostics,” he said, but health care systems are unable to fully exploit testing advancements because EHRs are not optimized to run testing rules, algorithms, and heuristics that can make the testing process faster and less costly.

“EHRs are built on a core of antiquated software,” Dr. Friedman tells CAP TODAY. “They’re not designed to increase clinical efficiency, but primarily designed to drop a bill and, secondly, to replicate paper rec-ords. And they’re so complex that if you touch it, you break it. Laboratory and radiology information systems tend to be more nimble but don’t have the reach that EHRs have.”

What is needed, Dr. Friedman argues, is what he calls an “integrated diagnostics server.” The idea is a server controlled by pathology and radiology that scoops up data and images for selected patients from the LIS, RIS, PACS, and so on.

“This would give you access to the entire set of pathology, radiology, and molecular diagnostics and essentially would, using algorithms, plot the most efficient way that the patient could travel through this whole diagnostic process and eliminate wasted time, days, and resources,” says Dr. Friedman, author of the Lab Soft News blog at http://labsoftnews.typepad.com.

Ideally, he says, this server would be paired with physical integrated diagnostic centers under the control of pathology and radiology that would “deal with any undiagnosed mass in the lesion in, say, the lung, the thyroid, or the kidney.” The centers would include nurses, clinicians, and physicians to help guide patients through the testing process with the goal of achieving a firm diagnosis within 24 to 48 hours for undiagnosed masses, “compared to the norm today of two to six weeks.”

Some steps are being taken in the direction of Dr. Friedman’s sweeping plan.

The pathology and radiology departments at the University of California, Los Angeles Medical Center have jointly funded a standalone diagnostic center that aims to let patients accomplish all the necessary imaging studies and tissue-collection steps during a single visit.

UCLA also is home to a painstaking effort to combine pathology and radiology cancer findings in a way that finds discordances more quickly and produces a dynamic, image-laden, easily shareable comprehensive report.

Dr. Wallace

Dr. Wallace

When senior leaders in the UCLA David Geffen School of Medicine’s pathology and radiology departments asked pulmonary pathologist W. Dean Wallace, MD, and informaticist Corey Arnold, PhD, to work on a way to combine pathology and radiology reports for lung cancer cases, they weren’t at first clear on the job ahead.

“We thought: ‘You mean we should get a staple gun so we can staple the reports together?’” Dr. Wallace said to laughter at the Executive War College meeting in May.

He, Dr. Arnold, and their colleagues on the UCLA development team had to devise a way to automatically pull radiology information system reports and DICOM-wrapped images, as well as pathology reports and slide images from Sunquest’s PowerPath anatomic pathology laboratory information system, into an integrated, Web-based reporting portal—dubbed RadPath. The original pathology and radiology reports had to be divided into sections so they could be navigated effortlessly on the Web, shared with the EHR, and printed as PDFs that could be given to patients requesting their records.

There was also the matter of determining the workflow. Should the originating diagnostic radiologist correlate the radiology and pathology reports? Perhaps it should be the radiologist who took part in the biopsy procedure? Or should the job lie with the pathologist? And how could this be accomplished in a way that did not require a lot of time?

The catalyst for this work was not merely some Platonic ideal regarding integrated diagnostics. Rather, it was pathology-radiology discordances in real practice that led to diagnostic delays, as shown in research published by Drs. Wallace and Arnold and colleagues (Oh AS, et al. Acad Radiol. 2015;22[4]:481–487). They reviewed the cases of 186 patients who underwent percutaneous lung biopsy of a parenchymal lesion at UCLA Health between January and December 2009. Five radiologists examined the CT or PET scans, while three pathologists classified the biopsied lesions. They discovered 12 discordant benign cases, four of which were found to be false-negatives.

An integrated pathology-radiology report can avert such mistakes while improving collaboration, said Dr. Wallace, who is an associate professor of pathology and laboratory medicine at UCLA.

“The clinicians, surgeons, and oncologists get a better picture of what we’re trying to say. Then, when they have a question, it’s often a more coherent question that they’re throwing back at us for the specific patient,” he said. “This improves the speed and accuracy of diagnosis. It catches discordances much quicker. By requiring pathologists and radiologists to compare and combine their findings, they find out about problems much faster, rather than six months later.”

Through late July, 96 lung cancer cases at UCLA Health had been completed using the RadPath system. In 91 of those cases, the radiology and pathology findings correlated. In three cases, the radiologist deferred to the pathologist’s diagnosis. And in two cases, the combined findings suggested a sampling error.

In an interview with CAP TODAY, Dr. Arnold says the UCLA team will need several hundred completed cases to tell RadPath’s true value in terms of how often it helps uncover potentially harmful discordances. He adds that it will not take many missed or delayed diagnoses for the system to prove its financial worth to UCLA.

“These are uncommon events to begin with,” says Dr. Arnold, who is an assistant professor in the departments of radiology and bioengineering. “We’re interested in those because for that patient, it’s everything. And from a cost perspective, it’s potentially quite large. You’re spending a small amount to prevent those large expenses.”

Dr. Wallace adds, in an interview, that the Web-based, easily shareable form of the RadPath report also has an intangible merit.

“Most of what we do in pathology is produce reports,” he says. “Everything that goes into pathology, all the resources and all the money, and by far and away the main thing we churn out is pieces of paper saying what we think or what we found. With RadPath, we’re producing that same information but in a much better, more dynamic format. There is more long-term value we see down the road than just the correlation.”

Dr. Abtin

Dr. Abtin

Another member of the RadPath development team, thoracic radiologist Fereidoun Abtin, MD, also sees a big benefit in finding discordances before they get to the tumor board stage.

“It is not uncommon that you sit down and, with just one case where there’s a discordance, you will end up in a tumor board for an hour of discussion,” says Dr. Abtin, associate professor of radiology at UCLA. “That’s time taken away from the management of this patient, and it’s creating this convoluted path of decision-making. This [RadPath] really makes it more streamlined.”

Speaking of tumor board meetings, Dr. Wallace says the RadPath system has had a remarkable impact on the time it takes him to prepare for them.

“If I use RadPath, it takes 20 minutes versus two and a half or three hours when I don’t use it,” Dr. Wallace says. “As a presentation tool, it is so much more powerful because I can call up all the associated molecular studies, ancillary tests, and all the previous reports.”

RadPath’s developers argue the system gives clinicians solace about the diagnostic process.

“At the end of the report, it is saying this is both the radiologist and the pathologist and we both think it is this particular diagnosis,” Dr. Abtin says. “That adds another layer of confidence for the clinicians. Two specialists really agree that, say, this biopsy is really just a pneumonia and you don’t need to worry about it. Or we think that this biopsy is not representative of your lung cancer and we need to rebiopsy. The driving force here is the clinicians. They really need this level of resolution to help their clinical judgment, given the complex, busy schedule they have.”

Dr.Yanagawa

Dr. Yanagawa

UCLA cardiothoracic surgeon Jane Yanagawa, MD, offers nothing but raves for the integrated diagnostic reporting system. She has received a handful of RadPath case reports so far.

“The main thing about it is that it makes everything so much more efficient,” she says. “It’s not that I don’t, for every single patient, look up the imaging or find the image that has the biopsy needle going in to know where the pathology report came from. But having it all in one place is about 1,000 times easier.”

Without the RadPath report, Dr. Yanagawa adds, she does not have access to pathology slide images to correlate with the radiological images or the medical literature references that are added to each report. She sees a potential boon in using the reporting system to find research topics and impress upon trainees the multidisciplinary nature of cancer care. She also anticipates a benefit for patient care.

“The patients we’re seeing are becoming more and more complex because of improvements in imaging and the importance of subtype histologies and gene mutations and all of that stuff. Every single patient is someone who should be discussed at a tumor board,” says Dr. Yanagawa, assistant professor of thoracic surgery at UCLA. “This makes it possible to give every single patient the multidisciplinary attention that modern patients need because of the complexity of their diseases and how much they know.”

Outside UCLA, there is positive reaction to the information made available thus far about RadPath. Surgical pathologist Michael D. Feldman, MD, PhD, spoke at a special session at the Radiological Society of North America’s 2014 annual meeting titled, “Radiology and Pathology Diagnostics: Is It Time to Integrate?” He is among those impressed with how UCLA is tackling the charge of improving pathology-radiology collaboration.

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