PACS must avoid driving radiology, patients apart

The International Society for Optical Engineering hosted the first conference and workshop on the subject. More than 25 years later, the development of PACS has followed paths that were then hard to predict.

As PACS continues to evolve, I believe it will be progressively deployed in surgical departments to help with surgical planning. Residents will be trained on virtual patients derived from radiological data. Digital imaging data will increasingly be used to guide minimally invasive procedures, improving patient safety and clinical outcomes.

In short, PACS is no longer an infrastructure belonging to the radiology department. It is an "infostructure" that a wide variety of healthcare professionals can access, thereby integrating imaging into effective patient management.

PACS is moving closer to patients, becoming a true clinical tool. But another important part of IT in radiology seems to be moving in the opposite direction. Stand-alone teleradiology is increasingly being proposed as a telereporting service. Remote radiologists visualize and interpret imaging studies that are sent from distant hospitals. They have no contact with either patients or referring physicians.

A document produced by the European Society of Radiology, in conjunction with the Radiological Section of the Union of European Medical Specialists, emphasizes the potential for teleradiology to create difficulties in the delivery of high-quality radiological services (www.myesr.org, Publications, Brochure 1). It raises the following points:

• Discussion between radiologists and referring physicians leads to a change in clinical diagnosis in 50% of cases. This type of radiological-clinical teamwork is much more difficult when using teleradiology services.
• Specific wording in reports can vary from country to country, making cross-border teleradiology extremely delicate.
• Reporting radiologists need full access to a patient's previous examinations to avoid errors. Access to the local PACS may be necessary.
• Teleradiology may lead some radiology departments to close and contribute to the deskilling of local radiologists. The promotion of subspecialty teleradiology could overlook the value of a generalist perspective.
• Radiographers can feel isolated if they are denied adequate direct supervision because the reporting responsibility has been outsourced.

These risks become more evident if teleradiology services offered by radiologists working in developing countries are considered. There is a real danger that quality of care will depend on the time of day or the day of the week when patients present with a medical problem.

Supporters of out-of-hours teleradiology argue that radiologists are more productive during the working day if they do not have to cover the night shift. Several firms sell teleradiology services on this basis. Reports are provided by radiologists educated in developed countries but now based in countries on the other side of the globe. This means the nighthawk radiologists are wide awake when the hospital radiologists are asleep. The teleradiologists will have licenses from the country or U.S. state that they are receiving imaging studies from, allowing them to sign the reports.

But workflow has already been adapted. Relatively underpaid radiologists working in developing countries are, in some cases, being asked to write a preliminary report overnight that can then be revised by a local radiologist in the morning prior to validation. Is this outsourcing or ghostwriting? What is your diagnosis?

Dr. Caramella is a professor of radiology at the University of Pisa in Italy.