The future progress of teleradiology—An empirical study in Sweden

This paper describes a novel teleradiology solution, its services and graphical user interfaces (GUIs), and the strategic decisions taken in the development of the services. The novel services are embedded in a radiology information infrastructure in Västra Götalandsregionen (VGR), Sweden. The application is fully integrated with all different RIS and PACS systems in the region and interconnected through the radiology information infrastructure. In practice, the solution offers new ways of collaborating through information sharing within a region. Knowledge can be used collectively to improve the radiology workflow and its outcomes for clinicians and patients. The new shared approach marks the beginning of a change from local to enterprise workflow. The challenges are to develop useful and secure services for different groups related to the radiological information infrastructure. It involves continuous negotiation with people concerning how they should collaborate within the region. The need for teleradiology as a service provided “by somebody” has disappeared in VGR; today it is a shared service embedded in the innovative radiology information infrastructure. This infrastructure is just a starting point for a novel and limitless telemedicine service including limitless healthcare actors and activities. The method applied for this study was action research. The study was carried out in collaboration between practitioners and researchers.     

Academic radiology and the emergency department: does it need changing?

RATIONAL AND OBJECTIVES: The increasing importance of imaging for both diagnosis and management in patient care has resulted in a demand for radiology services 7 days a week, 24 hours a day, especially in the emergency department (ED). We hypothesized the resident preliminary reports were better than generalist radiology interpretations, although inferior to subspecialty interpretations. MATERIALS AND METHODS: Total radiology volume through our Level I pediatric and adult academic trauma ED was obtained from the radiology information system. We conducted a literature search for error and discordant rates between radiologists of varying experience. For a 2-week prospective period, all preliminary reports generated by the residents and final interpretations were collected. Significant changes in the report were tabulated. RESULTS: The ED requested 72,886 imaging studies in 2004 (16% of the total radiology department volume). In a 2-week period, 12 of 1929 (0.6%) preliminary reports by residents were discordant to the final subspecialty dictation. In the 15 peer-reviewed publications documenting error rates in radiology, the error rate between American Board of Radiology (ABR)-certified radiologists is greater than that between residents and subspecialists in the literature and in our study. However, the perceived error rate by clinicians outside radiology is significantly higher. CONCLUSION: Sixteen percent of the volume of imaging studies comes through the ED. The residents handle off-hours cases with a radiology-detected error rate below the error rate between ABR-certified radiologists. To decrease the perceived clinician-identified error rate, we need to change how academic radiology handles ED cases.     

Teleradiology/PACS usage: A survey of the American Society of Emergency Radiology Membership

The purpose of this study was to assess the use of teleradiology/picture archiving and communications (PACS) systems for emergency patients by members of the American Society of Emergency Radiology (ASER). Results were tabulated from a survey mailed to ASER members in February 1997. The listed percentages are based on the total number of answers to a particular question. ASER members representing 76 medical centers responded to the survey. Forty-five of the centers (59%) were level I trauma centers, and 17 (22%) were level II trauma centers. Forty-five centers (59%) had teleradiology/PACS systems. Another 13 (19%) planned to acquire teleradiology/PACS equipment within a year. In 32 (74%) of the centers with teleradiology/PACS systems, patients with emergency conditions accounted for more than half of the total teleradiology/PACS volume. Teleradiology/PACS systems were utilized for head computed tomographic (CT) examinations in 35 centers (85%), body CT in 34 (81%), ultrasound in 28 (67%), plain radiography in 24 (57%), and magnetic resonance imaging (MRI) in 18 (44%). Final interpretations were made primarily from original films in 23 centers (56%), monitor image in 11 (27%), or both in 7 (17%). The most common uses for the teleradiology/PACS equipment were interpretations of examinations performed at another site within the same center in 24 centers (56%), wet readings from home in 18 (42%), interpretation of examinations from other centers in 25 (59%), and off-hours coverage of practice at another site in 18 (42%). Eleven centers (33%) reported rare or occasional technical limitations to examination interpretation, most commonly relating to loss of resolution or detail on the monitor image, preventing visualization of a finding. Teleradiology/PACS systems have resulted in quicker interpretations in 33 centers (82.5%) and reduced lost film count in 12 (29%). Seventy-eight percent of ASER members’ centers are expected to have teleradiology/PACS equipment within 1 year. Emergency conditions, off-hours coverage, and remote coverage of sites within the centers were the most frequent uses.     

The value teleradiology represents for Europe: A study of lessons learned in the U.S.

Pathology and demography have combined to fuel exponential demand for advanced medical imaging. To support this demand, radiology must move beyond traditional department or modality-based picture archiving and communication systems (PACS) to solutions that ensure access regardless of location. This article delineates underlying reasons for the growth in demand for access to medical imaging in both Europe and the United States. It explains why teleradiology/PACS is critical to support this growth in Europe. It discusses the benefits of and barriers to its widespread implementation as discovered in Canada and the U.S. and how these lessons learned relate to Europe.The article establishes the technological imperatives for teleradiology/PACS and presents three real-world case studies of successful data sharing and shared workflow models via single imaging implementations.

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CML HealthCare: Geographically spanning Canada and the United States with 129 sites performing nearly 5 million plus annual exams.

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Shields MRI: 29 facilities, including 3 Radiation Oncology centers, across an area 4 times the size of Switzerland.

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MRA/Novant: 40 radiologists working in a complete subspecialty reporting environment.

Finally, it provides a high-level list of selection criteria for teleradiology/PACS and examines how industry trends affecting the U.S. are important baseline considerations to the success of teleradiology/PACS in Europe.     

Integrating digital systems: commitment and collaboration

One year ago, the radiology department at Ball Memorial Hospital, a 350-bed facility in Muncie, IN, was completely film-based. The need to support a new all-digital, 35-room emergency department (ED) hastened the facility's transition to a digital environment. Today, with the exception of mammography, the hospital's imaging services are now digital. To develop and implement the project, the hospital formed an internal implementation team. An independent consultant was also hired to evaluate the impact of these new technologies and to provide an estimated cost payback. After research, site visits, and vendor demonstrations, the hospital selected a single vendor for its picture archiving and communication system (PACS), digital radiography (DR), computed radiography (CR), and overall project management. The DR system was installed in the ED to provide digital image capture for a full range of trauma exams. The ED also initially began utilizing a Web-based PACS distribution originally implemented for after-hours teleradiology. The majority of the hospital's imaging studies are captured with 2 multi-cassette CR systems that serve 7 exam rooms in the radiology department. The hospital also installed remote operations panels to expedite entry of patient and exam information. Technologists readily embraced both CR and DR systems. The Web distribution system now transmits images to hospital-based computers and to 150 remote referring physicians. The PACS platform automatically e-mails key images and radiology reports to referring physicians. Authorized physicians can also request reports and images on an as-needed basis. The PACS vendor had previously performed multiple integrations with the radiology information system (RIS) vendor; the integration of PACS and RIS was extremely smooth. One of the critical components of a successful conversion is experienced, dedicated management. The hospital retained professional project management services to facilitate implementation and to ensure adequate training for all users.     

Managing a Multisite Academic–Private Radiology Practice Reading Environment: Impact of IT Downtimes on Enterprise Efficiency

PurposeThe aim of this study was to assess whether the complex radiology IT infrastructures needed for large, geographically diversified, radiology practices are inherently stable with respect to system downtimes, and to characterize the nature of the downtimes to better understand their impact on radiology department workflow.MethodsAll radiology IT unplanned downtimes over a 12-month period in a hybrid academic–private practice that performs all interpretations in-house (no commercial “nighthawk” services) for approximately 900,000 studies per year, originating at 6 hospitals, 10 outpatient imaging centers, and multiple low-volume off-hours sites, were logged and characterized using 5 downtime metrics: duration, etiology, failure type, extent, and severity.ResultsIn 12 consecutive months, 117 unplanned downtimes occurred with the following characteristics: duration: median time = 3.5 hours with 34% <1.5 hours and 30% >12 hours; etiology: 87% were due to software malfunctions, and 13% to hardware malfunctions; failure type: 88% were transient component failures, 12% were complete component failures; extent: all sites experienced downtimes, but downtimes were always localized to a subset of sites, and no system-wide downtimes occurred; severity (impact on radiologist workflow): 47% had minimal impact, 50% moderate impact, and 3% severe impact.ConclusionsIn the complex radiology IT system that was studied, downtimes were common; they were usually a result of transient software malfunctions; the geographic extent was always localized rather than system wide; and most often, the impacts on radiologist workflow were modest.     

PACS/RIS系统在放射科工作流程优化中的作用

目的:探讨应用医学影像存档与通信系统(picture archiving and communication system,PACS)在医院放射科工作流程优化中的作用。方法:将放射科数字成像设备纳入PACS系统,将传统放射科工作流程与应用PACS后工作流程比较。结果:应用PACS工作流程后减少工作步骤,缩短报告发出时间,降低错误率。结论:应用PACS后明显提高了放射科的工作效率,方便了医疗、教学、科研和会诊,提高了医院的社会效益和经济效益。     

Technology-Assisted Virtual Consultation for Medical Imaging

PurposeThe aim of this study was to report the investigators’ preliminary experience in the implementation of a “virtual consult” (VC) system enabling consultations between radiologists and referring physicians in physically remote locations throughout their enterprise.MethodsReferrers and radiologists directly access the VC through the electronic medical record and PACS, respectively. Referrers may click a VC link associated with any examination report to instant message the appropriate subspecialist radiologist, who receives an alert allowing automatic loading of the examination. The radiologist and referrer may then discuss the examination via instant messaging as well as launch a real-time screen-share of the radiologist’s PACS display, with the option for either participant to control the display. Radiologists’ and referrers’ feedback was evaluated after the institution’s first 110 VC sessions.ResultsReferrers’ most common specialties were emergency medicine (27.3%) and internal medicine (13.6%); radiologists’ most common subspecialties were abdominal (33.6%) and thoracic (16.4%) imaging. Screen-shares lasted on average 12 ± 16 minutes. From 80% to 90% of referrers agreed that the VC was easy to use, improved their understanding of the radiology report, affected patient management, and enhanced radiologists’ role. Referrers found the VC to be particularly useful when traditional consultation was difficult because of location or time constraints or when seeking a quick response to a targeted question. Radiologists recognized referrers’ positive response to the VC, although they tended to view the VC as disruptive to normal workflow.ConclusionsThe VC addresses a key challenge in the current era of digital radiology practice and provides added value to referrers, though continued radiologists’ workflow optimization is warranted.     

Gradual PACS adoption

For more than a decade, radiology professionals have hoped that picture archiving and communications systems (PACS) would improve efficiency and reduce costs. However, pioneer PACS systems were extremely expensive, and they didn't always meet their users' needs. Recent changes mean that PACS are more accessible. Advances in technology have resulted in decreased costs and increased computer power, and many radiologists recognize that they must consider new tools, such as teleradiology, to compete. There are roughly five classes of digital image systems used by radiologists: modality clusters, on-call review and teleradiology, remote primary diagnosis, mini-PACS and PACS. Even though hospitals seem to view PACS as inevitable, the challenge is to manage PACS implementation economically. One answer is to install PACS incrementally. Once teleradiology and mini-PACS are in place, they can be used as the building blocks of full-fledged PACS. Because PACS have a broad impact on healthcare facilities, careful planning is needed. Design your system to support future, as well as current, applications. Another important planning step is to set goals for improved efficiency and cost reduction.     

The Value-Added Services of Hospital-Based Radiology Groups

The authors discuss the ways in which a single, cohesive, on-site radiology group adds value to both the processes of patient care and the success of the hospital. The value-added services fall into 6 categories: (1) patient safety, (2) quality of the images, (3) quality of the interpretations, (4) service to patients and referring physicians, (5) cost containment, and (6) helping build the hospital's business. If the hospital allows its radiology department to become fragmented by the intrusion of other specialists or teleradiology companies in remote locations, most of these added values would be lost, and chaos could ensue.     

The case for RIS/PACS integration

Why integrate PACS with the RIS? To improve workflow, of course, but what workflow? Much of the focus is on improving the flow of images for the radiologist, which is certainly a good thing to do, but what about the rest of the order process? Typical PACS system architecture begins with the HIS since this is where the correct patient demographic information and in many cases the orders originate. Correct patient and order information is sent from the HIS to the RIS using HL7 commands for Admission/Discharge/Transfer (ADT) and Order/Entry. HL7 is the communications protocol used in virtually all information systems. For the first step in communicating with PACS, patient and order information from the RIS is sent to a device called a PACS broker. This is necessary because most PACS systems do not support HL7 directly, and a translation is required. Images from each imaging modality are also sent to the broker using the DICOM standard. If an imaging modality does not support DICOM, then an additional box is used to convert the images to a DICOM file. The broker then sends completed DICOM files to the PACS for storage, distribution and viewing. That approach has worked well for the first stage of PACS utilization. However, experienced PACS users have identified the need to improve workflow, and many feel that closer communication with the RIS will solve many of the current limitations. This approach is sometimes called a "brokerless" solution but is probably better described as incorporating broker functions into the RIS. There are several potential advantages of incorporating the broker functions into the RIS: Access to all RIS information on patients, orders and results is available and can be used in many ways to improve workflow. Supporting all DICOM services directly from the RIS ensures that the latest and most complete information is always used. For example, DICOM Modality Worklists can be provided directly from the RIS, which guarantees that they are updated immediately. The RIS can manage the complete order workflow, not just images. License, implementation and support costs can be reduced by eliminating HL7 interfaces to an external broker. Managing workflow is the key to improved productivity and patient care from PACS. However, coordinated management of order workflow from the RIS and image workflow from the PACS is required to get the full benefit. The RIS has immediate and broad access to patient and order information. As a result, it is the natural place to take the lead in managing this coordinated workflow. While many older RIS and PACS systems are not yet capable of some of the integration features described above, several new systems are moving rapidly in that direction.     

Offshore teleradiology

Radiologists are responsible for providing prompt emergency radiology interpretations 24 hours a day, every day of the year. As a result of the increasing use of multidetector computed tomography, emergency radiology has increased significantly in volume over the past 5 years. Simultaneously, radiologists are working harder during the day because of the workforce shortage. Although teleradiology services located in the continental United States have been providing efficient coverage until recently, they are now having increasing difficulty recruiting radiologists who are willing to work at night. Addressing this problem is “offshore teleradiology.” With the increasing use of several enabling technologies—Digital Imaging and Communication in Medicine, the picture archiving and communication system, and the Internet—it is now possible to cover a domestic radiology practice at night from any location in the world where it is daytime. Setting up such a practice is nontrivial, however. The radiologists must all be American trained and certified by the American Board of Radiology. They must have medical licenses in every state and privileges at every hospital they cover. This article describes some of the details involved in setting up an offshore teleradiology practice. It also attempts to make a financial case for using such a practice, particularly in the current economic environment.     

IHE profiles applied to regional PACS

PACS has been widely adopted as an image storage solution that perfectly fits the radiology department workflow and that can be easily extended to other hospital departments. Integrations with other hospital systems, like the Radiology Information System, the Hospital Information System and the Electronic Patient Record are fully achieved but still challenging aims. PACS also creates the perfect environment for teleradiology and teleworking setups. One step further is the regional PACS concept where different hospitals or health care enterprises share the images in an integrated Electronic Patient Record. Among the different solutions available to share images between different hospitals IHE (Integrating the Healthcare Enterprise) organization presents the Cross Enterprise Document Sharing profile (XDS) which allows sharing images from different hospitals even if they have different PACS vendors. Adopting XDS has multiple advantages, images do not need to be duplicated in a central archive to be shared among the different healthcare enterprises, they only need to be indexed and published in a central document registry. In the XDS profile IHE defines the mechanisms to publish and index the images in the central document registry. It also defines the mechanisms that each hospital will use to retrieve those images regardless on the Hospital PACS they are stored.     

Emergency radiology in Canada: a national survey.

OBJECTIVE: To document the existing radiology services available to emergency physicians in hospitals across Canada and to preview future trends and needs. METHODS: Questionnaires (n = 130) regarding the type, availability and satisfaction with radiology services were distributed to radiologists and emergency physicians at 65 hospitals across Canada. RESULTS: Fifty-three (41%) questionnaires were returned, and 45 (35%) completed questionnaires from 35 hospitals were used for analysis (24 from radiologists and 21 from emergency physicians). Plain radiographs were available in all hospitals at all times. Ultrasonography, intravenous pyleograms and computed tomography (CT) were available in all departments during normal working hours; after hours, CT was unavailable in 1 hospital and ultrasonography was unavailable in 2. Focused assessment with sonography for trauma (FAST) was routinely performed for blunt abdominal trauma in 6 centres, and 10 centres had teleradiology services. Regarding the quality of emergency service, 7 of 45 responded "poor," 4 "average," 14 "good," and 17 of 45 rated service "excellent." Interestingly, most radiologists answered "good" or "excellent," and most of the "poor" responses came from emergency physicians. Regarding staff coverage after 5 pm, 34 hospitals provided CT services, 20 had ultrasonography staff available, and there was radiology nursing coverage in 14 hospitals. Clinical details on requisitions were generally rated "adequate" or "poor." Although most radiograph reports were available within 48 hours, some took longer. Hot-seat reporting was available in 11 centres. During normal working hours, radiologists were the first to read films in 5 of 35 hospitals. After hours, emergency physicians were the first to read films in all hospitals, but only 14 hospitals indicated they were "formally" trained to do so. CONCLUSION: This survey documents the strengths and weaknesses of the radiology services available to emergency physicians. The perceptions of emergency physicians and radiologists of the adequacy those services differ significantly.     

Internet-based radiology order-entry, reporting, and workflow management system for coordinating urgent study requests during off-hours

OBJECTIVE: Our aim was to develop a simple, low-cost, Internet-based application for radiology order-entry, reporting, and workflow management during off-hours. CONCLUSION: The system was quickly accepted by users both within and outside the radiology department, and it required very modest resources to develop, deploy, and support. In a busy on-call setting at a high-volume academic institution, the system described was effective in obtaining more thorough patient histories from referring physicians, reducing the number of telephone calls required, and documenting more rigorously the communication between radiologists and clinical services. These benefits allow the generation of more informative and timely radiology reports.     

Optimizing Imaging Clinical Decision Support: Perspectives of Pediatric Emergency Department Physicians

PurposeThe aim of this study was to solicit perspectives of pediatric emergency department physicians (PEDPs) to determine how software-based clinical decision support mechanisms (CDSMs) may integrate with existing imaging clinical decision support (ICDS) to optimize imaging utilization at the authors’ institution.MethodsThrough qualitative interviews, the authors explored how PEDPs define ICDS, how they seek and obtain radiologist consultation, and how the rollout of CDSMs at the institution may potentially affect clinical practice. Codes were developed and explicitly defined through literature review and analysis of a subset of interviews. Coding results informed thematic categories used to develop an explanatory model.ResultsAnalysis revealed three major thematic categories: (1) common influences on the decision process, (2) radiology consultation experience, and (3) PEDPs’ perspectives on CDSMs. PEDPs described radiologist consultation as a valuable component of ICDS but reported difficulty in coordinating imaging strategies with radiologists and other subspecialists. PEDPs described the exchange of ideas as especially worthwhile for scenarios that do not fit neatly into clinical pathways. Barriers to radiologist consultation include time, access to radiologists, and not wanting to disrupt radiologists’ workflow. PEDPs expressed optimism that CDSMs may improve their workflow and facilitate effective interaction with radiologists.ConclusionsPEDPs suggested that radiologist consultation will continue to be a valuable component of ICDS after the implementation of CDSMs by providing discussion-driven guidance to complement CDSM recommendations. The results also indicate that radiologists may consider strategies to facilitate effective interaction with PEDPs and reconcile conflicts of CDSMs with clinical practice.     

Interpretation of Emergency Department radiographs: a comparison of emergency medicine physicians with radiologists, residents with faculty, and film with digital display

OBJECTIVE: We determined the relative value of teleradiology and radiology resident coverage of the emergency department by measuring and comparing the effects of physician specialty, training level, and image display method on accuracy of radiograph interpretation. MATERIALS AND METHODS: A sample of four faculty emergency medicine physicians, four emergency medicine residents, four faculty radiologists, and four radiology residents participated in our study. Each physician interpreted 120 radiographs, approximately half containing a clinically important index finding. Radiographs were interpreted using the original films and high-resolution digital monitors. Accuracy of radiograph interpretation was measured as the area under the physicians' receiver operating characteristic (ROC) curves. RESULTS: The area under the ROC curve was 0.15 (95% confidence interval [CI], 0.10-0.20) greater for radiologists than for emergency medicine physicians, 0.07 (95% CI, 0.02-0.12) greater for faculty than for residents, and 0.07 (95% CI, 0.02-0.12) greater for films than for video monitors. Using these results, we estimated that teleradiology coverage by faculty radiologists would add 0.09 (95% CI, 0.03-0.15) to the area under the ROC curve for radiograph interpretation by emergency medicine faculty alone, and radiology resident coverage would add 0.08 (95% CI, 0.02-0.14) to this area. CONCLUSION: We observed significant differences between the interpretation of radiographs on film and on digital monitors. However, we observed differences of equal or greater magnitude associated with the training level and physician specialty of each observer. In evaluating teleradiology services, observer characteristics must be considered in addition to the quality of image display.