The time for diagnoses based on incomplete datasets is at an end; we must connect the ‘ologies’ with all of medicine, writes Dr. Brendan Devlin, a practising radiologist and Senior Clinical Advisor to Sectra.
Worlds don’t need to collide—what integrated diagnostics is actually about
There are some who might feel uneasy about integrating the way we work in diagnostics. Disciplines, sometimes dating back to the beginnings of modern medicine, have had their own way of working, their own culture, philosophy and an established place in patient care.
Pathology and radiology present very different working environments. Radiology departments are somewhat unpredictable workplaces, where a continual flurry of human beings—patients, clinicians, radiologists, radiographers and others—interact with each other, constantly moving in and out of examination and reporting rooms. Such an ad-hoc response to acute medical situations has required an active handling of information flows to allow professionals to cope.
Conversely, the pathology department is busy in a different fashion, focussing on the examination of blood, bodily fluid and tissue samples in a more organised environment, where workflow is more ordered, and where information flows have been less acute.
Even the hint of being thrust into such a different way of working could be an unsettling prospect for staff in either environment.
But we don’t necessarily need to erode identities or implement a full-blown merger between departments in order to realise the gains for patient care that are now achievable from closer, more collaborative working.
In fact, integrating diagnostics is in no way a takeover in either direction. At times installed radiology infrastructure might provide the technological platform to facilitate pathologists carrying out their work in a digital environment but both departments generally have more than enough of their own work to even consider getting involved in the management of the other.
Rather, integrated diagnostics is about linking the diagnostic processes, whether radiology, pathology, or any other ‘ology’, with all of medicine.
A matter of opinion—creating the informed reporter
Despite differences at the coalface, modern radiologists and pathologists carry a key common identity; and its one that’s more important than any shared frustration of their service being taken for granted.
At their core, radiology and pathology are both opinion based specialities. We give our opinions based on our analysis and interpretation of visual appearances—either scans and images of the live body, or the more colourful images of cellular pathology or cytology.
At their best these interpretations are informed by the wider clinical context, and they are often complementary to each other, especially in complex cases—with radiology providing the macro context of the biopsy and thus hopefully contributing to the level of diagnostic certainty in the final pathology report.
The advent of digital tools, means we now have an opportunity to connect information at all levels—so that the radiologist and the pathologist can both become fully informed reporters, producing the best possible opinions.
This is about delivering a richer and more complete supply of information to the reporting professional, and creating a methodology to more easily rectify data gaps which previously might have been quite a challenge. If the person creating the original report has all the information that is relevant—it is more likely to be complete.
A fully integrated messaging system should allow easy context relevant interaction with information silos and communication between radiologist, pathologist and clinician to the benefit of all.
But the historic position of pathology being the final arbiter, perhaps in the context of incomplete data sets, has had potential inherent weaknesses, particularly in atypical or marginal cases.
Radiologists have long been accustomed to their conclusions being tested, quality assured and reviewed in the light of new clinical data in what are often rapidly evolving clinical scenarios. With interpretation at the cornerstone of diagnostics, any final diagnosis given should be based on accurate information regarding the patient history, other examinations, and the most up to date data on the current patient status.
But this information has not been so easily accessible in the past, and in many cases throughout the world, it is still inaccessible, despite the emergence of electronic patient records and the now firmly established multi-disciplinary team (MDT) meeting.
The cumbersome task of bringing slides to an MDT meeting and displaying them on a linked optical microscope, has meant that often pathology reports have been completed based on information reviewed before the MDT meeting, meaning that the pathology report has been reliant on previous opinion, instead of a full interactive consideration of the possibilities in light of up to date data and professional opinions offered in the MDT. If this interactive quality assurance throws up continuing diagnostic uncertainty it may be wiser to repeat a biopsy rather than being definitive on an incomplete dataset.
Digitally integrated diagnostics
There is a strong argument for a single common platform for imaging studies. Pathology is becoming an imaging study, just in the same way as x-rays or CT scans. And in the move to digitisation, the filing, storing and marking of images is becoming similar for radiology and pathology, opening new opportunities for better ways of working.
Digitisation must happen for integrated diagnostics to work, but the benefits for pathologists should be welcomed. We can ease comparisons with previous examinations in the digital environment. We can bring an end to physical man handling of multiple slides. The ability to organise material automatically, to annotate and to streamline workflow, is all dramatically enhanced.
Our specialties have a frequent need for second opinions both from local colleagues and from regional or national experts. There is no doubt that this important function is simply transformed by working in a digital connected environment.
But there is also a bigger picture to consider. On their mission to integrate, diagnostic departments must look first and foremost at patient needs and to the service they are duty bound to deliver.
That might mean more than thinking about ‘my department’ or even ‘my hospital’. It may mean, and increasingly does mean, thinking about the service across a region or even across a country.
Integrated diagnostics can be about more than connecting different disciplines—it can be about solving pressures in resources, in recruitment, and making sub-speciality expertise available across wide geographical footprints. Departments must think about the big picture—regional IT, regional radiology and regional pathology services.
But, as we integrate technology, it is just as important to integrate mindsets as it is for datasets. We must acknowledge not just the differences but also the similarities in what we do, and convey the opportunities for quality assurance so that, even in difficult cases at the margins, we can be more confident than ever in our diagnoses and strive to give all patients the right treatment plan.
At every level this is simply about offering the best possible service to our patients. Full integration of our diagnosticians with each other and the wider clinical service is the way forward.
Dr. Brendan Devlin is a Senior Clinical Advisor to Sectra and a radiologist in the NHS. As lead radiologist, he was a key player in the conception, specification and implementation of NIPACS, which has revolutionised the delivery of imaging services in Northern Ireland. Dr. Devlin has sat on regional and national committees and was a member of the service review committee and the IT sub-committee of the Royal College of Radiologists for several years.