July 28, 2008
Tips for Offering Telerad —
Experts Discuss the Technical Issues
By Dan Harvey
Vol. 9 No. 15 P. 24
The shortage of available radiologists and ever-increasing demands by small hospitals in remote areas continue spurring teleradiology’s evolution, as does an ongoing subsumption of smaller facilities into larger, regional healthcare systems. Enterprises targeting these needs encounter substantial logistical complexities.
“They might not completely understand just how much it takes to put together a comprehensive teleradiology solution,” says John Lawder, president of TeleRAD IT, a provider of Web-based clinical management systems based in Royersford, Pa. “They think they can be up and running after they buy their own PACS and RIS and hire a couple of engineers.”
As Lawder suggests, it’s not that simple. Even groundwork is technologically intricate. It requires high-speed Internet connections, static public Internet protocol addresses, networking capabilities, reporting capabilities, and workstations and data centers before radiology systems such as PACS, RIS, electronic medical record, and speech recognition can be brought online.
“When you have multiple radiologists reading in a distributed environment, PACS serves as the data center and centralized platform that ties everything together. Also, a solid RIS is critical if you plan to do final reads,” says Lawder.
Further, well-established networking is necessary to create the critical circuit from the hospital, physician office, and imaging center clients to the data center and reading radiologists and back again. When done right, circuitous communication is accomplished in minutes or even seconds. “But you need the proper mechanisms in place,” Lawder says.
All those elements need to be effectively aligned by IT engineers. “Considering all of these components, teleradiology represents an extremely difficult engineering feat,” Lawder points out. “It almost doesn’t make sense for a radiology group to go it alone.”
As such, teleradiology success stories point to a rewarding collaboration among prospective providers, teleradiology service vendors, and client facilities.
Teleradiology in the Emergency Setting
One teleradiology success story is the emergency radiology department at Boston’s Brigham and Women’s Hospital because of its effort to expand the quality and scope of its radiology coverage.
“Until about four years ago, we only had staff coverage up to 11 pm. To provide optimal service, we realized we needed to expand to 24/7,” says Aaron Sodickson, MD, PhD, the department’s assistant director, who recalled the financial and practical considerations that came into play. “Teleradiology provided the appropriate synergy to bring in the revenue that would pay for the expansion in our academic setting.”
But the department also sought to extend its reach beyond its own walls by providing emergency radiology subspecialty service to other healthcare facilities. “Teleradiology not only enabled us to aggregate enough volume to justify a 24/7 presence at our level 1 trauma and academic medical center, but it also allowed us to provide emergency teleradiology throughout our service community,” says M. Stephen Ledbetter, MD, MPH, director of emergency radiology.
Now, Brigham and Women’s provides emergency radiology for several hospitals in Massachusetts that once were limited in overnight radiology coverage.
The most challenging portion of this endeavor involved the IT element, according to Sodickson. Specifically, this included the transmission and receipt of images and information accomplished via PACS and RIS. “First, we needed to receive the images from a client site, and that often involves some sort of store-and-forward technology located at the site that takes images from a modality and sends them straight to us,” he explains. “In some cases, that technology can take studies from a local PACS and transmit them to us. But we’ve set ourselves up to receive the studies at our end with our own PACS. We also have a separate teleradiology PACS that keeps these transmitted studies distinct from our local studies.”
RIS is just as essential as PACS. “We need to marry images with accession numbers to produce reports, as technologists at remote sites send images with requisitions for study interpretation,” explains Sodickson. RIS data include patient information such as history, indication for the exam, the ordering doctors and their contact information, and the number of images. The information is received via a secure, Web-based acquisition. “It allows the technologists to dictate [their] reports as we would for studies done at our own site. Ultimately, it enters into our PACS with an accession number, and the originating site is linked to that accession code,” he says.
Brigham and Women’s emergency department radiologists then view the study, dictate a report with speech recognition, sign off on the report, and send everything back to the emergency facility where the study was initially done. “The sending site can review our interpretation when they do their own final interpretation,” says Sodickson. “That’s a broad overview of the ‘round-trip.’”
Within that round-trip, Brigham and Women’s uses as many as 10 vendors for different elements. “For the IT portion, most things are plug and play,” says Ledbetter. “Outside of that, we work with two vendors, AD Mednet, which provides the technology to move images around, and Medicalis, who provides us with their Percipio RIS product.”
When a new client is brought in, those two elements are set up so little work is required from the vendor, adds Ledbetter. “We’re capable of creating a new site within our RIS. As far as moving the images, as we’re a regional operation, we can go right on site and set that up for clients. It needn’t be done remotely,” he explains.
One of teleradiology’s benefits is that it enables organizations to better distribute their subspecialty expertise. “As our subspecialty is emergency radiology, we can provide interpretations for emergency studies regardless of time, day, and patient location,” says Sodickson. “It would be impossible to duplicate our services everywhere, but teleradiology moved us beyond physical limitations, enabling us to provide unlimited coverage.”
But there’s another patient care benefit. “As we’ve already reviewed the images, we can activate care pathways before the patient arrives,” says Ledbetter.
This makes Brigham and Women’s regional model more effective than a multistate plan, Sodickson points out, as it provides teleradiology for numerous hospitals that transfer patients who need further treatment or evaluation at a tertiary care hospital or level 1 trauma center. “We’ve had numerous patients with hyperacute medical conditions transferred to us,” he says, expanding on Ledbetter’s point. “And thanks to the teleradiology relationship we’ve set up with these hospitals, we can review the patients’ imaging studies ahead of time with the accepting teams—trauma, surgery, etc—before the patient arrives at our site. This allows for expedited patient management. We can book the operating room ahead of time or mobilize an interventional radiology team or fully inform the consulting teams on the imaging findings.”
“It’s a win-win-win situation across the board,” Ledbetter adds. “For us, it provides us the necessary economies to expand coverage. For the sites we serve, it allows us to provide a much more personalized, regional, collaborative, and mutually beneficial relationship. But, most importantly, for the patients, it synchronizes with the normal patient referral patterns. It eliminates a lot of duplicative effort, which facilitates care.”
As an enterprise that started with a central locus and expanded its coverage, Advanced Medical Imaging Consultants (AMIC) met with similar success, albeit with some variation. AMIC originally covered a single community hospital in Fort Collins, Colo., and now provides radiology reading services for hospitals in sections of Colorado, Wyoming, and Nebraska.
“At first, we covered a single community hospital with 250 beds and an outpatient center that had its own PACS and RIS,” says J. Raymond Geis, MD, AMIC’s director of imaging informatics. “Then we began covering a few small hospitals in eastern Colorado and western Nebraska. All images came into the central hospital’s PACS, and we read off of that system.”
But then AMIC found that other smaller hospitals couldn’t find adequate radiology coverage. “We kept getting more and more calls from these same kind of facilities. However, that wasn’t the central hospital’s business. Further, the hospital didn’t have the manpower or focus to hook up with these other hospitals in a quick, easy, and cost-effective fashion.”
As a result of the situation, AMIC set up its own teleradiology infrastructure to meet the growing needs. “We evaluated different PACS and RIS solutions to find the systems that would optimize teleradiology,” Geis reports. “Many PACS and RIS are fairly similar, but their cost, speed, and connectability vary dramatically. So some systems would be incredibly expensive, while others were incredibly slow in transmitting images. But we did our homework and set up our infrastructure, which was very fast in terms of getting images to us from those small hospitals.”
With that infrastructure in place, AMIC established a second company, Medical Image Management, which provides the infrastructure to the places that need radiology coverage in its region, particularly the small, remote hospitals. “We now cover 20 sites that way,” says Geis.
He notes that the company acts as a radiologist and not as a nighthawk service, and it has grown big enough to provide subspecialty coverage. “For instance, a neurology case gets read by a neurologist. So basically, the small hospitals get the same kind of radiology service enjoyed by big hospitals,” he says.
AMIC not only provides a good template but, from the company’s experience, Geis has developed the following recommendations:
• As far as software, prospective teleradiology providers should purchase a thin-client, Web-based solution for any piece of technology, “whether it’s PACS, RIS, or dictation modules or any communication software used to connect with different sites.”
• Make sure everything is accessible via the Web, whether it is paperwork, procedures, or processes. “Inevitably, whenever you use paper, something will get lost and someone won’t see it. Further, when you put it on the Web, make sure it is easy to find; otherwise, no one is going to look for it.”
• Communication should be unified, especially among other radiologists. Unification can be achieved via technology such as instant messaging. “When you have radiologists working in different buildings, and even in different parts of the country or the world, you don’t want them working in isolation. You need some kind of system that easily fosters communication. Instant messaging programs are effective tools.”
In addition, Geis stresses that a system should never be set up so there is a single point of hardware failure between originating and receiving sites. “If there’s a tornado in eastern Colorado, hospitals should still be able to route images onto different lines,” explains Geis.
He emphasizes the importance of duplication so that access exists in both the originating and receiving sites. He also recommends that sites without an on-site radiologist forego buying their own PACS. Rather, they should just deploy good archiving technology. “That way, they can have a legal copy, and they can send the images to the teleradiology provider,” he says. “For example, we act as the backup archive while providing image distribution to small hospitals and their physicians.”
Geis’ other basic recommendations include the following:
• Formalization and standardization of interpretation criterion: “If your radiologists are spread out, in a geographic sense, it’s harder to keep a cohesive consciousness. Previous to teleradiology, this was much easier. Everyone would sit in the same room and talk among themselves, which fostered a general, positive sense of how everyone made their recommendations. Teleradiology forces us to place everyone on the same page.”
This involves what he describes as a personal thesaurus, which helps translate differences and ensures standardization and consistency in an environment that typically fosters disparities in work cultures, imaging equipment, protocols, security measures, networking capabilities, etc.
• The availability of prior studies: “Every study that comes into the teleradiology site needs to be verified by one of our own employees. Inevitably, when something comes in, it’s missing all of the images or the associated clinical history, relevant priors, or something else. You don’t want something to arrive on the radiologists’ work list until all of that information is there. As such, you need a sophisticated staff member to serve as the verification person. In that role, they not only have to account for all of the paperwork and count the images, but they also need to make sure the images are correct. For instance, with an MRI study, the need to make sure that all of the sequences were sent along with the relevant priors, which is extremely important, as a radiologist needs to see prior images.”
While teleradiology may seem an overwhelming activity, it reaps rich rewards. “For one thing, it leads to faster turnaround times which, of course, is essential to optimal patient care,” says Scott Giordanella, marketing director for NightHawk Radiology Services.
Further, this sector of the radiology profession caters to the increasing need for subspecialty reads. “The small, rural practices might not be able to recruit the subspecialist, which might not allow them to provide the kind of coverage they wish,” adds Giordanella. “Teleradiology service providers such as NightHawk can act as a subspecialist. People now understand that to keep a stable practice and offer more services to the community, they need to reach out to teleradiology groups for that kind of coverage.”
Essentially, teleradiology transcends the laws of physics. “Geographics have been tossed out the window, and time doesn’t matter,” says Lawder.
— Dan Harvey is a freelance writer based in Wilmington, Del., and a regular contributor to Radiology Today.