Dr Bhawan Paunipagar, Consultant Radiologist, Co-Ordinator of Dept of Radiology, Wockhardt Hospital Mumbai Central addresses the issue of quality and its importance in correct diagnosis for better treatment outcomes
Quality has become a hot topic in recent years, the entire medical enterprise is being pressured to address quality not only by the public, but also by healthcare services and by regulatory agencies that insist hospitals and physicians measure and improve healthcare quality. Many aspects of healthcare quality have been identified that are lacking and that need regular measurement and improvement.
Radiology is coming under increasing scrutiny by regulators with all parties questioning the value and effectiveness of practitioners. Quality is becoming a critical issue for radiology. Measuring and improving quality is essential not only to ensure optimum effectiveness of care and comply with increasing regulatory requirements, but also to combat current trends leading to commoditisation of radiology services.
A key challenge to implementing quality improvement programmes is to develop methods to collect knowledge related to quality care and to deliver that knowledge to practitioners at the point of care.
There are many dimensions to quality in radiology that need to be measured, monitored, and improved, including examination appropriateness, procedure protocol, accuracy of interpretation, communication of imaging results, and measuring and monitoring performance improvement in quality, safety, and efficiency.
Several important trends are making quality the centre of attention for both radiologists and the parties judging them:
(I) radiology is becoming more visible and central in healthcare delivery,
(ii) there is an exponential growth in medical imaging, and the threat of radiology becoming a commodity in the era of the Internet and international teleradiology,
(iii) imaging is increasingly performed by non-radiologists or by radiologists at remote locations who may not have access to the same information as local practitioners.
Hospitals are responding by looking for ways to track quality indicators and deliver vital knowledge to physicians to prevent errors and improve measurement and monitoring of practice efficiency and patient safety.
NABH (National Accreditation Board for Hospitals) is one such body that plays a vital role in approving and laying down guidelines in the line of the informatics those address quality issues.
Current approaches to quality assessment and improvement are costly, time-consuming, and incomplete. The tasks required are voluminous and data-intensive, challenges for people but not for machines. While cost may be a factor hindering adoption of informatics technologies, the lack of education is also important: Few radiologists and administrators are aware of the potential of informatics to provide the functionality they need.
Quality measures are becoming part of the regulatory, compliance, and reimbursement framework. In response to these changes in the healthcare environment, radiologists and hospital administrators are being spurred to plan and implement quality measurement and improvement procedures.
Quality is the extent to which the right procedure is done in the right way at the right time, and the correct interpretation is accurately and quickly communicated to the patient and referring physician.
Beyond the direct pressures on the medical system to improve healthcare quality, there is also a business case for quality in radiology. With the advent of picture archiving and communication systems (PACS), radiology is under threat of becoming a commodity.
Finally, quality is ultimately the core aspect of the professionalism of medicine. Ultimately, radiologists are the best equipped to discover the problems limiting the effectiveness of their practice and to guarantee the quality of their services. There is a growing perception that all radiologists provide an equivalent service globally and that cost is the only factor that needs to be considered in the marketplace. However, radiologists can differentiate themselves from competitors if they can demonstrate better quality.
Stephen Swensen, Past Chairman of Radiology, Mayo Clinic, makes a compelling argument “Radiology as a commodity will crash and burn in this flat world… For cents on a dollar, you can have images interpreted in other parts of the planet using teleradiology. Unless we can differentiate our product by quality—meaning quality as a combination of outcomes, safety, and service, We have to be able to not just say that we’re better; we have to be able to prove it.”
Appropriateness of the examination is represented by the term ‘the right procedure’. There are two aspects: appropriateness of the examination requested by the referring physician and appropriateness of the examination performed (the imaging protocol). Radiologists and referring physicians must be knowledgeable about which imaging procedure is appropriate for each clinical indication. The procedure protocol is represented by the term the right way. Once the correct procedure is requested, the correct protocol for the procedure must be selected and communicated to the technologist who will perform the study.
Accuracy of interpretation is represented by the term the correct interpretation. Once the imaging procedure has been performed, the images are reviewed by the radiologist. The radiologist’s task is to accurately perceive and interpret the imaging observations (radiologic diagnosis). Communication of results is represented by the phrase accurately and quickly communicated. Once the radiologist provides an interpretation and recommendation, those results must be communicated to the referring physician and the patient in a timely manner, depending on the type of result (i.e., critical results vs non-critical results). Radiology interpretation comprises three steps: (a) perception of image findings, (b) interpretation of those findings to render a diagnosis, and (c) decisions and recommendations about case management (next tests or treatments). Each of these steps poses pitfalls to accurate image interpretation. Informatics methods can support radiologists and help them reduce errors during each of these steps.
These methods include just-in-time methods to deliver knowledge at the point of care, computer-aided detection (CAD) to assist with perception, and decision support applications to reduce variation in interpretation. CAD is an informatics method for improving quality by helping radiologists perceive abnormal imaging observations. In CAD systems, a computer programme “reads” the images, detecting particular types of imaging findings that it has been trained to recognise. The central task of these systems is detection of particular imaging findings, such as calcifications, masses, or nodules.
A related task is diagnosis (i.e., interpretation of imaging findings). Because CAD systems seek specific types of image findings, the radiologist should not consider these systems a substitute for evaluating the entire image, as there are many other types of image findings that could be present beyond those the CAD system is trained to detect. Furthermore, CAD systems may not detect lesions that they are built to recognise.
CAD systems generally display regions of suspected abnormality as annotations on the image that the radiologist reviews. The CAD programmes are usually trained to be very sensitive (so as not to miss any true-positive lesions on the images). Consequently, there will often be one or more false-positive findings—CAD annotations on the image that the radiologist believes do not represent abnormalities and can be ignored.
Thus, the CAD reading is often regarded as a second opinion. The diagnosis is ultimately made by the radiologist, who takes into account the CAD output. Many studies have shown that such second opinions, whether rendered by a radiologist or a computer, increase the overall accuracy of the radiologist.
Finally, measuring and monitoring performance improvement in quality, safety, and efficiency is represented by the phrase patient and referring physician. Ultimately, the effectiveness of radiology is judged by the accuracy of radiologist performance, efficient service, and avoidance of unintended patient complications. Radiologists and institutions must measure and monitor indicators of quality, safety, and efficiency in their services to prove that imaging and their interventions are of high quality.
Responsibility for quality is fundamental to the practice of radiology. Computer applications to measure and improve quality can be successfully deployed. Informatics methods should not be regarded as futuristic developments on the horizon; such applications are already in routine use at many institutions and will likely become more prevalent in the future. Ultimately, as radiologists, quality is not just our goal, it is our responsibility, and deploying informatics methods will help us achieve our objectives of perfect diagnosis for a perfect treatment plan.