Over the past two decades, teleradiology has been a buzzword for what is new and cutting edge in the world of imaging science.
Unfortunately, early attempts also flattered to deceive, as limited bandwidth, high cost transmission and buggy software limited adoption.
While the technology necessary to form the backbone and technical infrastructure is now more readily available and becoming less costly with each IT advance, there are many fundamental questions that prospective clients should consider carefully before embracing teleradiology in its many forms.
Perhaps it is pertinent at this juncture to emphasise that teleradiology as defined as “the electronic transmission of radiologic images from one location to another for the purposed of interpretation and/or consultation” does not just encompass outsourcing of image interpretation to a third party provider but also refers to the ability that electronic transmission allows you to “best source” and load balance your image interpretation requirements even within individual groups.
Prior to deciding on whether your service needs to utilise teleradiology to supplement work flow and enhance quality of life issues for resident staff it is suggested that one considers several factors.
Know why you need it
1. Numbers game / turn around time
There has been a consistent increase in the number of imaging investigations year upon year. Even when the total number of investigations may have actually decreased, the complexity of the examinations has resulted in an increase in the work done and relative value units generated. In short, the demand for radiological services has demonstrated steady annual growth. In the author’s department average growth has ranged from 5% to 8% depending on the modality, with CT, MRI, ultrasound and interventional services featuring prominently. In a report on teleradiology, Merrill Lynch estimated that in the US, there could be a shortage of 15,000 radiologists by 2020. Clearly, there is a need to manage the numbers and preserve the quality of the reports generated as well as the quality of life of the radiologists involved.
Furthermore, even when departments have been able to cope with the numbers, albeit with delayed reporting, patients’ and clinicians’ expectations have changed and expedient reports on all studies have become a measured Key Performance Indicator for some departments. The pioneering teleradiology business model of Night Hawk services is perhaps the best example of how clinical requirement can be met in a climate of rising expectations, for out of hours services.
2. Remote sites and limited service
Teleradiology with a modern list-driven workflow can allow work to be efficiently channelled from high throughput areas to reporting stations, which may be experiencing lower workflow or consolidate reporting from distributed imaging centres to a common reporting centre, increasing efficiency. Also, in remote areas, with low density usage of imaging teleradiology allows for consolidated remote reporting and also second opinion reads when and if the local physician is unsure of what is on the image.
However, to enable the above to happen, the architecture of the image distribution system is of paramount importance. Three essential characteristics of such a system are:
- Web-based teleradiology-centric architecture that allows for true web deployment of reporting interface without need of additional hardware requirements at reading site.
- RIS-free design – allowing for reporting in a non proprietary text editor that is linked to PACs ID of the study and allows for easy importing back into local RIS database. This is especially important if a third-party provider is to be engaged.
- System is able to incorporate security and encryption of DICOM data as per ACR and ESR guidelines.
3. Subspecialty reporting
High-quality subspecialty-based reporting is often available only at tertiary referral centres, but may impact significantly on the management of the remotely located or temporally inconvenient patient. Economic and human resource constraints mean that it is often not viable to provide such services on site, 24/7.
Use of teleradiology, can alleviate this problem. This trend for 24/7 subspecialty reporting is currently being met by several teleradiology reading providers offering sub-specialty reports which are not provisional reads but often final or seco nd opinion consultations.
Short-term and long-term impacts
1. Impact on local radiological training
A reduction in training opportunities:
- Several years ago when one of the major public health groups in Singapore decided to embrace teleradiology reporting by engaging a third-party offshore provider, a strong reaction was stirred up in the hearts of young radiologist in training. Many felt that their livelihoods would be threatened and that the end of radiology as they knew it would be around the corner. Unfortunately some even chose to switch into other specialties. This may in the long term have a detrimental effect on staffing positions if fewer applicants are attracted to the specialty purely on economic grounds.
- Conversely, quality outsourced reporting may be employed to enhance training when the outsourced reports are used as a benchmark for training residents to check their own reports against. In addition, the freeing up of the residents from the “grunt” work of the plain film, allows them to focus on training in the cross sectional imaging modalities and interventional work.
2. Impact on the local radiologist
As the allure of outsourced teleradiology increased, some hospital administrators pondered the possibility of radiologist-free or at least minimally manned imaging centres, reducing reliance on the expensive interpreter for a more economical, 24/7, offshore virtual one. While there was some consolidation of services, to improve efficiency, it was heartening to see in letters to the press from clinical colleagues expounding on the other equally important roles that a radiologist plays in the clinical team managing the patient. It’s reassuring as a clinician to know that you can always call your friendly local radiologist to consult on some difficult images and entrust him with managing the examination. In fact, this radiologist-clinician communication is highlighted in the ESR position statement where it states that “if reporting of radiographs is taken away from close proximity with the patient, the clinical contact between the referring clinicians and radiologists is substantially reduced”, and this may have an impact in patient management.
The use of teleradiology can result in streamlining of work distribution to such an extent that the radiologist may actually end up being overburdened with studies from multiple sites on his work list. Perhaps in situations like this, offloading the work to accredited third-party providers can turn the circumstances around. In fact, in some centres in the US, when a department outsources work on weekends and other unsociable hours, outsourcing is perceived as a positive recruitment aid.
The use of electronic image transfer can also mean that dormant reporting capacity can be better utilised. Radiologists who have retired or have decided to work less due to family commitments can be enticed to work from home.
Medico-legal implications of offshore teleradiology reporting remain vague at best. This is complicated in jurisdictions where the credentialing body for medical specialties may be somehow related to the purchasing authority or provider of health services.
1. Qualifications / credentialing
At the very least the reporting radiologist should be subject to the same qualification requirements that apply to radiologists located in the home country of the patient. In this age of continuing medical education (CME) and practice certification, the offshore radiologist should attain the same CME requirements as local radiologists. Ensuring this will protect the purchaser of off-shore services a common baseline of quality of reporting and to a degree subject it to similar medico legal exposure should litigation arise. Some US institutions ensure this engaging / contracting home state credentialed radiologists based offshore, in strategic time zones, so that the local institution will have 24/7 cover.
2. Site accreditation
The site where reporting is done should be subject to similar guidelines of operation as the home institution. This is pertinent in light of the current trend for many hospitals to apply for Joint Commission International (JCI) and similar accreditation certification. Because teleradiology is viewed as an extension of the home institutions’ services, most accreditation bodies will require that similar operational standards are practised. Quality assurance checks, including IT security and confidentiality of patient data, should be applied to equipment, data storage and reports by way of ongoing audit of reports issued and re-credentialing of the site.
3. Professional liability and accountability
Does the duty of care between a patient and the radiologist reporting a radiological examination cease once the study is reported offshore? It can be argued that this relationship remains, once a radiologist accepts the request and reports on the film.
What about the clinician requesting the examination and the facility performing the study and subsequently sends it off overseas? Surely they must bear some accountability as well. Moreover, would patients agree to having their examinations read offshore, if they paid local rates? Should not the cost saving so achieved be transferred to them?
Teleradiology is here to stay, it is a powerful enabler if implemented correctly and will result in significant improvements in healthcare delivery. It is, however, essential that hospital administrators as well as local radiologists understand that there are significant medico-legal implications which remain unresolved. While reducing health care costs and 24/7 availibility may be important factors that may impact on the adoption of teleradiology outsourcing, other equally significant considerations including long-term impact on radiologist numbers and patient-clinician-radiologist relationships should also be given due consideration as you embark on choosing your outsource partner.