the status of teleradiology in Singapore?
What are the expected
benefits of teleradiology?
What are the limitations and potential pitfalls of
Links to published local
articles on 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
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.
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
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
5. Tapping on Previously Unavailable
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,
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.
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
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.
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.
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.
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
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.
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.
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.
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
d. Ad-hoc problem-solving
e. Conferencing in
f. Organising workflow in the radiology
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.
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.