Author: Dr. Manjul Tiwari.
Vasundhara Enclave, Delhi -110096
Abstract:
Major advances in telecommunications and computer systems and advances in the ability to capture medical information in digital form have accelerated the ability to apply telemedicine methods in a practical and affordable manner. These enabling factors are especially relevant to radiology known as Teleradiology the ability to obtain images in one location transmit them over a distance and view them remotely for diagnostic or consultative purposes which currently stands out as one of the most technologically and clinically advanced areas for telecommunication applications in Dentistry.
Introduction:
Rise of Telemedicine and Teleradiology in relation to Tele communication Systems
In the ensuing 130 years from the invention of the telephone every new method of communication has been explored for use in telemedicine applications. Telephonic voice communication among providers between providers and patients and between other stakeholders in health care delivery is a ubiquitous telemedicine application that we all probably take for granted but without which the health care system would grind to a halt.1,2
Extensive exploration 1,3 of closed circuit and broadcast television for patient consultations and for transmission of medical images from several specialties radiology, pathology, and dermatology was performed in the 1960s and into the 1970s. Among other investigators in this time frame, Dr Kenneth T. Bird of Massachusetts General Hospital (Boston) established an interactive television system 1,4 using direct microwave transmission from Logan Airport in Boston to the hospital to provide care for travelers.
In a similar vein the Walter Reed General Hospital (Washington, DC) installed a closed-circuit television connection between the department of radiology and the emergency room some time in the mid-1960s. Due poor contrast and spatial resolution and the need to send each image sequentially one at a time relegated the system to novelty status, and it was never used seriously for patient care1.
In the 1970s and gaining momentum in the 1980s, attention turned to computer-based approaches to telemedicine with a shift in interest from real time television applications to store and-forward methods 3 in which data are collected in digital form at an initiating site and are aggregated and stored for subsequent transmission to a receiving site. The store-and-forward approach simplifies operations by eliminating the need for all parties patients, providers and other support staff to be present at both sites simultaneously.
The store-and-forward approach is now the basis of teleradiology and many other telemedicine applications in which telemetry of data rather than direct televised face-to-face or voice contact between patients and providers can be used to deliver the service1.
Teleradiology systems became commercially available in the 1980s from a number of vendors but in retrospect, were very limited in quality and scalability. So-called camera-on-a-stick systems enjoyed a brief vogue mostly for hospital-to-home applications to provide after-hours coverage.
In sum, for teleradiology up to the early to mid-1990s, the relatively low performance and high costs of available computer systems, high costs of data transmission, and lack of practical and affordable digital image handling systems (including high-resolution work stations at originating and receiving sites) continued to block widespread adoption of the approach.
The technology factors holding back teleradiology all changed dramatically 4,5 in the past 10–12 years with the introduction of lower-cost communications systems such as the Internet, incredible improvements in price versus performance for computers, and wide adoption of picture archiving and communications systems by radiology practices. In the same time frame, medical imaging underwent a transformation from image recording and viewing on film images to the potential for direct digital capture and computer workstation viewing of images from all modalities. Taken together, these advances have provided a practical and affordable platform for implementing teleradiology1,6.
Teleradiology Applications[1]:
In the era before the widespread use of CT and US to evaluate patients presenting in the emergency room, 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 1.
In a 1999 survey of radiologists, Larson et al 7, found that 75%of responding multi radiologist practices and 30% of solo practices used teleradiology. In 92% of the former practices, radiologists used teleradiology to provide preliminary on call interpretations. Conventional radiography as cited in only 43% of responses and MR imaging in 47%. In another survey of 114 private hospitals reported by Saketk hoo et al 8, among the 97 responding institutions, 82% reported the use of teleradiology for nighttime coverage. The data from these surveys indicate that radiologists have embraced teleradiology and, by inference, must believe that it meets necessary requirements for accuracy and timely service7,8.
The use of on-call teleradiology for interpretation of images from off-hours examinations has continued to increase, due in part to the activities of a number of commercial enterprises founded specifically to provide outsourced off-hours coverage for radiology practices but also due to some academic and private practices that have begun offering substantially similar services1.
It is highly likely that the application of teleradiology to routine daytime practice will now rapidly increase since it affords a means of more efficiently matching the supply of radiologists with demand for their services than can be achieved through the distribution of radiologists on the basis of their physical presence in different practice locations especially when complex subspecialty studies are involved. 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.
Academic centers are likely to be approached to make their subspecialty expertise more available. The commercial companies nominally founded to provide on-call night hawk services are also moving assertively in this direction, and the descriptive term day hawking has now also entered the radiology lexicon1.
As the current trend continues toward more radiology being practiced remotely, it will promote and facilitate a substantial consolidation of providers into larger organizations whether they are radiology professional practice groups or commercial companies. Hospitals looking for better performance or more accountability in their radiology operations will turn to these entities and contract with them to manage their radiology departments. Smaller groups working in a generalist model of practice will be challenged to provide access to subspecialists and will face difficult decisions about whether to work with others or risk losing their franchises as their specialist colleagues in other disciplines demand more expertise in interpretation of imaging studies4.
Teleradiology is poised to play an important role in peer review and quality assurance. With the Joint Commission on Accreditation of Healthcare Organizations pushing for more evidence of performance evaluation between credentialing events, radiology groups will need to develop better systems for assessing the accuracy of their work and for peer review. In some settings, radiologists are being challenged by their physician colleagues and their institutions to more objectively demonstrate the quality and accuracy of their interpretations. The use of teleradiology can facilitate groups working together in reciprocity to review each others work or to contract with outside organizations to address these quality issues1.
Education in all medical disciplines has already been indelibly changed by telecommunications. Again, radiology is a leader because of the fidelity and flexibility of digital image management. Teaching files are available from national and international sources on the Internet, as are Web casts of lectures, case-of-the-day presentations, and teaching conferences. Travel is no longer necessary to access outstanding learning op-portunities, although teleeducation falls short on direct person-to-person mentoring, which provides tangible and intangible aspects that we should not under value2.
Research in radiology is being transformed through teleradiology in parallel with clinical practice. Image data from clinical trials can be collected faster and more efficiently by direct digital transfer than by shipping hard-copy film records6.
The ACR Imaging Network has secure connections to over 100 hospitals supporting data collection in 20 or more active trials 1,8. The pharmaceutical industry has discovered the value of imaging biomarkers for use as end points in clinical trials and will undoubtedly drive further network development.
Conclusion:
Several factors including the prevailing shortage of radiologists, the increasing use of advanced imaging methods, the consolidation of hospitals into regional delivery systems, and heightened expectations of patients and referring physicians for timely service—have fostered the increasing use of teleradiology. These factors have also helped underwrite the creation of new and potentially disruptive business models for service delivery that can be viewed as threats, opportunities, or both, but cannot be ignored1.
References:
ACKNOWLEDGEMENT:
I want to give my sincere gratitude and acknowledgement James H. Thrall, MD without whom this article cannot be prepared.
Telecommunication in Dental Radiography
Vasundhara Enclave, Delhi -110096
Abstract:
Major advances in telecommunications and computer systems and advances in the ability to capture medical information in digital form have accelerated the ability to apply telemedicine methods in a practical and affordable manner. These enabling factors are especially relevant to radiology known as Teleradiology the ability to obtain images in one location transmit them over a distance and view them remotely for diagnostic or consultative purposes which currently stands out as one of the most technologically and clinically advanced areas for telecommunication applications in Dentistry.
Introduction:
Rise of Telemedicine and Teleradiology in relation to Tele communication Systems
In the ensuing 130 years from the invention of the telephone every new method of communication has been explored for use in telemedicine applications. Telephonic voice communication among providers between providers and patients and between other stakeholders in health care delivery is a ubiquitous telemedicine application that we all probably take for granted but without which the health care system would grind to a halt.1,2
Extensive exploration 1,3 of closed circuit and broadcast television for patient consultations and for transmission of medical images from several specialties radiology, pathology, and dermatology was performed in the 1960s and into the 1970s. Among other investigators in this time frame, Dr Kenneth T. Bird of Massachusetts General Hospital (Boston) established an interactive television system 1,4 using direct microwave transmission from Logan Airport in Boston to the hospital to provide care for travelers.
In a similar vein the Walter Reed General Hospital (Washington, DC) installed a closed-circuit television connection between the department of radiology and the emergency room some time in the mid-1960s. Due poor contrast and spatial resolution and the need to send each image sequentially one at a time relegated the system to novelty status, and it was never used seriously for patient care1.
In the 1970s and gaining momentum in the 1980s, attention turned to computer-based approaches to telemedicine with a shift in interest from real time television applications to store and-forward methods 3 in which data are collected in digital form at an initiating site and are aggregated and stored for subsequent transmission to a receiving site. The store-and-forward approach simplifies operations by eliminating the need for all parties patients, providers and other support staff to be present at both sites simultaneously.
The store-and-forward approach is now the basis of teleradiology and many other telemedicine applications in which telemetry of data rather than direct televised face-to-face or voice contact between patients and providers can be used to deliver the service1.
Teleradiology systems became commercially available in the 1980s from a number of vendors but in retrospect, were very limited in quality and scalability. So-called camera-on-a-stick systems enjoyed a brief vogue mostly for hospital-to-home applications to provide after-hours coverage.
In sum, for teleradiology up to the early to mid-1990s, the relatively low performance and high costs of available computer systems, high costs of data transmission, and lack of practical and affordable digital image handling systems (including high-resolution work stations at originating and receiving sites) continued to block widespread adoption of the approach.
The technology factors holding back teleradiology all changed dramatically 4,5 in the past 10–12 years with the introduction of lower-cost communications systems such as the Internet, incredible improvements in price versus performance for computers, and wide adoption of picture archiving and communications systems by radiology practices. In the same time frame, medical imaging underwent a transformation from image recording and viewing on film images to the potential for direct digital capture and computer workstation viewing of images from all modalities. Taken together, these advances have provided a practical and affordable platform for implementing teleradiology1,6.
Teleradiology Applications[1]:
In the era before the widespread use of CT and US to evaluate patients presenting in the emergency room, 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 1.
In a 1999 survey of radiologists, Larson et al 7, found that 75%of responding multi radiologist practices and 30% of solo practices used teleradiology. In 92% of the former practices, radiologists used teleradiology to provide preliminary on call interpretations. Conventional radiography as cited in only 43% of responses and MR imaging in 47%. In another survey of 114 private hospitals reported by Saketk hoo et al 8, among the 97 responding institutions, 82% reported the use of teleradiology for nighttime coverage. The data from these surveys indicate that radiologists have embraced teleradiology and, by inference, must believe that it meets necessary requirements for accuracy and timely service7,8.
The use of on-call teleradiology for interpretation of images from off-hours examinations has continued to increase, due in part to the activities of a number of commercial enterprises founded specifically to provide outsourced off-hours coverage for radiology practices but also due to some academic and private practices that have begun offering substantially similar services1.
It is highly likely that the application of teleradiology to routine daytime practice will now rapidly increase since it affords a means of more efficiently matching the supply of radiologists with demand for their services than can be achieved through the distribution of radiologists on the basis of their physical presence in different practice locations especially when complex subspecialty studies are involved. 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.
Academic centers are likely to be approached to make their subspecialty expertise more available. The commercial companies nominally founded to provide on-call night hawk services are also moving assertively in this direction, and the descriptive term day hawking has now also entered the radiology lexicon1.
As the current trend continues toward more radiology being practiced remotely, it will promote and facilitate a substantial consolidation of providers into larger organizations whether they are radiology professional practice groups or commercial companies. Hospitals looking for better performance or more accountability in their radiology operations will turn to these entities and contract with them to manage their radiology departments. Smaller groups working in a generalist model of practice will be challenged to provide access to subspecialists and will face difficult decisions about whether to work with others or risk losing their franchises as their specialist colleagues in other disciplines demand more expertise in interpretation of imaging studies4.
Teleradiology is poised to play an important role in peer review and quality assurance. With the Joint Commission on Accreditation of Healthcare Organizations pushing for more evidence of performance evaluation between credentialing events, radiology groups will need to develop better systems for assessing the accuracy of their work and for peer review. In some settings, radiologists are being challenged by their physician colleagues and their institutions to more objectively demonstrate the quality and accuracy of their interpretations. The use of teleradiology can facilitate groups working together in reciprocity to review each others work or to contract with outside organizations to address these quality issues1.
Education in all medical disciplines has already been indelibly changed by telecommunications. Again, radiology is a leader because of the fidelity and flexibility of digital image management. Teaching files are available from national and international sources on the Internet, as are Web casts of lectures, case-of-the-day presentations, and teaching conferences. Travel is no longer necessary to access outstanding learning op-portunities, although teleeducation falls short on direct person-to-person mentoring, which provides tangible and intangible aspects that we should not under value2.
Research in radiology is being transformed through teleradiology in parallel with clinical practice. Image data from clinical trials can be collected faster and more efficiently by direct digital transfer than by shipping hard-copy film records6.
The ACR Imaging Network has secure connections to over 100 hospitals supporting data collection in 20 or more active trials 1,8. The pharmaceutical industry has discovered the value of imaging biomarkers for use as end points in clinical trials and will undoubtedly drive further network development.
Conclusion:
Several factors including the prevailing shortage of radiologists, the increasing use of advanced imaging methods, the consolidation of hospitals into regional delivery systems, and heightened expectations of patients and referring physicians for timely service—have fostered the increasing use of teleradiology. These factors have also helped underwrite the creation of new and potentially disruptive business models for service delivery that can be viewed as threats, opportunities, or both, but cannot be ignored1.
References:
- James H. Thrall. Teleradiology - Part I. History and Clinical Applications. Radiology 2007; 243:613– 617.
- Lucidcafe. Alexander Graham Bell. http: //www.lucidcafe.com/library/96mar/bell.html. Accessed February 11, 2007.
- Thrall JH, Boland G. Teleradiology. In: Dreyer KJ,Mehta A, Thrall JH, eds. PACS: guide to the digital revolution. New York, NY: Springer-Verlag, 2002;315–348.
- Thrall JH. Reinventing radiology in the digital age. I. The all-digital department. Radiology 2005;236:382–385.
- Thrall JH. Reinventing radiology in the digital age. II. New directions and new stake- holder value. Radiology 2005;237:15–18.
- Goldberg MA, Sharif HS, Rosenthal DI. Making global telemedicine practical and affordable: demonstrations from the Middle East. AJR Am J Roentgenol 1994;163:1495– 1500
- Larson DB, Cypel YS, Forman HP, Sunshine JH. A comprehensive portrait of teleradiology in radiology practices: results from the American College of Radiology’s 1999 survey. AJR Am J Roentgenol 2005;185:24–35.
- Saketkhoo DD, Bhargavan M, Sunshine JH, Forman HP. Emergency department image interpretation services at private community hospitals. Radiology 2004;231:190–197.
ACKNOWLEDGEMENT:
I want to give my sincere gratitude and acknowledgement James H. Thrall, MD without whom this article cannot be prepared.
In Association With
