The idea to address issues in teleradiology was triggered during the panel discussion on teleradiology during the Radiology & Imaging Conclave 2021 conducted by Express Healthcare. It culminated into an article written by Dr Sona Pungavkar. Dr Pungavkar is a medical director at SDRC; MR Consultant, Global Hospitals and S.L. Raheja Hospital. She is also the founder and ex-national co-ordinator, RAKSHA, – IRIA
The term ‘teleradiology’ entails electronic transfer of the scan data of a patient, from the scanner on which it is performed, to a remote site, where a radiology team can download the scan on their system and review the scan and prepare a report, which is then similarly transferred to the centre where the scan was performed, within a stipulated time.
The need for teleradiology in India is evident, as there is a shortage of radiologists. The burden is increased due to the large rural patient population, which does not have access to specialised medical care.
Requirements of a client using teleradiology services need to be focused on, as it is now becoming an integral part of practice in the country, especially in the recent pandemic situations. These have been discussed below.
Emergency reporting with short turn around times: Cost benefit ratio of employing a radiologist for emergency reporting is skewed due to competition faced by the stand alone centres and small hospitals, which have in-house scanning facilities. Hence, for patients in need of urgent reports, a scan centre can provide a report with a short turnaround time (TAT) using teleradiology. This means that the teleradiology provider needs to systematically arrange back up radiologists, maintaining the skill levels, in addition to availability.
Maintaining quality: In India, there is a challenge of provision of satisfactory training programs for residents. In addition, there is limited awareness of quality assurance parameters in radiology. The teleradiology services are mushrooming across the country, adding freshly passed out, eager to work from home radiologists, who lack the clinical experience to dish out a meaningful report. The degrees possessed by these radiologists, duration of experience, interpretation skills etc. are not assessed either by the teleradiology service provider or the centres requesting for the services.
Subspecialty reporting: Also, a teleradiology service provider is in assumption, that the radiologist who has been engaged by them for the reporting, has enough experience to handle the broad spectrum of cases. The fact that a bigger team, with subspecialised radiologists, is required to provide accuracy across the various modalities within radiology and across the systems, has been majorly overlooked.
Communication with the clinician: Reporting of a radiology scan is enhanced when there is a dialogue between the clinician and the radiologist, which can be termed as a multidisciplinary interpretation or clinical radiology. This has not been found to be a necessity within the teleradiology service provisions in India and has been inadvertently ignored. A solution for this needs to be met.
Lack of accountability: Also, there is apathy in the deliverance of the report, with an attitude that in case of an error in the report is never going to be traced back, from the remote site, to the person reporting in view of the faceless nature of the service. This is even more rampant, when the centre, which requests the service does not have a radiologist on board to perform reviews of the reports. Most teleradiology services are also not owned by radiologists and hence, they cannot measure the quality of reports being provided by the radiologists engaged by them. No peer review system exists in these setups. To go one step further, they may not be aware that a peer review system is a necessity to ensure quality.
Fast report issuance used as a selling point by centres as a competitive advantage: In order to stifle competition, radiology set ups, especially those run by non-radiologists focus on fast reporting, ignoring the drop in quality expected due to less time provided to the person reporting the scan. This is even more important in complicated studies or follow up scans requiring comparison.
Lack of a standard reporting format: As the team members with teleradiology service provider have the liberty to use their own format for reporting, the centre availing the service, usually does not have a standard format for maintaining consistency and improving the end user’s (i.e., the clinician’s) confidence in the report, with the patient being the overall loser.
Hence, when a centre requests a teleradiology service to partner, they need to address these points and work on them to provide satisfactory quality and consistency. There have to be random peer review mechanisms, which the teleradiology service provider must be under compulsion to provide to the centre on a regular basis. Alternatively, the peer review could be initiated by the centre with few senior and subspecialised radiologists across various systems, keeping the teleradiology service provider in full knowledge of a periodic assessment with a feedback mechanism.
The teleradiology service provider should also have a very stringent selection process for the recruitment of radiologists. Cognitive and non cognitive skills should be taken into account, in addition to the duration of experience.
The cognitive aspects of selection would include the qualification and the hours of experience and add-on training as well as research and publications, as happens in recruitment of an onsite radiologist. The non – cognitive skill set is more important especially in remote setting and includes ability to interact effectively (orally and more so in writing) so that accuracy of the reports is high and the findings along with expected complications, are described properly. The radiologist should have a recognition of his/her limits of knowledge or skill, as well as a willingness to seek assistance when needed. Also, the team member needs to be conscientiousness with evidence of thoroughness in the work done and a willingness to go beyond the call of duty, as in teleradiology in a remote site, a lot could depend on the report provided by the radiologist. Moreover, the expectations need to be set correctly and the practice of maintaining high standards needs to be emphasised.
There is a very urgent need to bring teleradiology services under regulations, as in happening in the west. Accreditation is important and an annual assessment, as is done in other domains of radiology, such as radiation safety, can be necessitated for teleradiology service industry.
On top of everything, the service providers and the centres, engaging them need to put the patient as the first priority and business after that.