Teleradiology Solutions' Dr Anjali Agarwal presents on Quality Assurance and Medico Legal Issues in Teleradiology. What can Radiologists do to protect themselves ? What are some of the stipulations necessary for teleradiology Solutions? For more info - write to info@telradsol.com

1. Quality Assurance & Medico-legal
issues in Teleradiology
Anjali Agrawal, MD
anjali.agrawal@telradsol.com
PGIMER, Chandigarh
August 2014

2. Teleradiology-Utility and Goals
 Main purpose: Timely radiologic consultation and accurate
interpretation, commensurate with the current practice norms
 Facilities without on-site radiologists, or limited on-site personnel
 Subspecialty expertise, second opinions, e-teaching
 Increased efficiency and overall quality of the practice
What is Teleradiology? Radiology images acquired at one location
transmitted to another for interpretation, consultation or reference

3. Quality Practice- Recommendations
Essence:
 Personnel
• Technical
 Communication of results
 Methods for quality assurance
ACR, ESR, RCR of the UK, Australasian and New Zealand College of
Radiologists, Canadian and the Singapore College of radiologists:
Standards governing teleradiology best practices

4. Quality Practice- Personnel
• Qualified/adequately trained technologists
• Qualified radiologists as per the requirements of the state of
origin of images
• Suitably trained support staff, computer and IT engineers

5. Quality Practice- Technical
 Image acquisition: Digital or use of Medical Grade Scanners to provide
image resolution greater than 2.5lp/mm. Compliance with DICOM
standard
 Image transfer: Over a WAN and use of VPN and firewalls to ensure
patient privacy and data integrity (HIPAA or European Commission’s
Directive on Data protection)
 Image compression: Lossless (2:1) or lossy compression up to 10:1 for CT
 Display equipment and work environment: Flat panel LCD monitors,
complete remote replica of in-house PACS workstation
 Integrated PACS and RIS platforms, Web-hosted solutions to facilitate
central management and easy accessibility

6. Quality Practice- Communication
 Effective and timely communication critical
• Reporting- RIS and now integrated PACS-RIS to generate and transmit a
standard radiology report
• Conditions needing urgent or immediate intervention or unexpected
findings- may warrant a phone call

7. Quality Assurance- Critical
Important for continuous improvement and accountability of the personnel
and improved patient care
Key measures of Quality – Accuracy and Timeliness of reporting

8. Workflow
Acquisition of
images
Transmission of images
and clinical information
over the internet
Interpretation
Verification of
data and images at
the receiving end
Result
communication

9. Swiss cheese model of medical error
•There are always holes through
which errors can creep through
• Random holes are system related
and can be blocked by multiple
layers (staffing, double reads,
checklists, workload)
• Common holes may be intrinsic
and need active intervention
Brook O R et al. RadioGraphics 2010;30:1401-1410

10. Series of different measures is more effective than one
 A series of five safeguards and defenses
have been introduced to minimize the
chances of latent failures aligning to
produce an error
Brook O R et al. RadioGraphics 2010;30:1401-1410

11. To err is human
 To reduce errors, we must change the way we do things
“Insanity is doing the same thing over and over again and expecting different results”,
Albert Einstein
 Avoid “blame game”

12. Quality Practice- Quality Assurance
 Methods for Quality Assurance

13. Checks for Quality Assurance
 Workflow: Coordination between data entry, technologist at the site of
image acquisition, workflow coordinator, radiologists- TEAMWORK
 Adequately qualified staff akin to a radiology department
 Suitably trained computer and IT engineers
 Communication of results

14. Quality Assurance Processes for Accuracy
 Peer review process
 Double read
 Continuous feedback
 Conferences discussing various errors and learning points

15. Potential Benefit of Focused Contemporaneous Dual
Read in Emergency Teleradiology
A Agrawal*, BK Desiraju**, SS Jayadeepa*, A Kalyanpur*
* Teleradiology Solutions
** IGIB, Delhi , India
Active survey
of errors
Peer Review

16. Regular Feedback to Radiologists
99.25
99.57
99.66
99.74 99.75 99.76 99.78 99.83 99.83 99.84 99.87
99.94
98.80
99.00
99.20
99.40
99.60
99.80
100.00
ABR 9 ABR 5 ABR 8 ABR 4 ABR 2 ABR 11 ABR 10 ABR 1 ABR 6 ABR 7 Anjali Agrawal, MD ABR 3
Accuracy Rate - ABR(External - Jan - Dec 2012)
Radiologist X
Accuracy Rate

17. Continuous education important to maintain skills in a virtual environment
QUALITY IS NOT AN ACT. IT'S A HABIT.

18. Quality Assurance Processes for Efficient Workflow and
Timeliness
Turnaround time
 Data transfer from site to server
 Data transfer from server to radiologist workstation
 Interpretation time for radiologist
Effective and timely communication of results
Radiologist availability for queries and protocols

19. Regular Feedback to Radiologists
37.99 37.24 37.43 37.76
39.65 40.00
36.94
15.00
20.00
25.00
30.00
35.00
40.00
45.00
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Turnaround time

20. Balancing Opposing Quality Determinants
 Compression for faster image transmission vs. possible loss of fine detail
 Lossless compression is a good compromise
 Fast turnaround versus detailed reporting
 Must use context and judgement
 Experience, experience, experience

21. Medicolegal issues
When do they arise?
 A) law is violated involving a third party (regulatory authority/hospital)
 B) The service rendered is not up to the expectation of the client
Progress in teleradiology outpaced the law- implications—guidelines are
sometimes vague and evolving

22. To err is human, what do I do to protect myself?
 Medical liability insurance
 You are accountable for what you do like a fellow radiologist or
another physician
 Where will you get sued if you are reading for the US from India?
Meet the standards of the institution, state and country

23. For Teleradiology Clients-Who to partner?
 Qualified Radiologist
 Meets the regulatory board requirements
Appropriate
Certification
Licensure Credentialing
Continuing
education

24. For Teleradiology Clients- Who to partner?
 Qualified Radiologist
 Meets the hospital board requirements
 Capable of secure continuous access to hospital imaging systems, secure
transmission of image and clinical data
 Capable of virtual workflow and easy communication with client
physicians

25. For Teleradiology Consultants
• From the legal standpoint, the radiologist performing interpretation via
teleradiology is held to the same standard as a radiologist on site at the
imaging center
• Insufficient clinical information and relevant prior studies
• Communication errors-operational risks that teleradiology practices must
specifically and pro-actively guard against

26. Conclusion
 Teleradiology practice models expected to match or exceed the quality
levels of the client groups
 Many potential steps where errors can occur
 Active quality assurance processes, regular internal and external feedback
and continuous education are important

27. Anjali Agrawal, MD
anjali.agrawal@telradsol.com
PGIMER, Chandigarh
August 2014
Dr. Anjali Agrawal is a consultant radiologist to Teleradiology Solutions,
where she heads the Delhi Operations of the group. She graduated in
medicine from the All India Institute of Medical Sciences followed by
Radiology training at AIIMS and the Baylor College of Medicine, Houston,
Texas. She is actively involved in the American Society of Emergency
Radiology and is one of the founder members of the Society for
Emergency Radiology in India.
About Dr. Anjali