The age of teleradiology

Assessment of Claimant, Clinical, and Financial Characteristics of Teleradiology Medical Malpractice Cases

Background The increasing use of teleradiology has been accompanied by concerns relating to risk management and patient safety. Purpose To compare characteristics of teleradiology and nonteleradiology radiology malpractice cases and identify contributing factors underlying these cases. Materials and Methods In this retrospective analysis, a national database of medical malpractice cases was queried to identify cases involving telemedicine that closed between January 2010 and March 2022. Teleradiology malpractice cases were identified based on manual review of cases in which telemedicine was coded as one of the contributing factors. These cases were compared with nonteleradiology cases that closed during the same time period in which radiology had been determined to be the primary responsible clinical service. Claimant, clinical, and financial characteristics of the cases were recorded, and continuous or categorical data were compared using the Wilcoxon rank-sum test or Fisher exact test, respectively. Results This study included 135 teleradiology and 3474 radiology malpractices cases. The death of a patient occurred more frequently in teleradiology cases (48 of 135 [35.6%]) than in radiology cases (685 of 3474 [19.7%]; P < .001). Cerebrovascular disease was a more common final diagnosis in the teleradiology cases (13 of 135 [9.6%]) compared with the radiology cases (124 of 3474 [3.6%]; P = .002). Problems with communication among providers was a more frequent contributing factor in the teleradiology cases (35 of 135 [25.9%]) than in the radiology cases (439 of 3474 [12.6%]; P < .001). Teleradiology cases were more likely to close with indemnity payment (79 of 135 [58.5%]) than the radiology cases (1416 of 3474 [40.8%]; P < .001) and had a higher median indemnity payment than the radiology cases ($339 230 [IQR, $120 790-$731 615] vs $214 063 [IQR, $66 620-$585 424]; P = .01). Conclusion Compared with radiology cases, teleradiology cases had higher clinical and financial severity and were more likely to involve issues with communication. © RSNA, 2024 See also the editorial by Mezrich in this issue.

Emerging Challenges and Opportunities in the Evolution of Teleradiology

OBJECTIVE. In recent decades, teleradiology has expanded considerably, and many radiology practices now engage in intraorganizational or extraorganizational teleradiology. In this era of patient primacy, optimizing patient care and care delivery is paramount. This article provides an update on recent changes, current challenges, and future opportunities centered around the ability of teleradiology to improve temporal and geographic imaging access. We review licensing and regulations and discuss teleradiology in providing services to rural areas and assisting with disaster response, including the response to the coronavirus disease (COVID-19) pandemic. CONCLUSION. Teleradiology can help increase imaging efficiency and mitigate both geographic and temporal discrepancies in imaging care. Technologic limitations and regulatory hurdles hinder the optimal practice of teleradiology, and future attention to these issues may help ensure broader patient access to high-quality imaging across the United States.

Diagnostic imaging trends in the emergency department: an extensive single-center experience

Background

Emergency Department imaging volume has increased significantly in North America and Asia.

Purpose

To assess Emergency Department imaging trends in a European center.

Material and Methods

The institutional radiological information system was queried for all computed tomography (CT), ultrasound (US), and magnetic resonance (MR) studies performed for the Emergency Department during 2002–2017. Descriptive statistics and linear regression analyses were used to assess overall study rates and temporal trends in overall and after-hours imaging after adjusting for patient visitations.

Results

CT use increased significantly from 38/1000 visits to 108/1000 at the end of the observation by 5.5 new exams per 1000 visits/year (P < 0.0001). US use increased gradually at a rate of 1.2/1000 per year during 2002–2008 with an accelerated annual increase of 6.4/1000 in 2009–2011 (P < 0.0001) raising US rates from 7/1000 to 28/1000 visits per year with stable rates from 2012 onwards. After on-site MR became available in 2004, its use increased from 0.3/1000 to 7/1000 at a rate of 1.9/1000 visits per year in 2005–2009 (P < 0.0001) and remained stable from 2010. While there was a significant increase in after-hours imaging, growth remained proportional to the overall trend in the use of CT, MR, and night-time CT with the exception of a slight decrease in after-hour US in favor of standard working hours (P < 0.0001).

Conclusion

All modalities increased significantly in volume adjusted usage. US and MR rates have been stable since 2012 and 2010, respectively, after periods of increase while CT use continues to increase. Demand for after-hours imaging was mostly proportional to the overall trend.

Ethics Certification of Health Information Professionals

OBJECTIVES

 To provide a model for ensuring the ethical acceptability of the provisions that characterize the interjurisdictional use of eHealth, telemedicine, and associated modalities of health care deliveiy that are currently in place.

METHODS

 Following the approach initiated in their Global Protection of Health Data project within the Security in Health Information Systems (SiHIS) working group of the International Medical Informatics Association (IMIA), the authors analyze and evaluate relevant privacy and security approaches that are intended to stem the erosion of patients' trustworthiness in the handling of their sensitive information by health care and informatics professionals in the international context.

RESULTS

 The authors found that while the majority of guidelines and ethical codes essentially focus on the role and functioning of the institutions that use EHRs and information technologies, little if any attention has been paid to the qualifications of the health informatics professionals (HIPs) who actualize and operate information systems to deal with or address relevant ethical issues.

CONCLUSION

 The apparent failure to address this matter indicates that the ethical qualification of HIPs remains an important security issue and that the Global Protection of Health Data project initiated by the SiHIS working group in 2015 should be expanded to develop into an internationally viable method of certification. An initial model to this effect is sketched and discussed.

University-Based Teleradiology in the United States

This article reviews the University of Arizona's more than 15 years of experience with teleradiology and provides an overview of university-based teleradiology practice in the United States (U.S.). In the U.S., teleradiology is a major economic enterprise with many private for-profit companies offering national teleradiology services (i.e., professional interpretation of radiologic studies of all types by American Board of Radiology certified radiologists). The initial thrust for teleradiology was for after-hours coverage of radiologic studies, but teleradiology has expanded its venue to include routine full-time or partial coverage for small hospitals, clinics, specialty medical practices, and urgent care centers. It also provides subspecialty radiologic coverage not available at smaller medical centers and clinics. Many U.S. university-based academic departments of radiology provide teleradiology services usually as an additional for-profit business to supplement departmental income. Since academic-based teleradiology providers have to compete in a very demanding marketplace, their success is not guaranteed. They must provide timely, high-quality professional services for a competitive price. Academic practices have the advantage of house officers and fellows who can help with the coverage, and they have excellent subspecialty expertise. The marketplace is constantly shifting, and university-based teleradiology practices have to be nimble and adjust to ever-changing situations.

Teleradiology from the provider's perspective-cost analysis for a mid-size university hospital

OBJECTIVES

Real costs of teleradiology services have not been systematically calculated. Pricing policies are not evidence-based. This study aims to prove the feasibility of performing an original cost analysis for teleradiology services and show break-even points to perform cost-effective practice.

METHODS

Based on the teleradiology services provided by the Greifswald University Hospital in northeastern Germany, a detailed process analysis and an activity-based costing model revealed costs per service unit according to eight examination categories. The Monte Carlo method was used to simulate the cost amplitude and identify pricing thresholds.

RESULTS

Twenty-two sub-processes and four staff categories were identified. The average working time for one unit was 55 (x-ray) to 72 min (whole-body CT). Personnel costs were dominant (up to 68 %), representing lower limit costs. The Monte Carlo method showed the cost distribution per category according to the deficiency risk. Avoiding deficient pricing by a likelihood of 90 % increased the cost of a cranial CT almost twofold as compared with the lower limit cost.

CONCLUSIONS

Original cost analysis is possible when providing teleradiology services with complex statutory requirements in place. Methodology and results provide useful data to help enhance efficiency in hospital management as well as implement realistic reimbursement fees.

KEY POINTS

• Analysis of original costs of teleradiology is possible for a providing hospital • Results discriminate pricing thresholds and lower limit costs to perform cost-effective practice • The study methods represent a managing tool to enhance efficiency in providing facilities • The data are useful to help represent telemedicine services in regular medical fee schedules.

Radiology and the mobile device: Radiology in motion

The use of mobile devices is revolutionizing the way we communicate, interact, are entertained, and organize our lives. With healthcare in general and radiology in particular becoming increasingly digital, the use of such devices in radiologic practice is inevitable. This article reviews the current status of the use of mobile devices in the clinical practice of radiology, namely in emergency teleradiology. Technical parameters such as luminance and resolution are discussed. The article also discusses the benefits of such mobility vis-à-vis the current limitations of the technologies available.

Adoption of telemedicine: from pilot stage to routine delivery

BACKGROUND

Today there is much debate about why telemedicine has stalled. Teleradiology is the only widespread telemedicine application. Other telemedicine applications appear to be promising candidates for widespread use, but they remain in the early adoption stage. The objective of this debate paper is to achieve a better understanding of the adoption of telemedicine, to assist those trying to move applications from pilot stage to routine delivery.

DISCUSSION

We have investigated the reasons why telemedicine has stalled by focusing on two, high-level topics: 1) the process of adoption of telemedicine in comparison with other technologies; and 2) the factors involved in the widespread adoption of telemedicine. For each topic, we have formulated hypotheses. First, the advantages for users are the crucial determinant of the speed of adoption of technology in healthcare. Second, the adoption of telemedicine is similar to that of other health technologies and follows an S-shaped logistic growth curve. Third, evidence of cost-effectiveness is a necessary but not sufficient condition for the widespread adoption of telemedicine. Fourth, personal incentives for the health professionals involved in service provision are needed before the widespread adoption of telemedicine will occur.

SUMMARY

The widespread adoption of telemedicine is a major -- and still underdeveloped -- challenge that needs to be strengthened through new research directions. We have formulated four hypotheses, which are all susceptible to experimental verification. In particular, we believe that data about the adoption of telemedicine should be collected from applications implemented on a large-scale, to test the assumption that the adoption of telemedicine follows an S-shaped growth curve. This will lead to a better understanding of the process, which will in turn accelerate the adoption of new telemedicine applications in future. Research is also required to identify suitable financial and professional incentives for potential telemedicine users and understand their importance for widespread adoption.

Attitude of korean primary care family physicians towards telehealth

Background

Recently, a revised telehealth legislation that allows direct doctor to patient teleconsultation was proposed in Korea. However, there have been some debates. This study aimed to examine the attitude of primary care physicians towards telehealth.

Methods

A questionnaire asking attitude towards telehealth and revised telehealth legislation was self-administered to 1,988 registered members of Practitioners Council of Korean Academy of Family Medicine. A total of 218 complete responses by family physicians were included in the study.

Results

Large proportion (60.6%) of participants disagreed to the main clause of revised telehealth legislation, which allowed doctor to patient teleconsultation. Participants tended to expect that negative outcomes are more likely to occur than positive outcomes after the enforcement of the revised telehealth legislation. Around 50% of participants had an intention to adopt telehealth just as soon (4.6%) or afterwards (45.4%). The majority of participants suggested that; primary care clinic as the most appropriate telehealth facility (75.4%); patients with low accessibility to medical care (74.3%) as the best target of telehealth service; and tele-radiology (61.9%) or tele-pathology (41.3%) as the most applicable medical field for telehealh service. Around 89% of participants suggested telehealth service fee to be similar or higher than current medical consultation fee.

Conclusion

The majority of family physicians participating in this study were not in favor of the revised telehealth legislation. However, the majority of the participants had an intention to adopt telehealth to their practice and held clear opinion about practical aspects of telehealth.

The healthcare off-shoring industry in developing economies--institutional and economic foundations: an Indian case

PURPOSE

Industrialized world-based healthcare providers are increasingly off-shoring low-end healthcare services such as medical transcription, billing and insurance claims. High-skill medical jobs such as tele-imaging and tele-pathology are also being sub-contracted to developing countries. Despite its importance, little theory or research exists to explain what factors affect industry growth. The article's goals, therefore, are to examine economic processes associated with developing economies' shift from low- to high-value information technology enabled healthcare services, and to investigate how these differ in terms of legitimacy from regulative, normative and cognitive institutions in the sending country and how healthcare services differ from other services.

DESIGN/METHODOLOGY/APPROACH

This research is conceptual and theory-building. Broadly, its approach can be described as a positivistic epistemology.

FINDINGS

Anti off-shoring regulative, normative and cognitive pressures in the sending country are likely to be stronger in healthcare than in most business process outsourcing. Moreover, such pressures are likely to be stronger in high-value rather than in low-value healthcare off-shoring. The findings also indicate that off-shoring low-value healthcare services and emergent healthcare industries in a developing economy help accumulate implicit and tacit knowledge required for off-shoring high-value healthcare services.

RESEARCH LIMITATIONS/IMPLICATIONS

The approach lacks primary data and empirical documentation.

PRACTICAL IMPLICATIONS

The article helps in understanding industry drivers and its possible future direction. The findings help in understanding the lens through which various institutional actors in a sending country view healthcare service off-shoring.

ORIGINALITY/VALUE

The article's value stems from its analytical context, mechanisms and processes associated with developing economies' shift to high-value healthcare off-shoring services.

Ethical and legal challenges for health telematics in a global world: telehealth and the technological imperative

Telehealth is one of the more recent applications of ICT to health care. It promises to be both cost-effective and efficient. However, there lies a danger that focusing mainly on pragmatic considerations will ignore fundamental ethical issues with legal implications that could undermine its success. Implicated here are, among others, changes in the nature of the health care professional patient relationship and informed consent, etc. The position of health informatics professionals as well as hard- and software providers is also affected. A further complicating factor is outsourcing. This paper identifies relevant issues and outlines some of their implications.

Telemedicine: What have we learned?

As the health care industry is facing many challenges and is undergoing extensive change, telemedicine is in the position to address these challenges and be an important part of health care's development. Telemedicine has been used for approximately a half century, in which researchers have explored the different technologies utilized, clinical outcomes, cost benefits, perceptions, and adoption challenges of its use. This paper reviews and summarizes these findings and presents possible future research endeavors. Examining what is known about telemedicine can aid in the development of innovative, sustainable and beneficial health technologies that could positively impact health care delivery and outcomes.

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.

The impact of globalisation on teleradiology practice

Some advocates of globalisation argue that a free market with little regulation is the best approach for achieving cost-effective healthcare. Healthcare, however, is different from other business activities in that it is typically less profit-driven; instead, it often involves the goal of providing equitable care to the underprivileged. Traditionally, the government has subsidised the expenses of delivering affordable healthcare to underserved communities. Because of the many recent advances in telecommunications technology, telemedicine has gained increasing attention. Teleradiology, in particular, is by far the maturest of all telemedicine disciplines and, thus, it may serve as a pivotal indicator of whether telemedicine on a global scale is feasible or not. In this paper, a prediction of the future landscape of globalised teleradiology operations is attempted based on the extrapolation of the historical trends in teleradiology practice as well as the growing pressure on federal and local governments to reduce their regulatory power under the General Agreement on Trade in Services (GATS).

Videoconference pediatric and congenital cardiology consultations: a new application in telemedicine

BACKGROUND

The relative rarity of congenital heart disease gives it an orphean disease status, requiring specialised centres. The present maturity of information technology allows telemedicine to be integrated into current medical practice. We report our experience of telemedicine between the cardiology department at St Pierre Hospital on the island of Réunion and the pediatric cardiology department at the teaching hospital in Toulouse.

AIMS

The aims of this work were to 1. verify the technical feasibility of transmitting echocardiographic images, 2. determine an optimal therapeutic strategy for each patient, and 3. deliver precise information live to patients and their families.

METHODS

Five pediatric cardiology videoconference consultation sessions were transmitted between April 2006 and May 2007. The videoconference equipment, POLYCOM VSX 7000 (R), was used to relay information between the two centres, using six high-debit digital telephone lines, allowing a transfer rate of 384 kbits/s and an image frequency of 25 frames per second. The echocardiographic equipment at St Pierre Hospital was connected to the videoconference equipment by an S-VHS video output. The transmitted sources alternated between the echographic video output and the signal from a video camera, with continuous audio transmission.

RESULTS

The telemedicine meeting was made up of three main elements: 1. a consultation with real-time echocardiographic acquisition and transmission, 2. a discussion between medical colleagues, and 3. a discussion with the family. Five videoconference consultation sessions were organised between April 2006 and May 2007. 22 patients were involved (median age 3 years, age range 7 days to 48 years). Heart disease was congenital in 20 patients, and acquired in 2 patients. The aim of the telemedicine consultation was to specify: 1. medical treatment in 7 patients, and 2. an indication for surgery or interventional catheterisation in 15 patients. There was no significant change in diagnosis, but in 2 patients with complex heart disease some anatomical clarifications were made. For 3 patients, the videoconference discussion was essential to get the extremely reticent families to accept the indication for surgery.

CONCLUSION

This is the first experience in France of telemedicine consultation for pediatric and congenital cardiology. These videoconferences allowed patients in the south of Réunion to benefit from a specialist opinion on optimal therapeutic strategy, with no delay or need to travel a long distance.

Is a black market in telemedicine on the horizon?

BACKGROUND

Regulation of a global market by regional licensure systems and trade barriers has significant drawbacks.

METHODS

Literature review of telemedicine, law and economics.

RESULTS

Today's patients are willing to use out-of-pocket dollars to purchase medical care from: (a) foreign physicians in the medical tourism market; and (b) nurse-practitioners in pharmacy clinics. As telemedicine comes of age, patients are likely to purchase more health care from foreign telemedical 'pharmacy' clinics to avoid the costs, and the hassle, of travel. Many of these foreign medicine providers are likely to be unlicensed. This is problematic because experience with Mydoc.com and Usanetrx.com demonstrates that today's patients are relatively unconcerned with the licensure status of telemedicine providers. Accordingly, the elements of a black market in telemedicine may be on the horizon. Strengthening medical licensure laws is unlikely to keep foreign providers out the US health care market forever. Alternatively, one method to minimize the size of a black market in telemedical services would be to allow the market to regulate itself through the creation of a commodities-type exchange.

CONCLUSION

Now is the time to open a global dialogue on how to regulate telemedicine.