Teleradiology in the Age of COVID and Beyond

The ongoing COVID-19 pandemic has resulted in significant disruptions to the healthcare system, including imaging care. One study estimated decreases in imaging volumes of 50 percent-to-70 percent for at least three months and encouraged measures like reduced working hours, salary cuts, and even layoffs to help offset the revenue cuts due to the pandemic¹. To comply with social distancing measures and protect personnel and patients against the spread of disease, many radiology practices have adopted teleradiology, or remote interpretation of medical images.

This has been a significant change in routine for many practitioners, and it is not entirely clear what work will look like once the pandemic subsides and providers are allowed to physically return to their workplaces. In this piece, we explore the challenges for adopting telemedicine and remote services in the imaging arena, as well as potential benefits that may encourage radiology practices to leverage teleradiology for the long term.

By definition, teleradiology is performed remotely and misses out on the benefits associated with being physically present. Keeping a physical presence can help foster a more collaborative community and bolster teamwork and relationships, whether it is with radiologists, radiology technologists, nurses, or other inter-and multi-disciplinary stakeholders. Referring physicians also appreciate having onsite radiologists for consultation purposes and collaborative conferences, such as tumor boards.

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For residents and fellows, sitting side-by-side with attending radiologists during read out and reviewing imaging studies together can be beneficial for their education and development, though techniques like video calls and screen-sharing address some of these issues². In addition, certain procedures, such as intravenous contrast administration, require the presence of an onsite radiologist, and the minimally invasive procedures of interventional radiology cannot be conducted remotely. In these cases, teleradiology is not an option.

Practices that adopt teleradiology need to equip personnel with tools to complete their work, but this process can be complicated. Home workstations must be powerful enough to handle image-intensive applications, and monitors must comply with regulatory specifications for quality assurance to ensure reliable visualization of findings, particularly for modalities, such as mammography with requirements specified by the Mammography Quality Standards Act³.

In addition, radiologists working remotely will need an adequate internet connection. Workflows can quickly become frustrating and, potentially, affect patient care if image-rich studies are bottlenecked by a slow connection. Furthermore, information technology services may be necessary to ensure that images are sent in a HIPAA-compliant manner. Notwithstanding some of these challenges, some radiology practices have documented how successfully and rapidly they equipped their radiologists for remote work during the pandemic^4,5, but practices without adequate funding or technical support infrastructure will not be able to adapt as quickly.

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Despite its challenges, teleradiology greatly expands access to diagnostic radiology services. An analysis of Medicare-participating radiologists within the United States found that rural areas were less likely than non-rural areas to have local radiologists⁶. In addition, rural areas with local radiologists tended to have a lower percentage of subspecialist radiologists than did non-rural areas.

Teleradiology can bridge the gap in imaging services between rural and non-rural areas. Patients in areas that lack local radiologists can still get diagnostic radiology services through radiologists working remotely. Care teams that wish to consult an expert on image interpretation can use teleradiology to get advice from an available radiologist. Generalist radiologists who want a second opinion from a more subspecialized colleague can simply transmit the images and communicate electronically. With teleradiology, patients and experts in rural areas can get high-quality imaging advice without having to travel to more populated urban areas with more advanced healthcare systems.

Furthermore, the ability to quickly recruit radiologists through teleradiology can address staff shortages during weekends, evenings, and holidays and better equip practices to handle unexpected surges in imaging volumes. Staff shortages are more pronounced in rural areas, where there may not be enough local radiologists to provide around-the-clock coverage.

Teleradiology benefits more than just diagnostic radiology. Interventional radiologists often meet with patients in clinics to perform examinations and pre-operative assessments. Through phone or video calls, teleradiology allows interventional radiologists to reach patients who cannot make it to physical appointments. These patients may have co-morbidities that restrict their ability to travel or put them at high risk of complications from infection, or they may live in rural or underserved urban areas without reliable access to healthcare^7. Teleradiology can provide basic services and continuity-of-care to patients who otherwise would not be able to obtain them.

As a field, radiology is especially open to new technologies and innovations that have the potential to improve patient outcomes and care workflow, and teleradiology is no exception. Image interpretation, in particular, with the creation of centralized databases and distribution of images through secure internet connections, often lends itself to remote work. Due to the pandemic, radiology practices everywhere have had to rely more heavily on teleradiology to keep providers safe.

Once the pandemic subsides, however, relative reliance on remote work will inevitably shift again. Many practices will likely consider or have the opportunity for a hybrid model in which some radiologists work onsite and others work off-site. Onsite radiologists will be necessary to supervise certain procedures and cultivate relationships with technologists, nurses, trainees, and other providers; while other radiologists will take advantage of teleradiology and its substantial potential for greater collaboration and patient reach, particularly in rural areas.

Teleradiology was already being utilized before the pandemic began, but the pandemic has brought it to the forefront of radiology practices and has energized our community to consider how we can use it to benefit our patients even more.

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_References

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_{3. Hardy K. Managing Monitors for Digital Mammography. Radiol Today. 2012;13(10):26.}

_{4. Tridandapani S, Holl G, Canon CL. Rapid Deployment of Home PACS Workstations to Enable Social Distancing in the Coronavirus Disease (COVID-19) Era. Am J Roentgenol. Published online May 20, 2020:1-3. doi:10.2214/AJR.20.23495}

_{5. Sammer MBK, Sher AC, Huisman TAGM, Seghers VJ. Response to the COVID-19 Pandemic: Practical Guide to Rapidly Deploying Home Workstations to Guarantee Radiology Services During Quarantine, Social Distancing, and Stay Home Orders. Am J Roentgenol. Published online June 30, 2020:1-4. doi:10.2214/AJR.20.23297}

_{6. Rosenkrantz AB, Wang W, Hughes DR, Duszak R. A County-Level Analysis of the US Radiologist Workforce: Physician Supply and Subspecialty Characteristics. J Am Coll Radiol. 2018;15(4):601-606. doi:10.1016/j.jacr.2017.11.007}

_{7. Hoffman DA. Increasing access to care: telehealth during COVID-19. J Law Biosci. 2020;7(1). doi:10.1093/jlb/lsaa043}