We live in a highly connected global village where the Internet has made remote healthcare widely available round-the-clock. Teleradiology, an important part of telemedicine, involves remote diagnosis through digitized images and remote advice. The process has been beneficial to a majority of the world’s population, as it balances out the maldistribution of radiologists the world over. Used in war-torn areas, outer space, on board ships, and in Antarctica, teleradiology, however, leaves some questions unanswered in the milieu of its operations in India and elsewhere.

Lakshmi Gopal of Medindia spoke to Dr Sumer Sethi, MD, Sr Consultant Radiologist at VIMHANS, Delhi and Director of Teleradiology Providers, a unit of Prime Telerad Providers Pvt Ltd. An author of many academic papers and books on radiology, Dr Sethi specializes in musculoskeletal and neuroradiology.

Q. What is telemedicine and teleradiology all about and why are they important?

A. Teleradiology is the process of transmitting and receiving digital radiology images comprising of X-ray, ultrasound, MRI, etc., from one location to another through a secure digital network. The images are transmitted using advanced computer systems, typically over the Internet. Through teleradiology, images can be sent to another part of a hospital, or anywhere in the world. It is a means of electronically transmitting radiographic patient images and consultative text from one location to another.

Q. How is teleradiology important from the consumer’s point of view? Does it bring down costs and improve diagnosis?

A. Teleradiology brings the best medical opinion available to the consumer’s doorstep. The consumer does not have to travel long distances to big cities with medical infrastructure. He can avail of expert opinion and quality reports in his remote hometown, saving on the costs of travel and accommodation. Teleradiology also helps the patient secure diagnostic reports in 30 minutes’ time nowadays, enabling faster treatment.

Q. What is the Medical Council of India’s stand on teleradiology as a form of practice in India?

A. The Medical Council of India currently does not have any specific guidelines for telemedicine. Therefore, the standards applicable to radiologists are also used for teleradiologists.

Q. What do you foresee for the future of teleradiology in India in terms of demand and supply within the country and outside?

A. The demand for radiologists is great in India and abroad - they are, however, in short supply. Teleradiology helps adjust this imbalance. India has a lot of talent and our doctors have emerged as one of the major providers of teleradiology services in the Indian subcontinent, the US, Africa, and the Middle East. Here, I must mention my company - Teleradiology Providers. Its key strength is that we have extensive experience working across both public and private hospital facilities. We have sub-specialist abilities and experience in the areas of neuroradiology, breast and cardiac imaging.

We also provide our own customized teleradiology software along with a dedicated web-based server platform and have the ability to link up with any centre in the world irrespective of the Internet speeds available.

Q. Teleradiology raises interesting ethical and practical issues. These include patient confidentiality, data security and image authenticity. How should these issues be tackled?

A. Teleradiology is a globally well-accepted method of radiology report delivery, and its systems and processes are usually governed by standards like the Digital Images in Communications and Imaging (DICOM) version 3.0, 1993 and the US Health Insurance Portability and Accountability Act (HIPAA) 1996.

All healthcare organizations must make sure that their teleradiologists are sensitized to the issues of patient confidentiality and data security. Teleradiologists, even when they work from remote locations, are basically responsible doctors and must keep their patients’ records confidential.

There is a chance of data security being compromised when teleradiologists use an email facility to support reporting - this should be avoided.

Image authenticity becomes an issue when a teleradiologist uses a jpeg image for reporting, instead of a DICOM image. The DICOM format for images gives clearer pictures and is ideally suited to radiology.

Q. How can accuracy of reporting be increased?

A. For accuracy of reporting, it is better if the same chest X-ray or mammogram is shown to two radiologists. The practice followed in medical colleges is that radiology reports are usually double or triple read - first the junior resident reads it, then the registrar, followed by the faculty member, who has the final say.

It would definitely make sense to follow such best practices and have standard double reads of reports to increase accuracy and cut down on ambiguity.

The computer may play a significant role in this area in future - recognizing patterns that could be later super-read by radiologists. This will increase efficiency and reduce the margin of error in spotting a significant issue.

Q. There are many teleradiology companies making the same claims of quality and efficiency today. Who do you think will survive the rat-race?

A. In the long term, only players with competent and quality systems in this field who follow all standard Internet security protocols like DICOM and HIPAA will survive.

Q. If there is an error in diagnosis, who shares the responsibility in a court of law?

A. Here, the same law applies, as onsite reporting. Teleradiologists take full responsibility for error in diagnosis in a court of law. In our company, teleradiologists take full responsibility of their work - they carry their own indemnity insurance. Further, our performance improvement program continuously monitors quality and performance parameters, ensuring an ongoing analysis of workflow and turnaround times, random quarterly audits of reports, and statistical reviews of important events with our chief radiologist.

Q. What is super cloud computing technology? Will it be able to afford low-cost diagnosis? What are the new techniques prevalent in teleradiology in the west? Have they reached India?

A. Super cloud computing can help store and share data, and connect more easily without large capital expenditures. It offers a platform for better scalability and flexibility. In our industry, the ability to work with large volumes of data with greater ease provides benefits beyond better scalability and cost savings - it makes a difference in patient care. With a cloud-based solution, images can be shared digitally at different locations.

Benefits for the patient in super cloud computing are that turnaround time is shortened and there are fewer interruptions and breakdowns.

The new technique prevalent in the west has to do with image pattern recognition by computers that the teleradiologist super-reads. This is not available in India yet.

Q. How can teleradiology help patients in remote rural areas in India? How can the cost of treatment come down for the poor in urban and rural areas?

A. It is very unfortunate that while 70 percent of India’s population lives in villages, the healthcare available there is meager. Also, the quality of rural healthcare can hardly be defined as state-of-the-art. As part of its Corporate Social Responsibility drive, Teleradiology Providers have taken the initiative to bring state-of-the-art diagnostics to a rural centre located in Mirpur, Haryana, where we do reporting free of charge.