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By Matt Skoufalos

In addition to holding the distinction of being the first true digital specialty in medicine, the utility of medical imaging in generating objective information about the body, its disease states, chemical processes and essential anatomical construction makes the discipline an inherently collaborative one. At a time when patients’ entire medical histories can be synchronized with high-resolution pictures of their physical tissue itself, imaging has emerged as “a critical partner in clinical care for just about any other specialty, with very few exceptions,” said Dr. Christopher Wald.

A radiologist of 22 years and the current chair of the American College of Radiology (ACR) informatics commission, Wald has seen the imaging field become both narrower at its highest levels and broader at its base, the ultra-precise data it collects helping to advance specialties throughout the world of medicine. In the age of personalized medicine, medical imaging is the connective tissue that supports professionals in every phase of the patient care continuum, from orthopedics to oncology to the emergency room. And the power of imaging to detect diseases before they are known to the patient – and while they are still curable – has saved countless lives in breast and lung cancer screening programs, which are typically run by imaging departments.

Because the quantitative data it yields help inform decisions around clinical interventions, medical imaging is front and center in cross-disciplinary conversations around diagnosis, treatment planning, post-acute care and research, Wald said. The same data produced by imaging devices enables computer-assisted quality assurance that even allows imaging systems to improve themselves, compensating better for artifacts, monitoring and reducing radiation doses, and helping department leaders “make data-driven decisions on the useful life of equipment based on its actual observed utilization,” he said.

Aside from any of those applications, however, medical imaging is fundamentally a referral-based specialty, Wald said; by that token as well, it is an inherently collaborative discipline, distinct from other specialties. Radiologists must maintain good relationships with referrers to continue getting their business; more importantly, they must also keep up with research across a variety of disciplines in order to provide relevant analysis and reporting on the imaging studies they perform.

“We have to be engaged with clinicians,” Wald said; “unless we know what they’re looking for, we cannot provide that. The days of a radiologist simply describing what they see; that doesn’t cut it anymore. Today, you want a radiology report that is actionable, and stated in agreed-upon terms; a report that synthesizes the imaging information with the clinical information from the patient’s chart, and clearly states, ‘Here’s what I think this is, and, if necessary, here is what other imaging test might be helpful to clarify or follow a diagnosis.’ ” Increasingly, imaging departments are developing programs to assist in following such recommendations over time to ensure they are followed.

By those measures, he said, “If I want to be effective, I have to collaborate.”

From a patient perspective, Wald said it’s “absolutely desirable” for clinical colleagues to collaborate with one another as well. He sees these opportunities as occurring “upstream from imaging,” i.e., clinical decision support in identifying the correct exam prior to performing it; and “downstream,” in clear reporting that follows to the referring physician. Wald also advocates for radiologists to make themselves available to their referring colleagues and patients to discuss and clarify their findings.

“On occasion, the radiologist’s opinion may differ greatly from the referring provider’s, and the recipient of the report will call you back and say, ‘let’s look at this together,’ ” he said. “Other times, the radiologist will completely redirect the clinical thinking and action with an unsuspected imaging diagnosis. Mutual trust and good working relationships contribute directly to safer patient care.”

One of the contingencies of being a digital specialty, however, is that medical imaging is entirely dependent upon informatics support, and in Wald’s estimation, that can either accelerate or impede its success. There are myriad technologies that support medical imaging in its totality, but the fundamental three – electronic health records (EHR), natural language transcription systems and PACS – “may have all evolved in silos at many facilities,” Wald said, and lack optimal front-end interoperability from the user’s perspective.

“While some imaging departments are fortunate enough to be working with a dedicated radiology informatics team that reports to them and maintains special knowledge about imaging IT over time, others may have to deal with enterprise informatics teams made up of general IT support specialists, who may not have the opportunity over time to develop the specific imaging informatics knowledge to be completely effective,” he said.

“In addition, there are multiple custom interfaces that have been built in imaging departments to facilitate the flow of data, all of which are slightly different from each other,” Wald said. “Therefore, maintaining a well-functioning and optimized workflow for radiology departments and individual radiology tasks is no small feat.”

IT systems can offer better native interoperability by way of a single sign-on across platforms. Workflow support software can help imaging departments create structured work lists that can be shared across locations, prioritized by clinical criteria, and which have access to patients’ clinical and imaging histories.

“If you want to achieve this level of integration and enhanced workflow, you really need help and investment to get such a workflow solution, and you need help from your imaging IT department to make that happen,” Wald said.

“New clinical knowledge in general, and information about individual patients specifically, is emerging so quickly as to outpace the ability of an individual human being to keep up,” he said. “In all but the biggest institutions, which have so many radiologists that they can be super sub-specialized, we’re at risk of falling behind in having all the information top-of-mind that we need to properly interpret the image.”

“We face a massive information management challenge,” Wald said, and addressing it will require technological solutions to interoperability challenges as well as shifts in thinking from practitioners. Developing a more precise, shared language in EHR and case reporting will enable IT-based systems to leverage their heft fully in support of radiologists’ interpretations.

“Medicine is practiced by humans,” he said; “humans use language, and language can be ambiguous. Whether it’s a paper chart or an EHR, the inherent ambiguity of unstructured language may limit our ability – or the computer’s – to properly utilize information that was created by a clinician, and to put that knowledge to work figuring out what diseases or symptoms may be present. Radiologists themselves have been known to dictate detailed descriptions of an imaging study in their very own personal style. I call this ‘radiopoetry,’ tongue in cheek, but unfortunately, this can sometimes make it hard for others to understand or act on their findings.”

“In philosophy and poetry, you can create a beautiful tension by using language in a nonstandard way,” he said, “but when it comes to the transmission for information in health records and medical reports, you really don’t want that.”

As the current chair of the ACR Informatics Commission, Wald also supports work to resolve some of those natural language concerns. He cites the ACR-developed (Breast Imaging-Reporting and Data System) BI-RADS as a poster child of how “we’ve standardized” the lexicon and reporting measures to help ensure that “the downstream people know exactly what the radiologist diagnosed on the mammograms.”

Through committees of radiologists and referring physician consultants, ACR is also supporting the development of RADS that are applicable to other imaging subspecialties. Radiologist volunteers and ACR staff also are building out ACR Assist modules that encode these RADS systems, giving the imaging industry an opportunity to include them inside the voice-recognition applications radiologists use in practice. With further advancement of a shared, standardized language, Wald expects that “the reports that we hand back to our clinical colleagues and patients can be as relevant, unambiguous and actionable as possible.”

Nicole M. Patterson, director of clinical engineering at UC West Chester Hospital in West Chester Township, Ohio, believes that “targeted communication” helps keep her staff familiar with the needs of the imaging department professionals with whom they interact. Her technicians make their rounds among imaging staff daily, building one-on-one relationships that establish a foundation for her own weekly contacts with them. Being proactive to their needs at a granular level helps to strengthen those interdepartmental relationships at a directorial level, where higher-level conversations about the 6,500 devices she oversees can occur.

“From director to director, we’re reviewing contracts, we’re reviewing any type of critical device trends; if there’s failures, what are we doing to mitigate those,” Patterson said.

Across UC Health System, the imaging and clinical engineering teams hold monthly enterprise imaging meetings that are also attended by nursing staff and other hospital leaders – “almost the same attendees that would attend our capital equipment discussions,” Patterson said. It’s a recent change that “is definitely beneficial,” because it offers the opportunity for all stakeholders to discuss their shared concerns ahead of capital purchases, she said.

“They’re a listening ear, and there’s a summary report that’s drafted, so when we’re at the capital equipment table, they’re not blindsided,” Patterson said. “Afterwards, people who aren’t usually as in the weeds [with individual devices] as the imaging department and we are do remember maintenance information on a certain device, or that there’s uptime issues in certain areas when it comes to capital equipment.”

Those roundtable meetings have led to a deepening of inter-departmental relationships during the normal course of their operations, as well as more frequent conversations about ways in which those involved in the talks can support one another, particularly during the novel coronavirus (COVID-19) pandemic.

“We’ll meet formally monthly and quarterly, but between that, as events occur, we’re on top of those,” Patterson said. “I’m definitely proud of where we’re moving, not only as a site, but as a system. We talk daily on an operational level, so if there’s any concerns there, we’re able to send a staff member. In this time as we’re fiscally strapped, communication has been very important.”

The high visibility of imaging equipment metrics available to both Patterson’s department and the UC West Chester imaging team also offers opportunities for each unit to derive performance improvements across the board.

“Data is so powerful that sometimes you get the question that you didn’t want to answer,” she said. “Sometimes it’s information overload. The beauty of providing visibility on how we operate is that my direct counterpart within imaging is aware of what’s going on, or can even question it. There’s times I can think something is mission-critical, but my director can say, ‘This can actually wait.’ ”

“I really feel like being able to lay everything out on the table, being open to input or opinions, that’s happened here a lot,” Patterson said. “It’s definitely a collaborative space here.”

Daniel Gonzales has spent 30 years of his 35-year radiology career in leadership positions, and 20 of those as an imaging director. In those roles, Gonzales, currently the director of diagnostic imaging for Carlsbad Medical Center in Carlsbad, New Mexico and vice-president of the American Society of Radiologic Technologists (ASRT), said he’s learned that the best way to improve inter-departmental collaboration is by fostering one-on-one relationships with staff throughout the facility.

“What I’ve found out over the years of being able to work with the nursing staff and the medical staff – building that relationship, and trying to realize that we’re all in this for the same thing – is without imaging, you lose a lot,” Gonzales said. “We’ve found out in the coronavirus era that these departments whose employees have been affected by coronavirus have put a big stress on the facility.”

Throughout the pandemic, two imaging technologists under his supervision have missed time from work because of the virus; the temporary loss of one, a sonographer, “put a big strain on our ultrasound unit,” Gonzales said, “because he’s the only one who does echocardiograms.”

“They realized that we’re in a situation where you have to work together to have a solution,” he said. “Once we start losing staff, it’s going to be a really tough place to work.”

At Carlsbad Medical Center, collaboration is fostered through daily encounters among various staffers whose tasks lead them to interact with members of one another’s specialties. Director-level conversations happen almost daily, and Gonzales says department leaders work to settle any issues that arise before any problem is exacerbated.

“Hospital staff can get in a rut,” Gonzales said. “I say, ‘If you have an issue with the department, please come to me. I can get this settled, I can work with the staff to know what the issue is, and if we can’t get this solved, we’ll go to the next level.’ ”

“I like to have a really good rapport with physicians, radiologists and administration; through communication and collaboration, that’s how we’re going to get things done here,” he said.

Gonzales leans on those personal relationships and the hierarchy of departmental leadership to foster important conversations around issues like staffing, as well as clinical concerns and equipment upgrades, in which numerous stakeholders share interests in the outcome. Managing inter-departmental chains of communication for the long term offers significant benefits for everyone involved; failing to do so can invite just as many setbacks.

“Keeping up with technology is one of the main goals as a director,” Gonzales said. “I have to take it day by day, and month by month, through changes of administration, and work at upgrading our system yearly.”

“We have to build towards that,” he said. “I need collaboration among physicians when I do this.”

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