TELERADIOLOGY AND PACS

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.    REFERENCES

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