Improving Cancer Diagnosis and Care Patient Access to Oncologic Imaging and Pathology Expertise and Technologies: Proceedings of a Workshop (2018) / Chapter Skim
Currently Skimming:
Ensuring the Quality and Accessibility of Diagnostic Expertise and Technologies
Ensuring the Quality and Accessibility of Diagnostic Expertise and Technologies
Pages 16-35
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From page 16... ...
. ENSURING THE QUALITY AND ACCESSIBILITY OF DIAGNOSTIC EXPERTISE AND TECHNOLOGIES A number of workshop participants examined strategies to enhance expertise in oncologic imaging and pathology, including improving education and training, expert consultations, telemedicine and telementoring, and clinical decision support.
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From page 17... ...
They are also taught how to prepare their reports in a standardized fashion, communicate critical results to clinicians, and learn about factors that contribute to communication gaps. Fennessy added that appropriate communication of results is also emphasized in the Cancer Imaging Fellowship Program at Brigham and Women's Hospital/DanaFarber Cancer Institute.
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From page 18... ...
The Accreditation Council for Graduate Medical Education/American Board of Medical Specialties specify six core competencies in medical education, including patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. During their training, residents and fellows receive semiannual milestone reporting on their progress in acquiring these competencies.
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From page 19... ...
The American Board of Pathology certifies 11 pathology fellowships, and there are a number of additional subspecialty fellowships relevant to oncology, she said. Nayar described current residency training in oncologic pathology, including the requirement to use standardized reporting formats with tumor staging information for resected specimens: "During residency, the utilization of templates and standardized reporting is common .
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From page 20... ...
In 2011, the European Society of Oncologic Imaging20 was established to promote research activities and other advances related to cancer imaging. Several workshop participants discussed whether pathology and radiology residencies should have a greater focus on oncology, as well as the need for subspecialty fellowships in oncologic pathology and imaging.
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From page 21... ...
One fellow specializes in women's oncology -- half of the fellowship is devoted to breast imaging and the remainder is focused on reading CT, MRI, and ultrasound scans in general oncology. The final cancer imaging fellow has a translational focus, with one-third of the fellowship devoted to research, and the other two-thirds split between nuclear imaging (e.g., PET scans)
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From page 22... ...
She added that radiologists need to learn and use the technical language that their oncology and pathology colleagues use. Several workshop participants suggested that integrating radiology and pathology disciplines in clinician training programs has the potential to improve cancer diagnosis and care.
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From page 23... ...
He said that the duplication of such infrastructure in community settings may be prohibitively expensive and inefficient. He suggested it might be more feasible to develop mechanisms for community physicians to refer certain patients for testing and care available at larger academic institutions and comprehensive cancer centers if they do not have the expertise or technologies available in the community setting.
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. Cohen added that the issue is not just about whether an individual clinician has subspecialty training, but about taking a systems approach to improving patient access to oncologic pathology and imaging.
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She added that in addition to real-time approaches, access to subspecialty expertise will also require referrals and the development of consultation networks for subspecialty support. Hricak suggested forming second opinion networks and cancer imaging consortia so that those who lack oncologic imaging expertise in their own practices have an easy mechanism to request second opinions for suspected cancer diagnoses.
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From page 26... ...
In smaller practice settings, Larson suggested that practices designate local experts in oncologic imaging or pathology who can teach and provide feedback to others in their practice. Fennessy noted that community radiologists who are part of the Brigham and Women's Hospital/Dana-Farber Cancer Institute system can participate in educational seminars via video conferencing to stay informed and receive CME credits.
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From page 27... ...
She said organized ways to ensure clinicians are keeping up with the rapidly changing knowledge base are needed. Diagnostic Management Teams Zutter said the complexities involved in cancer diagnosis have challenged the traditional paradigm of pathology testing, in which a clinician orders a test, a lab performs the ordered tests and returns results, and an individual clinician collates and interprets the information.
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From page 28... ...
Telementoring Baker reported on Project ECHO,23 a teleconsulting and telementoring partnership to disseminate knowledge and build capacity in regions lacking specialty or subspecialty medical care. "We can't duplicate what's available at the major cancer centers in every community in America, but there is some middle ground where we can improve what is currently available and provide resources to these communities so patients get better care and physicians have more support," Baker said.
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From page 29... ...
. The University of Texas MD Anderson Cancer Center adopted Project ECHO 4 years ago to help underserved communities manage cervical dysplasia, a precursor to cervical cancer, Baker reported.
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From page 30... ...
Clinical Decision Support A number of workshop participants discussed clinical decision support tools in cancer care. Ramin Khorasani, professor and vice chair of radiology at Harvard Medical School and co-founder and director of the Center for Evidence-Based Imaging at Brigham and Women's Hospital, described clinical decision support as the iterative interaction of a clinician with a computer to improve clinical decision making by reducing unwarranted variation in care and improving adherence to what is known to benefit patients.
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From page 31... ...
. Gregory Riely, medical oncologist at the Memorial Sloan Kettering Cancer Center, stressed that clinical practice guidelines, such as those developed by the National Comprehensive Cancer Network and ASCO, are the underpinnings for clinical decision support.
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From page 32... ...
Challenges with Developing and Implementing Clinical Decision Support Tools A number of workshop participants described challenges with clinical decision support tools, including clinician acceptance, a lack of interoperability within and among health systems, and development and maintenance costs. Shirts said clinician acceptance is one of the largest barriers to implementing clinical decision support, noting that one review found clinicians override drug safety alerts approximately 50 to 90 percent of the time (van der Sijs et al., 2006)
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From page 33... ...
Because clinical decision support tools can facilitate the insurance preauthorization process for genomic testing and reimbursement, it can improve clinician acceptance and use of decision support. He added that implementation of clinical decision support tools can also foster acceptance by payers to reimburse complex genomic testing in appropriate clinical contexts.
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From page 34... ...
Instead, he said that following clinical decision support recommendations could be used to defend against medical malpractice suits. However, this is dependent on a high-quality decision support tool and ensuring that the information entered into the system is "precise and of good integrity, and that the alert content is representative of the patient.
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From page 35... ...
These costs include the work of committees deciding on the clinical decision support rules, the alerts that should be included, and how the system should be designed; the time and effort to adapt the system based on pilot testing and clinician feedback; and costs to make the decision support system interoperable. "The costs of building and maintaining clinical decision support networks are often ignored or minimized; however, these costs can be substantial, especially if clinical decision support is implemented independently at each health care institution," Shirts said.
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