One trend, in medicine, is for primary-care and specialty physicians to use ultrasound—and, perhaps, other imaging modalities—in their practices. From my perspective (and with 20 years of experience as an imaging and hospital administrator and consultant, US medicine is evolving away from fee-for-service reimbursement and toward outcomes-based payment for patient care. Both imaging and the way we use imaging are rapidly changing, and we should think about how to use imaging in the most effective manner.
Only 25 years ago, both CT and MRI were rare and in their infancy, ultrasound was crude, and the vast majority of radiology involved plain radiography or some variant of radiographic technology. It took the development of inexpensive computing power to drive the radiology technologies that we have today. Because of the relatively limited scope of radiology in 1980, however, the primary-care physicians and specialists of that time could have a reasonable command of which imaging study to order in a particular episode of clinical care.
Advances in imaging are largely the result of digital imaging, and they have roughly paralleled (and been facilitated by) increases in computing speed. Digital images have the unique ability to be analyzed using algorithms, and they also provide for manipulation to improve the accuracy of interpretation. An aspect of increasing imaging capability is, however, the need to recognize when a specific modality is appropriate for use. New technologies do not always make a material difference in the diagnosis of a condition, and this implies a role for the radiologist in helping referring physicians to determine the appropriate imaging for a given condition.
We can no longer assume that referring physicians are fully conversant with which imaging study or procedure will accomplish their diagnostic goals. Moreover, we cannot assume that referring physicians will accomplish those goals in the most economical manner; this is becoming increasingly important, as medicine moves toward accountable care.
The increasing complexity of imaging dictates that radiologists assume the more important role of diagnostic consultants. In this role, they should be expected to both understand the technology armamentarium and to be prepared to assist referring physicians with the selection of the appropriate imaging tool to use for a given patient and diagnostic goal.
Unfortunately, economic, regulatory, and medicolegal constraints in the current fee-for-service environment might make this new role counterintuitive for practicing physicians. We cannot, however, make progress toward a shared goal of providing care that is more effective (both clinically and from a cost perspective) unless we make this change.
Evidence-based Protocols
A common thread running through all of imaging, in its relationship with clinical medicine, is the shift to a more active role for radiologists in the development of evidence-based imaging pathways that can be integrated into medicine. Augmenting this process is the need for radiologists to be more available to listen to clinicians’ diagnostic problems and to recommend an appropriate imaging course.
Protocols are often viewed with a good deal of suspicion by physicians—in particular, by physicians who have a concerned patient in front of them. It is easiest, in many instances, to begin at the end and throw the most advanced imaging available at the diagnostic problem, in the name of applying the so-called art of medicine to the totality of the patient’s circumstances.
The art of medicine is a very valuable concept, but it is possible both to use science (as expressed by evidence-based protocols) and to allow nuancing of the evidence by the physician. Process control is found in documentation, measurement, and some system of accountability that provides periodic review of outcomes. Physicians should be allowed to depart freely from the protocol on an individual-patient basis, but should provide documentation of the reasons for such departures, and the results of such actions should be reviewed in the context of patient outcomes.
Protocol Development
A key aspect of any protocol is buy-in by those who are charged with applying the protocol, and this is only achieved by allowing the physicians who are affected on the referring side to have a voice in the process. I advise selecting only physicians with clinical credibility among their peers, but they must also be physicians who are proponents of evidence-based medicine.
Radiology’s part in this process is to develop basic protocol outlines and to explain the evidence for the protocol, but radiology representatives must also be receptive to the practical needs and concerns of primary-care and specialty physicians. In selecting radiology participants in the protocol-development process, it is very important for radiology to recognize the need for practicality and to understand how imaging will be delivered in the overall context of a patient’s care. If barriers are created, protocols will fail.
In any discussion of protocols, there must be other voices in the room—if not through their presence, then certainly through some mechanism that addresses their concerns. The first of these is, of course, the patient. The harms of false-positive imaging findings have become a popular point in the discussion of evidence-based medicine, but patients are much more often concerned with the potential for false-negative results and the impact of those findings. False findings are inevitable, but we must not fail to weigh the relative costs of false positives and false negatives (and compare the potential for false negatives), before and after protocol implementation.
The other representative in the protocol development room must be the economist. Health care exists in the real economic world, extending from the cost to a patient of taking time off from work for a laboratory or imaging appointment to how competitive US corporations can be in a world economic environment in which the US national health-care burden is double that of competing nations.
The economic analysis must include all aspects of the proposed protocol, including downstream impact on the personal and economic cost of care. Many of the aspects of the economic analysis will have a clinical side as well. For example, does each aspect of the imaging protocol move the decision process closer to diagnostic certainty, or does a study merely confirm or duplicate an existing finding? From the long-term perspective, will the protocol affect the need for future care or the severity of a chronic condition? In any event, in these times, a protocol cannot be finalized before evaluation of the full range of its economic impact.
In addition, protocols need to be dynamic. Imaging (along with our understanding of the human condition) is constantly evolving, with the result that protocol development is an evolutionary process that requires continual review of protocols in the context of medical evidence, including the experience of those who are using the protocols. As is the case with protocol development itself, the review of protocols needs to be the subject of an organized and systematic process.
Conclusion
At a time when we find imaging capabilities at an all-time high, there is a pressing need to implement and document evidence-based medicine in everyday clinical practice. This mandates the effective use of imaging by primary-care and specialty physicians alike.
Complicating this task is the increasing complexity of modern imaging, as evidenced by subspecialization in diagnostic radiology. In this environment, it is imperative for radiologists and referring physicians to collaborate in the development of protocols governing both what imaging is used and who is responsible for that imaging.
Effective protocols are evidence based, are developed in a collaborative and collegial environment, are patient friendly, and take into consideration the economic realities of health care—without compromising quality. Protocols are essential to the measurement of performance, and they must apply to all who order (as well as those who provide) imaging.
Notwithstanding the importance of protocols, there must be room in the system for physicians to exercise the art of medicine and override a protocol in the care of an individual patient. In such instances, however, the reasons for departing from a protocol need to be documented, and outcomes should be tracked, as a part of an ongoing protocol-development process.
Gerald R. Kolb is vice president for business development for Matakina International Ltd, with a twenty-year history as an evangelist for excellence and accountability in breast imaging. Comments and questions are welcome at gerald.kolb@volparadensity.com.