quality assurance and medico legal issues - teleradiology solutions
TRANSCRIPT
Quality Assurance & Medico-legal issues in Teleradiology
Anjali Agrawal, MD [email protected]
PGIMER, Chandigarh August 2014
Teleradiology-Utility and Goals
Main purpose: Timely radiologic consultation and accurate interpretation, commensurate with the current practice norms
Facilities without on-site radiologists, or limited on-site personnel
Subspecialty expertise, second opinions, e-teaching
Increased efficiency and overall quality of the practice
What is Teleradiology? Radiology images acquired at one location transmitted to another for interpretation, consultation or reference
Quality Practice- Recommendations
Essence:
Personnel
• Technical
Communication of results
Methods for quality assurance
ACR, ESR, RCR of the UK, Australasian and New Zealand College of Radiologists, Canadian and the Singapore College of radiologists: Standards governing teleradiology best practices
Quality Practice- Personnel
• Qualified/adequately trained technologists
• Qualified radiologists as per the requirements of the state of origin of images
• Suitably trained support staff, computer and IT engineers
Quality Practice- Technical
Image acquisition: Digital or use of Medical Grade Scanners to provide image resolution greater than 2.5lp/mm. Compliance with DICOM standard
Image transfer: Over a WAN and use of VPN and firewalls to ensure patient privacy and data integrity (HIPAA or European Commission’s Directive on Data protection)
Image compression: Lossless (2:1) or lossy compression up to 10:1 for CT
Display equipment and work environment: Flat panel LCD monitors, complete remote replica of in-house PACS workstation
Integrated PACS and RIS platforms, Web-hosted solutions to facilitate central management and easy accessibility
Quality Practice- Communication
Effective and timely communication critical
• Reporting- RIS and now integrated PACS-RIS to generate and transmit a standard radiology report
• Conditions needing urgent or immediate intervention or unexpected findings- may warrant a phone call
Quality Assurance- Critical
Important for continuous improvement and accountability of the personnel and improved patient care Key measures of Quality – Accuracy and Timeliness of reporting
Workflow
Acquisition of images
Transmission of images and clinical information
over the internet
Interpretation Verification of
data and images at the receiving end
Result communication
Swiss cheese model of medical error
•There are always holes through which errors can creep through • Random holes are system related and can be blocked by multiple layers (staffing, double reads, checklists, workload) • Common holes may be intrinsic and need active intervention
Brook O R et al. RadioGraphics 2010;30:1401-1410
Series of different measures is more effective than one
A series of five safeguards and defenses have been introduced to minimize the chances of latent failures aligning to produce an error
Brook O R et al. RadioGraphics 2010;30:1401-1410
To err is human
To reduce errors, we must change the way we do things
“Insanity is doing the same thing over and over again and expecting different results”, Albert Einstein
Avoid “blame game”
Quality Practice- Quality Assurance
Methods for Quality Assurance
Checks for Quality Assurance
Workflow: Coordination between data entry, technologist at the site of image acquisition, workflow coordinator, radiologists- TEAMWORK
Adequately qualified staff akin to a radiology department
Suitably trained computer and IT engineers
Communication of results
Quality Assurance Processes for Accuracy
Peer review process
Double read
Continuous feedback
Conferences discussing various errors and learning points
Potential Benefit of Focused Contemporaneous Dual
Read in Emergency Teleradiology
A Agrawal*, BK Desiraju**, SS Jayadeepa*, A Kalyanpur* * Teleradiology Solutions ** IGIB, Delhi , India
Active survey of errors
Peer Review
Regular Feedback to Radiologists
99.25
99.57 99.66
99.74 99.75 99.76 99.78 99.83 99.83 99.84 99.87 99.94
98.80
99.00
99.20
99.40
99.60
99.80
100.00
ABR 9 ABR 5 ABR 8 ABR 4 ABR 2 ABR 11 ABR 10 ABR 1 ABR 6 ABR 7 Anjali Agrawal, MD ABR 3
Accuracy Rate - ABR(External - Jan - Dec 2012)
Radiologist X
Accuracy Rate
Continuous education important to maintain skills in a virtual environment
QUALITY IS NOT AN ACT. IT'S A HABIT.
Quality Assurance Processes for Efficient Workflow and Timeliness
Turnaround time
Data transfer from site to server
Data transfer from server to radiologist workstation
Interpretation time for radiologist
Effective and timely communication of results
Radiologist availability for queries and protocols
Regular Feedback to Radiologists
37.99 37.24 37.43 37.76 39.65 40.00
36.94
15.00
20.00
25.00
30.00
35.00
40.00
45.00
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Turnaround time
Balancing Opposing Quality Determinants
Compression for faster image transmission vs. possible loss of fine detail
Lossless compression is a good compromise
Fast turnaround versus detailed reporting
Must use context and judgement
Experience, experience, experience
Medicolegal issues
When do they arise?
A) law is violated involving a third party (regulatory authority/hospital)
B) The service rendered is not up to the expectation of the client
Progress in teleradiology outpaced the law- implications—guidelines are sometimes vague and evolving
To err is human, what do I do to protect myself?
Medical liability insurance
You are accountable for what you do like a fellow radiologist or another physician
Where will you get sued if you are reading for the US from India? Meet the standards of the institution, state and country
For Teleradiology Clients-Who to partner?
Qualified Radiologist
Meets the regulatory board requirements
Appropriate Certification
Licensure Credentialing Continuing education
For Teleradiology Clients- Who to partner?
Qualified Radiologist
Meets the hospital board requirements
Capable of secure continuous access to hospital imaging systems, secure transmission of image and clinical data
Capable of virtual workflow and easy communication with client physicians
For Teleradiology Consultants
• From the legal standpoint, the radiologist performing interpretation via teleradiology is held to the same standard as a radiologist on site at the imaging center
• Insufficient clinical information and relevant prior studies • Communication errors-operational risks that teleradiology practices must
specifically and pro-actively guard against
Conclusion
Teleradiology practice models expected to match or exceed the quality levels of the client groups
Many potential steps where errors can occur
Active quality assurance processes, regular internal and external feedback and continuous education are important
Anjali Agrawal, MD [email protected]
PGIMER, Chandigarh August 2014
Dr. Anjali Agrawal is a consultant radiologist to Teleradiology Solutions, where she heads the Delhi Operations of the group. She graduated in medicine from the All India Institute of Medical Sciences followed by Radiology training at AIIMS and the Baylor College of Medicine, Houston, Texas. She is actively involved in the American Society of Emergency Radiology and is one of the founder members of the Society for Emergency Radiology in India.
About Dr. Anjali