International Radiology Exchange - Lessons in Teleradiology Outreach


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International Radiology Exchange - Lessons in Teleradiology Outreach

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International Radiology Exchange - Lessons in Teleradiology Outreach

  1. 1. Lessons Learned in Teleradiology for Global Health - Providing Imaging Services to Rwanda, Africa: Our Experience, Lessons, and Cases in International Outreach Efforts for Acute/Urgent Radiological Conditions Sung H. Kim, MD Stewart Worrell, MD Matt Schmitz, MD Efren Flores, MD Garry Choy, MD 
  2. 2. Exhibit Goals <ul><li>Introduction to and MGH Imaging Global Health Programs </li></ul><ul><li>Discuss informatics tools used to provide zero-cost teleradiology – how teleradiology can be practiced from areas where extensive IT infrastructure does not exist such as lack of IT support, PACS, and digital imaging) </li></ul><ul><li>Pictorial essay of actual cases of cases from referral sites including Haiti, Cambodia, and Africa </li></ul>
  3. 3. and MGH Imaging Global Health Programs <ul><li>Efforts in development of educational material for radiology outreach have been the work of volunteers from International Radiology Exchange ( and MGH Imaging Global Health Programs </li></ul><ul><li> is a non-profit outreach organization of volunteer radiologists, a multi-institutional effort </li></ul><ul><li>MGH Imaging Global Health Programs are based at an academic medical center </li></ul>
  4. 4. Outreach Model Primary International Medical Outreach Organizations NGOs Volunteer Organizations
  5. 5. Collaborating Organizations <ul><li>Partners in Health </li></ul><ul><li>Interplast </li></ul><ul><li>WiRED International </li></ul><ul><li>Operation Village Health </li></ul><ul><li>iCons International Consultation Service </li></ul><ul><li>Harvard Neurology Residency-India Exchange </li></ul><ul><li>Harvard Medical School – China Exchange Program </li></ul><ul><li>Mount Auburn Hospital </li></ul>
  6. 6. Where Has iRadX and MGH Imaging Global Health Programs Served? <ul><li>Cambodia </li></ul><ul><li>Burundi </li></ul><ul><li>Malawi </li></ul><ul><li>Rwanda </li></ul><ul><li>Haiti </li></ul><ul><li>China </li></ul>
  7. 7. <ul><li>Low-cost Informatics Solutions for Teleradiology Outreach </li></ul>
  8. 8. Requirements For Image Transmission From Technology-Limited Areas <ul><li>Internet Connection (typically only modem-based and low bandwidth connections are available) </li></ul><ul><li>Adequate data transfer speeds for practical use </li></ul><ul><li>Support for simple image formats such as JPG & GIF as well as DICOM </li></ul>
  9. 9. Limitations in Providing Teleradiology Infrastructure <ul><li>Hardware </li></ul><ul><ul><li>Many systems require special servers or appliances </li></ul></ul><ul><ul><li>VPN and other network devices needed </li></ul></ul><ul><li>Cost </li></ul><ul><ul><li>Who will pay for all this? </li></ul></ul><ul><ul><li>Who will handle the demands of technology infrastructure? </li></ul></ul>
  10. 10. Real-life IT Challenges <ul><li>Many systems still film-based; not digital </li></ul><ul><li>PACS and DICOM usually are not ubiquitous as in developed nations </li></ul><ul><li>Older, legacy systems do not enable simple DICOM image export </li></ul><ul><li>Anonymization / Privacy prior to transferring </li></ul>
  11. 11. Images Can Be DICOM or JPG/GIF Acquired Via Digital Camera of Actual Film or Console
  12. 12. Selected Examples of Tools <ul><li>Email </li></ul><ul><li>Web-based imaging storage service such as Picasa </li></ul><ul><li>Mobile Image transmission: </li></ul><ul><ul><li>Mobile based MMS </li></ul></ul><ul><li>HIPAA Compliant Secure Digital Document Delivery services: </li></ul><ul><ul><li>Yousendit </li></ul></ul><ul><li>DICOM transmission services </li></ul><ul><ul><li>Intelemage </li></ul></ul>
  13. 13. Email <ul><li>Electronic mail is a proven and reliable method of communication </li></ul><ul><li>Email with attachments is often the only data transfer tool available to providers </li></ul><ul><ul><li>Simple and Fast </li></ul></ul><ul><ul><li>Free </li></ul></ul><ul><ul><li>Allows for attachments ( images and other documents) </li></ul></ul><ul><ul><li>Depending on service, may not be HIPAA compliant or secure </li></ul></ul><ul><ul><li>May not allow for transfer of large datasets </li></ul></ul>
  14. 14. Web-based Imaging Storage Services <ul><li>Web-based image storage platforms such as Picasa can be utilized </li></ul><ul><ul><li>Simple web-based access </li></ul></ul><ul><ul><li>Manages JPG and GIF images effectively </li></ul></ul><ul><ul><li>Native image organization and management tools </li></ul></ul><ul><ul><li>Free web-based accounts </li></ul></ul><ul><ul><li>Media sharing </li></ul></ul>
  15. 15. Picasa Cases are organized by folders
  16. 16. Picasa Each folder is organized by built-in layout tool
  17. 17. Picasa Each JPG or GIF image can be viewed individually
  18. 18. Secure File Transfer Services <ul><li>Numerous file transfer services currently exist such as YouSendit </li></ul><ul><li>YouSendit is HIPAA compliant </li></ul><ul><ul><li>Large file transfer up to 2GB </li></ul></ul><ul><ul><li>File delivery tracking </li></ul></ul><ul><ul><li>Password protected secure delivery </li></ul></ul>
  19. 19. YouSendit
  20. 20. Mobile-Phone MultiMedia Messaging Service (MMS) Even in resource poor settings, mobile technology is ubiquitous and more frequently available than land-based internet connections Analogous to text messaging, multimedia messaging (MMS) on enabled-cellular phones can transmit multimedia including images, audio, and video to other mobile devices or email accounts
  21. 21. DICOM transfer with Services such as inteleGRID from Intelemage <ul><li>Using inteleGRID , users submitting images can use a simple URL to begin upload process ( ) </li></ul><ul><li>No special hardware, software, or VPN's are required allowing anyone to use it </li></ul><ul><li>Volunteer radiologists of iRadX are alerted each time a new study is received </li></ul>
  22. 22. DICOM transfer inteleGRID from intelemage
  23. 23. <ul><li>Pictorial Review of Selected Cases </li></ul>
  24. 24. Pictured: Ratanakiri Provincial Hospital, Cambodia and x-ray reading room iRadX Partner, Operation Village Health, Center for Connected Health @ Massachusetts General Hospital
  25. 25. Cases from Rwanda via Teleradiology ( Autoimmune Hepatitis TB resulting in chronic ureteral stricture/obstruction and marked cortical atrophy Neonatal Pulmonary TB
  26. 26. Cases from Haiti via Teleradiology ( TB TB VSD Hirschsprung’s HIV Cholangiopathy Neurocysticercosis
  27. 27. Cases from Rwanda via Teleradiology ( Patient VJ is a 14-year-old male with one month history of leg pain. The pain started in the knee and migrated to the distal thigh. The patient had been febrile. (A) and (B) Plain films of the left femur showed a large area of permeative lytic lesion extending from mid diaphysis to distal metaphysic with a possible sequestrum (blue arrow). Biopsy was performed which showed focal myositis without evidence of malignancy. (D) Subsequent 4-month follow-up study showed marked improvement of the soft tissue mass and improving periosteal reaction
  28. 28. Cases from Rwanda via Teleradiology ( Patient MM is a 18-year-old female with 6-month history of nonpainful mass in the distal lower leg. She was being treated for osteomyelitis but radiographs were obtained to rule out malignancy. (A) The radiographs of the tibia and fibula showed aggressive sunburst periosteal reaction in the mid to distal tibia with associated mass corresponding to the patient’s photo (B). Diagnosis of osteosarcoma was made and chest imaging was recommended for metastatic work up. (C) Staging chest CT showed multiple nodules consistent with metastatic disease. Unfortunately the patient expired within the year following diagnotic work-up.
  29. 29. Cases from Rwanda via Teleradiology ( Patient NG is a 4-year-old patient presenting with fever and seizures. Patient received a CT scan from the nearest major hospital of Kigali. Abscess, parasitic infection, and malignancy were considered. Case was sent from neurosurgeon for second opinion regarding full range of differential diagnostic considerations. Due to significant mass effect, patient was taken to surgery for treatment/further diagnosis. Diagnosis was neurocysticercosis at the time of surgery.
  30. 30. Cases from Rwanda via Teleradiology ( Patient DM is a 12-year-old male with back pain for months who also developed left hip pain so that he was unable to walk. Plain film of the pelvis was obtained which showed joint space narrowing and erosion of the left sacroiliac joint. Concern for septic joint was raised based on the film and the clinical team performed aspiration. One liter of purulent material was obtained from the left SI joint. Although no organism was isolated, tuberculosis was presumed at last update.
  31. 31. Cases from Rwanda via Teleradiology ( Patient SG is a 45-year-old male who presented with vague abdominal pain. Plain film of the abdomen revealed mass pneumoperitoneum. The case was interpreted within 5 minutes of receipt from Rwanda, Africa. Communication was made to the referring physician and patient was immediately transferred for surgery to evaluate for perforated ulcer versus small bowel obstruction (SBO) with perforation. Pathology is still pending but surgeons found a perforated bowel from a large obstructing small bowel tumor.
  32. 32. Cases from Rwanda via Teleradiology ( NB is a 3-month-old status post NG tube placement but referring physicians could not find the tip and unclear if patient was successful. Radiologists via teleradiology identified tip was coiled in mouth
  33. 33. Cases from Rwanda via Teleradiology ( CN is a 45-year-old patient with history of HIV with fevers presents with heterogeneous lesion in liver. Ultrasound sweep images and static images provided demonstrating loculated intrahepatic collection. Surgical aspiration confirmed liver abscess.
  34. 34. Summary – Teaching Points <ul><li>Many informatics tools are free, universally accessible, and user friendly, enabling effective practice of teleradiology for international outreach </li></ul><ul><li>Teleradiology outreach can be performed easily without significant IT infrastructure investment </li></ul><ul><li>Important urgent and emergent cases can be transmitted for consultation via teleradiology from any setting </li></ul><ul><li>A referring physician from anywhere around the world can seek the expertise of a radiologist </li></ul>
  35. 35. For more information <ul><li>Thank you for viewing this exhibit. For a copy of this presentation or for information relating to this exhibit, please contact: </li></ul><ul><ul><li>Sung H. Kim MD [email_address] </li></ul></ul><ul><ul><li>Garry Choy, MD </li></ul></ul>