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Current Concepts in Teleradiology
IN SMALL ANIMAL MEDICINE AND SURGERY
WWW.ADVANCESINSMALLANIMAL.COM
VOLUME 24, ISSUE 10 • OCTOBER 2011
Current Concepts in Teleradiology STEPHANIE ESSMAN, DVM, MS, DACVR DEPARTMENT OF VETERINARY MEDICINE AND SURGERY COLLEGE OF VETERINARY MEDICINE UNIVERSITY OF MISSOURI COLUMBIA, MO 65211 The term “teleradiology” encompasses a number of concepts ranging from simple electronic transfer of compressed images via email to advanced, sophisticated transfer of medical images to a remote server. Regardless, it is the point-to-point communication of radiographic images with the purpose of obtaining an interpretation.1 Veterinary teleradiology first became available in the 1990s but was limited due to excessively large file sizes and slow internet speeds. With the rapid advances in information technology and decrease in cost of bandwidth, the applicability and ease of teleradiology has rapidly advanced and is becoming widely available. EARLY TELERADIOLOGY Early teleradiology services were provided by large companies that contracted with radiologists as independent contractors or employees. This essentially made the large company the “middle man,” and it was the company that typically worked and communicated with the veterinarian. The veterinarian would send the images to the company, either electronically or via mail, the company would digitize the images, and send them to one of the contracted radiologists. The radiologist would then write and send back an official radiologist report usually via the middleman company. This was an indirect, but necessary, method of communication, because the software used for image transmission and, in many cases, image acquisition was proprietary.2
MODERN TELERADIOLOGY Modern teleradiology, however, utilizes an open standard of communication called DICOM. DICOM is the universally accepted standard medical image format and transmission protocol. Once the DICOM standard became widely accepted, foundation was laid for standard nonproprietary communication between imaging modalities and the veterinary clinic picture and archiving communication system (PACS). Although not required, reputable vendors in the veterinary market should develop their equipment to be DICOM compliant, allowing free communication between digital
“If a veterinarian approaches the integration of teleradiology into the clinic by simply comparing the turnaround times and cost, it is likely that they will be dissatisfied with the service.” systems, the hospital PACS, and the veterinarian’s choice of radiologist. Although large companies are still commonly used and are a valid choice for a teleradiology option, because of these developments in communication, the company’s software is no longer required to transmit images to a radiologist. Any veterinary clinic with access to the Internet can easily send images directly from their digital system to their radiologist of choice. This more direct method of image interpretation often results in an overall decrease in cost for interpretation, but more importantly, enables the veterinary practitioner to develop a professional relationship with a radiologist of their choice.
CONSIDERATIONS IN THE USE OF TELERADIOLOGY The DICOM Standard When incorporating teleradiology into a practice, several things need to be taken into consideration in order to maximize the advantages of this service. First and foremost, when purchasing digital equipment, it is of utmost importance that the system being considered is able to send images using the DICOM standard. It is not uncommon for many vendors to claim they are DICOM compliant and not be DICOM-send compliant.2 The system should allow the veterinarian to change
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A D VA N C E S
3 key pieces of information in the system: application entity (AE) title information, the port number, and the internet protocol (IP) address. This allows direct communication with the radiologist’s server and allows vendor independent (nonproprietary) compression of images and avoids vendor lock in. The radiology service that is chosen should be able to easily assist in getting the veterinary clinic’s system ready to send images to the radiologist’s server, have easy image upload, and report distribution with quick access to IT support should it be needed. Confidence in the Radiologist Secondly and perhaps most imperative, in order to really benefit from a teleradiology service, the veterinarian must find a radiologist or group of radiologists that they trust and with whom they can develop a positive working relationship. If a veterinarian approaches the integration of teleradiology into the clinic by simply comparing the turnaround times and cost, it is likely that they will be dissatisfied with the service. To ensure the teleradiology experience is optimized, 4 components of a service are required of a radiologist and should be expected by the clinical practitioner. First, a thorough evaluation of the history by the radiologist is required, meaning a
thorough and complete history is submitted with the case. Second, the exam should be assessed to ensure the diagnostic quality is adequate. Third, the images are interpreted and a report generated that is complete and thorough, free of vague conclusions and differentials. Fourth, and perhaps arguably the most important, is the post-examination consult with the referring veterinarian.3 This is perhaps the most overlooked and underutilized component of teleradiology. While this certainly does not need to occur in every case that is sent for an interpretation, it is necessary that the veterinarian develop a relationship with a radiologist whom they feel comfortable calling to discuss a case. In addition, they should have confidence that if needed, the radiologist will be the individual that contacts the practitioner to discuss difficult or confusing cases or if more information is required to ensure an adequate interpretation. The lack of a direct professional relationship between the referring veterinarian and radiologist increases the risk for miscommunication and misunderstandings and underutilizes the benefit of teleradiology all together. Turnaround Time and STAT Option Thirdly, a reasonable rapid turnaround time (2 to 4 hours) and an optional STAT
service are also important factors to take into consideration.4 However, the veterinarian should be wary of services that offer exceedingly fast turnaround times. It takes time to download and interpret the images and generate a report. Excessively fast turnaround time leads to short, incomplete reports and increases the possibility of errors. A good report that is complete and beneficial to the veterinary practitioner requires personal thought and insight rather than macro-generated or pre-written reports. CONCLUSIONS Teleradiology is rapidly becoming established as a standard in patient care, providing rapid access to image interpretation by a consulting radiologist. This allows an increased number of hospitals, particularly those in an emergency or rural setting, access to the services of a radiologist. However, to best utilize this service, it is imperative that the veterinary practitioner be concerned with more than just low cost and rapid turnaround time. The development of a professional relationship with a radiologist can help propel the value of teleradiology beyond the confines of image interpretation, allowing complete integration of radiology and the radiologist into the practice, thus enhancing the teleradiology experience.
A D VA N C E S
REFERENCES 1. Jarvis L, Stanberry B. Teleradiology: threat or opportunity? Clin Rad 2005;60:840-845. 2. Poteet BA. Veterinary Teleradiology. Vet Radiol Ultrasound 2008;49:S33-S36. 3. Borgstede, JP. Radiology: Commodity or Specialty. Radiology 2008;247:613-616. 4. Animal Insides website. http://www. animalinsides.com/learn/radiologistsonly/312.htm Accessed July 2011.
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WWW.ADVANCESINSMALLANIMAL.COM
VOLUME 24, ISSUE 10 • OCTOBER 2011
Current Concepts in Teleradiology STEPHANIE ESSMAN, DVM, MS, DACVR DEPARTMENT OF VETERINARY MEDICINE AND SURGERY COLLEGE OF VETERINARY MEDICINE UNIVERSITY OF MISSOURI COLUMBIA, MO 65211 The term “teleradiology” encompasses a number of concepts ranging from simple electronic transfer of compressed images via email to advanced, sophisticated transfer of medical images to a remote server. Regardless, it is the point-to-point communication of radiographic images with the purpose of obtaining an interpretation.1 Veterinary teleradiology first became available in the 1990s but was limited due to excessively large file sizes and slow internet speeds. With the rapid advances in information technology and decrease in cost of bandwidth, the applicability and ease of teleradiology has rapidly advanced and is becoming widely available. EARLY TELERADIOLOGY Early teleradiology services were provided by large companies that contracted with radiologists as independent contractors or employees. This essentially made the large company the “middle man,” and it was the company that typically worked and communicated with the veterinarian. The veterinarian would send the images to the company, either electronically or via mail, the company would digitize the images, and send them to one of the contracted radiologists. The radiologist would then write and send back an official radiologist report usually via the middleman company. This was an indirect, but necessary, method of communication, because the software used for image transmission and, in many cases, image acquisition was proprietary.2
MODERN TELERADIOLOGY Modern teleradiology, however, utilizes an open standard of communication called DICOM. DICOM is the universally accepted standard medical image format and transmission protocol. Once the DICOM standard became widely accepted, foundation was laid for standard nonproprietary communication between imaging modalities and the veterinary clinic picture and archiving communication system (PACS). Although not required, reputable vendors in the veterinary market should develop their equipment to be DICOM compliant, allowing free communication between digital
“If a veterinarian approaches the integration of teleradiology into the clinic by simply comparing the turnaround times and cost, it is likely that they will be dissatisfied with the service.” systems, the hospital PACS, and the veterinarian’s choice of radiologist. Although large companies are still commonly used and are a valid choice for a teleradiology option, because of these developments in communication, the company’s software is no longer required to transmit images to a radiologist. Any veterinary clinic with access to the Internet can easily send images directly from their digital system to their radiologist of choice. This more direct method of image interpretation often results in an overall decrease in cost for interpretation, but more importantly, enables the veterinary practitioner to develop a professional relationship with a radiologist of their choice.
CONSIDERATIONS IN THE USE OF TELERADIOLOGY The DICOM Standard When incorporating teleradiology into a practice, several things need to be taken into consideration in order to maximize the advantages of this service. First and foremost, when purchasing digital equipment, it is of utmost importance that the system being considered is able to send images using the DICOM standard. It is not uncommon for many vendors to claim they are DICOM compliant and not be DICOM-send compliant.2 The system should allow the veterinarian to change
PAG E 2
A D VA N C E S
3 key pieces of information in the system: application entity (AE) title information, the port number, and the internet protocol (IP) address. This allows direct communication with the radiologist’s server and allows vendor independent (nonproprietary) compression of images and avoids vendor lock in. The radiology service that is chosen should be able to easily assist in getting the veterinary clinic’s system ready to send images to the radiologist’s server, have easy image upload, and report distribution with quick access to IT support should it be needed. Confidence in the Radiologist Secondly and perhaps most imperative, in order to really benefit from a teleradiology service, the veterinarian must find a radiologist or group of radiologists that they trust and with whom they can develop a positive working relationship. If a veterinarian approaches the integration of teleradiology into the clinic by simply comparing the turnaround times and cost, it is likely that they will be dissatisfied with the service. To ensure the teleradiology experience is optimized, 4 components of a service are required of a radiologist and should be expected by the clinical practitioner. First, a thorough evaluation of the history by the radiologist is required, meaning a
thorough and complete history is submitted with the case. Second, the exam should be assessed to ensure the diagnostic quality is adequate. Third, the images are interpreted and a report generated that is complete and thorough, free of vague conclusions and differentials. Fourth, and perhaps arguably the most important, is the post-examination consult with the referring veterinarian.3 This is perhaps the most overlooked and underutilized component of teleradiology. While this certainly does not need to occur in every case that is sent for an interpretation, it is necessary that the veterinarian develop a relationship with a radiologist whom they feel comfortable calling to discuss a case. In addition, they should have confidence that if needed, the radiologist will be the individual that contacts the practitioner to discuss difficult or confusing cases or if more information is required to ensure an adequate interpretation. The lack of a direct professional relationship between the referring veterinarian and radiologist increases the risk for miscommunication and misunderstandings and underutilizes the benefit of teleradiology all together. Turnaround Time and STAT Option Thirdly, a reasonable rapid turnaround time (2 to 4 hours) and an optional STAT
service are also important factors to take into consideration.4 However, the veterinarian should be wary of services that offer exceedingly fast turnaround times. It takes time to download and interpret the images and generate a report. Excessively fast turnaround time leads to short, incomplete reports and increases the possibility of errors. A good report that is complete and beneficial to the veterinary practitioner requires personal thought and insight rather than macro-generated or pre-written reports. CONCLUSIONS Teleradiology is rapidly becoming established as a standard in patient care, providing rapid access to image interpretation by a consulting radiologist. This allows an increased number of hospitals, particularly those in an emergency or rural setting, access to the services of a radiologist. However, to best utilize this service, it is imperative that the veterinary practitioner be concerned with more than just low cost and rapid turnaround time. The development of a professional relationship with a radiologist can help propel the value of teleradiology beyond the confines of image interpretation, allowing complete integration of radiology and the radiologist into the practice, thus enhancing the teleradiology experience.
A D VA N C E S
REFERENCES 1. Jarvis L, Stanberry B. Teleradiology: threat or opportunity? Clin Rad 2005;60:840-845. 2. Poteet BA. Veterinary Teleradiology. Vet Radiol Ultrasound 2008;49:S33-S36. 3. Borgstede, JP. Radiology: Commodity or Specialty. Radiology 2008;247:613-616. 4. Animal Insides website. http://www. animalinsides.com/learn/radiologistsonly/312.htm Accessed July 2011.
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