Teleradiology offers opportunities, challenges

Providing teleradiology services offers a tremendous opportunity and clinical benefit, but requires clearing hurdles such as IT infrastructure issues, medicolegal requirements, and business considerations, according to Katherine Andriole, Ph.D., of Brigham and Women's Hospital in Boston.

Imaging procedures are growing in the U.S. about 15% a year, while the number of radiologists is increasing only by about 2%. Teleradiology can help fill that gap; it may also allow for improved patient care, providing subspecialty consultations and primary interpretation when no local radiologist is available, according to Andriole.

"It's much easier to move the work to the radiologist, rather than move the radiologist to the work," she said.

Many radiology practices feel providing teleradiology reading services may also offer a competitive advantage, Andriole added. It's important, though, to be aware of the political ramifications of providing this type of service, she noted.

Andriole spoke during a hot topic session at the 2008 Society for Imaging Informatics in Medicine (SIIM) meeting in Seattle, sharing Brigham and Women's Hospital's experience in offering teleradiology services.

"One of the things that we try to do is use diplomacy," Andriole said, rather than trying to go in to undermine local radiology businesses. "You might want to think about how you go about gaining business. Are you adding value to something that doesn't exist at a location, or are you replacing somebody's livelihood?"

IT requirements

Andriole discussed some of the functional and technical requirements needed to provide teleradiology services. Functional requirements include current image transmission and display; comparison studies, if possible; the reason for the examination and supporting clinical history, if possible; a reporting process; and the communication of results. Minimal interruption of workflow and an archiving plan to handle risk management needs are also needed, she said.

Technical requirements include the transmission infrastructure (accessing the Internet); RIS, PACS, and report generation capability, at a minimum; the ability to deal with multiple foreign medical record numbers (creating exceptions in PACS); protocol enhancements for quality; and report delivery, according to Andriole. An optimal scenario would utilize computerized order entry, RIS, PACS, report generation, and electronic medical record (EMR) functionality, she said.

"It's often very important to ask a vendor, if you're choosing a particular system, [if] they do https," she noted. "In terms of security, you would think that's a no-brainer. But there are a number of teleradiology systems out there that don't do this very well. Then you're stuck dealing with your networking folks and getting things behind firewalls and using routers and so on."

An integration engine should accommodate HIS/RIS, PACS, speech recognition, faxing capabilities, and the ability to send HL7 messages using foreign medical record numbers to a remote information system. It may also have to handle systems from multiple vendors at different remote sites.

During implementation, some issues to consider include having a contract in place, remote site training, local support staff training, staffing to meet the imaging volume, quality assurance, and communication, according to Andriole.

"These are computing systems, and they will go down on occasion," she said. "You need to communicate with the site; they are your customers. Their customers -- the patients -- are impacted by this as well. So the best thing is communication on all sides."

Sites also have to prepare for management and support, including having an industry-strength system, Andriole said. Redundancy, a backup plan, and service contracts should also be in place.

Business considerations

Some business and economic considerations include contracting (such as product definition and metrics), accounts that may come and go, equipment and system costs, and accounting for overhead costs, according to Andriole.

The ability to scale should also be considered. "Can you afford success?" she asked.

In addition, sites need to be aware of medicolegal concerns, including the varying licensure and credentialing requirements in different states, regions, and countries, Andriole said.

Professional liability issues, including the duty of care, should also be weighed. "I think case law legislation is going to catch up with this rapidly developing area of healthcare," she said. "We don't have the answers yet as to what the ramifications may be ... but having a written policy is probably one way to start."

As for data security and patient confidentiality, teleradiology systems should maintain patient privacy, authenticity, and integrity, Andriole said. This includes audit trails, electronic signature, password protection, and data encryption.

Risk management must be performed as well. While legal record archival should be performed at the acquisition site, sites may want to locally archive the studies for a period of time, she said.

"You also want to have adequate backup to prevent accidental loss of data, as well as to manage downtime events," Andriole noted. "These are all costs you want to think about up-front."

The integrity and quality of transmitted data is the responsibility of both the sender and receiver, so agreed-upon protocols and clear lines of accountability are essential when setting up the service, she said.

The teleradiology system in place must also maintain image quality, according to Andriole. "It could be considered negligent for you, the radiologist, to produce and examine substandard-quality images by reasons of inferior equipment," she said. "It may pay to buy a little more expensive technology, and to maintain that you have the image quality that you, as the radiologist, feel comfortable making the interpretation."

By Erik L. Ridley staff writer
August 25, 2008

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Telemammography project achieves success, April 28, 2008

Effective communication is crucial for radiology department success, March 20, 2008

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