HealthCare Business News spoke with Professor Paul M. Parizel regarding the challenges his organization will face in 2017 and beyond. In addition to his leadership of the European Society of Radiology, he is the chairman of the Antwerp University Hospital department of radiology and a full professor of radiology at the University of Antwerp.

HCB News: Please give your American counterparts who may not be that familiar with the European Society of Radiology (ESR) a little bit of background on the society.
PP: ESR was founded in 2005 by merging the European Congress of Radiology (ECR) and the European Association of Radiology (EAR). The ESR is an apolitical, nonprofit organization dedicated to strengthening and unifying European radiology. The ESR is headquartered in Vienna, Austria, and has offices in Barcelona, Spain; Brussels, Belgium; Bratislava, Slovakia; and Bogota, Colombia.

The ESR currently has more than 69,300 members from 157 countries. As such, it is the largest radiological society in the world. Its primary mission is to organize the European Congress of Radiology (ECR) which is held in Vienna each year in March. The ECR is the leading annual radiology meeting in Europe. Other tasks of the ESR include the harmonization of teaching programs throughout Europe, the maintenance of the European Institute for Biomedical Imaging Research (EIBIR), the coordination of teaching activities within, as well as outside, Europe [ESOR — European School of Radiology] and assistance in raising training standards and the level of radiological services throughout the world. The ESR works closely with national radiological societies and subspecialty societies across Europe and beyond. The ESR also monitors developments on the European Union which could have an impact on research and practice in radiology.

HCB News: We understand this is the first year the presidency of the ESR and ECR is held by the same person. What prompted this change?
PP: It is a great honor, and also a huge responsibility, to assume this new position of ESR president and chairperson of the ECR Programme Planning Committee. The ECR is well established as the foremost congress in radiology in Europe. Until a few years ago, nominations and elections for the ‘cursus honorum’ of the ECR and ESR took place independently of each other. This implies that we have had brilliant presidents of our society, who never became president of the congress, and vice versa.

As both the society and the congress were getting bigger, it was decided to re-evaluate and re-tune the strategic plan so that appointments were fully integrated, instead of running on parallel tracks. This means that after the one-year term as ESR president, who presides over the ECR, you automatically become chairperson of the ESR board of directors and thus the decision-maker for all society-related matters. Bringing the congress and the society under one umbrella better utilizes our human, political and financial resources. I am convinced that this will improve communication with our members, enhance our international standing and facilitate relationships with other societies.

HCB News: What are the ESR’s immediate and long-term goals?
PP: The goals of the ESR are, and always have been, to strengthen, harmonize and unify European radiology, to the benefit of European patients. I am proud to inform you that many objectives have been successfully reached. Our society has developed the European Diploma in Radiology (EDiR), a certified standard of radiological knowledge, deemed appropriate for independent practice in general radiology. The knowledge base for the examination is laid out in the ESR European Training Curriculum for Radiology (ETCR), which serves as a template for training radiologists and to enhance the quality of care for patients. The ETCR has been officially endorsed by 66 member societies worldwide. An updated version (edition 2016) is published on the ESR website. The European School of Radiology (ESOR) assists in harmonizing radiological education in Europe. The ESOR raises the standards in the field of scientific radiology, extends and coordinates teaching resources worldwide and helps young radiologists to achieve the knowledge and skills to fulfill tomorrow’s requirements. All of these initiatives are taking place under the umbrella of the ESR.

HCB News: What is your vision for the future?
PP: Given the galloping pace of change in radiology, I expect quite a large degree of evolution. In a very general sense, I think radiology will move further along the continuum from ‘art’ to ‘science,’ in other words, from producing ‘pretty images’ to quantitative data sets. At the same time, communication with referring clinicians is moving away from descriptive reports to a more standardized structured approach. Both of these developments are examples of radiologists needing to adapt their ‘analog’ minds to the requirements of a digital and quantitative working environment.

On a scientific level, the increasing prevalence of precision medicine is likely to become a key issue for radiologists. Thanks to advancements in medicine, some previously fatal diseases have been reduced to chronic disorders. Radiology will play a more important role in the diagnosis and follow-up of such diseases by developing biomarkers based on volumetric measurements, perfusion (blood flow), spectroscopy (metabolic information), hybrid imaging (molecular imaging) and functional information.

Radiology will also play a more important role in gathering information for evidence-based medicine which will have an impact on which studies will continue to be reimbursed. In this respect, clinical decision support (CDS) systems are expected to grow and play a more important role in reimbursement decisions by governments and health insurance companies. I expect minimally invasive procedures and interventions under imaging guidance to continue to grow, and I think it is essential to invest in interventional radiology. Technological evolutions will continue to help us to provide more accurate diagnoses with lower radiation doses (or no radiation at all, like MRI and ultrasound). Radiology will continue to grow as a tool in screening and risk stratification, provided that it can make the leap to providing unambiguous results.

HCB News: How is the ESR preparing for the future?
PP: Preparing for the future can be daunting, as by the time one’s preparations are complete, there is often a whole new set of challenges ahead. This is why the ESR has adopted a rather ‘open-ended’ approach for our activities, allowing for them to be adapted and extended as times change. The future from the point of view of the ESR is to help current and future radiologists to fulfill their potential and provide the best possible health care. That means providing education and professional tools that help them to develop, but it also means providing the surrounding infrastructure such as curricula and certification. In all of these areas, the ESR has its finger on the pulse. Two particularly good examples are the European Training Curriculum for Radiology (ETCR) and the new eLearning platform, Education on Demand. A lot of work has gone into making the ETCR comprehensive and useful to radiologists at different stages of professional development.

The key characteristic is that the ETCR is a ‘living document,’ designed to be regularly updated. By necessity, education should reflect the reality of current daily practice. Otherwise, considering the rapid rate of progress in radiology, we are preparing people for a professional environment that is already outdated. Therefore, the ESR Education Committee conducts a regular review of the ETCR to ensure that we are guiding radiologists in the right direction. The educational resources on the ESR’s eLearning platform are also regularly extended and updated to achieve the targets set out in the ETCR. The final dimension of this is the European Diploma in Radiology (EDiR), which assesses candidates’ ability using the ETCR as a reference, meaning diploma holders have a qualification that very accurately reflects their competence in the modern world of radiology.

The EDiR is open to candidates from all over the world, and not just Europeans. It is rapidly becoming an important standard of quality for radiologists throughout the world who are applying for a job or for a promotion. Quality of care, patient safety and standards in radiology continue to be priority areas for the ESR. A number of pilot implementations of the ESR iGuide, the clinical decision support platform using ESR imaging referral guidelines, started this year. We published 19 basic clinical audit templates (level I), and in 2017, will complete the ESR Audit Tool with a range of general service templates (level II), plus our work with the RSNA on developing templates for structured reporting continued throughout 2016. In the area of radiation protection, tremendous progress was made by the EuroSafe Imaging campaign with the establishment of dedicated subgroups on image quality and clinical DRLs, as well as the new Euro-Safe Imaging Stars initiative that creates a network of imaging institutions committed to best practice in patient safety.

Research is among the most important issues in all medical fields, including radiology. This is why I am particularly proud to say that the European Institute for Biomedical Imaging Research (EIBIR) celebrated its 10th anniversary at ECR 2016, a testament to its crucial role in supporting researchers in transforming their ideas into reality. The ESR’s efforts to enhance radiation protection research were put on a more solid footing with the establishment of the European Alliance for Medical Protection Research in cooperation with four other medical societies.

This alliance gives visibility to the medical field within radiation protection research and will shape this landscape for years to come. I have just scratched the surface of the many projects and initiatives that the ESR is involved in, but I hope it gives an impression of the society’s general philosophy. The organization has already achieved quite a lot in just over a decade of activity, but there is no shortage of ambition to keep moving forward.

HCB News: What do you see as the major issues and challenges facing radiologists in Europe today? Does this vary greatly by country?
PP: The economic situation is challenging for many European radiologists. Governments are reducing health care expenditures, implementing austerity measures and forcing hospitals to save money. Technologically advanced medicine, and radiology in particular, is negatively perceived as a driving force in the spiraling health care costs. However, given the demographics of an aging population, the demand for high-quality imaging is continuously increasing, from screening and prevention through to the monitoring of the effectiveness of a treatment. Moreover, there is a rapidly growing influence of information technology in imaging.

There are, obviously, differences between European countries, but the fundamental conundrum of European radiology remains the same throughout the continent: decreasing financial means and increasing demand for services. It is a challenge for the ESR to understand this diversity and to offer tailored solutions.

HCB News: What do you see as the big future trends in radiology?
PP: I am profoundly convinced that radiology is at the cusp of very big changes. We are facing a change of paradigm. This can be perceived as threatening, but, as always, changes also bring new opportunities. Please allow me to focus for a few moments on the new opportunities, rather than on the threats. I strongly believe that radiology is rapidly evolving from being a descriptive, qualitative branch of medicine toward quantification of diseases and lesions. Two elements are necessary to successfully achieve this evolution: reliable, high-quality, high-resolution, volumetric 3-D acquisition sequences; and software allowing quantification of volumes of anatomic structures and lesions. For example, in brain imaging, 3-D MRI sequences are being developed into a reliable and reproducible imaging biomarker for disease progression.

At the same time, radiology is moving from anatomical to functional analysis of disease processes. Functional information is a very broad concept, and it comes in a variety of flavors. In brain imaging, which is my primary field of interest, the first one that comes to mind is fMRI, which is based on bold contrast. But there are other techniques to provide functional information, such as perfusion imaging, assessing CSF flow dynamics, brain and spinal cord motion, etc. The big caveat is that we often miss a yardstick by which to calibrate our measurements between patients, sequences and vendors. Therefore, I am a strong believer in the mandatory calibration of machines and equipment with phantoms.

In clinical terms, radiology must aspire to become a vertically integrated medical specialty, especially regarding interventional treatments. For example, in patients admitted with an acute stroke, the ‘chain of command’ should go through radiology: diagnosis, establishment of the core of the infarct versus the penumbra (for example, by perfusion imaging), mapping of collateral vessels, and then, immediately, interventional endovascular stroke treatment and follow-up of the patient by the (interventional) radiologist. Endovascular stroke treatment is having the biggest impact on lives and quality-adjusted life-years of our patients. Therefore, radiologists should aspire to be recognized as clinicians.

Finally, I believe that we need to improve how we communicate with clinicians and with patients. Structured reporting, using a standardized template and a fixed lexicon (RADLEX) are certainly the way forward if we want to prepare our output for the oncoming age of data mining and big data.