Abstract

Radiology and public health have an emerging opportunity to collaborate, in which

radiology's vast supply of imaging data can be integrated into public health information
systems for epidemiologic assessments and responses to population health problems. Fueling
the linkage of radiology and public health include (i) the transition from analogue film to
digital formats, enabling flexible use of radiologic data; (ii) radiology's role in imaging across
nearly all medical and surgical subspecialties, which establishes a foundation for a
consolidated and uniform database of images and reports for public health use; and (iii) the
use of radiologic data to characterize disease patterns in a population occupying a geographic
area at one time and to characterize disease progression over time via follow-up
examinations. Radiology's role in public health is being tested in disease surveillance systems
for outbreak detection and bioterrorism, such as the Electronic Surveillance System for the
Early Notification of Community-based Epidemics. Challenges for radiologic public health
informatics include refining the systems and user interfaces, adhering to privacy regulations,
and strengthening collaborative relations among stakeholders, including radiologists and
public health officials. Linking radiology with public health, radiologic public health
informatics is a promising avenue through which radiology can contribute to public health
decision making and health policy.
This seminar gives in detail the effects of radiology in interoperability health system.

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1.0 Introduction
Radiology is a branch of medicine that uses imaging technology to diagnose and treat
disease. Radiology may be divided into two different areas, diagnostic radiology and
interventional radiology. The field of therapeutic radiology, which uses x-rays to treat cancer,
is now called radiation oncology. Doctors who specialize in radiology are called radiologists.
Radiology has been a distinct medical specialty with unique technical challenges from its
inception. The origins of specialisation can be traced back to the technical nature of X-ray
image capture and perhaps more significantly the difficulty of exposing, transporting and
developing images on fragile glass plates for subsequent interpretation. Despite pressure in
the early 1900s to define radiology as a technical service, radiographic image interpretation
and reporting required medically trained specialists. Therefore, radiologists have been clinical
specialists, who have been obliged to also become experts in image capture technology,
broad-based advances in engineering and, more recently, applications of information
technology for healthcare, which continue to drive and be driven by radiology.
Radiology is now the key diagnostic tool for many diseases and has an important role in
monitoring treatment and predicting outcome. It has a number of imaging modalities in its
armamentarium which have differing physical principles of varying complexity. The
anatomical detail and sensitivity of these techniques is now of a high order and the use of
imaging for ultrastructural diagnostics, nanotechnology, functional and quantitative
diagnostics and molecular medicine is steadily increasing. Technological advances in digital
imaging have also enabled the images produced to be post-processed, manipulated and also
transmitted rapidly all over the world to be viewed simultaneously with the transmitting
centre. Radiologists have been strongly involved in these technological developments and
have been responsible for much of the evaluation of the strengths and weaknesses of different
investigations. Radiologists have developed the knowledge of the appropriate integrated
imaging algorithms to maximise clinical effectiveness. They have also been responsible for
the implementation of these developments into the clinical setting and for ensuring the best
use of assets and healthcare resources.
The improved image clarity and tissue differentiation in a number of situations has
dramatically increased the range of diagnostic information and in many cases the
demonstration of pathology without the requirement of invasive tissue sampling (histology).
This increased information also requires careful interpretation without preconception to avoid
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prejudging the findings. The use of imaging for functional evaluation and cellular activity has
created a new challenge for radiologists whose training has predominantly been based on the
anatomical and pathological model with limited experience in physiology and cell function. It
has therefore been the case that in some super specialist areas of work, clinician specialists
may believe that radiologists have not contributed sufficiently to the care of patients . It is
therefore incumbent on radiologists to mobilise their skills to utilise these new approaches to
evaluate clinical questions in the most effective way. For this reason the radiological training
programme for Europe is now mainly system- and disease-focussed to ensure that
radiologists can respond to the multiple interactions of patient care.
Although the training programmes are repositioning radiology in this way, these
developments are now occurring and are affecting all radiologists who in general, at present,
are satisfied with their overall position within the respective health care system in most
European countries. Radiologists have no difficulties in finding professionally fulfilling and
well-paid employment. Indeed the rapid rise in workload and complexity of examinations
have resulted in a shortage of radiologists in most countries which may reduce the
opportunity or desire to move and up-date sufficiently with these advances. The availability
of high-speed internet transfer of images may affect the requirement and role of local
radiologists by transferring images to major centres for rapid specialist interpretation. Thus
the rapidly developing and expanding field of imaging becomes a challenge to our specialty,
especially as it has also become so attractive to others. We should therefore be concerned to
ensure the future of radiology as a medical specialty and take into consideration the forces
and the dynamics surrounding our profession by meeting them with foresight and flexibility.
Although as a specialty we must embrace the opportunities that these developments create,
the requirements to embrace all aspects of the speciality are now considered unattainable for
any individual, especially in an environment where the clinicians themselves are focussed on
specific anatomical or disease-related areas as specialists. Therefore the dilemma for
radiology and radiologists is how to achieve the objectives of the specialty and still provide a
comprehensive service within the confines of a radiology department where so many of the
tasks previously undertaken by clinicians are now the province of radiology.
1.1 Why do we need radiology in interoperability health systems
Numerous facilities in clinical services are collectively used by different specialties:
operating rooms are not owned by surgeons anymore, ICUs have become independent of
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departments of cardiology, internal medicine, or neurology, while emergency rooms are not
part of traumatology departments. Hospital beds are no longer dedicated to individual
specialists or specialties and are available for radiologists for one or two nights following
interventional procedures in some hospitals. At present the radiology department remains
predominantly the domain of the radiologist, but this is changing and there is no specific
reason why imaging facilities should not be used by other clinical specialists trained in
imaging, and images produced in these departments may also be reported remotely.
New knowledge in imaging is being developed at an increasingly rapid rate. The field of
radiology has expanded dramatically. The range of radiology covers diseases from the foetus
through to the multi-morbid aging population, from prostate to the pituitary gland and from
pancreatic neoplasia to bone dysplasia. No single person can master all the available
knowledge. However, the referring physicians need a clinical interface with the imaging
specialist. In order to create added value for the referring clinician, the radiologist must fully
understand the clinical problem. The radiologist is expected to be able to do this at a different
level and for all medical specialties. Therefore clinical experience is required before
embarking training in imaging, and appropriate training in specific clinical specialties may
also be needed. If not, imaging may increasingly be regarded as a sub-entity within the
clinical specialty and in that setting each specialty will take care of its own specialised
imaging and training, and the influence of the radiological expertise would diminish.
Public recognition of the clinical role of radiology is essential and is very much dependent on
contact with the patients . However, over the past years radiologists reading more and more
complex examinations have become less and less visible for patients and the public.
Moreover, in some health care systems the emphasis of radiology work is placed on the in-
patient referrals to major general (secondary) and university (tertiary) hospitals where the role
of the radiologist as part of the team is less obvious to the patient. There has been less focus
on the provision of radiology services to primary care (including general practitioners and
office based specialists), where the requirements are different, with a need for a more general
service but still involving a range of imaging services, and where the individual role of the
radiologist is more obvious to the patient.
In some countries clinical specialists may be the primary providers and interpreters of
imaging in their offices. This has potential disadvantages for the patients. The self-reporting
clinician may focus on the images to confirm or refute a preconceived clinical diagnosis
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whereas the interface of a radiologist, reporting the images, provides an independent opinion.
It is also suboptimal for funding healthcare, as self-referral has been shown to increase
numbers of radiological procedures and consequently costs. Moreover, radiologists will
ensure the appropriate use of equipment and quality control, and apply radiation protection
principles which are particularly pertinent with the massive increase in the use of multi-
detector CT .
Radiology has prospered by staying ahead of the wave of progress. But radiologists will have
to change many of their attitudes and rethink their professional training to accommodate to
the dramatic revolution and evolution of radiology . Radiologists need to adapt to the changes
in technology in order for the profession to deliver the service that patients expect and
medical progress requires


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2.0 The effect of radiology in interoperability health systems
1. Radiology act as Gatekeeper in interoperability health systems
While the term gatekeeper has traditionally been applied to primary care physicians, the
radiologist can also have a role in insuring that medical resources are utilized efficiently and
appropriately. A gatekeeper can be defined as a person who is positioned between an
organization and the individuals who wish to utilize the resources within that organization.
While the primary care physician may be the patients first contact in the medical system, the
radiologist often becomes involved in the initial diagnostic workup. Moreover, the results of
the radiological examination may determine the need for additional diagnostic tests, specialist
referral and/or hospital admission.
One of the methods that radiologists can use to facilitate the appropriate allocation of
resources is clinician education. Performing the appropriate exam can save the patient both
the cost and the ionizing radiation associated with unnecessary/unindicated exams.
Considering the rapid technological advances in radiology, regular clinicoradiographic
meetings/lectures could greatly enhance the clinicians ability to order the appropriate
studies. While the majority of studies ordered by clinicians are appropriate, occasionally the
radiologist may feel that there is a more suitable investigation for the clinical question.
Communicating this concern to the ordering clinician can result in the collaborative selection
of the appropriate study and a learning opportunity for both parties. This type of collaboration
between radiologists and clinicians can be taken a step further by jointly developing clinical
decision rules or guidelines for imaging.
2. Radiology reduces cost
Radiologists can also reduce costs the costs of unnecessary imaging by avoiding a practice
that has come to be known as self-dealing. Self-dealing occurs when a referring physician
makes money, directly or indirectly, by a referring a patient for a medical imaging procedure.
The referring physician typically gains financial benefit by billing for the technical
component of the procedure, because the referring physician either owns the equipment or
leases time on the equipment from an otherwise independent imaging provider. With such a
financial incentive, the referring physician may increase their ordering of diagnostic imaging
services beyond their usual level of utilization. By avoiding self-dealing, radiologists can help
to reduce the risk of financially motivated increases in diagnostic imaging.
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Radiologists can also help contain increasing healthcare costs by influencing policy decisions
of private payers and the government. The American College of Radiology (ACR) is actively
involved with both private payers and the government. For example, in 2004, United Health
Care consulted with the ACR to implement imaging protocols for more than 190 conditions.
The Government Relations (GR) department of the ACR has staff who attend numerous
fundraisers throughout the year to speak with the congressmen and congresswomen who will
ultimately influence public health policy Actively campaigning to close loopholes in the
Stark laws has the potential to significantly reduce total imaging costs within the United
States. In addition, the GR staff represent the interests of radiologists at meetings such as the
AMA. In 1999, the ACR formed RADPAC whose goal is to support and elect pro-radiology
candidates at the federal level through the voluntary contributions of members of the
American College of Radiology Association (ARCa).

3. Radiology helps in providing health care (example in cancer screening)
Generally considered the domain of the primary care provider, public health encompasses a
range of topics including immunizations, cancer screening, and other key health care services
for reducing morbidity and mortality in the population. While radiologists are certainly
involved in public health/ preventative medicine (e.g. breast and colon cancer screening), it is
not immediately obvious that the radiologists practice can be used as a vehicle to encourage
increased adherence to cancer screening. Admittedly, radiologists do not have the
longitudinal patient-physician relationships that give primary care physicians the opportunity
to foster preventative health behaviors in their patients. Fortunately, there are naturally
occurring life transitions or health events that are believed to motivate individuals to adopt
risk-reducing health behaviors. These events have been termed teachable moments.
The concept of the teachable moment can be applied to the radiologists practice and may
directly or indirectly serve as a method to improve quality of care by enhancing healthy
lifestyles or by improving adherence to other screening tests. For example, mammography
could be considered a teachable moment for educating patients about the risk of colon
cancer and encouraging colorectal cancer screening. Rates for colon cancer screening lag
behind those of breast, cervical, and prostate cancer. Further, women participate in colorectal
cancer screening at a rate lower than men. The American Cancer Society estimates that there
will be approximately 106,608 new cases of colon cancer and 41,930 new cases of rectal
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cancer in 2006; therefore increasing the rates of colorectal cancer screening among women
could have a significant impact on public health.
While productivity pressures and the absence of an existing patient-physician relationship
preclude the radiologist from personally assessing and counselling each patient, changes
could be made in the diagnostic radiology encounter without significant changes in
infrastructure or staffing. For example, the patient could fill out a brief questionnaire
regarding adherence to cancer screening behaviors prior to their mammogram. Patients who
require additional cancer screening services could then be given pertinent educational
material. Such a model is not without precedent. Patients routinely are asked to fill out forms
that answer demographic and health-related questions prior to other medical appointments. In
addition, a recent meta-analysis by Stone et al. demonstrated that organizational changes in
clinical procedures, infrastructure, redesign of jobs, and facilities was consistently more
effective that physician-directed or patient directed educational efforts for promoting
adherence to cancer screening.
Cancer screening could be further facilitated by the development of centralized screening
cores Womens health imaging cores offering screening mammography, bone density
screening, and ultrasound already exist. If CT colonography, CT lung cancer screening,
and/or coronary calcium scoring are ever approved by the government or insurance
companies, then a CT scanner could be added to such a facility. The familiarity of such a
clinical setting would increase the convenience and potentially decrease the personal cost of
screening; two factors that are cited as important predictors of adherence to cancer screening.
In addition, utilization of information technology could also increase the efficacy of such
imaging cores without requiring significant additional costs in labor or infra-structure.
Software could be adapted to detect noadherence with health screening and subsequently
electronically notify the primary care clinician. Other ways to use information technology
include pop-up displays of needed services at the patients next appointment or automated
generation of patient reminders similar to screening mammography.
Increased involvement of the radiologist in promoting cancer prevention/early detection
offers a number of potential benefits. In addition, using existing imaging tests to successfully
promote cancer prevention increases the underlying value of the imaging test and may
improve the cost-effectiveness of the original test. For example, successful application of the
screening mammography encounter as a teachable moment for colon cancer screening may
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further improve the cost-effectiveness of screening mammography programs after accounting
for decreased colon cancer morbidity and mortality. Finally, adoption of such preventive
medicine initiatives within the radiology department can foster a more collaborative
relationship with primary care physicians that will likely demonstrate an important added
value of radiographic services.

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3.0 Risks and benefits of radiology in interoperability health system
As a patient, you may have concerns about the imaging procedures prescribed for you. How
much medical radiation is too much? What are the benefits of CT scans? Does my age or
gender affect my risk? What are the risks? This section of this seminar answers the questions.

3.1 A Sense of Balance.
3.1.1 Radiation in Medical Imaging Has Its Benefits
For a brief snapshot that shows the power of medical imaging, consider these findings:
Use of mammography to screen for breast cancer has resulted in a declining death
rate, improved survival rate, and better treatment options1
Performing coronary CT angiography to examine the heart vessels in patients with
chest pain helps guide treatment decisions with high accuracy and avoids costly
invasive procedures2
Incorporating advanced medical imaging procedures into healthcare has significantly
increased life expectancy in the US3

3.1.2 Radiation in Medical Imaging Has Its Risks
Almost all medical procedures, including imaging procedures that use radiation, have risks
associated with them. Physicians and patients should carefully consider the potential benefits
and the risks when considering the use of imaging techniques that involve radiation.
Each patient's clinical situation is different, but here are some things for healthcare providers
to consider when deciding whether or not an imaging procedure that uses medical radiation is
the right choice.
What is the purpose of the procedure? For example, is it to arrive at a diagnosis,
assess treatment response, or is it preventive screening?
Are there alternative imaging procedures that could accomplish the same goal without
medical radiation, such as ultrasound or magnetic resonance imaging?
What are the risks of not having the imaging procedure done?
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How old is the patient? The risks for pediatric and adolescent patients may be
different than for adults.
Is the patient pregnant, possibly pregnant, or breastfeeding?
What other procedures is the patient likely to undergo during this workup?
What is this person's radiation exposure from previous medical procedures? For
example, has the person undergone multiple CT or nuclear medicine scans in the past?
What is this person's occupational exposure to radiation, if any?
Will the imaging exam be performed on low-dose equipment?

Healthcare providers and their patients are encouraged to discuss these issues and any other
potential risks with the treatment team, including the radiologist in charge of supervising the
imaging procedure.
Physicians and other healthcare providers can consult their radiology colleagues or a medical
physicist for more information.












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Conclusion
The world of radiology is changing rapidly and radiologists have to be proactive in this
process to survive. The subject is now too broad and complex for an individual to remain a
comprehensive provider. As a result radiologists need to group themselves as specialists in
particular systems or disease-based areas while finding a mechanism to provide a high-
quality service. Radiologists must also be clinicians and understand the clinical features,
natural history and treatments of the diseases that they are requested to investigate. Therefore,
if radiologists want to add value to the chain of healthcare they need to sub-specialise to a
greater or lesser extent according to their working circumstances. Teleradiology services may
be appropriate for small and rural practices as part of an area network especially during
nights and weekends and for interaction with GPs and patients. Radiologists must also
interact more directly with patients and primary care physicians to provide a comprehensive
diagnostic and advisory service prior to the patient entering the secondary care service by
managing the investigations of the patients themselves. This will increase efficiency, clinical
effectiveness of the service and speed up the referral process. Radiologists in the teaching
hospitals will also need to specialise to a higher degree in order to provide a tertiary referral
service, communicate and advise clinical experts and to conduct and drive imaging research
as true experts in their field.

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