Improvements to the collaborative workflow processes between radiologists and pathologists are critical in cancer diagnoses. Implementing a system or process that allows optimal communication exchange between radiology and pathology will provide immediate benefits for practitioners and patients. It will also provide other users of radiology and pathology information, including cancer surveillance initiatives with more accurate and complete data on the status of cancer at the state and national level. Unfortunately, there is often little to incentivize institutions to develop the necessary infrastructure for radiology and pathology systems to share information with each other. Considering that the two specialties have different member organizations, there is currently no organizational home to host the interoperability or drive the different systems to interoperate.
There are several opportunities to consider for improving the current radiology-pathology workflow processes and systems. As previously discussed, radiology and pathology information systems must support the workflows required for the specialties to exchange specimen findings and ensure clinical concordance on each case. In a recent survey by CAP, 88 percent of responding pathologists indicated that they would like to review radiologic images. 31 Achieving this will require continued refinement of electronic standards such as CAP’s Cancer Protocols and Checklists and RSNA’s Report Templates to support the interoperability between pathology and radiology systems that allow access to each other’s findings. The group also noted that while the DICOM standards for image exchange in radiology have been in the market for several years, the DICOM supplement for digital pathology (Supplement 145) [†], has only recently been released (July 2010). 32 While it will take commercial developers some time to implement this standard into their systems, it creates an opportunity for the market to develop products specifically designed to meet the needs of this new collaborative model. To further support these needs, the workgroup identified four gaps in current standards efforts that should be addressed in the future.
- The need to develop ordering/requisition standards that enable radiologists to uniquely identify tissue samples and link them to the associated clinical information for submission to the pathology laboratory
- The need to develop appropriate linkages between documents so that the appropriate information can be reviewed during a concordance process
- Paradoxically, the need to develop standardized reporting templates that pathologists can use to report non-malignant findings
- The need to establish a mechanism to document concordance between radiology and pathology results
A second potential opportunity to improve radiology-pathology workflow systems is to view the interaction as a model for an episode of patient care with reimbursement components that could foster concordance meetings and collaborative quality improvement programs between the specialties. It is important that these models enable a wide range of partners to interact both within an institution and between institutions. The group noted that electronically reporting the results of diagnostic studies to cancer registries could be the first step in developing these models as it would foster the use of standardized reporting templates that are already available while offering the tumor registries the benefits of more timely reporting of cancer incidence.
Another opportunity is for the two specialties to foster educational exchanges between the disciplines and expose both practitioner types to training in the other discipline. These efforts should be implemented at the medical school, post-graduate medical education, and continuing medical education levels. Recently, ACR launched the American Institute for Radiologic Pathology (AIRP). The institute will offer a Radiologic-Pathologic Correlation course beginning in January 2011. 33 This course will provide radiology residents with an opportunity to learn the corresponding pathologic counterpart of their findings and emphasize the correlation between pathology and the medical images. 33
In this analysis we have focused primarily on breast cancer as a model. However, the two specialties are also collaborating in many other types of malignancies. Future studies should examine the role of the radiology-pathology workflow processes in the broader clinical setting. These studies should include efforts to quantify both the rate of discordant findings and their public health effects. Their results should be used to develop dedicated quality assurance programs including quality measures and best practice guidelines that address the needs of pathologist, radiologist, and the patients they serve.