TURKISH SOCIETY OF RADIOLOGY Standard on Teleradiology 1. INTRODUCTION This standard has been prepared to improve the quality of public healthcare by means of telemedicine and is aimed to be a guide for the appropriate use of teleradiology technique. The standard serves as a guideline and has no special mission to recover the legal shortcomings. A patient-centered approach has been utilized and advised during the preparation and in the use of the standard. Specific to any clinical situation, the performance of the prerequisites that were not described in this standard is the responsibility of the physician who performs or interprets a radiological examination. The physician may modify the standard in case of a special reasonable clinical condition. Teleradiology allows a continuous education beside an instant interpretation of the images and a possibility for a second opinion. Users in different locations may interpret the images synchronously. Teleradiology may utilize an access to the radiological comments and provides a significant support to healthcare if used appropriately. The use of teleradiology does not reduce the responsibility of the supervision and management of the radiological services. The radiology service is an integrated clinical process. In this process the radiologist has the responsibility to determine the examination algorithm, to plan the exam, to perform additional examinations if needed, to use contrast agents, to prevent the patients from the radiation hazards, to interpret the images with the help of clinical and previous imaging data, to dictate the report, to discuss the results with the referring clinicians and to practice educational and administrative roles. Radiology report is a by-product in this process and can not be isolated from the remaining steps. For these reasons teleradiology should not be accepted just as a report dictation and must be considered as one of the components of radiology service. 2. RELEVANT DESCRIPTIONS 1. Teleradiology: Transmission of radiological images and the related data from one location to another for the purposes of interpretation and/or consultation. 2. Site: Unit, center or institution that gives the radiology service. 3. Transmitting site: The site that performs the radiologic examinations and sends the images with the related data to another site for interpretation. 4. Receiving site: The site that interprets reports or gives a second opinion to the images. 5. Reporting: The process of composing a final report after interpreting the images in light of the clinical data (It is recommended to use the Turkish Society of Radiology [TSR]Reporting Standards). 6. Second opinion: Frequently used when subspecialty expertise is needed. Additional evaluation is taken from another radiologist before a final report. It can not be used as a final report. 7. Wet reporting: Rapid, short and object-oriented reporting usually done in emergency cases. A final report is done later by the same or another radiologist. 8. Addendum: Additional report that includes the corrections or new findings after the approval of original report.
3. THE AIM OF TELERADIOLOGY The aim of teleradiology should be to provide a more widespread and high-quality radiology service to the patient and public. 4. INDICATIONS a. To provide consultative and interpretative radiologic services. b. To provide a rapid access to the radiologic reports and images in emergency or non-emergent cases. To provide an opportunity to the on-call radiologists to prepare a wet report. c. To provide subspecialty support as needed. d. To provide educational opportunities to the radiologists. e. To promote the quality and efficiency of radiology service. f. To provide radiological interpretation to the transmitting site. g. To support professional and continuing medical education. h. To support telemedicine. 5. MISUSES AND INAPPROPIATE IMPLEMENTATIONS a. The use of teleradiology to compensate for radiologist shortage or absence. b. Applications that may threaten the patients health. 6. QUALIFICATIONS OF PERSONNEL a. Transmitting site personnel qualifications: Transmitting site should comprise of at least one radiologist, one radiographer or a radiology technician, and a system manager with informatics certification. b. Receiving site personnel qualifications: Receiving site should appoint a sufficient number of radiologists compatible with the workload. Those radiologists should be certified in teleradiology and have to be given user tuition. c. Both sites should hire information technologists and technicians who will be responsible form the computer systems and infrastructure. The quantifications? of the personnel in the receiving site should be identical to those of the transmitting site. All the quantifications should be documented. 7. TELERADIOLOGY PROCESSES A. Transmitting site Transmitting site should hire a radiologist. The acquisition of the images without a radiologist and then their utilization via teleradiology should only be possible in below cases: 1. Disasters and war like conditions 2. Screening programs limited by mammography and chest x-ray. The requests in the transmitting site should be evaluated by the radiologist. The indication of the examination should be clear enough for the radiologist. The radiologist should consent to the examination, make the plan, pay attention to the preventive issues, control the exam quality, and perform additional examinations where necessary. Informed consent: All patients should be informed on their examinations and a consent form should be taken. Patients should also be informed of the
teleradiological process and the responsible radiologists who would interpret the images. A satisfactory explanation is essential for the safety and security of the images during teleradiology. B. Transmission The types and specifications of the transmission elements should be documented by the transmitting site. Diagnostic loss in the images should not be acceptable at the receiving site. Patient demographics, site information, labels and measurement data should all be transmitted without errors. The selection of the images that will be transmitted is the responsibility of the radiologist at the transmitting site. I. Image acquisition and digitizing Image acquisition should be done according to the TSR guidelines. a. Direct image acquisition: All the data set including the image matrix and pixel byte depth that is obtained by a digital modality should be transferred to the teleradiology system. DICOM standard should be used. b. Digitized images: 1. Small matrix images: Each image should be digitized to a matrix size as large as or larger than that of the original image by the imaging modality. The digitized images or video frame grab with this method are acceptable. 2. Large matrix images: These images should be digitized to a matrix size corresponding to 2.5 lp/mm or greater measured in the original detector plane. These images should be digitized to a minimum 10 pixel byte depth. II. Data compression: Data compression may be used to increase transmission speed and reduce storage requirements. Several methods, including both reversible and irreversible techniques, may be used under the direction of a qualified physician, with no reduction in clinically significant diagnostic image quality. The types and ratios of compression used for different imaging studies transmitted and stored by the system should be selected and periodically reviewed by the responsible physician to ensure appropriate image quality. The radiologist at the receiving site should have the option to access the uncompressed or lossless images as needed. Other requirements: The patient name, identification number, examination date and time, type of examination, related anatomical area and its orientation, name of the imaging site, type of the image compression method and the compression ratio should be embedded on the image. The clinical data needed for the interpretation should be transferred by the images or the electronic health records of the patient should be accessible by the receiving site as needed. C. Receiving site: Monitors: The qualification of the monitors which will be used for the interpretation should meet the aims of teleradiology and the related TSR guidelines.
8. ARCHIVING AND IMAGE RETRIEVAL Teleradiology systems should be compatible with both transmitting site s regime of maintaining medical records and national rules of medical record keeping. The location, type and duration of the archiving should meet the legal requirements of the transmitting site. Both sites should have an archiving procedure and policy corresponding to hard copy archiving policies. Each individual examination data folder should include the patient and examination database records which contain patient name, identification number, examination date, time and type, name of the institution. A space has to be provided for a short clinical information. Previous images of the patient should be prefetched at a reasonable speed on the demand of teleradiologists. 9. SECURITY Teleradiology systems should provide network and software security protocols to protect the confidentiality of patient s identification and imaging data consistent with national requirements. There should be measures to safeguard the data and ensure data integrity against intentional or non-intentional corruption of the data. 10. RELIABILITY AND REDUNDANCY Written policies and procedures should be in place to ensure continuity of teleradiology services. These should include patient data backup systems, telecommunication links and backups, and a disaster plan. 11. AUTHORIZATION AND RESPONSIBILITIES Teleradiology service in Turkey should only be given by a radiologist who has an official specialty diploma that allows legal employment in the Republic of Turkey. The authority and the responsibilities of the radiologist that works in any of the sites should be clear and written. These physicians should work to fulfill their professional legal responsibilities. Radiologists in both sites are responsible from the examination quality. The communication information of the teleradiology staff in both sites should be accessible by the stakeholders of the process. Images stored in either site should meet the jurisdictional requirements of the transmitting site. There is no need to archive the images in the receiving site if they are archived properly at the transmitting site. If required, archiving in the receiver site should meet the jurisdictional requirements of the transmitting site. How the images will be archived should be recorded in written form. Teleradiologists should work in accordance with the rules, regulations and laws defined for the transmitting site. 12. DOCUMENTATION Communication is one of the critical components of the technology. Teleradiologists who provide reports should follow the report dictation standard of TSR. A teleradiology report should contain the type of the service (primary interpretation, second opinion etc.), the name of both the transmitting and receiving sites, the name of the related radiologists in both sites, date of the examination and the communication data. The name of the interpreting radiologist should clearly take place in the document. The documents should be kept as long as the law requires. An approved document should not be changed. Any addendum that has to be made in emergency or
non-emergent cases should be recorded. Supplements or documents related with the radiology report should be stored separately. 13. QUALITY CONTROL AND IMPROVEMENT, PATIENT SAFETY CONCERNS. Both sites should have written plans about quality control, improvement and patient safety. These plans should meet the sites policies and TSR standards. 14. TASK GROUP This standard has been prepared by the cooperation of Imaging Informatics Working Group of TSR and RIS&PACS Working Group of TurkMIA. Participants: Mustafa Özmen, Deniz Akata, Nuri Tasalı, Hasan Yiğit, Oğuz Dicle, Üstün Aydıngöz, Utku Şenol, Levent Altın, Uğur Toprak, Ayhan Üçgül, Tan Cimilli, Levent Çelik. 15. REFERENCES a. American College of Radiology. ACR Standard on Teleradiology: Resolution 11, 2002 b. American College of Radiology. ACR Technical Standard for Electronic Practice of Medical Imaging: Resolution 13, 2007 c. TSR Standards of Guidelines and Standards Committee. d. European Commission Green Paper on the European Workforce for Health COM (2008) 725 final This standard has been prepared with the coordination of TSR Guidelines and Standards Committee and the contribution of above participants. The aim of this standard is to provide a common language and behavior among our colleagues in their practices and to enable a high level of healthcare for patients. The widespread use of this guideline, which has been prepared with the efforts of our experienced colleagues and in light of international sources, and continuous improvement of the standard with feedbacks are our greatest expectations.