The state of teleradiology in 2003 and changes since 1999

Night Radiology Coverage for Trauma: Residents, Teleradiology, or Both?

BACKGROUND

Overnight radiology coverage for trauma patients is often addressed with a combination of on-call radiology residents (RR) and a teleradiology service; however, the accuracy of these 2 readers has not been studied for trauma. We aimed to compare the accuracy of RR versus teleradiologist interpretations of CT scans for trauma patients.

STUDY DESIGN

A retrospective analysis (March 2019 through May 2020) of trauma patients presenting to a single American College of Surgeons Level I trauma center was performed. Patients whose CT scans were performed between 10 pm to 8 am were included, because their scans were interpreted by both a RR and teleradiologist. Interpretations were compared with the final attending faculty radiologist's interpretation and graded for accuracy based on the RADPEER scoring system. Discrepancies were characterized as traumatic injury or incidental findings and missed findings or overcalls. Turnaround time was also compared.

RESULTS

A total of 1,053 patients and 8,226 interpretations were included. Compared with teleradiologists, RR had a lower discrepancy (7.7% vs 9.0%, p = 0.026) and major discrepancy rate (3.8% vs 5.2%, p = 0.003). Among major discrepancies, RR had a lower rate of traumatic injury discrepancies (3.2% vs 4.4%, p = 0.004) and missed findings (3.4% vs 5.1%, p < 0.001), but a higher rate of overcalls (0.5% vs 0.1%, p < 0.001) compared with teleradiologists. The mean turnaround time was shorter for RR (51.3 vs 78.8 minutes, p < 0.001). The combination of both RR and teleradiologist interpretations had a lower overall discrepancy rate than RR (5.0% vs 7.7%, p < 0.001).

CONCLUSIONS

This study identified lower discrepancy rates and a faster turnaround time by RR compared with teleradiologists for trauma CT studies. The combination of both interpreters had an even lower discrepancy rate, suggesting this combination is optimal when an in-house attending radiologist is not available.

The Accuracy of On-Call CT Reporting in Teleradiology Networks in Comparison to In-House Reporting

(1) Background: We aimed to compare the accuracy of after-hours CT reports created in a traditional in-house setting versus a teleradiology setting by assessing the discrepancy rates between preliminary and final reports. (2) Methods: We conducted a prospective study to determine the number and severity of discrepancies between preliminary and final reports for 7761 consecutive after-hours CT scans collected over a 21-month period. CT exams were performed during on-call hours and were proofread by an attending the next day. Discrepancies between preliminary and gold-standard reports were evaluated by two senior attending radiologists, and differences in rates were assessed for statistical significance. (3) Results: A total of 7209 reports were included in the analysis. Discrepancies occurred in 1215/7209 cases (17%). Among these, 433/7209 reports (6%) showed clinically important differences between the preliminary and final reports. A total of 335/5509 of them were in-house reports (6.1%), and 98/1700 were teleradiology reports (5.8%). The relative frequencies of report changes were not significantly higher in teleradiology. (4) Conclusions: The accuracy of teleradiology reports was not inferior to that of in-house reports, with very similar clinically important differences rates found in both reporting situations.

The Current State of Teleradiology Across the United States: A National Survey of Radiologists' Habits, Attitudes, and Perceptions on Teleradiology Practice

PURPOSE

To explore the current state of teleradiology practice, defined as the interpretation of imaging examinations at a different facility from where the examination was performed.

METHODS

A 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.

RESULTS

Among 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.

CONCLUSION

Despite 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.

Anatomy of an Extensible Open Source PACS

The conception and deployment of cost effective Picture Archiving and Communication Systems (PACS) is a concern for small to medium medical imaging facilities, research environments, and developing countries' healthcare institutions. Financial constraints and the specificity of these scenarios contribute to a low adoption rate of PACS in those environments. Furthermore, with the advent of ubiquitous computing and new initiatives to improve healthcare information technologies and data sharing, such as IHE and XDS-i, a PACS must adapt quickly to changes. This paper describes Dicoogle, a software framework that enables developers and researchers to quickly prototype and deploy new functionality taking advantage of the embedded Digital Imaging and Communications in Medicine (DICOM) services. This full-fledged implementation of a PACS archive is very amenable to extension due to its plugin-based architecture and out-of-the-box functionality, which enables the exploration of large DICOM datasets and associated metadata. These characteristics make the proposed solution very interesting for prototyping, experimentation, and bridging functionality with deployed applications. Besides being an advanced mechanism for data discovery and retrieval based on DICOM object indexing, it enables the detection of inconsistencies in an institution's data and processes. Several use cases have benefited from this approach such as radiation dosage monitoring, Content-Based Image Retrieval (CBIR), and the use of the framework as support for classes targeting software engineering for clinical contexts.

Geographic Distribution of Radiologists and Utilization of Teleradiology in Japan: A Longitudinal Analysis Based on National Census Data

BACKGROUND

Japan has the most CT and MRI scanners per unit population in the world, and as these technologies spread, their geographic distribution is becoming equalized. In contrast, the number of radiologists per unit population in Japan is the lowest among OECD countries and their geographic distribution is unknown. Likewise, little is known about the use of teleradiology, which can compensate for the uneven distribution of radiologists.

METHODS

Based on the Survey of Physicians, Dentists and Pharmacists and the Static Survey of Medical Institutions by the Ministry of Health, Labour and Welfare, a dataset of radiologists and CT and MRI utilizations in each of Japan's 1811 municipalities was created. The inter-municipality equity of the number of radiologists was evaluated using Gini coefficient. Logistic regression analysis, based on Static Survey data, was performed to evaluate the association between hospital location and teleradiology use.

RESULTS

Between 2006 and 2012 the number of radiologists increased by 21.7%, but the Gini coefficient remained unchanged. The number of radiologists per 1,000 CT (MRI) utilizations decreased by 17.9% (1.0%); the number was highest in metropolis and lowest in town/village and the disparity has widened from 1.9 to 2.2 (1.6 to 2.0) times. The number of hospitals and clinics using teleradiology has increased (by 69.6% and 18.1%, respectively). Hospitals located in towns/villages (odds ratio 1.61; 95% confidence interval 1.26-2.07) were more likely to use teleradiology than those in metropolises.

CONCLUSIONS

Contrary to the CT and MRI distributions, radiologist distribution has not been evened out by the increase in their number; in other words, the distribution of radiologists was not affected by market-derived spatial competition force. As a consequence, the gap of the radiologist shortage between urban and rural areas is increasing. Teleradiology, which is one way to ameliorate this gap, should be encouraged.

A cost comparison of travel models and behavioural telemedicine for rural, Native American populations in New Mexico

OBJECTIVE

The purpose of this study was to model the cost of delivering behavioural health services to rural Native American populations using telecommunications and compare these costs with the travel costs associated with providing equivalent care.

METHODS

Behavioural telehealth costs were modelled using equipment, transmission, administrative and IT costs from an established telecommunications centre. Two types of travel models were estimated: a patient travel model and a physician travel model. These costs were modelled using the New Mexico resource geographic information system program (RGIS) and ArcGIS software and unit costs (e.g. fuel prices, vehicle depreciation, lodging, physician wages, and patient wages) that were obtained from the literature and US government agencies.

RESULTS

The average per-patient cost of providing behavioural healthcare via telehealth was US$138.34, and the average per-patient travel cost was US$169.76 for physicians and US$333.52 for patients. Sensitivity analysis found these results to be rather robust to changes in imputed parameters and preliminary evidence of economies of scale was found.

CONCLUSION

Besides the obvious benefits of increased access to healthcare and reduced health disparities, providing behavioural telehealth for rural Native American populations was estimated to be less costly than modelled equivalent care provided by travelling. Additionally, as administrative and coordination costs are a major component of telehealth costs, as programmes grow to serve more patients, the relative costs of these initial infrastructure as well as overall per-patient costs should decrease.

Analysis of dominant factors affecting fatigue caused by soft-copy reading

RATIONALE AND OBJECTIVES

The aim of this study was to analyze the dominant factors affecting fatigue caused by soft-copy reading to identify a method for decreasing fatigue in clinical practice.

MATERIALS AND METHODS

Two types of fatigue-fatigue in the central nervous system and subjective visual fatigue-were evaluated using a critical fusion frequency test and a questionnaire administered to 17 male radiologists before and after soft-copy reading. Reading-induced fatigue was assumed to be affected by 20 hypothetical factors associated with personal characteristics, time required for reading, content or amount of reading, and the reading environment. We used multiple linear regression analysis with a variable selection method to detect the best combination of factors capable of expressing variations in each of the measured fatigue values. The effects of the detected (dominant) factors on fatigue were also examined based on coefficients of the dominant factors in multiple regression models.

RESULTS

Fatigue in the central nervous system decreased with a higher corrected visual acuity and a higher ambient illuminance in the reading room and was also affected by the type of monitor used. Visual fatigue was relieved when there was a larger difference in the brightness of the monitor and the surfaces surrounding the monitor and tended to be more severe when glasses rather than contact lenses were worn.

CONCLUSIONS

Increasing the ambient illuminance, using an appropriate type of monitor, improving the corrected visual acuity, and using contact lenses rather than eyeglasses could help decrease reading-induced fatigue in male radiologists.

Medical imaging displays and their use in image interpretation

The adequate and repeatable performance of the image display system is a key element of information technology platforms in a modern radiology department. However, despite the wide availability of high-end computing platforms and advanced color and gray-scale monitors, the quality and properties of the final displayed medical image may often be inadequate for diagnostic purposes if the displays are not configured and maintained properly. In this article-an expanded version of the Radiological Society of North America educational module "Image Display"-the authors discuss fundamentals of image display hardware, quality control and quality assurance processes for optimal image interpretation settings, and parameters of the viewing environment that influence reader performance. Radiologists, medical physicists, and other allied professionals should strive to understand the role of display technology and proper usage for a quality radiology practice. The display settings and display quality control and quality assurance processes described in this article can help ensure high standards of perceived image quality and image interpretation accuracy.

Do long radiology workdays affect nodule detection in dynamic CT interpretation?

PURPOSE

A previous study demonstrated decreased diagnostic accuracy for finding fractures and decreased ability to focus on skeletal radiographs after a long working day. Skeletal radiographic examinations commonly have images that are displayed statically. The aim of this study was to investigate whether diagnostic accuracy for detecting pulmonary nodules on CT of the chest displayed dynamically would be similarly affected by fatigue.

METHODS

Twenty-two radiologists and 22 residents were given 2 tests searching CT chest sequences for a solitary pulmonary nodule before and after a day of clinical reading. To measure search time, 10 lung CT sequences, each containing 20 consecutive sections and a single nodule, were inspected using free search and navigation. To measure diagnostic accuracy, 100 CT sequences, each with 20 sections and half with nodules, were displayed at preset scrolling speed and duration. Accuracy was measured using receiver operating characteristic curve analysis. Visual strain was measured via dark vergence, an indicator of the ability to keep the eyes focused on the display.

RESULTS

Diagnostic accuracy was reduced after a day of clinical reading (P = .0246), but search time was not affected (P > .05). After a day of reading, dark vergence was significantly larger and more variable (P = .0098), reflecting higher levels of visual strain, and subjective ratings of fatigue were also higher.

CONCLUSIONS

After their usual workday, radiologists experience increased fatigue and decreased diagnostic accuracy for detecting pulmonary nodules on CT. Effects of fatigue may be mitigated by active interaction with the display.

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.

Minimally invasive postmortem telebiopsy

For the past 10 years, medical imaging techniques have been increasingly applied to forensic investigations. To obtain histological and toxicological information, tissue and liquid samples are required. In this article, we describe the development of a low-cost, secure, and reliable approach for a telematic add-on for remotely planning biopsies on the Virtobot robotic system. Data sets are encrypted and submitted over the Internet. A plugin for the OsiriX medical image viewer allows for remote planning of needle trajectories that are used for needle placement. The application of teleradiological methods to image-guided biopsy in the forensic setting has the potential to reduce costs and, in conjunction with a mobile computer tomographic scanner, allows for tissue sampling in a mass casualty situation involving nuclear, biological, or chemical agents, in a manner that minimizes the risk to involved staff.

Teleradiology: evolution and concepts

Teleradiology has become a reality for several years now, but its existence still has not been freed from all controversies. From the beginning the military has been the driving force for teleradiology. Today teleradiology has many purposes worldwide ranging from services for expert or second opinions to international commercial diagnostic reading services. Ten years ago image quality, transmission speed and image compression were important issues of debate. Today the focus is on clinical governance, medico-legal issues and quality assessment. The increasing use of teleradiology reflects the changing world of clinical practice, service delivery and technology.

Long radiology workdays reduce detection and accommodation accuracy

PURPOSE

The aim of this study was to measure the diagnostic accuracy of fracture detection, visual accommodation, reading time, and subjective ratings of fatigue and visual strain before and after a day of clinical reading.

METHODS

Forty attending radiologists and radiology residents viewed 60 deidentified, HIPAA-compliant bone examinations, half with fractures, once before any clinical reading (early) and once after a day of clinical reading (late). Reading time was recorded. Visual accommodation (the ability to maintain focus) was measured before and after each reading session. Subjective ratings of symptoms of fatigue and oculomotor strain were collected. The study was approved by local institutional review boards.

RESULTS

Diagnostic accuracy was reduced significantly after a day of clinical reading, with average areas under the receiver operating characteristic curves of 0.885 for early reading and 0.852 for late reading (P < .05). After a day of image interpretation, visual accommodation was no more variable, though error in visual accommodation was greater (P < .01), and subjective ratings of fatigue were higher.

CONCLUSIONS

After a day of clinical reading, radiologists have reduced ability to focus, increased symptoms of fatigue and oculomotor strain, and reduced ability to detect fractures. Radiologists need to be aware of the effects of fatigue on diagnostic accuracy and take steps to mitigate these effects.

What factors affect the productivity and efficiency of physician practices?

BACKGROUND

Increasing the productivity and efficiency of physician practices could help relieve the rapid growth of US healthcare costs and the expected physician shortage. Radiology practices are an attractive specific focus for research on practices' productivity and efficiency because they are home to many purportedly productivity-enhancing operational technologies. This affords an opportunity to study the effect of production technology on physicians' output. As well, radiology is a leader in the general movement of physicians out of very small practices. And imaging is by the fastest-growing category of physician expenditure.

RESEARCH DESIGN

Using data from 2003 to 2007 surveys of radiologists, we estimate a stochastic frontier model to study the effects of practice characteristics, such as work hours, practice size, and output mix, and technologies used in work production, on practices' productivity and efficiency.

RESULTS

At the mean, the elasticities of output with respect to practice size and annual hours worked per full-time physician were 0.73 and 0.51, respectively. Some production technologies increase productivity by 15% to 20%; others generate no increase. Using "nighthawks"--ie, contracting out after-hours work to external firms that consolidate workflow--significantly increases practice efficiency.

CONCLUSIONS

The general US trend toward larger practice size is unlikely to relieve cost or physician shortage pressures. The actual effect of purportedly productivity-enhancing operational technologies needs to be carefully evaluated before they are widely adopted. As the recently-developed innovations of nighthawks and hospitalists show, practices should give more attention to a possible choice to "buy," rather than "make," part of their output.

Radiology practices' use of external off-hours teleradiology services in 2007 and changes since 2003

OBJECTIVE

Our objective is to report patterns of utilization of external off-hours teleradiology services (EOTSs) in 2007 and changes since 2003.

MATERIALS AND METHODS

We analyzed non-individually identified data from the American College of Radiology's 2007 Survey of Member Radiologists and its 2003 Survey of Radiologists. Responses were weighted to be nationally representative of individual radiologists and radiology practices. We present descriptive statistics and multivariable regression analysis results on the use of EOTSs in 2007 and comparisons with 2003.

RESULTS

Overall, 44% of all radiology practices in the United States reported using EOTSs in 2007. These practices included 45% of all U.S. radiologists. Out-of-practice teleradiology had been used by 15% of practices in 2003. Regression analysis indicates that, other practice characteristics being equal, in 2007, primarily academic practices had lower odds of using EOTSs than private radiology practices. Also, large practices (>or= 30 radiologists) had lower odds of using EOTSs than practices with 15-29 radiologists. Small practices (1-10 radiologists) had high odds, but nonmetropolitan practices did not. There were no significant differences by geographic region of the United States.

CONCLUSION

Use of EOTSs was widespread by 2007, and it had been increasing rapidly in the preceding few years. Patterns of use were generally as might be expected except that nonmetropolitan practices did not have high odds of using EOTSs.

Hageseth's principle of extraterritorial jurisdiction and international telemedicine

At what point does an international telemedicine transaction create a sufficient commercial nexus to allow one country the authority to impose its laws on a foreign telemedicine providers? Some light on this matter was shed by the US case of Hageseth versus Superior Court. The authority for extraterritorial jurisdiction is found in the US Constitution, which requires the states to cooperate in matters of law enforcement. Similar cooperation from foreign nations cannot be expected. Unless a defendant is charged with a capital offence, nations are rarely willing to extradite their citizens. As the unlicensed practice of medicine is not a capital offence, it is unlikely that an unlicensed telemedicine provider would be extradited to the US. Because low-volume unlicensed offshore telemedicine providers are unlikely to be extradited or to be subject to trade sanctions, they may be able to operate beyond the law.

The reasons that many radiology practices don't use off-hours services

PURPOSE

To compare radiology practices that use external, internal, and no off-hours services.

METHODS

From August 2005 to June 2006, 300 nonspecialty hospitals randomly selected from the AHA Guide 2005 Edition were contacted by telephone, e-mail, and mail, with attempts made to speak to the chiefs of radiology. A total of 115 responses were obtained (a 38.3% response rate), with 64 from radiology practices that used external off-hours services, 13 from practices with internal services, and 38 from practices with no services. The demographics of the practices in the 3 categories were compared, and answers to category-specific survey questions were tabulated. Responses were analyzed using descriptive statistics.

RESULTS

Radiology practices using internal off-hours services were significantly larger (mean size, 19.9 full-time radiologists) than those using external off-hours services (mean size, 8.2 full-time radiologists) and those not using any off-hours service (mean size, 10.7 full-time radiologists). A sufficient number of radiologists or residents covering nights had the highest reported importance in the decision not to adopt an external service. Cost and quality concerns were also cited. The consistency of interpreting radiologists known to a practice had the highest importance in the decision to use an internal rather than an external off-hours service. Frequent reasons cited for radiologists to take regular internal off-hours employment were financial incentives provided and a preference for off-hours shifts.

CONCLUSIONS

As long as there are sufficient numbers of radiologists and residents to handle the volume of interpretations, many practices will not use external off-hours services. Such services could help increase their adoption by offering lower cost and proven quality.

Radiologists' clinical practice of neuroimaging

PURPOSE

Because of the importance of neuroimaging as a radiology subspecialty, the aim of this study was to provide a detailed portrait of the demographics, clinical activities, and practices of radiologists heavily involved in neuroimaging.

METHODS

The authors analyzed data from the ACR's 2003 Survey of Radiologists, a large, stratified random-sample survey in which respondents were guaranteed confidentiality. The survey achieved a 63% response rate, and responses were weighted to make them representative of all radiologists in the United States.

RESULTS

Three-fourths of US radiologists reported doing neuroradiology; 9% reported that neuroradiology was their main subspecialty, and 9% reported spending more than 50% of their clinical work time doing neuroradiology. Of these latter two categories, more than about 75% had certificates of added qualification (CAQs) in neuroradiology, and more than 80% had done neuroradiology fellowships. However, of those spending more than 50% of their clinical work time doing neuroradiology, 7% neither had CAQs nor had done fellowships in the field. One-fourth of radiologists with CAQs or who had done neuroradiology fellowships spent less than 30% of their clinical work time doing neuroradiology. One-third to one-half of neuroimaging was performed by radiologists not heavily involved in the field. Only 6% to 8% of radiologists heavily involved in the field were women, compared with 22% in other subspecialties.

CONCLUSIONS

Neuroimaging has the great strength of being a relatively well-integrated subspecialty in that a very large majority of those heavily involved in its practice have CAQs and did fellowships in the field. Among possible concerns are the relatively few women in the field and the apparent waste of expertise resulting from one-fourth of those with neuroradiology subspecialty training or certification being relatively little immersed in its practice.

DicomWorks Teleradiology: secure transmission of medical images over the internet at low cost

We developed a completely secured teleradiology solution tailored for e-mail teleradiology applications at low-cost. Data processing consists in creating a couple of files with an encrypted and compressed image archive and a 128 bits decoding key file. No proprietary file format or encryption scheme is used. Files are exchanged using the e-mail (SMTP and POP) protocols, but FTP or sFTP can be used for better performances. Software includes original features such as real-time interactive JPEG compression, instant archive preview or secured data cleanup when a user logs off. We believe that this flexible, integrated and easy to use solution is a robust alternative to more complex architectures for simple image transmissions or occasional circumstances.