The ABCs of Teleradiology Quality Control

The basics of teleradiology QC include speed, security and accuracy. How do you get the images - often data-intensive multislice CT studies - from here to there and back fast, securely and accurately? And while technical issues are a top priority, credentialing and customer service need to be considered in the QC equation, too.

The teleradiology business is booming. "Within the last few years, we've seen all teleradiology companies double their operations every six months with no signs of business slowing down," says Brent Backhaus, chief technology officer for Virtual Radiologic Consultants (VRC of Minneapolis).

Why the boom? For starters, teleradiology can aid the bottom line. Take Deaconess Billing Clinic (Billings, Mont.). The hospital pays Nighthawk Radiology (headquartered in Coeur d' Alene, Idaho, with remote reading in Sydney, Australia) about $20,000 a month for overnight reading services. PACS Specialists Laurie Walter points out, "That's a lot less expensive than a night radiologist."

The surge is not limited to nighthawk services. Both nighthawk providers and anytime-anywhere reading by staff radiologists can improve patient care by providing access to subspecialists. And let's not forget the radiologist shortage. Teleradiology can keep radiologists happy by shouldering (or at least easing) the night-reading
burden, and it can be used to fill gaps by providing a part-time FTE radiologist.

Sites that develop and adhere to a solid QC plan will reap the benefits of efficient and effective teleradiology. But a missing ingredient can frustrate clinicians, compromise patient care, violate HIPAA or chip away at the bottom line. Fortunately,
getting it right is fairly straightforward.


Getting the images where they need to be means high-speed internet connections these days. "Faster [internet connections] are always better, but cost more," VRC's Backhaus explains. Options include business class DSL or cable modems, T1 lines, DS3 (essentially 3 T1 lines bunched together) and corporate intranets. Typically, a high-speed cable modem ensures a download speed in the range of 6 to 9 megabits per second. Backhaus says sites with a slower bandwidth connection might install an image compression gateway device to facilitate faster data transfer with the teleradiology vendor.

Most hospitals encounter some tradeoffs as far as speed, image compression and image quality. VRC's Backhaus says it typically takes about 13.5 minutes to transmit 100 CT slices from a hospital to VRC servers if the hospital has a T1, business-class DSL or business-class cable internet connection without any image compression in use. With an image compression device in place, diagnostic quality images can be transmitted from one side of the United States to the other at the rate of 100 CT slices in 57 seconds. The tradeoff that the hospital must evaluate involves the cost of the internet connection, the cost of an image compression device, the potential for over-compression leading to unacceptable image quality and the desire to transmit data as quickly as possible.

Next Generation Radiology (Great Neck, N.Y.) relies on eMed's (Burlington, Mass.) Enterprise to enable real-time remote radiology services. eMed Matrix serves as the practice's PACS solution. The practice's four imaging locations communicate with a central server and archive, with eight remote reading stations that query the server. Next Generation provides web access for referring physicians and outsources some work to university centers. David Katz, MD, president of Next Generation, admits, "It requires a real dedication to IT." The practice relies on a pair of fused T1 lines, a.k.a. "a fat pipe," to provide the bandwidth of two T1 lines and enable radiologists to download and read images within minutes of study completion.

Deaconess Billings Clinics uses a Radworks 6.1 sending station coupled with a T1 connection and high-speed VPN to transfer images from Montana to Sydney; the set-up transfers a head CT in two to three minutes.

MacNeal Health Network (Berwyn, Ill.) is close to a teleradiology pioneer; the health system has relied on Images on Call (IOC of Dallas) tools to enable radiologists to complete night readings at home for about a decade. IOC's ViewStation Software, DICOM Gateway, Video DigitizerStation and Sockets Internet facilitate the teleradiology process. The hospital is equipped with a DSL line, and radiologists' home workstations are connected by DSL or a cable modem. Rick Provus, MD, director of nuclear medicine, says, "A single or 16-slice CT takes about a second an image to receive. If there are any delays, it's because the 16-slice scanner reformats data before sending the images."

Delta Radiology Group (St. Louis, Mo.) serves nine hospitals in Missouri and Arkansas. The group recently turned to VRC for after-hours, weekend and holidays services. Bill Sweat, MD, president and CEO, says the hospitals have different connections to enable fast reading with high-speed DSL being most common. "A VRC engineer meets with us and the hospital to recommend the best option as far as speed and cost for each site," he explains. "Typically, images are sent to the VRC radiologists within seconds, and VRC guarantees a turnaround time of 30 minutes. We've had turnaround in the five to 10 minute range at our first hospital."


Luckily, worries over the security of teleradiology systems need be few. "All teleradiology systems are secure," Provus confirms. Most companies use 128-bit encryption and TCP/IP (transmission control protocol/internet protocol), which resends images if any packets are dropped, ensuring that the data sent are the data received. IOC, for example, pairs 128-bit encryption with wavelet compressed TIF files to allow only users with IOC software to view the images.

Next Generation Radiology relies on SSL/HTTPS (for data authentication and encryption) and a watchdog firewall to deliver secure images. The company also contracts with an outside consultant for ongoing monitoring and quarterly penetration testing to make sure that the system is truly secure. Director of Information Systems Daniel Castaldo explains, "Everybody needs penetration testing. It will be required once HIPAA goes full swing." Images and data also are internally protected through physician passwords.

Nighthawk Radiology meets HIPAA regs via triple des encryption and site-to-site VPN tunnels. "We use an online requisition with a password," Walter explains. "The requisition includes the number of images, and the Nighthawk radiologist can't read the study if that same number of images aren't received." Nighthawk's support staff ensure that the images match the requisition. A similar cross-check is employed when the report is sent back to Deaconess.

VRC employs a similar approach. Hospital support staff enter patient demographic data to complete an online order. VRC radiologists review the information on the RIS; reports are automatically faxed to pre-designated locations or viewed on the RIS. Image transfer requires two layers of login and 128-bit encryption.


Like other QC components, both the teleradiology provider and the hospital must address accuracy. Nighthawk Radiology's system mirrors the traditional reading room with all radiologists reading from a centralized location, easily facilitating second opinions. Trained technical assistants also provide a second review. Deaconess Billings Clinic adds a next-day overread for all Nighthawk night reads and resolves discrepancies via fax or email.

American College of Radiology (ACR) guidelines dictate that teleradiologists be licensed in the transmitting and receiving states and credentialed in the sending facility. VRC adheres to the guidelines, but provides all radiologists on the system with access to images. This means radiologists, who typically read from home, can instant message each other for a second opinion as necessary. Delta Radiology also overreads VRC images and reports for accuracy the next day.

Next Generation Radiology's approach mirrors the traditional approach. "Our teleradiology system is integrated with the RIS, so any misspelled names are flagged," Katz explains. "We also train our techs to make sure that if 106 images are scanned, then 106 images are archived. Finally, techs take and post a brief history with each study. The radiologists make sure the history correlates with the images."


Getting teleradiology technology right is absolutely key, but there are human aspects to this high-tech offering as well.

Deaconess Billing's Walter advices teleradiology wannabes to research the turnover rate if they want to outsource nightreads. "We spent a lot of time and money credentialing new radiologists with a prior teleradiology provider because the company had a high turnover," she explains.

It's also a good idea to a get a handle on a provider's turnaround metrics. Does the company guarantee a certain turnaround time? Does the provider stop adding additional sites if its daily turnaround time exceeds a certain figure?


The teleradiology QC plan should start early in the game. That is, after a hospital decides to install teleradiology equipment or contracts with a teleradiology provider, it should examine test cases on a weekly or bi-weekly basis for a few weeks. Bob Maher, national sales and marketing manager for IOC (Dallas), says, "You can tell pretty easily if images aren't diagnostic quality." Typically, teleradiology software makes automatic adjustments and any tweaking is minor, such as correcting the window/level settings on the CT scanner.

If speed is an issue, the hospital will usually need to assess its local internet connections or the radiologist's home connection if he or she is reading from home; minor adjustments like a VPN edge device or additional compression can help, but ultimately speed is what it is and a higher-speed connection may be in order.

After any initial kinks are worked out, the local QC plan, including monitor calibration schedule, should suffice for teleradiology workstations. Regular security testing is in order, and when all technical and human teleradiology components are connected and integrated, the hospital can expect smooth sailing.