What is teleradiology?

What is the status of teleradiology in Singapore?

What are the expected benefits of teleradiology?

What are the limitations and potential pitfalls of teleradiology?

Links to published local articles on teleradiology

 

 

What is teleradiology?

 

Teleradiology is the electronic transmission of radiologic images from one location to another for the purposes of interpretation and/or consultation. Today, it is possible to transmit images from the entire range of diagnostic modalities to a remote site for interpretation.

 

What is the status of teleradiology in Singapore?

 

Teleradiology within Singapore was first explored in the public sector in the 1990s when efforts were made to establish teleradiology consultation between Stanford University and Singapore General Hospital for MRI and CT studies. Similar services in the private sector commenced in 1992 for teleradiology of plain radiographs and ultrasound. The most recent local teleradiology initiative was officially announced in early 2006. This involved sending images from selected polyclinics of the National Healthcare Group to an offshore teleradiology service provider in Bangalore, India, at an initial capital investment of about S$2.3 million.

 

What are the expected benefits of teleradiology?

 

1. Provision of Radiological Interpretation Services Where They are Not Readily Available

Teleradiology has been used to facilitate radiological interpretation of images from centres where workload is insufficient to justify a fully staffed radiology department, or where there is a significant shortage of on-site radiologists.

 

2. Access to Subspecialty Radiological Input

Modern imaging studies, especially those of complex cases, often require detailed review by radiologists trained in the corresponding subspecialty area. Through teleradiology, centres without on-site subspecialty radiological capability can benefit from the expert opinion of subspecialised radiologists in a different department.

 

3. Out-of-hours Radiology Service and Consultation

Teleradiology can allow centres that are not adequately staffed to provide a 24-hour radiological service. Images acquired during odd hours can be sent to a teleradiology reporting centre for review.

 

4. Enhancing Education and Information-sharing Across Medical Facilities

Teleradiology can be harnessed to increase the variety of case presentations, learning opportunities and tutorials for radiologists and non-radiologists alike. Images can also be shared across top tertiary centres during multidisciplinary meetings, with the aim of enhancing patient care.

 

5. Tapping on Previously Unavailable Radiological Resources

Teleradiology can allow radiologists working part time or in the private sector to report studies from a remote location, assisting in the clearance of any existing backlog and reducing the heavy workload on radiology departments in hospitals.

 

6. Reduction in Health Care Costs

The use of teleradiology to enable interpretation of images by radiologists in countries where the labour costs are significantly lower has been actively explored by several countries, including Singapore.

 

What are the limitations and potential pitfalls of teleradiology?

 

1. Legal Issues

 

The provision of a teleradiology service outside of a national boundary has several legal implications.

 

a. Medical Registration. Any local requirements with regard to accreditation, recertification, revalidation and continuous professional development should be applicable to the radiologist in the remote reporting centre. These are essential requirements to ensure that minimum standards of reporting are maintained, regardless of the location of the teleradiology service provider.

 

b. Liability. The duty of care must be clearly defined, especially in the contracts between the requesting centre and teleradiology provider, with regard to the liability of the service provider and reporting radiologist should any medical mismanagement arise from an erroneous report. The avenues through which a patient may seek redress for inappropriate radiological investigations, especially if this crosses national boundaries, need to be worked out. In the event of erroneous reporting, the teleradiology provider must be subject to the same consequences as the on-site provider, i.e., be censured and sued for damages, and possibly even be barred from practising by the local regulatory body.

 

c. Medical Confidentiality. The transmission of data needs to comply with local requirements with regard to security and protection of data. Measures should be in place to ensure that images sent to the teleradiology provider are only viewed by authorized personnel, and that the images are not used for other purposes without the prior consent of the patient.

 

d. Radiation Safety. As the risks of medical radiation are real, it is important to justify each radiological examination, using appropriate protocols and customizing the examination to suit the patient. This is usually done by on-site radiologists who vet investigation request forms, read through the clinical notes and discuss the case with the requesting physician. Such processes may not be adequately addressed in offshore teleradiology.

Furthermore, there may be commercial pressures on the teleradiology service provider to suggest more examinations or perform more complicated studies. This, in turn, can lead to an increase in radiation dose to the patient, which may not be justified.

 

e. Workload issues. Pressure to remain commercially viable can potentially lead teleradiology centres to accept workloads beyond their capability. This has serious implications for quality of reporting and radiological services, as radiological accuracy has been shown to decrease when the radiologist is overworked and fatigued.

 

2. Communication

 

Clear communication of findings and their implications is a critical aspect of any radiology service. In teleradiology, how the reporting radiologist communicates the study results is a concern that needs to be addressed.

 

a. Communication with the referring clinician.

The radiologist interacts with clinical colleagues in both formal (reports) and informal (telephone calls, corridor consultations, email exchanges, multidisciplinary meetings, etc) settings. The use of teleradiology limits the avenues through which such communication can be achieved, and may affect the relationship between radiologist and clinician. The need for radiologists to communicate directly with the referring physician in the event of any urgent or significant unexpected findings can be more challenging for a remote provider to fulfill.

 

b. Communication with the patient.

There is a need to clarify whether the patient is required to give consent for images to be transferred to another country for reporting. The reporting radiologist may also be required to communicate scan findings directly to the patient. In such cases, the radiologist must be able to communicate the findings and required follow-up actions to the patient or caregiver in a clear and concise manner.

 

3. Service Quality

 

The modern radiologist plays the following imaging consultancy roles, in addition to the writing of reports:

 

a. Advising on optimal imaging or diagnostic work-up

b. Justification of examinations in individual patients

c. Optimising and tailoring individual examinations

d. Ad-hoc problem-solving

e. Conferencing in multidisciplinary teams

f. Organising workflow in the radiology department

g. Quality control

 

Any cost-benefit assessment should therefore factor in the other key roles that an on-site radiologist plays, as compared to the function of a remote teleradiology provider.

 

The quality of service provided by a remote teleradiology service may also be hampered by limited or lack of access to patient case notes (which are often handwritten), previous investigation results and the inability to directly converse with or examine the patient (which is key in protocoling of certain imaging studies). The remote teleradiology service provider is also unable to cater for the ‘hands-on’ aspects of radiology such as ultrasound or interventional procedures. Without in-depth knowledge of local variations in disease prevalence, the remote teleradiology provider may be unable to interpret the imaging findings accurately.

 

4. Impact on Local Radiology Service

 

The widespread use of remote teleradiology services, especially if driven purely by economic forces, can lead to a loss of local radiological expertise. If a large proportion of imaging studies are sent to an offshore location for reporting, there will be significant implications on the training of junior radiologists and the experience of existing radiologists. This may lead to a decreased attractiveness of the medical subspecialty, thus reducing the number of trainees entering radiology. Such a situation has serious implications for the critical mass required by a small nation such as Singapore, potentially exacerbating the already unfavourable radiologist-to-population ratio.

 

Links to published local articles on teleradiology

 

1. Teleradiology Outsourcing – Rumblings from the ground by Dr Jeffrey Goh. Published in Singapore Medical Association News in May 2006.

http://www.sma.org.sg/sma_news/3805/Globalisation_of_Medicine_JG.pdf

 

2. Teleradiology in Singapore – Taking Stock and Looking Ahead by Dr Lionel Cheng and Dr Samuel Ng. Published in Annals of the Academy of Medicine, Singapore in August 2006.

http://www.annals.edu.sg/PDF/35VolNo8Aug2006/V35N8p552.pdf