Prior Studies in Teleradiology: the Unavailable, the Invisible and the Unknown-Unknown

How can a teleradiologist reliably have access to prior studies (and their reports)?

Prior to 2011, when I moved to telerad, the thought never really crossed my mind. Until then, I had only worked on-site in hospital systems or outpatient imaging centers. Whenever I had a study on a patient, all prior exams were on the record for me to see. (I’m old enough that this included actual folders with films in them.) At worst, I’d have to request an “archived” older study, but it never took long to get it.

There are tele setups out there that can run the same way. For instance, suppose I’m an employee of a hospital, and the facility gives me a workstation which can remote-in to their system and function just like one of their on-site terminals. I should be able to do anything aside from strolling down a hallway to physically interact with the file room if they still have one.

I have never personally had a “remote workstation equal to on-site” setup. My first tele company provided coverage to over 2,000 facilities. The company had its own workstations and proprietary software. Each client had its own separate system. The telerad company and the clients’ IT people had to work together to make their systems interact effectively, but that interaction was never quite as good. My subsequent telerad gigs had smaller scale versions of the same challenge.

I have thus never been able to reliably “see” all of a patient’s prior imaging. In my 2,000-plus facility job, for instance, I only knew about and could review prior exams if the tech currently imaging a patient took the trouble to upload older ones. If the techs were too busy (to do the uploading or simply to look and see if there was anything to upload), or if they just didn’t care, I got nothing. As far as I would be able to tell, the patient had never been imaged before.

Sometimes, that doesn’t matter so much. If I’m providing a preliminary review of a CT for appendicitis at 3 a.m. and someone onsite with access to all priors will render a final report in just a few hours, do I really need a scan from five years ago to offer a comment on whether a 4 mm lung nodule might be called stable?

Most of my work, by contrast, has been final reports, not prelims, and it does nobody any good for me to read studies without having relevant priors or even knowing if they might exist. It’s bad for patient care if proper comparison doesn’t happen, and even a delay can have bad consequences. It can look bad to anybody observing the situation, from the patient him- or herself to the patient’s referrer to other rads. (In contrast, these situations can look appetizing to hungry lawyers.)

It can be downright annoying and time-wasting too. Suppose I generate a no-comparison report, and the referrer has to ask for an addendum, assuming he or she notices the shortfall. There is even more potential for complexity and suboptimal care enters the picture if you add the variable of images but not reports of prior studies being visible/available.

Want to take it a step further? Suppose a tech sends me the most recent prior study, but it turns out there was an older one that would have made a better comparison. Maybe I would ideally also pull up an old bone scan, but the tech, understandably, only thought to send me a prior CT because that is the modality of the current exam. Remember that I might not even know about the existence of any of these priors if my telerad system doesn’t reliably query them all from the client facility. They could all be my “unknown unknown.”

In a radiology forum thread, folks were discussing situations in which telerads are trying to provide a good service, but on-site facilities were spotty in uploading prior studies/reports. As is usually the case with social media, there was a broad range of opinion.

Some were vehement that, especially in today’s market, the tele entity can and should put its foot down: The clients must reliably provide the priors/reports. Write it as a condition of the contract so failing to do so represents a breach! Have your rads refuse to read non-emergent studies without the right comparisons! (Granted, how you can do that when you don’t even know if those priors exist is a mystery to me.)

Such tough talk might be great if you can back it up with action. As the tele entity, however, are you that sought after that you can let non-compliant clients go, or willing to annoy all of the referrers whose studies your rads are refusing to read?

Other approaches sounded more diplomatic and likely more effective to me. The docs (and patients!) are generally not the ones standing between your rads and prior studies. Administrators who fail to fix the underlying systemic problems are the challenge. You have to speak their language and, unfortunately, the rationale that “patient care might suffer” doesn’t always motivate them. Advising them that they and their facilities are legally vulnerable by not fixing the issue (especially when you have a written record of giving them this advice) hits a little closer to home.

There is one thing I have also noticed during my own battles over the issue. The best solutions depend on techs, or other humans, as little as possible. Every time you count on a human doing something, you incorporate the potential for that human to fumble the ball. That can be a tech forgetting or not bothering to look for priors and/or failing to upload them. It can be a rad failing to realize that there may be priors in the system and making the necessary efforts to get what is missing. Even a workforce that is 100 percent diligent will make mistakes.

A reliable automated system is what you want. It might cost more upfront, and it will surely have subsequent costs for maintenance and upgrades. However, once you have it in place, the issue of missing priors—including the “unknown unknown” — will be drastically reduced if not eliminated.