Anales de la RANM

101 A N A L E S R A N M R E V I S T A F U N D A D A E N 1 8 7 9 Pablo R. Ros An RANM · Año 2019 · número 136 (02) · páginas 99 a 102 INTEGRATED DIAGNOSIS: EARLY EXPERIENCE se or organ oriented institutes since the COEs coordi- nate the efforts of specialists of different departments dealing with specific portions (spine, brain, sellar re- gion, etc.) or diseases (oncology, degenerative, seizu- res, etc.) of an organ system (6) In a Diagnostic Institute, the first COE typically esta- blished is that of Cancer Diagnosis, since in many De- partments of Radiology, Pathology and Genetics the- re already are Divisions or Sections focused in this key disease. There may be other disease based COEs in Diagnostic Institutes devoted to diseases where diagnosis by imaging, pathology and genetics bene- fits by a coordinated approach by specialists. COEs for Neuro Degenerative, Cardiometabolic, Immuno- logic and Pediatric Diseases are after the Oncologic Diagnosis COE, frequently founded in Diagnostic Institutes. In general, once the concept of ID is em- braced by a healthcare organization it is natural to de- velop COEs paralleling existing Institutes. For instan- ce, if an integrated healthcare organization has Neu- rological, Cancer, and Gastrointestinal Health Insti- tutes, the Diagnostic Institute will develop COEs de- dicated to mirror the existing Institutes in support of the healthcare system major areas of interest (3). Besides disease based COEs as the ones mentioned, there are others in Diagnostic Institutes. It makes sen- se to establish COEs centered in Population Health, Innovation, Diagnostic Optimization and Computa- tional Sciences. Integration of radiological and pathological images, and thus achieving and integrated rad-path or diag- nostic report as is done in Tumor Boards, is the most common manifestation of ID. Establishing a Diag- nostic Institute provides the opportunity to expedi- te the electronic integration of radiological and ana- tomic pathology specimen images. Through single, already commercially available PACS workstations, images can be displayed side-by-side and electroni- cally linked, resulting in the so-called Integrated Tu- mor Board workstation (Figure 2). This is commonly one of the earliest and most successful initiatives of a Diagnostic Institute. The Integrated Tumor Board allows identifying and reconciling discordances bet- ween radiologic and pathologic findings in every case where radiological and surgical pathology images are performed, and not only in the handful of cases pre- sented in the Tumor Boards. Also, a reconciled, inte- grated report is issued and stored in the patient’s elec- tronic medical record in all concordant cases. The final disposition of the case is linked to artificial intelligence (AI) engines for best management, po- tential steerage of patients to clinical trials and au- tomatic monitoring of the follow up images for res- ponse. Clearly, an Integrated Tumor Board impro- ves quality and reduces risks. Of the different Tumor Boards the most advanced in the adoption of an ID approach is that of Breast Cancer. Radiology, Pathology and Genetics participate in screening programs of healthy population. The op- portunity provided by a Population Health COE within a Diagnostic Institute is to offer Integrated Health Screening combining imaging, laboratory and genetic testing. This testing is age and gender tailored and includes screening for the top 25 gene- tic defects, laboratory key screening indicators, such as tumor markers and lipid panel, and imaging. Ima- ging screening of populations has blossomed and currently the following tests are insurance and US government approved: mammography, calcium sco- ring, CT colonography and lung cancer screening. Others imaging screening tests are considered out- of-pocket expenses, such as breast and prostate can- cer screening fast MRI scans and ultrasound scans for aortic aneurysm and liver steatosis. Both ends of the health care financial spectrum such as, executive physical exams programs and Accountable Care Or- ganizations (ACOs) are interested in exploring inte- grated health screening programs. The reasons are opposed since in the first case is market differentia- tion, and in the latter, cost savings. Appropriate test utilization is of paramount impor- tance for radiologists, pathologists and geneticists, since there is a clear tendency to conserve resour- ces and decrease the cost of diagnosis. In Radiolo- gy there is already a long tradition of using Deci- sion Support Systems (DSS) based upon agreed ap- propriateness criteria put forward by organizations such as the American College of Radiology (ACR). There is no such tradition for pathology (labora- tory) and genetics, but there is interest in forming Diagnostic Testing teams composed by expert clini- cal pathologists and clinicians, to explore AI appli- cations for laboratory test optimization rather than DSS. C ANC ER D I AGNOS I S COE AND I NT EGRAT ED TUMOR BOARDS Table 1 Example of the organizational structure of a Diagnosis Institute in an Academic Medical Cente in the US. Note the D partments of Radiology, Pathology and Genetics are divided in organ, technology or disease based Divisions, Sections and in some situations Centers. Figure 2. Integrated Diagnosis Workstation: In the same PACS workstation, mammography and breast ultrasound images are displayed integrated with surgical drawings, macroscopic specimen section and histology whole-slides in H&E and RE. Image courtesy of SECTRA POPULATION HEALTH COE DIAGNOSTIC TEST OPTIMIZATION COE