Teleradiology Timothy P. Farrell, M.D., F.A.C.R. President Quantum Imaging & Therapeutics Associates Quantum Imaging & Therapeutics AssociatesPast-President Pennsylvania Radiological Society

Teleradiology: Definition Teleradiology is a means of electronically transmitting radiographic patient images and consultative text from one location to another. Teleradiology is a means of electronically transmitting radiographic patient images and consultative text from one location to another.

Teleradiology: Costs Can vary from $15,000 to $20,000 for low end equipment to more than $100,000 for high performance systems. Can vary from $15,000 to $20,000 for low end equipment to more than $100,000 for high performance systems. –a high quality sending station will cost approximately $35,000 to $40,000. –a dual CRT receiving/viewing station will cost in the $45,000 to $55,000 range.

Teleradiology: Components 1. An image sending station 2. A transmission network 3. A receiving/image review station

Teleradiology: Components Patient images are electronically encoded in a digital format at the sending station, sent on the transmission network and received, viewed, and possibly stored at the review station. Patient images are electronically encoded in a digital format at the sending station, sent on the transmission network and received, viewed, and possibly stored at the review station.

Sending Station: The Source What can be sent? Anything! What can be sent? Anything! –Non-digital (conventional) films can be digitized using scanners. –Most studies are now digital from the start: Computed Radiography, Digital Radiography Computed Radiography, Digital Radiography CT CT Ultrasound Ultrasound MRI MRI Etc. Etc.

Sending Station: The Source Connection can be directly from the equipment (CT scanner, etc.) or from a PACS (Picture Archiving System). Connection can be directly from the equipment (CT scanner, etc.) or from a PACS (Picture Archiving System). Requires adherence to the Digital Imaging and Communication in Medicine (DICOM) lossless compression standard. Requires adherence to the Digital Imaging and Communication in Medicine (DICOM) lossless compression standard. DICOM gateway is required between the source and the transmission network. DICOM gateway is required between the source and the transmission network.

Sending Station: The Source

A virtual private network (VPN) is required to assure compliance with the Health Insurance Portability and Accountability Act (HIPAA). A virtual private network (VPN) is required to assure compliance with the Health Insurance Portability and Accountability Act (HIPAA). VPN’s can be software or hardware based. VPN’s can be software or hardware based.

Transmission Network Wire Wire Fiber optics Fiber optics Microwave Microwave Internet Internet

Receiving/Image Review Station Consists of: Consists of: 1.Network interface 2.Personal computer with storage medium (e.g. hard disk drive) 3.One or more TV monitors 4.Optional hard copy device printer

Receiving/Image Review Station

The radiologist at the station can access the image via the computer and display it on the TV monitor. The radiologist at the station can access the image via the computer and display it on the TV monitor. The radiologist then performs software manipulation functions to "enhance" the image. The radiologist then performs software manipulation functions to "enhance" the image.

Receiving/Image Review Station The radiologist analyses the images and makes an interpretation, based on the clinical information (history) received. The radiologist analyses the images and makes an interpretation, based on the clinical information (history) received. The radiologist communicates the results back to the Sending Station (source) or another designated site. The radiologist communicates the results back to the Sending Station (source) or another designated site.

Receiving/Image Review Station

Where is this? Where is this? –“Upstairs” –Across town –Somewhere in Pennsylvania –Anywhere in the USA –Anywhere in the world

Teleradiology Is it “Medicine”? Is it “Medicine”? You bet it is!

Teleradiology: How is it used? Internal: Internal: –Within a hospital –Within a healthcare system (Examples: University of Pennsylvania, PinnacleHealth System) –Within a Practice (Example: Quantum Imaging)

Internal Teleradiology Nearly every radiology practice in Pennsylvania uses this. Nearly every radiology practice in Pennsylvania uses this. Used mostly during the day. Used mostly during the day. Allows studies to be consolidated to Image Review Stations. Allows studies to be consolidated to Image Review Stations. –Improves turn-around time, increases efficiency. –Allows for “subspecialty” reads

Internal Teleradiology: The Quantum Experience Quantum Imaging & Therapeutics Associates – Central Pennsylvania Quantum Imaging & Therapeutics Associates – Central Pennsylvania 50+ Radiologists 50+ Radiologists Services Harrisburg (PinnacleHealth System, Holy Spirit Hospital) and York (Wellspan). Services Harrisburg (PinnacleHealth System, Holy Spirit Hospital) and York (Wellspan).

Internal Teleradiology: The Quantum Experience Opened a Teleradiology Center in Opened a Teleradiology Center in Location: Lewisberry, Pennsylvania Location: Lewisberry, Pennsylvania Staffed by two radiologists from 6:30 am until midnight. Staffed by two radiologists from 6:30 am until midnight. Staffed by one radiologist from midnight until 6:30 am. Staffed by one radiologist from midnight until 6:30 am. –Has the physical capability to staff four radiologists concurrently, without adding equipment.

Internal Teleradiology: The Quantum Experience

How is our Teleradiology Center used? How is our Teleradiology Center used? During the day (6:30 am – 5:00 pm): During the day (6:30 am – 5:00 pm): –Subspecialty work: MRI MRI PET PET Echocardiography Echocardiography CT CT Nuclear Medicine Nuclear Medicine

Internal Teleradiology: The Quantum Experience How is our Teleradiology Center used? How is our Teleradiology Center used? During the evening (5:00 pm - midnight): During the evening (5:00 pm - midnight): –Heaviest volume from hospital emergency departments ( studies). –Mixed cases: CT, plain films, Ultrasound, Nuclear Medicine, MRI. –Radiologists can read 8-10 cases per hour.

Internal Teleradiology: The Quantum Experience How is our Teleradiology Center used? How is our Teleradiology Center used? Overnight (Midnight – 6:30 am): Overnight (Midnight – 6:30 am): –Busiest time: midnight – 2:00 am –Average = 50 cases, mostly CT scans –Trauma cases can be time-consuming and complicated. –Radiologists can read 7-9 cases per hour.

Internal Teleradiology Because Pennsylvania radiologists do Internal Teleradiology, they have: Because Pennsylvania radiologists do Internal Teleradiology, they have: –Image sending stations. –Transmission network (usually wire). Use of “internal” systems or phone lines is a weak link. –Receiving/image review station(s).

Teleradiology: How is it used? External Teleradiology: Imaging studies are sent outside of a hospital system, clinic or physician practice for interpretation by radiologists. External Teleradiology: Imaging studies are sent outside of a hospital system, clinic or physician practice for interpretation by radiologists.

External Teleradiology Who uses this? Who uses this? –Non-radiologist physicians: orthopedic surgeons, urologists, neurologists, etc. Almost always during the day. Example: Local Central Pennsylvania Orthopedic Surgery Practice. Example: Local Central Pennsylvania Orthopedic Surgery Practice. –Sends MRI studies to the Cleveland Clinic for interpretation.

External Teleradiology Who uses this? Who uses this? –Hospitals, clinics: also route studies to radiologists for interpretation. Almost always during the day. Example: Clearview Imaging, Allentown Example: Clearview Imaging, Allentown

External Teleradiology Who uses this? Who uses this? –Radiology Practices: send cases during the off-hours, often overseas. Why? Why? –Quality of Life issue: case volume is high and is increasing. Most radiologists do not want to work overnight shifts. –Most Pennsylvania radiology practices are not large enough or do not have the manpower to have dedicated “overnight” radiologists (“Nighthawks”).

External Teleradiology - Overseas Why is this done? Why is this done? –Time difference: Midnight in Harrisburg is 10:30 am in Bangalore, India and 2pm in Sydney, Australia. –Cost: Radiologists in India are cheaper than those in the USA.

External Teleradiology - Overseas Big Business: Google “Teleradiology”. Sponsored links are: Big Business: Google “Teleradiology”. Sponsored links are: –NightHawk Radiology –Virtual Radiologic –US Radiology on Call –RadLinx –Diagna –National Teleradiology –Superior Imaging –Teleradiology Solution

External Teleradiology - Overseas Problems: Problems: –There is a radiologist shortage in the United States. This is especially true in Pennsylvania. Most overseas radiologists have been trained in the United States. Most overseas radiologists have been trained in the United States. –They fill the training positions of physicians who could be practicing in the US. –Instead of practicing in the US, they return to their native countries.

External Teleradiology - Overseas Problems: Problems: –Exporting jobs: not just radiologists, but also: IT IT Assistants Assistants Everybody in the “Receive/Image Review Station” chain Everybody in the “Receive/Image Review Station” chain –Sending $ out of the USA.

External Teleradiology - Overseas American College of Radiology (ACR) recommends that radiologists who are performing distant reads are: American College of Radiology (ACR) recommends that radiologists who are performing distant reads are: 1.Board Certified by the ABR. 2.Carry licenses and Malpractice Insurance in the state where the image was obtained. 3.Are credentialed at the source facility.

External Teleradiology - Overseas … But in 2003, the Indian technology giant Wipro “tested the waters” by using Indian radiologists who were neither licensed nor Board-certified in the United States.

External Teleradiology - Domestic Many teleradiology “suppliers” are now using more US-based radiologists. Many teleradiology “suppliers” are now using more US-based radiologists. Most are based in the Pacific time-zone. Most are based in the Pacific time-zone. No major supplier is Pennsylvania-based. No major supplier is Pennsylvania-based. Other training centers are offering Teleradiology services. Other training centers are offering Teleradiology services. –Cleveland Clinic –University of Virginia

External Teleradiology In Pennsylvania: External Teleradiology = Out-of-state Radiology!

Teleradiology Business Can we do this in Pennsylvania? YES! Can we do this in Pennsylvania? YES! –6 medical schools (Jefferson, Drexel, Penn State, Temple, Penn, Pitt) –Have the technology –Have access to Broadband network deployed across Pennsylvania

Teleradiology Business Pennsylvania is losing this! Pennsylvania is losing this! Imaging Studies and therefore jobs, are being sent out of Pennsylvania. WHY? Imaging Studies and therefore jobs, are being sent out of Pennsylvania. WHY?

Teleradiology Business 1. No “Teleradiology” Law – requiring PA licensure for those practicing medicine via Teleradiology. 2. Liability Insurance Problems 3. Radiologist shortage 1.Insurance Company dominance. 2.High Medicare/Medicaid population.

Teleradiology Business Let’s do something about this!

Thank You!