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The effective development and use of clinical imaging guidelines requires an understanding of who the stakeholders are, what their interests in the process are, and what roles they should play. If the appropriate stakeholders are not engaged in the right roles, it is unlikely that clinical imaging guidelines will be successfully developed, relied on, and actually used. Some stakeholders are obvious: for the development of clinical imaging guidelines, both imagers and those who request examinations, such as general practitioners, internists, and medical specialists, must be involved. To gain acceptance, other relevant groups are stakeholders, including medical societies, other health care professionals, insurers, health IT experts and vendors, and patients. The role of stakeholders must be dictated by their specific interest. For some, involvement in the creation of guidelines is the right role. For others, such as regulators or insurers, reviews or invitations to comment are required, and for others, such as medical educators, it is probably sufficient to provide information and create awareness. Only through a careful consideration of who the stakeholders are and what are their interests are the successful development, acceptance, and use of clinical imaging guidelines likely to occur. Future efforts must focus on collaboration, particularly among groups that create clinical imaging guidelines and those that can support their use, and on regulatory roles and mandates.

An International Atomic Energy Agency (IAEA) TechnicalMeeting on Justification of Medical Exposure and the Use ofAppropriatenessCriteriawasheldonMarch12-14,2013with3aims: (1) to explore what clinical imaging guidelines (CIG) arecurrently available, (2) to define the problems associated withclinical imaging guideline creation and use, and (3) to begin toestablishconcreteplansforinternationalcollaborationtoachievewideruseofCIG.TheunderlyingconceptisthattheuseofCIGcan improve patient care by improving the appropriate use ofimaging. This meeting was the second of 3 annual workshops,with further ones planned [1], and was organized and supportedbytheIAEAincooperationwiththeWorldHealthOrganization.Sixty medical professionals and regulators, from more than 30countries, participated. The 4 papers that follow in this issueevolved from the meeting, based on presentations, breakoutsessions,anddiscussions.Theintentofthisintroductoryarticleisto put the 4 papers into perspective, by specifically addressingwhatCIGare,whytheyaredifficulttobothproduceanddeploy,and why and how they are important.Several terms are used to describe the concept of guidelinesforclinicalimaging,including“appropriatenesscriteria,”“referralguidelines,” and “justification criteria” [2-5]. CIG (a term usedthroughout the papers) are developed using well-described,transparent methodology and available peer-reviewed literaturetocreaterecommendationsthatindicatewhichimagingexams,ifany,aremostlikelytobeclinicallyusefulinaspecificsetting.CIGare intended to inform the decision of the health care provider,thepatient,andtheradiologistastowhichimagingtest(again,ifany)torequestandperform.Buttheguidelinesarenotabsolute:The ultimate decision is based on many factors, includingpatient-specific ones (eg, risk factors, preferences), disease prev-alence, and availability of expertise and equipment. That is, ifMRI is the best choice but no MRI unit is available, thenchoosing anotherexamis reasonable. If ultrasound wouldbe thebest choice, but no local expertise is available in this area, thenanother imaging study may be recommended.The ACR Appropriateness Criteria on low-back pain pro-vide a good example of the intent of the guidelines. This topicincludes 6 variant scenarios. They range from “acute low backpain with no red flags” (as described in the text), for which therecommendation is that no imaging be done, to cauda equinasyndromewithmultipleorprogressivedeficits,withMRIratedas“usuallyappropriate”andlumbo-sacralx-rayandCTas“possiblyappropriate.” In this setting, based on clinical judgment, ifneither MRI norCT is available, then x-ray may be appropriate.A widely held belief is that imaging is often inappropriatelyused,withbothoveruse(by20%-50%)andunderuse.Amongtheexplanations for overuse are financial self-interest, medicolegalconcerns,expedience,andpatientdesire.Concernabouttheriskofionizingradiationmayleadtoinappropriateunderuse,asmaylackof availability of equipment or expertise. All stakeholders have ahigh level of interest in improving the quality of care and makingthe practice of medicine increasingly evidence based; the use ofsound guidelines is one important approach to this goal.Basingallmedicaldecisionsonrelevantevidenceisnotalwayspossible,becauseevidenceisessentiallynevercompleteforagivendisease, patient, and setting. Many organizations have produceddocuments that provide guidance or otherwise support evidence-based medicine. For example, the Cochrane Collaboration, amultinational nonprofit organization dedicated to improvinghealthcarethroughevidence-basedmedicine,producessystematicreviewsthatcanbeusedasthebasisofcare[6].Severalsocietiesandorganizations produce methodologically sound guidelines specif-ically for imaging. These include the American College of Cardi-ology[5],thegovernmentofWesternAustralia[7],andradiologysocieties such as the Royal College of Radiologists in the UnitedKingdom [4], the Canadian Association of Radiologists [8],theFrench Radiology Society [9], and the ACR [3].Methods for guideline development for clinical care arefairly well defined, based on an approach developed by the

A recent international meeting was convened by two United Nations bodies to focus on international collaboration on clinical appropriateness/referral guidelines for use in medical imaging. This paper, the second of 4 from this technical meeting, addresses barriers to the successful development/deployment of clinical imaging guidelines and means of overcoming them. It reflects the discussions of the attendees, and the issues identified are treated under 7 headings: ■ Practical Strategy for Development and Deployment of Guidelines; ■ Governance Arrangements and Concerns with Deployment of Guidelines; ■ Finance, Sustainability, Reimbursement, and Related Issues; ■ Identifying Benefits and Radiation Risks from Radiological Examinations; ■ Information Given to Patients and the Public, and Consent Issues; ■ Special Concerns Related to Pregnancy; and ■ The Research Agenda. Examples of topics identified include the observation that guideline development is a global task and there is no case for continuing it as the project of the few professional organizations that have been brave enough to make the long-term commitment required. Advocacy for guidelines should include the expectations that they will facilitate: (1) better health care delivery; (2) lower cost of that delivery; with (3) reduced radiation dose and associated health risks. Radiation protection issues should not be isolated; rather, they should be integrated with the overall health care picture. The type of dose/radiation risk information to be provided with guidelines should include the uncertainty involved and advice on application of the precautionary principle with patients. This principle may be taken as an extension of the well-established medical principle of "first do no harm."

Workforce shortage, workload increase, workplace changes, and budget challenges are emerging issues around the world, which could place quality imaging at risk. It is important for imaging stakeholders to collaborate, ensure patient safety, improve the quality of care, and address these issues. There is no single panacea. A range of improvement measures, strategies, and actions are required. Examples of improvement actions supporting the 3 quality measures are described under 5 strategies: conducting research, promoting awareness, providing education and training, strengthening infrastructure, and implementing policies. The challenge is to develop long-term, cost-effective, system-based improvement actions that will bring better outcomes and underpin a sustainable future for quality imaging. In an imaging practice, these actions will result in selecting the right procedure (justification), using the right dose (optimization), and preventing errors along the patient journey. To realize this vision and implement these improvement actions, a range of expertise and adequate resources are required. Stakeholders should collaborate and work together. In today's globalized environment, collaboration is strength and provides synergy to achieve better outcomes and greater success.