A critical analysis focusing on the field of teleradiology

Introduction

Health Resources Services Administration defines telehealth as the provision of any healthcare-related activity (including clinical health care itself but also healthcare education, public health and health administration) by means of electronic information and telecommunications technology. Therefore, the concept of telehealth is broader than the concept of telemedicine, as the latter only considers the remote use of clinical services while the former comprises both clinical and non-clinical aspects of healthcare.¹

Amongst the possible telehealth services, lies what is known as teleradiology – the transmission of patients’ radiological images between different locations (either within the same organization or between organizations, and even across regions and countries). ²

Teleradiology has become a reality in most countries for several years now and its use remains on the rise. Although teleradiology is not without controversies, it appears to be a valuable tool to tackle a few of the most serious challenges of healthcare systems, including sustainability, workforce durability, care quality and education.³ The role of teleradiology in each of these fields and the major difficulties concerning its application will be reviewed and analysed in this article.

Healthcare sustainability

Telehealth allows healthcare providers to optimize the utilization of healthcare resources by conducting virtual consultations, reducing the need for physical infrastructure and the associated forms of energy usage (lighting, heating, etc). Such virtual appointments also reduce the need for patients and healthcare providers to travel to physical healthcare facilities, resulting in a significant reduction in carbon emissions from transportation. This is particularly beneficial in rural areas where patients may have to travel long distances to access healthcare services. A recent study published in the Journal of NPJ digital medicine shows that Stanford Healthcare Virtual healthcare system reduced their 2021 greenhouse gases emissions by nearly 17,000 metric tons as compared to treating those same patients in person. This is the equivalent of over 2100 homes’ energy use for a year or the CO2 sequestered by nearly 20,000 acres of US forest in one year. ⁴ (Fig 1)

Figure 1: Avoided greenhouse gas emissions from televisits at Stanford Healthcare (2019-2021) (Adapted from REF 4)

A recent large retrospective study from Spain looked at the impact on carbon emissions of digital appointments and digital access to test results and medical reports.⁵ The authors found that through avoiding the need for patients to travel to clinics for assessment or to collect printed results there was a reduction in 6,655 tons of CO2 emissions in a one-year period. 640,122 digital appointments were conducted during the study in 2020 which avoided 1,957 net tons of CO2 emissions and the download of 3064646 digital reports avoided 4698 net tons of CO2 emissions. The authors concluded that each digital appointment avoided 3.1kg net CO2 emissions whilst every digital report downloaded instead of being physically collected avoided 1.5kg net CO2 emissions.

Another study undertaken in the central Catalan region looked at the environmental effect of telemedicine services through reduction in patient visits to hospital.⁶ In the period between January 2018 and June 2019, 9034 face-to-face visits were avoided, saving almost 4000 hours of travel time and a distance of almost 200,000 km. The authors found a reduction in almost 12,000 litres of fuel, saving almost 16,000 euros. Other studies have found similar favourable reductions in environmental impact through the use of telemedicine.^7,8

Whilst these studies focused on telehealth in general, much of what was found can be extrapolated to teleradiology:

The storage of patient images and reports in online applications can replace the need for printed paper reports or the download of images onto compact discs (CDs). Without the need to print and produce these, significant reductions in waste and carbon emissions can be achieved without compromising patient care. In addition, this also negates the need for patients to travel to the hospital site to physically collect images and reports. ⁶

The carbon footprint associated with patient travel to additional sites to obtain a second opinion can also be reduced through the use of virtual networks. Such networks allow images to be transferred to alternative sites for expert review without the need for patients to travel. ⁵

Reduction in travel burden also affects the radiologists delivering care. Rather than having to attend the hospital site, radiologists can access patient images from home using a home workstation which can reduce the carbon footprint associated with staff travel to the hospital site. Radiologists working remotely from home can also reduce the need for hospital-based radiology reporting rooms to be up and running 24/7. This has a knock-on effect on electricity bills and the associated environmental impact of unused office space. ⁷

Workforce flexibility

Over 80% of health systems worldwide are reporting shortages in their radiology departments.⁹ Over 67% of people on earth do not have access to radiologists and there are disparities between countries and within countries. In Figure 2 we can see the disparities in the availability of radiologists clearly illustrated; the US for example has just over 49,000 radiologists while 14 African countries have no radiologists at all.¹⁰ There is also vast discrepancies in the availability of radiological imaging equipment with many countries lagging behind the WHO recommended ratio of equipment vs population.^11-13

Figure 2: Number of radiologists per million inhabitants (Adapted from REF 11)

There is limited to no data on the availability of medical technology in these countries. However, the data available shows only 6 African countries reporting no CT scans at all, less than 10 reporting no mammograms and/or SPECT machines and 11 African countries do not have MRI machines. Less than 10 African countries have PET scans with all of these countries reporting only 1 PET scan available.¹⁴

There are several ways in which teleradiology may positively impact the healthcare workforce (reviewed in ^15-17):

Doing more with less

Taking advantage of teleradiology services allows the current pool of radiologists worldwide to be shared globally. Countries with few or no radiologists can take advantage of radiologists located elsewhere through the transmission of patient images and reports.

In smaller departments, the need to recruit radiologists from every subspecialty can be negated as scans can be transferred to larger sites with access to the required subspecialist. For example, a small radiology department may not need to recruit a dedicated paediatric neuroradiologist given their small patient cohort but can utilise the skills of a dedicated paediatric neuroradiologist at another hospital site.

Teleradiology can also allow the remote reporting of patient scans out of hours without needing to have radiologists onsite at every facility 24/7. Through the use of so-called ‘radiologist hubs’, a smaller number of radiologists can offer on-call cover to a large geographical area from a remote location.¹⁸

The ability to cross cover sites can also help with short-term shortages such as sick leave or maternity leave. Such periods of absence may be short lived or occur with little notice and the hiring of an additional radiologist may not be feasible or required if a portion of the workload can be shared through teleradiology networks to sites with a more ample workforce.

Enhancing job satisfaction

One of the key factors that influence job satisfaction in healthcare workers is the quality of care they are able to provide to their patients. In radiologically under-served systems, access to teleradiology services which improve patient outcomes can lead to increased job satisfaction for care providers.

Enabling workplace flexibility (hybrid and remote working opportunities)

The COVID-19 pandemic forced the global adoption of remote work and the development of remote and hybrid working models. Such models allow a better work–life balance for radiologists who may have personal commitments that favour more flexible working patterns and the ability to work from home.

Productivity may be also greater with studies demonstrating remote healthcare workers are up to 56% more productive and make 40% fewer mistakes than their in-facility counterparts. In addition, absenteeism dropped by 41% on average and staff retention went up by 12%.^15,16,19

Care quality

Variability in the availability and quality of imaging services across different populations is vast and can result in disparate patient outcomes. This is particularly common in more rural or underserved communities. In Nigeria for example, there is only 1 radiologist for every 600,000 people and there are 14 countries in sub-saharan Africa without a single radiologist.^20,21 Even when there are regional radiologists, many smaller, more ‘niche’ imaging subspecialties are not large enough to have radiologists on the ground at every healthcare facility. A child with a complex congenital brain abnormality would benefit from the opinion of a dedicated paediatric neuroradiologist but in many cases, patients such as this may be asked to travel to a larger or more subspecialist facility which can be costly, add unnecessary delays and may not be possible if the patient is acutely unwell. In some areas, patients may be asked to travel up to 100km for their images to be reported.²¹

Teleradiology can be a great tool for reducing this variability through provision of round-the-clock care and access to the highest level of expert opinion which may otherwise not be possible.²⁰ The capacity to send imaging cases externally to be reviewed by a subspecialist without the need for the patient to travel can have a profound impact on the patient’s ongoing treatment without incurring additional financial burden or delaying essential treatment. Cases can even be sent across international borders to take advantage of global experts in the field and get remote assistance from specialised centres with complex diagnoses – something which would be nearly impossible without the use of teleradiology. Through the use of telecommunications, the reporting radiologist can maintain contact with the referring clinicians to answer patient-specific questions as required, even in cases of cross-border reporting (3). Teleradiology can also offer help during surges in patient volumes, which often come with increases in imaging workload, as seen during the COVID-19 pandemic, with the added benefit of helping to reduce the number of staff on site and therefore the risk of cross-infection between staff members and patients.^20,22

Teleradiology services can also improve the speed at which reports can be provided which can have a huge impact on patient outcomes in time-critical cases. A patient with an acute stroke may present to a facility without radiologist cover overnight and would usually have to wait several hours for their images to be reviewed by a radiologist. Through teleradiology, access to facilities with 24-hour cover or through utilization of radiologists in different time zones, patients can receive a diagnosis in minutes. With improvements in handheld technology, cases such as this can be accessed and interpreted through smartphones or other mobile devices, allowing real-time image interpretation from offsite clinicians without the need to be located in a healthcare facility.²³

Education

Up until recently, pre- and postgraduate education in the field of medical sciences was mainly transmitted through classic teaching methods, including direct, face-to-face interactions complemented by physical books and peer-reviewed medical articles. In the last decade, technological advances have allowed slow, progressive inclusion of e-learning (i.e., learning conducted via electronic media, typically on the internet) in health sciences education, in both formal and informal ways. This process became highly accelerated during the recent COVID-19 pandemic, and radiology, as a technology-driven medical specialty, has led the way in the adoption of new remote teaching methodologies in healthcare-care related subjects during those challenging times.²⁴

In a similar way to on-site radiology education, it is important to apply the standards for scholarship of teaching in remote, teleradiology teaching, including considering ahead the audience and the learning objectives before deciding the best technology tool to use, in a process that is known as “backward design”.²⁵

Possible didactic e-modalities include modules, lectures, case conferences, quizzes, digital teaching files, “flipped classrooms”, journal clubs and even virtual readout sessions.^25-28 Whenever appropriate, open live video and audio communications, text chat, screen share, real time screen annotation features, audio response systems, raising hand option, embed scrolling image series and meeting breakout rooms can be used to enhance the e-learning experience and the retention levels.^25-28

The daily incorporation of online education has allowed the emergence of a recent, alternative practice for radiologists, known as “academic teleradiology”.^.29 Such full-time or part-time positions are already being offered by some Academic Radiology departments, providing advantages in the recruiting processes and also in retaining top talent.²⁹

Advantages of online education are numerous and include time-savings in commuting or distant travel, less costs for students, reduced ecological footprint, possibility to knowledge share with students/practitioners located in remote geographical locations and better work-life balance. Nevertheless, utilisation of teleradiology for educational purposes also presents some disadvantages, such as increased fatigue due to subconscious dissonance, higher workload in preparing initial online courses, more difficulties in engaging participation and interest, less personalised feedback, security breaches, lower image quality and risk of social isolation. ^25-28

In conclusion, online education appears to be particularly suited for radiology and it will certainly become even more widespread in the future, contributing to the modernization of medical education. ³⁰

Challenges in teleradiology

Aside from the recognition of teleradiology’s inability to provide interventional services, other challenges of teleradiology in routine practice include (but are not limited to) the following (reviewed in ^18,31).

Requirement of available internet connection

In order to utilize teleradiology, an internet connection is required by both the transmitting and the receiving site which may prohibit many lower income or rural areas from taking advantage of the service. Even if internet connection is available, adequate download and upload speeds are required in order to access patient images, generate and transmit reports in a timely manner.

Potential failure of technology

There are multiple potential failures in technology that can have a profound impact on the teleradiology service being delivered, including lack of transmission, interruptions, delays, and failure of software and hardware. Such problems may be particularly common in more rural or underserved communities and even a short ‘downtime’ can have significant impact on delivery of care.

Lack of technological expertise

Even if there is adequate technology in an area to provide teleradiology, consideration must also be given to the staff involved in the service. In order for scans and reports to be uploaded/downloaded effectively, the staff involved must be familiar with the technology and able to identify and rectify problems as required. In many economically developing regions, staff may have very little experience with the relevant technology and adequate training must be given to ensure a smooth service. The employment and training of well-educated technologists must also be considered, on whom the quality of image acquisition is highly dependent.

Ergonomic factors

It is crucial that equipment set up at remote sites maintains any mandatory quality standards and allowances made for any relevant ergonomic factors. Monitor calibration, voice recognition, environmental lighting and noise amongst other aspects should be considered with the aim for off-site working to maintain the same high standards as those offered in a traditional hospital setting.

Data protection and security

As in any healthcare delivery, patient confidentiality and security of data is imperative This can be particularly difficult to achieve when patient images and reports are being sent across national or international boundaries. The protection of patient data must be considered at every stage in the service, from the initial upload of images to the subsequent transfer of the report from the remote reporting site. Such data protection steps should not prevent the reporting radiologist from accessing comparative images or relevant patient history and when anonymisation techniques are utilised, care must also be taken to ensure that the correct images and reports are assigned to the correct patient.

Licensing requirements

When teleradiology services utilise radiologists from other countries or even regions within countries, it is important to consider any additional licensing requirements. For example, if a scan undertaken in a particular country is then sent across international borders to be reported, the reporting radiologist may require additional medical licensing from the host country. Obtaining such medical licences can be a costly and timely process and must be taken into account when setting up an international teleradiology service.

Initial setup costs

The initial setup costs of a teleradiology service can be vast. As well as infrastructure costs (both in terms of virtual network set up and physical equipment requirements), there is also the cost of additional training and licensing required for any staff involved. Although in the long term, such services may be cost-saving, this initial large setup cost can be a barrier for smaller sites or those located in economically developing countries, particularly as these sites may require the purchase, upgrade or replacement of existing medical equipment to offer a sufficient service.

Lack of onsite presence

Although the use of telecommunications can allow off-site radiologists to maintain contact with onsite clinicians, the lack of onsite presence and physical detachment between the two groups can lead to a lack of a sense of community. Although the primary job of a radiologist is to provide imaging reports, they remain an integral part of the clinical team and can play a key role in management discussions. The lack of onsite presence of teleradiologists also precludes the ability for them to perform ultrasound or undertake image-guided procedures such as biopsies, angiograms, stents and drains. For this reason, some patients may still require transfer to another facility.

Peer review and audit

It is imperative that an established quality assurance programme is carried out in any teleradiology service to ensure the highest quality of patient care. This will require effective communication between the transmitting and receiving sites, the ability to ask for second opinions and obtain longitudinal follow up when required.

Conclusion

Judicious use of teleradiology may offer at least a partial solution to major healthcare challenges, from shortage of healthcare professionals to sustainability.

Nevertheless, it is important to note that while teleradiology offers numerous benefits, it is not a panacea and should be seen as a complementary approach to traditional healthcare delivery. Indeed, certain healthcare services still require in-person reporting, consultations, and interventions. Therefore, a balanced approach that combines teleradiology with conventional diagnostic and interventional radiology practices is crucial for an effective and sustainable healthcare system and achieving this equilibrium at a national level requires political will, insight, coordination, and management of seemingly disparate factors.

Key points

1. A sustainable healthcare system is crucial. Teleradiology can help to reduce the carbon footprint associated with healthcare without compromising quality of care through reduced energy usage, decreased waste production and reduction in patient and staff travel amongst other factors.
2. There is a global shortage of radiologists. Teleradiology allows the most efficient use of the shared pool of radiologists currently available through the use of virtual networks, enhancing workforce durability.
3. Teleradiology can improve quality of care by providing access to expert opinions without the need for patient travel and can help reduce discrepancies in the care received across disparate geographic landscapes.
4. E-learning and sharing of cases through online platforms allows for a new type of radiology education which can reach a larger audience and has heralded the development of ‘academic teleradiology’.
5. Challenges in teleradiology are not limited to the inability to provide interventional services. Infringements in data protection and patient confidentiality, poor technological infrastructure, insufficient computer literacy and set-up costs are just some of the obstacles that need to be overcome for teleradiology to continue to succeed.

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Reviewers: Rizza Jean Rivera (YEL 2022, Philippines), Jan Begenat (YEL 2022, Germany)