The working patterns of radiologists have undergone enormous changes in the last 10 to 15 years. Technological advances with digital images have contributed significantly to these changes. Technology allows radiologists to work remotely from where images are acquired by radiographers. Distances from which they can issue a report can vary -- they can work from their offices in the same institution as the images are acquired, offices in a different institution, or even from home.
Whilst distant remote or home working is gaining acceptance, there is also an increasing recognition of the need for radiologists to exist within local radiology departments to support radiographers, and also to support the referring clinical teams with regular face-to-face dialogue in their role as consultants, as described at ECR 2015 by Dr. Nicola Strickland, from London's Hammersmith Hospital. Hence, hospitals continue to employ local radiologists to work in hospitals -- as they recognize their important role.
By 2007, all the National Health Service (NHS) Trusts (i.e., hospital groups) in England had replaced hardcopy films with PACS, and radiologists are no longer dependent on hardcopy films to issue reports. In the U.K., consultant radiologists largely participate in three types of activities: emergency radiology, special interest radiology, and general reporting activity (GP and accident and emergency referrals).
All NHS consultant radiologists participate in one of the four types of emergency radiology delivery: adult diagnostic emergency radiology, pediatric emergency radiology, interventional emergency radiology (vascular and nonvascular intervention), and emergency neurointerventional radiology.
The volume of work for emergency radiology varies according to the time of day, and delivery models are different for daytime and nighttime. In nighttime adult emergency radiology, the volume of work tends to be much smaller compared with daytime. Hence, there has been increased use of the "distributed network model" of teleradiology. This allows for the frequency of night-working to be significantly reduced amongst the networked group of hospitals. Daytime adult emergency and acute inpatient services continue to be delivered largely by local radiologists.
The models for delivery of emergency radiology have been evolving over the last few years. Distributed network models have become established due to remote reporting becoming possible in a digital age. Distributed networks require a teleradiology platform, i.e., IT infrastructure connected to the local hospital RIS and PACS. Many private companies have invested in the teleradiology platform infrastructure and connections, to enable distributed network models to support emergency diagnostic radiology.
Short-staffed district general hospitals have been unable to deliver the nighttime radiology with their own local radiologists safely. They have turned to private distributed networks for delivery for night emergency radiology. Private outsourced teleradiology networks cover a large number of hospitals at the same time at night. Some NHS hospitals are also working collaboratively to deliver night diagnostic emergency networks, with all their own radiologists participating in a nighttime, network-wide on-call rota. They also use a teleradiology platform for reporting.
In comparison, emergency neurointervention has always been delivered via a centralized network model. The patients needing neurointervention are transferred to the neurocenter from the district general hospitals.
Network models are evolving for interventional and pediatric radiology too. Either local radiologists participate in a distributed network on-call rota, or via a centrally delivered network model. The Nottingham Pediatric Network is an example of a centralized network of pediatric radiology delivery with pediatric radiologists travelling to neighboring hospitals to deliver their services, both emergency and nonemergency. Hospitals can individually decide the best methodology for delivering their emergency radiology workload.
A distributed network of diagnostic radiology requires use of a teleradiology platform for reporting, regardless of whether this is an outsourced private teleradiology network or an in-sourced collaborative network.
The connection and workflow aspects include:
- Current images for reporting are transmitted from local hospital PACS to the teleradiology platform sent via DICOM push.
- PACS also transmits the recent "relevant" prior via DICOM push (e.g., a previous CT head exam will be sent, if the CT head report is required).
- Request information (electronic request or scanned request card) and scheduling information (date and time of appointment) is sent via HL7 ORM message from hospital RIS to the teleradiology platform.
- Reports created on the teleradiology platform are sent back to hospital RIS and PACS by HL7 ORU message.
The limitations of reporting from a teleradiology platform (whether for a private outsourced network or an NHS collaborative network) include:
Lack of full imaging history. DICOM push will only send a single relevant prior image. Hence, a radiologist reporting a head CT maybe be presented with a head CT done six months ago, but not be aware of the brain MRI done for the same patient three months ago.
Lack of previous radiology reports. Whilst the relevant prior image may be available on the teleradiology platform, the radiologist will not have access to the associated reports. CT head images may be available, but the report will not be available to the teleradiologist.
Lack of access to clinical information like blood results, histopathology reports, clinical correspondence, discharge summaries, etc. Blood results, histopathology, and clinical correspondence are accessible to local radiologists reporting on RIS/PACS often by a mouse click.
Understanding the limitations of teleradiology platform reporting is important when deciding what kind of services can be safely be delivered by a Teleradiology Platform based reporting:
Nighttime diagnostic emergency radiology network is well proven for teleradiology platform reporting, and continues to evolve. Types of scans done at night in hospitals are limited to critical, life-threatening conditions like head injury, low Glasgow Coma Scale (GCS), road traffic accidents, low blood pressure (possible aortic dissections, etc.). For these conditions, there are very specific questions without much reliance on previous imaging history, previous reports, blood tests, previous histopathology etc.
Nighttime networked teleradiology is justified in its use because it allows local radiologists to be rested, and frequency of night working is greatly reduced for individuals. It is recognized that night working is not good for workers' health -- radiologists are no different. Hence, the benefits of nighttime networked teleradiology outweigh the risks from reporting on a teleradiology platform, both to patients and radiologists.
For day-time emergency and inpatient radiology, local radiologists engage in regular face-to-face or verbal dialogue with acute surgeons, acute physicians, and orthopedic surgeons regarding management of inpatients in the hospital. They are often referred to as duty or on-call radiologists. In many hospitals, radiologists participate in the daily trauma meetings and advise orthopedic surgeons on the appropriate use of cross-sectional imaging. Similar acute emergency multidisciplinary team meetings (MDTMs) would also benefit acute physicians, surgeons, and radiologists, and optimize the use of expensive imaging in patient management decisions, and discharge planning.
Dialogue and consultation is important for high-quality patient care, and hence, local reporting models must continue. Evolution of daily acute emergency MDTMs would reduce the cost burden from inappropriate requests from physicians and surgeons who may often request the wrong investigation; we do see examples of ultrasound, then CT and MRI done for the same patient, when MRI done in the first instance could have saved time and expense. Where there is regular, formal dialogue between referring consultants and radiologists, the inappropriate imaging requests tend to be very low or nonexistent, as seen with the evolution of cancer MDTMs in the NHS.
In special interest reporting, radiologists already participate in face-to-face weekly MDTMs with clinicians. Here, radiologists get regular feedback on their reporting. This regular reflective learning allows them to provide very high-quality actionable reports in their special interest area. Cancer staging and follow-up investigations are amongst the types of reports issued by special-interest radiologists. When reporting special-interest work, radiologists do need access to blood results such as tumor markers (e.g., CA-125, carcinoembryonic antigen [CEA], and CA-19.9), inflammatory markers (e.g., C-reactive protein [CRP] and erythrocyte sedimentation rate [ESR]), histopathology reports, MDTM outcome summary, clinical correspondence etc.
Hence, special-interest reporting is not suited for teleradiology platform reporting. These should be reported on a local RIS/PACS either by onsite reporters or remote reporters. Remote reporters are radiologists reporting on a hospital RIS/PACS but from a distant location such as their home, and they do not use a teleradiology platform.
General reporting for GPs: This predominantly consists on plain-film reporting with a large proportion of chest x-rays. Previous imaging history is important when reporting chest x-rays in particular, hence they should be reported on enterprise RIS/PACS (not on a teleradiology platform). Enterprise RIS/PACS reporting can be done onsite or even remotely (e.g., a radiologist reporting from home via a virtual private network [VPN] connection).
Accident and emergency plain film reporting for fractures usually has a simple yes/no answer, and hence networked teleradiology platform-based reporting can be used in these cases.
Use of teleradiology platform-based reporting is being used extensively for nighttime emergency diagnostic radiology, in a distributed radiology network. This use is justified, as described above. However, the limitations of teleradiology platform-reporting should be understood, and it should be avoided in daytime emergency and inpatient reporting, special interest reporting, and GP chest x-ray reporting.
Dr. Neelam Dugar is consultant radiologist at Doncaster Royal Infirmary, U.K., and former chair of the Royal College of Radiologists' Imaging Informatics Group.
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