Privacy and security in teleradiology

Teleradiology is probably the most successful eHealth service available today. Its business model is based on the remote transmission of radiological images (e.g. X-ray and CT-images) over electronic networks, and on the interpretation of the transmitted images for diagnostic purpose. Two basic service models are commonly used teleradiology today. The most common approach is based on the message paradigm (off-line model), but more developed teleradiology systems are based on the interactive use of PACS/RIS systems. Modern teleradiology is also more and more cross-organisational or even cross-border service between service providers having different jurisdictions and security policies. This paper defines the requirements needed to make different teleradiology models trusted. Those requirements include a common security policy that covers all partners and entities, common security and privacy protection principles and requirements, controlled contracts between partners, and the use of security controls and tools that supporting the common security policy. The security and privacy protection of any teleradiology system must be planned in advance, and the necessary security and privacy enhancing tools should be selected (e.g. strong authentication, data encryption, non-repudiation services and audit-logs) based on the risk analysis and requirements set by the legislation. In any case the teleradiology system should fulfil ethical and regulatory requirements. Certification of the whole teleradiology service system including security and privacy is also proposed. In the future, teleradiology services will be an integrated part of pervasive eHealth. Security requirements for this environment including dynamic and context aware security services are also discussed in this paper.     

Legal issues in teleradiology-distant thoughts!

Advancements in computer technology and telecommunications have meant that all diagnostic images can now be acquired as digital signals, however the ethicolegal concepts surrounding this innovation remain unclear. In the UK there are limited practice guidelines on legal issues relating specifically to telemedicine or teleradiology. It is not yet clear whether the current law relates to telemedicine in the same way that it does for other medical specialties, or whether telemedicine raises new legal issues that need clarification. This article attempts to outline some of the potential legal issues, but the absence of case law and legislation in this area will ensure that many questions remain unanswered. The legal implications of teleradiology/telemedicine are addressed, and literature, laws and professional guidelines from the UK, USA, Australia and New Zealand are reviewed, focusing on the American licensure laws, professional relationships with patients with regards to liability, responsibility, accountability and duty of care issues, as well as issues of missed diagnosis, misdiagnosis, security and confidentiality. Teleradiology, while being actively practised worldwide, gives rise to many unanswered medicolegal questions. It is suggested that guidelines need to be implemented to safeguard patients and professionals alike.     

Economic impact of real-time teleradiology in thoracic CT examinations

Conventional teleradiology is a useful tool, but sometimes we have found it to be an insufficient means of investigation because the radiological specialists cannot indicate the imaging protocol during the investigation. The purpose of our study was to evaluate the efficacy of real-time teleradiology, which will improve the quality of medical management. Ten radiologists evaluated thoracic CT scans of 50 patients transmitted through teleradiology retrospectively. We evaluated whether or not the contrast enhancement study was performed effectively on the basis of the clinical data and after interpretation of the pre-contrast scans. The clinical data showed that 47.6% of the CT contrast enhancement examinations were not necessary. After interpretation of the pre-contrast CT scans, 66.6% of the contrast-enhanced scans were considered unnecessary. Real-time teleradiology will improve the quality of medical management providing the virtual presence of radiologists, and will save medical costs.     

Teleradiology: part of a comprehensive telehealth system

Present technologic limitations do not allow completely accurate reproduction of a chest film, the gold standard of teleradiology. Although interpretation accuracy of broad-band teleradiographs is reasonably good and encouraging, the low level of confidence engendered by teleradiology interpretations in narrow-band transmission is self-evident in view of the tendency to provide an immediate provisional report followed later by a signed report after direct viewing of the film. Despite this, the important observation, putting things into perspective, was made by Andrus and Bird, namely that "the question is not whether teleradiology is preferable to direct visualization when either is available, but whether teleradiology offers an acceptable universally applicable method to augment the usefulness of the radiologist." Although fiberoptic guides may well lace the country in a few years, providing ample capacity and superb transmitted images, there are several options presently worth investigating now. These could provide teleradiology services to remote and rural communities, depending on the level of need and skills at the remote site, the availability and cost of transmission, and the need for access to 24-hour consultation services. The future role of teleradiology on a much larger scale within a regional network of health care facilities has yet to be defined, based on the perceived need for reasonable access to expensive but precise imaging methods. On the face of it, it would seem unlikely that small community hospitals will be able to afford the cost and maintenance of CT and MR scanners, digital angiography, and other useful and accepted imaging services.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Current State of Teleradiology Across the United States: A National Survey of Radiologists’ Habits,Attitudes, and Perceptions on Teleradiology Practice

PurposeTo explore the current state of teleradiology practice, defined as the interpretation of imaging examinations at a different facility from where the examination was performed.MethodsA national survey addressing radiologists’ habits, attitudes, and perceptions regarding teleradiology was distributed by e-mail to a random sample of ACR members in early 2019.ResultsAmong 731 of 936 respondents who indicated a non-teleradiologist primary work setting, 85.6% reported performing teleradiology within the past 10 years and 25.4% reported that teleradiology represents a majority of their annual imaging volumes; 84.4% performed teleradiology for internal examinations and 45.7% for external examinations; 46.2% performed teleradiology for rural areas and 37.2% for critical access hospitals; 91.3% performed teleradiology during weekday normal business hours and 44.5% to 79.6% over evening, overnight, and weekend hours. In all, 76.9% to 86.2% perceived value from teleradiology for geographic, after-hours, and multispecialty coverage, as well as reduced interpretation turnaround times. The most common challenges for teleradiology were electronic health record access (62.8%), quality assurance (53.8%), and technologist proximity (48.4%). The strategy most commonly considered useful for improving teleradiology was technical interpretation standards (33.3%). Radiologists in smaller practices were less likely to perform teleradiology or performed teleradiology for lower fractions of work, were less likely to experience coverage advantages of teleradiology, and reported larger implementation challenges, particularly relating to electronic health records and prior examination access.ConclusionDespite historic concerns, teleradiology is widespread throughout modern radiology practice, helping practices achieve geographic, after-hours, and multispecialty coverage; reducing turnaround times; and expanding underserved access. Nonetheless, quality assurance of offsite examinations remains necessary. IT integration solutions could help smaller practices achieve teleradiology’s benefits.     

Standardization of teleradiology using Dicom e-mail: recommendations of the German Radiology Society

Until recently there has been no standard for an interoperable and manufacturer-independent protocol for secure teleradiology connections. This was one of the main reasons for the limited use of teleradiology in Germany. Various teleradiology solutions have been developed in the past, but the vast majority have not been interoperable. Therefore an ad hoc teleradiology connection was impossible even between partners who were already equipped with teleradiology workstations. Based on the evaluation of vendor-independent protocols in recent years the IT Working Group (AGIT) of the German Radiology Society set up an initiative to standardize basic teleradiology. An e-mail based solution using the Dicom standard for e-mail attachments with additional encryption according to the OpenPGP standard was found to be the common denominator. This protocol is easy to implement and safe for personalized patient data and fulfills the legal requirements for teleradiology in Germany and other countries. The first version of the recommendation was presented at the 85th German Radiology Convention in 2004. Eight commercial and three open-source implementations of the protocol are currently available; the protocol is in daily use in over 50 hospitals and institutions.     

The diagnostic performance of a PC-based teleradiology link.

AIM: Evaluation of the diagnostic performance of a personal computer based teleradiology link. MATERIALS AND METHODS: Two experienced radiologists assessed 100 cases, all based on chest and skeletal films using teleradiology for 50. These assessments were compared with the consensus of a panel of three independent radiologists. RESULTS: Diagnostic performance of teleradiology and conventional film was similar (sensitivity 88 vs. 90%; specificity 96 vs. 90%; accuracy 91 vs. 90%; not significant). However, the quality of teleradiology images was rated poorer, and the confidence in diagnosis was lower with teleradiology. ROC curve analysis, taking into account diagnostic confidence, showed significantly poorer performance for teleradiology at all thresholds when chest X-rays only were considered. There was no significant difference for skeletal images, although the two smooth curves crossed, suggesting teleradiology might be better when the specificity is high. CONCLUSION: These findings suggest that when this type of teleradiology system is used, the value of rapid reporting must be balanced against poorer image quality, particularly for chest X-rays.     

Rechtliche Rahmenbedingungen der Teleradiologie

The following article describes the legal aspects of teleradiology in Germany. At first we analyze the general significance of teleradiology in the sense of"achieving medical service over spatial distances". Next we take a closer look at teleradiology according to the German Radiation Control Law ("Deutsche R?ntgenverordnung") in the sense of primary diagnostic findings. It is obvious that, apart from the Radiation Control Law, several other laws have to be obeyed when using teleradiology. Currently all of these legal requirements concerning teleradiological service can be fulfilled by applying modern IT.     

Goals, requirements and prerequisites for teleradiology

Summary Specific radiological requirements have to be considered for the realization of telemedicine. In this article the goals and requirements for an extensive introduction of teleradiology will be defined from the radiological user's point of view. Necessary medical, legal and professional prerequisites for teleradiology are presented. Essential requirements, such as data security, maintenance of personal rights and standardization, must be realized. Application-specific requirements, e. g. quality and extent of teleradiological functions, as well as technological alternatives, are discussed. Each project must be carefully planned in relation to one's own needs, extent of functions and system selection. Topics, such as acknowledgement of electronic documentation, reimbursement of teleradiology and liability, must be clarified. Legal advice and the observance of quality guidelines are recommended. Eingegangen am 12. Januar 1997 Angenommen am 12. Februar 1997     

Diagnostic performance of teleradiology in cervical spine fracture detection.

This study was done to assess the diagnostic accuracy of high-resolution (5 lp/mm) teleradiology for detecting cervical spine fractures. Single radiographs from 25 patients with and 25 patients without cervical spine fractures were transmitted between two units of our teleradiology system (Dupont DTR 2000) located 5 miles apart. Each image was examined by four readers. Fracture detection accuracy was assessed by generating receiver operating characteristic (ROC) curves and comparing the areas under each reader's curves for original and transmitted images. Two readers had statistically significant better fracture detection using nontransmitted images, whereas two had no significant differences in accuracy. The authors conclude that high resolution in and of itself is not adequate for fracture detection, and that issues concerning image contrast manipulation also will have to be addressed before teleradiology systems can be used for clinical cervical spine fracture screening.     

Die Zukunft der Teleradiologie: Ergebnisse des Expertentreffens Teleradiologie des Gesundheitsnetzkongresses 2001

Legal prerequisites have substantial influence on the development of teleradiology. At an expert meeting (Mannheim, 8.6.2001) a proposal for a teleradiology article in the new German x-ray ordinance has been set up. An exception of the demand for a doctor trained in radiation protection at the point of examination shall be established for emergency cases. To realize the intended improvement of patient care measurements for quality assurance concerning the medical personnel and processes are necessary. Along with other current developments the basis of secure regional teleradiology networks is now built up.     

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.     

Basics of German teleradiology

The methods and techniques of teleradiology are used in numerous clinical specialties. Several teleradiology projects have been state-aided in Germany over the last 10 years. Using the teleradiology standard proposed by the German Radiology Society, some of these systems are also interoperable. Several techniques are available for realizing teleradiology connections, including Web servers, virtual private networks (VPNs), and e-mail-based solutions. For the establishment of a new teleradiology connection, the needed applications must be analysed in order to find an adequate and cost-effective solution. Legal, financial, and data security aspects must also be taken into account. Legal regulations for the use of teleradiology-guided examinations in Germany demand a high technical and organisational standard for the set-up and the quality control of teleradiology installations.     

Teleradiology in the emergency department: opportunity and danger

Teleradiology is an established fact in developed countries. It has been the subject of intense professional and even legal debate in recent years because the quality of care and the role of the radiologist as a medical specialist are at stake. The opportunities and the dangers involved in teleradiology are discussed in this article. The use of teleradiology in certain circumstances in the emergency department can result in significant benefits when done right; however, it is evident that poorly implemented teleradiology services can lead to significant decreases in the quality of care (for example when the aim is to provide a low cost reporting service through outsourcing). Radiologists must use their knowledge and collaboration to ensure that they have the main role in the design, management, and performance of teleradiology services. The stance of our scientific societies together with the legal and regulatory frameworks must be the pillars that support teleradiology as a medical act.     

Telerradiología en la urgencia,oportunidad y amenaza

Teleradiology is an established fact in developed countries. It has been the subject of intense professional and even legal debate in recent years because the quality of care and the role of the radiologist as a medical specialist are at stake. The opportunities and the dangers involved in teleradiology are discussed in this article. The use of teleradiology in certain circumstances in the emergency department can result in significant benefits when done right; however, it is evident that poorly implemented teleradiology services can lead to significant decreases in the quality of care (for example when the aim is to provide a low cost reporting service through outsourcing).Radiologists must use their knowledge and collaboration to ensure that they have the main role in the design, management, and performance of teleradiology services. The stance of our scientific societies together with the legal and regulatory frameworks must be the pillars that support teleradiology as a medical act.     

Teleradiology applications with DICOM-e-mail

For the connection of several partners to a Dicom-e-mail based teleradiology network concepts were developed to allow the integration of different teleradiology applications. The organisational and technical needs for such an integration were analysed. More than 60 institutions including 23 hospitals in the Rhein-Neckar-Region, Germany were connected. The needed functionality was grouped in six teleradiology applications (emergency consultation, tele-guided examinations, expert consultations, cooperative work, scientific cooperations and homework with on call services) and their technical and organisational needs according to availability, speed of transfer, workflow definitions and data security needs was analysed. For the local integration of teleradiology services the setup and workflow is presented for a standalone teleradiology workstation and a server based teleradiology gateway. The line type needed for different groups of applications and users is defined. The security concept and fallback strategies are laid out, potential security problems and sources of errors are discussed. The specialties for the emergency teleradiology application are presented. The DICOM-e-mail protocol is a flexible and powerful protocol that can be used for a variety of teleradiology applications. It can meet the conditions for emergency applications but is limited if synchronous applications like teleconferences are needed.     

Toward the appropriate use of teleradiology

Teleradiology involves much more than merely transmitting images and information between two points: teleradiology consists of sharing knowledge and working together in a network. It facilitates rapid access to radiological reports and second opinions, remote consulting among physicians, improved patient care, access to complex tools for postprocessing and computer-aided diagnosis, support for research and training projects, ties between isolated healthcare providers and busier or more experienced providers, 24-hour coverage, and competition among radiology departments. A close relation with the radiologist leads to better care. However, teleradiology should not have negative effects on the efficacy of the clinical radiology service that is closest to the patient. This article focuses on the legal requirements of teleradiology services and on the clinical problems that can arise in teleradiology settings, with the ultimate aim of ensuring the appropriate use of teleradiology to improve healthcare.     

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.     

Quality improvement through teleradiology: opportunities and challenges

Teleradiology is rapidly establishing its presence as an effective solution to the problem of provision of radiological services in remote locations. Although significant effort has been put into the development and establishment of quality assurance (QA) processes required for the implementation and conduct of this new technology, little attention has been given to the possible use of teleradiology in enhancing quality and safety of radiological practice, and as an alternative to conventional quality improvement (QI) initiatives. This paper critically evaluates teleradiology from the point of view of its potential use in QA/QI and considers its possible advantages as well as limitations. Considering the unique features of teleradiology such as remote access that can be simultaneous at multiple sites, rapid transfer of information and computerized data storage as well as good reproducibility and reliability of data, the authors argue that teleradiology represents an ideal tool which can not only be equivalent to other methods of QA in radiology but in some instances may be superior to them.     

Swiss teleradiology survey: present situation and future trends

The purpose of this study was to obtain a survey about the present situation including the usage pattern, technical characteristics and the anticipated future of teleradiology in Switzerland. An internet-based questionnaire was made available to all members of the Swiss Society of Radiology. Questions concerning current teleradiology usage, the type of transmitted modalities, the technology employed, security, billing issues and the anticipated future of teleradiology were addressed. One hundred and two (22.67%) of 450 radiologists responded to the survey. Of the total, 41.2% (42) were teleradiology users, 35.3% (36) planned to use teleradiology in the near future and 24.5% (25) did not use or plan to use teleradiology. The mean number of examinations transmitted per month was 198 (range 1–2,000) and the mean distance was 33 km (range 1,250 km). An emergency service was considered the most important purpose (mean score 6.90; minimum 1, maximum 10) for the use of teleradiology, followed by image distribution (mean 6.74) and expert consultation (mean 6.61). The most commonly transmitted modality was computed tomography (mean 8.80), followed by conventional X-rays (8.40) and magnetic resonance imaging (8.32). The most commonly transmitted format was Digital Imaging and Communications in Medicine (DICOM) (66.7%), followed by bitmap/Joint Photographic Experts Group (jpg) (38.1%), using the DICOM send/receive protocol (52.4%), followed by the hypertext transfer protocol (26.2%) and e-mail (21.4%). For security a secure connection (54.8%) followed by encryption (14.3%) and anonymization (9.5%) was used. For the future, image distribution was rated the most important aspect of teleradiology (7.88), followed by emergency (7.22) and expert consultation (6.53). Development of legal regulations is considered most important (8.17), followed by data security guidelines (8.15). Most radiologists believe that insurance companies should pay for the costs of teleradiology (37.3%), followed by the radiologist (33.3%). In conclusion, in Switzerland a wide spectrum of teleradiology applications and technologies is in use. Guidelines and reimbursement issues remain to be solved.