Could Teleradiology contribute to “cross-borders” standardization of imaging protocols in cancer management?
Writer: Dror Nir, PhD
Teleradiology is accepted as a legitimate medical service for several years now. It has many clinical utilities worldwide, ranging from services for expert or second opinions to comprehensive remote management of radiology departments in hospitals. Rapid advances in web-technologies infrastructure eliminated the barriers related to the transfer, reading and reporting of radiology images from remote locations. Today’s main controversies are related to issues that are relevant also to “in-house” radiology departments; e.g. clinical governance, quality assessment, work-flow and medico-legal issues.
The concept of Teleradiology is as simple as plotted in this chart.
Images are automatically uploaded from the imaging system itself or from the institution’s PACS. Reports are sent to the “client” within few hours.
The value for the users goes well beyond mere image interpretation, for example:
- On-site physicians have more time to spend with patients.
- Offering of additional subspecialty/multidisciplinary expertise.
- Comprehensive image-interpretation and reporting service at reduced time-span and reduced cost
- Sharing images and reports with referring physicians and patients with no effort.
As an example for “cross-border” standardization of a major existing radiology service, let’s consider the use-case of centralized review of mammography images. I know, quite ambitious! And; politically very challenging!
But; seem to be technologically and clinically feasible, at least according to the below quoted publication:
Teleradiology with uncompressed digital mammograms: Clinical assessment
Julia Fruehwald-Pallamar, Marion Jantsch, Katja Pinker, Ricarda Hofmeister, Friedrich Semturs, Kathrin Piegler, Daniel Staribacher, Michael Weber, Thomas H. Helbich
published online 13 April 2012.
Abstract
Purpose
The purpose of our study was to demonstrate the feasibility of sending uncompressed digital mammograms in a teleradiologic setting without loss of information by comparing image quality, lesion detection, and BI-RADS assessment.
Materials and methods
CDMAM phantoms were sent bidirectionally to two hospitals via the network. For the clinical aspect of the study, 200 patients were selected based on the BI-RAD system: 50% BI-RADS I and II; and 50% BI-RADS IV and V. Two hundred digital mammograms (800 views) were sent to two different institutions via a teleradiology network. Three readers evaluated those 200 mammography studies at institution 1 where the images originated, and in the two other institutions (institutions 2 and 3) where the images were sent. The readers assessed image quality, lesion detection, and BI-RADS classification.
Results
Automatic readout showed that CDMAM image quality was identical before and after transmission. The image quality of the 200 studies (total 600 mammograms) was rated as very good or good in 90–97% before and after transmission. Depending on the institution and the reader, only 2.5–9.5% of all studies were rated as poor. The congruence of the readers with respect to the final BI-RADS assessment ranged from 90% and 91% at institution 1 vs. institution 2, and from 86% to 92% at institution 1 vs. institution 3. The agreement was even higher for conformity of content (BI-RADS I or II and BI-RADS IV or V). Reader agreement in the three different institutions with regard to the detection of masses and calcifications, as well as BI-RADS classification, was very good (κ: 0.775–0.884). Results for interreader agreement were similar.
Conclusion
Uncompressed digital mammograms can be transmitted to different institutions with different workstations, without loss of information. The transmission process does not significantly influence image quality, lesion detection, or BI-RADS rating.
Keywords: Breast cancer, Imaging, Digital mammography, Teleradiology, Comparative studies
What could be the benefits from centralizing mammography interpretation through Teleradiology?
- A baseline protocol that could enable pulling together large number of cases from different populations without having to worry about differences in practice and experience of reporters. This will enable better epidemiology studies of this disease.
- Quantified measure, in real-time, of the relative quality of imaging between institutions could contribute to bringing all screening services to a maximal level.
- Development of comprehensive training program for radiologists involved in mammography based screening of breast cancer.
- Better information sharing between all players involved in the pathway of each individual patient could improve clinical decision making and patient’s support.
- Lower costs of screening programs, disease treatment and follow-up.
Who could organize and carry out such an operation?
There are many reputable large university hospitals already offering Teleradiology services. They are already supported by government’s funds in addition to the fact that the service itself is carrying profits. I’m not listing any of these for obvious reasons, but; google “teleradiology” will bring you many results.
Dr. Nir,
Thank you for this article.
It seems that there are only upsides, no down sides to Teleradiology.
It is practiced in the US and the off shore films readers are primarily in India.
I know that there are standards in the US, and I don’t know if they are in complete agreement with the europeans. In Clinical Chemistry there is the AACC and the IFCC. There are differences, but they are reviewed at meetings at least twice a year. The College of American Pathologist (CAP) has been engaged in standards creation for surgical pathology in concert with surgeons and oncologists for cancer coding, and laboratory test evaluation with the AACC. The need for changes was highlighted by the revision of the Clinical Laboratory Improvement Act, which was driven by error in cytology screening. In all of these instances, the standards are developed out of expert committees. There are manuals developed by the NCCLS, and now there is statistical software provided by the NCCLS for statistical quality control guided by work for years at the University of Wisconsin, and the standards are reviewed monthly by select committees. As you can imagine, a lot of attention is devoted to outliers.
It must be comparable in medical imaging. A friend of mine from Kosovo has directed surgical procedures from Virginia in Kosovo by tele-surgery for about 7 years. .
The review process is quite intensive. I think that much work is put into meta-analysis of the published studies (80% are rejected). This study is more interesting in the sense that the analysis is based on data available. The field is almost at the point where the variables used for decisions could be quantitated digitally, retained, and used in a database for analysis. The strength of each variable could be weighted, and weak criteria might be rejected. It woulkd then be possible to envision two readers who have different interpretations because they are at the “edge” of either choice being likely. This would drive another level of quality that was not possible a decade ago.
Exactly the point I was making with this post: the time is right and the technology is there. It represents a real opportunity for organizing knowledge in a way that will drive progress. Needs to be done!
Dror Nir, PhD
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