Radiology is a technology-driven field. According to a study by the American College of Radiology, imaging procedures are growing approximately 15% annually against an increase of only 2% in the radiologist population thus contributing to a worldwide growing shortage of radiologists. Teleradiology allows a continuous education beside an instant interpretation of the images and a possibility for a second opinion. Users in different locations may interpret the images synchronously. Teleradiology may utilize an access to the radiological comments and provides a significant support to healthcare if used appropriately. The use of teleradiology does not reduce the responsibility of the supervision and management of the radiological services. The radiology service is an integrated clinical process. In this process the radiologist has the responsibility to determine the examination algorithm, to plan the exam, to perform additional examinations if needed, to use contrast agents, to prevent the patients from the radiation hazards, to interpret the images with the help of clinical and previous imaging data, to dictate the report, to discuss the results with the referring clinicians and to practice educational and administrative roles. Radiology report is a by-product in this process and can not be isolated from the remaining steps. For these reasons teleradiology should not be accepted just as a report dictation and must be considered as one of the components of radiology service.
1. Teleradiology: Transmission of radiological images and the related data from one location to another for the purposes of interpretation and/or consultation.
2. Site: Unit, center or institution that gives the radiology service.
3. Transmitting site: The site that performs the radiologic examinations and sends the images with the related data to another site for interpretation.
4. Receiving site: The site that interprets reports or gives a second opinion to the images.
5. Reporting: The process of composing a final report after interpreting the images in light of the clinical data.
6. Second opinion: Frequently used when subspecialty expertise is needed. Additional evaluation is taken from another radiologist before a final report. It can not be used as a final report.
7. Wet reporting: Rapid, short and object-oriented reporting usually done in emergency cases. A final report is done later by the same or another radiologist.
8. Addendum: Additional report that includes the corrections or new findings after the approval of original report.
The aim of teleradiology should be to provide a more widespread and high-quality radiology service to the patient and public.
a. To provide consultative and interpretative radiologic services.
b. To provide a rapid access to the radiologic reports and images in emergency or non-emergent cases. To provide an opportunity to the on-call radiologists to prepare a wet report.
c. To provide subspecialty support as needed.
d. To provide educational opportunities to the radiologists.
e. To promote the quality and efficiency of radiology service.
f. To provide radiological interpretation to the transmitting site.
g. To support professional and continuing medical education.
h. To support telemedicine.
a. Transmitting site personnel qualifications: Transmitting site should comprise of at least one radiologist, one radiographer or a radiology technician, and a system manager with informatics certification.
b. Receiving site personnel qualifications: PrimaRad appointed a sufficient number of radiologists compatible with the workload. Those radiologists are certified in teleradiology and have to be given user tuition.
A. Transmitting site
Transmitting site should hire a radiologist. The acquisition of the images without a radiologist and then their utilization via teleradiology should only be possible in below cases:
1. Disasters and war like conditions
2. Screening programs limited by mammography and chest x-ray.
The requests in the transmitting site should be evaluated by the radiologist. The indication of the examination should be clear enough for the radiologist. The radiologist should consent to the examination, make the plan, pay attention to the preventive issues, control the exam quality, and perform additional examinations where necessary. Informed consent: All patients should be informed on their examinations and a consent form should be taken. Patients should also be informed of the teleradiological process and the responsible radiologists who would interpret the images. A satisfactory explanation is essential for the safety and security of the images during teleradiology.
The types and specifications of the transmission elements should be documented by the transmitting site. Diagnostic loss in the images should not be acceptable at the receiving site. Patient demographics, site information, labels and measurement data should all be transmitted without errors. The selection of the images that will be transmitted is the responsibility of the radiologist at the transmitting site.
I. Image acquisition and digitizing
Image acquisition should be done according to the TSR guidelines.
a. Direct image acquisition:
All the data set including the image matrix and pixel byte depth that is obtained by a digital modality should be transferred to the teleradiology system. DICOM standard should be used.
b. Digitized images:
1. Small matrix images: Each image should be digitized to a matrix size as large as or larger than that of the original image by the imaging modality. The digitized images or video frame grab with this method are acceptable.
2. Large matrix images: These images should be digitized to a matrix size corresponding to 2.5 lp/mm or greater measured in the original detector plane. These images should be digitized to a minimum 10 pixel byte depth.
II. Data compression:
Data compression may be used to increase transmission speed and reduce storage requirements. Several methods, including both reversible and irreversible techniques, may be used under the direction of a qualified physician, with no reduction in clinically significant diagnostic image quality. The types and ratios of compression used for different imaging studies transmitted and stored by the system should be selected and periodically reviewed by the responsible physician to ensure appropriate image quality. The radiologist at the receiving site should have the option to access the uncompressed or lossless images as needed.
The patient name, identification number, examination date and time, type of examination, related anatomical area and its orientation, name of the imaging site, type of the image compression method and the compression ratio should be embedded on the image. The clinical data needed for the interpretation should be transferred by the images or the electronic health records of the patient should be accessible by the receiving site as needed.
C. Receiving site:
Monitors: The qualification of the monitors which will be used for the interpretation should meet the aims of teleradiology and the related Saudi guidelines.
Teleradiology systems are compatible with both transmitting site’s regime of maintaining medical records and national rules of medical record keeping. The location, type and duration of the archiving should meet the legal requirements of the transmitting site. Both sites should have an archiving procedure and policy corresponding to hard copy archiving policies. Each individual examination data folder should include the patient and examination database records which contain patient name, identification number, examination date, time and type, name of the institution. A space has to be provided for a short clinical information. Previous images of the patient should be prefetched at a reasonable speed on the demand of teleradiologists. Images are kept for 6 months on our servers and backup is made every day at 2 AM.
Teleradiology systems do provide network and software security protocols to protect the confidentiality of patient’s identification and imaging data consistent with national requirements. There are measures to safeguard the data and ensure data integrity against intentional or non-intentional corruption of the data.
Communication is one of the critical components of this technology. A teleradiology report should contain the type of the service (primary interpretation, second opinion etc.), the name of both the transmitting and receiving sites, the name of the related radiologists in both sites, date of the examination and the communication data. The name of the interpreting radiologist should clearly take place in the document. An approved document should not be changed. Any addendum that has to be made in emergency or non-emergent cases should be recorded. Supplements or documents related with the radiology report.
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