Informatics: Linchpin of Personalized Medicine
In urging radiologists to adopt a new focus on quality improvement, RSNA outgoing president Gary Becker, MD, outlines the steps necessary to achieve this goal and calls informatics integral to the process. “As we enter the era of personalized medicine and value-based purchasing in medicine, delivery of the highest quality, most efficient care will depend on quantitative imaging and informatics,” Becker told a full house during his presidential address on November 29 at the 2009 RSNA meeting in Chicago, Illinois.
Gary Becker, MD
After outlining his case for why quality matters and employing the history of astronomy to prove his point that quality improvement is incremental and is a quantitative applied science, Becker turned to the 2007 New Horizons lecture given by Elias Zerhouni, MD, then director of the US National Institutes of Health, to show the audience where medicine is heading and why imaging and informatics are essential to getting us there. In that lecture, Zerhouni described the future of medicine as what he called P4 medicine: personalized, preemptive, predictive, and participatory. “Personalized means individually customized; preemptive means treating individuals at risk for disease before symptoms appear; predictive means treating only those patients most likely to respond to treatment, and least likely to experience adverse consequences; and participatory means a cooperative network of patients and health care providers,” Becker explains. “All of these missions of future medicine are highly dependent on quantitative approaches and informatics, and imaging is going to play a central role.” In the P4 medicine of tomorrow, the right person will get the right treatment at the right time, and Becker believes that imaging will play a crucial part. “Images offer so many compelling features: They are quantitative, nondepletable resources, unlike a biopsy specimen or a blood sample, and are provided nondestructively, unlike surgical specimens, for example,” Becker says. “They are excellent localizers that provide high temporal and spatial resolution and multidimensional information.” More Data to Come Consequently, the amount of information now flooding modern reading rooms will continue to increase, bringing new opportunities in screen detection, lesion characterization or diagnosis, assessment of therapeutic response, and image-guided intervention. The new opportunities can be seized, however, only through new software applications yet to present themselves. “A robust array of validated software tools will be required to realize the full potential,” Becker notes. Becker shares an example provided by Larry Schwartz, MD, from Memorial Sloan-Kettering Cancer Center, New York, New York, in which therapeutic response is assessed in a patient with non–small-cell lung cancer. Linear measurements showed only a 7.9% decrease in tumor size, while volumetric CT revealed a 25.7% decrease. Another striking example demonstrated the remarkable ability of double-contrast MRI in predicting tumor response to angiogenesis inhibition, on the second day of therapy, in a patient with a colon carcinoma. “Single-intensity and bidirectional transfer contrast are greatest when angiogenesis is active,” Becker explains. “On day two of using the angiogenesis inhibitor, the transfer contrast was down to 31% of baseline, and by the end of cycle two, it was down to 15%. Of potentially equal importance for other patients, early establishment of nonresponsiveness could help avoid unnecessary side effects and save precious time for more effective therapies.” Becker believes that the greatest benefits of quantitative imaging will accrue when such data are uploaded to a nationwide informatics grid that includes reports from radiology, laboratory, pathology, the electronic medical record, and genomics as fundamental data sources. “Under strict policy and security, these data are published, managed, integrated, and then analyzed and rendered through a number of applications,” Becker says. He cites the example of the National Cancer Institute’s Cancer Biomedical Informatics Grid, which has begun to do all that he outlines. Low-hanging Fruit Becker shares several examples of how various institutions are implementing quality measurement, and the role of IT-enabled decision-support tools. “Some of the biggest safety and quality gains radiology can offer involve IT-enabled decision-support tools for physicians in multiple departments and specialties,” he says. “Prime examples include computerized radiology order entry, which brings appropriateness criteria to the point of care, and electronic image sharing, which can reduce duplicate studies and minimize unnecessary radiation exposure.” Several slides contributed by Keith Dreyer, DO, assistant chair of informatics at Massachusetts General Hospital in Boston, depicted a seven-year analysis of the impact of radiology order entry with decision support on outpatient procedure volumes. A sample screen from the system indicates red, or low utility, for a noncontrast head CT ordered for dementia. Becker explains that a physician can override, cancel, or edit the clinical information, but the analysis demonstrates that decision support influences behavior. “After system implementation, a dramatic change in ordering behavior resulted in a striking leveling effect on the volume growth for CT,” Becker notes. He also cites the experience in Minnesota of the Institute for Clinical Systems Improvement, which reports a nearly identical result for radiology order entry with decision support for high-tech imaging. “Clearly, order entry with decision support is powerful in shaping physicians’ behavior,” he notes. Additional gains in radiology quality improvement will be made with structured reporting and computer-aided detection and diagnosis, Becker predicts. “Structured reports will standardize our work output, eliminate errors of omission, and facilitate everything from ordering and scheduling to clinical care, billing, and research,” he says. “In computer-aided detection, we’ll see algorithms for screen detection, diagnosis, and assessment of response to therapy with improved accuracy and throughput as the data deluge continues.” Becker adds, “These exciting glimpses reveal what’s possible when performance measurement fuels performance improvement and when quantitative imaging and informatics are applied to improve accuracy, enhance workflow, and enable decision support.” Recommendations In urging all attendees to join the quality-improvement movement, Becker suggests a visit to the RSNA Web site, where multiple resources are available under the quality tab. He also recommends putting the following closing points to work: First, what you do not measure, you cannot know. Second, what you do not know, you cannot improve. Third, measurement starts the cycle that underpins continuous quality improvement. Fourth, safety and quality are habits that flourish in a culture of improvement, but are quickly extinguished in a culture of blame. Establish a culture of improvement. Fifth, quantitative imaging and informatics are certain to play a central role in P4 medicine. “Stay aggressive and adopt new quantitative methods as they evolve, because as a radiologist, you will be a key figure,” Becker concludes. Cheryl Proval is editorial director of Radinformatics and and editor of Radiology Business Journal.