Impact of teleradiology on radiology departments. Professor Iain McCall University of Keele Robert Jones and Agnes Hunt Orthopaedic Hospital Oswestry. UK
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Impact of teleradiology on radiology departments.
Professor Iain McCallUniversity of Keele
Robert Jones and Agnes Hunt Orthopaedic Hospital
Oswestry.UK
e-Health: making healthcare better for European citizens
e-Health tools or solutions include:Health information networksElectronic health recordsTelemedicine servicesWearable, portable monitoring systems Health portalsLifestyle management
Teleradiology and Teleconsultation.
Shorten waiting lists and enable productivity gains
Medical support to remote areas or difficult access
Enhanced medical attention for chronic diseases
Access to specialised care with expertise shortage
Significant contribution to EU economy
Teleradiology in USA
Primary interpretation of study 19% On call preliminary findings 89%Consultation with other Radiologists 22%Consultation with referring physician 8%Peer review 3%
Larson DB et al AJR 2005 185 24-35
NightHawk Pros
Global network of US trained Radiologists.Provides 24 hour 7 days a week coverage.Reports used as preliminary readings only.Double read and transcribed by referring radiologist the next day.Referring radiologist still on call in a secondary position.All positive results phoned to referring clinician.5% of each months cases audited.
Teleradiology in Europe
Radiologists home to base.Linkage within radiology practices.Reporting services to isolated communities.Wide area networks: eg Scandanavia, SpainAdvice from specialist centreNight and weekend cover. (Low usage ) Cross border commercial reporting services.
Valuable impact.
Assist in managing work flow fluctuations.
Enable radiologists to do more hands on work.
Routine work undertaken efficiently.
Valuable impact.
Provides a 24/7 service for small hospitals.
Specialist Neuroradiology review service.
May provide a good financial option.
Valuable impact
Access to subspecialty opinions
Subspecialty radiology for a group of hospitals.
Support if shortage of radiologists.
Network Architecture
PACS Hospital CPACS Hospital D
ABS AB
S
PACS
Hospital A
ABSAB
S
PACS
Hospital B
Corporate network with multiple PACS
Healthcare Node
100Mb
100Mb
100Mb
Hospital E
100Mb
Community PACSConcentric network
XIMEC
CPDABS
34 Mbps
34 Mbps 34 Mbps
34 Mbps
HC3
Medical image digitali zation
Health Channel
Key ICT projects in Catalonia
Public telecommunications network 1Gbps
Detrimental Impact
Reduced reporting skills for examinations.
Resources removed from department.
Loss of radiologists.
Loss of link with clinicians.
Detrimental Impact
Re-reporting of examinations.
Increased reviewing reports with clinicians.
Self referral by clinicians reducing workload.
Quality Issues in Teleradiology.
Routine MR studies not available to trainees
Staffing implications in Teleradiology.
Small departments may lose radiologistsCentralisation of reporting.Radiographers isolated with high-tech equipmentAdequate sessional allocation for reporting.Radiology departments may disappear.
Establish an online e-market place within the field of radiology
A ‘many to many’ connection functioning as a commodity brokering and exchange of radiological services
Large Regional contracts to companies15% of national Radiology budget Mobile imaging units Primary care referralsImages reported in European centre Report returned to primary care doctor
Using Outsourced Independent service providers.
ReportingClinician did not know radiologistReporting style not familiarNumerous examinations re-reported locallyComplicated reports to GPs and relevance of findings unclear.
SolutionBetter communicationImproved quality controlFeedback to outsource radiologists Extensive audit
Dixon A, Webster P Imaging management 2007 7 (3)16-17
Using Outsourced Independent service providers.
ProblemsIdentification of appropriate patientsHad to be ambulant and no contrast High volume low complexityStatic units case mix more complex and costly.
SolutionCentral online booking Access to previous examinations
Dixon A, Webster P Imaging management 2007 7 (3)16-17
Service delivery
Using Outsourced Independent service providers.
Statutory requirementsMany issues of confidentiality and legislation
SolutionRegistration and on specialist register in country of
residence of patients.Proper knowledge of language (EU Directive 2005/36/ EC)EU working time directive .Revalidation, recertification and appraisal same as local
radiologists.
Dixon A, Webster P Imaging management 2007 7 (3)16-17
Teleradiology interpretations of emergency department CT scans.
Prospective observational study.
Teleradiologist v in-house emergency CT interpretation.
Head, cervical spine, chest, abdomen and pelvis - 550 scans
Major discrepancies - 32 (5.8%) scans
7/160 head, 1/29 C Spine, 3/64 chest, 21/297 abdo/pelvis
8/550 Major discrepancies by teleradiologist misinterpretation.
Platts-Mills TF et al J of Emergency Medicine 2010 38 188-95
Improving quality through routine subspecialty teleradiology consultation
2012 consecutive CT and MR studiesReported by general radiologistReviewed by subspecialistReverse for controls21.1% disagree - 99% important or v important85% - specialist’s views in generalist’s reportEliminated unnecessary procedures More specific follow-up examinations
Kangarloo H et al Acta Radiol 2000 7 149
Quality Issues in Teleradiology.
Informing clinician of urgent or unexpected findings.
Informing patients of findings and advice.
Discussion of findings and continuity of management.
Communication.
Patient/Physician relationship with regard to proximity and responsibility.
Quality Issues in Teleradiology
Inability to integrate:image management systems.teleradiology systems with other health care information.different registration numbers and security issues.access to remote work-listsaccess to EPR
Thrall J Radiology 2007 294(2) 325
Quality Issues in Teleradiology.
Outsourced after-hours teleradiology service: overall discrepancy rate of 1.09% . Abdominal CT was 2.1%
Wong WS et al J Am Coll Radiol 2005 2 478-484
There is no evidence that teleradiology improves outcomes or saves money.
Havorsen PA and Kristiansen IS BMJ 1996 312 1333-1336
Little overall difference in clinical opinion between ISP and NHS reports. Casemix bias in favour of ISP.
RCR 2006 ISP audit www.rcr.ac.uk
ESR teleradiology guidelines
Organise services between source radiologist and teleradiology provider to ensure that :Clinical evaluation and data is provided.Requirments of Euratom 97/43 are fulfilled.Report and images are reviewed with clinicians.Unexpected findings communicated and discussed.
Quality Issues in Teleradiology in Europe.
Multiple languages in Europe.
Diverse health care systems.
Differing training programmes.
National registration authorities.
Varied payment systems and income.
It is the responsibility of the practice contracting teleradiology services to ensure that the reporting radiologist is, in relation to the jurisdiction of the site of image acquisition, appropriately registered/licensed, credentialed, indemnified and possesses the required specialist qualifications (and any required revalidation thereof)
Radiologist
Principles of International Clinical Teleradiology
A Service Agreement must clearly define and document the legal arrangements and responsibilities between the referring and interpreting sites
Documentation
System to document electronic “fingerprints” of interpreting radiologist including verification of routing must be in place to prevent “ghosting” of reports
Ethics
Principles of International Clinical Teleradiology
EU regulation of cross border e-Health
Cross border teleradiology rapid development
Complex EU regulation
Proposed guidelines but not legally binding
Amendments to cross border directive
EU legal and regulation of e-Health
No specific legislation exists at EU level that specifically targets e-Health services and products.
Regulation of doctors reporting teleradiology in EuropeMutual recognition of professional qualification
Directive - 2005
EU legal and regulation of e-Health
e-Health services provided by the internetAny service normally provided for remuneration, at a distance by electronic means and at the individual request of a recipient.
e-Commerce directive 2000/31/ECQuality criteria for health related websites
com 2002/667/ECProfessionals must inform user of: identity, address,
VAT number, professional registration details
EU legal and regulation of e-Health
Contracts for e-Health goods and servicesGoverned by normal national contract lawContracts between parties in different EU states drawn in state of either purchaser or providerElectronic signature if used covered by:
Advanced electronic signature directive 1999/93/EC
EU Communication on Telemedicine for the benefit of patients healthcare systems and society
Teleradiology
Cope with peak workloads
Ensure round the clock service
Reduce waiting lists for specific examinations
Above all, reduce costs
Defines set of actions to be taken by member states EU commission and other stakeholders
Building confidence in and acceptance of telemedicine services.
Bringing legal clarity
Solving technical issues and facilitating market development
EU Communication on Telemedicine for the benefit of patients healthcare systems and society
EU Communication on Telemedicine for the benefit of patients healthcare systems and society
EU member states actions:2010: Assess needs and priorities in telemedicine to
form part of the national strategies
2011: assessed and adapted national regulations enabling wider access to telemedicine services addressing
Accreditation,
Liability,
Reimbursement,
Privacy
Data protection
Formal EU guidelines on teleradiology .
Promised December 2009.
Still being discussed within commission
Teleradiology is not telemonitoring.
It is a medical act
Cross-border Healthcare Directive
Free movement of health servicesQuality - Safety - Privacy - ConfidentialityProtection - Compensation Reimbursement of care outsideContinuity of care - InteroperabilityPrinciple of recognition for Prescription Standards for Quality and Safety - Audit
monitoring
Cross-border Healthcare Directive
Healthcare provider in country of affiliation:has contract regarding image diagnostic services, service provided and liability resolved by the terms of the contractno prior contract, member state where patient is insured is responsible for the quality of services it out-sources
Teleradiology – No specific comments
Views of DG Sanco
ESR Teleradiology guidelines
Fully qualified Radiologists.Registered in transmitting and reporting country.Subject to providers quality and revalidation requirements.Proper knowledge of source national language .
Service organised between source radiologist and provider.
Article 13 – paragraph 1 amendment
The member state shall ensure that the use of e-health and other telemedicine services:Adhere to the same professional medical quality and safety standards as those in use for non electronic healthcare provisionOffer adequate protection to the patients notably through the introduction of appropriate regulatory requirements for health professionals similar to those in use for non electronic healthcare provision.
Cross border health directive
Cross border health directive
Member states shall guarantee that registers in which health professionals are listed are available to relevant authorities in other member states.
Member states shall immediately and proactively exchange information about disciplinary and criminal findings against health professionals where they impact upon their registration or their right to provide services.
Article 10 paragraph 2b - amendment
Conclusion
Teleradiology is an asset for radiology departments
Radiology departments must manage teleradiology.
Teleradiology quality equal to traditional radiology
European legal framework for teleradiology needed
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