Teleradiology: Images from Here to There...Now

Advances in telecommunications technology are having a huge impact on the field of medicine, and particularly in radiology. More bandwidth has allowed for the nearly instantaneous transmission of patient images and information from one location to another, no matter how many miles span between them. If an understaffed emergency department is in need of nighthawk coverage (or if day-time radiologists want to get some sleep at night), a virtual radiology provider can help. If rural or smaller communities need better access to healthcare, a virtual private network that links facilities to a sub-specialized group of radiologists may be the way to go. And even if surging imaging volumes are overburdening a radiology department during normal working hours or on weekends, a remote radiologist may be able to offer some assistance. Teleradiology is a staple — and growing — service that’s here to stay.

NORrad (Northern Radiology), a 15-hospital diagnostic imaging partnership in Timmins, Ontario, Canada, is extending radiological care to patients living in rural and remote communities throughout Northeastern Ontario. Thanks to the sophistication of PACS and digital image capture, NORrad hospitals rely on teleradiology to send their digitally acquired patient images to a centralized hub of radiologists in Timmins via a dedicated wide area network (WAN).

The practice of sending radiological images over the internet is relatively new, as broadband, high-speed internet connections have revolutionized the speed at which patient images are transmitted. Such advances have helped further the widespread utilization and acceptance of teleradiology.

Many teleradiology providers allow healthcare facilities to outsource the readings of their medical images dependent on their needs. For example, these vendors serve small and medium sized hospitals and offer day, night and weekend coverage as well as vacation coverage. Initially used as a way to obtain preliminary reports, vendors say more sites are requesting final interpretations.  NORrad is similar to this in many ways, but has the distinct advantage of an implemented MPI (master patient identifier), says Mike Gasparotto, PACS administrator for NORrad.

Still, regardless of how teleradiolgy is practiced, the benefits are the same all around: timely access to radiology care via remote imaging interpretations.

NORrad’s workflow in a film-based environment was impeded until it installed Agfa Healthcare’s Impax PACS. “Prior to PACS, if a critically ill patient in Hearst, Ontario, needed his or her films looked at, there was a good chance the patient and films would be transferred to Timmins [about a 3-hour drive],” says Gasparotto. With PACS, radiology studies are acquired in filmless departments and electronically transmitted over large bandwidth to awaiting radiologists in Timmins. Images are instantly read and reports are returned back to the hospital within minutes.

In addition to improved report turnaround times, teleradiology has expanded access to subspecialized, radiological care to the patient community. Rural physicians who may lack access to or experience with modalities such as CT, MRI and specialties such as orthopedics, can rely on NORrad. Remote consultation also is possible. “A physician at one of the small hospitals can contact an orthopedic surgeon in Timmins to get a consultation in a matter of minutes,” says Gasparotto.


Outsourcing imaging interpretation

“Teleradiology today has made huge strides from just five years ago,” says Eduard Michel, MD, medical director, Virtual Radiologic Company (VRC), a teleradiology provider based in Minneapolis, Minn. “At that time people were doing teleradiology mainly at night. Today, teleradiology has been accepted into the mainstream practice of radiology.”

A number of factors have contributed to the growing utilization of remote radiology reading services. Consider the nature of the field today: research shows that radiology imaging services amount to 15 percent of a hospital’s total system revenue, imaging volumes have tripled and many practices provide 24-hour coverage. In addition, current staffing shortages plague many healthcare institutions.

As telecommunications technology and equipment has improved, and medical imaging continues to be a revenue generator for healthcare facilities, teleradiology offers a way to mitigate radiology staffing shortages and handle increasing image volumes. Hospitals, clinics and imaging facilities nationwide utilize remote radiology for night time coverage, as well as read surplus exams produced on weekends, holidays, and more recently, during the day. 
“University-based healthcare institutions with a mix of doctors and residents do not rely too heavily on teleradiology service providers,” says Michel. “The primary users are private practice radiology groups, and the sizes of these groups vary. VRC works with one and two person groups, as well as groups that consist of more than 50 radiologists. Additional users include smaller-sized community hospitals and hospitals with Level 1 trauma centers.”

Emergency departments are a niche market for teleradiology firms. Rather than have an on-site radiologist up at all hours during the night to read studies, EDs can transmit their CT scans, ultrasound studies, MRIs and x-ray images over the internet to remote radiologists at the peak of their work hour. Attending physicians typically receive a preliminary report in 30 minutes or less.

Strict rules and regulations do apply however. The American College of Radiology has established a set of teleradiology standards that mandate physicians be licensed in both transmitting and receiving states, as well as be credentialed at each transmitting healthcare facility. Malpractice insurance is another important concern, and the ACR says, “physicians should consult with their professional liability carrier to ensure coverage in both the sending and receiving sites.” (Visit http://www.acr.org/s_acr/sec.asp?CID=3553&DID=22307 for more information)


Emerging trends: day-time coverage

“Teleradiology got its start by covering night business for a vast array of [healthcare facilities] across the country — everything from small rural hospitals that could not get radiology coverage, to large trauma centers, and everything in between,” says Ben Strong, MD, ABIM, ABR, a radiologist who works with VRC.

For the past several years, night time teleradiology has been relied upon for the generation of preliminary reports. These reports allow doctors to intervene and provide treatment for patients in critical situations, but Strong explains that they are held to a different completeness standard. “They are used specifically for the directed management of a patient in acute situations,” he says. The on-site, day-time radiologist is accountable for completing the report the next day.

Strong says a developing trend in teleradiology is a transition away from just the generation of preliminary reports. “Day-time coverage and the production of final reports is a percentage of the teleradiology business that is growing by leaps and bounds,” says Strong. “I think this is not only a testament of the unwillingness of radiologists to stay up at night, but also the girth of radiology in this country. There are just more radiology studies performed every day than can be read by competent, sub-specialty trained radiologists. Hospitals and imaging centers across the country are recognizing that as fact. They are buried in overflow of studies that can not be covered by normal day staff.”

Located in Tucson, Ariz., Strong was one of the first doctors VRC hired to provide day-time radiology coverage for healthcare facilities. Strong typically works Wednesday through Sunday, 8 a.m. to 5 p.m. EST. “I have two different types of work days,” explains Strong. “My work day during the week is typically dedicated toward MRI reading. The studies mostly come from imaging centers and hospitals around the country that have their MSK [musculoskeletal] or body MRI radiologist on vacation, or else there are excess studies that can not be covered.

“My weekend days are similar to an exciting emergency room shift,” he continues. “Most of the imaging centers are closed and most of the [radiology studies] I see are night-time studies acquired in emergency rooms and emergent care clinics, as well as the occasional hospital inpatients. Those are the studies I really love. I am able to read them very quickly and I find them very interesting and challenging. With a 30-minute turnaround time, the reports get back to [attending physicians] very quickly and we are having a direct impact on the course of patient care.”

In addition to the legal obligations required for remote reading, other challenges include dealing with the image quality and standardization of the digital studies that the radiologists receive. Different hospitals may have varying imaging protocols and remote radiologists are subjected to the talent and training of numerous technologists. Albeit a concern at first, Strong says in the end, the variety has made him a better radiologist all around. “After doing this for two years, I can read anything,” he says. “I have seen every type of scanner produce every type of image, acquired across 40 states at a volume that is more than twice than what a normal radiologist reads in one year.”


Bread and butter teleradiology

Despite growth in day-time coverage and subspecialty services, the bread and butter of teleradiology is nighthawk coverage. Night time is a time when many EDs get hectic and busy. To provide the necessary radiology coverage, hospitals can hire another full-time radiologist, keep the day-time radiologists on call or rely on nighthawk coverage.

Sumter Radiology, a five-person reading group for 260-bed Tuomey Healthcare Systems in Sumter, S.C., does the latter and utilizes Nighthawk Radiology Services Inc. The Coeur d’Alene, Idaho-based company provides off-hour radiology services for U.S. hospitals and medical centers. Nighthawk has a staff of 50 radiologists who are based in Sydney, Australia, to cover U.S. hospitals in the East and the Midwest and in Zurich, Switzerland, to cover U.S. hospitals in mountain and Pacific states.

“We are a small group and it would be too costly to hire another partner to do the after-hours work,” says Tim Pannel, MD, a radiologist and a member of Sumter Radiology. “Instead, the Nighthawk radiologists read any study acquired at our hospital after 11 p.m. Also, the emergency room has become very busy at night. There has been a big change in doctor’s ordering patterns for imaging studies. It seems that physicians order studies 24-hours a day, and want and need immediate interpretations of those studies.

“In the early to mid-’90s, we were doing on average two or three CT scans a night,” he continues. “Now we are probably averaging 15 to 20 CT scans a night.”

NightHawk offers preliminary reading services in diagnostic radiology from 5 p.m. to 11 a.m. EST on weekdays and 24 hours a day on weekends and holidays. Studies are sent to Nighthawk’s centralized teleradiology reading centers in a compressed DICOM format and evaluated, after which a typewritten report is sent back to the attending physician in about 20 minutes.

Stevens Memorial Hospital (SMH) in Norway, Maine, is a 50-bed hospital serviced by a two-man reading group called Western Maine Radiology. William Portner, MD, chairman of the department of radiology at SMH, says the group was able to recently operate with two radiologists because of Nighthawk.

As Portner and his partner get some rest at night, Nighthawk’s pool of radiologists in Australia and Sydney are busy at work reading a plethora of images from multiple U.S. hospital sites, including any CT or MRI scans sent from SMH. Only Nighthawk radiologists credentialed at SMH will read the studies and fax back a preliminary report to the attending physician. “From the time the study is acquired to the time the physician at SMH gets the report is a total of 15 to 20 minutes,” says Portner, “and I can not beat that time in my house…which is much, much closer to the hospital than Australia.”

Portner emphasizes that he is still on call and will not leave any attending ER physician in the lurch. “If the physician wants to talk to me or get an additional, second opinion, I am available,” he adds. However, Portner does not always need to be called for a second opinion, and he typically returns to SMH the next morning well-rested and ready to work his normal, daily shift.

“Radiology is one of the few branches of medicine that is 99 percent digital,” opines Portner. “When you have digital and DICOM, you can manipulate the data and send them anywhere you want. Teleradiology gives you reliable, quality radiologic services around the clock. It’s the ability to have quality interpretations any time, day or night, regardless of the size of the healthcare institution.”