Teleradiology Timothy P. Farrell, M.D., F.A.C.R. President Quantum Imaging & Therapeutics Associates Quantum Imaging & Therapeutics AssociatesPast-President

TeleradiologyTeleradiology

Timothy P. Farrell, M.D., F.A.C.R.Timothy P. Farrell, M.D., F.A.C.R. PresidentPresident

Quantum Imaging & Therapeutics AssociatesQuantum Imaging & Therapeutics AssociatesPast-PresidentPast-President

Pennsylvania Radiological SocietyPennsylvania Radiological Society

Teleradiology: DefinitionTeleradiology: Definition

TeleradiologyTeleradiology is a means of is a means of electronically transmitting electronically transmitting radiographic patient images and radiographic patient images and consultative text from one consultative text from one location to another.location to another.

Teleradiology: CostsTeleradiology: Costs

• Can vary from $15,000 to $20,000 Can vary from $15,000 to $20,000 for low end equipment to more than for low end equipment to more than $100,000 for high performance $100,000 for high performance systems. systems. – a high quality sending station will cost a high quality sending station will cost

approximately $35,000 to $40,000. approximately $35,000 to $40,000. – a dual CRT receiving/viewing station will a dual CRT receiving/viewing station will

cost in the $45,000 to $55,000 range.cost in the $45,000 to $55,000 range.

Teleradiology: ComponentsTeleradiology: Components

1. An image sending station 1. An image sending station

2. A transmission network 2. A transmission network

3. A receiving/image review station 3. A receiving/image review station

Teleradiology: ComponentsTeleradiology: Components

• Patient images are electronically encoded Patient images are electronically encoded in a digital format at the sending station, in a digital format at the sending station, sent on the transmission network and sent on the transmission network and received, viewed, and possibly stored at received, viewed, and possibly stored at the review station. the review station.

Sending Station: The SourceSending Station: The Source

• What can be sent? Anything!What can be sent? Anything!– Non-digital (conventional) films can be Non-digital (conventional) films can be

digitized using scanners.digitized using scanners.– Most studies are now digital from the Most studies are now digital from the

start:start:•Computed Radiography, Digital RadiographyComputed Radiography, Digital Radiography•CTCT•UltrasoundUltrasound•MRIMRI•Etc.Etc.


• Connection can be directly from the Connection can be directly from the equipment (CT scanner, etc.) or from a equipment (CT scanner, etc.) or from a PACS (Picture Archiving System).PACS (Picture Archiving System).

• Requires adherence to the Digital Requires adherence to the Digital Imaging and Communication in Imaging and Communication in Medicine (DICOM) lossless compression Medicine (DICOM) lossless compression standard.standard.

• DICOM gateway is required between the DICOM gateway is required between the source and the transmission network.source and the transmission network.



• A virtual private network (VPN) is A virtual private network (VPN) is required to assure compliance with required to assure compliance with the Health Insurance Portability and the Health Insurance Portability and Accountability Act (HIPAA).Accountability Act (HIPAA).

• VPN’s can be software or hardware VPN’s can be software or hardware based.based.

Transmission Network Transmission Network

•WireWire

•Fiber opticsFiber optics

•MicrowaveMicrowave

•Internet Internet

Receiving/Image Review Receiving/Image Review Station Station

Consists of:Consists of:1.1. Network interface Network interface

2.2. Personal computer with storage Personal computer with storage medium (e.g. hard disk drive) medium (e.g. hard disk drive)

3.3. One or more TV monitors One or more TV monitors

4.4. Optional hard copy device printer Optional hard copy device printer

Receiving/Image Review Receiving/Image Review StationStation


• The radiologist at the station can The radiologist at the station can access the image via the computer access the image via the computer and display it on the TV monitor. and display it on the TV monitor.

• The radiologist then performs The radiologist then performs software manipulation functions to software manipulation functions to "enhance" the image. "enhance" the image.


• The radiologist analyses the images The radiologist analyses the images and makes an interpretation, based and makes an interpretation, based on the clinical information (history) on the clinical information (history) received.received.

• The radiologist communicates the The radiologist communicates the results back to the Sending Station results back to the Sending Station (source) or another designated site.(source) or another designated site.



• Where is this?Where is this?– ““Upstairs”Upstairs”– Across townAcross town– Somewhere in PennsylvaniaSomewhere in Pennsylvania– Anywhere in the USAAnywhere in the USA– Anywhere in the worldAnywhere in the world

TeleradiologyTeleradiology

• Is it “Medicine”?Is it “Medicine”?

You bet it is!You bet it is!

Teleradiology: How is it Teleradiology: How is it used?used?

• Internal: Internal: – Within a hospital Within a hospital – Within a healthcare system (Examples: Within a healthcare system (Examples:

University of Pennsylvania, University of Pennsylvania, PinnacleHealth System)PinnacleHealth System)

– Within a Practice (Example: Quantum Within a Practice (Example: Quantum Imaging)Imaging)

Internal TeleradiologyInternal Teleradiology

• Nearly every radiology practice in Nearly every radiology practice in Pennsylvania uses this.Pennsylvania uses this.

• Used mostly during the day.Used mostly during the day.• Allows studies to be consolidated to Allows studies to be consolidated to

Image Review Stations.Image Review Stations.– Improves turn-around time, increases Improves turn-around time, increases

efficiency.efficiency.– Allows for “subspecialty” reads Allows for “subspecialty” reads

Internal Teleradiology: The Internal Teleradiology: The Quantum ExperienceQuantum Experience

• Quantum Imaging & Therapeutics Quantum Imaging & Therapeutics Associates – Central PennsylvaniaAssociates – Central Pennsylvania

• 50+ Radiologists50+ Radiologists

• Services Harrisburg (PinnacleHealth Services Harrisburg (PinnacleHealth System, Holy Spirit Hospital) and System, Holy Spirit Hospital) and York (Wellspan).York (Wellspan).


• Opened a Teleradiology Center in 2001.Opened a Teleradiology Center in 2001.

• Location: Lewisberry, PennsylvaniaLocation: Lewisberry, Pennsylvania

• Staffed by two radiologists from 6:30 am Staffed by two radiologists from 6:30 am until midnight.until midnight.

• Staffed by one radiologist from midnight Staffed by one radiologist from midnight until 6:30 am.until 6:30 am.– Has the physical capability to staff four Has the physical capability to staff four

radiologists concurrently, without adding radiologists concurrently, without adding equipment.equipment.



• How is our Teleradiology Center used?How is our Teleradiology Center used?

• During the day (6:30 am – 5:00 pm):During the day (6:30 am – 5:00 pm):– Subspecialty work:Subspecialty work:

•MRIMRI

•PETPET

•EchocardiographyEchocardiography

•CTCT

•Nuclear MedicineNuclear Medicine



• During the evening (5:00 pm - midnight):During the evening (5:00 pm - midnight):– Heaviest volume from hospital emergency Heaviest volume from hospital emergency

departments (80-100 studies).departments (80-100 studies).– Mixed cases: CT, plain films, Ultrasound, Mixed cases: CT, plain films, Ultrasound,

Nuclear Medicine, MRI.Nuclear Medicine, MRI.– Radiologists can read 8-10 cases per hour.Radiologists can read 8-10 cases per hour.



• Overnight (Midnight – 6:30 am):Overnight (Midnight – 6:30 am):– Busiest time: midnight – 2:00 amBusiest time: midnight – 2:00 am– Average = 50 cases, mostly CT scansAverage = 50 cases, mostly CT scans– Trauma cases can be time-consuming and Trauma cases can be time-consuming and

complicated.complicated.– Radiologists can read 7-9 cases per hour.Radiologists can read 7-9 cases per hour.

Internal TeleradiologyInternal Teleradiology

• Because Pennsylvania radiologists do Because Pennsylvania radiologists do Internal Teleradiology, they have:Internal Teleradiology, they have:– Image sending stations. Image sending stations. – Transmission network (usually wire). Transmission network (usually wire).

Use of “internal” systems or phone lines Use of “internal” systems or phone lines is a weak link. is a weak link.

– Receiving/image review station(s).Receiving/image review station(s).

Teleradiology: How is it Teleradiology: How is it used?used?

• External Teleradiology: Imaging External Teleradiology: Imaging studies are sent outside of a hospital studies are sent outside of a hospital system, clinic or physician practice system, clinic or physician practice for interpretation by radiologists.for interpretation by radiologists.

External Teleradiology External Teleradiology

• Who uses this?Who uses this?– Non-radiologist physicians: orthopedic Non-radiologist physicians: orthopedic

surgeons, urologists, neurologists, etc. surgeons, urologists, neurologists, etc. Almost always during the Almost always during the dayday..•Example: Local Central Pennsylvania Example: Local Central Pennsylvania

Orthopedic Surgery Practice.Orthopedic Surgery Practice.– Sends MRI studies to the Cleveland Clinic for Sends MRI studies to the Cleveland Clinic for

interpretation.interpretation.

External TeleradiologyExternal Teleradiology

• Who uses this?Who uses this?– Hospitals, clinics: also route studies to Hospitals, clinics: also route studies to

radiologists for interpretation. Almost radiologists for interpretation. Almost always during the day.always during the day.•Example: Clearview Imaging, AllentownExample: Clearview Imaging, Allentown


• Who uses this?Who uses this?– Radiology Practices: send cases during Radiology Practices: send cases during

the off-hours, often overseas.the off-hours, often overseas.•Why?Why?

– Quality of Life issue: case volume is high and is Quality of Life issue: case volume is high and is increasing. Most radiologists do not want to work increasing. Most radiologists do not want to work overnight shifts.overnight shifts.

– Most Pennsylvania radiology practices are not Most Pennsylvania radiology practices are not large enough or do not have the manpower to large enough or do not have the manpower to have dedicated “overnight” radiologists have dedicated “overnight” radiologists (“Nighthawks”).(“Nighthawks”).

External Teleradiology - External Teleradiology - OverseasOverseas

• Why is this done?Why is this done?– Time difference: Midnight in Harrisburg Time difference: Midnight in Harrisburg

is 10:30 am in Bangalore, India and 2pm is 10:30 am in Bangalore, India and 2pm in Sydney, Australia.in Sydney, Australia.

– Cost: Radiologists in India are cheaper Cost: Radiologists in India are cheaper than those in the USA.than those in the USA.


• Big Business: Big Business: GoogleGoogle “Teleradiology”. “Teleradiology”. Sponsored links are: Sponsored links are: – NightHawk RadiologyNightHawk Radiology– Virtual RadiologicVirtual Radiologic– US Radiology on CallUS Radiology on Call– RadLinxRadLinx– DiagnaDiagna– National TeleradiologyNational Teleradiology– Superior ImagingSuperior Imaging– Teleradiology SolutionTeleradiology Solution


• Problems:Problems:– There is a radiologist shortage in the There is a radiologist shortage in the

United States. United States. This is especially true in This is especially true in Pennsylvania.Pennsylvania.•Most overseas radiologists have been Most overseas radiologists have been

trained in the United States.trained in the United States.– They fill the training positions of physicians who They fill the training positions of physicians who

could be practicing in the US.could be practicing in the US.– Instead of practicing in the US, they return to Instead of practicing in the US, they return to

their native countries. their native countries.


• Problems:Problems:– Exporting jobs: not just radiologists, but Exporting jobs: not just radiologists, but

also:also:• ITIT

•AssistantsAssistants

•Everybody in the “Receive/Image Review Everybody in the “Receive/Image Review Station” chainStation” chain

– Sending $ out of the USA.Sending $ out of the USA.


American College of Radiology (ACR) American College of Radiology (ACR) recommends that radiologists who recommends that radiologists who are performing distant reads are:are performing distant reads are:

1.1. Board Certified by the ABR.Board Certified by the ABR.

2.2. Carry licenses and Malpractice Insurance Carry licenses and Malpractice Insurance in the state where the image was in the state where the image was obtained.obtained.

3.3. Are credentialed at the source facility.Are credentialed at the source facility.


… … But in 2003, the Indian technology But in 2003, the Indian technology giant Wipro “tested the waters” by giant Wipro “tested the waters” by using Indian radiologists who were using Indian radiologists who were neither licensed nor Board-certified neither licensed nor Board-certified in the United States.in the United States.

External Teleradiology - External Teleradiology - DomesticDomestic

• Many teleradiology “suppliers” are now Many teleradiology “suppliers” are now using more US-based radiologists.using more US-based radiologists.

• Most are based in the Pacific time-zone.Most are based in the Pacific time-zone.• No major supplier is Pennsylvania-based.No major supplier is Pennsylvania-based.• Other training centers are offering Other training centers are offering

Teleradiology services.Teleradiology services.– Cleveland ClinicCleveland Clinic– University of VirginiaUniversity of Virginia


In Pennsylvania:In Pennsylvania:

External Teleradiology = Out-of-state External Teleradiology = Out-of-state Radiology!Radiology!

Teleradiology BusinessTeleradiology Business

• Can we do this in Pennsylvania? YES!Can we do this in Pennsylvania? YES!– 6 medical schools (Jefferson, Drexel, 6 medical schools (Jefferson, Drexel,

Penn State, Temple, Penn, Pitt)Penn State, Temple, Penn, Pitt)– Have the technologyHave the technology– Have access to Broadband network Have access to Broadband network

deployed across Pennsylvaniadeployed across Pennsylvania


Pennsylvania is losing Pennsylvania is losing this!this!

Imaging Studies and therefore Imaging Studies and therefore jobsjobs, are , are being sent out of Pennsylvania. WHY?being sent out of Pennsylvania. WHY?


1.1. No “Teleradiology” Law – requiring No “Teleradiology” Law – requiring PA licensure for those practicing PA licensure for those practicing medicine via Teleradiology.medicine via Teleradiology.

2.2. Liability Insurance ProblemsLiability Insurance Problems

3.3. Radiologist shortageRadiologist shortage1.1. Insurance Company dominance.Insurance Company dominance.

2.2. High Medicare/Medicaid population.High Medicare/Medicaid population.


Let’s do something about this!Let’s do something about this!

Thank You!Thank You!

Documents

Teleradiology Timothy P. Farrell, M.D., F.A.C.R. President Quantum Imaging & Therapeutics Associates Quantum Imaging & Therapeutics AssociatesPast-President