Interstate Practice of Dental Teleradiology in the United States: The Effect of Licensing Requirements on Oral and Maxillofacial Radiologists' Practice Patterns.

BACKGROUND: In the United States, each state has independent licensing standards. Dentists wishing to practice in more than one state must apply to each individually. The goal of this study was to assess whether board-certified oral and maxillofacial radiologists interpreted images taken outside the states in which they were licensed and whether coverage provided by the malpractice insurance plans to which they subscribed affected their behavior. MATERIALS AND METHODS: An electronic survey was sent to all current members of the American Board of Oral and Maxillofacial Radiology, with a response rate of 74%. Descriptive statistics were calculated. RESULTS: The majority of respondents (54.6%) indicated they write reports for patients in states for which they do not have a dental license. An even larger majority (80.0%) do not know whether their malpractice insurance protects them in these cases. Qualitative responses indicate that there is confusion among practitioners as to what is legally permitted pertaining to teledentistry of this nature. CONCLUSIONS: Much of the work in which oral and maxillofacial radiologists engage may be considered teledentistry. In other settings, teledentistry has been proposed as a means to improve access to care for vulnerable populations, yet current licensure laws may make this more difficult to implement. Based on the results of our survey, many oral and maxillofacial radiologists in practice may be considered to be practicing without a license. Portability of diagnostic images may make it more difficult to enforce geographic practice boundaries. A national licensure system would be easier to enforce while maintaining high levels of patient safety.

State medical licensure for telemedicine and teleradiology.

Physician medical licensure is state based for historical and constitutional reasons. It may also provide the best method for guaranteeing patient protection from unqualified, incompetent, impaired, or unprofessional practitioners of medicine. However, a significant cost for physicians practicing telemedicine is having to obtain multiple state medical licenses. There is reasonable likelihood that model legislation for the practice of telemedicine across state boundaries will be passed in the next few years, providing physicians with a simpler process for license reciprocity in multiple states via interstate licensing compacts. Physicians would have to be licensed in the state in which the patient resides. Patient complaints would still be adjudicated by the medical licensing board in the state where the patient resides according applicable state legislation.

Features and limitations of mobile tablet devices for viewing radiological images.

PURPOSE: Mobile radiological image display systems are becoming increasingly common, necessitating a comparison of the features of these systems, specifically the operating system employed, connection to stationary PACS, data security and rang of image display and image analysis functions. MATERIAL AND METHODS: In the fall of 2013, a total of 17 PACS suppliers were surveyed regarding the technical features of 18 mobile radiological image display systems using a standardized questionnaire. The study also examined to what extent the technical specifications of the mobile image display systems satisfy the provisions of the Germany Medical Devices Act as well as the provisions of the German X-ray ordinance (RöV). RESULTS: There are clear differences in terms of how the mobile systems connected to the stationary PACS. Web-based solutions allow the mobile image display systems to function independently of their operating systems. The examined systems differed very little in terms of image display and image analysis functions. CONCLUSION: Mobile image display systems complement stationary PACS and can be used to view images. The impacts of the new quality assurance guidelines (QS-RL) as well as the upcoming new standard DIN 6868 - 157 on the acceptance testing of mobile image display units for the purpose of image evaluation are discussed.

[Teleradiology - update 2014]. / Teleradiologie - Update 2014.

Due to economic considerations and thanks to technological advances there is a growing interest in the integration of teleradiological applications into the regular radiological workflow. The legal and technical hurdles which are still to be overcome are being discussed in politics as well as by national and international radiological societies. The European Commission as well as the German Federal Ministry of Health placed a focus on telemedicine with their recent eHealth initiatives. The European Society of Radiology (ESR) recently published a white paper on teleradiology. In Germany §3 section 4 of the Röntgenverordnung (RöV, X-ray regulations) and DIN 6868-159 set a framework in which teleradiology can also be used for primary reads. These possibilities are already being used by various networks and some commercial providers across Germany. With regards to cross-border teleradiology, which currently stands in contrast to the RöV, many issues remain unsolved.

ACR white paper on teleradiology practice: a report from the Task Force on Teleradiology Practice.

Teleradiology services are now embedded into the workflow of many radiology practices in the United States, driven largely by an expanding corporate model of services. This has brought opportunities and challenges to both providers and recipients of teleradiology services and has heightened the need to create best-practice guidelines for teleradiology to ensure patient primacy. To this end, the ACR Task Force on Teleradiology Practice has created this white paper to update the prior ACR communication on teleradiology and discuss the current and possible future state of teleradiology in the United States. This white paper proposes comprehensive best-practice guidelines for the practice of teleradiology, with recommendations offered regarding future actions.

A review of medical image watermarking requirements for teleradiology.

Teleradiology allows medical images to be transmitted over electronic networks for clinical interpretation and for improved healthcare access, delivery, and standards. Although such remote transmission of the images is raising various new and complex legal and ethical issues, including image retention and fraud, privacy, malpractice liability, etc., considerations of the security measures used in teleradiology remain unchanged. Addressing this problem naturally warrants investigations on the security measures for their relative functional limitations and for the scope of considering them further. In this paper, starting with various security and privacy standards, the security requirements of medical images as well as expected threats in teleradiology are reviewed. This will make it possible to determine the limitations of the conventional measures used against the expected threats. Furthermore, we thoroughly study the utilization of digital watermarking for teleradiology. Following the key attributes and roles of various watermarking parameters, justification for watermarking over conventional security measures is made in terms of their various objectives, properties, and requirements. We also outline the main objectives of medical image watermarking for teleradiology and provide recommendations on suitable watermarking techniques and their characterization. Finally, concluding remarks and directions for future research are presented.

[Medical and legal aspects of teleradiology in Germany]. / Medizinische und rechtliche Aspekte der Teleradiologie in Deutschland.

In teleradiology, imaging data are transferred over a distance. This service is provided for the purpose of consulting or teleradiological reading in the narrower sense. Once a justification has been proposed in the latter, the examination is performed under the responsibility of a radiologist who is not present on site. The need for teleradiology services often derives from sparsely populated areas, a shortage of doctors, or the need for cost-efficient provision of radiological examinations. The providers and recipients of teleradiology services enter into an agreement specifying conditions for data transfer. The German ionizing radiation (medical exposure) regulations demand that the teleradiologist holds radiation protection qualifications and is able to reach the examination site within 45 - 60 minutes. In Germany, teleradiology services are still limited to nights, weekends, and vacations, although the German regulations allow an expansion under certain circumstances. Efforts to fundamentally change radiology in favor of teleradiology are putting the status of a radiological medical act as well as current teaching models at risk, thereby indirectly sustaining physician shortage. Transnational teleradiology services offer the possibility of cost reduction, taking advantage of out-of-hour reading and wage fluctuation. At the same time, such services are associated with deficits in quality and availability of personnel as well as the quality of medical services. In the long-term teleradiology concepts will fundamentally change radiology. Smaller radiology units will concentrate on daily business and fast reporting. Larger units also providing academic teaching can use teleradiology networks to offer specialized readings.

Teleradiology: evolution and concepts.

Teleradiology has become a reality for several years now, but its existence still has not been freed from all controversies. From the beginning the military has been the driving force for teleradiology. Today teleradiology has many purposes worldwide ranging from services for expert or second opinions to international commercial diagnostic reading services. Ten years ago image quality, transmission speed and image compression were important issues of debate. Today the focus is on clinical governance, medico-legal issues and quality assessment. The increasing use of teleradiology reflects the changing world of clinical practice, service delivery and technology.

[The analysis of legal basis of telediagnosis and teleconsultation in clinical practice. are we allowed to consult our patients via phone? Part I]. / Analiza podstaw legalnosci telekonsultacji i telediagnostyki w codziennej praktyce klinicznej. Czy wolno konsultowac pacjentów przez telefon? Czesc I.

BACKGROUND: Telemedicine means the delivery of medical service without personal contact between the patient and physician. Although Polish legal regulations do not prohibit so called "distant medical treatment", they do not specify clear and ambiguous terms of such a service. The practitioner faces numerous doubts concerning the telediagnosis and teleconsultation. The authors discuss the problems of acceptability of telediagnosis and teleconsultation in Poland. MATERIAL AND METHODS: The material comprised a whole set of legal acts of the Polish and European origin that could have any impact on the legal basis of telemedicine in Poland. The method applied was of interpretative nature, and the texts of above-mentioned acts were thoroughly analyzed, providing the first comprehensive study on this subject. RESULTS: The results applied to practitioners of numerous medical specializations, but it should be stated that the examples studied and analyzed focused on teleconsultations in occupational medicine. The analysis revealed that current legal regulations do not specify the exact form the medical consultations should acquire. Nevertheless, it should be admitted that "distant consultation"; via the Internet, phone or other means of IT is not prohibited. The authors emphasize, however, that the distant consultations should be treated as an exception to the rule, which says that the patient should be personally consulted by the physician. CONCLUSIONS: The achievements of information technology greatly contributes to the quality of diagnostic and therapeutic processes. The existence of many unclear and ambiguous rules and opinions makes it necessary to establish legal regulations specifying the principles of distant exchange of medical data.

Securing a web-based teleradiology platform according to German law and "best practices".

The Medical Data and Picture Exchange platform (MDPE), as a teleradiology system, facilitates the exchange of digital medical imaging data among authorized users. It features extensive support of the DICOM standard including networking functions. Since MDPE is designed as a web service, security and confidentiality of data and communication pose an outstanding challenge. To comply with demands of German laws and authorities, a generic data security concept considered as "best practice" in German health telematics was adapted to the specific demands of MDPE. The concept features strict logical and physical separation of diagnostic and identity data and thus an all-encompassing pseudonymization throughout the system. Hence, data may only be merged at authorized clients. MDPE's solution of merging data from separate sources within a web browser avoids technically questionable techniques such as deliberate cross-site scripting. Instead, data is merged dynamically by JavaScriptlets running in the user's browser. These scriptlets are provided by one server, while content and method calls are generated by another server. Additionally, MDPE uses encrypted temporary IDs for communication and merging of data.

Emergency radiology without the radiologist: the forensic perspective.

PURPOSE: The aim of this paper is to describe two cases from the authors' forensic archive database in which teleradiology was related to unfavourable outcomes. MATERIAL AND METHODS: Two patients underwent autopsy after unexpected death following road accidents. In one case, death was caused by multiple cervical fractures following minor neck injury in the presence of diffuse idiopathic skeletal hyperostosis. In the other case, death was due to delayed isthmic aortic rupture occurring after thoracic blunt trauma in a young adult. Both conditions were diagnosed at autopsy only. RESULTS: In both cases, the lethal outcome was due to the failure to obtain radiological reports of the X-rays performed in the emergency department. Radiological diagnoses could have been established by activating the teleradiology service which, according to the hospitals' teleradiology protocols, is available on demand in cases of emergency only, as selected by the physician requesting the service. CONCLUSIONS: These cases suggest the high risk of excluding the radiologist from the management of patients whose images are transmitted via a teleradiology system.

The impact of globalisation on teleradiology practice.

Some advocates of globalisation argue that a free market with little regulation is the best approach for achieving cost-effective healthcare. Healthcare, however, is different from other business activities in that it is typically less profit-driven; instead, it often involves the goal of providing equitable care to the underprivileged. Traditionally, the government has subsidised the expenses of delivering affordable healthcare to underserved communities. Because of the many recent advances in telecommunications technology, telemedicine has gained increasing attention. Teleradiology, in particular, is by far the maturest of all telemedicine disciplines and, thus, it may serve as a pivotal indicator of whether telemedicine on a global scale is feasible or not. In this paper, a prediction of the future landscape of globalised teleradiology operations is attempted based on the extrapolation of the historical trends in teleradiology practice as well as the growing pressure on federal and local governments to reduce their regulatory power under the General Agreement on Trade in Services (GATS).