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Radiologic Imaging and Teleradiology in the Emergency Department

Teleradiology is a relatively new, but rapidly advancing field that is impacting the practice of emergency physicians across the country. Teleradiology refers to the transmission of digital images, usually across high-bandwidth lines, to a remote location for the purposes of providing real-time radiological interpretations.

The explosion in diagnostic imaging studies ordered through emergency departments, especially coupled with a relative shortage of board-certified radiologists in the US, has lead to the development of entrepreneurial companies that provide radiologists to interpret these studies, especially at night, often from a remote location. These companies are sometimes referred to as "nighthawk" services, and provide radiological interpretations primarily, though not exclusively, on the night shift. CT scans are the most common diagnostic study utilized, but MRIs, ultrasounds, and even plain radiographs may be interpreted based on the specific needs of local institutions.

There are several issues concerning teleradiology that are specific concerns for emergency physicians. The first issue for emergency physicians concerns the timeliness of reports. The decisions that emergency physicians make with respect to patient care are often based upon the interpretations of imaging studies. The treatment decisions have significant implications for patient care and any delay in reporting results may have negative consequences.

Another issue that affects emergency physicians occurs when the local radiologist provides the "final" interpretation, often the next day or even several days later, and their interpretation differs substantially from the preliminary reading. Needless to say, any significant change in the original interpretation of an imaging study may have a profound impact upon the original diagnosis, treatment, and disposition of the patient, to say nothing of the medical-legal implications.

Another concern is the qualifications and background of the radiologists reading the initial radiological studies. Although many of the teleradiology companies require board certification and licensure in the same state as the local radiologist, there is no guarantee of such a quality measure.

Because of the profound implications that these initial radiological interpretations have upon emergency physicians’ decision-making, emergency physicians should demand the following requirements for "nighthawk" services:

  1. The interpretations should be available on a timely basis after completion of the study. In addition, the radiologist must be available, in real time, by phone for discussion and/or consultation with the treating emergency physician.
  2. The radiologist providing the service should be licensed in the state where the images are performed. The radiologists should meet the same credentialing requirements as radiologists within the local healthcare facility, such as board certification / board eligibility. In summary, they should meet or exceed the qualifications of the in-house radiologists.
  3. The original as well as the final interpretations must be documented in writing and must be a permanent part of the patient’s medical record. This documentation is necessary in the event that the local radiologist changes or disagrees with the original interpretation. Any discrepancy should be part of the institution’s ED-radiology quality improvement process, as well.

The American College of Radiology has several practice guidelines that address issues in teleradiology regarding the interpretation of images in the emergency department:

Credentialing/Qualifications
The radiologist shall be certified in Radiology or Diagnostic Radiology by the American Board of Radiology or the American Osteopathic Board of Radiology.
or
The radiologist shall have training in an Accreditation Council for Graduate Medical Education (ACGME) approved general or diagnostic radiology residency program that included documented training in all imaging modalities that he/she intends to interpret, or shall meet the qualifications stated in the ACR practice guidelines or technical standards for the particular modality being performed or interpreted.

Teleradiology Qualifications
The official interpretation of images must be done by a physician who has:

  1. An understanding of the basic technology of teleradiology and its strengths and limitations, and who is knowledgeable in the use of the teleradiology equipment.
  2. Demonstrated qualifications as delineated in the appropriate American College of Radiology (ACR) guidelines or standards for the particular diagnostic modality being transmitted through teleradiology.

Licensure
Physicians who interpret images transmitted by teleradiology should maintain the licensure required for providing radiologic service at both the transmitting and receiving sites. When interpreting images from a hospital, physicians should be credentialed and obtain appropriate privileges at that institution. These physicians should consult with their professional liability carrier to ensure coverage in both the sending and receiving sites.

Physicians who are involved in practicing teleradiology will conduct their practice in a manner consistent with the bylaws, rules, and regulations for patient care at the transmitting site.

Communication
Effective communication is a critical component of diagnostic imaging. Quality patient care can only be achieved when study results are conveyed in a timely fashion to those ultimately responsible for treatment decisions.

Timely receipt of the report is more important than the method of delivery.

Preliminary reports may be communicated in writing, electronically, or verbally, and communication should be documented. These preliminary communications should be reproduced into a permanent format as soon as practical and appropriately labeled as a preliminary report, distinct from then final report, when such a distinction is appropriate.

As soon as possible a change between the preliminary and final interpretation should be reported in a manner that reliably ensures receipt by the referring or treating physicians, when such changes may impact patient care. Documentation of communication of any discrepancy should be incorporated in the final report.

Timeliness
It is the policy of the ACR that radiologists provide comprehensive imaging services to patients seen in the emergency department and provide timely consultative services for a patient’s physician.

Many radiology practices provide similar timely interpretations for ED imaging examinations after normal working hours and on weekends and holidays by scheduling coverage by qualified radiologists on site an/or via teleradiology.

Developed by members of ACEPs Emergency Medicine Practice Subcommittee on Contemporaneous Interpretation of CT Scans

Timothy Seay, MD, FACEP, Committee Chair
Scott M. Davis, MD, FACEP, Subcommittee Chair
Timothy A. Burrell, MD, MBA, FACEP
Diana L. Fite, MD, FACEP
Azita Hamedani, MD, MPH
Michael G. Mikhail, MD, FACEP
Angela Siler Fisher, MD

Reviewed by the ACEP Board of Directors, June 2006

References

ACR Practice Guideline for Radiologist Coverage of Imaging Performed in Hospital Emergency Departments

ACR Practice Guideline for Performing and Interpreting Diagnostic Computed Tomography (CT)

ACR Practice Guideline for Communication of Diagnostic Imaging Findings

ACR Technical Standard for Electronic Practice of Medical Imaging*

* Policy updated. Link is to current policy.

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