Radiology Groups reading studies forwarded from multiple, often remote facilities is not a new concept, but technical challenges frequently limit the effectiveness of this service and the resulting product of the effort is typically the final report and nothing else.
One of the major benefits of a Radiology Picture Archiving and Communications System (PACS) is its ability to preserve all of the work products associated with the study created by the technologist and radiologist during study preparation and interpretation. Paper-based information from requisitions to consent forms can be scanned into the PACS and associated with the study. The window/level settings, graphical- and text-based overlays created by the radiologist can be preserved as the Presentation State of the images. Key images can be flagged and shorthand text notes conveying the gist of the report can be created and saved as Key Image Notes. And of course the radiologist’s final report completes the package. A PACS can preserve all of this clinical information along with the image data in an electronic file that can be accessed and viewed simultaneously by all of the caregivers responsible for the patient’s care. And all of this radiology information can be combined with a patient’s cardiology studies, laboratory results, medication history and case summaries via the Physician Portal of the Electronic Medical Record System.
If the resulting product of a remote interpretation is nothing more than the final report, all of the caregivers are being deprived of the wealth of clinical information contained in those work products created by the radiologist during interpretation, the Presentation States, Key Image Flags and Key Image Notes. Furthermore, it is not unusual for that final report to be delayed by several hours at best, while it loops its way through the editing and sign-off process. That short-hand Key Image Note might easily be the first piece of clinical findings that reaches the referring physician. In my opinion, a teleradiology solution that promises to deliver more than a preliminary finding should also deliver all of the work products along with the final report.
The technology challenges actually start at the very beginning of the teleradiology process.
It is well known that even current generation PACS are far from being truly open systems. Idiosyncrasies in the DICOM headers can affect the way the images acquired by one PACS appear on a display screen of another PACS. The teleradiology system needs to be able to correct for these idiosyncrasies.
Admittedly not all PACS support DICOM Greyscale Softcopy Presentations States (GSPS) or Key Image Notes (KIN), but that is bound to change in the near future, so a new Teleradiology system should support both of these DICOM SOP Classes on day one.
My point is that the deliverable product of a remote interpretation should be the final report AND all of the work products associated with that study. That means returning the new version of the study, along with all those additional work products, back to the originating PACS. That brings up another technical challenge. The originating PACS will most likely match this new version of the study with the original version, based on the patient Name, Accession Number, etc., but how does the originating PACS determine that the study status has changed from unread to read? Hopefully the originating PACS can accept an HL-7 update from the local RIS when the associated report is received. IF not, this is a bit of a loose thread.
Another issue is that of the relevant priors. Does the technologist have to manually forward the relevant priors along with the new study? Is the originating PACS capable of auto-forwarding both the new study (based on predefined meta data criteria) and the relevant priors to the teleradiology system? And at the end of the interpretation, what becomes of the relevant priors, and for that matter the new study? Is all of this study data simply deleted from the teleradiology system? Seems like a waste of bandwidth to keep forwarding relevant priors over and over again, each time a new study is generated for the same patient. Wouldn’t it make sense to “archive” all of the studies received by the teleradiology system, so they are available for comparison purposes? That means the teleradiology system would have to be able to partition its Directory database by originating facility, and possibly deal with multiple Medical Record Numbering Systems.
My argument is simply this, the product of a remote interpretation should be just as inclusive as the product of an in-house interpretation, for the benefit of the caregivers and the patient. The technology required to achieve this application is considerably more than yesterday’s teleradiology system. In fact the technology is beyond most current generation PACS. The ability to accept, display, and manage radiology study data from disparate PACS and return an interpreted study with all the associated work products to the originating PACS in a format that that PACS can recognize as its own is the purview of the PACS-Neutral Archive.
Radiology Practices and Health Systems interested in remote interpretation of Radiology studies would be well served if they carefully consider their respective expectations of such a service and then fully investigate the claims of the system providers, many of which may not fully appreciate the technical requirements of such a system.