Integrative Diagnostics: A Vision for Better Care

Introduction‏

As a breast imager I form part of a team that makes‏ the diagnosis of breast cancer. That team typically‏ comprises radiologists and pathologists and increasingly‏ includes geneticists. A patient’s journey from screening‏ mammogram to definitive surgical management can‏ take weeks or even months as she and her care team‏ piece together the puzzle that will identify her path to‏ survivorship. Ask a breast cancer survivor about the‏ moment she heard she had cancer and you’ll hear her‏ relive that moment with crystal clarity. For most patients‏ receiving this dreaded news the overwhelming desire is‏ to move expeditiously from diagnosis to treatment and‏ any delay can seem agonising. The disconnected nature‏ of our health system can compound this wait, requiring‏ patients to request and deliver outdated CDs in order‏ to seek second opinions. Inequities multiply the stress‏ as women from minoritised communities wait longer to‏ complete the diagnostic process, travelling further to‏ secure advanced imaging when necessary. We need to‏ do better.‏ 

The landmark Institute of Medicine report, “To Err is‏ Human” identified a 10-15% diagnostic error rate that‏ is responsible for thousands of deaths and some of the‏ costliest malpractice suits. A follow up report: ”Improving‏ Diagnosis in Healthcare”, pointed to “information‏ integration and interpretation” as a key opportunity to do‏ better.

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But what does “better” look like? Imagine a diagnostic‏ pathway that seamlessly directed patients to the‏ correct imaging modality according to their presenting‏ symptoms. A process that sequenced testing across‏ multiple departments with the patient’s convenience‏ and wellbeing top of mind. Picture a holistic view of the‏ pertinent patient data that used compelling graphics‏ to support physicians in decision making and created‏ materials that would allow the patient to understand‏ and fully participate in their care. Dare to dream of‏ a feedback loop that identified patients at risk and‏ afforded an earlier diagnosis.

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A fantastical utopia? Not at all. The digitisation of‏ pathology, advances in computing power and the‏ ability of artificial intelligence to extract and knit‏ together relevant data elements means that “Integrative‏ Diagnostics” are within our grasp.

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With radiologist and pathologist colleagues we‏ explored this topic in a publication titled “Integrative‏ Diagnostics: The Time is Now”1 for the Journal of‏ the American College of Radiology. In this paper we‏ reviewed the limitations of the current fragmented‏ diagnostic process and its impact on not only the‏ quality but also the cost of care. We also highlighted the‏ significant barriers that stand in the way.‏

No sector both promotes and frustrates innovation‏ simultaneously like healthcare. While on the one hand‏ we push the boundaries to personalise treatment of‏ cancer through immunotherapy, on the other hand‏ we are still sending faxes. Initiatives to transcend our‏ diagnostic silos exist but they are few and far between.

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Is it our United States fee for service payment system‏ that keeps us locked in our segmented process? There‏ is in fact no meaningful incentive for a collaborative‏ process. Tumor Boards, an essential component of‏ high value cancer care, are largely unreimbursed. With‏ imaging volumes at an all-time high and physician‏ burnout exacerbating workforce shortages, the energy‏ to advocate for disruptive payment models that better‏ support an integrated approach to diagnostic medicine‏ is understandably lacking.‏

The unfulfilled promise of AI must take some blame.‏ Surely there’s an algorithm that can effectively extract‏ administrative costs from the system freeing personnel‏ to focus on patient related tasks? In a ChatGPT enabled‏ world why is breast imaging the rare imaging specialty‏ issuing patient friendly lay letters? Why can’t we issue‏ patient facing communications that reference data from‏ both imaging and pathology as well as the Electronic‏ Health Record in a format that meets the patient where‏ they are? The requirements of the 21st Century Cures‏ Act to make test results immediately available have‏ piled additional burdens of communication onto already‏ overworked clinicians rather than driving innovation that‏ could inform patients in an intelligent but automated way.‏

Maybe we ourselves are the biggest barrier? We settle‏ into specialty “swim lanes” very early. How often do we‏ ask a medical student: “what specialty are you applying‏ to” rather than “what problems in healthcare do you‏ want to solve”? Do we need to create cross functional‏ diagnostic teams whose training experience bridges‏ radiology, pathology and genomics? Should there be a‏ diagnostic medicine residency? Leaders in the field like‏ Dr Nick Bryan who established the founding Department‏ of Diagnostic Medicine at the University of Texas Dell‏ School of Medicine have cracked open the door to a‏ novel training pathway but questions abound about how‏ to scale this approach.‏

I’m encouraged by the several cross-specialty‏ conversations on Integrative Diagnostics in which I’m‏ participating but I’m sanguine about the inertia that will‏ need to be overcome. As healthcare spending in the‏ U.S. continues to climb with outcomes that fail to match‏ those peer economies we must continue to strive for‏ the oft cited goal of “value-based healthcare”. For our‏ patients navigating the complexities of a system that‏ often seems designed for every stakeholder but them‏ we must strive to do better. Integrative Diagnostics is‏ what better looks like.‏

Conflict of Interest‏

Board member and stockholder NextGen Healthcare‏ Medical Advisory Board member: Agamon Healthcare‏ and Ryver.ai. ‏