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.     

The German teleradiology system MEDICUS system description and experiences in a German field test

MEDICUS is a teleradiology system which has been developed in a joint project of the German Cancer Research Center (Deutsches Krebsforschungszentrum) and the Transfer Center Medical Informatics (Steinbeis-Transferzentrum Medizinische Informatik) in Heidelberg, Germany. The system is designed to work on ISDN lines as well as in a local area network. Special attention has been given to the design of the user interface and data security, integrity, and authentication. The software is in use in 13 radiology departments in university clinics, small hospitals, private practices, and research institutes. More than 25 thousand images have been processed in 6 months. The system is in use in six different application scenarios. MEDICUS is running under the UNIX operating system. The connection of the modalities could in most cases not be realized with the DICOM protocol as older machines were not equipped with this standard protocol. Clinical experiences show that the MEDICUS system provides a very high degree of functionality. The system has an efficient and user friendly graphical user interface. The result of a comparison with other systems shows that MEDICUS is currently the best known teleradiology system. Cost reductions are already obvious, but additional research has to be performed in this field. An even more powerful commercial successor is currently under construction at the Steinbeis-Transferzentrum Medizinische Informatik in Heidelberg.     

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.     

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.     

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.     

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.     

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.     

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.     

Does the digital signature of the DICOM standard meet the requirements of German law?

The DICOM standard offers the possibilities to generate electronic signatures, valid according to German laws. This enhances the reliability of the correlation between image and patient data. However, only so called qualified electronic signatures--conveniently issued by an accredited supplier--are permissible and not rejectable as evidence in German jurisdiction and are completely equivalent to the handwritten signatures. These qualified electronic signatures can be executed only by individuals, whereas the former are not applicable to technical apparatus like image generating modalities. In consequence, a modality is able to provide its pictures with a "common or advanced signature" solely. This limits the use of the digital signature of the DICOM standard for further applications, e.g. the verifiability within the teleradiology.     

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.     

Results of and comments on the 1998 survey of the American Association of Academic Chief Residents in Radiology

RATIONALE AND OBJECTIVES: The American Association of Academic Chief Residents in Radiology annually surveys residency programs on a variety of issues related to residency training. The survey allows for comparison between programs regarding training and follows trends on current issues. MATERIALS AND METHODS: Questionnaires were mailed to all accredited programs in the United States (188 programs). The questionnaire consisted of questions regarding general demographic information and specific topics regarding residency training. The 1998 survey focused on turf issues, teleradiology use, residency selection, and prior training. RESULTS: Completed surveys from 61 programs (32.4%) were returned. Important findings included (a) the ongoing turf battles regarding vascular and obstetric-gynecologic ultrasound, both in general hospital and emergency department patients, (b) the use of teleradiology by most residents, and (c) the low percentage of women in radiology residency programs. CONCLUSION: The information obtained during yearly surveys is useful for program evaluation and future planning. Current survey results indicate an increasing use of teleradiology in residency over the past 4 years. The turf battles in ultrasonography (both vascular and obstetric) have remained unchanged over the same time frame.     

Evaluation des CHILI-Teleradiologienetzwerks nach 4 Jahren im klinischen Einsatz

The CHILI teleradiology network has more than 60 installations in Germany and the USA. Radiological images and cardiological multiframe series are exchanged in clinical routine. This article investigates in what way and how often the system is used. This is done by means of accounting files that are produced automatically by the system. User functions, transmission protocols, data quantity, frequencies and time of data transmission and teleconferences are evaluated and discussed in this paper. Different application scenarios have been identified and are described and analyzed as well. An important result is, that the system is not merely an emergency system. Instead, it is used in daily routine as a multifunctional, multimodality workstation with advanced features for teleradiology and telecardiology.     

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.     

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 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.     

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.     

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.     

Quality of Training in Radiation Oncology in Germany

PURPOSE: To evaluate residents' satisfaction with their training in radiation oncology, the first nationwide survey was done in 2006. Results were presented at the 2006 annual meeting of the German Society of Radiation Oncology (DEGRO). MATERIAL AND METHODS: A questionnaire with 39 questions regarding training in radiation oncology in Germany was developed and sent by e-mail. Questionnaires were returned by mail and analyzed anonymously. RESULTS: 96 questionnaires were received. A total of 88% of respondents are pleased with their decision of training in radiation oncology. Residents are strongly motivated by their interest in oncology. Quality of training is heterogeneous and not optimal. Training in three-dimensional treatment planning, radiochemotherapy and intracavitary brachytherapy is judged adequate, whereas special techniques such as intensity-modulated radiotherapy (IMRT) and permanent prostate implants are not covered by the majority of institutions. Organization of training in the departments is often judged insufficient. CONCLUSION: Radiation oncology is attractive for young doctors. However, training quality for radiation oncologists in Germany was judged to be heterogeneous and needs to be optimized. For this, results of this survey may be helpful. The overall positive judgment may help to attract more students into the field of radiation oncology, an issue that becomes increasingly important given the shortage of doctors and the strong competition with other disciplines. Modern techniques, such as IMRT, need to be integrated into training programs in order to maintain the high standard of radiation oncology in Germany.