The U.K.'s great teleradiology debate

2014 06 17 12 33 50 494 George Mc Innes 200

Bruce Sparrow could have quietly tweeted last week that the Royal College of Radiologists (RCR) was issuing a position statement on teleradiology, but instead, the RCR's communications and external affairs officer took the unusual step of issuing a full press release bang in the middle of the U.K. Radiological Congress (UKRC) when everybody was networking, lecturing, wining, and dining. This shows how seriously the RCR takes this issue, and the debate started in earnest when the teleradiology community got back to "proper" work.

Dr. George McInnes is senior medical adviser U.K., for Telemedicine Clinic, and a consultant radiologist.Dr. George McInnes is senior medical adviser U.K., for Telemedicine Clinic, and a consultant radiologist.
Dr. George McInnes is senior medical adviser U.K., for Telemedicine Clinic, and a consultant radiologist.

If a teleradiology service cannot demonstrate that it is at least as safe, accurate, and efficient as the locally provided alternative, then it should not exist, so this statement is a very important first step in creating a basic standard for teleradiology in the U.K.

Fortunately, having followed developments at the General Medical Council (GMC), as well as good clinical and information governance guidelines, and having adhered to the stringent stipulations of our clients, those of us using the expertise of radiologists who may not all be U.K. born and bred -- or who practice in far-flung locations where the sun shines at night -- have been working according to these principles for many years.

The RCR Teleradiology Position Statement 2014 identifies 13 principles for ensuring a safe high quality integrated teleradiology service. It points out that the "optimum radiology service is one provided locally where radiologists can maintain a regular dialogue with referrers and with those acquiring the images."

Dr. Henrik Agrell, managing director of Telemedicine Clinic (TMC) -- which has offices in Barcelona, Reading, Sydney, and in Sweden -- agrees. He originally conceived the idea of "Radiology in Network," or RIN, back in 2009 and is in active discussions with many U.K. hospital trusts (or groups).

Setting up teleradiology at home

Ideally, we would have a network of hospitals in our local area connected together by teleradiology so a radiologist might cover on-call from home on a rota of, say, 1:50. However, anyone who has tried to set up a new home teleradiology service simply to cover on-call at their hospital using their own IT department knows how difficult even that can be. The complexity of linking the different RIS and PACS from neighboring hospitals, and being able to see previous images and reports, the "bread and butter" of teleradiology companies, is frankly beyond the scope of most hospitals' IT departments, even if they happen to be on friendly terms with their colleagues next door.

Henrik has always said that he would just as soon connect a local network of National Health Service (NHS) hospitals using TMC's proprietary platform and case management expertise to facilitate exactly what the college is asking for rather than go to the trouble of finding large numbers of remote radiologists to do the same thing.

As somebody who uses both the TMC setup and that of my local hospital, I know which I would rather use from the point of view of security, simplicity, and speed. Nevertheless, it requires foresight, imagination, and a lot of planning to facilitate this local network and, above all, the cooperation of local radiologists who have hitherto preferred in increasingly large numbers to plug in to a remote teleradiology service and wash their hands of on-call for good.

The idea of a local network is great until you factor in the increasing complexity of the referrals (appropriate or otherwise) and the need for a range of subspecialist expertise. The more radiologists on call, the less attractive the arrangement becomes.

Benefits down under

Companies that have recognized the advantage of having a group of radiologists sitting with each other in an office in Australia, covering U.K. night calls during their daytime, have captured the enthusiasm of the more far-thinking radiology departments in the U.K.

The days of the lonely home-based teleradiologist are numbered because they valiantly resist the eyelid-closing force of the circadian rhythm, and grapple with logins for individual hospital RIS systems while trying not to wake the family in the next room. With an economy of scale that allows a neuroradiologist, a gastrointestinal radiologist, a musculoskeletal radiologist, and a chest radiologist to look at the same scan at the same time, the complex trauma scans that vex the lone radiologists at home become very easy.

The RCR's Principle four states that, "Patients should be clearly informed if their imaging tests are to be reported by a radiologist working outside the service where the images were acquired," but it isn't as simple as that. Assuming they are in a position to respond, the question I'd like to ask patients who have just had a stroke or a road traffic accident would be:

"We can wake up our local radiologist who is asleep, who was working today, and who will not be working tomorrow if we wake him up. We can contact a lone British radiologist at home who works for a U.K.- based teleradiology company, who may or may not have worked today, or we can send your scans to an office in Australia where a team of radiologists sit wide awake and poised, waiting for work, and where they can discuss any tricky findings with each other. Which do you prefer?"

If only the RCR, Royal Australian and New Zealand College of Radiologists (RANZCR), and respective professional and legal bodies could embrace the equivalent competence of radiologists in each country to promote a more open framework for covering the ever-increasing nighttime work, then we could report each other's work during our daylight hours without any fuss.

Nike: Just do it

I think it is fair to say that all established teleradiology companies operating in the U.K. already adhere to the principles identified by the RCR for "ensuring a safe, high quality integrated teleradiology service," both for routine and on-call work.

Principle seven of the RCR document states that any radiologist, including those in teleradiology, "should have access to previous imaging and an appropriate clinical history when issuing a report." While we can easily obtain previous images and reports, it is the clinical history that is often lacking due to poor local governance.

Swedish radiologists who report for TMC are appalled at the clinical information a U.K. radiologist receives from referring clinicians of all grades. You might call it the Nike approach to imaging: "Just do it" is a common refrain, when asked for more clinical information.

Principle 12 asks for "a clear process for communicating urgent findings;" this has been in place in teleradiology for many years, yet is lacking in many U.K. hospitals.

Legal aspects

The legal aspects require serious consideration. Dr. Philip Gishen has pointed out in his response to last week's article on that Radiology Reporting Online only uses U.K. radiologists, either based in the U.K. or Australia, and that they are GMC-registered. TMC also uses exclusively GMC-registered radiologists who have undertaken or will undertake (depending on the GMC revalidation date) the full revalidation process.

In contradiction to the European Union's position, TMC agrees with the RCR that teleradiology should be provided in accordance to the legislation of the country where imaging took place and not the country where the image was reported. Accordingly, any legal case arising from a TMC report made in Australia would be dealt with through the U.K. legal system.

TMC has a purpose-built, secure reporting platform that can anonymize images and reports, and maintains a stringent recruitment process that rejects 15% to 20% of applicants, double reads 40% of routine work, 100% of U.K. body, and 10% of neuroradiology on-call work. The company provides feedback disagreements electronically to all radiologists and employs an independent responsible officer to ensure full GMC revalidation for all its radiologists.

Returning to a world where U.K. radiologists are up all night reporting an increasing number of nighttime referrals would be welcomed by nobody. TMC encourages the development of local networks and, where appropriate, including national experts like pediatric radiologists to cover on-call and can provide the infrastructure when a local solution fails to do so. But we recognize that with the increasing subspecialist nature of night work, at least some backup from suitably qualified radiologists on the other side of the world will always be desirable.

Finally, at last week's UKRC, it was paradoxical to see the same radiologists from overworked departments contracting their work to one teleradiology company, while they and their colleagues moonlighted for other companies. Clearly we have a capacity issue in the U.K., but am I alone in worrying that this is perpetuating rather than solving the problem?

Sending images to Australia at night and using the additional capacity of GMC registered and revalidated radiologists from other parts of Europe to meet the needs of U.K. departments struggling to reach targets just makes sense. There is one U.K.-based teleradiology company who would have preferred the RCR's principles to have supported their longstanding marketing strategy that only U.K.-based, U.K.-qualified radiologists with the FRCR qualification should ever report U.K. images. However, they will be disappointed because the RCR statement of these principles strengthens the position of their competitor companies who have already applied them.

Dr. George McInnes is senior medical adviser U.K., for Telemedicine Clinic, and a consultant radiologist with the Poole Hospital Foundation Trust.

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular vendor, analyst, industry consultant, or consulting group.

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