Where Does Telemedicine Achieve a Cost Reduction Effect? Cost Minimization Analysis of Teleradiology Services in Japan

Background: Telemedicine as a technology is expected to resolve issues such as doctor shortages and disparities in medical services. However, high costs of system installation and maintenance inhibit its widespread use. Introduction: This study involved a cost minimization analysis for installation of a teleradiology system in the Hokkaido prefecture of Japan. Conditions under which system utilization is cost-efficient and system utilization is effective for cost reduction were analyzed. Materials and Methods: A cost minimization analysis was conducted using three geospatial points of 50, 100, and 200 km from Sapporo city, the prefectural capital of Hokkaido, assuming a central imaging diagnosis center in Sapporo. The analysis was conducted from the standpoint of both patients and requesting hospitals. Results: From the patient's standpoint, a cost reduction effect was observed at all three distances from system installation. In contrast, from the hospital's standpoint, a cost reduction effect was found only when teleradiology examination was conducted from a distance of at least 100 km from Sapporo. Discussion: Results show that the cost reduction effect for patients increased as the travel distance increased. Although the teleradiology service is beneficial for a wide range of patients, the financial burden on requesting hospitals is significant. Conclusions: The following conditions were found necessary to reduce the requesting hospital's financial burden: the hospital should be far from the imaging diagnosis center, an inexpensive system is to be selected, and the system needs to be utilized continuously.

An economic evaluation of Japanese telemedicine, focusing on teleradiology and telepathology

We collected information by postal survey from 622 medical institutions reported to be using telemedicine in Japan. The questionnaire asked about willingness to pay (WTP) for telemedicine and willingness to undertake (WTU) it. The Kernel Estimation Method was used to obtain WTP for teleradiology (4379 yen), telepathology (9526 yen), teleconferencing (2084 yen) and teleconsultation (633 yen). The estimated WTU were teleradiology (3875 yen), telepathology (17,918 yen), teleconferencing (3230 yen) and teleconsultation (3643 yen). These values are larger than the current charges that customers actually pay or providers receive. Multiplying these values by the number of medical institutions that had implemented telemedicine allows the total annual benefits of telemedicine to be estimated, e.g. for teleradiology, the annual benefit in terms of WTP and WTU (millions of yen per year) were 140.20 and 1101.75, respectively. Based on the results of the survey, specific policy measures to promote telemedicine further include improvement of quality and reimbursement.

The Empirical Foundations of Teleradiology and Related Applications: A Review of the Evidence

INTRODUCTION

Radiology was founded on a technological discovery by Wilhelm Roentgen in 1895. Teleradiology also had its roots in technology dating back to 1947 with the successful transmission of radiographic images through telephone lines. Diagnostic radiology has become the eye of medicine in terms of diagnosing and treating injury and disease. This article documents the empirical foundations of teleradiology.

METHODS

A selective review of the credible literature during the past decade (2005-2015) was conducted, using robust research design and adequate sample size as criteria for inclusion.

FINDINGS

The evidence regarding feasibility of teleradiology and related information technology applications has been well documented for several decades. The majority of studies focused on intermediate outcomes, as indicated by comparability between teleradiology and conventional radiology. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include reductions in patient transfer, rehospitalization, and length of stay.

Organizational centralization in radiology

Traditionally, hospitals have a radiology department, where images are taken and interpretation occurs. Teleradiology makes it possible to capture images in one location and transmit them elsewhere for interpretation. Organizational centralization of radiology interpretations is therefore of interest. Empirical data have been collected in qualitative interviews of 26 resource persons with substantial experience with picture archiving and communication systems and teleradiology, from 12 departments of radiology in Norway. The response rate was 90%. A total of 21 theoretically possible types of centralization of image interpretation were identified, representing combinations of three categories of geographical centralization, and seven categories of centralization according to function. Various advantages and disadvantages of centralization were identified. Organizational changes may be decisive for the future of teleradiology, but it may be wise to plan for change in small steps, since we know little about how broad future organizational changes based on teleradiology will be, or what will decide how far particular organizations will go.

[Teleradiology in a family practice on the Dutch island of Ameland: a cost-benefit analysis]

OBJECTIVE

To calculate the costs and benefits of the introduction of teleradiology at a general practice on the Dutch island of Ameland from the perspectives of three different entities: (a) the family doctor (investor); (b) patients; and (c) health insurance companies.

DESIGN

Descriptive, cost-benefit analysis.

METHOD

For the year 2009, one and a half years after the introduction of a teleradiology facility at a general practice in Ameland, the operational and financing costs, the patient's saved travel time and expenses and the teleradiology costs for health insurance companies were compared with the costs that would have been made without teleradiology.

RESULTS

In 2009, 426 X-rays had been taken at the general practice of which 241 for trauma and 185 for non-traumatic cases. With a reimbursement of € 100 per X-ray taken during normal working hours and € 200 for those taken during evenings and weekends, benefits for the family doctor (investor) were € 46,698 and the costs amounted to € 45,710, or a positive balance of € 980. Patients' savings in travel time and expenses were calculated at € 111,068. Health insurance companies reimbursed a minimum of € 89,265 less on diagnosis and treatment.

CONCLUSION

The introduction of teleradiology a general practice in Ameland resulted in a considerable cost reduction for patients as well as for health insurance companies. In the future, diagnosing in this manner could be expanded in particular to regions in which the distances to hospitals are greater: a part of secondary healthcare could be conducted at a reduced cost.

Teleradiology: friend or foe? What imaging's now indispensable partner means for radiology's future and for the quality of care

Over the past half decade, teleradiology companies have served as invaluable business partners to local radiology providers grappling with declining reimbursements, shrinking budgets, and an imaging utilization explosion that has rendered workloads unmanageable. The teleradiology business model has helped to stabilize local imaging groups through economies of scale to control costs, by facilitating rapid workflow and report turnaround times, and offering a broad range of subspecialty expertise. Teleradiology has landed radiology at an important crossroads and market forces are actively shaping its future. This article examines the role of technological innovation in teleradiology's success, and suggests that persistent technological and operational limitations raise important questions regarding quality of care. This article also joins the imaging industry's discussion as to whether radiology can be (or has been) commoditized, and explores the feasibility of the commoditization of imaging and its impact on traditional radiology practice. There appears to be an important role for teleradiology in the provision of radiology services going forward, and yet boundaries must be thoughtfully drawn in order to achieve best practices for the specialty's future. tion, commoditization.

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.

Burden of cancer and projections for 2016, Indian scenario: gaps in the availability of radiotherapy treatment facilities

Plausible projections of future burden of cancer in terms of incident cases and requirement of radiotherapy treatment facilities at the national and state level are useful aids in planning of cancer control activities. The present communication attempts to provide a scenario for cancer in India during the year 2001 and its likely change by 2016 for all sites of cancer as well for selected leading sites. Further, a study was made of: (i) the state-wise distribution of radiotherapy treatment facilities and short falls; and (ii) pattern of investment of finances through central assistance by Government of India for cancer control activities during the various plan periods. The age, sex and site-wise cancer incidence data along with populations covered by 12 Indian population based cancer registries were obtained from the eighth volume of Cancer Incidence in Five Continents (CIV-VIII) and other published reports. Pooled age sex, site specific cancer incidence rates for twelve registries were estimated by taking weighted average of these registries with respective registry population as weight. Population of the country and states according to age and sex for different calendar years viz. 2001, 2006, 2011 and 2016 were obtained from the report of Registrar General of India. Population forecasts were combined with the pooled incidence rates of cancer to estimate the number of cancer cases by age, sex and site of cancer for the above 5-yearly periods. The existing radiotherapy facilities available in the country for cancer treatment during the year 2006 was based on the published reports and updated through personal communication from the Ministry of Health of India. During the year 2001, nearly 0.80 million new cancer cases were estimated in the country and this can be expected to increase to 1.22 million by 2016 as a result of change in size and composition of population. The estimated numbers were greater for females (0.406 millions, 2001) than males (0.392 millions, 2001). Lung, esophagus, stomach, oral and pharyngeal cancers are much higher in men while in women, cancers of cervix and breast are predominant forms followed by those of oral cavity, stomach and esophagus. Considering all the sources, it was noted that during the year 2006, there were 347 teletherapy units in the country as against a requirement of 1059. The state-wise analysis of the distribution of RCCs, and radio-therapy units shows wide gaps in the availability of facilities. The existing treatment facilities for cancer control in-terms of radiotherapy and financial allocation are woefully inadequate to take care of even the present load. The only way to fight this scourge under such circumstances is to have pragmatic programmes and policies based on currently available scientific information and sound public health principles.

DicomWorks: software for reviewing DICOM studies and promoting low-cost teleradiology

DicomWorks is freeware software for reading and working on medical images [digital imaging and communication in medicine (DICOM)]. It was jointly developed by two research laboratories, with the feedback of more than 35,000 registered users throughout the world who provided information to guide its development. We detail their occupations (50% radiologists, 20% engineers, 9% medical physicists, 7% cardiologists, 6% neurologists, and 8% others), geographic origins, and main interests in the software. The viewer's interface is similar to that of a picture archiving and communication system viewing station. It provides basic but efficient tools for opening DICOM images and reviewing and exporting them to teaching files or digital presentations. E-mail, FTP, or DICOM protocols are supported for transmitting images through a local network or the Internet. Thanks to its wide compatibility, a localized (15 languages) and user-friendly interface, and its opened architecture, DicomWorks helps quick development of non proprietary, low-cost image review or teleradiology solutions in developed and emerging countries.

Report of the ACR task force on international teleradiology

Telemedicine is becoming an increasingly important tool in the practice of medicine throughout the world. For radiologists, telemedicine translates to teleradiology. Because an increasing amount of imaging is now archived in a digital format, and with the application of more powerful computers in radiology, digital image transmission between display stations is becoming commonplace. The ability to move large diagnostic image data sets to display stations anywhere in the world using the Internet and other high-speed data links is solving some problems and creating others. Medicine and radiology will be challenged in many ways by the issues created from the application of this burgeoning technology. Our task force was charged with investigating the evolving practice of international teleradiology and with developing a pubic statement to be adopted by the ACR Council (). This white paper is our effort to define those issues we believe to be most pertinent to international teleradiology as we know them today. Will these issues be changing? Certainly. For some facets of the issue, there are currently more questions than answers. We describe several scenarios that we believe are acceptable practices of international teleradiology as well as some that are not. We believe that much will be written about international teleradiology in the future as the issues of credentialing, quality assurance, licensure, American Board of Radiology certification, the maintenance of certification, jurisdictional and medical liability issues, patient privacy, fraud and medical ethics are more precisely defined and shaped by state and federal legislation and medical jurisprudence. This white paper is our assessment of what we believe to be the major challenges that exist as of this writing.

Commoditization of the international teleradiology market

Telemedicine improves access to medical care. However, telemedicine will also increase market volatility because of its ability to stimulate price competition and the insidious way it shifts liability for providing medical services. To cope with increased volatility, other economic sectors have evolved commodities markets by making greater use of standardized forward/future contracts. In the past, the need for medical services to be produced and consumed locally and a lack of an objective definition for medical quality, prohibited the use of forward contracts for health-care services. However, telemedicine, and the increasing use of statistical definitions of medical quality now make standardized forward contracts for health-care services conceivable. Commoditization of teleradiology would offer several advantages including increasing market transparency, a mechanism for ensuring medical quality, and a means for bringing capital into the health-care sector. To reap the benefits of a commodities market in teleradiology, the key will be for market stakeholders to overcome their fear of the unknown in order to organize a central exchange.

Teleradiology: a case study of the economic and legal considerations in international trade in telemedicine

Growth in the global market for telemedical services is being driven by economics. Two operational models are already recognizable. "Nighthawk" providers are virtually indistinguishable from their domestic counterparts with respect to medical malpractice liability and price for service. Indian providers, in contrast, offer deep price discounts on services, but jurisdictional loopholes are likely to allow these providers a method to avoid medical malpractice liability. Hospitals that outsource their radiology services need to be aware of these differences, because hiring Indian telemedical providers will likely result in a shift of medical malpractice liability from providers to hospitals.

Referring Physicians' Attitudes Toward International Interpretation of Teleradiology Images

OBJECTIVE

We evaluated referring physician attitudes toward the international interpretation of radiologic images.

MATERIALS AND METHODS

A five-question, scenario-based survey describing features of a hypothetic local radiology firm compared with those of its hypothetic overseas counterpart, international radiology, was sent by mail to 350 physicians from a broad range of medical and surgical specialties. One hundred nineteen physicians responded, for a response rate of 34%. Referring physicians were asked to indicate their preference for local versus international interpretation in each scenario using a 5-point Likert scale, with a score of -2 indicating a strong preference for international services, 0 indicating no preference, and 2 indicating a strong preference for local services.

RESULTS

When all variables are held to be equal, referring physicians strongly prefer local services (mean score, 1.77; SD, 0.77). When international teleradiology provides either a 2-day faster turnaround time for reports or a 30 dollars lower out-of-pocket cost to the patient, referring physicians still prefer local services, although less than they did with all variables held equal (mean score, 0.42-0.44; SD, 1.30-1.40). When international teleradiology provides both a 2-day faster turnaround time and a 30 dollars lower out-of-pocket cost to the patient, referring physicians preferred international teleradiology, albeit only slightly (mean, -0.25; SD, 1.50). Finally, when the credentials of the international radiologists are perceived to be less than those of the local radiologists, even in the face of faster turnaround time and 30 dollars lower cost to the patient, referring physicians overall strongly prefer local services (mean, 1.51; SD, 0.86).

CONCLUSION

Referring physicians prefer local interpretation of radiologic images to international interpretation when all things are equal. However, the timeliness of image interpretation and the cost to the patient are important factors in this decision.

Telemedicine in wound healing

Better care for patients and improved health care depends on the availability of good information which is accessible when and where it is needed. The development of technology, more specifically the Internet, has expanded the means whereby information can be acquired and transmitted over large distances enabling the concept of telemedicine to become a reality. Telemedicine, defined as the practise of medicine at a distance, encompasses diagnosis, education and treatment. It is a technology that many thought would expand rapidly and change the face of medicine. However, this has not happened and during the last decade although certain telemedicine applications, such as video-consulting and teleradiology, have matured to become essential health care services in some countries, others, such as telepathology, remain the subject of intensive research effort. Telemedicine can be used in almost any medical specialty although the specialties best suited are those with a high visual component. Wound healing and wound management is thus a prime candidate for telemedicine. Development of a suitable telemedical system in this field could have a significant effect on wound care in the community, tertiary referral patterns and hospital admission rates.

Cost-effective handling of digital medical images in the telemedicine environment

BACKGROUND

This paper concentrates on strategies for less costly handling of medical images. Aspects of digitization using conventional digital cameras, lossy compression with good diagnostic quality, and visualization through less costly monitors are discussed.

METHOD

For digitization of film-based media, subjective evaluation of the suitability of digital cameras as an alternative to the digitizer was undertaken. To save on storage, bandwidth and transmission time, the acceptable degree of compression with diagnostically no loss of important data was studied through randomized double-blind tests of the subjective image quality when compression noise was kept lower than the inherent noise. A diagnostic experiment was undertaken to evaluate normal low cost computer monitors as viable viewing displays for clinicians.

RESULTS

The results show that conventional digital camera images of X-ray images were diagnostically similar to the expensive digitizer. Lossy compression, when used moderately with the imaging noise to compression noise ratio (ICR) greater than four, can bring about image improvement with better diagnostic quality than the original image. Statistical analysis shows that there is no diagnostic difference between expensive high quality monitors and conventional computer monitors.

CONCLUSION

The results presented show good potential in implementing the proposed strategies to promote widespread cost-effective telemedicine and digital medical environments.

Cardiovascular PACS: recent KLAS findings

To assist in providers' need for knowledge in this important area, KLAS conducted a study focusing on uses, benefits and challenges with Cardiovascular PACS (CPACS)--as reported by providers themselves. The report focuses on several considerations, including: quantifiable benefits; functional strength of remote cardiac image management; and advice for choosing and implementing a CPACS system.

Diagnosing pneumonia in rural Thailand: Digital cameras versus film digitizers for chest radiograph teleradiology

Background

Accurate surveillance for pneumonia requires standardized classification of chest radiographs. Digital imaging permits rapid electronic transfer of data to radiologists, and recent improvements in digital camera technology present high quality, yet cheaper, options.

Methods

We evaluated the comparative utility of digital camera versus film digitizer in capturing chest radiographs in a pneumonia surveillance system in rural Thailand using a panel of radiologists; the gold standard was the hard-copy radiograph. We calculated sensitivity and specificity and conducted a receiver operator characteristics (ROC) analysis.

Results

Of the 192 radiographs from patients with clinical pneumonia, 166 (86%) were classified as pneumonia on the hard copies. Sensitivity and specificity for identifying pneumonia were 89% and 73% for the camera and 90% and 65% for the digitizer. In the ROC analysis, there was no statistically significant difference in the area under the curve (camera, 0.86; film digitizer, 0.91, p = 0.29). The digital camera set cost $965 compared to $3000 for the film digitizer.

Conclusion

Detection of pneumonia was not measurably compromised by using digital cameras compared with film digitizers. The 3-fold lower cost of the digital camera makes this technology an affordable and widely accessible alternative for surveillance systems, vaccine trials, and perhaps clinical use.

Cost-minimization analysis of a wide-area teleradiology network in a French region

OBJECTIVE

The objective of our study was to perform a cost-minimization analysis of a wide-area teleradiology network.

DESIGN

A prospective analysis of all transmissions over 1 year (data transmitted at the time of the remote consultation, and health outcomes of patients from medical record).

INTERVENTION

The inter-hospital teleradiology network of the Aquitaine area (RIHRA) is a telemedicine system enabling the management of remote emergencies and elective radiology consultations.

MAIN OUTCOME MEASURE

A cost-minimization study enabled a comparison of care procedures following the use of the network with those which would have been implemented without the network. The outcome measures of effectiveness were the transfers, hospitalizations, and consultations avoided or added. Fixed and variable costs were estimated.

RESULTS

Among the 664 transmissions included in the study, 562 (85%) were performed in emergency and 102 (15%) for elective (non-emergency) cases. In emergency, 48% of transfers were avoided. For elective teleconsultations, a transfer was avoided for 37% of the patients and hospitalization for 12%. An extra consultation occurred after remote consultation for 2% of the patients. Annual saving can be estimated at 102,779 EUR for the Aquitaine area.

CONCLUSIONS

This study underlines the efficiency of an inter-hospital teleradiology network. A qualitative evaluation of the impact of the use of the system should be carried out to improve technical and organizational operations.

[Teleradiology: economic research analysis of CT investigations in a small hospital]

PURPOSE

To evaluate, discuss and compare economic aspects of teleradiological applications in CT examinations in a small hospital. Scenario (1): CT examination by an extern institution including transport of a patient. Szenario (2): External consultation of an internal CT examination (teleradiology according to ROV). Scenario (3): Complete in-house radiology department. To evaluate economic aspects of teleradiology service providers.

MATERIALS AND METHODS

Costs have been separated into fixed and variable costs in a model. Total costs of 500 CT examinations per year have been calculated for the three scenarios. A break-even analysis has been performed to determine the necessary/minimal number of CTs per year for economical advantages. The number of CT consultations for teleradiology service providers to make profit has been calculated.

RESULTS

Scenario (1): This is the most cost-effective scenario for 500 CTs per year, but most time-consuming. Beyond 548 CTs per year using a single slice CT and 965 CTs per year using a multislice CT the teleradiology scenario [scenario (2)] is most cost-effective. Beyond 1065 CTs per year an in-house radiology department [scenario (3)] is economically reasonable. On the basis of 30 Euros per CT consultation a teleradiology service providing system will be profitable starting from 322 CT consultations per year.

CONCLUSION

Teleradiology applications are economically reasonable in a wide range in small hospitals. CT teleradiology services can also be provided on a cost-effective basis at a reachable number of consultations.

Acquisition and evaluation of radiography images by digital camera

To determine applicability of low-cost digital imaging for different radiographic modalities used in consultations from remote areas of the Ecuadorian rainforest with limited resources, both medical and financial. Low-cost digital imaging, consisting of hand-held digital cameras, was used for image capture at a remote location. Diagnostic radiographic images were captured in Ecuador by digital camera and transmitted to a password-protected File Transfer Protocol (FTP) server at VCU Medical Center in Richmond, Virginia, using standard Internet connectivity with standard security. After capture and subsequent transfer of images via low-bandwidth Internet connections, attending radiologists in the United States compared diagnoses to those from Ecuador to evaluate quality of image transfer. Corroborative diagnoses were obtained with the digital camera images for greater than 90% of the plain film and computed tomography studies. Ultrasound (U/S) studies demonstrated only 56% corroboration. Images of radiographs captured utilizing commercially available digital cameras can provide quality sufficient for expert consultation for many plain film studies for remote, underserved areas without access to advanced modalities.

[Teleradiologic follow up of patients treated with aortic stent grafting]

BACKGROUND

A study has confirmed the possibility of follow up in the local hospital of patients who have undergone endovascular repair. We present a cost analysis of such a regimen compared to follow up at a university hospital.

MATERIAL AND METHODS

By using discharge data from the Norwegian Patient Register we identified a group of patients which could have been followed up at their local hospital for their stent-grafted abdominal aortic aneurysm and estimated the cost effects of performing follow ups locally.

RESULTS

The cost analysis showed a potential for cost savings from local follow ups, especially from moving from inpatient care at the university hospital to outpatient care locally. The result of this cost analysis differs from other Norwegian studies of teleradiology by identifying a possibility for more cost-effective treatment.

INTERPRETATION

Using teleradiology to follow up these patients will free up capacity in the university hospital. Most probably, other groups of patients can also be followed up by teleradiology. The university hospitals can use this freed-up capacity for new patients. Teleradiology could lead to more efficient use of health care facilities, which should be in the interest of the health authorities.

Three-Dimensional Teleradiology for Surveillance Following Endovascular Aortic Aneurysm Repair:A Feasibility Study

PURPOSE

To study the feasibility of 3-dimensional (3D) teleradiology in surveillance of patients treated with stent-grafts for abdominal aortic aneurysm (AAA).

METHODS

Between April 2002 and November 2003, 8 AAA patients (7 men; median age 73 years, range 62-84) with stent-grafts had follow-up computed tomograms (CT) performed at their local hospital and transmitted without loss across a broadband connection to the university hospital. On both monitors, the radiologists were presented with the complete CT axial dataset, sagittal and coronal reformatted slices, and a 3D volume-rendered reconstruction. The two radiologists were then able to simultaneously perform measurements and real-time manipulations of the axial and 3D pictures, which were discussed over the telephone or using a videoconferencing unit. Patient satisfaction, the radiologists' evaluation of the method, and the potential cost savings were explored.

RESULTS

Twelve follow-up CT scans were performed on the 8 patients. The time for transmission over the teleradiological network averaged 5 minutes, and the evaluation required 15 minutes at the university hospital. The overall technical quality of the images was rated as good by the university radiologist. In 11 studies, the stent-grafts were satisfactory, but a type III endoleak was detected in one 5.5-year-old stent-graft. Neither radiologist had a problem identifying the endoleak. Patients had confidence that the examination at the local hospital was of good quality; they all felt that they received good care and were pleased with avoiding travel to the university hospital. From the economic analysis, an annual savings of 40,000 Euros (USD 52,304) was projected, mostly due to avoiding hospital stays and outpatient consultations at the university hospital.

CONCLUSIONS

The experiences from this study are encouraging, but a larger series will be necessary for a thorough evaluation of 3D teleradiology as a surveillance method for aortic stent-graft patients.

[Is teleradiology service in primary health care cost-effective?]

BACKGROUND

Not many analyses have been performed of the cost-effectiveness of telemedicine services. A teleradiology service linking a general practice in rural Norway up with the local hospital in the nearest town was established in 1998.

METHODS

Savings on traveling expenditure were registered for all patients who underwent elective examinations in Otta during the first year of service. Over a four-month period in 2002, records were made of whether patients undergoing emergency examinations were taken in to the local general practice or referred to the hospital. These data are key factors in the evaluation of cost-effectiveness. The method employed is a cost-minimisation analysis in which the costs of teleradiology are compared to the costs incurred when patients go to hospital for a radiological examination.

RESULTS

On the basis of data for 3006 patients, an estimated annual NOK 1.4 million (USD 200,000) were saved on travelling expenditures and by patients or their employers because of working hours not lost. Annual costs of NOK 50,000 were avoided because radiological examinations in the surgical out-patient clinic are no longer necessary. Annual costs of NOK 400,000 include investments in equipment, lease of a broadband connection, and less efficient utilization of equipment and surgeries. Examinations done twice incurred estimated annual costs of NOK 40,000. The cost-minimization analysis shows that on an annual basis the service saves costs of NOK 1 million (USD 160,000).

INTERPRETATION

This study shows that telemedicine is most likely to be cost-effective when annual patient load and travel costs are high, together with relatively low investment costs.

Telemetry takes off

After a slow start, payers are signing on to the telemedicine trend, as rural hospital and major medical centers come to see the benefits of cooperation.

Economic impact of real-time teleradiology in thoracic CT examinations

Conventional teleradiology is a useful tool, but sometimes we have found it to be an insufficient means of investigation because the radiological specialists cannot indicate the imaging protocol during the investigation. The purpose of our study was to evaluate the efficacy of real-time teleradiology, which will improve the quality of medical management. Ten radiologists evaluated thoracic CT scans of 50 patients transmitted through teleradiology retrospectively. We evaluated whether or not the contrast enhancement study was performed effectively on the basis of the clinical data and after interpretation of the pre-contrast scans. The clinical data showed that 47.6% of the CT contrast enhancement examinations were not necessary. After interpretation of the pre-contrast CT scans, 66.6% of the contrast-enhanced scans were considered unnecessary. Real-time teleradiology will improve the quality of medical management providing the virtual presence of radiologists, and will save medical costs.

[Teleradiology for emergency cranial computed tomography]

PURPOSE

We report our experience with the teleradiologic service provided by a center hospital (CH) for emergency cranial computed tomography (CCT) in two regional hospitals (RH) during a 12-month period. The clinical and economic impact of teleradiology will be discussed as well as the acceptance by the clinicians of the regional hospitals.

MATERIAL AND METHODS

In 2001, 213 CT-scans in 202 patients were performed and reported using teleradiology. Teleradiologic and final medical diagnosis were analysed by the medical reports. The transfer of the patients to a CH and their further treatment were checked. The referring physicians in the RH were asked to complete a questionnaire about the teleradiological support.

RESULTS

18 (9 %) patients had to be urgently transferred to a CH based on the CT findings in the teleradiological reports. 24 patients (11 %) were transferred to a center hospital during further treatment. 80 % of patients were treated in the RH.

CONCLUSION

CT data transfer is reliable and efficient. Teleradiology reduces costs by avoiding unnecessary transport of patients for diagnostic procedures. Teleradiology improves patient management by reducing time from admittance to decide about further treatment. Teleradiology enables rapid selection of the best-equipped center hospital for the management of the patient's disease. Teleradiology is well accepted by the physicians in the RH. In the RH, teleradiology has become an indispensable standard procedure in the emergency diagnostic workup of cerebral trauma patients and in patients with acute unclear neurological symptoms.

Evaluation of a "no-cost" Internet technology-based system for teleradiology and co-operative work

The aim of this study was to assess the suitability of a no-cost system based on standard Internet technology components for teleradiology. The system was composed of free software (communication, DICOM viewer, compression) and standard off-the-shelf hardware components. For different image (CR, CT, MR) and network types (LAN and ISDN) the File Transfer, Audio and Video Conference, and Co-operative Work properties were examined and compared with the literature referring to standard complete packages and dedicated teleradiology systems. The main advantages of the no-cost system are: price; ease of use; independence from specific hardware; and potential connection to any possible partner. The performance of the File Transfer and the Audio and Video Conference was comparable to the other system groups with slight disadvantages in the usability. For Co-operative Work the employed "application sharing" technology does not meet the clinical requirements, which applies identically to the standard complete packages. Here the specialized systems prove superior, although they are proprietary. With minimal restraints the evaluated no-cost solution can be used for File Transfer and Conference scenarios. The usage for Co-operative Work with ISDN is not recommended, unless for the purpose of gaining experience or when dealing with small amounts of cases or images.

Design of a centralized telemedicine model in Palestine

To provide patients with easy-access telemedicine services in Palestine, a simple and low-cost telemedicine system has been established. The system is based on a star topology network between local hospitals and a main telemedicine centre. In a pilot trial, a computerized tomography image was transmitted from a local hospital connected to the telemedicine service centre by ISDN (128 kbit/s). A videoconferencing discussion between the two ends was held. The performance of the system was satisfactory. The transmission time for a 1 MByte image was about 60 s. A conference was conducted to discuss this real clinical case by use of interactive sharing of the medical record. The session lasted 20 min. Encouraging results were obtained. The pilot study suggests that telemedicine can overcome existing isolation problems of cities and villages and the difficulties of transferring patients from one location to another.

Telemedicine: an overview

Telemedicine involves the transfer of medical data for use in diagnosis, treatment and education. The interaction may involve two-way live audio and video visits between patients and medical professionals, sending patient monitoring data from the home to a clinic or transmitting patient images and medical file from a primary care provider to a specialist. Telemedicine is already widely used in radiology, cardiac monitoring and other forms of remote patient monitoring and in targeted population groups such as correctional care populations, the military and veterans' health care.

A review of the experience with teleradiology in Australia

Because of the geographical dispersion of the Australian population (25-30% of the total population of 20 million live outside metropolitan areas), there has been considerable interest in the use of teleradiology. In general, the provision of teleradiology by private radiology practices has been successful. However, as regards the provision of publicly funded, statewide teleradiology services, progress has been slower than expected, following enthusiastic support for the technology in the early 1990s. While there have been some notable successes in the implementation of publicly funded teleradiology services, given the delays that have been experienced in Australia, there is a case for a closer connection between the conduct of teleradiology evaluation studies and the incorporation of the results into health policy. This link would ensure that the benefits of technology are made available to the public in as short a time as possible.

Teleradiology in a military training area

A pilot teleradiology project was established for the medical service providers at the Pohakuloa Training Area (PTA) in Hawaii. It connected them with radiologists at Tripler Army Medical Center (TAMC) on the island of Oahu, approximately 400 km away. This involved changing the standard practice of sending soldiers from the PTA to a civilian hospital in Hilo for radiographs. These emergency trips to Hilo, 55 km away, were expensive, manpower intensive, and dangerous due to road and weather conditions. During 51 days of a training exercise involving 2600 personnel, 29 evacuations were avoided, which would have cost $36,569 in total. The expected savings during one year of training were $176,540. The cost of teleradiology during the first year, including the cost of the equipment, was $167,203. Over five years, the costs and savings were estimated to be $349,940 and $882,700, respectively.

Digitizing pediatric chest radiographs: comparison of low-cost, commercial off-the-shelf technologies

OBJECTIVE

To compare low-cost, off-the-shelf technology for digitizing pediatric chest radiographs.

MATERIALS AND METHODS

Forty pediatric chest radiographs (hard copy), each with a single abnormality, were digitized using a commercial film digitizer and two low-cost

METHODS

a digital camera and a flatbed scanner. A stratified, randomized, block design was used where 20 readers evaluated 40 different images to determine the ability to accurately detect the abnormality. Readers then rated all 160 images (40 images x 4 methods) for conspicuity of the abnormality and overall image quality.

RESULTS

Abnormalities were correctly identified on 82.3 % of hard copy images, 82.9 % of flatbed scanner images, 74.3 % of film digitizer images, and 69.7 % of digital camera images (p < 0.05) when compared to hard copy or flatbed scanner images. Lesion conspicuity was rated higher on hard copy (p < 0.05) than all digitized images. Conspicuity ratings were similar for flatbed scanner and film digitizer images, but lower in digital camera images (p < 0.05). For overall image quality, all were rated significantly different from each other (p < 0.05), with hard copy > flatbed scanner > film digitizer > digital camera images.

CONCLUSION

A low-cost flatbed scanner yielded digital pediatric chest images which were significantly superior to digital camera images While flatbed scanner images were interpreted with the equivalent diagnostic accuracy of hard copy images, they were rated lower for image quality and lesion conspicuity.

Multi-site interventional real-time procedure demonstrations with the use of integrated services digital network connections

PURPOSE

To evaluate the effectiveness and cost of commercially available video conferencing units and standard Integrated Services Digital Network (ISDN) connections for real-time multi-site transmissions of interventional procedures.

METHODS

A network of five separate interventional radiology departments-three in the Czech Republic and one each in Austria and the USA-was established using Polyspan (Polycom in the USA) View Stations and ISDN connections. This network was used for transmissions of 16 live interventional procedures to the Sixth International Workshop on Interventional Radiology in Prague, Czech Republic in June 2000.

RESULTS

The transmissions were successful and of sufficient quality to contribute to the educational success of the workshop. The cost of the ISDN transmissions was a fraction of satellite transmission costs.

CONCLUSION

Multi-site real-time interventional procedure transmissions using video conferencing Polyspan (Polycom) View Stations and ISDN connections are a promising means of improving interventional tele-education and decreasing its cost.

Remote-rendered 3D CT angiography (3DCTA) as an intraoperative aid in cerebrovascular neurosurgery

OBJECTIVE

To assess the viability and utility of network-based rendering in the treatment of patients with cerebral aneurysms, we implemented an intraoperative rendering system and protocol using both three-dimensional CT angiography (3DCTA) and perspective volume rendering (PVR).

MATERIALS AND METHODS

A Silicon Graphics InfiniteReality engine was connected via a Fast Ethernet network to a workstation in the neurosurgical operating room. A protocol was developed to isolate bone and vessels using an appropriate transfer function. Three-dimensional CT angiogram images were volume rendered and transmitted to the workstation using a bandwidth-conserving remote rendering system, and were rotated, cut using clipping planes, and viewed using normal and perspective views. Twelve patients with intracranial aneurysms were examined at surgery using this system.

RESULTS

Rendering performance at optimal operating bandwidths (50-60 Mb/s) was excellent, with regeneration of a high-resolution image in less than 1 s. Network performance varied in two cases, slowing image regeneration. Surgeons found the images to be useful as an adjunct to conventional imaging in understanding the morphology of complex aneurysms and their relationship to the skull base.

CONCLUSIONS

Intraoperative volume rendering using 3DCTA is achievable over a network, can reduce hardware costs by amortizing hardware among multiple users, and provides useful imaging information during the surgical treatment of cerebral aneurysms. Future operating suites may incorporate network-transmitted three-dimensional images as additional sources of imaging information.

Teleradiology at the tertiary-level Women's and Children's Hospital in South Australia

This article relates to a teleradiology trial undertaken in 1998-1999 at the Women's and Children's Hospital (WCH) in Adelaide, the capital of South Australia. The trial involved linking the hospital to a range of rural and remote sites in South Australia and the Northern Territory. The main aim of the project was to evaluate the advantages, limitations, benefits, and costs of a teleradiology service provided by WCH. The major finding from the study is that for a tertiary hospital providing second opinions in complex medical cases, a new form of business justification is required for teleradiology. The justification would include an emphasis on the range of high-level services that a subspecialist hospital such as the WCH can provide. The justification would also include the range of benefits to different parties, particularly the patient, and the intangible nature of many of the benefits.

[Digital imaging system are rapidly introduced in Swedish departments of radiography. This calls for new strategic planning]

Diagnostic radiology in Sweden is changing rapidly to digital (filmless) technique. The advantages are more rapid delivery of radiologic service, better working conditions and less negative effects on the environment. Teleradiology is also facilitated. The Swedish Board of Health and Welfare has investigated the speed with which this change is taking place. In 1998, 26 of the 118 departments of diagnostic radiology had already turned digital; it is estimated that in the near future at least five departments will become fully digital each year. For planning purposes, less emphasis should be put on the supply of radiographic film, and more on telecommunications, computer hardware and digital storage.

Transportation savings and medical benefits of a teleneuroradiological network

Since 1996, Turku University Central Hospital has offered teleradiology consultations regarding computerized tomography examinations of the brain to three regional hospitals in Finland, in which neurosurgical or neuroradiological specialist services are not available, in order to avoid unnecessary patient transportation. We performed a retrospective survey of the teleconsultations performed in 1998. Medical records and the relevant radiology images were obtained. During the study period, teleconsultations were carried out for a total of 83 patients, of whom 16 were transported to the university hospital (i.e. 81% of these patients had avoided unnecessary transportation). The total savings amounted to 42,100 ECU. Of the 16 transported patients, 12 were immediately operated on in the university hospital. It was judged that, because of the consultation service, the patients undergoing an operation had benefited from a more rapid and a more complete recovery. In 1998 the teleradiology consultation service was established as part of the routine work of the Medical Imaging Centre and a fee for its services was adopted.

Update on digital image management and PACS

Information technology is becoming a vital component of all health care enterprises, from managed care services to large hospital networks, that provides the basis of electronic patient records and hospital-wide information. The rationale behind such systems is deceptively simple: physicians want to sit down at a single workstation and call up all information, both clinical data and medical images, concerning a given patient. Picture archiving and communication systems (PACS) are responsible for solving the problem of acquiring, transmitting, and displaying radiologic images. The major benefit of PACS resides in its ability to communicate images and reports to referring physicians in a timely and reliable fashion. With the changes in economics and the shift toward managed and capitated care, the teleradiology component of PACS is rapidly gaining momentum. In allowing remote coverage of multiple sites by the same radiologists and remote consultations and expert opinion, teleradiology is in many instances the only option to maintain economically viable radiologic settings. The technical evolution toward more integrated systems and the shift toward Web-based technology is rapidly merging the two concepts of PACS and teleradiology in global image management and communication systems.

[Experiences with teleradiology in general practice in Oppland]

BACKGROUND

Our aim was to evaluate one year of operation of a newly established teleradiology service for people in Mid- and North Gudbrandsdalen (30,000 inhabitants). In Otta, one radiographer works with digital pictures (phosphorus plate technology). Pictures are sent to the local hospital in Lillehammer (115 kilometres away) by a broadband network (for health services only) for radiological evaluation.

MATERIAL AND METHODS

We have measured the scope of the service, patient satisfaction, management stability and efficiency, and financial aspects (the latter are not included in this article).

RESULTS

Over one year we have examined 3,081 persons (skeleton, thorax, sinuses). A majority of patients (90%) thought it was better for them to be examined at Otta. Waiting time was short, rarely more than one week. No re-examinations due to insufficient picture quality were required. Some expected and some unexpected problems occurred. Pictures from 37 patients were lost and could not be radiologically evaluated. The lead time from when pictures were taken to when the requisitioning doctor received the report, was too long (one to three weeks). The digital pictures are not easily available to hospital physicians. Copies must be made on film.

INTERPRETATION

Our experience is positive. Most problems will be solved by storing copies at Otta, by better organisation of the radiologic service, and by establishing a digital picture archiving and communication system (PACS) at the hospital.

The cost-effectiveness of teleradiology at the Women's and Children's Hospital in Adelaide

The cost-effectiveness of teleradiology was examined in a trial conducted at the Women's and Children's Hospital (WCH) in Adelaide, from February 1998 to February 1999. The trial showed that, with the large distances between remote hospitals and metropolitan hospitals, teleradiology, relative to the transfer of remote patients, could be highly cost-effective, but that a new form of cost justification is required for teleradiology for tertiary hospitals providing second opinions in special cases. A series of compelling case studies proved the economic and social value of teleradiology at the WCH.

Ethical issues in teleradiology

Teleradiology is the electronic transmission of radiographic images from one geographic location to another for the purposes of diagnosis and/or consultation. It raises interesting ethical and practical issues which have received relatively little attention in the radiology or ethics literature to date. These include confidentiality, data security and technological reliability, consent, competence, interprofessional and professional-patient relationships, and the organization of medical services. This paper reviews these issues, discussing how far these are new concerns in radiological practice, and makes suggestions for minimum ethical and professional standards for teleradiological practice.

Ultrasound and other imaging technologies in the intensive care unit

As technology advances, more imaging and procedures are performed at the bedside on critically ill patients in ICUs, thereby eliminating the risks of transporting patients. These imaging techniques can serve as diagnostic and therapeutic tools in treating the acute and chronic consequences of injured, critically ill patients. One area of growth is ultrasonography. Critical care applications of ultrasonography are expanding, and the learning curve of surgeons and intensivists performing some of these studies is improving. Ultrasonography can supplement physical examination and provide useful "real-time" information on nearly every body cavity. Other imaging technology is also available in a portable form, enabling imaging directly at the bedside. Images are now becoming readily and easily available with the advancement of teleradiology. Some of the imaging modalities are still in development, and their clinical effectiveness is being studied. In the future, more uses of these various imaging technologies may become evident and cost-effective.

Economic analysis of teleradiology applications with KAMEDIN

The teleradiology system KAMEDIN (German Telekom), installed on HP-Unix- and NT-Workstations, was evaluated in different scenarios and a cost-benefit-analysis was performed. CT examinations were transferred from a PACS workstation (GE) to KAMEDIN using DICOM-3 protocol. Teleconferences were realized with an intensive care unit by LAN, with a radiology department at 5 km. distance by ISDN, and with an on duty radiologist 22 km. away by ISDN. On average, 36 CT slices per patient were transferred. Overall costs (costs for hardware, software, support, ISDN-fees, and staff) were compared to possible cost reduction, mainly concerning transportation and films. These three scenarios could be realized during daily routine work. Differing in their amount of transportation cost reduction, two applications (intensive care unit, radiologist on duty) showed a break-even at 1817, respectively 528 teleconferences/year. Improvement of cost-effectiveness can be obtained on the conditions that existing hardware will be used and that the automatic data transfer will be improved. Combining all optimisation factors, the break-even decreased to a minimum of 167, respectively 77 teleconferences/year. The optimisation of patient management is an additional--but in this study, not yet counted--advantage of teleradiology.