Detangling Teleradiology in Private Practice
Only a Web-based, thin-client system should be considered by teleradiology providers, according to J. Raymond Geis, MD. It is also vital, Geis says, to make all information available on the Web and to save all data in a searchable form. These requirements apply to more than images and reports; they should cover detailed clinical data and demographic information as well. He adds that all vendors will claim that they offer Web-based thin clients, but genuine thin clients will not require browser plug-ins and will not use setup.exe for installation.
J. Raymond Geis, MD
Geis is cofounder of Medical Image Management and is a radiologist at Advanced Medical Imaging Consultants, PC, Fort Collins, Colo. At the Society of Imaging Informatics in Medicine (SIIM) 2008 annual meeting in Seattle on May 16, he presented Private Radiology Practice Perspective within the meeting’s 24x7 Radiology session. Geis’ group covers 22 sites in three states. To provide teleradiology services, the group developed and implemented its own RIS and PACS. The group’s radiologists not only serve multiple sites, but work from many different locations themselves, forming what Geis describes as a virtual radiology group. As he puts it, the only thing that the imaging sites have in common is that they make medical images and use Geis’ radiology group. Everything else differs. A great obstacle, Geis reports, is that huge disparities exist among sites. Radiologists attempt to provide a unified standard of service, but they must cope with differences in imaging equipment, protocols, proprietary software, and contrast; hospital cultures and communication methods; image orientation, translations/thesauri, demographics, standardization, and exam descriptors; and networks, interfaces, firewalls, and other security measures. In addition, many of the sites (such as hospitals in the same city) will not communicate with each other, making coordination still more difficult. When information comes from multiple sources, Geis says, data verification becomes a far more challenging problem—and an even more crucial one. In particular, advanced postprocessing requires optimal coordination of systems, especially when it goes beyond 3D reconstruction to include stenosis calculations or calcium scoring. Adding Value The best radiologists will do more than state what is on the images; if their goal is to help clinicians, Geis says, they must provide value-added interpretations. Combined with the images, these interpretations assist clinicians in making decisions (and should be provided whenever clinicians need them, around the clock). Interpretations based on prior reports are simply inadequate, Geis says; prior images must be available, if they exist. To coordinate access to prior images from many disparate systems, his practice employs a staff member to determine whether such images exist, find them, and place them in the central archive. If an electronic medical record is unavailable from a referring site, this person also manages the manual collection of paper laboratory/pathology and other clinical data for scanning or faxing into the archive, in what Geis calls a system that works, but is not efficient. Geis recommends duplicating all components needed to provide teleradiology services, from systems to data, so that there can be no single point of failure that would bring down the operation for any length of time. Archives must be maintained at both the site where the images originate and at the central site. Any practices that have not yet started to archive everything, forever, should be planning to do so, Geis says, because nothing less will be acceptable. In at least one location, the archive should use DICOM part 10 to avoid the data-migration problems associated with compressed, proprietary archives. Networks must have multiple ways of getting information from the modality to the radiologist, especially over the last mile at both sending and reading sites. At some radiologists’ homes, Geis says, dual T1 lines are used in case one fails. Cultural Changes Radiologists in Geis’ group now use instant messaging for general communication, as well as to request consultations from each other. To provide teleradiology services in some settings, it will be necessary to change other operating methods, at least to some degree. In many hospitals, Geis says, these methods may have been in place for 30 to 40 years, so the teleradiology provider must acquire a thorough knowledge of the way things have always been done before making changes. Because teleradiology requires moving information, firewalls will be breached; although authorization is used, the opportunity for security problems escalates. In addition to strengthening security measures, Geis notes that maintaining full audit trails for data access is a necessity. The ideal teleradiology service, Geis concludes, is one of high added value, with great communication in place among both information systems and people and with excellent levels of reliability and efficiency. Today’s practices have high reliability, but face so many disparity-based challenges that they have only moderate efficiency and added value, communication is often poor, and their interface capabilities range from middling to impossible. SIIM members have access (at to all presentations and podcasts from the 2008 annual meeting, and access to selected presentations is available to nonmembers.