The 2015 U.K. Radiological Congress (UKRC) debate on outsourcing was fascinating, with a myriad of views expressed. But despite what the broadcaster and session moderator Krishnan Guru Murthy may think, home reporting for radiologists has been around in the U.K. National Health Service (NHS) and elsewhere for between 10 and 15 years.
To date, home reporting has been used largely for ad-hoc reporting at nighttime and weekend ad-hoc emergencies. Ten years ago a radiologist doing a night on-call would be called once or twice at night for a CT head scan report. CT images could be adequately reviewed on a 19-inch laptop monitor due to the larger pixel size of CT images. Hence, with a small investment by the NHS trust, or hospital group, encrypted laptops could be bought for all radiologists who could review and report CT images from home on their Web-based PACS and issue a report on the radiology information system (RIS).
The advantages for the hospital were quicker turnaround times and lower expense claims for travel during on-call sessions. There were benefits to radiologists too because home reporting on laptops was less onerous than having to drive into the hospital in the middle of the night. Hence, it was a win-win situation for all.
However, this type of reporting was ad-hoc, and used for emergencies only. One CT head exam with 20 images could take 1-5 minutes to download over a slow home broadband speed, and it was even slower with a dial-up connection in the early days.
Body CTs would take longer at 5-10 minutes. In comparison, within the hospital, the workstations are connected at speeds of more than >100 mbps, and the images for reporting are available instantly. It would also take radiologists working on a laptop more time to review images and compare with prior exams, because they were working on a single monitor; the traditional hospital reporting setup for radiologists includes three monitors.
The time taken for reporting scans on a home laptop would be three to four times more than for radiologists on a hospital workstation. Hence, per report issued, home reporting was slow and inefficient compared to a radiologist reporting in the hospital. However, it was more efficient than driving into hospital for ad-hoc emergency cases. Home reporting soon became fairly established practice for night on-call and weekend emergencies in the NHS.
Many outsourcing teleradiology companies like Medica, 4ways Healthcare, and others have used home reporting concepts too. However, unlike the NHS, they have made radiologists more efficient and productive in their own homes. They have set up radiologists with a three-monitor workstation similar to hospital setups. The current study for reporting and relevant prior study are precached on their home reporting workstation. Hence, images are available instantly to the teleradiologists when they start reporting -- no waiting for images to download.
Radiologists working for teleradiology companies cover multiple hospitals at the same time, whilst doing night emergency on-call. So instead of the traditional model of having 10 on-call radiologists each reporting two to three CTs at night, teleradiology companies have transformed how nighttime emergency reporting is delivered to the NHS. They have enabled one radiologist who is awake at home, reporting for many NHS trusts hundreds of miles away. They could be reporting 20-30 CTs over a 12-hour period (8 p.m. to 8 a.m.) -- thus, more efficient use of radiologists' time.
This type of networked multi-institutional teleradiology reporting has required significant investment in technology, as well as manpower resources.
A one-time technology investment includes:
- Three-monitor home-workstations for radiologists
- Teleradiology platform software to display radiology images for diagnostic review and support the creation of reports
- DICOM and HL7 connections to multiple hospitals RIS and PACS
HL7 ORM (order message) would be used to send the electronic request from the RIS to the teleradiology platform. Current images and relevant priors would be sent via DICOM push. HL7 ORU messages would be used to transfer radiology reports from the teleradiology platform back to the hospital RIS and PACS.
Manpower investment required by teleradiology companies include:
Employ adequate number of radiologists to run a regular rota
Provide technical support for radiologists during the night
Provide regular clerical support for radiologists. Clerical support would include proofreading reports before they go out (to avoid voice recognition errors), and also to contact referring clinicians on behalf of the radiologists (e.g., communicating significant and unexpected findings that may require urgent attention) to make radiologists efficient
There are disadvantages and limitations to multi-institutional teleradiology platform reporting:
Lack of instant access to full imaging history. The teleradiology platform will only have access to current images for reporting, and relevant priors pushed to it. If the radiologist needs more studies and images they would need to phone the hospital, and request transfer from PACS. This is cumbersome for radiologists.
Lack of access to prior radiology reports. Transfer of prior images does not include reports, as PACS do not make reports available via standards like DICOM structured report.
Teleradiologists do not have instant access to important clinical information like blood results, histopathology reports, clinic letters, discharge summaries etc., which play a huge role in radiologists being able to issue actionable reports.
However, as nighttime emergencies usually have a yes/no answer (bleed, stroke, dissection, etc.), reporting on a teleradiology platform is found to be acceptable -- despite the above-mentioned limitations. However, multi-institutional teleradiology should be used with caution for elective reporting for cancer staging and follow-ups.
In this column I have discussed home working for nighttime emergencies on a multi-institutional teleradiology platform. In my next column, I will discuss how radiologists can perform routine elective reporting from home on the enterprise RIS-PACS. The technology support required is completely different than the multi-institutional teleradiology platform.
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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