Teleradiology laws lag behind growth of modality

Teleradiology has matured into a significant and effective element of the healthcare system in Europe. But the legal framework needed to safeguard quality standards in the sector has not yet been established, according to speakers at the 2007 Management in Radiology congress held in the U.K.

Radiologists are concerned about accountability and the lack of a suitable system for monitoring
professional standards, according to Dr. Richard FitzGerald, a consultant radiologist at the Royal Wolverhampton National Health Service Trust. A growing number of companies provide teleradiology services, and hospital departments that would normally interview candidates and insist on checking references when hiring a staff radiologist are quite prepared to employ teleradiologists solely on the basis of accreditation supplied by these companies.

With the exception of breast imaging, no national or international guidelines exist on what is an acceptable error rate in reading radiological images, FitzGerald said.

European medical authorities have been complacent regarding the need to prevent physicians found to have unsatisfactory standards from simply moving to another country, he said. The proposed European Union agreement on cross-border health services requires regulatory bodies to exchange information on the professional status of such individuals.

The U.K. Department of Health issued guidelines that require teleradiologists providing services for hospitals in the U.K. to be registered with the General Medical Council, the national regulatory authority. It has also proposed standards for the quality of the images provided and insisted on competence in the English language for those producing the reports, according to Dr. Laurence Sutton, clinical director of the imaging department of the Calderdale Royal Hospital in Halifax.

PATIENTS’ INTERESTS

Early last year, the European Union began the process of developing regulations on cross-border services. But it noted the importance of teleradiology by conducting consultation exercises on cross-border health services, Sutton said. At those
2007 exercises, the European Society of Radiology and the European Union of Medical Specialists insisted that the goal of proposed regulations should be to create a system that emphasizes the fundamental importance of patients’ interests rather than focusing solely on cost issues.

The ESR also proposed that radiologists be registered and accredited in the countries to which they are providing a service. They should be subject to the same regulatory requirements demanded by that country's national authorities on issues such as continuing medical education, appraisal, and recertification, according to the society.

Sutton noted widespread concerns over the effects of outsourcing radiological services on new entrants to the discipline. He feared that a young radiologist working in a district general hospital would no longer have access to the routine musculoskeletal scans that have been vital to the training of earlier generations.

EUROPEANS NOT ALONE

Radiologists in Europe were not alone in expressing some anxiety about the current legal framework for teleradiology. Dr. Seong Ki Mun, director of the Imaging Science and Information Systems Center at Georgetown University in Washington, DC, pointed out that the Medicare health insurance system has rules stating that its funds should not be distributed to nonresident healthcare providers. Yet U.S. referring hospitals share a percentage of their reimbursement on teleradiology services with the provider, which is sometimes based outside the U.S. The legal position is unclear, but hospitals may be accused of illegally diverting Medicare funds, he said.

A U.S. system based on separate accreditation procedures for medical staff in each of the 50 states causes a number of problems for teleradiology providers. The largest provider of off-hours image reading is Idaho-based NightHawk Radiology Services. It employs radiologists who on average have been certified in 38 different states. The requirement for separate professional indemnity insurance coverage in each state is an additional administrative and cost burden on these companies. Some experts have even suggested that the U.S. rules on state licensure may be targeted by the General Agreement on Trade in Services as an unwarranted barrier to trade, Mun said.

Dr. Erik Ranshaert, founder of Eurad Consult, a Belgium-based teleradiology services company established in 2001, defended the professional standards within the sector. He insisted that the quality of services provided by teleradiology companies would at least match and probably exceed those of the client hospital's in-house service.

DOUBLING UP

Ranshaert described the technology and working procedures used by his company, which is based in Mechelen and carries out more than 30,000 reports on MRI examinations each year for clients in Belgium, the U.K., and the Netherlands. Each of those images is read by two separate radiologists employed by the company. That double reading is a useful guarantee of safety and should become standard practice in all hospital radiology departments, he said.

Dr. Philip Gishen, clinical director of radiology at London's Hammersmith Hospital, defended the reputation of hospital radiology departments. He pointed out that a hospital radiologist typically works in the same room as others, and an image may be scrutinized by several colleagues who would also discuss their interpretations of the findings in a multidisciplinary team meeting. Although no formal arrangements may exist for the second reading of an image, it is unlikely that it would be seen by just a single pair of eyes, he said.

Ranshaert pointed out another aspect of his compan's working practices that he felt would help to ensure a higher standard of service than that normally provided by a hospital radiology department. The technology available to the company's cadre of radiologists is capable of automatically recording any discrepancies in the results of the two readings of a particular image. It also provides weekly or monthly reports on the performance of each radiographer.

“I think this is unique. I don't know of any hospitals where they do this as a standard policy,” he said.

Ranshaert is also developing a system for teleradiologists to virtually attend multidisciplinary meetings on the patient concerned. 

Mr. Bonner is a freelance writer based in London.