ACVR and ECVDI consensus statement for teleradiology.

Increased demand for the interpretation of diagnostic images by board-certified radiologists and profound advancements in technology have led to extremely rapid growth in the field of veterinary teleradiology over the past decade. The aim of this consensus statement is to provide a guideline for best practices for quality and safety in veterinary teleradiology. The statement addresses appropriate image acquisition and transmission, the creation of teleradiology submissions, quality control in teleradiology, and appropriate documentation of imaging reports, as deficiencies in any of these areas may directly affect the standard of patient care. The consensus statement may be used as a guide for radiologists, primary care veterinarians, technicians, and students for the use of teleradiology in practice.

What Is the Best Way for Patients to Take Photographs of Medical Images (Radiographs, CT, and MRI) Using a Smartphone?

BACKGROUND: Teleradiology has become one of the most important approaches to virtual clinical diagnosis; its importance has only grown during the coronavirus 2019 pandemic. In developing countries, asking patients to take photographs of their images using a smartphone can facilitate the process and help keep its costs down. However, the images taken by patients with smartphones often are of poor quality, and there is no regulation or standard instruction about how to use smartphones to take photographs of medical examination images effectively. These problems limit the use of smartphones in remote diagnosis and treatment. QUESTIONS/PURPOSES: To formulate a set of guidelines for the most appropriate and effective use of smartphones to capture images (radiographs, CT images, and MR images), and to determine whether these guidelines are more effectively adopted by patients of differing ages and genders. METHODS: In this prospective study, a set of step-by-step instructions was created with the goal of helping patients take better smartphone photographs of orthopaedic diagnostic images for transfer to telemedicine services. Following the advice of surgeons, experts in smartphone technology, imaging experts, and suggestions from patients, the instructions were modified based on clinical experience and finalized with the goals of simplicity, clarity, and convenience. Potentially eligible patients were older than 18 years, had no cognitive impairment, and used smart phones. Based on that, 256 participants (patients or their relatives and friends) who visited the orthopaedic department of our hospital from June to October 2020 potentially qualified for this study. A total of 11% (29) declined to participate, leaving 89% (227) for analysis here. Their mean age was 36 ± 11 years, 50% were women (113 of 227), and the patient himself/herself represented in 34% (78 of 227) of participants while relatives or friends of patients made up 66% (149 of 227) of the group. In this study, the diagnoses included spinal stenosis (47% [107 of 227]), disc herniation without spinal stenosis (31% [71 of 227]), vertebral fractures (14% [32 of 227]), and other (7% [17 of 227]). Each study participant first took photographs of their original medical images based on their own knowledge of how to use the smartphone camera function; each participant then took pictures of their original images again after receiving our instructional guidance. Three senior spine surgeons (YZ, TQL, TCM) in our hospital analyzed, in a blinded manner, the instructed and uninstructed imaging files based on image clarity (the content of the image is complete, the text information in the image is clearly visible, there is neither reflection nor shadow in the image) and image position (it is not tilted, curled, inverted, or reversed). If either of these conditions was not satisfied, the picture quality was deemed unacceptable; two of three judges' votes determined the outcome. Interobserver reliability with kappa values for the three judges were 0.89 (YZ versus TQL), 0.92 (YZ versus TCM), and 0.90 (TQL versus TCM). RESULTS: In this study, the overall proportion of smartphone medical images deemed satisfactory increased from 40% (91 of 227) for uninstructed participants to 86% (196 of 227) for instructed participants (risk ratio 2.15 [95% CI 1.82 to 2.55]; p<0.001). The proportion of acceptable-quality images in different age groups improved after instruction, except for in patients aged 51 years or older (3 of 17 uninstructed participants versus 8 of 17 instructed participants; RR 2.67 [95% CI 0.85 to 8.37]; p = 0.07). The proportion of acceptable-quality images in both genders improved after instruction, but there was no difference between the genders. CONCLUSION: We believe our guidelines for patients who wish to take smartphone photographs of their medical images will decrease image transmission cost and facilitate orthopaedic telemedicine consultations. However, it appears that patients older than 50 years are more likely to have difficulty with this approach, and if so, they may benefit from more hands-on assistance from clinic staff or younger relatives or friends. The degree to which our findings are culture-specific should be verified by other studies in other settings, but on the face of it, there is little reason to believe our findings would not generalize to a reasonable degree. Other studies in more heterogeneous populations should also evaluate factors related to levels of educational attainment and wealth differences, but in the meantime, our findings can give clinical teams an idea of which patients may need a little extra assistance. LEVEL OF EVIDENCE: Level II, therapeutic study.

"From the technology came the idea": safe implementation and operation of a high quality teleradiology model increasing access to timely breast cancer assessment services for women in rural Australia.

Breast cancer is the most commonly diagnosed cancer in Australian women. Providing timely diagnostic assessment services for screen-detected abnormalities is a core quality indicator of the population-based screening program provided by BreastScreen Australia. However, a shortage of local and locum radiologists with availability and appropriate experience in breast work to attend onsite assessment clinics, limits capacity of services to offer assessment appointments to women in some regional centres. In response to identified need, local service staff developed the remote radiology assessment model for service delivery. This study investigated important factors for establishing the model, the challenges and enablers of successful implementation and operation of the model, and factors important in the provision of a model considered safe and acceptable by service providers. METHODS: Semi-structured interviews were conducted with service providers at four assessment services, across three jurisdictions in Australia. Service providers involved in implementation and operation of the model at the service and jurisdictional level were invited to participate. A social constructivist approach informed the analysis. Deductive analysis was initially undertaken, using the interview questions as a classifying framework. Subsequently, inductive thematic analysis was employed by the research team. Together, the coding team aggregated the codes into overarching themes. RESULTS: 55 service providers participated in interviews. Consistently reported enablers for the safe implementation and operation of a remote radiology assessment clinic included: clinical governance support; ability to adapt; strong teamwork, trust and communication; and, adequate technical support and equipment. Challenges mostly related to technology and internet (speed/bandwidth), and maintenance of relationships within the group. CONCLUSIONS: Understanding the key factors for supporting innovation, and implementing new and safe models of service delivery that incorporate telemedicine, will become increasingly important as technology evolves and becomes more accessible. It is possible to take proposed telemedicine solutions initiated by frontline workers and operationalise them safely and successfully: (i) through strong collaborative relationships that are inclusive of key experts; (ii) with clear guidance from overarching bodies with some flexibility for adapting to local contexts; (iii) through establishment of robust teamwork, trust and communication; and, (iv) with appropriate equipment and technical support.

Effectiveness and efficiency of teleimaging in the transplantation process: a mixed method protocol.

BACKGROUND: The transplantation process usually takes place without transplant teams being able to use imaging data to assess graft quality. The decision of whether to go get the graft or not is therefore limited and suboptimal. "Cristal images" is a teleimaging project allowing real-time visualization of images of the organs of the donor. The objective of our study is to assess whether the use of a secure teleimaging can improve the effectiveness and efficiency of the procurement and transplantation processes. METHODS: We will use the exhaustive national registry of organ allocation and transplantation, and compare outcomes before the deployment of "Cristal images" (years 2015-2016) and after it becomes operational (years 2018-2019) for heart, lung, liver and kidney transplant in a before-after study, combined with a preference elicitation study. The primary endpoint will be the number of successful organ transplantations. Secondary endpoints will be related to the efficiency of the transplant process (decision making, transportation, cost) and a preference elicitation study will determine the relative preferences of transplant teams towards few "Cristal images"' components or potential developments, which are yet to be determined through a qualitative analysis based on interviews with professionals. DISCUSSION: This study will provide stakeholders data on the efficiency of real-time visualization for transplant teams and identify the levers likely to influence the technology use among these teams. TRIAL REGISTRATION: clinicaltrials.gov: NCT03201224 , 13 June 2017, retrospectively registered.

Media messaging in diagnosis of acute CXR pathology: an interobserver study among residents.

The objectives of the study were to determine whether diagnostic accuracy and reliability by on-call teams is affected by communicating chest radiograph (CXR) images via instant messaging on smartphones in comparison to viewing on a workstation. 12 residents viewed 100 CXR images each with a 24% positive rate for significant or acute findings sent to their phones via a popular instant messaging application and reported their findings if any. After an interval of 42 days they viewed the original DICOM images on personal computers and again reported their findings. There were no statistically significant differences in accuracy, agreement, sensitivity, specificity, positive predictive value or negative predictive value between desktop workstation viewed images and images sent via the mobile application. Media messaging is a useful adjunct for quick second opinions on radiological images, without significant decay in diagnostic accuracy. If technical, ethical and legal issues are addressed, it could be incorporated into practice as a useful adjunct.

Reliability of smartphone-based teleradiology for evaluating thoracolumbar spine fractures.

BACKGROUND CONTEXT: Timely interpretation of computed tomography (CT) scans is of paramount importance in diagnosing and managing spinal column fractures, which can be devastating. Out-of-hospital, on-call spine surgeons are often asked to evaluate CT scans of patients who have sustained trauma to the thoracolumbar spine to make diagnosis and to determine the appropriate course of urgent treatment. Capturing radiographic scans and video clips from computer screens and sending them as instant messages have become common means of communication between physicians, aiding in triaging and transfer decision-making in orthopedic and neurosurgical emergencies. PURPOSE: The present study aimed to compare the reliability of interpreting CT scans viewed by orthopedic surgeons in two ways for diagnosing, classifying, and treatment planning for thoracolumbar spine fractures: (1) captured as video clips from standard workstation-based picture archiving and communication system (PACS) and sent via a smartphone-based instant messaging application for viewing on a smartphone; and (2) viewed directly on a PACS. STUDY DESIGN: Reliability and agreement study. PATIENT SAMPLE: Thirty adults with thoracolumbar spine fractures who had been consecutively admitted to the Division of Orthopedic Surgery of a Level I trauma center during 2014. OUTCOME MEASURE: Intraobserver agreement. METHODS: CT scans were captured by use of an iPhone 6 smartphone from a computer screen displaying PACS. Then by use of the WhatsApp instant messaging application, video clips of the scans were sent to the personal smartphones of five spine surgeons. These evaluators were asked to diagnose, classify, and determine the course of treatment for each case. Evaluation of the cases was repeated 4 weeks later, this time using the standard method of workstation-based PACS. Intraobserver agreement was interpreted based on the value of Cohen's kappa statistic. The study did not receive any outside funding. RESULTS: Intraobserver agreement for determining fracture level was near perfect (κ=0.94). Intraobserver agreement for AO classification, proposed treatment, neural canal penetration, and Denis classification were substantial (κ values, 0.75, 0.73, 0.71, and 0.69, respectively). Intraobserver agreement for loss of vertebral height and kyphosis were moderate (κ values, 0.55 and 0.45, respectively) CONCLUSIONS: Video clips of CT scans can be readily captured by a smartphone from a workstation-based PACS and then transmitted by use of the WhatsApp instant messaging application. Diagnosing, classifying, and proposing treatment of fractures of the thoracic and lumbar spine can be made with equal reliability by evaluating video clips of CT scans transmitted to a smartphone or by the standard method of viewing the CT scan on a workstation-based PACS. Evaluating video clips of CT scans transmitted to a smartphone is a readily accessible, simple, and inexpensive method. We believe that it can be reliably used for consultations between the emergency physicians or orthopedic or neurosurgical residents with offsite, on-call specialists. It might also enable rural orcommunity emergency department physicians to communicate more efficiently and effectively with surgeons in tertiary referral centers.

Utility of contemporaneous dual read in the setting of emergency teleradiology reporting.

PURPOSE: Emergency radiology requires rapid and accurate interpretation of imaging examinations. Missed findings may lead to adverse outcomes. Double reporting may be used to minimize errors. Limited contemporaneous double reporting may be most efficient and cost-effective, but no data exists. This study is intended to examine the benefits of double reading and identify examinations where this would be most useful. METHODS: In this study, dual reporting was conducted in a parallel reading environment in a teleradiology practice for 3779 radiological procedures performed at two radiology centers in the USA over a period of 4 months. Discrepancies between reads were scored using the ACR peer review scoring system and grouped by modality and body part. Errors were tabulated across the study types, followed by identification of statistically significant differences. The interaction between image number and odds of an error was ascertained. RESULTS: In 145 instances (3.8%; 95 % CI, 3.2-4.4%), double reporting identified errors, leading to report modification. Study type was significantly related to error frequency (p = 0.0001), with higher than average frequencies of error seen for CT abdomen and pelvis and MRI head or spine, but lower than average for CT head, CT spine, and ultrasound. Image number was positively associated with error odds, but was not independently significant in a joint logistic regression model that included study type. CONCLUSION: Dual reporting identifies missed findings in about 1 of 25 emergency studies. This benefit varies substantially across study types and limited double reporting, merits further investigation as a cost-effective practice improvement strategy.

Reliability of the BI-RADS Final Assessment Categories and Management Recommendations in a Telemammography Context.

PURPOSE: The aim of this study was to evaluate the intradevice and interdevice reliability of four alternatives for telemammography-computed radiography, printed film, a film digitizer, and a digital camera-in terms of interpretation agreement when using the BI-RADS® lexicon. METHODS: The ethics committee of the authors' institution approved this retrospective study. A factorial design with repeated measures with 1,960 interpretations was used (70 patients, seven radiologists, and four devices). Reliability was evaluated using the κ coefficient for intradevice and interdevice agreement on malignancy classification and on BI-RADS final assessment category. RESULTS: Agreement on malignancy classification was higher than agreement for BI-RADS final assessment category. Interdevice agreement on malignancy classification between the film digitizer and computed radiography was ranked as almost perfect (P < .001), whereas interdevice agreement for the other alternatives was ranked as substantial (P < .001), with observed agreement ranging from 85% to 91% and κ values ranging from 0.70 to 0.81. Interdevice agreement on BI-RADS final assessment category was ranked as substantial or moderate (P < .001), with observed agreement ranging from 64% to 77% and κ values ranging from 0.52 to 0.69. Interdevice agreement was higher than intradevice agreement. CONCLUSIONS: The results of this study show very high interdevice agreement, especially for management recommendations derived from malignancy classification, which is one of the most important outcomes in screening programs. This study provides evidence to suggest the interchangeability of the devices evaluated, thereby enabling the provision of low-cost medical imaging services to underserved populations.

Telemedicine Systems in Uterine Transplant: A Feasibility and Reliability Study of the Pre-Grafting Teleradiological Evaluation of the Uterus Graft.

The pre-grafting Tele-Radiological (TRE) evaluation of the Uterus Graft (UG) on Telemedicine Systems, in Uterus Transplant (UT) is studied by diagnostic sensitivity-specificity analysis based on simulation of TRE of the UG on 10 MR sets of female pelvic digital images by two radiologists, assessing a. The vascular variations of the grafts, and b. The inflammatory and neoplastic lesions of the UG. The pre-grafting TRE of the UG showed: a. Diagnostic unreliability for vascular variations, b. A high diagnostic reliability for inflammatory and neoplastic diseases of the UG (100%), making the MRI based TRE of the UG in UT, feasible and highly reliable for the remote pre-grafting diagnosis of UG pathologic lesions, but unreliable for integrated vascular anatomic and pathologic UG remote evaluation for pre-grafting and pre-transplant decision support and planning.

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.

Watermark Compression in Medical Image Watermarking Using Lempel-Ziv-Welch (LZW) Lossless Compression Technique.

In teleradiology, image contents may be altered due to noisy communication channels and hacker manipulation. Medical image data is very sensitive and can not tolerate any illegal change. Illegally changed image-based analysis could result in wrong medical decision. Digital watermarking technique can be used to authenticate images and detect as well as recover illegal changes made to teleradiology images. Watermarking of medical images with heavy payload watermarks causes image perceptual degradation. The image perceptual degradation directly affects medical diagnosis. To maintain the image perceptual and diagnostic qualities standard during watermarking, the watermark should be lossless compressed. This paper focuses on watermarking of ultrasound medical images with Lempel-Ziv-Welch (LZW) lossless-compressed watermarks. The watermark lossless compression reduces watermark payload without data loss. In this research work, watermark is the combination of defined region of interest (ROI) and image watermarking secret key. The performance of the LZW compression technique was compared with other conventional compression methods based on compression ratio. LZW was found better and used for watermark lossless compression in ultrasound medical images watermarking. Tabulated results show the watermark bits reduction, image watermarking with effective tamper detection and lossless recovery.

[Teleradiological report turnaround times: An internal efficiency and quality control analysis]. / Teleradiologische Prozess- und Untersuchungszeiten: Eine institutsinterne Effizienz- und Qualitätsanalyse.

AIMS: The teleradiological examinations performed at the Charité were analyzed for the purpose of internal quality and efficiency control. Data included the type and number of examinations performed, the time of day and week the examination was performed and the differences in teleradiologist report turnaround times. MATERIAL AND METHODS: A retrospective analysis of the radiology information system (RIS) database of all teleradiological computed tomography examinations performed at the Charité from 2011 through 2013 was carried out. The search retrieved 10,200 teleradiological examinations which were included in the analysis. The records were analyzed for the time of the day and week the examination was performed, the interval between examination and time of reporting, the type of teleradiological examination and the campus in which they were performed. RESULTS: The number of teleradiological examinations performed increased continuously during the observation period. Computed tomography of the head was the most frequently performed type of examination with 86%. Taking all forms of examination into consideration it took an average of 34 min until a report was written. Over the 3-year observation period the times remained virtually unaltered. CONCLUSION: During the 3-year observation period nearly constant report times could be observed in spite of the increased numbers of examinations. This indicates an efficiency enhancement and rational integration of teleradiology into the radiological workflow.

Comparison of diagnostic accuracy of plain film radiographs between original film and smartphone capture: a pilot study.

The use of mobile devices for medical image capture has become increasingly popular given the widespread use of smartphone cameras. Prior studies have generally compared mobile phone capture images to digitized images. However, many underserved and rural areas without picture archiving and communication systems (PACS) still depend greatly on the use of film radiographs. Additionally, there is a scarcity of specialty-trained or formally licensed radiologists in many of these regions. Subsequently, there is great potential for the use of smartphone capture of plain radiograph films which would allow for increased access to economical and efficient consultation from board-certified radiologists abroad. The present study addresses the ability to diagnose a subset of radiographic findings identified on both the original film radiograph and the captured camera phone image.

Comparison of European (ESR) and American (ACR) white papers on teleradiology: patient primacy is paramount.

The ACR and European Society of Radiology white papers on teleradiology propose best practice guidelines for teleradiology, with each body focusing on its respective local situation, market, and legal regulations. The organizations have common viewpoints, the most important being patient primacy, maintenance of quality, and the "supplementary" position of teleradiology to local services. The major differences between the white papers are related mainly to the market situation, the use of teleradiology, teleradiologist credentialing and certification, the principles of "international" teleradiology, and the need to obtain "informed consent" from patients. The authors describe these similarities and differences by highlighting the background and context of teleradiology in Europe and the United States.

A national teleradiology programme in Mali: implementation and results.

We reviewed the national teleradiology programme in Mali to establish whether it improved diagnosis for patients and improved the referring doctor's ability to give an accurate diagnosis. The teleradiology programme connected the University Hospital in Bamako to all seven regional hospitals in Mali and one private health clinic. The pilot phase began in 2005 in three hospitals. Initially the implementation involved connections via broadband, but subsequently satellite antennae were provided at three remote hospitals in the north. Between 2005 and 2013, X-ray and mammogram images from 5628 patients were read by teleradiology. Radiologists provided the sole diagnosis for 29% of cases (i.e. the referrer did not make a diagnosis) and altered the regional doctor's diagnosis in 12% of cases. The proportion of cases for which the regional doctor gave no diagnosis decreased from 93% to 24% over the same period, indicating an increase in the doctors' confidence and incentive to test their own diagnosis. The percentage of cases for which regional doctors made an inaccurate diagnosis decreased to 3% in 2013. Use of the teleradiology service varied widely between hospitals. Successful implementation depended on local ownership of a network, which was developed in close collaboration with hospital leadership, national radiologists and other healthcare personnel.

The accuracy of mobile teleradiology in the evaluation of chest X-rays.

We assessed the diagnostic accuracy of digital photographs of plain film chest X-rays (CXRs) obtained using a mobile phone. The study was a randomized, non-inferiority trial, in which physical plain film CXRs viewed on a light box were compared with digital photographs of plain film CXRs. CXRs were selected from a database of radiology studies to show common pathologies found in Botswana associated with pneumonia, lung carcinoma, tuberculosis, pneumothorax and interstitial disease, as well as normal findings. The pre-selected diagnoses were subsequently verified by a second radiologist. Seven radiologists were randomized to review 75 plain film CXRs on light boxes before viewing 75 digital photographs, or vice versa. Their responses were considered correct if they matched the pre-defined diagnosis. For both modalities, the correct diagnosis was provided in 79% of cases; for plain film CXRs, the correct diagnosis was provided in 82% of cases and for digital photographs the correct diagnosis was provided in 76% of cases. The difference in diagnostic accuracy was -5.7% (95% CI: -10.8% to -0.5%), which confirmed non-inferiority (P<0.001) for the primary outcome of diagnostic accuracy. A subgroup analysis demonstrated non-inferiority for lung carcinoma and pneumonia images, although non-inferiority was not achieved for pneumothorax, tuberculosis, interstitial disease or normal images. The study demonstrates that digital photographs of CXRs obtained via a mobile phone equipped with a digital camera are non-inferior to plain film CXRs.

Integration of federated medical systems for vendor neutral image access in teleradiology applications.

This paper proposes a framework designed to interconnect medical imaging facilities and teleradiology service providers on a single access interface. This framework aims to solve the interoperability issues of Picture Archiving and Communication System (PACS), Radiology Information System (RIS) and Hospital Information System (HIS) developed by different vendors and enrich the digital health record delivered to non-local radiologists or physicians with the integrated information from several systems. This is achieved by introducing a "Grid Agent" into the domain of medical software systems, which seamlessly integrates with present systems and forms a network to deliver data between other Grid Agents and the "Grid Manager". Resultant solution decreases the access time of medical images by non-local medical staff and increases the efficiency and durability of the teleradiology service architecture.