What Emergency Physicians Want From Radiology

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Paul SierzenskiResults of a study¹ released in Chicago, Illinois, during the 2010 annual conference of the RSNA confirm what many in both the radiology and emergency-medicine communities already knew: Utilization of imaging in the emergency department has exploded. According to the Radiology study,¹ emergency-department visits that included CT imaging increased from 2.7 million in 1995 to 16.2 million in 2007, with no signs of a tapering off in growth. A similar Archives of Internal Medicine study² shows growing use of both CT and MRI as tools for evaluating potential neurological conditions; it concludes that the greatest imaging increase in emergency departments since 1997 has been in head CT and MRI. Fresh research³ from the 2011 annual conference of the American College of Cardiology (held in New Orleans, Louisiana) confirms CT angiography’s effectiveness in triage for patients with acute chest pain. Paul Sierzenski, MD, RDMS, director of emergency-medicine ultrasound at Christiana Care Health System (Wilmington, Delaware) predicts, “The emergency department will continue to be the highest and most rapidly growing area for imaging in the health-care system, but one of the things that often fails to be communicated is that we use imaging because it works. Imaging has value, and CT in particular has been, and is, one of the best diagnostic tools we have in emergency medicine.” Utilization, he observes, continues to increase not only because of imaging’s status as an effective diagnostic tool, but because of the complexity of the clinical conditions of many emergency-department patients. “The population of patients with comorbidities that are difficult to diagnose is on the rise,” he notes. Imaging plays a critical diagnostic role for that population, he adds. Reform’s Front Runner Sierzenski points out that emergency-medicine physicians are currently the only non-government-employed clinicians in the United States who are required, by federal law, to see patients. The volume that they accommodate and the efficiency with which they must perform their work mean that wasteful processes are not an option. “If there’s anyone, in any specialty, who doesn’t see waste in the way he or she performs, he or she is not being honest,” he observes. “There’s clearly fragmentation of service, no matter what the clinical scenario.” He stresses that radiology will have to work even more tightly with emergency medicine as health-care reform’s provisions take hold, exploding an already exceedingly high volume of patients requiring fast, cost-effective care. “Like any practitioners, we’d like it all—rapid turnaround, extreme accuracy, and interaction,” he says. “Without a doubt, though, speed is probably the number-one need in emergency medicine. Our volumes keep going up—the pressures we all have are going up; speed is the key. Radiologists should understand that clinicians have a unified definition of a ‘contemporaneous reading,’ and that is during the active care of the patient.” There are examples, Sierzenski says, of facilities around the country that are successfully cultivating a deeper collaboration between the two specialties. At Christiana Care Health System, “We’re looking at providing radiation-exposure feedback on patients who are high-volume emergency-department users,” he says. “We’ve published data on a set of patients who have been seen hundreds of times in the emergency department, sharing their radiology utilization, as well as exposure. Having the collaboration between emergency-department and radiology to bring that to light is very helpful.” Sierzenski also looks to tools such as computerized decision support and computerized provider order entry to refine emergency physician’s use of imaging. In Boston, Massachusetts, for instance, Massachusetts General Hospital and Brigham and Women’s Hospital have been employing these tools to identify which patients will benefit most from high-tech imaging in the emergency department. “These facilities continue to work toward improving the patient-centered approach while reducing costs,” he says. “We’re all looking for consistency in service because variation results in waste, and eliminating waste is big in health-care reform.” Service Gaps Consistency in radiological services, Sierzenski observes, remains elusive for some facilities—particularly academic medical centers, where nighttime preliminary interpretations by second- or third-year radiology residents remain standard. “If you can go to a community hospital in rural Kansas and have a board-certified radiologist read a study during the night, why are there prestigious institutions where a resident reads the study for overreading by an attending physician the next day?” he asks. “Is that the standard of care the community expects from radiology? I would say no. That gap should be closed.” Another service gap cited by Sierzenski occurs in communication, which is fragmented among many specialties, including radiology and emergency medicine. “The communication gap just continues to grow,” he observes. “We need to work productively with our colleagues in radiology to minimize waste of service, reduce cost of care, and reduce radiation exposure. I don’t think there’s any way to do this on one single front. There needs to be collaboration in working to achieve this goal.” Part of this sea change will be opening the lines of communication among institutions, since emergency-department physicians tend to deal with patients who have been receiving health-care services from multiple hospitals. “If there’s a flow of information from institution to institution, we can better assess whether a patient warrants imaging,” he says. “A lot of the common ground between radiology and emergency medicine includes providing high-quality service in as efficient a manner as possible. An information highway for medicine that would allow information to flow from hospital to hospital would help with that.” For the future, Sierzenski looks to health IT to provide the final leap in delivery of radiology results to emergency physicians. “I would anticipate that sooner or later, imaging information will be delivered via smartphone, and it will be in the hands of the treating physician in real time,” he says. “Communicating directly with the practitioner is currently difficult, but it would be ideal.” Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.