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Review of Current Radiology Consultation Models and Experience with Resident Driven Services

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Review of Current Radiology Consultation Models

Hernan R. Bello Velez MD, Dexter Mendoza MD, Frederic Bertino MD, David Theriot MD, Ryan B. Peterson MDDepartment of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta GA


Objectives

  1. 1)  Review the models of radiology consultation services reported in the literature

  2. 2)  Explore the published experience with resident-driven radiology consult services in academic centers

  3. 3)  Describe the opportunities, challenges, and triumphs in implementing radiology consultation services

     

Background

Referring physicians often seek the radiologists’ guidance not only in selecting appropriate imaging and in determining diagnosis, but also in directing management and treatment.

The increased productivity boosted by technological advances has resulted in fewer opportunities for radiologists to interact face to face with their referring colleagues.

A single-center study identified a decrease in in-person consultation of 82% for radiographs and 44% for cross sectional imaging after implementing a PACS system (1).

With the threat of radiology commoditization and with the national shift towards value- based-care, preserving our reputation as imaging experts and proving our value to patients and the healthcare system have become more important than ever.

One way of doing so is through the implementation of consultation services.

 

Approach to Radiology ConsultationAdapted from Gunderman and Chou (2)

Radiologists assume their consultant role based on their own preference and their institutional culture. Below are some of the most common practice styles along with their benefits and drawbacks.

           The Isolated Radiologist

  • -  The radiologist and reading room (RR) are hard to reach

  • -  No meaningful relationship with ordering providers

  • -  The radiologist is not regarded as a consultant

  • -  Minimizes interruptions and increases volume-based productivity

  • -  Increased risk of commoditization of radiology

    The Abvailable Radiologist

  • -  The RR is easy to reach and radiologists respond readily, acting as consultant only when explicitly asked

  • -  Few and shallow relationship with ordering providers

  • -  Remains focused on volume-based productivity with persistent risk of commoditization

    The Eager Radiologist

  • -  Regular interactions with clinicians (e.g. in patient care areas and multidisciplinary conferences)

  • -  Radiologist is a vital member of the healthcare team

  • -  May decrease volume-based productivity

  • -  Potential to improve value-based imaging care by increasing exam appropriateness and efficiency of communication

    The Embedded Radiologist

  • -  The radiologist works in the same area where providers practice and contributes to patient care in real time

  • -  Radiologist has strong relationships with clinicians and patients

  • -  Reliance of referring providers on the radiologist is more apparent to both parties

  • -  Clearly decreased volume-based productivity

  • -  May be impractical and unnecessary in many situations


    Imaging Consultation Models Reported in the Literature

    Formal Consultation

    First championed by Drs. Shuman and Heilman in 1979 who suggested that radiologists are the best equipped to plan a complex imaging work-up and should assume a leadership role (3).

    Benefits may include reduction in time to establish a diagnosis, potentially reducing length of stay, and increased appropriateness (and decrease in number) of imaging, which may all decrease cost.

    High-end imaging utilization reduction was achieved when radiologists vetted exams, resulting in 4% cancelled studies and 9.3% changes to an alternate, more appropriate study (4).

    Resident-Led

    Radiology residents have been involved in implementing consultation services since before the broad implementation of PACS (5,6).

    Initiatives include briefly rounding with medical teams (7), carrying a consult phone to centralize imaging- related questions (8), integrating the clinical team on rounds on a daily basis (9), as well as using technology in the form of mobile phone “apps” (10), and virtual rounds (11).

    Surveys found a majority of participants believe active involvement of radiology residents improved patient care, as well as their own training and education (7,9).

    Embedded Radiology Reading Rooms

    Decentralize the radiology department by placing RRs within clinical areas including cancer centers, ICUs, and EDs, increasing radiologists’ visibility and facilitating consultation.

    Embedded RRs result in frequent visits from clinicians to review imaging and discuss cases—46% vs. 6.7% in one study (12). Ordering clinicians agree that consultations significantly benefit patient care (12-14).

    Potential for reducing repeat imaging when outside studies can be reviewed on-site with the radiologist.

    Direct Patient Review and Reporting

    Direct patient-radiologist encounters to review the patient’s recent imaging findings.
    Secondarily aimed at increasing the visibility and raising awareness of the role imagers play in healthcare.

    Surveys have shown that a majority of patients want to see their images (15), but don’t have a strong preference regarding who provides the results (16), or prefer to receive results directly from their referring clinician (17).

    After meeting with a radiologist to review their imaging , patients express great satisfaction with the experience and many opt to meet with the radiologist to review their imaging in the future (13,18,).



References

Reiner B, et al. Impact of filmless radiology on frequency of clinician consultations with radiologists. AJR Am J Roentgenol. 1999 Nov;173(5):1169-72.

Gunderman R, Chou H. The Future of Radiology Consultation Radiology 2016; 281:6–9

Shuman WP, Heilman RS. The radiologist as a consultant. JAMA. 1979 Oct 5;242(14):1519-20.
Ingraham B, et al. Reductions in High-End Imaging Utilization With Radiology Review and Consultation. J Am Coll Radiol. 2016 Sep;13(9):1079-82. Baker S, Rosenberg Z, Adel H. The Operation of a Ward-Based Radiology Consultation Service. Radiology, 1984;152:331-333.

Khorasani R, et al. Design and Implementation of a New Radiology Consultation Service in a Teaching Hospital. AJR, 1994;163:457-459.
Salama G, et al. Improving Care and Education Through a Radiology Resident-driven Clinical Consultation Service. Acad Rad, 2017;24:1175-1181. Trakhtenbroit M, Abdollahian D, Horton K, Johnson P. Choosing Wisely and Imaging 3.0 Professional Development: Radiology Resident Consultant Service. . J Am Coll Radiol, 2016;13:730-732
Mamlouk M, Anavim A, Goodwin S. Radiology Residents Rounding With the Clinical Teams: A Pilot Study to Improve the Radiologist's Visibility as a Consultant. Journal of the American College of Radiology, Volume 11, Issue 3, March 2014, Pages 326-328
Retrouvey M, Trace A, Johnson L, Shaves S. Streamlining the Radiology Consultation Service in the Digital Era. Journal of the American College of Radiology, Volume 14, Issue 11, November 2017, Pages 1464-1467

Fefferman NR, et al. Virtual radiology rounds: adding value in the digital era. Pediatr Radiol. 2016 Nov;46(12):1645-1650. Epub 2016 Aug 3.

Tillack AA, Borgstede JP.. An evaluation of the impact of clinically embedded reading rooms on radiologist-referring clinician communication. J Am Coll Radiol. 2013 May;10(5):368-72

Mohan SK, Hudgins PA, Patel MR, Stapleton J, Duszak R Jr, Aiken AH. Making Time for Patients: Positive Impact of Direct Patient Reporting. AJR Am J Roentgenol. 2018 Jan;210(1):W12-W17

Rosenkrantz AB, Lepor H, Taneja SS2, Recht MP. Adoption of an integrated radiology reading room within a urologic oncology clinic: initial experience in facilitating clinician consultations. J Am Coll Radiol. 2014 May;11(5):496-500.

Cabarrus M, et al. Patients Prefer Results From the Ordering Provider and Access to Their Radiology Reports. J Am Coll Radiol. 2015 Jun; 12(6):556-62. 16. Basu PA, et al. Creating a patient-centered imaging service: determining what patients want. AJR Am J Roentgenol. 2011;196:605–610.
Mangano M, Rahman A, Choy G, Sahani DV, Boland GW, Gunn AJ. Radiologists' role in the communication of imaging examination results to patients: 
perceptions and preferences of patients. AJR Am J Roentgenol. 2014;203:1034–1039.

Mangano M, Bennett S, Gunn A. Creating a Patient-Centered Radiology Practice Through the Establishment of a Diagnostic Radiology Consultation Clinic. American Journal of Roentgenology. 2015;205: 95-99


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