Teleradiology Today: The Quality Concept and the Italian Point of View

Teleradiology: Toward the Standardization

Teleradiology—the ability to obtain images in one location, transmit them over a distance, and view them remotely for diagnostic or consultative purpose ^{1 –13} —has been explored for nearly 50 years and is part of the more encompassing concept of “telemedicine,” that is, the delivery of healthcare services over a distance. ^1,2 Teleradiology is one of the most established and most widely used forms of a larger entity called telemedicine. ^{3 –6}

In a narrow definition, teleradiology has been defined as obtaining a specialist opinion by transmission of digital X-ray images to a radiologist elsewhere (often in a tertiary center). ⁷

A wider definition by the Canadian Association of Radiologists in 2008 ⁸ says that teleradiology is the electronic transmission of diagnostic imaging studies from one location to another for the purposes of interpretation and/or consultation. This definition covers both interconnectivity of PACS networks and remote teleradiology. American College of Radiology definition in 2002 ⁹ adds educational aspects by saying that teleradiology may allow even more timely interpretation of radiological images and give greater access to secondary consultations and improved continuing education; images may be viewed simultaneously by users in different locations.

A definition suitable for most purposes is the following: “teleradiology is the ability to obtain images in one location, transmit them over a distance, and view them remotely for diagnostic or consultative purposes.” ^1,2 According to the European Society of Radiology, teleradiology is the electronic transmission of radiographic images from one geographic location to another for the purposes of interpretation and consultation. ¹⁰

Before 1990, telemedicine applications, including teleradiology, were relatively unimportant and largely ignored by state practice of medicine statutes or professional societies. ^1,2 In 1994, the American College of Radiology published the ACR Standard for Teleradiology. ¹¹ In this technical standard, the American College of Radiology stated that physicians providing official interpretations with teleradiology methods should maintain licensure at both the initiating and receiving sites and should hold staff credentials if a hospital was the originating site of an examination.

Teleradiology: Emerging Problems

Technological advances, the expansion of digital imaging systems and the ability to transmit and view remotely in a relatively short time a large number of images without significant degradation, have opened new perspectives for the application of teleradiology. ¹²

On one hand, although the use of teleradiology offers new perspectives, on the other hand, we are facing new problems, related to the method and its application, which necessarily must be addressed and resolved to preserve the quality criteria of the medical radiological activity. Teleradiology must not only be considered as a simple electronic transmission of images in different locations, from where they are produced, but to assure the right dignity to clinical diagnosis, it should also keep intact the quality criteria of diagnostic radiology and accomplish the standard principles of medical radiology. ¹³

Therefore, it is necessary to define the different areas of application and to establish specific requirements for its successful implementation to prevent an indiscriminate and consequently dangerous use for population, instead of having a good potential resource.

Teleradiology, in its various applications, makes part of the telemedicine organization and has to be considered as an innovative element in the rational planning of the Units of Diagnostic Imaging, to optimize the response to local needs.

Therefore, its use, established exclusively to ensure the diagnosis and treatment, can be justified only by the state of health of the patient in the particular circumstances of time and place. The use of teleradiology cannot justify the failure to purchase or the denial of the renewal of diagnostic imaging equipment or the lack of recruitment of radiologists needed to make functional the work equipment, according to the standard requirements for the accreditation of health facilities. Therefore, the use of teleradiology cannot be applied in the “outpatient radiological activity,” which must necessarily have a responsible radiologist on site. ^12,13 Teleradiology should also not justify the purchase and installation of equipment in health facilities where there is not an Operational Unit of Diagnostic Imaging.

The use of teleradiology must be exercised in compliance with rules and principles necessary to maintain its proper use and must be designed taking into account the needs of global quality, both technical and medical. ^12,13

Its aim should not be to optimize costs versus benefits but to ensure the accessibility to the diagnostic imaging and to the correct diagnosis throughout the country. The use of teleradiology requires thus a rigorous organization under the responsibility of radiologists, based on strict rules, known by all operators, and formalized by protocols, drowned up by the radiologist and experts belonging to the health system and the involved structure.

The Quality Concept in Teleradiology and the Italian Position

The increasing use of advanced imaging methods, the consolidation of hospitals into regional delivery systems, and heightened expectations of patients and referring physicians for timely service have thus fostered the increasing use of teleradiology. These aspects have also helped underwrite the creation of new models of care that are promising to improve quality of care and quality of service to patients and thus to simultaneously improve medical care delivery and improve the quality of work life for radiologists. ^1,2

Teleradiology is thus expected to improve the efficiency, efficacy, and productivity of the Health Care process, however, with particular attention to the already listed problems. One direction that appears to offer major opportunity is that of radiologists using teleradiology to support each other in their practices and even create new connection and practice models over the networks using the advances of the Information and Communication Technologies and collaborating with all of the actors involved in teleradiology.

A basic issue is thus to support the working in quality in the heterogeneous process of care using teleradiology. Special guidelines have been proposed in Italy to face these aspects.

These guidelines for quality assurance in teleradiology were elaborated in the framework of the activities on quality assurance in diagnostic and interventional radiology of the Istituto Superiore di Sanità (ISS) and of the Istituto Superiore per la Prevenzione e Sicurezza del Lavoro.

In 2010, they published in Italian the report “Linee guida per l'assicurazione di qualità in teleradiologia” (Rapporti ISTISAN 10/44). ¹² In the document, criteria for the application of teleradiology are discussed together with their clinical and quality control aspects. In the annexes, organizations schemes, as well as technological aspects and elements of costs, are described.

As the content is still valid and current, it has been both translated into English and updated to improve and enlarge its dissemination over the world with the Report (Rapporti Istisan 13/38) entitled “Guidelines for quality assurance and technical requirements in teleradiology. English translation and Revision of Rapporti Istisan 10/44” by the “Società Italiana di Radiologia Medica,” that is, the Italian Society for Medical Radiology and by the ISS, that is, The Italian NIH. The work is available at URL: (www.iss.it/binary/publ/cont/13_38_web.pdf). ¹³

This guide intends to provide, not only to radiologists and technicians but also to other health practitioners involved, the elements of information and method for organizing the teleradiology, respecting the needs of medical ethics, patient safety, including informed consent, even with regard to radiation protection, privacy, and quality.