European Society of Radiology (ESR). ESR white paper on teleradiology: an update from the teleradiology subgroup. Insights Imaging. 2014;5:1-8. [PMID: 24443129 PMCID: PMC3948905 DOI: 10.1007/s13244-013-0307-z]

Navigating Challenges in Teleradiology Implementation: A Case Study from Saudi Arabia's Healthcare System

Background and Aims

Teleradiology is the practice of interpreting medical images acquired in an off-site location. Teleradiology has been utilized widely around the world to address the needs for subspecialty coverage, workload balancing, and as a solution for understaffing. This study aims to assess the perceptions of teleradiology among radiologists in Saudi Arabia, investigate any challenges they might face, and explore strategies that would help mitigate those challenges.

Methods

A cross-sectional study using a self-administered electronic questionnaire was conducted to collect responses from radiologists practicing or having practiced teleradiology in Saudi Arabia. The questionnaire was conducted from January to June 2023, and 105 responses were included in the analysis. The responses were analyzed using chi-squared testing to investigate factors affecting the radiologists' perceptions.

Results

The most common challenges for teleradiology were access to patients' health records, access to prior imaging exams, and concerns about image quality assurance. Around 74% of participants perceived teleradiology to be beneficial for geographic, after-hour, and subspecialties coverage. Teleradiology was also perceived to help reduce the turn-around time of radiology interpretations. Better communication with referring physicians and technologists was seen as a way to help improve teleradiology services.

Conclusion

The findings suggest that the perception of teleradiology's challenges and benefits may not be influenced by experience, workplace, or subspecialty. Emphasis should be placed on the importance of quality assurance of images acquired remotely. Addressing the concerns and challenges related to access to patients' health records is also crucial to ensuring the successful implementation of teleradiology in the country.

The growing role of telemedicine - possibilities and regulations concerning teleradiology in Poland

In recent years, imaging studies have become increasingly used at various stages in the management of patients with various conditions and disorders. This process results in a necessity to provide an increasing number of exams, which involves a growing role of radiologists in assessing and reporting those exams. The article discusses tele-radiology as a method that can improve access to radiology services, presenting its potential benefits, as well as the risks involved. It analyses access to radiology healthcare services in Poland in the context of the international and Polish legal provisions concerning the right to healthcare. While funding for imaging studies for patients is widely available and imaging equipment in Poland is improving despite some shortages, the main barrier is identified in the number of specialists capable of assessing the exams. Teleradiology can alleviate this shortage, so the article presents legal provisions and international good practice guidelines in this area, focusing on documents issued by the European Society of Radiology, the American College of Radiology, and the British Royal College of Radiologists. The guidelines concerning such aspects as patients' rights, teleradiologists' qualifications, communication and reporting, responsibility, and technical requirements may help make teleradiology a safe and valuable component of the healthcare system in Poland.

Radiologists' experiences and perceptions regarding the use of teleradiology in South Africa

Background

Teleradiology was implemented in South Africa in 1999, but the subsequent uptake was low and slow. The onset of the coronavirus disease 2019 (COVID-19) pandemic catapulted South African healthcare into the arena of teleradiology. This created the environment for re-examining the factors that enable or inhibit the uptake of teleradiology in both the public and private sectors.

Objectives

This article reports on a study of a select sample of private and public sector radiologists' experiences with, and perceptions of, the benefits, opportunities, challenges and barriers to the implementation of teleradiology in the South African context.

Method

Qualitative data on the perceived benefits and challenges of teleradiology, as well as on its enablers and the barriers to its implementation, were collected and analysed.

Results

The uptake of teleradiology in the sample increased by 15.9% during the COVID-19 pandemic. The results demonstrated that teleradiology was perceived to have clear benefits on operational, personal and societal levels.

Conclusion

It is important to address structural barriers to the implementation of teleradiology. Clear communication strategies and multistakeholder engagement are also required.

Contribution

By investigating radiologists' experience with teleradiology, this study provides an understanding of the benefits, opportunities, challenges and barriers to implementation of services. These insights enable informed decision-making and stakeholder engagement and provide a foundation for establishing recommendations for the viable implementation of teleradiology in South Africa and other lower- and middle-income countries to promote access to healthcare.

Impact of Magnetic Resonance Imaging on Healthcare in Low- and Middle-Income Countries

Magnetic resonance imaging (MRI) played a significant role in the digital health platforms that influenced and supported modern medicine. However, there is a shortage of MRI in low- and middle-income countries (LMICs). The International Society of Radiology offers a detailed plan for LMICs to advance imaging quality in the global health agenda. The overarching objective of this scoping review was to determine the impact of MRI in healthcare in LMICs. This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify available evidence. We systematically searched four academic databases for peer-reviewed literature published between 2018 and 2021, namely, Medline, PubMed, Web of Science, and Scopus, as well as Google Scholar as a source for gray literature. The search identified 54 articles. We identified a range of reasons for introducing MRI in LMICs. Nonetheless, some challenges to accepting MRI as a method of healthcare have been reported, including technological, regulatory, and economical challenges. To implement the proposed plan, the involvement of professional and international organizations is considered crucial. The establishment of an International Commission on Medical Imaging under the umbrella of international organizations is suggested and collaboration with other diagnostic disciplines is encouraged to raise awareness of the importance of upscale diagnostics at large and to foster its integration into the care pathway globally.

Teleradiology: good practice guide

Teleradiology is the electronic transmission of radiological images from one location to another with the main purpose of interpreting or consulting a diagnosis and must be subject to codes of conduct agreed upon by professional societies. The content of fourteen teleradiology best practice guidelines is analyzed. Their guiding principles are: the best interest and benefit of the patient, quality and safety standards homologous to the local radiology service, and use as a complement and support of the same. As legal obligations: guaranteeing rights by applying the principle of the patient's country of origin, establishing requirements in international teleradiology and civil liability insurance. Regarding the radiological process: integration with the local service process, guaranteeing the quality of images and reports, access to previous studies and reports and complying with the principles of radioprotection. Regarding professional requirements: compliance with the required registrations, licenses and qualifications, training and qualification of the radiologist and technician, prevention of fraudulent practices, respect for labor standards and remuneration of the radiologist. Subcontracting must be justified, managing the risk of commoditization. Compliance with the system's technical standards.

The concept of the invisible radiologist in the era of artificial intelligence

The radiologists were traditionally working in the background. What upgraded them as physicians during the second half of the past century was their clinical training and function precipitated by the evolution of Interventional Radiology and Medical Imaging, especially with ultrasonography. These allowed them to participate in patient's diagnosis and treatment by direct contact as well asvia multidisciplinary medical consultations. The wide application of teleradiology and PACS pushed radiologists back again which is no longer acceptable, especially in view of the amazing applications of artificial intelligence (AI) in Radiology. It is our belief that clinical radiologists have to be able to control the penetration of AI in Radiology, securing their work for the benefit of both clinicians and patients.

How to improve access to medical imaging in low- and middle-income countries ?

Imaging has become key in the care pathway of communicable and non-communicable diseases. Yet, there are major shortages of imaging equipment and workforce in low- and middle-income countries (LMICs). The International Society of Radiology outlines a plan to upscale the role of imaging in the global health agenda and proposes a holistic approach for LMICs. A generic model for organising imaging services in LMICs via regional Centres of Reference is presented. The need to better exploit IT and the potential of artificial intelligence for imaging, also in the LMIC setting, is highlighted. To implement the proposed plan, involvement of professional and international organisations is considered crucial. The establishment of an International Commission on Medical Imaging under the umbrella of international organisations is suggested and collaboration with other diagnostic disciplines is encouraged to raise awareness of the importance to upscale diagnostics at large and to foster its integration into the care pathway globally.

TSR guidelines for the practice of teleradiology: 2021 update

This update of Turkish Society of Radiology's (TSR) guidelines for the practice of teleradiology is intended to provide a reference framework for all parties involved in delivering imaging services away from the immediate vicinity of the patient. It includes relevant definitions and general principles, features organizational modes and qualifications of the practicing parties, lists technical issues, and addresses such management and legal aspects as archiving and documentation, security and privacy, reliability, responsibilities, quality inspection and improvement, reimbursement and accountability.

COVID-19 imaging: Diagnostic approaches, challenges, and evolving advances

The role of radiology and the radiologist have evolved throughout the coronavirus disease-2019 (COVID-19) pandemic. Early on, chest computed tomography was used for screening and diagnosis of COVID-19; however, it is now indicated for high-risk patients, those with severe disease, or in areas where polymerase chain reaction testing is sparsely available. Chest radiography is now utilized mainly for monitoring disease progression in hospitalized patients showing signs of worsening clinical status. Additionally, many challenges at the operational level have been overcome within the field of radiology throughout the COVID-19 pandemic. The use of teleradiology and virtual care clinics greatly enhanced our ability to socially distance and both are likely to remain important mediums for diagnostic imaging delivery and patient care. Opportunities to better utilize of imaging for detection of extrapulmonary manifestations and complications of COVID-19 disease will continue to arise as a more detailed understanding of the pathophysiology of the virus continues to be uncovered and identification of predisposing risk factors for complication development continue to be better understood. Furthermore, unidentified advancements in areas such as standardized imaging reporting, point-of-care ultrasound, and artificial intelligence offer exciting discovery pathways that will inevitably lead to improved care for patients with COVID-19.

e-Health and telemedicine implementation in facial paralysis: challenges and pitfalls

During the current Covid-19 pandemic, a lot of changes had to be made in the care of patients with facial nerve paralysis (FNP). FNP is a life-changing condition with effects on both physical (both esthetic and functional) and psychological aspects of the patient's life. Telemedicine could be a suitable alternative in the therapy for these patients, since it is often not possible to travel to outpatient clinics or to have normal face-to-face appointments with treating physicians because of pandemic restrictions. This review provides an overview of the current literature in the treatment of FNP during the pandemic and the role of telemedicine/e-Health. Secondly, we will discuss the challenges and pitfalls of implementing e-Health and telemedicine applications in clinical practice. Level of evidence: Not ratable.

Accelerated implementation of remote reporting during the COVID-19 pandemic

AIM

To assess, via a survey of UK radiological departments, if the COVID-19 pandemic led to a change in radiological reporting undertaken in a home environment with appropriate IT support.

MATERIALS AND METHODS

All imaging departments in the UK were contacted and asked about the provision of home reporting and IT support before and after the first wave of the pandemic.

RESULTS

One hundred and thirty-seven of the 217 departments contacted replied, producing a response rate of 61%. There was a 147% increase in the provision of remote access viewing and reporting platforms during the pandemic. Although 578 consultants had access to a viewing platform pre-pandemic, this had increased to 1,431 during the course of the first wave.

CONCLUSION

This survey represents work undertaken by UK NHS Trusts in co-ordinating and providing increased home-reporting facilities to UK radiologists during the first wave of this global pandemic. The impact of these facilities has been shown to allow more than just the provision of reporting of both elective and emergency imaging and provides additional flexibility in how UK radiologists can help support and provide services. This is a good start, but there are potential problems that now need to be overcome.

Workload for radiologists during on-call hours: dramatic increase in the past 15 years

Background

The objective of this study is to investigate the workload for radiologists during on-call hours and to quantify the 15-year trend in a large general hospital in Western Europe.

Methods

Data regarding the number of X-ray, ultrasound and computed tomography (CT) studies during on-call hours (weekdays between 6.00 p.m. and 7.00 a.m., weekends, and national holidays) between 2006 and 2020 were extracted from the picture archiving and communication system. All studies were converted into relative value units (RVUs) to estimate the on-call workload. The Mann–Kendall test was performed to assess the temporal trend.

Results

The total RVUs during on-call hours showed a significant increase between 2006 and 2020 (Kendall's tau-b = 0.657, p = 0.001). The overall workload in terms of RVUs during on-call hours has quadrupled. The number of X-ray studies significantly decreased (Kendall's tau-b = − 0.433, p = 0.026), whereas the number of CT studies significantly increased (Kendall's tau-b = 0.875, p < 0.001) between 2006 and 2020. CT studies which increased by more than 500% between 2006 and 2020 are CT for head trauma, brain CTA, brain CTV, chest CT (for suspected pulmonary embolism), spinal CT, neck CT, pelvic CT, and CT for suspected aortic dissection. The number of ultrasound studies did not change significantly (Kendall's tau-b = 0.202, p = 0.298).

Conclusions

The workload for radiologists during on-call hours increased dramatically in the past 15 years. The growing amount of CT studies is responsible for this increase. Radiologist and technician workforce should be matched to this ongoing increasing trend to avoid potential burn-out and to maintain quality and safety of radiological care.

Emerging Challenges and Opportunities in the Evolution of Teleradiology

OBJECTIVE. In recent decades, teleradiology has expanded considerably, and many radiology practices now engage in intraorganizational or extraorganizational teleradiology. In this era of patient primacy, optimizing patient care and care delivery is paramount. This article provides an update on recent changes, current challenges, and future opportunities centered around the ability of teleradiology to improve temporal and geographic imaging access. We review licensing and regulations and discuss teleradiology in providing services to rural areas and assisting with disaster response, including the response to the coronavirus disease (COVID-19) pandemic. CONCLUSION. Teleradiology can help increase imaging efficiency and mitigate both geographic and temporal discrepancies in imaging care. Technologic limitations and regulatory hurdles hinder the optimal practice of teleradiology, and future attention to these issues may help ensure broader patient access to high-quality imaging across the United States.

Teleworking beyond teleradiology: managing radiology departments during the COVID-19 outbreak

Abstract

Teleradiology solutions are playing an essential role during the COVID-19 outbreak. Activity at radiology departments must be maintained and adapted to this new situation beyond teleradiology. Teleworking should be extended to the rest of non-medical radiology department areas. A comprehensive perspective based on our own experience during the COVID-19 outbreak has been performed highlighting the value of teleworking for almost all areas implied in the workflow of radiology departments beyond radiologists. Personal and technical requirements for successfully adapting to this new scenario are discussed including the opportunities that this unprecedent situation is bringing for reorganizing workflow and developing new projects.

Key Points

• Teleradiology solutions are playing an essential role during the COVID-19 outbreak.

• Teleworking should be extended to the rest of non-medical radiology department areas whenever possible.

Centralized expert HRCT Reading in suspected idiopathic pulmonary fibrosis: Experience from an Eurasian teleradiology program

PURPOSE

To share experience from a large, ongoing expert reading teleradiology program in Europe and Asia aiming at supporting referring centers to interpret high-resolution computed tomography (HRCT) with respect to presence of Usual Interstitial Pneumonia (UIP)-pattern in patients with suspected Idiopathic Pulmonary Fibrosis (IPF).

METHOD

We analyzed data from 01/2014 to 05/2019, including HRCTs from 239 medical centers in 12 European and Asian countries that were transmitted to our Picture Archiving and Communication System (PACS) via a secured internet connection. Structured reports were generated in consensus by a radiologist with over 20 years of experience in thoracic imaging and a pulmonologist with specific expertise in interstitial lung disease according to current guidelines on IPF. Reports were sent to referring physicians. We evaluated patient characteristics, technical issues, report turnaround times and frequency of diagnoses. We also conducted a survey to collect feedback from referring physicians.

RESULTS

HRCT image data from 703 patients were transmitted (53.5% male). Mean age was 63.7 years (SD:17). In 35.1% of all cases diagnosis was "UIP"/"Typical UIP". The mean report turnaround time was 1.7 days (SD:2.9). Data transmission errors occurred in 7.1%. Overall satisfaction rate among referring physicians was high (8.4 out of 10; SD:3.2).

CONCLUSIONS

This Eurasian teleradiology program demonstrates the feasibility of cross-border teleradiology for the provision of state-of-the-art reporting despite heterogeneity of referring medical centers and challenges like data transmission errors and language barriers. We also point out important factors for success like the usage of structured reporting templates.

The impact of contracts on outsourcing computed tomography examinations from a Swedish public university hospital to a private radiology unit

INTRODUCTION

After years of outsourcing without detailed contracts from one of Sweden's largest university hospitals to external radiology units, the hospital started to use a specific contract for outsourcing computed tomography (CT) examinations. The purpose of this study was to compare the cost-effectiveness of two outsourcing approaches, where examinations were performed either with a detailed, specific contract (with-contract) or without (no-contract), between a hospital radiology department and private external units.

METHODS

This retrospective study included a group of electively outsourced CT-examinations (n = 132) and a control group of in-house CT-examinations (n = 132), selected from the three different types of CT-examinations referred from the Departments of Oncology and Hematology. These examinations were randomly selected from four different groups over two time periods of one year each, one being outsourcing without a contract (no-contract, during 2013), one time period with a specific contract (with-contract, during 2014) and two control groups of examinations performed in-house within both these time periods. We compared outsourced examinations (both no-contract and with-contract groups) and in-house examinations. The comparison of these groups include five parameters; management-time, patient waiting-time, the quality of the examinations, - image interpretations and costs.

RESULTS

During 2013, management-time for CT-examinations was longer in the outsourced group (no-contract) than in the in-house group, with a statistical significance (P = 0.002). Fewer examinations performed in-house and in the with-contract group needed re-interpretation than in the no-contract group. CT-examinations in the with-contract group were associated with shorter overall management-time, patient waiting time and lower costs compared to the no-contract group.

CONCLUSION

Using a contract with detailed specifications for outsourcing CT-examinations may be an effective way of reducing patient waiting time. Outsourcing based on a well-founded contract can be cost-effective, compared with outsourcing without a detailed plan for the services required.

[Multihospital use of imaging techniques in decentralized trauma care]

BACKGROUND

Decentralized trauma care in the Wald and Weinviertel region in the north of lower Austria comprises five hospitals for primary care including one regional trauma center. Due to the geographical position and adverse weather conditions a web-based teleradiology system was established to ensure the best possible treatment and joint access to the results of radiological investigations.

OBJECTIVE

The article describes a new picture archiving and communication system (PACS), which provides an online teleradiological workflow between the central trauma care unit and peripheral departments in a local trauma network as well as the advantages and disadvantages.

MATERIAL AND METHODS

A corporately used PACS enables streaming-based full access to studies which are created within the system. Radiological studies can be obtained on request from all subscribers within the network.

RESULTS

Teleradiological networks can essentially contribute to a suitable treatment pathway in an association of hospitals and therefore lead to a rapid initiation of treatment.

CONCLUSION

Especially in rural areas with decentralized trauma care, the joint use of teleradiological resources can lead to a better treatment quality.

Telesonography in emergency medicine: A systematic review

Ultrasound is an efficacious, versatile and affordable imaging technique in emergencies, but has limited utility without expert interpretation. Telesonography, in which experts may remotely support the use of ultrasound through a telecommunications link, may broaden access to ultrasound and improve patient outcomes, particularly in remote settings. This review assesses the literature regarding telesonography in emergency medicine, focussing on evidence of feasibility, diagnostic accuracy and clinical utility. A systematic search was performed for articles published from 1946 to February 2017 using the Cochrane, Medline, EMBASE, and CINAHL databases. Further searches utilising Scopus, Google Scholar, and citation lists were conducted. 4388 titles were identified and screened against inclusion criteria which resulted in the inclusion of 28 papers. These included feasibility, diagnostic accuracy and clinical pilot studies. Study design, methodology and quality were heterogeneous. There was good evidence of feasibility from multiple studies. Where sufficient bandwidth and high quality components were used, diagnostic accuracy was slightly reduced by image transmission. There was evidence of clinical utility in remote hospitals and low-resource settings, although reliability was infrequently reported. Further exploratory research is required to determine minimum requirements for image quality, bandwidth, frame rate and to assess diagnostic accuracy. Clinical trials in remote settings are justifiable. Telecommunication options will depend on local requirements; no one system conveys universal advantages. The methodological quality of research in this field must improve: studies should be designed to minimise bias, and must include details of their methods to allow replication. Analysis of cost effectiveness and sustainability should be provided.

A global perspective on capsule endoscopy

A search of the internet today to quantify the estimated value of capsules from a global perspective, easily delivers figures stating around $200 million in 2014 to about $400 million by 2020, which would be approximately 10% of the gastrointestinal endoscopic market. Is this a steep rise within just six years or could the capsule market do even better? What chances does this offer and what are the key aspects for future success? By 2020, more than 1 billion people are aged sixty or older and around one third of them will live in what the UN calls "more developed regions". Naturally, this brings an increased demand for colorectal cancer screening and surgery. But keeping in mind that basically every healthcare system, in any country, is already operating at its limits, how do we secure future treatment for a growing community? Surely more competition will steadily bring down prices for capsules. However, that does not ease the amount of time that is spent to properly read any video and issue a valid diagnosis for every patient. This article intends to give an overview about the current global market for capsule endoscopy (CE) with a perspective on typical patients, their indications, and how the capsules are used and by whom. Further aspects, such as standardization of training, reading and future trends will also be elaborated on.

The Empirical Foundations of Teleradiology and Related Applications: A Review of the Evidence

INTRODUCTION

Radiology was founded on a technological discovery by Wilhelm Roentgen in 1895. Teleradiology also had its roots in technology dating back to 1947 with the successful transmission of radiographic images through telephone lines. Diagnostic radiology has become the eye of medicine in terms of diagnosing and treating injury and disease. This article documents the empirical foundations of teleradiology.

METHODS

A selective review of the credible literature during the past decade (2005-2015) was conducted, using robust research design and adequate sample size as criteria for inclusion.

FINDINGS

The evidence regarding feasibility of teleradiology and related information technology applications has been well documented for several decades. The majority of studies focused on intermediate outcomes, as indicated by comparability between teleradiology and conventional radiology. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include reductions in patient transfer, rehospitalization, and length of stay.

Real-Time Tele-Mentored Low Cost "Point-of-Care US" in the Hands of Paediatricians in the Emergency Department: Diagnostic Accuracy Compared to Expert Radiologists

BACKGROUND

The use of point-of-care ultrasonography (POC US) in paediatrics is increasing. This study investigated the diagnostic accuracy of POC US in children accessing the emergency department (ED) when performed by paediatricians under the remote guidance of radiologists (TELE POC).

METHODS

Children aged 0 to 18 years accessing the ED of a third level research hospital with eight possible clinical scenarios and without emergency/severity signs at the triage underwent three subsequent US tests: by a paediatrician guided remotely by a radiologist (TELE POC); by the same radiologist (UNBLIND RAD); by an independent blinded radiologist (BLIND RAD). Tele-radiology was implemented using low cost "commercial off-the-shelf" (COTS) equipment and open-source software. Data were prospectively collected on predefined templates.

RESULTS

Fifty-two children were enrolled, for a total of 170 ultrasound findings. Sensitivity, specificity, positive and negative predictive values of TELE POC were: 93.8, 99.7, 96.8, 99.4 when compared to UNBLIND RAD and 88.2, 99.7, 96.8, 98.7 when compared to BLIND RAD. The inter-observers agreement between the paediatricians and either the unblind or blind radiologist was excellent (k = 0.93). The mean duration of TELE POC was 6.3 minutes (95% CI 4.1 to 8.5). Technical difficulties occurred in two (3.8%) cases. Quality of the transmission was rated as fair, good, very good and excellent in 7.7%, 15.4%, 42.3% and 34.6% of cases respectively, while in no case was it rated as poor.

CONCLUSIONS

POC US performed by paediatricians in ED guided via tele-radiology by an expert radiologist (TELE POC) produced reliable and timely diagnoses. Findings of this study, especially for the rarer conditions under evaluation, need further confirmation. Future research should investigate the overall benefits and the cost savings of using tele-ultrasound to perform US "at children's bedsides", under remote guidance of expert radiologists.

Imaging Informatics: 25 Years of Progress

The science and applications of informatics in medical imaging have advanced dramatically in the past 25 years. This article provides a selective overview of key developments in medical imaging informatics. Advances in standards and technologies for compression and transmission of digital images have enabled Picture Archiving and Communications Systems (PACS) and teleradiology. Research in speech recognition, structured reporting, ontologies, and natural language processing has improved the ability to generate and analyze the reports of imaging procedures. Informatics has provided tools to address workflow and ergonomic issues engendered by the growing volume of medical image information. Research in computeraided detection and diagnosis of abnormalities in medical images has opened new avenues to improve patient care. The growing number of medical-imaging examinations and their large volumes of information create a natural platform for "big data" analytics, particularly when joined with high-dimensional genomic data. Radiogenomics investigates relationships between a disease's genetic and gene-expression characteristics and its imaging phenotype; this emerging field promises to help us better understand disease biology, prognosis, and treatment options. The next 25 years offer remarkable opportunities for informatics and medical imaging together to lead to further advances in both disciplines and to improve health.

ESR teleradiology survey: results

With recent developments of teleradiology technology and services, it has become necessary to better evaluate its extent and use among different countries in Europe. With this goal in mind, the ESR launched two specific surveys intended to gather the current state of adoption and implementation of teleradiology in clinical practice. A special focus on differentiating between insourcing teleradiology services among partners of the same organisation and outsourcing to external services was an essential part of the design of these surveys. The first survey was addressed to 44 national societies of different countries in Europe, while the second survey was intended for all practicing radiologist ESR members. While the results of these surveys reported here may provide a wealth of information to better understand the trends in adoption of teleradiology in Europe, they only represent a snapshot at a certain point in time. The rapid development of telecommunication tools as well as a fundamental change in practice and healthcare economics will certainly influence these observations in the upcoming years. These data, however, will provide objective and relevant parameters for supporting the efforts of experts and policy makers in promoting appropriate criteria and guidelines for adequate use of teleradiology in clinical practice.

Main Messages

• Understand concepts and challenges of teleradiology

• Provide insight into current trends and solutions for teleradiology

• Compare differences in teleradiolgy strategies between countries in Europe

• Establish a reference on statistical data of usage of teleradiology in Europe

Results of an Italian survey on teleradiology

OBJECTIVES

The aim of this study is to present the results of the Italian survey on teleradiology (TR).

METHODS

Two radiologists created an online electronic survey using the Survey Monkey web-based tool. The questionnaire was then improved by suggestions from a multidisciplinary group of experts. In its final form, the survey consisted of 19 multiple-choice questions. Space was left below each question for participants to add their personal comments. Members of Italian Society of Medical Radiology (SIRM) were given 2 weeks to perform the survey.

RESULTS

A total of 1599 radiologists, corresponding to 17 % of all SIRM radiologists, participated into the online survey. As a result, 62 % of participants have a positive opinion on teleradiology, while 80 % including 18 % with a negative opinion believe that teleradiology will have a future. 55 % of responders (n = 874) use teleradiology in their clinical practice. The majority of users adopt intra-mural teleradiology for coverage of emergencies (47 %), of night and weekend shifts (37 %) or to even out distribution workload (33 %). Most responders still show concern on the use of teleradiology. In particular, they think that teleradiology is too impersonal (40 %), and that it is responsible for insufficient communication with the referring clinician (39 %).

CONCLUSIONS

The majority of Italian radiologists are favorable to teleradiology. However, they have concerns that teleradiology may further reduce communication with the referring clinician ad patient.

Effect of color visualization and display hardware on the visual assessment of pseudocolor medical images

PURPOSE

Even though the use of color in the interpretation of medical images has increased significantly in recent years, the ad hoc manner in which color is handled and the lack of standard approaches have been associated with suboptimal and inconsistent diagnostic decisions with a negative impact on patient treatment and prognosis. The purpose of this study is to determine if the choice of color scale and display device hardware affects the visual assessment of patterns that have the characteristics of functional medical images.

METHODS

Perfusion magnetic resonance imaging (MRI) was the basis for designing and performing experiments. Synthetic images resembling brain dynamic-contrast enhanced MRI consisting of scaled mixtures of white, lumpy, and clustered backgrounds were used to assess the performance of a rainbow ("jet"), a heated black-body ("hot"), and a gray ("gray") color scale with display devices of different quality on the detection of small changes in color intensity. The authors used a two-alternative, forced-choice design where readers were presented with 600 pairs of images. Each pair consisted of two images of the same pattern flipped along the vertical axis with a small difference in intensity. Readers were asked to select the image with the highest intensity. Three differences in intensity were tested on four display devices: a medical-grade three-million-pixel display, a consumer-grade monitor, a tablet device, and a phone.

RESULTS

The estimates of percent correct show that jet outperformed hot and gray in the high and low range of the color scales for all devices with a maximum difference in performance of 18% (confidence intervals: 6%, 30%). Performance with hot was different for high and low intensity, comparable to jet for the high range, and worse than gray for lower intensity values. Similar performance was seen between devices using jet and hot, while gray performance was better for handheld devices. Time of performance was shorter with jet.

CONCLUSIONS

Our findings demonstrate that the choice of color scale and display hardware affects the visual comparative analysis of pseudocolor images. Follow-up studies in clinical settings are being considered to confirm the results with patient images.

Comparison of European (ESR) and American (ACR) white papers on teleradiology: patient primacy is paramount

The ACR and European Society of Radiology white papers on teleradiology propose best practice guidelines for teleradiology, with each body focusing on its respective local situation, market, and legal regulations. The organizations have common viewpoints, the most important being patient primacy, maintenance of quality, and the "supplementary" position of teleradiology to local services. The major differences between the white papers are related mainly to the market situation, the use of teleradiology, teleradiologist credentialing and certification, the principles of "international" teleradiology, and the need to obtain "informed consent" from patients. The authors describe these similarities and differences by highlighting the background and context of teleradiology in Europe and the United States.

Holistic approach to design and implementation of a medical teleconsultation workspace

While there are many state-of-the-art approaches to introducing telemedical services in the area of medical imaging, it is hard to point to studies which would address all relevant aspects in a complete and comprehensive manner. In this paper we describe our approach to design and implementation of a universal platform for imaging medicine which is based on our longstanding experience in this area. We claim it is holistic, because, contrary to most of the available studies it addresses all aspects related to creation and utilization of a medical teleconsultation workspace. We present an extensive analysis of requirements, including possible usage scenarios, user needs, organizational and security issues and infrastructure components. We enumerate and analyze multiple usage scenarios related to medical imaging data in treatment, research and educational applications - with typical teleconsultations treated as just one of many possible options. Certain phases common to all these scenarios have been identified, with the resulting classification distinguishing several modes of operation (local vs. remote, collaborative vs. non-interactive etc.). On this basis we propose a system architecture which addresses all of the identified requirements, applying two key concepts: Service Oriented Architecture (SOA) and Virtual Organizations (VO). The SOA paradigm allows us to decompose the functionality of the system into several distinct building blocks, ensuring flexibility and reliability. The VO paradigm defines the cooperation model for all participating healthcare institutions. Our approach is validated by an ICT platform called TeleDICOM II which implements the proposed architecture. All of its main elements are described in detail and cross-checked against the listed requirements. A case study presents the role and usage of the platform in a specific scenario. Finally, our platform is compared with similar systems described into-date studies and available on the market.

Addressing requests for emergency ultrasonographic examinations when implementing teleradiology services

PURPOSE

To prospectively assess how to address requests for ultrasonographic examinations when setting up an on-call teleradiology service.

MATERIALS AND METHODS

An analytical prospective study was performed from January 2012 to December 2012 inclusively. All requests received for after-hours ultrasonographic examinations during this period were analyzed. Ultrasound requests were classified as being postponable until working hours, replaceable by an alternate cross-sectional imaging modality, or urgent and needing to be performed after hours.

RESULTS

A total of 176 requests for ultrasonographic examinations were analyzed. They predominantly included requests for abdominal and pelvic ultrasonographic examinations (63%). Thirty-nine requests (22.2%) were considered as postponable, 49 (27.8%) as replaceable and 64 (36.4%) as both postponable and replaceable. Twenty-four requests (13.6%) were considered as urgent; they consisted of 10 requests for venous duplex Doppler ultrasonographic examinations of the lower limbs, eight requests for testicular ultrasonographic examinations, five for pelvic ultrasonographic examinations and one for soft-tissue ultrasonographic examination. In these urgent cases, realistic options were either to transfer the patient to another institution or to train emergency department physicians in ultrasonography for local handling.

CONCLUSION

Although the need for addressing requests for ultrasonographic examinations should be taken into account when setting up an on-call teleradiology service, it should not impede such plans.

Teleradiology for remote consultation using iPad improves the use of health system human resources for paediatric fractures: prospective controlled study in a tertiary care hospital in Italy

Background

The growing cost of health care and lack of specialised staff have set e-Health high on the European political agenda. In a prospective study we evaluated the effect of providing images for remote consultation through an iPad on the number of in-hospital orthopaedic consultations for children with bone fractures.

Methods

Children from 0 to 18 years diagnosed with a bone fracture by the radiologist during the hours when an orthopaedic service is provided only on-call were eligible for enrollment. Cases were enrolled prospectively during September and October 2013. A standard approach (verbal information only, no X-Ray provided remotely) was compared to an experimental approach (standard approach plus the provision of X-ray for remote consultation through an iPad). The primary outcome was the number of orthopaedic in-hospital consultations that occurred. Other outcomes included: immediate activation of other services; time needed for decision-making; technical difficulties; quality of images and diagnostic confidence (on a likert scale of 1 to 10).

Results

Forty-two children were enrolled in the study. Number of in-hospital consultancies dropped from 32/42 (76.1%) when no X-ray was provided to 16/42 (38%) when the X-rays was provided (p < 0.001). With remote X-ray consultation in 14/42 (33.3%) cases services such as surgery and plaster room could be immediately activated, compared to no service activated without teleradiology (p < 0.001). Average time for decision making was 23.4 ± 21.8 minutes with remote X-ray consultation, compared to 56.2 ± 16.1 when the X-ray was not provided (p < 0.001). The comparison between images on the iPad and on the standard system for X- Ray visualisation resulted in a non statistically significant difference in the quality of images (average score 9.89 ± 0.37 vs 9.91 ± 0.30; p =0.79), and in non statistically significant difference in diagnostic confidence (average score 9.91 ± 0.32 vs 9.92 ± 0.31; p = 0.88).

Conclusions

Remote X-ray consultation through Aycan OsiriX PRO and iPad should be considered as a means for reducing the need of in-hospital orthopaedic consultation during on-call times, and potentially decrease the cost of care for the health system. In the future, alternative systems less expensive than Aycan OsiriX PRO should be further developed and tested.