Has the Time Come for Integration of Radiology and Pathology?

More collaboration between radiologists and pathologists could speed up diagnoses, increase accuracy, and improve patient outcomes, say advocates of an integrated diagnostic service

For years, certain pathologists and radiologists have floated the idea that an integrated diagnostic service involving both medical specialties could improve patient safety and contribute to improved patient outcomes. Now that the U.S. healthcare system is encouraging tighter integration of clinical services, advocates of an integrated diagnostic service involving radiology and pathology believe that the era of integrated diagnostics may be soon upon us.

There is appeal to the concept of an integrated diagnostic service that would deliver a single, unified report to the referring physician. For example, pathologists and radiologists often work together to work up certain types of cancer. They bring complementary skills to the diagnostic process. Often, particularly in complex cases, their collaboration improves the precision of their respective diagnoses and points the physician to the most appropriate therapies for the patient.

How Radiology and Pathology Can Add Value to Improve Patient Outcomes

This is one reason why a growing number of physicians from the two disciplines argue that closer collaboration could improve diagnosis and treatment of cancer as well as guide better decision-making in other areas. Another factor in support of more collaboration in diagnostics involves the respective advances in the diagnostic technologies used by pathologists and radiologists. That is why there is value in pairing high-definition, advanced imaging from radiology with the latest high-tech tools available to pathologists to ensure the most accurate findings.

“It’s all about driving value to the patient at the workflow, imaging, and text-mining levels to improve outcomes,” declared Michael Feldman, M.D., Ph.D., Director, Office of Pathology Informatics, Associate Professor of Pathology and Laboratory Medicine at the Hospital of the University of Pennsylvania, in a Diagnostic Imaging article. “It makes for a more efficient diagnostic process, better informed practitioners and an environment of reduced errors.” Feldman was speaking at a special session on pathology-radiology integration at the 2014 Radiological Society of North America (RSNA) annual meeting.

Integrating Radiology and Pathology Began More Than a Decade Ago

Merging pathology/laboratory medicine with radiology is not a new idea. Richard Friedberg, M.D., Ph.D., currently Chairman, Department of Pathology, Baystate Health, was among the first to champion the idea in 1997 when he helped create a single Diagnostic Medicine Service Line (combining pathology, radiology, and nuclear medicine across three states) with the Department of Veteran Affairs Atlanta Healthcare Network, known today as VA Southeast Network (VISN7). The College of American Pathologists (CAP) noted Dr. Friedberg’s achievement in a CAP Today article.

Bruce A. Friedman, M.D., Emeritus Professor of Pathology, University of Michigan Health System, in 2007 pointed out the 10 top benefits to diagnostic integration. These benefits ranged from “integrated reports of pathologists and radiologists working collaboratively” leading to “higher levels of quality” to “the merger of medical imaging, molecular imaging, and molecular diagnostics” being “the future of diagnostic medicine.” Friedman made these comments in a Lab Soft News post.

“The future of radiology, pathology, and lab medicine are all similarly dependent on information technology, molecular diagnostics, and imaging technology. Pooling resources and strategic goals in these three areas of inquiry will have a powerful multiplier effect on the merged specialty,” he stated in the Lab Soft News post.

EHRs and HIT Removing Barriers to Pathology-Radiology Integration

Today, the widespread adoption of electronic health record (EHR) systems and improving health information technology (HIT) system interoperability is removing one big barrier to integrating clinical workflows. “It doesn’t always happen smoothly or easily because systems historically were built independently. Now we’re getting to a point where we are migrating to systems that facilitate and allow interactions to occur more seamlessly,” stated Feldman in an exclusive interview with Dark Daily.

“It’s not that the pathologist never looks at the radiology when they do breast pathology,” he added. “They do, but they have to go and fetch it from other systems. The amount of effort it takes to do that is high, so it adds considerable time to the diagnostic process. What is changing this situation is the development of integrated workflows. With these new tools, when the pathologist is looking for relevant diagnostic information—whether from radiology or pathology—it is immediately there, it’s available, and it’s been annotated so that it is ready to be digested.”

In a 2012 BMC Medicine article, lead author James Sorace, M.D., M.S., Senior Medical Officer at the Assistant Secretary for Planning and Evaluation Department of Health and Human Services (HHS), also argued for an end to the traditional pathology-radiology workflow where “both specialties remain ad hoc and occur in separate ‘silos,’ with no direct linkage between their case accessioning and/or reporting systems, even when both departments work for the same host institution.”

In advancing his argument, Sorace pointed out that technological advances in pathology (increased use of molecular diagnostic techniques, digital imaging, and quantitative image analysis) and radiological imaging were inviting radiology-pathology integration.

“Despite technical challenges that limit integration within current workflow models, the opportunity for pathology-radiology integration to improve patient care is great, and more importantly, the tools to achieve this exist,” he wrote.

Breast cancer diagnosis and treatment is one area where sharing of clinical information and images between radiology and pathology is seen as extremely beneficial. In a previous SciMetrika study, Sorace estimated that radiological-pathological discordance caused missed or delayed diagnosis in 5% of all new breast cancer cases in the United States in 2010.

In addition to improving breast cancer diagnoses, increased collaboration could benefit a wide range of other patients.

Sharing Clinical Information through Integrated Information Systems

Dr. Feldman says the integration of the two disciplines does not require the creation of a new hospital department. Instead, shared workflows and integrated information systems are needed to enhance collaboration.

“What you’re doing is creating an opportunity for data to be shared and acted upon jointly and in a manner that cross-informs each diagnostic specialist,” he told Dark Daily. “That’s the value. It’s not that Radiology and Pathology suddenly have to become one big, happy department.”

There is, however, an opportunity to value the data independently, as well as have the two data sets inform each other, Feldman noted.

“It is good for patients for pathologists and radiologists to be thinking about and cross-checking and cross-validating that the lesion that was seen radiographically is represented by the tissue that was sampled,” he added. “There are many, many different organ systems where that plays a role,” such as bone, soft tissue, lung, liver, thyroid, and pancreas to name a few.

Changing Role for Pathology Biggest Obstacle to Integration

Yet obstacles to integration remain, including the growth of digital pathology. “Pathology is where radiology was with respect to digital imaging 10 years ago—where we know it’s going to happen. There’s promising technology out there, but it hasn’t yet happened to the point where it’s widely adopted and standardized,” said Curtis Langlotz, M.D., Ph.D., Professor of Radiology and Biomedical Informatics at Stanford University School of Medicine, in the Diagnostic Imaging story. “I think both radiology and pathology have recognized the need for structured reporting—where you actually have a standard for reporting certain things. And, pathology has just been at it longer.”

Mitchell Schnall, M.D., Ph.D., Eugene P. Pendergrass Professor of Radiology Chairman, Department of Radiology at the University of Pennsylvania, told the RSNA session that overcoming the cultural barrier might be a bigger hurdle and would require the two disciplines to redefine their relationship.

“Radiologists are used to ordering tests and having them come back to them so they can make a decision,” said Schnall in the Diagnostic Imaging story. “Now, we’re developing a diagnostic process with pathology that runs parallel to and supports them. It’ll change roles, and that might be the biggest challenge to making this a reality.”

—Andrea Downing Peck

Related Information:

Radiology and Pathology: Time to Integrate

Integrating Pathology and Radiology Disciplines: An Emerging Opportunity?

Why Pathology and Lab Medicine Should Merge with Radiology

Integrating Radiology, Pathology Would Improve Diagnostics, Aid Patients

Tapping the Potential Synergy of Radiology, Pathology

Ten Reasons for Merging Pathology/Lab Medicine with Radiology

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