No reading of outside films

| June 25, 2007

I recently received a memo from my institution’s radiology department sent from the VP and Chairman of Radiology with the above title.  I have cut and paste the text of that memo below:

"The purpose of this memo is to inform you of some changes in the Department of Radiology that are designed to promote quality assurance.  Currently, [Institution name] Radiologists are often asked to provide a reading on studies that have been obtained and previously read outside of the [Institution name] system.  As we cannot control the quality of the external product, we will no longer be providing this service.  Such films may be used only as a comparison to studies obtained at [Institution name].

We appreciate your cooperation in this matter.  If you have comments or concerns, please do not hesitate to contact either one of us, as your business is important to our department."

As people speak of diagnostic imaging and laboratory medicine merging, how might this blind rejection impact workflow between the specialties?  Who will review outside films for patient management?  Does this mean increased numbers of radiology studies amongst several institutions when patients seek other opinions – "we will only read our own cases." 

I can certainly understand the department’s reluctance to review outside films when the quality of the images may be in question and additional evaluation or deferral of diagnosis is in the best interests of the patient.  I find it surprising that with DICOM standards for radiology, this would be an issue.  Or is it an issue of reading hard copies, as it used to be done, compared with PACS images on a bank of monitors? 

Pathologists as well are asked to review cases prepared elsewhere when the specific methods of processing, cutting, staining are possibly and probably unique to that pathologist’s own institution.  As patient’s seek additional pathology and/or clinical opinions concerning treatment and management of their disease and slides "travel", we are often faced with histology and immunohistochemistry (IHC)slides which may have little or no resemblance to routine H&E sections or IHC stains prepared in our own laboratories.  Nonetheless, we offer opinions on outside material regularly as added quality assurance and review for patient’s seeking second opinions or review of pathology material prior to definitive treatments.  Accreditations for laboratories and cancer centers require it.  Certainly in a minority of cases, opinions may be deferred because the slides may not be of diagnostic quality or damaged in the course of transport for review.  Fortunately, these are a minority of cases and in most cases the review process of outside material creates added quality and value for the patient. 

Large referral or consultation centers make this part of their daily clinical practice in support of pathologists and their patients, far removed from knowing how the specimens were obtained, processed, fixed, stained, coverslipped, labeled and reviewed prior to being seen elsewhere.  How is one even assured that slide is from the correct patient?  It may be a source of medical error even within one’s own laboratory that is not unique. 

How might this impact the practice of pathology PACS signout or remote signout when the metadata, normally present on radiology films and fixed to those images is more transparent?

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Category: Histology, Radiology

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