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PACS: Diminishing the Distance and Enabling the Real-Time Services in Teleradiology

The pandemic time has unveiled a plethora of opportunities and brought in a paradigm shift in work culture – Remote Working, driven by technology. This has enabled the continuation of services irrespective of location and time without compromising the quality-of-service delivery. But this remote working is not a new concept in Radiology. Many radiologists have been supporting the clinicians irrespective of their location and time through teleradiology and delivering quality patient care without delay.

Teleradiology, identified with remote working is actually vibrant, spontaneous, and into real-time work. All this is possible because of PACS.

PACS – Picture Archiving and Communication System; a system involved in acquiring the medical images, transmission, viewing, storage, and retrieval of same images. Basically, PACS is an electronic version of the file room and reading room for radiologists. PACS works as a host that integrates the radiological images acquired from different radiological imaging modalities (X-Ray, Ultrasound, CT, MRI, PET Scan, Nuclear Medicine, etc…) with a network of information system (RIS and or HIS), EMR, different work stations and image storage/archival system.

Since 1980, PACS has undergone many transformations in multiple ways. All these have been worked out to improve – the transmission of images without any compromise on its quality, archiving and retrieving of data (images and other information) for reference without any delay, communication between the referring Physician, and reporting radiologist. The fundamental parts of PACS are – imaging acquisition, display workstations, archive servers. The workflow is customized based on the modality of images and criticality of the cases marked in the raised work orders

Today, the Web-based PACS offers many additional features like AI-Assisted Decision Support systems, Multi-Media Enhanced Reporting (MMER), an intuitive user interface, intelligent work aids (personalized tools and layout), mobile extensions, multimedia communication tools, etc that boost reading/reporting, making it a smart PACS. It is a coordinator between multiple processes (software & hardware) and applications enabling the image reporting as a real-time service supporting referring physicians.

The benefit of all these features has resulted in reduced TAT, improved productivity of department, better management of emergency / critical cases, and maintenance of data security. It also enables the viewing of images for reporting from anywhere – inside the department or at the nursing station or on mobile gadgets (mobile/notepads/laptops) or remote reporting sites (Teleradiology).

PACS infrastructure is evolving with advancements in medical imaging technologies and it is highly scalable to keep up the pace with the increasing number of imaging and reporting. This scalability can involve – the addition of more no. of imaging modalities, storage space, no. of work stations, integration of artificial intelligence and machine learning or any other features.

PACS in Hospitals / Tele-reporting service providers with different modalities and multiple work stations use Vendor Neutral Archive (VNA) which brings about compatibility between the different software of imaging machines and PACS’ networking. VNA ensures seamless functioning of data receiving, transmission, integration, and archival and saves time by providing one viewing experience/interface irrespective of the origin of data acquisition.

Cloudex Solutions: extending teleradiology with cloud-based PACS

Cloudex has set its tele-reporting infrastructure with the advanced smart PACS that provides a convenient workflow and easy-to-use interfaces/dashboard. These advanced online PACS is capable of handling multiple modalities and multiple workstations providing the browser as the main viewing tool enhancing the faster TAT.

The teleradiologists login into the browser and start with the flexibility of time ensuring the tele-reporting services for 24x 7 x 365. Now hospitals / diagnostic centers have the advantage of need-based tele-reporting depending on the imaging modality/subspecialty/timing (full time or night hawk services) instead of traditional reporting apart without a huge investment in digitalized workflow and storage. The experience of the PACS administrator adds a lot of value especially in critically marked/emergency cases apart from their regular maintaining or managing or troubleshooting roles.

Cloudex with its flexibility in working and range of tele-reporting services aims to support its clients (healthcare service providers) in overcoming obstacles faced while delivering patient care and have a winning edge towards patient satisfaction.

At Cloudex, we support you to have that winning edge.

Panademic Crisis Boon Teleradiology

A medical system by which patient’s radiological images from a variety of health care facilities are transmitted electronically for review and reporting by experienced, offsite radiologists and that’s teleradiology. The resulting reports are then transmitted back to the original facility, providing key insights about the images and helping to determine the course of further patient care. The true fact is that this system is grown within the medical field over the last number of decades, only a few are familiar with the particulars of teleradiology.

Now in the present scenario use of teleradiology is highly recommended as the covid 19 crisis threatens the entire world. Moreover, it ensures the safety of professionals and patients simultaneously. However, optimization of IT solutions and implementation of the right change process is a significant milestone for a successful transition.

Radiology plays an important role during the pandemic as it is essential to maintain the continuity of the health service to the patients. Using such technology based on the transmission of radiological patient images from one location to another and allows radiologists to provide services without having to be in contact with the patient is peculiarly important to minimize the expansion of the covid 19 virus.

In some countries, radiology departments in public and private experienced this solution of remote working, showing a positive impact during the outbreak.

The physical distance between the technologist radiologist, the referring physicians, and the patient is of great advantage now as concerns the present situation. If the concerned patient is in self-quarantine due to exposure to a covid patient, in such situation teleradiology helps much with doctors as being able to read, albeit from far x-rays or CT scan of coronavirus patients.

In China at an early stage of a pandemic outbreak, before swab testing was really available, CT scan was used by doctors to assess the probability of covid 19 infections, same time used to track and monitor the progression of the disease as described by some researchers from China.

Teleradiology allows radiologists to work and be productive when isolated from the rest of their community, while the necessity for social distancing is inevitable in the current pandemic, definitely help to restrict the virus transmission. This practice of receiving images to interpret from a facility and that too is out of radiologists’ geographical vicinity is a truly valuable contribution at this time of unprecedented crisis. By supporting areas of the physician shortage and backing up they are in hospital counterparts, teleradiology serves in a significant way to relieve some of the stresses that global health care systems are currently experiencing.

Medical Science has proven time and again that when the resources are provided, great progress in the treatment, cure, and prevention of diseases can occur.

When there is a crisis we can use two brush strokes to write the word ‘crisis’. One brush stroke stands for danger and the other for opportunity. In a crisis, be aware of the danger but on the other hand recognize the opportunity. It’s really an unpredictable situation for the medical field globally, the danger is on the way we move on. But on the other side of the coin, we are forced to find innovative solutions to problems we may never face before.
When we approach the crisis from a hopeful perspective rather than with a stance of resistance, we can navigate this difficult situation by making it beneficial for the modern medical system knows to be teleradiology.

Teleradiology Enhancing The Patient Satisfaction and Quicker TAT for Referring Physician

Once upon a time, teleradiology was considered as a fragmented and interrupted experience where the images, texts, and speeches were getting delivered on a different medium. And the poor communication between the referring physician and teleradiologist might have resulted in confusion in the patient’s mind or the high cost or undesirable clinical outcomes.

Currently, technological advances have revolutionized the way teleradiology is conducted and is contributing to quality healthcare service delivery. Today, teleradiology represents the integration of the many advanced multimedia technologies which supports the upload/download of reports along with other necessary support documents (other than radiological images), display of images (multiple viewing/screening options), tools for image annotation, image/report archival and retrieval, communication between the group/team, audio reporting and its conversion into text report are some of the important features facilitating the remote reporting equivalent to real-time reporting.

At present, Teleradiology addresses the key concern of the referring physician – accurate report at the earliest with the provision of communicating with teleradiologists in real-time.

These concerns get addressed and benefit him in multiple ways.

Benefit of Support from the extended team during the deciding moments becomes crucial for those who are based in healthcare centers where the radiology department works in stipulated working hours or patients are referred to other centers for radiology services. In such a scenario, the treating physician is benefitted by receiving accurate reports within the decided TAT and can interact with the teleradiologist for further clarification. Overall, the referring physician has an extended team outside his team (employed/assigned team) to support him in providing quality patient care and on whom he can rely during his crucial deciding moments.
Benefit of 24 x 7 Reporting services empowers the referring physician in providing quality patient care round the clock without any delay. This benefits the physician as well as patient in saving the time and cost, the shift of patient to emergency service and unexpected situation.
Benefit of Expert Opinion when an ambiguous situation. A qualified and expert panel of subspecialists can support the referring physician in more than one way – correct diagnosis, prognosis, and working out the appropriate treatment plan or in understanding/monitoring the treatment outcome. This works wonders for the multispecialty hospitals who need the subspecialty reporting and expert opinions for critical cases additional to their regular radiologist’s reporting; especially in cases of Orthopaedic, Neurology, Oncology, Paediatric or Emergency to name a few.
Benefit of Remote Reporting has brought about a paradigm shift in the quality of patient care extended in primary or secondary care centers located in tier 2 / 3 towns or geographically challenging locations. Teleradiology has built a connection where referring physicians can interact with the reporting teleradiologist in real-time. As a result, Referring Physician can inform the patient about the criticality of the patient in emergency cases and guide the patient in taking appropriate action or referring a patient to comprehensive healthcare centers at right time.
Benefit of Selective Reporting services is an option where the referring physician can choose from different types of teleporting services based on the need; like during the absence of regular radiologists due to holiday/weekend / off-duty / night-time. The different services available to opt for are night call reporting, weekend reporting, overload reporting, vacation reporting. All these selective options are available to ensure patient care without any delay.
Benefit of Answers to the queries of Patient which helps in building trust. Many times, the internet-savvy patient from the metro and tier 1 town throws a series of queries for a better understanding of the situation and for taking appropriate action (shift to a specialty center for surgery/treatment). The patient’s interaction with the reporting teleradiologist who has given the detailed imaging report helps in briefing those critical characteristics playing a crucial role in prognosis. The building of trust depends on many aspects and this can prove to be one of the ways.

Cloudex Radiology Solutions empowers the Referring Physician with a winning edge…

Cloudex teleradiology services empowered with its qualified & experienced experts and subspecialty teleradiologist extends the benefits of technologically advanced infrastructure (RIS-PACS) supported with interactive multimedia components, advanced visualization, and communications (voice message/text/messenger app-based communication, etc.). All these features help in low TAT, quality reporting, and increase the Physician’s satisfaction and confidence with service resulting in effective clinical outcome – patient care. In today’s competitive world where the patient is ready to go extra mile for better information, better patient care, better treatment option; Teleradiology empowers the referring physician with that winning edge.

At Cloudex, we support you to have that winning edge.

How Teleradiology Can Help Early Management of Acute Stroke

Dr. Shriram Varadharajan, Consultant Neuroradiologist (Neuroimaging & Stroke)

Awareness of stroke and immediate arrival to the hospital plays a major role in its treatment and recovery. Unlike acute coronary syndrome (ACS – heart attack) where pain plays a prominent role in patients presenting early, stroke patients ignore the negative signs such as sudden onset weakness or numbness. Often minor stroke or TIA (transient ischemic attack) serves as a warning for subsequent major stroke (CVA – cerebrovascular accident). Stroke patients need to complete timely evaluation with various imaging tools. Treatment decisions in acute stroke require ultrafast imaging. It should be performed immediately after clinical triage and emergency stabilization of the patient.

Imaging starts with the very basic question of differentiating Ischemic (clot in the vessels supplying the brain) from Hemorrhagic stroke (bleed) using a simple plain CT scan. Ischemic stroke patients may be given an injection called intravenous thrombolysis (IVT or clot lysis). Plain CT aims to exclude hemorrhage and established large infarcts which are contraindications to intravenous thrombolysis. Additional findings such as hyperdense vessel sign and ASPECTS are helpful to decide on endovascular thrombectomy. Further vascular imaging (imaging of the blood vessels – CT Angiography) is used in Ischemic stroke to detect patients with large vessel occlusion (LVO) i.e. clot inside larger blood vessels. They may need additional emergency endovascular thrombectomy (EVT or clot removal) using advanced catheter-based techniques in DSA (cath.) lab.

These treatments are currently offered to patients presenting within narrow time windows of stroke onset (3-4.5 hours for injection – IVT and 6 hours for cath. lab – EVT). CTA involves evaluating routine angiography and additional venous/delayed phases, regarding the site and presence of LVO as well as to estimate collateral status.

However, few patients who arrive late (beyond 4.5 to 6 hours and till 16-24 hours) can also be treated based on their imaging if we can identify salvageable penumbra (affected brain parenchyma but without permanent damage) using advanced imaging techniques that analyze brain parenchymal perfusion.

All of these decisions can also be taken collectively and more accurately using MRI. Ultrafast Stroke MRI takes less than 20 minutes using limited protocols and involves basic sequences as well as Angiography. MRI in acute stroke can be done without having to administer intravenous contrast and is especially very useful in differentiating from other mimics. Parenchymal and vascular information both can be obtained. MRI involves DWI for infarct core and MRA for LVO while FLAIR mismatch can be used for IVT in stroke patients with unknown time of onset or wake-up strokes. SWI can help detect thrombus/clot burden in RBC rich clots and serve as a penumbral marker by demonstrating vessels with raised oxygen extraction.

Teleradiology can thus be very effective in acute Stroke if reporting can be accelerated to avoid time delays. Simplified reporting formats can be developed based on local logistics. Although CT and CTA are widely practiced in acute stroke, MRI provides a non-contrast one-stop solution in the emergency especially if reported immediately by dedicated, trained tele-stroke Radiologists. Structured reports for such time-based emergency situations like acute stroke help avoid medico-legal consequences especially in the era of evidence-based medicine and helps guide the referring physicians in making treatment decisions.

References

1. Varadharajan S, et al. Computed tomography angiography in acute stroke (revisiting the 4Ps of imaging). Am J Emerg Med. 2016 Feb;34(2):282-7

2. Varadharajan S. ASAP In Stroke Imaging – Need to Simplify and Standardize in Emergency. Accepted for publication in Neurology India

Quality in Teleradiology Reporting

“Quality is the extent to which the right procedure is done in the right way at the right time, and the correct interpretation is accurately and quickly communicated to the patient and referring physician.” Hillman et al

Teleradiology is playing a crucial role in delivering patient care with its prompt and quality service.

The quality of radiological reporting depends on multiple parameters apart from the internal review and external feedback system like

Communication between the reporting radiologists and referring physician for better understanding of the case

PACS and workflow management

Operational team (CTC)

Access to reporting tele-radiologist for clarification / discussion

The Internal Parameters can be listed as –

1. Internal Quality Assurance Team sets up an auditing system involving methodology on random review of the reports and peer reviews at regular intervals. The key performance indicators (KPIs) are prepared by the team in alignment with the organization’s objective and external auditor’s standards (if involved). The experts evaluate the reporting by carrying out random double reporting, peer review, and discuss the discrepancies with reporting radiologists.

Evaluation of the discrepancies, formulation, and implementation of corrective measures followed by evaluation of implementation is a cyclic process in order to improve the quality of report and service delivery. The option of contacting the reported tele-radiologist for further clarification and discussion on prognosis is available.

The new recruits are initially engaged in preliminary reporting for familiarization with the tele-reporting system and are supported with constant review and feedback. This also involves eLearning, teleconferencing, telemedicine, and other technological processes.

2. Procedure Protocol indicates the Right Procedure & Right Way which impacts many other parameters. The protocol includes a checklist drafted by the team on imaging procedures, image uploading/transfer, availability of support documents, defined TAT for emergency & regular cases, filled request form, to & fro communication between the referring physician and reporting radiologists, assigning of images to radiologists, etc.

3. Credentials of the tele-radiologists including the sub-specialization and experience per se augment the value of the report. In critical cases like emergency / STAT reporting, the unique skill of picking up the hidden markers in a short time plays a critical or decisive role. Their clinical focus in reporting improves referring physician’s proficiency to advise or decide on suitable investigations/management of patients.

4. TAT is variable and crucial for referring physicians in taking control of the situation, be it for emergency or regular cases. Today, because of the technological benefits, the TAT for an emergency case is approximately less than 30 minutes whereas for any inpatient or outpatient 4 to 8 hours is maintained. Especially in teleradiology, the other factor which determines the TAT is mutual agreement between the service provider & referring center and considering cost factor as well.

5. Miss Rate is determined by continuous reviewing of reports at regular intervals by the review panel and a lot of measures are undertaken to keep it low. The positive culture of the review panel establishes an environment that is instructive, supporting cognitive debiasing and retrospective analyses. Clients are also encouraged to report “misses” by categorizing them based on their implicating severity. Feedback and discussions with referring physicians help in the process.

The External Parameters which can be considered are

1. Client’s feedback system serves two purposes – understanding the quality of report and reporting services although both (service provider and referring center) would have laid down the SOPs to be followed at either end. The upload of images of other recently conducted investigations, along with other laboratory, pathology reports and previous documents like discharge summary / clinical and operational notes helps in the accurate and detailed interpretation of the images.

2. Accreditations by the authoritative body confirms compliance with protocols set by the authority matching the industry requirement and benefitting every stakeholder. Inspections are conducted to check the protocol implementation and service delivery at regular intervals and the certification is renewed accordingly. If any discrepancy is noticed, a Plan of Correction (POC) is provided with the timeline for implementation.

Cloudex Solutions ensuring the right procedure, the right way, right time, and correct interpretation

A team comprising of qualified experts like radiologists, clinicians, and technologists who are well supported with state-of-the-art RIS PACS technology, round the clock (24 x 7 x 365) reporting services complement to the client’s advantage. The objective of doing the right thing at right time in the right way is achieved by integrating programs to adhere to protocol, utilize the quality improvement tools, and conduct of skill up-gradation workshops.

Cloudex brimming with experts and a wide range of tele-reporting services ensures delivery of the correct interpretation at right time in the right way; enabling the healthcare service provider to deliver quality patient care without delay and assuring proper treatment saving on time and money.