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.     

From shared data to sharing workflow: Merging PACS and teleradiology

Due to a host of technological, interface, operational and workflow limitations, teleradiology and PACS/RIS were historically developed as separate systems serving different purposes. PACS/RIS handled local radiology storage and workflow management while teleradiology addressed remote access to images. Today advanced PACS/RIS support complete site radiology workflow for attending physicians, whether on-site or remote. In parallel, teleradiology has emerged into a service of providing remote, off-hours, coverage for emergency radiology and to a lesser extent subspecialty reading to subscribing sites and radiology groups.When attending radiologists use teleradiology for remote access to a site, they may share all relevant patient data and participate in the site's workflow like their on-site peers. The operation gets cumbersome and time consuming when these radiologists serve multi-sites, each requiring a different remote access, or when the sites do not employ the same PACS/RIS/Reporting Systems and do not share the same ownership. The least efficient operation is of teleradiology companies engaged in reading for multiple facilities. As these services typically employ non-local radiologists, they are allowed to share some of the available patient data necessary to provide an emergency report but, by enlarge, they do not share the workflow of the sites they serve.Radiology stakeholders usually prefer to have their own radiologists perform all radiology tasks including interpretation of off-hour examinations. It is possible with current technology to create a system that combines the benefits of local radiology services to multiple sites with the advantages offered by adding subspecialty and off-hours emergency services through teleradiology. Such a system increases efficiency for the radiology groups by enabling all users, regardless of location, to work “local” and fully participate in the workflow of every site. We refer to such a system as SuperPACS.     

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.     

Qualitätssicherung mit Teleradiologie

Teleradiology offers many applications for quality assurance in medicine. The spectrum reaches from electronic consultations in emergency or special cases and double reading--along with new models of cooperative work and medical networks--to technical quality assurance and integration into interinstitutional and patient controlled health records. Regional teleradiology networks based on server concepts can fulfill the developing technical and organisational requirements. The increasing mobility arising from smaller radiological equipment and improved accessibility to experts with minimized visualisation and reporting systems will change the radiological world of tomorrow, especially in combination with the usage of knowledge based systems in reference data bases and computer assisted diagnosis (CAD). Teleradiology by itself must be liable to quality assurance measurements to prevent unnecessary radiation exposure or danger to the doctor patient relation.     

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.     

Teleradiologie – Update 2014

Due to economic considerations and thanks to technological advances there is a growing interest in the integration of teleradiological applications into the regular radiological workflow. The legal and technical hurdles which are still to be overcome are being discussed in politics as well as by national and international radiological societies. The European Commission as well as the German Federal Ministry of Health placed a focus on telemedicine with their recent eHealth initiatives. The European Society of Radiology (ESR) recently published a white paper on teleradiology. In Germany §3 section 4 of the Röntgenverordnung (RöV, X-ray regulations) and DIN 6868-159 set a framework in which teleradiology can also be used for primary reads. These possibilities are already being used by various networks and some commercial providers across Germany. With regards to cross-border teleradiology, which currently stands in contrast to the RöV, many issues remain unsolved.     

Cross-border teleradiology—Experience from two international teleradiology projects

Teleradiology aims to even radiologists’ workload, ensure on-call services, reduce waiting lists, consult other specialists and cut costs. Cross-border teleradiology widens this scope beyond the country borders. However, the new service should not reduce the quality of radiology. Quality and trust are key factors in establishment of teleradiology. Additionally there are organizational, technical, legal, security and linguistic issues influencing the service. Herein, we have used experiences from two partially European Union funded telemedicine projects to evaluate factors affecting cross-border teleradiology.Clinical partners from Czech Republic, Denmark, Estonia, Finland, Lithuania and the Netherlands went through 649 radiology test cases in two different teleradiology projects to build trust and agree about the report structure. Technical set-up was established using secure Internet data transfer, streaming technology, integration of workflows and creating structured reporting tool to overcome language barriers.The biggest barrier to overcome in cross-border teleradiology was the language issue. Establishment of the service was technically and semantically successful but limited to knee and hip X-ray examinations only because the structured reporting tool did not cover any other anatomical regions yet.Special attention has to be paid to clinical quality and trust between partners in cross-border teleradiology. Our experience shows that it is achievable. Legal, security and financial aspects are not covered in this paper because today they differ country by country. There is however an European Union level harmonization process started to enable cross-border eHealth in general.     

Teleradiologie in der Zahnmedizin

Teleradiology is a means of electronically transmitting radiographic patient images and consultative text. This offers a new way to communicate with other radiologists and transferring clinicians. Different applications of teleradiology, such as on-call services for emergency departments or rural regions, as well as expert consultation (second opinion) already have been realized. Especially in concern of dental radiography, analog (film-based) imaging gets progressively replaced by digital imaging. The combination with ultrafast data transfer offers an increasing efficacy in diagnosis and therapy, acceleration of communication and new means of quality assessment in patient care. Various applications of teleradiology concerning dental medicine are discussed.     

Cost-benefit study of different application scenarios in teleradiology

Summary With the increasing number of users and technical improvements, there are several application scenarios of teleradiology. To perform a cost-benefit analysis, an approach is presented, which focuses on both monetary and qualitative aspects. Process-related, qualitative and quantitative evaluations are described. The prestudy compares the radiological workflow before and after the introduction of a teleradiology system. A scoring model is part of the qualitative evaluation. The quantitative study focuses on costs and savings. Amortisation and a net present value of savings versus costs can be derived using dynamic investment methods. Savings can be achieved after a short time under ideal conditions, but there is no guarantee for a reimbursement for all systems. Eingegangen am 20. Dezember 1996 Angenommen am 6. Februar 1997     

Remote expert consultation for MRI procedures by means of teleradiology

From April 1992 to January 1993, radiology expert opinion for MRI procedures was offered by means of teleradiology. The experiment was carried out in addition to an existing service of a mobile MRI unit. MRI images were sent by means of teleradiology via regular telephone lines from the mobile MRI unit to an academic hospital, which served as expert consultation centre. During this period, 43 requests for expert opinions were performed. This article describes the clinical effects of these expert opinions, and the technical and organisational requirements to perform teleradiology in daily clinical practice.     

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.     

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.     

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.     

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.     

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.     

Highlights from the scientific and educational abstracts presented at the ASER 2012 Annual Scientific Meeting and Postgraduate Course

The American Society of Emergency Radiology 2012 Annual Scientific Meeting and Post-Graduate Course encompassed a wide range of topics: traumatic and non-traumatic emergencies, radiation dose management, technical innovations and advancements, emergency preparedness, mass casualties, and teleradiology. This article highlights the scientific and educational abstracts presented at the meeting.     

Teleradiology requirements and aims in Germany and Europe: status at the beginning of 2000

Specific radiological requirements have to be considered for realization of telemedicine. In this article the goals and requirements for an extensive implementation of teleradiology are defined from the radiological user's point of view. Necessary medical, legal and professional prerequisites for teleradiology are presented. Superior requirements, such as data security and privacy or standardization of communication, 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 like legal acceptance of electronic documentation, reimbursement of teleradiology and liability must be clarified in the future. Received: 20 January 2000; Revized: 19 April 2000; Accepted: 20 April 2000     

Teleradiology Uppsala-Sydney for nighttime emergencies: preliminary experience

BACKGROUND: The development of digital imaging systems for radiology in combination with the possibility to transfer large quantities of data over the Internet has increased the interest in teleradiology. Transferring nighttime examinations to an evaluation center in a daytime zone may provide improved patient security, better working hours for radiologists, and reduced costs for emergency radiological services. PURPOSE: To evaluate the time required for transferring radiological information from Uppsala (Sweden) to Sydney (Australia). MATERIAL AND METHODS: A radiologist in Sydney reported on radiological examinations performed in Uppsala. The time required for downloading 75 examinations and returning 24 reports was registered. RESULTS: Downloading was completed in <60 min for all conventional radiological examinations, but only 44% of computed tomography (CT) examinations with >65 images. Reports were completed in <10 min. Turnaround time was directly related to the time required for downloading the images. The Sydney report was available in Uppsala within 30 min of the in-house report in 79% of examinations. CONCLUSION: The main challenge for emergency teleradiology is the time required for downloading large volumes of data over the Internet.     

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