1.
INTRODUCTION
Teleradiology
is the electronic transmission of radiologic images from one location to
another for the purpose of interpretation or consultation. These radiological patient images include
x-rays, CTs, and MRIs. Teleradiology may
allow more timely interpretation of radiologic images and give greater access
to secondary consultations. With
teleradiology, users in different location may at the same time view images. Many reported that teleradiology improve
patient care by allowing radiologist to provide service without having to be at
patient location. Teleradiology allows
specialist to be available 24 hours.
Teleradiology
utilizes standard technologies such as the internet, telephone line, wide area
network, local area network (LAN) and the latest high tech being computer
clouds (Wikipedia, 2012). There is a specialized
software that used to transmit the images and allow the Radiologist to analyze
hundred of images for a given study.
Recent research on teleradiology, (Wikipedia, 2012) have shown
technologies such as advanced graphic processing, voice recognition, and image
compression are often used.
The use of
teleradiology reflects the changing world of clinical practice, service
delivery and technology. Nowadays, the
delivery of health is changing and teleradiology is part of that change, which
also includes the globalization of radiology.
Teleradiology
aims to even radiologists’ workload, ensure on call services, reduce waiting
lists, consult other specialists and cut costs (Ross, Sepper and Pohjonen,
2009). Other benefits of teleradiology
include rationalize on-call services, to improve the reporting capacity of
health care organizations, to balance the workload across radiologists or domestic
health care institutions, and to link remote imaging facilities with a central
hospital (Ross, Sepper and Pohjonen,
2009).
A picture
archiving and communication system (PACS) perform the tasks like taking in
images, archiving images, and sends the images to workstation for display, while
saving the images and shall not lose them.
Every system had the ability to zoom, pan, window and level. Other than that, they can even flip and
rotate images and every system also have measurement tools.
A PACS
consists of four major components. These
components are the imaging modalities such as x-ray plain film, CT and MRI, a
secured network for the transmission of patient information, workstations for
interpreting and reviewing images, and archives for the storage and retrieval
of images and reports.
Most PACS
handle images from various medical imaging instruments including ultrasound,
magnetic resonance (MR), positron emission tomography (PET), computed
tomography (CT), endoscopy, mammograms, digital radiography, computed
radiography (CR), ophthalmology, and many more.
In the early
days of PACS, that was considered plenty.
Over time people start to look more into PACS and modify the system they
had designed to do more work of a radiology department for the future and some
can even turn 2D images into 3D images.
2.
LITERATURE
REVIEW
From the
research (Lundberg, Wintell and Lindskold, 2009) showed the global demand for
teleradiology is increasing because of the shortage of highly trained
radiologists who can provide the services needed in healthcare today.
Recent
research (Ng, Wang and Ng, 2006) showed that multimedia messaging service (MMS)
mobile phone technology offers a simple, cheap, quick, and effective solution
to the problem of scan interpretation.
Other than that, the MMS technology is demonstrated to be a useful media
for the transmission of high quality images to assist in the diagnostic process
and implementation of emergent clinical therapy.
From study of
(Reponen et al., 2005), the researchers noted that electronic patient record
(EPR) and PACS can be connected to wireless terminals which deliver information
to the point of care. Throughout their
studies, the researchers used mobile teleradiology using special type mobile
phones such as smartphones and personal digital assistant (PDA) with phone
functions to deliver information. Result
shows these terminals are feasible for emergency situations and mostly for
evaluation of neurosurgical CT images.
Recent
research (Pallamar et al., 2012) showed digital mammography images can be
transferred from one location to another via data link. However, there are technical limitations due
to limited transmission capacities and some centers overcome these by
compressing images for transmission. So
researchers did the study to demonstrate the feasibility of sending
uncompressed digital mammogram, and the result shows uncompressed digital
mammograms can be transmitted to different institutions with different
workstation, without loss of information and the transmission process does not
significantly influence image quality, lesion detection, or BIRADS rating.
Teleradiology
has been practiced to certain extent for more than two decades. However, the real boost of cross border
service has not been achieved (Ross, Sepper and Pohjonen, 2009). So, from (Ross, Sepper and Pohjonen, 2009)
done the research on cross border teleradiology to find out the possible
challenges in building a cross border teleradiology service. The researcher found that cross border
teleradiology is currently a narrow service limited by the linguistic barriers,
trust and legal issues and the most important challenge is to ensure that
teleradiology does not in any way reduce the quality of radiology services
provided to the citizen (Ross, Sepper and Pohjonen, 2009).
Binkuysen and
Ranschaert (2010) noted that in their survey, reasons to make use of
teleradiology services can be a growing or changing workload, a structural or
temporary shortage of radiologists, and a shortage of expertise. In some situations teleradiology is also used
for educational purposes. According to
their study, the most common purpose of teleradiology is to transmit images to
radiologists at home, to ease the burden of being on-call.
Recent
research of Benjamin, Aradi and Shreiber (2009) spotted that the nighthawk
service helps radiology groups improve their quality of life by outsourcing
their off-hours, on-call duties, to a third party. It is estimated that more than 50 percent of
US radiology groups now use this service and the main use of nighthawks is for
emergency radiology (Benjamin, Aradi and Shreiber, 2009). Based on the commercial success of nighthawk
teleradiology services, a new ‘dayhawk’ market is emerging and still on studies
by researchers.
Jarvis and
Stanberry (2005) noted that teleradiology is a powerful tool, now available to
complement the practice of clinical radiology, to make radiology more
universally available, to speed diagnosis and management, and to assist in
obtaining specialist opinions. Nowadays,
noted the presence of a robust teleradiology link to home, especially when an
extension of PACS transmit a full range of radiology imaging. The casualty officers and on call junior
doctors will have immediate access to a consultant opinion at home 24 hours and
this can develop into an on call from home hot reporting service which may be
advantageous to the staff in the hospital, and often to the patients (Jarvis
and Stanberry, 2005).
The early PACS
implementations focused primarily on providing the basic PACS functions such as
image retrieval and viewing (Wetering and Batenburg, 2008). However with the trends towards PACS integration
optimization many technological advances are made and some emerging
technologies such as computer-assisted reading (CAR) and computer-aided
diagnosis can be incorporated.
Sutton (2010)
stated that by implement full hospital-wide PACS in all hospitals, this placed
UK in a strong position to facilitate full national data sharing across all
healthcare organizations to improve patient care.
Hirschorn and
Dreyer (2010) mentioned that 3D or advanced visualization has already happened
in some PACS. PACS have incorporated not
only the basic 3D manipulations of MPR and MIP, but also vessel tracing for
angiographic studies, virtual endoscopic views for flying through hollow
viscera like the trachea or intestines, and surface rendering for complex
fractures such as those of the tibial plateu, including the ability to remove
unwanted bones that obscure the view, like the femoral condyles (Hirschorn and
Dreyer, 2010).
Bellon
et al., (2010) talked about the advantages of PACS where with PACS image
related information can be easily accessed throughout the entire hospital or
even beyond as the most important product in a hospital is information when the
very purpose of radiology is to provide information that later will be combined
with other information and lead to decision or therapy plans. The researchers also look at the factors that
influence the design of tomorrow’s systems, especially those in larger
multidisciplinary hospitals.
Recent research
(Faggioni et al., 2010) discovers the advanced technology attains to improved
PACS performance. One of these is
holographic PACS for enhanced speed and storage. According to Faggioni (2010), holographic
media are an emerging technology which could overcome the physical barriers to
approach data storage through a powerful combination of high storage transfer
densities and fast data transfer rate.
Kari et al.,
(2005) noted that presentations of multi-modality images, tele-conference and
the electronic archival are playing significant role in the routine clinical
work. Researcher did the study on WEB
based teleradiology where in several external institutes are WEB based
connected to the central archives and can access the necessary or available modalities. The systems offer advantages in medical
consultations of radiologists and clinical partners. Other advantages is evident in graduate and
continuous postgraduate trainings where a training database has been installed
on a server providing training and learning possibilities in order to get more
experiences with the tele-evaluation (Kari et al., 2005).
3.
DISCUSSION
3.1 Advantages
and Benefits of Teleradiology and PACS
Presently,
more often there is a need to share data between different hospital in a
region. The problem is that different
hospital use different PACS system.
Because of different PACS system used, some images or data are not
allowed to be displayed or archived in other hospital. Because of this, (Fernandez-Bayo, 2010) conduct
a study and recommend one approach to solve this problem where he noted that
the best approach is to use integration standards and follow the Integrating of
Healthcare Enterprise (IHE). According
to Fernandez-Bayo (2010), IHE is an initiative by the healthcare industry and
institutions to improve the way healthcare computer systems share
information. IHE allows sharing images
from different hospitals even if they have different PACS system. Fernandez-Bayo (2010) noted that among the
different solutions available to share images between different hospitals, IHE
organization presents the Cross Enterprise Document Sharing profile
(XDS). The advantage is images do not
need to be duplicated in a central archive to be shared among the different
healthcare organizations, they only need to be indexed and published in a
central registry. Other benefits by
using this system includes allowing everybody in the hospital to consult and
add information and also prevent the partial or total loss of the patient’s information. This system also opens the possibility of
setting up telemedicine projects where the data can be shared among different
centers or hospitals.
According to
Binkuysen and Ranschaert (2010), ten years ago image quality, transmission
speed, and image compression were important issues in teleradiology. However, today the focus is on clinical
governance, medico-legal issues, and quality assessment. In the future there will be no distinction
between PACS and teleradiology. Virtual
imaging organizations will become reality.
Nowadays,
in many institutions there is a growing tendency towards overflow of workload,
because the demand for imaging procedures is increasing. Teleradiology should be able to solve this
type of overflow problems. Now, with full
hospital-wide PACS, allows professional healthcare for viewing access not only
within the diagnostic imaging department but also within outpatient clinics and
the wards. According to Sutton (2010),
the benefits of this full implementation of a trust wide PACS became clear to
all who had introduced PACS into the healthcare environment in terms of patient
management, reporting efficiencies and wider organizational improvements thus
can reduce workload.
In
some countries, the role of teleradiology also included that images can be
transmitted to other organizations within or outside the country for the
purposes of reporting. However, there is
a reporting standards set by department of health in terms of technical quality
and accuracy, to provide high quality service.
Sutton (2010) noted that by implement this, there has been a dramatic
fall in the number of patients waiting.
Because most of the problem in diagnostic imaging there is always lack
of imaging capacity, lack of radiologists for reporting and poor working
practices which increase patient’s waiting time.
3.2 Gadget
Used for Teleradiology
Ridley
(2012) reported that from John Hopkins School of Medicine, researcher did the
study to compare between PACS and IPad in diagnostic accuracy for detecting
pulmonary embolism in emergency situation.
From the study, result shows no difference between the use of IPad and
PACS workstation in diagnostic. IPad
also seemed like a faster method of display which is good for patient with
pulmonary embolism who needs emergency treatment. If the patient is required to be transferred
to another hospital for treatment, the secondary consultant shall not waste
time to review the images by loading the CD to computer, but they can only see
from IPad where previous consultant sent the images.
Other
than IPad, smartphone also seemed to have advantage for emergency treatment. In one study about effective treatment of
stroke patients, Ridley (2012) reported that therapy could be delivered more
quickly by physicians who are able to diagnose stroke patients simply by
whipping out their smartphones. The physicians,
wherever they are can interpret the CT brain images by viewing images on a
smartphone sent by radiologist, rather than waste time to wait for that CT films
to be sent to the clinic to review.
Thereby, evaluation and treatment completion turnaround time can be
reduced.
In
hospital, the problem usually occur after office hour when most of the expertise
or senior doctors not available in hospital.
Most patients being sent to emergency department for diagnosis are
attended only by medical officer.
Diagnosis is highly dependent on accurate interpretation of scans by
experienced clinicians (Ng, Wang and Ng, 2006).
Because of that, the researcher did the study on multimedia messaging
service (MMS) teleradiology to provide emergency neurosurgical service. Ng, Wang and Ng (2006) noted that MMS takes
only a few minutes to send and receive and allow senior doctors to view
important images and make important clinical decisions to enhance patient
management in an emergency situation.
With MMS, medical officer can take the relevant images directly from the
mobile phone from the PACS, off the computer screen and send to the expertise
to review. By doing this, the expertise
can quickly informed medical officer about the emergent clinical decision
making, and this will improved level of confidence of both side.
3.3 Technological
Advances With PACS
During
the earlier days, PACS can only be used for image viewing and retrieval. Nowadays many technological advances are made
for the future PACS in terms of technical requirements such as computer-assisted
reading (CAR) and computer-aided diagnosis (CAD) and central image provider for
post-processing and workflow of clinical and research medical images. Now as medical imaging became important to
other departments outside radiology, PACS has become a clinical collaboration
tool.
From
recent research (Wetering and Batenburg, 2008), one of technological advances
in PACS is computer-assisted bone age assessment which can be integrated with
clinical PACS for advanced image analysis purposes. Radiologist or radiographer can assess
patient’s bone age by using CAD developed based on phalangeal and carpal bone
growth in PACS.
Other
technological advance in PACS is CAD and cuing and the adoption of intelligent application
of informatics. Noted that the adoption
of CAD will become routine in the coming years, especially in the detection of
lung nodules and breast cancers.
Wetering
and Batenburg (2008) spotted that full field digital mammography (FFDM),
benefit of computer-aided detection, computer-assisted classification and PACS
can be realized. FFDM requires high
resolution monitors to enable the physicians to visualize the minute details
for accurate diagnosis, so PACS with the integration and application of breast
imaging are associates with several challenges to provide required image
display and interpretation, communication and storage.
As
of now the days of 2D PACS are numbered.
3D PACS are the latest way to go for now and into the future. According to Hirschorn and Dreyer (2010),
three-dimensional (3D) imaging services as well as the workflow involved in combination
of 3D imaging services with PACS and radiology information systems are serious
challenges for hospitals nowadays and to the future. However, Faggioni et al., (2010) noted that
another advanced possibility is 4D imaging which is useful especially in
cardiac radiology to evaluate the function of the myocardium or the cardiac
valves. Beyond that, a shift in the near
future toward 5D data which for instance, metabolic data by means of
radiolabelled tracers (Faggioni et al, 2010) and advanced PACS systems should
be able to handle this kind of information.
Another
advance technology in PACS is image-assisted surgery system (IASS) which is
designed on the concept of an image-integrated electronic patient record (EPR)
and used of existing knowledge of PACS and the associated medical imaging
informatics infrastructure (Wetering and Batenburg, 2008). This IASS allows patient centered images and
data to be staged at the server and delivered to the workstation for review
before, during and after surgery.
Intelligent
data mining will also take on greater importance with PACS which is another
advance in PACS. Intelligent data mining
allows image processing and data extraction that will ease the interpretation
process for radiologists. Mining objects
include radiology reports, correlative imaging studies and electronic medical
records.
For
today and for the future development, the researchers discover the
SuperPACS. The SuperPACS merges the
capabilities of PACS and teleradiology services and allows radiology groups
serving multi-sites to work efficiently both locally and remotely and fully
satisfy the physicians, patients, and hospital administrators
expectations. This efficiency means the
ability to deliver the radiologist’s end product, the report with maximum speed
and accuracy under any business scenario.
The
problem with PACS is when there is a huge volume of data such as cardiac
ultrasound and angiography which generate hundreds of MB of data for each study
to be transferred to PACS and to keep these exams permanently available. However Costa et al. (2008) stated that there
is a Web-enabled PACS software solution that is specially oriented to support
demanding cardiac imaging laboratories.
It provides a cost efficient digital archive, ensures full online
availability of studies and simplifies the transmission of medical data over
the internet.
Howell
(2012) reported that there is a new system in PACS called vendor neutral
archives (VNAs). VNAs offer many
departments and practices perfect and seamless image storing and archiving
capability across any PACS. VNAs were
created when there was a complaint on PACS where PACS cannot share images with
other departments and cannot migrate studies to another facility. There is also a new emerging protocol called
medical imaging network transport (MINT).
When MINT and VNAs being merged, it gives more advantages to doctors and
patients. For example, when doctors want
to know whether that child has had a CT at another hospital so they don’t
duplicate that study, they can use this new system. This could keep radiation doses as low as
they can for kids.
3.4 Security
and Privacy in Teleradiology
There
is one problem in teleradiology, which is a legal issue. Modern teleradiology means more and more
cross organizational or even cross border service which can create a legal
issue problem. For past years, many
system developers do not know how to create a security concept. Recent research (Ruotsalainen, 2009) defined
the requirements needed to make different teleradiology models trusted. Those requirements include a common security
policy, common security and privacy protection principles and requirements,
controlled contracts between partners and the use of security tools. Today onward there is a security and privacy
protection requirements, controls, safeguard and security services which make
modern teleradiology being trusted in such a way that confidentiality,
integrity and availability of information.
In
case of legal issue, patients have the right to sue the radiologist and the
company. According to Bonmati, Morales
and Bach (2011), the radiologist is required to subscribe to a liability
insurance which shall protect radiologists from economic loss if they are being
sued in relation to their professional activities. Also in the case of teleradiology, it is
necessary to subscribe for an insurance cover for this type of activity and
guaranteeing coverage in all countries where it is carried out (Bonmati, Morales
and Bach, 2011). The teleradiology
service must always guarantee patient confidentiality and must comply with the
data protection law of the countries of origin and destiny.
4.
CONCLUSION
Teleradiology has
become more accessible and feasible to physicians with the helped of PACS.
Through
teleradiology, images can be sent to another part of the hospital, or to other
locations around the world. Other than
transmitting images and information, teleradiology also consists of sharing
knowledge and working together in a network.
It helps rapid access to radiological reports and second opinions,
remote consulting among physicians, improved patient care, access to complex
tools for post processing and computer-aided diagnosis, support for research
and training projects, tie between isolated healthcare providers and busier or
more experienced providers, 24 hour coverage, and competition among radiology
departments.
The use of teleradiology eliminates the
need to travel from home to the hospital and can be used to consolidate calls
between multiple locations. It is a strategy that radiologists have widely
adopted to meet the changing needs of their practices. One
radiologist can potentially cover a number of locations where there might not
be enough work for a full-time radiologist, and one subspecialist can
potentially provide consultations for patients in many practice locations.
Shortage of
radiologists, increase use of advanced imaging methods, the consolidation of
hospitals into regional delivery systems, and high expectations of patients and
referring physicians for timely service are the factors that encourage the
increasing use of teleradiology. These
factors also helped to create the new and potentially disruptive business
models for service delivery that can be viewed as threats and opportunities.
Radiologists also
need to recognize and accept the changes in organizational structure while the
service expectations are taking place in the health care system through the
availability of teleradiology and PACS.
No matter what happens to the economy, the needs of digital imaging are
not going away and cannot be ignored.
Because of this teleradiology is here to stay and should be considered
as the future of healthcare delivery although some issues still need to be
addressed.
5.
RECOMMENDATION
Most hospitals
in Malaysia have switched from film to fully digital with PACS. Now in
Malaysia is also moving towards the new era of teleradiology and
PACS. However, there are still
limitation in terms of financial and quality of life that affect the
development of teleradiology. More
research are required to be conducted in Malaysia regarding teleradiology and
PACS to alert all the healthcare organization about the benefit of
teleradiology.
Other than
hospitals in city area, smaller hospitals in rural area are also required to
provide PACS system and teleradiology so that patients in rural area can get the
same benefit as patients in urban areas and cities.
Department of
health in Malaysia should adopted some agenda to maximize the benefits of
existing IT systems and promote improved patient care and productivity in the
healthcare industry.
6.
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