Abstract
In 1998, a teleradiology system was established in Croatia. It connects 34 CT, MRI and DSA scanners in 29 hospitals with a referral centre in the neurosurgery department in Zagreb. In the first three years of its use, the network saved more than 400,000 km of patient transportation (i.e. without a teleconsultation, all of the patients would have had to be transported to the nearest referral neurosurgical unit). During the first seven years, an archive with 25,366 expert opinions was collected. A total of 7103 (28%) expert opinions were provided for the distant regional hospitals. The most common diagnoses for patients from regional hospitals were neurotrauma (53%), cerebrovascular diseases (22%) and brain tumours (19%). The teleradiology system was used less often for lumbar disc disease (4%), hydrocephalus or other neurosurgical disorders (2%). The most valuable results from teleradiology were the decisions about proper and effective patient treatment. In Croatia, the national teleradiology network for neurosurgery has speeded up therapy, avoided unnecessary travelling for patients and reduced costs.
Introduction
The first telemedicine systems in Croatia started operating in 1993 for telepathology consultations, and used the ordinary telephone network (PSTN) for data communication. 1,2 In 1997, 15 new computer tomography (CT) units were installed in the small regional medical centres, thus creating the requirement for radiologists at the local hospitals to be able to consult experienced radiologists at larger medical centres. This led to the implementation of a national teleradiology network, which connects all CT scanners in the public hospitals to a national referral centre (Figure 1). There are now 18 regional centres connected to the main telemedicine centre in Zagreb.
Croatian national teleradiology network
Teleradiology
The local telemedicine workstations were designed as mini-picture archiving and communication systems (PACS) and in many hospitals they served as the core for the implementation of department-wide PACS networks. Teleradiology workstations are PCs capable of acquiring an image from the CT, MRI or DSA video signal. The initial data written is demographic information, history of illness and basic diagnostic information, and the program simply takes the picture from the CT or MRI scanner and enables different analyses and measurements. All medical information and pictures represent an archive which is accessible whenever it is needed. Workstations operate in DICOM (Digital Imaging and Communication in Medicine) format, because most scanners are of an older type. Consultations are possible interactively or on the store and forward principle. Each workstation runs the ISSA application (VAMStec, Zagreb), an archive system with the patient as the archive subject. A communication module called PHAROS (VAMStec, Zagreb) connects different workstations through ordinary telephone lines or digital communication media. Both the ISSA and the PHAROS programs run in a Windows environment.
Patient data with medical images are sent to the workstations automatically. Based on the unique identification of each workstation in the teleradiology network, second opinions are automatically transmitted to the location of the original examination.
There is also a connection between ten neurosurgical departments in seven cities in Croatia (Zagreb, Osijek, Slavonski Brod, Rijeka, Pula, Split and Zadar) which enables the rapid exchange of medical information between neurosurgeons and, after triage, the appropriate hospitalisation of patients in the nearest neurosurgical department.
The neurosurgery department at the University Hospital Centre in Zagreb was selected as the main referral centre for telemedicine in neurosurgery, because this institution is able to provide neurosurgical expertise 24 hours a day. The teleradiology network enables communication between the reference neurosurgical centre and regional hospitals, and also multidirectional connections between different hospitals.
The typical workflow is as follows. After a patient is scanned, the images are transferred from the CT scanner into the ISSA application. The reading radiologist then types the report into ISSA and the whole examination is then sent to the referral centre using the PHAROS module. Neurosurgeons at the referral centre can then open that examination in ISSA, review the images and type in their second opinion. The second opinion is sent back to the remote centre, where a radiologist can review it and perform any further actions required. In acute trauma cases, such consultations give the neurosurgeons at the referral centre the opportunity to decide whether a neurosurgical procedure is required. This enables faster response in such cases, as well as avoiding unnecessary patient travel.
Results
Without a telemedicine consultation, all of the patients would have to be transported to the nearest referral neurosurgical unit for clinical and neuroradiological evaluation, and eventual subsequent treatment. Thus for each teleradiology examination, a journey was avoided. The avoided travel was calculated as the number of examinations from each centre multiplied by the distance to the referral centre in Zagreb. Within the first three years of operation, the use of teleneuroradiology saved 400,000 km of patient travel.
In the seven-year period from August 1998, an archive was collected with 25,366 expert opinions at the neurosurgery department. Most of the expert opinions (18,293; 72%) were provided for departments at the University Hospital Centre in Zagreb.
The main value of the teleradiology system is represented by the 7103 (28%) expert opinions provided for the distant regional hospitals. The most common diagnoses for patients from regional hospitals were neurotrauma (3764 or 53%), cerebrovascular diseases (1563 or 22%) and brain tumours (1350 or 19%). The teleradiology system was used less often for lumbar disc disease (284 or 4%), and hydrocephalus and other neurosurgical disorders (142 or 2%).
The most valuable uses for teleradiology were decisions about proper and effective patient treatment. A total of 1278 patients (18%) were admitted urgently to our department and operated on, while 2629 patients (37%) were scheduled for elective operations. A further 3196 patients (45%) were treated in regional hospitals following our instructions.
Discussion
The Republic of Croatia was not the first country to employ teleradiology in neurosurgery. In the early 1990s, management of neurosurgical referrals with teleradiology was described in both Europe and America. 3–6
In Croatia the public health-care system is of high quality in the city of Zagreb and also in other centres that have university hospitals such as Osijek, Rijeka and Split. However, in smaller towns there are regional hospitals that are not equipped with sophisticated medical equipment and some of them do not have specialist departments. All public hospitals in Croatia are equipped with CT scanners, which represent a basic neurosurgical diagnostic tool. Thus the implementation of a teleradiology system was a priority for neurosurgical cases.
The primary goals of the teleneuroradiology system were fulfilled completely, with overall savings in patient transport of 400,000 km in the first three years of operation. Furthermore, as neurosurgeons at the referral centre were able to obtain a detailed patient status and images before the patient arrived, the subsequent surgical interventions were carried out much more quickly. Numerous patient lives were saved due to the use of the telemedicine system. The whole network has been heavily used over the years, with system upgrades taking place in some remote centres.
Patients who were urgently transported to our department and operated on had compressive intracranial haematomas (e.g. acute epidural haematoma, acute subdural haematoma), or decompensated brain tumours, certain intracranial aneurysms or hydrocephalus. Many other patients with intracranial tumours, intracranial aneurysms, lumbar disc disease or hydrocephalus were scheduled for operation and were operated on later. However, the majority of patients could be properly treated in regional hospitals so they were not transported to our department. Only a few of them had such severe brain injury that their condition might deteriorate during transportation, so it was suggested that they should be treated in a regional hospital. Others have also reported good experience with a reduction of adverse effects during patient transportation. 7
Diagnosis in neurosurgery is for the most part based on visualisation of different radiological techniques (e.g. CT, MRI, DSA). The introduction of a telemedicine system in neurosurgery means fast and proper diagnosis, even in distant parts of the country, in hospitals that do not have expensive neurosurgical units. Treatment results are better, mortality is reduced and disability is avoided. 8
Communication with specialists helps the physicians in regional hospitals to gain new knowledge in treating certain diseases. In pathological conditions where highly sophisticated treatment is needed, a patient can be quickly transported to a specialized hospital. Therefore unnecessary diagnostic and therapeutic procedures are avoided, while patient stay in the regional hospitals is shortened. At the same time, highly specialized departments are not overloaded with cases that could be treated in regional hospitals and the unnecessary transport to a specialist simply for consultation is avoided. There are savings as a result of avoiding unnecessary patient transportation, establishing the proper diagnosis more quickly, better treatment results and increased use of hospital capacity.