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Teleradiology, European perspective


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Presentation given at the Annual Scientific Meeting of the Royal College of Radiologists. Barbican Centre, London, Sept 11th, 2012

Published in: Health & Medicine

Teleradiology, European perspective

  1. 1. Dr. Erik R. RanschaertRadiologistJeroen Bosch Hospital
  2. 2.  to understand the current role of teleradiology to be able to “map” the current usage of teleradiology throughout Europe to be aware of the problems related to teleradiology to be aware of and anticipate to the changes in radiology dpts. due to telemedicine and teleradiology
  3. 3.  Teleradiology (TR) is the electronic transmission of radiographic images from one geographical location to another for the purpose of interpretation and consultation. Wide deployment of PACS in combination with the overall presence of high-bandwidth Internet have facilitated the transmission of medical images for diagnostic purposes
  4. 4. Source: EC eHealthBenchmarking III report, April 2011
  5. 5.  PACS availability is 100% in Nordic countries Percentage of hospital PACS reaches 97% in the Netherlands, 96% in Belgium and 95% in the UK High availability rates are also found in Austria, Portugal and Spain Only 25% French and 23% Greek hospitals have a PACS Source: EC eHealth Benchmarking III report, April 2011
  6. 6.  76% of hospitals have stand- alone PACS 23% of the hospitals have a PACS integrated in a national or regional network Most regional networks are in Nordic countries and UK TR is mainly present in countries with regional networks Source: EC eHealthBenchmarking III report, April 2011
  7. 7.  TR has become part of regular workflow in hospitals or hospital groups with geographically split locations Integration of hospitals in regional or national networks facilitates the use of teleradiology In smaller hospitals it is mainly used for off-hour readings and emergency readings National and international commercial TR providers have emerged in the past decade, facilitating the outsourcing of diagnostic readings
  8. 8.  Extensive German nationwide trauma network linking more than 850 care providers While Germany has enough capacity for treating severe trauma based on the number of hospitals in the country, these are not geographically distributed to provide trauma care to all citizens TKmed aims to deliver teleradiology coverage for these trauma networks It is Germanys first nationwide teleradiology network to incorporate advanced security architecture
  9. 9. Peripheral Hospital or Hospital group Teleradiology company Private Imaging Centre Hospital w/ split locations Commercial network Outsourcing Second Opinion Outsourcing On-call readings Commercial TR services TR Outsourcing On-call readings TR T R•On-call radiologist‟s home •In-house distribution workload •Medical professionals •On-call radiologist‟s home •Patients •Emergency readings, expert National In-house opinions Regional International Copyright E. R. Ranschaert®
  10. 10. According to the ESR, teleradiology applicationsshould be distinguished as: when providing a patient aremote primary interpretation of an imaging study In this situation there is a more or less explicit patient-doctor relationship : when providing a secondopinion or a remote expert consultation. In this instance, the relationship is between two professionals or institutions.
  11. 11.  The applications that are being developed in a number of Member States are different from Regional teleradiology is based on a network of multisite PACS belonging to the same organization or to a consortium  Integration with Electronic Patient Record ensures access to clinical information.  the regional nature of these projects favours the contacts between radiologists and prescribers who know each other and share agreed protocols.  it allows optimization of resource allocation and homogenization of quality throughout a region
  12. 12.  Online survey held in 2011 Purpose:  map the current usage of TR in Europe  evaluate the current and future opinion about TR Methods:  Online survey, SurveyMonkey®  Social media, e-mail, ESR website  Online for 1 month (Sept – Nov 2011) 368 participants from 35 European countries
  13. 13. Teleradiology is used by 65% of the respondents  “other” types  Second opinions (3%)  TR company (3%)  On-call and emergency  Primary reporting from home  Mammography screening  Research
  14. 14. Other reasons (8%) Only for emergencies To avoid working time breaches For mammo screening
  15. 15.  …other:  university to county hospital  to hospitals within region  to affiliated hospital  to screening centre
  16. 16. Agree DisagreePossibility to ask for second opinion 82% 6%Availability of radiologists (calls ,emergency) 72% 10%Temporary capacity problems 69% 10%Workload & lifestyle 66% 15%Possibility to sub-specialise 54% 16%Improved quality of services 49% 24%Improved cost-efficiency 44% 20%Practice becomesmore attractive 38% 23%
  17. 17. Agree disagreeInsufficient information (clinical, images) 69% 17%Insufficient communication 68% 15%Impersonal 55% 21%Insufficient QA 44% 24%Complexity of logistics involved 38% 28%Unstable/insecure 19% 48%
  18. 18. Agree disagreeLoose control over business 60% 17%Reduced quality of reports 54% 24%Danger for urgent diagnoses 51% 26%Instability of jobs& income 49% 15%Negative for training of residents 48% 29%Reduced Q of patient care 48% 28%Loss of radiological skills 34% 35%
  19. 19. Agree disagreeClear national & EU legislation 81% 6%Obligatory Quality Assurance system 78% 4%Further implementation IHE profiles 66% 2%Obligatory training in TR 66% 14%Usage of “common” TR platform 61% 6%Obligatory double readings 57% 17%TR only by EU radiologists 51% 21%
  20. 20. agree disagreeYes 65% 12%Yes if pricing and reimbursement is regulated 60% 16%No, TR should be organised within member state 35% 38%Yes commercial imagebrokers should be allowed to do this 33% 38%No, should be freely allowed as commercial service 14% 63%
  21. 21. Advantages of TR in general improves collaboration greater efficiencyReasons for outsourcing as part of planned workflow for second opinions for night readingsAdvantages of outsourcing possible to obtain second opinions availability for night calls and emergency readings possible to solve temporary capacity problemsDisadvantages of outsourcing insufficient information (history, EPR) insufficient communication with cliniciansThreats & dangers of outsourcing loose control over business, fear for reduction of value of work reduced quality of reportsHow improve Quality of TR? clear national & EU legislation obligatory QA systemShould cross border TR be allowed? yes if regulated within EU yes if pricing/reimbursement
  22. 22.  Analysis of qualitative data:  80% has (strongly) positive opinion  46% thinks its importance will grow  20% mentions the need for further standardisation + a better financial and legal regulation
  23. 23.  A wide usage of teleradiology throughout Europe is perceived, however mainly for in-house purposes There is great demand for adapted EU-wide legislation, price regulation and QA framework Although there is a overwhelming positive attitude towards TR, less than 50% thinks that its importance will grow
  24. 24.  The real boost of teleradiology didn’t take place yet  most TR activity is in-house (1,2)  in EU it accounts for ≤ 2% of all procedures, in USA ±20%(3)  >50 % of revenues comes from UK and Germany The demand for TR services is largely depending on the need for radiologists: ▪ number of radiologists is growing with ±2% ▪ volume of radiological procedures is a increasing at ± 4% CAGR (4) Sources: (1)P. Ross presentation MIR 2011, (2)ETR survey, (3)Frost & Sullivan, (4) The Moran Company
  25. 25. 1. Infrastructure: PACS, regional network2. Demand for radiologists3. Political climate4. Cost of healthcare5. Acceptance of TR services by radiological community and patients
  26. 26. INHABITANTS / RADIOLOGISTIN 2010(*) Shortage:  mainly in UK and Germany  less in NL and Spain (*) numbers include residents in trainingTeleradiology - AnIntegral Part of eHealth Agenda in Europe2 Jul 2011, Som SainathanKamalasekar, Frost&Sullivan
  27. 27.  Political acceptance of TR varies per country  outsourcing is accepted by the public inpatient sector in the UK, Germany, Italy, Spain, Norway and Sweden  outsourcing remains politically difficult in other countries e.g. France TR grows where Ministries of Health are pushing new targets  In UK the governments cancer and stroke goals necessitate carrying out images and scans 24/7, thus boosting teleradiology reporting  In the NL the government wants to bring 1st line diagnostic imaging closer to the patient (extramural facilities), this will probably boost teleradiology reporting
  28. 28.  The Europe 2020 vision is opening the way for e-health, as it is believed to have the potential to reduce public expenditure on healthcare There is a coordinated effort to overcome the current barriers An additional stimulus is provided for implementation of standards to support sharing of medical information (e.g. XDS-I and IHE-XDS) Teleradiology is therefore very likely to become an integral part of healthcare delivery across Europe
  29. 29.  e-Health Action Plan (2012-2020) Concerns expressed by ESR (May 2011)  Teleradiology is not properly regulated in Europe. The ESR requests that due consideration is given to the specificities of teleradiology in order to ensure utmost patient safety  Teleradiology should be explicitly defined as a medical act in order to ensure quality of care and patient safety  The same level of guarantee, in terms of quality and safety, must be applied to these services as compared to “standard” medical acts
  30. 30.  Increasing costs + decreasing budgets for HC TR is perceived as a relatively low cost solution  in Sweden TR is ± 40% cheaper than hiring a locum  growing demand to capitalise on available technologies Based upon these assumptions the total teleradiology market is expected to grow 14.5% between 2010 and 2017(1) (1)Healthcare Europa, Frost & Sullivan
  31. 31.  Fear that radiology will be reduced to a “tradable commodity” instead of medical act Low support in radiological community for cross-border TR Considerable uncertainties about teleradiology regarding legal aspects, privacy & security Several key issues need to be addressed to improve confidence in and acceptance of cross-border TR Source: Thesis Dr. Peeter Ross, “Data Sharing and Shared Workflow in Medical Imaging” Dec. 2011
  32. 32. € Patient Language LexiconQA Copyright E. R. Ranschaert®
  33. 33. 1. Quality: QA framework including standards and regulations2. Privacy and Security: EU-wide harmonisation of regulations regarding protection of personal data for cross-border services. Information privacy remains the greatest source of concern.3. Standards (IHE): platforms allowing seamless integration of PACS and EPR for TR purposes, further implementation of IT-systems that are IHE- compliant4. Legal: uniform EU-Legislation regarding TR as “Medical Act”, protection of patient’s rights5. Financial: moreflexibility needed in financial regulations proper to socialized medicine, different reimbursement schemes need to be harmonised/adapted6. Language: semantic interoperability needs to be solved, e.g. international lexicon, standardisation of radiological terminology, translation software
  34. 34.  Define Teleradiology as a medical act in its own right Establish uniform accreditation criteria for teleradiology providers throughout the EU Stress the importance of the delivery of high-quality healthcare according to patient International quality standards Address the necessity of careful monitoring and auditing of service providers Clarify that the legal organisation of teleradiology is the responsibility of the member state where the patient undergoes the imaging procedure or telemedical referral Guarantee that patients are fully informed (informed consent)
  35. 35. New generation PACS: Advanced TR Patient-centric : Handheld platforms with new applications Online image archiveother specialties functionalities Online consultations M-Health (contracting,Multidisciplinary procurement) Second opinions Mobile Teleradiology conferencing
  36. 36. Source:, 14 Nov. 2011
  37. 37. Social / Financial Public Comparative demographic responsibility policy quality indicators Connectivity changes Engaged patient Empowered patient• Patient empowerment is an increasing and undisputed fact• Patients are more informed and thus more opinionated• Informed patients will shop for healthcare providers that meet their specific needs and expectations• Informed patients want more customization and move convenienceAcknowledgements to Dr. Jan SchillebeekcxMIR 2011 Nice 40
  38. 38.  Patient becomes manager of own online image archive  Images can be presented to and interpreted by any doctor/specialist  Redundant imaging procedures can be avoided  Potential for savings in healthcare expenditures Development of new services for patients offered via websites and apps:  Second opinions in radiology  More direct communication with radiologists is likely to evolve  Increased availability of radiologists is needed: online consultation, social media
  39. 39.  TR in Europe is there to stay and its impact will increase Several key challenges need “Replace „I‟ with „we‟ to be solved to improve the acceptance of TR and A clear regulatory framework illnessbecomeswel is required to enable the use lness.” of cross-border teleradiology Radiology departments should be prepared for the Swami “Copernican revolution” in Satchidananda healthcare
  40. 40. 1. Ranschaert ER, Barneveld Binkhuysen FH: European Teleradiology now and in the future: results of a survey, InsightsintoImaging, Acceptedforpublication2. Barneveld Binkhuysen FH, Ranschaert ER: Teleradiology: evolution and concepts, European Journal of Radiology 2011 78(2) 205–2093. European Society of Radiology (ESR). ESR 2006 VII Telerad white paper,, 2006.