Teleradiology needs first-rate quality assurance

A small but growing number of European hospitals and clinics are outsourcing reporting work to external organizations. In the absence of European teleradiology guidelines, such centralized services must demonstrate watertight quality-assurance procedures, particularly when operating across national borders.

At least two companies offer pan-European teleradiology reporting services. The Barcelona-based European Telemedicine Clinic targets demand from Scandinavian and U.K. hospitals. Competitor Eurad Consult serves clients in the Netherlands and the U.K. from its premises in Mechelen, Belgium.

The European Parliament has yet to catch up with this latest healthcare technology trend. Regulations-or even recommendations-relating to quality, security, privacy, and liability issues in cross-border radiological data transactions simply do not exist. Service providers and clients must ensure that outsourced reports comply with all local standards of care.

"Patients need to be sure that the teleradiologist is at least as good as the radiologist back home," said Dr. Jan Schillebeeckx, a radiologist and cofounder of Eurad Consult. "This means that the teleradiologist should meet or even exceed those standards met by radiologists practicing in the local country."

Rigorous QA is essential for every aspect of a teleradiological transaction, from the robustness of technical infrastructure and transmission protocols to the reporting radiologist's efficiency and diagnostic competence. In the absence of formal advice from European authorities, Eurad Consult has instituted its own policies to guarantee reliable teleradiology, Schillebeeckx told delegates at September's joint EuroPACS/MIR meeting in Trieste, Italy.

"There is an urgent need for European guidelines on teleradiology, and I strongly believe that there is a need for an established QA program within these guidelines," he said.

Virtual private networks transmit all radiological data to and from Eurad Consult's reporting suite. The company also observes local laws on data privacy, which sometimes go above and beyond European Union legislation. Reporting radiologists must be properly insured against medical negligence in the countries from which they receive reports. A diagnostic error will lead to proceedings in the patient's home court, not the radiologist's. Teleradiologists must also gain local accreditation to practice radiology, in addition to holding a European medical license.

"Of course, you need to be sure that the radiologists working in your teleradiology center are well trained," Schillebeeckx said. "I hope one day that it will be possible to have a single accreditation provided by a European organization, but at the moament that is not the case."

The content of the radiological report itself is also extremely important, he said. One of the first hurdles Eurad Consult had to overcome when setting up cross-border teleradiology was the realization that clients needed reports written in their native language.

"Initially, we thought that we could deliver the report in English and that everybody would understand it. That is not the case. If you work with a client in Germany, you need to be able to deliver a report in German. For clients in France, you must deliver a French report," he said.

Regular clinical auditing is used to ensure that reports are both comprehensible and correct. Eurad Consult pledges to subject 20% of all teleradiological reports performed in the first three months of a new client contract to radiological peer review. The number of reports evaluated drops to between 5% and 10% after this initial period.

Reports containing an error are classified on a four-point scale, according to the severity of the discrepancy. These range from a simple sense error with a word omitted or a minor interpretative error to a moderate or serious interpretative error (see table). The level of error scales with the likely severity of clinical impact. Discovery of any grade 3 or 4 errors triggers an immediate "significant incident report" and requires urgent follow-up.

"Remedial actions are carried out and reported back to the referring institution in a timely manner. In this way the teleradiology center can ensure that lessons learned from such incidents are incorporated into the regular practice of the organization," Schillebeeckx said.

Full details of the clinical audit, including nonsignificant errors, are passed on to clients as part of a monthly performance report. The report also includes figures on actual turnaround times compared with contracted times, response times to telephone calls, feedback from patients and/or referrers, and confirmation of reporting radiologists' local accreditation and indemnity insurance. Contracted hospitals in return provide benchmarking information.

"It is important that we get continuous feedback from the referring hospital. We ask that they provide us information on key performance indictors-anonymized, of course-in the interest of comparing our own performance with others," he said.