Radiologists: Leading “imaging wisely” initiatives

Radiologists play a unique role in ensuring the appropriate use of diagnostic imaging examinations, particularly neuroimaging, according to an article published in the December issue of the AJNR American Journal of Neuroradiology. Four members of the American Society of Neuroradiology (ASNR) encourage radiologists to be proactive and lead the initiative for physicians to utilize evidence-based guidelines and clinical decision support (CDS) systems when ordering imaging exams for their patients.

The Choosing Wisely campaign, launched in 2012 by nine professional societies, including the American College of Radiology (ACR), has steadily expanded, as has the list of overused tests. Nearly 25% of these overused diagnostic tests relate to neuroimaging. In their article, the authors discuss five examples of adult and pediatric neurological conditions in which the selection of appropriate imaging is often challenging for referring physicians and for which specific guidelines have been developed. These include traumatic brain injury, lower back pain, syncope, headache, and hearing and vision loss.

The primary reasons why physicians order inappropriate exams have been identified as time constraints associated with fee-for-service reimbursement which can result in a shorter time for physicians to research appropriate exams or consult a radiologist, unwillingness to confront patients who demand specific imaging exams, and adherence to a defensive-mentality posture to avoid the risk of malpractice litigation. The forthcoming mandatory requirement by the U.S. Centers for Medicare and Medicaid (CMS) to use some form of CDS technology before ordering advanced imaging examinations is expected to offset this somewhat.

But the authors point out that more should be done to educate medical students and residents, including radiology residents. They write, “One of the important obstacles to promoting adoption of resource-conscious neuroimaging ordering habits relates to the difficulty of disseminating the relevant guidelines among the referring physicians. Despite the inclusion of ‘systems-based practice’ as one of the 6 core competencies of the Accreditation Council for Graduate Medical Education, awareness of imaging appropriateness is not being emphasized in residency training.” They cited studies that show radiology residents’ knowledge of appropriateness criteria is lacking.

Max Wintermark, MD, professor of radiology at Stanford University School of Medicine, and co- authors, encourage radiologists to guide and support their clinician colleagues during the transition to value-based care. “Effectively guiding referring providers toward appropriate imaging use will rely on improving clinicians’ knowledge and effective communication among all members involved in the care of patients which includes radiologists. These goals can be achieved on a clinician-to-radiologist level or as a part of larger clinician-support projects and initiatives.”

They recommend that improving knowledge about imaging appropriateness must be made a top priority by radiologists. Radiologists need to proactively communicate with their colleagues, and be educational leaders in this initiative.

They also recommend that radiologists participate in the American College of Radiology’s Radiology Support, Communication and Alignment Network (R-SCAN™) project launched in 2016.1 R-SCAN is a Practice Quality Improvement project that focuses on improving imaging use for 11 topics detailed in the Choosing Wisely campaign. The R-SCAN project enables radiologists to implement turn-key, clinically relevant projects that introduce imaging appropriateness, clinical decision support and radiologist-led education. All participants in

R-SCAN receive free access to the CDS tool ACR Select®, and follow a web-based step-by-step process that generally requires 12-15 hours of radiologist time.

“The R-SCAN project provides an opportunity for radiologists to positively influence the appropriate use of imaging and to emphasize their value as integral members of the health care team,” the authors concluded.


  1. Accessed January 5, 2017.
  2. Buethe J, Nazarian J, Kalisz K, et al. Neuroimaging Wisely. AJNR Am J Neuroradiol. 2016 37;12: 2182-2188. (
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