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  1. 1. Global Teleradiology - An internet-based application for optimization of health care delivery across domestic and international borders Authors Arjun Kalyanpur, MD CEO and Chief Radiologist, Teleradiology Solutions. Firoz Latif Senior IT Manager, Teleradiology Solutions. Sanjay Saini, MD William P. Timmie Professor and Chairman of Radiology Emory University School of Medicine Surendra Sarnikar Doctoral Candidate, University of Arizona
  2. 2. 1. Introduction Teleradiology refers to the electronic transmission of radiological images, such as X-rays, Computed Tomograms (CT’s), and Magnetic Resonance Images (MRI’s) across geographical locations for the purposes of interpretation and consultation. The digital radiological images are typically transmitted using standard telephone lines, satellite connections, or wide area networks (WANs). Teleradiology is an empowering technology and a facilitator for enhanced medical care. Teleradiology enables a single radiologist to simultaneously provide services to several hospitals independent of their location and also allows the exploitation of global time differences to provide emergency night coverage by personnel in a different time zone working a day shift. Additionally, the quality of care delivered by a wide awake, alert physician working a day shift is far superior to that provided by a radiologist who is up all night. Subspecialty opinions delivered to locations where the expertise is otherwise unavailable are an added benefit. In this paper, we describe the current state-of-art in teleradiology, the benefits of the clinical practice of teleradiology, and the technical, regulatory and security issues related to teleradiology. We begin by providing a historical background describing the evolution of global teleradiology. 2. Teleradiology: A Historical Background Although the concept of Teleradiology was first tested and clinically utilized in the late 1950’s in Canada, the high cost of transmission and the variability in digital imaging protocols limited the widespread adoption and application of teleradiology applications. However, the rapid progress in digital communication technologies and the development of efficient internet-based software for image transmission, storage and display in the
  3. 3. 1990’s has significantly reduced the technical barriers to teleradiology adoption. In addition to the above developments, the universal adoption of the DICOM standard, as required by the ACR-NEMA (American College of Radiology and the National Electronic manufacturers association) has enabled the wide spread adoption of teleradiology applications. Today Teleradiology has become both global and online. The precedent for globalization of teleradiology was set by the Information Technology services Industry which has pioneered the concept of the Global Office where the work “follows the sun” - i.e. divisions in different time zones connected over a WAN provide a 24-hour workforce, with no individual having to work a night shift at any location. Extended to teleradiology, this means that the interpreting radiologist for a given hospital can potentially be located anywhere on the globe and day-night time differences can be exploited to staff the ER night shift. Teleradiology Solutions has been among the first to utilize this technology to influence patient care across the world. A paper published by Kalyanpur et al., from Yale University showed that this was both technically and clinically feasible [1]. In addition, several market-based factors such as staffing shortages, increase in imaging volumes, new technology and insurance and regulatory changes have also contributed to the growth and development of Teleradiology. We briefly describe these factors below. Radiologist Staffing Shortage: A significant shortage of radiologists (estimated at approximately 20%) became apparent in the US towards the turn of the millennium, with a large cohort of senior radiologists retiring from practice and training programs not
  4. 4. having grown adequately to keep pace with the increased needs. In many other parts of the world, a similar shortage of trained/skilled radiologists exists. As might be expected, in a time of staffing shortages, it is the night shift in the community hospital that is typically hit the hardest, although academic departments also stand to benefit from having their off-hours/overflow work done remotely by faculty based offshore [2]. Increase in Imaging Volumes: The rapid evolution of faster imaging technologies such as multislice CT, faster MRI scanners and sequences, coupled with an ageing population in the US has led to a consistent per year increase in imaging volumes in recent years. Increase in Trauma Imaging Utilization: The development of newer applications of CT in the emergency setting has necessitated a large increase in 24 hour radiologist coverage at hospital emergency rooms [3]. In addition, the Health Care Financing Administration (HCFA) has requires that, in order for the services to be billable, overnight coverage for radiological services be provided by a fully trained and certified radiologists, rather than residents/trainees [4]. This has resulted in a large increase for overnight radiologist services. 3. A Service Delivery Model for Teleradiology Advances in information and communication technologies in the past decade have enabled new extensions to teleradiology facilitating new models and avenues for delivering radiological services. The foremost application of teleradiology is in the emergency setting. In emergency situations, teleradiology facilitates a prompt response by bringing the emergently performed images to the off-site radiologist that allows for timely diagnosis and the timely administration of appropriate treatment.
  5. 5. Workflow and Routing Service Emergency Departments Rural & Remote Clinics Large Hospitals Nighttime Offshore Services Sub-speciality Services Overflow and Remote Reading Figure 1. A Service Delivery Model for Teleradiology “Nighthawk” Services: Teleradiology within the US led to the development of the nighthawk concept wherein a radiologist is able to simultaneously provide services to multiple hospitals via teleradiology links to a central reading facility (often the radiologist’s home). Thereby enabling a single radiologist to simultaneously staff the night shift at multiple hospitals. The process is cost-effective to hospitals, as the need to recruit night shift personnel is minimized. Radiology to remote locations: Teleradiology also enables the provision of radiological services to remote locations where the technical infrastructure for radiological scanning exists, but a radiologist is not available on site. Optimization of workflow: Teleradiology also increases the efficiency of a radiologist by ensuring that he/she spends the most part of his/her time delivering quality care to the maximum number of patients. This is achieved by bringing the images to the radiologist rather than vice versa, thereby saving physician commuting time and increasing the range and reach of the radiologists’ expertise. Within large radiologist groups servicing multiple hospitals and imaging centers, teleradiology also permits the optimal distribution of work based on need and the availability of radiologists.
  6. 6. Subspecialty consultations: Teleradiology enables the wider availability of subspeciality consultations wherein images of a specific body region/modality need to be referred to the radiologist with expertise in the interpretation of that type of study. 4. Technical Requirements for Teleradiology The key components of a Teleradiology system include a picture archiving and communications system (PACS), a radiology information system (RIS) and a reliable and secure high-speed connectivity between the remote sites. These put together with standards for imaging and systems/procedures for security and contingency practices complete the technical aspects of Teleradiology. These are further discussed in the following sections. 4.1 Picture Archiving and Communications System An efficient web-based PACS is the cornerstone of a clinical teleradiology practice. PACS is the information system used for the acquisition, storage, communication, archival, viewing and manipulation of radiologic images and related data. This definition of PACS indicates that PACS is made up of several important components. These are: Acquisition Devices: These could be modalities with digital output capabilities or devices such as frame grabber and digitizers that convert the analog output from imaging modalities to a digital format. Storage: This includes short term as well as long-term archival solutions. This allows radiologists to have easy access to relevant prior studies for comparison. Long-term archives need not have instant accessibility and hence optical disks or tape drives could be used for this purpose.
  7. 7. Communication: PACS requires high-speed connectivity to enable rapid transfer of images to viewing workstations, over LAN and WAN (the latter is what constitutes teleradiology). Transmission of images is based on protocols of imaging standards called DICOM. Transmission of non-image data like text uses HL7 standards. More on DICOM and HL7 will be discussed in later sections. Software: Image viewing and manipulation software are most often an integral part of PACS. Image viewers can be on a Diagnostic workstation, review workstation or could be done utilizing a web-based module. Diagnostic workstations are high end systems with high resolution flat panel displays while review workstations/ web viewers can be standard desktop PCs. Image Compression: Given the large file size of typical radiologic images, an important feature required facilitating rapid image transfer and throughput in Teleradiology is compression. Compression algorithms used may be industry standard like JPEG 2000 or could be proprietary to the vendor. It has been noted that compression settings of up to 10:1 can be tolerated in clinical teleradiology without compromise or loss of clinically relevant data, for review of CT images [6]. In the case of plain radiographs, even higher settings may be tolerated. 4.2 Radiological Information Systems RIS is often a subsystem of Hospital Information System (HIS), but can be also be a stand-alone entity and may or may not be connected to PACS and/or RIS. While PACS mainly deals with images, RIS/ HIS deals with data associated with patient demography, studies and reports. RIS is often what guides the workflow of a Teleradiology practice. Though RIS was used as a report generation and distribution tool earlier, commercially
  8. 8. available RIS packages currently have integrated many features like voice recognition, staff scheduling, work distribution, invoicing, etc. At Teleradiology Solutions, a RIS has been developed by an in-house software development team and customized using radiologists’ input to meet the requirements of a busy teleradiology practice. 4.3 Connectivity Requirements With optical fiber cables traversing the depths of our oceans, high volume data transfer across geographically separated locations, in the present day, is a non-issue. These high speed connections allow Teleradiology service providers to serve clients half way around the globe, with report turn-around times comparable to the ones from local radiologists. An ideal connectivity solution for Teleradiology providers would be multiple T1 lines which would each provide bandwidths of up to 1.544 Mb/s. A single radiologist working from home may use DSL connectivity, provided adequate throughput is confirmed prior to clinical use. Apart from bandwidth, one would also require other networking components such as routers, firewalls, VPN concentrators, and intrusion detection and prevention systems. As the service being provided is a clinical service, typically in the emergency setting, a high level of communication between the site of origin and interpretation of the images is mandatory. This involves the utilization of fax systems capable of handling high volume data, direct telephonic contact and video and teleconferencing. 4.4 Data Standards DICOM is the industry standard used for transfer of radiologic images between different hosts claiming conformance. DICOM is a standard developed by a joint committee set up by American College of Radiology (ACR) and National Electrical Manufacturers
  9. 9. Association (NEMA). HL7 (Health Level Seven) is the standard for the exchange, management and integration of electronic healthcare information like clinical and administrative data. Using HL7 compatible software streamlines the workflow considerably. For example, if PACS and RIS of a Teleradiology practice are HL7 enabled, as soon as a new study is received by the PACS a new order is created on RIS, using patient demography and study details from the DICOM file, eliminating duplication of work. 5. Securing Patient Data Teleradiology providers, being HIPAA [7] covered entities must have adequate privacy and security practices defined, as Protected Health Information (PHI) and electronic Protected Health Information (EPHI) are transmitted over public networks on a regular basis. The Privacy Rule deals with all forms of patients’ protected health information, whether electronic, written, or oral, while, the Security Rule covers only protected health information that is in electronic form, including EPHI that is created, received, maintained or transmitted. Technical safeguards are relatively easy to implement. With a huge spectrum of network security solutions available off the shelf today, building and managing a secured network is not a huge challenge. What is significantly more challenging is stopping the data from unauthorized access due to administrative breaches, and hence bulk of the HIPAA privacy rules are to do with Administrative and Physical safeguards. These breaches could only be plugged by educating employees about Privacy and Security practices followed by the organization and ensuring that these practices are implemented.
  10. 10. The security rule does not prescribe any specific technologies – being technology neutral allows covered entities to choose solutions based on their specific requirement. Technical safeguard standards include Access Control, Audit Controls, Data Integrity, Person or Entity Authentication and Transmission Security. Our in-house developed RIS solution (Tele-RIS) is used as a case in point here to illustrate/demonstrate how it complies with the above standards. Access Control mechanisms are used to make sure that a person or software can only access and modify resources he/she is authorized for. Access Controls standard require the implementation of several features such as unique user identification, automatic logoff, and data encryption procedures. In addition, the following functionality also needs to be implemented: Emergency Access Procedure: This implementation specification requires a covered entity to establish procedures to retrieve EPHI during emergencies. Tele-RIS adequate backup for power or network outages, but in case of a total outage, a backup procedure for the entire workflow from order entry to report distribution is well defined. Operating from different geographical locations also helps in dealing with contingencies. Audit Controls: are useful for recording and examining information system activity, especially when determining if a security violation occurred. Any addition, deletion or remarkable modification on Tele-RIS is logged for audit purposes. Data Integrity: Data could be altered during transit or in storage. EPHI that is improperly altered or destroyed can result in clinical quality problems for a covered entity, including patient safety issues. This could happen by both technical and non- technical sources. A user can change the data, accidentally or maliciously. Tele-RIS
  11. 11. addresses this problem using techniques like data validation and normalization of databases. Person or Entity Authentication: Authentication involves confirming that users are who they claim to be. Tele-RIS uses a username/password combination for authentication. In recent times many applications incorporated the use of biometrics for authentication. Transmission Security: This standard requires a covered entity to: “Implement technical security measures to guard against unauthorized access to electronic protected health information that is being transmitted over an electronic communications network.” 6. Conclusions In this paper we describe the state-of-art in teleradiology and present a service delivery model for providing cost-effective and flexible radiological services. The proposed model can enable the delivery of radiological services to several hospitals independent of their location and allows the exploitation of global time differences to provide emergency night coverage in Emergency Departments. In addition, we also describe the technical, regulatory and security issues related to teleradiology. References 1. Emergency radiology coverage: technical and clinical feasibility of an international teleradiology model. Kalyanpur A, Weinberg J, Neklesa V, Brink J and Forman H. Emergency Radiology December 2003; 10(3) 115-118
  12. 12. 2. Implementation of an International Teleradiology Staffing Model. Kalyanpur A., Neklesa V, Brink J., Pham, D., Stein S., Forman H. Radiology August 2004; 232:415- 419 3. Spigos D, Freedy Left, Mueller C. 24 hour coverage by attending physicians, a new paradigm. Am J Roentgenol 167: 1089-1090 4. Health Care Financing Administration (1995) Medicare Program: Revisions to payment policies and adjustments to the relative value units under the physical fee schedule for the calendar year 1996 Fed Reg 60: 63124 5. Impact of Overnight Staff Coverage of a University Hospital Emergency Room via International Teleradiology. Kalyanpur, A., Casey, S., Michel, E. RSNA December 2002, Chicago, IL 6. Evaluation of JPEG and Wavelet Compression for Teleradiology Transmission of Direct-Digital Body CT Images. Kalyanpur A., Neklesa V. P., Taylor C. R., Daftary A., Brink J. Radiology 2000 217: 772-779 7.