The use of ultrasound in teleradiology-also called telesonography-has not been extensively covered in the radiology literature, but it is of growing interest to radiology groups.
Since the initial wave of adoption in the mid-1990s, ultrasound miniPACS have been credited with reducing the costs of film, processing, and storage. They are also said to expedite workflow and enable radiologists to expand the scope of their practices. A 1998 study at Duke University compared the accuracy of film and soft-copy interpretations for 440 sonograms and found no statistical differences in rates of error (AJR 1999;173;1175-1179).
With diagnostic teleradiology links to ultrasound miniPACS, physicians, particularly ob/gyns, can obtain an expert consultation while the exam is still under way. This not only can expedite immediate treatment but may save the cost of additional exams at a location where a specialist works. This streamlined exam, interpretation, and treatment process can enable all physicians involved to provide better patient care.
Two sites that have installed ultrasound miniPACS and had positive experiences are the University Hospital of Arkansas and Kaiser Permanente Northwest.
A joint endeavor to provide better care to ob/gyn patients by physicians affiliated with the University Hospital of Arkansas in Little Rock led to the purchase of an ultrasound miniPACS. The ob/gyns serving the hospital also operated a private practice at a nearby University Hospital-affiliated outpatient clinic. A full-time sonographer had been hired, but a radiologist was only at the facility one day a week when complex and difficult cases were specifically scheduled. The ob/gyns were interpreting exams the rest of the week, but a formal archiving system had not been implemented.
In 1996, the two practices jointly funded the purchase of an ultrasound miniPACS and diagnostic teleradiology system linking the Women's Health Center in the Freeway Medical Center with the radiology department at the hospital.
From the outset, both groups recognized the ease of consultation that such a system connected by a dedicated T1 wide area network would provide, said Dr. Teresita Angtuaco, director of imaging at University Hospital. The radiology practice had only two ultrasound specialists, with support from three other radiologists specializing in body imaging. Yet the outpatient clinic showed a clear need for radiology services five days a week. Diagnostic teleradiology met this need.
Before the installation, the clinic had had to reschedule a high-risk patient at the Women's Health Center for a follow-up exam on the day when the radiologist was there. Using the diagnostic teleradiology system, it has become possible for the radiologists at the hospital's imaging department to look at the images as they are being generated and provide an immediate professional opinion.
"Normal cases are read at the clinic and in the hospital's ob/gyn department by our four maternal fetal medicine specialists," Angtuaco said. "The radiologists are contacted for difficult and abnormal cases. The patients are pleased they do not have to return for another exam, and an immediate interpretation facilitates patient treatment. Everybody involved benefits."
Although there have been no formal evaluations of workload efficiencies or cost savings, the ultrasound miniPACS has made the practice of medicine much easier for all the physicians, according to Angtuaco. The overall case load of ultrasound exams has almost doubled since 1996 with no accompanying need to increase the number of radiologists or maternal fetal medicine specialists. Approximately 98% of the exams are filmless, all of them available for review by any physician who needs to see them. Since fetal ultrasounds must be stored for 21 years, the fact that a year's worth of exams can be fit into a space the size of a shoebox is likely to bring cost savings as well.
Because of the success of the diagnostic teleradiology link, additional ones have been added both at a family practice clinic about 10 miles away and also at Arkansas State Health Department Clinic about half a mile away. There, a daily ob/gyn clinic is held, and the radiologists provide real-time consultation from the imaging department.
"There was not enough of an ultrasound case volume requiring the services of a radiologist to justify our on-site presence there," Angtuaco said. "Yet some cases need immediate radiology interpretation. The system eliminates the time it would take to go to the facility and return."
Angtuaco's dream is to have the University Hospital and Women's Health Center better serve the geographically dispersed high-risk obstetric patients who come to see its specialists. High-risk patients travel up to three hours to see specialists. While undergoing an exam in the local physician's office, many of these patients could be examined remotely by ob/gyn specialists and the interpretations provided by radiologists via teleradiology. What prevents this is the lack of high-speed, low-cost telecommunications connections. With the implementation of next-generation Internet technology, her dream may become a reality.
Kaiser Permanente Northwest, an HMO with 445,000 members, covers a 100-mile region along the Interstate 5 corridor from Salem, OR, to Longview, WA. Members requiring hospitalization are served by a Portland-based hospital, which does a large volume of inpatient and outpatient imaging. Two outpatient medical offices have day surgery centers and large imaging departments, and there are several smaller outpatient medical offices. A group of 30 radiologists serves all facilities.
With such a large, dispersed operation, the radiology department started investigating PACS technology in 1995 as a way to take care of the patient population more effectively. The department wanted to identify a means by which work could be dispersed to radiologists at all the different sites, so that intelligent workload distribution could shorten report turnaround times. Because the patient population was mobile, access to a central repository of images was also desired. Finally, the radiologists wanted the ability to consult with each other.
Implementation of large-scale PACS was too costly, said Dr. Susan Wolf, who was chief of ultrasound when the system was installed. Ultrasound PACS, combined with links to all sites in the Kaiser computer network, seemed a sensible way to test the feasibility of the technology.
Shortly after ultrasound miniPACS was installed, only about 2% of all ultrasound exams were printed to film. The department, looking to save money, encouraged physicians to accept reports from soft-copy reading and to review exams from computer workstations. A major gain occurred in radiologist/sonographer interaction, along with a documented increase of one case per ultrasound modality by technologists.
Kaiser did not formally measure the impact of the technology because everyone was too busy, according to Wolf.
"The volume of exams from the emergency department keeps increasing. The system rapidly became part of the woodwork and functioned as we hoped," she said.
The system provided the ability to easily access images and to regulate workloads of a dispersed and highly mobile staff of radiologists. It has 18 ultrasound units, seven full diagnostic workstations, four smaller workstations, and two archives. Based on the performance of the ultrasound mini-PACS, Kaiser is prepared to expand this network into a much larger, multimodality PACS.
MS. KEEN is a PACS consultant and principal at i.t. Communications in Sanibel, FL.
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