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5 Influencing Factors in Tele-Radiology Reporting

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Radiology reporting with shorter TAT aided with tele reporting has brought about significant improvement in patient care outcomes in many departments of medical centers. Radiology report plays a crucial role in terms of diagnosis and treatment planning. And sometimes, a few minutes of waiting period feels like long years and one wonders how to overcome those anxious moments of dilemma. Silence prevails on the patient’s side whereas an array of actions happens on the other side for radiology reporting. So, behind the complexity of radiological image interpretation lies an array of actions involving technology, protocols, coordination, communication, expertise which keep happening seamlessly. Many of these are visible in action status at the reporting stations or work stations of radiologists (on-site/off-site).

The radiologist/teleradiologist’s work-station is made up of hardware, software, and appropriate furniture & interiors. Factors like illumination in working space, ergonomics of chair & table to smallest of an object like a mouse which can possibly trigger the discomfort level to radiologists matters in the process. Briefing out these dynamic factors for understanding behind the scene actions in teleradiology –

1. Hardware:

  • The dual QHD monitors of size 21 / 30” diagonally equivalent to a 3 or 5 megapixel are used to view the images and write reports simultaneously. This monitor size reduces the need for repeated zooming in or panning out.
  • CPU with 8th generation, 16 GB RAM, 1GB GPU memory to match the speed of the image interpretation process of the radiologist.
  • V shaped keyboard and optic mouse with a scroll which contours the fit into adult hand providing the ergonomic posture for convenient working.
  • Bluetooth enabled headsets helps in audio and dictation.

2. Software:

  • PACS provides seamless transmission of images in correct order along with other required supporting health documents.
  • DICOM calibration to meet the DICOM standards which ensures the image displayed is perceptually linearized. This software also provides alerts for out-of-compliance issues through emails/notification.
  • Notification system alerting the radiologists on an upcoming critical case that needs urgent attention, TAT alarm, call out from other physicians for case discussion/clarification.

Communication platforms contribute in an immeasurable manner. The interaction between the reporting teleradiologist and referring physician is crucial and is a deciding factor and lifesaving in many cases. The alerts/notification / textual or audio messages etc have added speed to the reporting system.

  • TAT enhancing voice recognition services add lot of value to teleradiology services. It enables teleradiologist in engaging more time in image interpretation and sparing them from initial drafting of reports with features like Real-time self-editing, formatting, auto-punctuation, and electronic signature. It works as workflow accelerator helping in completing the greater number of image reporting in given time frame.

3. Furniture & Interiors:

  • The versatility of working space supports the radiologist’s long working hours. The ergonomics of the furniture like height of a table, lumbar supporting chair with adjustable seat height are important for comfortable viewing and reporting. This subtlety adds in promoting alertness and efficiency.
  • Luminance is given special care so as to safeguard radiologists from ocular distress and physical strain. The minimum standards of 350 ccd/m2 is maintained.

4. Connectivity & Server: Speed is the vital part because a lot of activity depends upon it – transmission, downloading, and storage-related rendering or archival of images, interpretation, and reporting of images.

  • A dedicated reliable high-speed internet connectivity is maintained. The minimum required internet speed is 512 KBPS-1MBPS whereas the speed of 4-8 MBPS is considered ideal enabling a smooth process for interpretation & reporting, and desirable speed is above 25 MBPS for interpretation of large image data set.
  • The whole process is supported through cloud computing or a quality-controlled web server

5. Cybersecurity: The infrastructure of PACS & DICOM are build keeping in mind the various guidelines provided by HIPPA/FDAs which are further integrated or upgraded with mitigation measures decided by the Teleradiology companies as company policy or SOP decided upon with their clients. Some of the well-known measures are selective encryption of the DICOM header/files, transport security, image de-identification, water-marking or digital signatures, and access to the system thru assigned user ID/password, etc.

Cloudex’s user-friendly work stations delivering customer satisfying results

At Cloudex, reporting stations are configured involving lots of detailing to ensure that teleradiologists are able to concentrate on interpretation and reporting without any distractions/interruptions and operational issues. The reporting platforms are integrated with various software like voice-recognition dictation, multimedia communication, notification apart from the latest PACS & case managing RIS. Importance is also given to illuminance, work-space comfort, sitting ergonomics, monitor configuration for maintaining teleradiologit’s optimal concentration and efficiency. We invest beyond infrastructure too for creating a conducive environment that is free from administrative burdens or logistical hurdles for teleradiologists. The organization’s emphasis on accuracy of reporting without a miss at required TAT facilitates in winning the confidence of referring Physician and scoring high on service satisfaction score.

Cloudex with its wide range of teleradiology services – Emergency, Subspecialty, Nighthawk, Round-the-clock, Weekend / Holiday, Second Opinion; enables the referring physician or medical center in having an edge of being quick, effective, and efficient in delivering patient care. At Cloudex, we support you to have that winning edge.

Teleradiology

Role of CT Chest and Teleradiology for 30 Minute Report in Current COVID-19 Pandemic

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India is going through a grave crisis with a rising number of Covid cases. People are deprived of timely medical care due to an overwhelmed health care system. People are dying in ambulances and waiting areas for want of beds and essential life support. Health care facilities are facing difficulty in triaging the patients and deciding on whom to treat first. RT-PCR and antigen tests are recording high false-negative rates and there is an inordinate delay in getting the test reports too, which is adding to the delay and confusion in care delivery.

It turns out that the majority of casualties are due to viral pneumonia which is resulting in low blood oxygen saturation levels. Timely diagnosis of the lung pathology and grading of its severity can help save the lives of many. Unfortunately, the endless wait for a diagnosis of Covid by RT-PCR / antigen to decide on hospital admission has taken many a life. There are instances where a breathless patient diagnosed with Covid like pneumonia with CT chest given a score of almost 30 percent of lung affected had to wait for her RT PCR result which came negative twice after waiting nearly 48 hours each time around to get admitted in a hospital. Her wait ended when a hospital agreed to admit her to their SARI (Severe Acute Respiratory Illness) ward despite her RT PCR negative status, but unfortunately, it was too late and she succumbed to the savage virus.

There are innumerable similar deaths happening in all the badly hit cities of India. Hospitals are not able to decide whether to admit or not and if admitted, to the Covid care ward or the non-Covid one. A few hospitals thus decided upon setting up a ward for the breathless and named it SARI (Severe Acute Respiratory Illness) ward like in the case mentioned above. Still, there was a confusion on admission criteria when the Union Health Ministry in its revised national policy for admission of COVID-19 patients on 8th May said “A suspect case shall be admitted to the suspect ward of COVID Care Centre (CCC), Dedicated COVID Health Centre (DCHC) of Dedicated COVID Hospital (DHC) as the case may be,” in the directive to all the states and Union Territories and that no private or government hospital shall deny admission/care to any patient and that positive coronavirus disease (Covid-19) report is no more mandatory for admissions.

The relevance of a CT chest cannot be emphasized more in the current situation. A CT Chest in the symptomatic patient can quickly assess the lungs and with the help of CORADS score can determine whether the lung is affected or not and classify the disease into non-Covid / low/high possibility of Covid pneumonia. A CT Severity Score of 0-25 out of 25 in the meanwhile can grade the lung involvement into mild (<30%), moderate (30 – 60%), and severe (>60%) disease. The radiologist can quickly assess the CT chest according to these criteria and issue a report, and the quantitative report greatly aids the treating physician to triage the patients and prioritize admission and treatment delivery.

In the current pandemic scenario, the Turn-around-time (TAT) of any diagnostic test (imaging, laboratory, or pathological) plays a crucial role in diagnosis and saving a life. The highly virulent strain of COVID is playing its trick with widely conducted RT-PCR but gets caught in CT Chest. While RT-PCR results are taking up to 48-72 hours at many places due to the unmanageable load, CT chest reports are delivered in less than an hour and are helping physicians in faster diagnosis, prioritization of admissions, and treatment plan for the sick and high-risk patients with comorbidities.

The Healthcare system is facing multifaceted challenges, the biggest one being the shortage of staff and expertise. Hospitals and diagnostic centers are looking for support in a quick, accurate diagnostic process with an unmanageable number of cases every hour. Teleradiology is capable of providing the required support in reporting the large numbers in less time irrespective of the system’s location (urban/rural). Simultaneously serving multiple centers, each teleradiology system has its own team of radiologists and TAT management protocols wherein reports are delivered in promised time despite the large volume.

The teleradiology service providing consistency, shorter TAT, and quality reports benefit the referring physician- aids in diagnosis and guides treatment plan; develops a strong relationship with its client resulting in delivery of quality patient care with high patient satisfaction score. 

We at Cloudex have absorbed the gravity of the situation and are working 24*7*365 doing our best to help and serve the country’s healthcare system in this crisis. Our promise to the needy is a report within 30-45 mins for every suspected Covid CT Chest.

Cloudex Radiology Solutions delivers shorter TAT than agreed upon … benefiting referring Physician’s quick action.

Cloudex’s team including administration, operation, and teleradiologists are encouraged to develop a close relationship with the client’s team for familiarity and communication comfort; resulting in delivery of reports within TAT bundled with quality and accuracy. Here, strategically knitted workflow incorporated with advanced technology and expertise ensures the shortest TAT without compromising on the quality that serves & impresses the clients. 

The team also emphasizes performance measures, report quality, communication with the referring physician apart from TAT which contributes to the partnered client’s undivided focus on patient care delivery. These efforts of both teams help in remaining competitive and having a winning edge in demonstrating value-based service delivery.

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

Teleradiology Kannur

The Whistle That Never Blew: Real-Time Communication Between Teleradiologists & Referring Physician Aids Diagnosis and Quick Clinical Decision

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40-year-old Rani (name changed) in Kerala (Southern state of India) had a Barking cough along with episodes of breathing problems. Many times, had consulted many physicians to get relief from her racking cough which used to get aggravated during the winter season. This year Rani consulted a pulmonologist who listened to her medical history patiently and advised her for a chest CT. The Radiologist who was seeing the CT image had doubts of history and finding mismatch and discussed it with a pulmonologist then reported the presence of a metallic foreign body, and she got referred to a tertiary center with a Bronchoscope facility. The lodged metal (whistle) got removed, and it shocked Rani. She remembered her childhood whistle incident and got relieved to breathe with ease. Whistle… a fun toy brings in many tangy fun-filled childhood memories. And seeing the metal whistle, remembered that she had swallowed one in her childhood while playing with her friends. Scared of getting a scolding from her parents, she drank loads of water to dislodge it and remained silent about the whole incident with her parents. And with progressing time, this incident faded away from her memory. But the lodged whistle did not remain silent. It kept causing.

Many hidden subtle factors have played a crucial role in restoring the easeful breathing of Rani.

  • The multiple one-to-one communication between pulmonologist and teleradiologist benefited both caregivers. 
  • Teleradiologists‘ experience and the back-and-forth interaction with pulmonologists helped in the identification of the abnormality as a foreign body and encouraged the pulmonologist to refer the patient to a tertiary center for removal of the foreign body. 
  • The communication between the pulmonologist and endoscopy surgeon at the tertiary center resulted in the successful removal of the impacted whistle and smooth recovery of the patient. 

The information related to medical history, current illness, physical examination findings, and other diagnostic investigational reports helps the teleradiologists in providing the referring physician with accurate diagnosis and thus helps decide on an appropriate treatment plan with their interpretation. They make deliberate attempts at avoiding any underrating or overlooking of certain possibilities. 

Today, programmers, system designers, and developers have incorporated multiple modes of communication (voice/video conferencing like face to face, text or voice messages/chatbox, emails, etc.) into PACS. The different verbal and written communications have enabled the possibility of instant and face-to-face interaction breaking the anonymous barrier aiding the collaboration and understanding between the referring physician and teleradiologists; eliminating the assumption of nameless/faceless association between the distanced healthcare providers. 

Good, effective communication is an integral part of good patient care. The contemporary gadgets, programs & systems have enabled a faster, reliable communication platform adding value to the caregiver and patient relationship resulting in higher scores of patient satisfaction. Effective communication of referring physicians with his patients ensures a better understanding of the clinical situation facilitating better decision-making by patient / supporting family members and their involvement in treatment management. 

Cloudex Radiology Solutions communicates with Referring Clients aiding diagnosis and clinical decision …

“I want to express my gratitude to Cloudex and Drs. because of whom all this was possible …” 

Whatsapp messages received to express thanks by Rani’s Pulmonologist says it all.

Our team of experienced, qualified & expert Teleradiologists and PACS administrators understand the significance of communication and work closely with referring client’s team.

Various initiatives incorporated for communication are as follows:

  • The protocols are customized based on the type of imaging modality, involved body parts, and the patient’s critical condition. 
  • Ensuring receipt of various information along with image transfer for a better understanding of situation/interpretation and saving on TAT.
  • The administrators managing the advanced PACS are quick in attending to the queries raised by reporting radiologists and coordinate with the referring client’s team, especially in cases of emergency.  
  • The Teleradiologists raise the red flag to get either the additional information from the referring caterer for a better understanding of the situation from the referring Physician.
  • If needed, textual/verbal communication is facilitated between the reporting radiologists and referring physicians for the achievement of the desired goal – delivery of appropriate patient care. 

The whistle removal story whistles loudly that communication is the key to the success of a team. Here everyone- patient, tertiary center, pulmonologist, and teleradiologist succeeded. The communication between the pulmonologist and teleradiologist improved the working relationship between these care providers and helped the referring physician inaccurate diagnosis and planning of further care, thus gaining the confidence and satisfaction score of patients as winning edge among his peers. 

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

Teleradiology Proves as a Reliable, Efficient and Economically Viable Services for All Stakeholders

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The discovery of Radiology by Wilhelm Roentgen, Professor of Physics at University of Wurzburg, Germany in 1895; has revolutionized the way trauma and illnesses are diagnosed and treated. Today, Radiology is not only aiding the diagnostic skills of the physician but also used for quantitative measurement of anatomic and functional processes, image-guided invasive interventional procedures, and an assessment of functional / performance of the organs.

Technology and Teleradiology:

Teleradiology integrated with advanced technology is capable of delivering rapid, reliable, real-time healthcare services without any delay/interruptions irrespective of the geographical limitations and access to specialized reporting services. The digital radiological images are compatible to be viewed on different electronic mediums (electronic monitor/display, note pads, mobile). The radiological image reaches the Radiologist’s workstation without any subsequent intervention for enhancement and review. Various software (PACS & DICOM standards) and hardware support the whole system in maintaining the quality of the image during the process (acquisition, transmission, storage, retrieval); and different compression techniques are employed to contain huge data and maintain the integrity of the digital images. Healthcare service delivery with quality, promptness, correct diagnosis, and appropriate treatment adds to the patient’s satisfaction. This whole system encompasses reliability, efficiency, and economically valued services for every stakeholder.

  • Reliability: The protocols, technology-based systems, and multimedia-driven communication channels have made Teleradiology one of the reliable medical services. The other contributing factors are quality of reports, access to a range of tele-reporting services (nighthawk/subspecialty / after-hour services/emergency / second opinion/weekend), experiences and expertise of the radiologists. And this reliability is intangible. It supports the referring physician or emergency department in real-time similar to on-site radiologist whereas for the centers (primary/secondary) present in rural or in geographically challenging places (for e.g., mountain terrains) it provides the physician in delivering medical care without any delay, helps the patient in deciding on transfer (trauma/emergency) or shift to a tertiary center, and encourages the efficient use of the healthcare facilities. 
  • Efficiency: Time is a crucial factor in patient care delivery. Teleradiology contributes to it by enabling Physician to take important decisions and delivering prompt services. It improves the Emergency department’s capacity & throughput whereas, in multispecialty tertiary hospitals, it works out as an alternate coverage for after-hours / vacation/weekends and plays important role in clearing the department’s stack. Teleradiology enhances the efficiency of healthcare centers (Secondary / Primary / Diagnostic centers) by facilitating patient care without delay, providing access to subspecialty reporting, handling postoperative complications, and reducing the readmission rates.
  • Economical, low-budget solutions with high value for money have been encouraging and are one of the main reasons for constant transformation and adaptation of teleradiology in line with the technology and demand in medical services. Every stakeholder, be it patient or hospital management or radiologist or treating physician gains reasonably from Teleradiology. The satisfied patient adds a competitive and winning edge to serving medical facilities.  

–     Clinically, the Physician is able to gain patient confidence and satisfaction by delivering prompt patient care with accurate diagnosis and appropriate treatment.

–     Radiologists are able to manage better work-life balance and have networked with sub-specialty radiologists.

–     Hospital management wins in multiple ways; efficiently provides medical services round the clock, handles emergency / critical cases without added costs or overheads, delivers patient care without any delay/interruption. And thereby succeed in achieving popularity with word-of-mouth promotion through satisfied patients.

–     Patients are the ultimate beneficiary of this whole system with prompt medical care which not only saves time and money but also lives. Availability of imaging reports at once provides an option to decide on many things like treatment plan/necessity to travel or shift to a specialized center, organizing fund, and emotional support.

Cloudex Radiology Solutions backs the quick TAT with reliability and efficiency…

Cloudex’s panel of qualified, experienced, and expert teleradiologists are capable of providing the interpretation of the radiological image with accuracy and profoundness in details that aid in the revelation of the underlying cause of abnormalities. Our team stands up to the statement on quality as briefed in Radiographics, 2011. 31(6): p. 1511-27 – “Quality in radiology is multi-dimensional and includes measuring, monitoring and improving various aspects of the workflow, including examination appropriateness, procedure protocol, the accuracy of interpretation, timely communication of imaging results as well as performance improvements in safety and efficiency”. We, at Cloudex work with the hospitals / diagnostic centers as a team in ensuring quality patient care from the point of entry, through scan to report delivery by involving the reporting radiologist at each stage ensuring the right protocol, adequacy, and safety of procedure while delivering the accurate interpretation within expected TAT.

Cloudex along with its reliable and efficient team delivers teleradiology services and helps its referring physician or medical facility in winning more satisfied patients as a winning edge in this competitive field.

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

Screening Mammography

SCREENING MAMMOGRAPHY

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Mammography is an  X-Ray of the breasts carried out on a machine dedicated to it because the breast is not of uniform thickness and requires a dedicated unit. It is conical in shape, narrow in the region of the nipple. The tissues need to be flattened to separate them & achieve better visualization. Moreover, the breast moves with respiration and needs to be fixed. Hence, compression is applied to the breast resulting in a little bit of discomfort for few seconds. The compression results in the reduced thickness of the breast and the radiation to the breast are decreased. The benefits of mammography far outweigh the slight discomfort.

When mammography is carried out on an individual without any symptoms, it is called screening mammography whereas if carried out on an individual with symptoms, it is called diagnostic mammography in which additional views have to be carried out. 

With the advancement in technology and the world going digital, mammography machines are now digital. Hence, mammograms carried out anywhere can now be viewed by expert breast radiologists in any part of the world thanks to teleradiology. The scans can be viewed & reviewed very easily & comfortably from anywhere, which is a huge benefit. Considering the lockdowns during Covid times where one couldn’t travel, this makes it so comforting for patients to get their mammography at a local setup and get an expert from any part of the world to give an opinion on it. It saves a lot of time, money & effort.

Breast cancer like many other cancers is a silent painless disease and by the time it becomes a palpable lump, it is fairly large in size. Early detection leads to a reduction in morbidity & mortality and more options of treatment. Hence, screening mammography is important as it can detect cancer before it becomes palpable.

At times there is no mass palpable and microcalcification is the only sign of malignancy. Screening helps to detect cancers when they are too small to be palpable as well as the ductal carcinoma in situ. Microcalcifications, the hallmark of breast cancer are detected only on mammography.

Screening protocols vary from country to country depending on the incidence of breast cancer.

In India, for the general population, the protocol is as follows:-

  1. Once between 35-40 years of age. If the breast is dense on the mammogram, an ultrasound must also be carried out.

2. Age 40-50 Once in 2 years 

3. Age > 50 Once in 18 months -2 years if the breast is fatty and annually if dense.

Screening is continued usually till 75 years or till the time, there is the likelihood of life expectancy of 10 or more years.

However, for the high-risk group, screening is more aggressive. Depending on the risk, at times MRI breast is started annually starting at 25 years and mammography at 35.

In the case of 1st-degree relatives of those with premenopausal breast cancer, Screening is started 10 years earlier than the age at which the relative was diagnosed.

For women in the reproduction age group, screening is best done in the immediate postmenstrual phase when the breast is softest and there is no likelihood of pregnancy. Ideally, no talc/ deodorant should be used prior to the test to avoid artifacts. A two-piece dress is ideal for the test which takes less than 10 minutes. Two views, craniocaudal & mediolateral of each breast are carried out which results in global imaging including the axillae. With the new full-field digital mammography machines with tomosynthesis, the information from mammograms is way more than the older machines.

High-risk individuals:

There are risk factors that one can’t change-:-

1. Getting older.-most breast cancers diagnosed after age 50. With advancing age immunity decreases.

2. Low immunity includes diabetes, autoimmune disorders, patients on immunosuppressants & chemotherapy 

3. Inherited gene mutations, such as BRCA1 and BRCA2.

4. Early menarche before age 12 and late menopause post 55 results in prolonged exposure to hormones and increased risk

5. Dense breasts are a risk factor & also result in difficulty in the detection of abnormalities on a mammogram.

6. Prior history of breast cancer or certain non-cancerous breast diseases like atypical hyperplasia or lobular carcinoma in situ.

7. Family history of breast or ovarian cancer.  Risk is high if a first-degree relative or multiple maternal/ paternal family members with breast or ovarian cancer. A first-degree male relative with breast cancer also raises a woman’s risk.

8. Prior H/O radiation therapy to the chest or breasts ( say for Hodgkin’s lymphoma) before age 30.

9. Diethylstilbestrol (DES), given to prevent miscarriage raises the risk for the woman & her daughters. 

10. Pollution & adulteration

Risk Factors one Can Change:-

  1. Sedentary existence

2. Obesity with increased abdominal circumference.

3. Hormone replacement therapy & oral contraceptives 

4. Having the first pregnancy after age 30, not breastfeeding, and not having borne children raises the drink

5. Smoking & drinking.

6. Stress- combat it through yoga, exercise, and meditation.

Have you got your screening mammography done? If eligible for it and you haven’t got it done, PLEASE DO IT NOW.

Author:

Dr.Padmavati Dua

Erstwhile Senior Consultant

Diwan Chand Aggarwal Imaging Centre, New Delhi 

Yashoda Hospital, Kaushambi, Ghaziabad 

Col. Pant’s Imaging Centre, Green Park, New Delhi

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