Radiologists without borders

A ripple of recognition ran through the audience as the slide appeared on the screen. Consultant radiologists exchanged glances and some shifted in their seats. The slide was headed 'Teleradiology' and the first bulletpoint asked simply: 'threat or opportunity?'

It was Wednesday 9 March 2009, and the occasion was a packed scientific meeting at the British Institute of Radiology (BIR) in London, UK. Packed because Professor Erika Denton, the UK Department of Health's then national clinical lead for imaging, was on the podium and her subject was nothing less than 'The future of diagnostic imaging in England'. Denton is an accomplished speaker and consultant radiologist well liked for her knowledgeable, no-punches-pulled approach.

No surprise, then, that Denton, who led the deployment of picture-archiving and communication systems (PACS) across the NHS, should tackle teleradiology head-on, with bulletpoints two and three of her slide referencing 'governance issues' and 'revalidation issues'. No surprise, either, that four years on from that landmark presentation, radiologists, health economists, academics, professional bodies and even governments are still trying to answer her question.

The commodification of radiology

Although teleradiology continues to become a global phenomenon, not everyone agrees that offsite reading of patient scans offers a qualitative or economically sensible response to the ever-rising tide of workload reporting.

In the US, where teleradiology began to take off about 15 years ago, the logic of the service was readily understood, but in-house radiologists perceived the development of remote services as a threat. Radiologists were becoming 'invisible' to their patients because their reports were passed to the referring physician and, as a result, had come to be regarded as mere commodities.

The commodification of radiology may be a problem but, if it is, it has been going on for some time, since before teleradiology came on the scene.

In a paper for the Radiological Society of North America, William G Bradley Jr from the Department of Radiology, University of California, San Diego, US, put the blame for commodification on PACS itself. Before PACS, he pointed out, clinicians would regularly come down to the radiology department to discuss their cases, sometimes providing additional medical history data that might lead to a more accurate diagnosis. In the process, they got to know each other.

"Now that we have fully implemented PACS, we rarely see our clinicians," he wrote. "They can see the images and read our reports in their offices or clinics or on the floors of the medical centre. The only time the clinicians call us is when they disagree with a reading. They rarely come down to the radiology department any more since we can each pull up the same image on PACS from different locations and discuss it over the telephone. As a result, many of the clinicians cannot put a name to the face of many of our junior faculty, fellows or residents. The camaraderie of the old days is gone; we have already become commoditised."

Even in Russia, a country of more than six and a half million square miles and nine time zones - the perfect candidate, you may think, for teleradiology - there is an absence of clinician camaraderie in some quarters. Dr Oleg Pianykh, writing for the blog AuntMinnieEurope, claims that the number of Russian radiologists (1.3 per 10,000 people) has not grown since the 1980s. Citing his own involvement in several teleradiology projects in Russia, Pianykh notes that relatively poor remuneration poses another potential barrier to the growth of the technology.

"The average monthly salary of a Russian radiologist outside of Moscow dwells well below the Apple iPad price tag - making him or her genuinely uninterested in any new technology," he writes. "Occasional governmental financial injections and local kickbacks do not help. As a result, most Russian radiologists have yet to develop a personal interest in teleradiology. The lack of adequate compensation creates another teleradiology bottleneck: conflicts of interest. For instance, underpaid radiologists tend to view patients as their personal source of income. Naturally, this undermines the entire concept of clinical data sharing: why should I share 'my' patients with anyone else?

"I have seen hospitals where radiology departments started with centralised PACS, but degraded into a mess of individual USB drives used by radiologists to store 'their' patients' images. Forget about teleradiology."

Patient safety: at the heart of the debate

In France, radiology has also thrown protective arms around its standards and practitioners. In a debate on the Medica stand at the UKRC conference and exhibition two years ago, there was a discussion about a new charter unveiled by the French College of Radiology, covering practice, ethics, payment, legal, technical, quality assurance and training issues.

The charter lays down some tough guidelines as to who can practise teleradiology in France. It had been produced because of an influx of companies coming into France that were not only undercutting French radiologists in price but also their quality was not always known. These guidelines 'explain' to regional health agencies how to organise, manage and promote teleradiology, covering contracts between companies and hospitals, payments and the nationality of radiologists - and hospitals are obliged to follow them.

In that debate, the experienced consultant radiologist Dr Peter Mayor said that, from the patient's point of view, it was absolutely imperative that they were assured that the quality of the service being provided was optimum and that it was based on thorough training and a lot of experience.

In the UK, that quality was a given, said Mayor, as it would be in France. However, the quality of radiology reporting from outside national boundaries was not always known. "You can understand that the French Government may want to be protectionist about their own films and their own work for their own radiologists - and from a consultant radiologist's point of view, that is to be applauded."

Mayor's view, and that of the French, stems from putting patient safety at the heart of this debate - and it is a view shared by Dutch radiologist Dr Paul Algra, consultant radiologist at the Medical Centre Alkmaar in the Netherlands. That nation, too, is struggling with some aspects of teleradiology, notably with those second-opinion services that are being outsourced to India.

Algra knows India well - in fact, he led a team out there in 1999 to help train a core of local radiologists in updated CT techniques. He told The Indian Express at the time: "They have the required knowledge about the CT scan machine, but what they lack is experience."

He is in favour of second-opinion reporting - but does not support the practice of sending the images to India. He told Frances Rylands-Monk, AuntMinnieEurope associate editor: "I'm not against doing business with India. I just don't agree with sending exams outside of the country - whether it's to India, France, Germany or Australia. Referring physicians should know who the teleradiologist is. Also, the reading radiologist should have access to old examinations, clinical information, and preferably to the hospital information system."

This is a view expressed many times by UK-based and trained radiologists.In February 2010, the Royal College of Radiologists (RCR) produced its document 'Standards for the provision of teleradiology within the United Kingdom'. Under the heading 'Changing the way diagnostic imaging services are delivered', in which it looks at drivers for change, including local healthcare organisations (HCOs) where there is a need to address reporting capacity deficiencies, it says: "The potential opportunities to use the benefits of teleradiology are therefore twofold: 1. data sharing across several HCOs to utilise any underused reporting capacity; and 2. 'outsourcing' to an independent reporting service outside the main framework of the NHS. Such opportunities are only fully realised when clinically useful reports are issued. This is most likely when the radiologists issuing reports have access to previous imaging and other diagnostic and clinical data, and are available for consultation with referrers."

A closing of national ranks?

Building on this is a current proposal by Dr Nicola Strickland (a candidate this year for RCR president) for a regional on-call service using in-sourced NHS teleradiology in partnership with SECTRA, the private sector company that now owns and operates the Image Exchange Portal, which enables 250 UK hospitals to share diagnostic images with each other.

So the concerns about outsourcing abroad are as strong in the UK as they are in France and the Netherlands. Writing on a UK Imaging Informatics Group thread in January this year, Dr Neelam Dugar, its highly respected outgoing chair, used these words when answering a colleague's question on the legality of outsourcing to a place outside the EU: "As far as I know, any radiologist in any country in the world can report on NHS patients, provided they can get the business from the NHS. For me, this is a very worrying issue, as NHS patients (like myself) do not have the right to a choice of... radiologist - or even a choice of the country in which a doctor may be working from."

In July 2010, the Department of Health published its white paper 'Equity and Excellence - Liberating the NHS', which contained the promise to patients: 'No decision about me without me'. The yawning gap between that promise and the situation outlined by Dugar is self-evident.

The irony that a technology that transcends geographical boundaries should lead to a closing of national ranks should not be lost on anyone. But neither should the fact that this protectionism is as much to do with patient safety as it is self-interest.

In its short history, teleradiology has reduced the burden on in-house radiology departments, enabled health providers to meet greater patient expectations and, in the UK at least, led to the development of OnTrack technology, which automates the retrieval of scans to be read along with the patient's relevant historical images. This last achievement alone has the potential to save thousands of lives by quickly clearing backlogs of unreported film.

Denton's perceptive presentation at the BIR in 2009 had five bulletpoints in all. The last two were: 'potential for improved work/life balance'; and 'improved report turnaround'. Many observers would add another: 'the potential for directing specific scans to specialist groups of radiologists'.

Teleradiology has a massive role to play in improving outcomes. We are only at the beginning of what will be a transformative voyage of discovery for this technology over the next few years. Patients across the globe will be grateful that we made the journey.