presentation given at MIR@ECR session, Vienna, March 2013

1. REPORT ON THE DEVELOPMENT OF AN
ESR WHITE PAPER FOR TELERADIOLOGY
Erik R. Ranschaert
s‟Hertogenbosch/NL
MIR@ECR

2. INTRODUCTION
TELERADIOLOGY WHITE PAPER
• What is teleradiology? • History & background
• What is changing? • Purposes & objectives
• Why a white paper? • Materials & methods
• Progress & difficulties
• Prospects
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

3. WHAT IS TELERADIOLOGY
• Variant of radiology, existing medical practice
• Remote activity is stressed
• Involves electronic transmission of patient data
• images & request
• relevant clinical data, priors
• associated patient-identifiable and health-related information
• crossing boundaries of hospital/organisation
• Sometimes crossing national boundaries
• Teleradiology is part of Telemedicine concept
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

4. WHAT IS CHANGING
4 MEGA-TRENDS POLITICAL CHANGES in EU
1. importance of technology grows • e-Health is on political agenda
• Digitisation of society & medicine • Great faith in telemedicine
• Mobility of data and images • Greater efficiency in health care
• (Disruptive) innovations making • Cost-saving factor
images “viewable” everywhere
2. New financing systems HC, savings • Freedom to provide & seek medical
services within EU member states
3. Further (Health Service)
internationalisation/globalisation of
markets & services • Electronic commercial services at
distance are allowed (Information
4. Increased democratisation of medical
knowledge, empowerment of patients Society Service)
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

5. E-HEALTH IS ON POLITICAL AGENDA
…“We need to be more
aware of the fact that ICT
needs to be integrated in
our HC system. Almost
every MD has a
smartphone, so much more
can be done with that”
…(2011)
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

6. IMAGES BECOME MOBILE
• m-Health
• Growing number of possibilities and apps for
• radiology & teleradiology
• image storage & sharing
• communication with referring doctors
and patients
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

7. WHY A NEW WHITE PAPER?
FACTS CONSEQUENCES
• New methods of delivering diagnostic • Setting of standards is essential to
services are developing at high speed maintain high quality level
• Increasing commercialisation and • Quality of care needs to be maintained
internationalisation of health services and safeguarded
• Patient needs to remain central, has to
• Increasing competition between be protected
hospitals and other HC providers
• Radiology profession needs to be
• Increased fragmentation of services protected
• Increased cross-border activities • Regular update of standards is
necessary to keep up with changing
• Growing importance of teleradiology, environment and trends
also in Europe
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

8. HISTORY
• ESR eHealth and Informatics Subcommittee
Meeting @ ECR 2012
• Chairman Prof. Dr. Osman Ratib
• Request to write new white paper on
teleradiology
• Gather group of radiologists with expertise in
different fields of teleradiology
• Involvement of several member of the ESR
EU Affairs subcommittee
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

9. BACKGROUND INFORMATION
• ESR Brochures (published until 2009)
• Brochure I (Teleradiology)
• Brochure VII (2006 White Paper)
• EU Staff Working Document
• Published in 2012
• Analysis of current legislation and
regulations
• Partly result of negotiations with
EU stakeholders and EU ESR
Affairs subcommittee
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

10. RELEVANT ESR PUBLICATIONS
• ESR Guidelines for the Communication of Urgent and Unexpected Findings
Volume 3 (2012), Number 1 (Feb), p.1-3; DOI: 10.1007/s13244-011-0135-y
• Usability of irreversible image compression in radiological imaging. A position paper by
the European Society of Radiology (ESR)
Volume 2 (2011), Number 2 (Apr), p.103-115 , DOI: 10.1007/s13244-011-0071-x
• Good Practice for Radiological Reporting. Guidelines from the European Society of
Radiology.
Volume 2 (2011), Number 2 (Apr), p.93-96, DOI: 10.1007/s13244-011-0066-7
• The future role of radiology in healthcare.
Volume 1 (2010), Number 1 (Jan), p.2-11, DOI: 10.1007/s13244-009-0007-x
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

11. EU STAFF WORKING DOCUMENT
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

12. EXISTING STANDARDS
• Italy: SIRM Teleradiologia (2004)
• UK
• RCR standards for teleradiology in UK (2010)
• RCR position statement on teleradiology (2012)
• France:
• Teleradiology Charter -- French National Radiological Council
• Téléimagerie – Téléradiologie: Recommandations du SNITEM et du Conseil professionnel de
la radiologie
• Spain: “Update on Teleradiology” Paper on appropriate use of teleradiology (2011)
• USA:
• ACR Standard for Teleradiology (2003)
• Report of ACR Task Force on International Teleradiology (2005)
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

13. NEW ACR WHITE PAPER ON TELERADIOLOGY PRACTICE
• Topics addressed:
• Current state of Teleradiology
• Positives and negatives of teleradiology
• Services offered to end-users (including patients)
• Recommendations based upon following principles:
1. Patient primacy
2. On-site coverage is preferred
3. There should be a single high professional standard of quality for both
teleradiology providers and on-site radiologists
4. Teleradiology services should be incorporated into local operations and be
assimilated into the usual medical staff credentialing and privileging process
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

14. RECOMMENDATIONS FROM ACR TASK FORCE
• “The teleradiologist”
• Professional qualifications, licensure
• The teleradiologist‟s work environment
• ergonomic factors
• monitor characteristics
• Ambient lighting
• Responsabilities of the teleradiologist
• Responsible for all elements in the process (image quality, process before and after
image acquisition)
• Supervising role of radiologist
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

15. OTHER ISSUES ADDRESSED
• Privacy & security issues
• Ghost reading
• Relevance of priors, imaging reports and EMR integration
• Communication
• Physician-physician relationship
• communication radiologist – radiographer
• Urgent reports
• Audit trail (log)
• Quality monitoring
• discrepancy reporting
• TAT‟s
• Billing issues
• Competitive Market Forces – predatory business practices
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

16. PURPOSE & OBJECTIVES OF ESR-WP
• Purpose:
• “Readable” document
• Easy access(www)
• Easy updating
• Usable on a pan-European basis, mentioning local differences
• Materials & methods:
• ESR “Task Force”
• “secure” collaborative platform
• online publishing format (Wiki-type platform)
• Result: an online freely accessible reference document (Wikipedia-type)
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

17. MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

18. THE TASK FORCE
Name Task
Osman Ratib Chairman ESR subcommittee
Erik Ranschaert Chairman task force, coordinator
Jan Schillebeeckx Liaison ESR-EU, legal issues
Peter Mildenberger Interoperability standards, data protection
Neelam Dugar interoperability standards, technical issues
Nicola Strickland Auditing standards
Lluis Donoso Quality issues, ESR position
Peeter Ross Technical, legal
Remy Demuth Liaison ESR-UEMS, legal issues
Jan Bosmans Radiology reporting
Jean-Philippe Masson reviewing
Eric Guillemot reviewing
Giles Boland Liaison ESR-ACR
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

19. MATERIALS & METHODS
GOOGLE DRIVE GOOGLE GROUPS
• Collaborative platform • Online discussion group
• Online storage and sharing of relevant • Common mail-address for
documents and papers discussions within task force
• Google Docs: • Messages may contain direct link
• Online writing, reviewing and to documents published & stored
editing of chapters on Google Drive
• Access limited to task force
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

20. ONLINE DOCUMENT SHARING
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

21. GOOGLE GROUPS
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

22. ONLINE EDITING & REVIEWING
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

23. WIKI-PLATFORM
• Wiki software (wiki engine or wiki application)
• collaborative software
• web application running on one or more web servers
• content, including all current and previous revisions, is usually stored in
file system or database
• allows to share knowledge online and to update the publication regularly
• Will be used for online freely accessible publication of White Paper
• Examples
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

24. MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

25. MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

26. PROGRESS
• MIR ANNUAL MEETING 2012
• First formal meeting of task force
• Discussion of Table of Contents
• Distribution of tasks
• Existing ESR guidelines and relevant (national) documents will be used as reference
• “New” topics will be added
• Communication methods
• Emerging business models
• Mobile radiology
• Patient-directed services
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

27. CHAPTERS
Chapter Title
1 Regulatory aspects, EU legal issues
2 Collateral information
3 Financial, reimbursement
4 Technical issues
5 Licensing, registration, accreditation
6 Liability issues
7 Quality assessment
8 Communication issues
9 Patient safety & security
10 Workload, ergonomics
11 Mobile radiology
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

28. RESULTS
• Analysis and discussion of EU Staff Working Paper
• Chapters:
• Foreword and introduction
• Relevance of clinical information & priors
• 2 drafts : Communication -- Technical aspects
• Discussions in Google groups on various issues and definitions
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

29. FOREWORD & INTRODUCTION
• Current status of teleradiology
• usage in EU, changing environment, images becoming mobile
• types of teleradiology
• Teleradiology definition
• EU: Teleradiology is considered as a form of telemedicine
• Telemedicine is “not a new medical act” according to the EU SWP
• Teleradiology should not be different from the normal radiological act
• ESR:
• teleradiology is a medical act
• Patient care/service is central
• the quality of care to patients is improved only when teleradiology makes available a
remote radiologists in cases where no local radiologist is easily available
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

30. CLINICAL INFORMATION AND PRIORS
• Importance of access to relevant clinical information and priors
• To improve accuracy of imaging process
• Recommendation to use electronic request form
• Reporting:
• Avoid abbreviations, local slang
• Concise but relevant reports
• Relevance of facilitating communication with local clinician(s)
• Recommendations for tele-radiologist
• how to handle the request
• how to deal with insufficient information
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

31. TECHNICAL
• Storage and access to images
• Report creation, transfer and retention
• Types of teleradiology, transmission techniques
• Image quality, compression techniques, bandwidth
• Safety & security issues
• Teleradiologist‟s work-environment
• Ergonomics
• workstation
• Mobile imaging (usage, quality, safety etc)
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

32. DIFFICULTIES
• Finding incentives to put pen on paper
• Usage & interpretation of existing documents (national societies, EU)
• Pan-European concept, transcending “local” regulations
• Differences due to „subsidiarity principle‟ in organisation of HC in member states
• Cultural differences
• employment status of radiologists
• financing and reimbursement
• teleradiology usage
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013

33. FUTURE PROSPECTS
• Task force is gaining experience with the collaborative platform
• Start has been given, more chapters to follow
• GoToMeetings will be held to discuss topics/chapters commonly
• Deadline: 4 th trimester 2013
• Approval of white paper by ESR Executive Council
• Publication on Wiki platform
MIR@ECR 2013 - ERIK RANSCHAERT MD March 8, 2013