TELERADIOLOGY:VIRTUES, VICES,

AND MALPRACTICE VIOLATIONS

Society for Emergency Radiology,Third Annual Meeting

Bengaluru, India September 23-25, 2016

Leonard Berlin, MD, FACRDepartment of Radiology

Skokie Hospital, Skokie, IL

Professor of RadiologyRush University Medical College

andUniversity of Illinois

Chicago, IL

Samuel Fildes, The Doctor, 1891

2001: Nighthawk Radiology founded to provide night-time preliminary reports;

hospital staff radiologist would over-read and issue final report next morning.

2002: Teleradiology Solutions-- International company --Founded by Arjun Kalyanpur

Teleradiology:Status 2016

• Many teleradiology companies• Gaining acceptance• Increasing demand for service, and for

radiologists• Recruiters hired to find radiologists• Emerging as its own specialty Diag Img,com 9-1-16

The Virtue of International Teleradiology

Potential to improve the quality andtimeliness of radiology services by providing

interpretations when local physiciansperforming those services are unable to

provide immediate coverage.

Teleradiology Volume Increasing

• Marked increase in CT scans(90 M in US)

• Marked increase in ED volume• Expect 6.5 million exams in 2016 in US Diag Img,com 9-1-16

Virtues of TeleradiologyFor The Recipient (Customer)

• Immediate interpretation• Read by radiologic sub-specialist• 3,165 MSK CT and MR exams were referred

to MSK trained radiologists for second opinions. Second opinions were more accurate than outside reports in 82% of exams.

Chalian et al. AJR Online 4-9-16

Virtues of TeleradiologyFor The Radiologist Employee:

Why Jobs Are Sought• Better lifestyle• Set own working hours and location• Modern technology• Increasing workload• Pay comparable with hospital or office based• Guaranteed payment

Diag Img.com 9-1-16

Vices of Teleradiology For Radiologists

• Teleradiologists may not have access to prior images and reports, and other pertinent current clinical patient information

• Increased risk of error due to limited communication with ref doctor, and inability to compare with previous studies

• Increased percentage of sick patients; few healthy patients• Possible loss of patient confidentiality if images are not

received real-time, streamed to server, cloud, PACS, increased likelihood of malpractice lawsuits?

Vices of Teleradiology For the Recipient (Customer)

• Distant, impersonal relationship between ref. doctor and radiologist

• Limited time to procure previous studies for comparison

• Limited direct communication between ordering doctor and radiologist

• Increased chance of being sued for malpractice?

Teleradiology: Liability

• The interpreting physician is responsible for the quality of the images being reviewed.

• The use of teleradiology does not reduce the responsibilities for the management and supervision of radiologic medicine.

ACR T.S. for Electronic Practice of Medical Imaging Eff. 10-1-07

The Potential Malpractice Pitfalls for Teleradiologists

The single biggest problem in communication is the illusion that it

has taken place.

George Bernard Shaw

2013 Survey of ACR MembersRegarding Communication

(3,400 Responses)

• 82% aware of ACR PG-Communication, 18% are not• 61% have written policy• 97% agree communication of emergency findings to

ref. physicians should be in person or by phone• 24% agree communication to significan–unexpected

findings to ref. physicians should be in person or by phone

In-Person Communication BetweenRadiologist and Surgeon

Electronic systems and PACS can minimize need for direct in-person consultation but can create ambiguity and fail to foster

between radiologist and physician the patient’s condition.In-person meeting led to change in attending surgeons

impression and treatment in 43% of cases. Communication that relies solely on electronic medical record can result in failures of full exchange that can be remedied by in-person

collaboration.

Dickerson et al. JACR 2016

Nighthawk Settles Missed Brain Aneurysm Case for $500,000

• 47 y.o. man admitted to ER with chest and back pain• Nighthawk radiologist compares current with previous films,

concludes aneurysm has not changed• Five days later, patient dies of ruptured aneurysm• Defendant radiologist admits missing the bleeding• “It’s a big issue, this off-site reading by teleradiologists.

People go to hospitals to be taken care of and they don’t always know who’s behind the curtain taking care of everybody.”

The Roanoke Times, 5-2-08

Missed Stroke Suit in N.J. Settled for $475,000

• 44 y.o. man admitted to ED w severe headache• Rad interprets CT scan teleradiologically as normal• Twelve hours later pt suffers stroke, left with

neurologic deficits• Def rad admits hard copy shows stroke, but such

signs may not be as readily discernable thru the electronic communication.

Shields, ACR Bull, 7/09

Missed Stroke Suit in N.J. Settled for $475,000

Plaintiff attorney says defendant radiologist had duty to properly interpret films, irrespective of the

means in which he chooses to do so, and defendant radiologist could not excuse himself for

misinterpretation because of electronic transmission, if the transmission was not as

reliable as hard copy.Shields, ACR Bull, 7/09

Reckless Reading

Medical malpractice lawsuit filed against radiologist and teleradiology company alleging that because company pays

radiologist per exam read, radiologist reads too fast and therefore makes more errors.

The perception process has two components, one rapid and the other slow…Radiologic

studies cannot be “speed-read.” Interpretations require search, and search takes time. The value of a long search is

exaggerated, but experience does not earn us the right to short-circuit our interpretation

time.

Christensen Radiology 1981;138:361

Incidentalomas:The Latest Radiological Dilemma

Incidentalomas Are Increasing: Why?

Better Resolution

• Increase in CT exams; est. 90 million in 2016

• Increase in spatial and contrast resolution of CT over the past decade

IncidentalomasSite Modality Percentage

Lungs CT Chest 50%

Kidneys Abd CT 15%

Liver Abd CT 15%

Thyroid Gland Neck US 67%

The chance that the incidentaloma could represent a lethal CA is less than 1%

Welch, Overdiagnosed, 2011

The Radiologist’s DilemmaAs imaging technology advances, the frequency of incidentalomas will increase proportionately. This

presents a dilemma for radiologists. If there is reasonable belief that the incidentaloma is of no clinical significance, then mentioning it will lead to a cascade of tests, sometimes resulting in complications. But if rad decides not to mention it, and in the unlikely event the incidentaloma later turns out to have been an early CA or finding of other significant disease, and the patient’s

health has been jeopardized, medical malpractice litigation could well ensue.

What To Do About Incidentalomas

Don’t call it an abnormality. Call it normal. Protect the patient from overdiagnosis and overtreatment. Don’t mention the finding in the radiology report and don’t tell the referring physician so he won’t feel obliged to

tell the patient. We should lower the intensity with which we react to incidentalomas.

Welch, Overdiagnosis, 2011, pp 90-101

Individual’s Right To Know

A physician undertaking a physical exam has a duty to disclose what he has found and to warn examinee of any finding that would indicate the

patient is in any danger.

Betesh v USA, 400 F Supp 238 (DC1974)

Perhaps All Incidentalomas Should Be Reported

Over 90% of patients want to be informed of any abnormalities found in their radiologic examinations or

other tests.Schreiber, AJR 1995;165:467

The physician’s obligation is to present the medical facts accurately to the patient…physicians should disclose all

relevant medical information to patients.AMA Code of Ethics 2010-2011

Standard of Care

• Usual and customary care in local community….• Usual and customary care in national

community….…under same or similar circumstancesi.e., How do other institutions, physicians and radiologists deal with incidentalomas

No Consensus For Reporting Incidentalomas

• Survey of 27 radiologists at Hopkins, NYU and Stanford• 12% incidentalomas found in body CT• 100% agreements in none• Rate of agreement ranged from 30% to 85%• Wide disagreement (low as 30%) in cysts of kidney, liver,

pancreas, ovary• Lack of agreement across academic institutions and

within individual institutionJohnson, JACR 2011;8:762

ACR White Paper on Incidentalomas

• Encapsulated consensus of ACR Incidental Findings Committee

• Guidance for reporting Ifs in liver, kidneys, adrenal glands, pancreas

• Questionnaire sent to all ACR members, 38% read White Paper

• 57% adhere to W.P. recommendations

Health Imaging, 10/23/13

POSSIBLE TRIAL DIALOG:

Q: Doctor, why didn’t you report the potentially abnormal finding?

A: Because I thought the finding was almost certainly of no significance, and it would

have led to a number of unnecessary and possibly dangerous tests.Q: Could it have represented an early cancer?A: Yes, but probably no more than a 1% chance.

TRIAL DIALOG: (cont.)

Q: Well, Doctor, in this case it was 100%. Shouldn’t you have let the patient and his private physician decide whether further testing was indicated? Did you not deprive the patient, who is now dying of cancer rather than living and cured, of his inalienable right to make his own decisions about his health?

Intervention is the capstone of modern medicine; it is simply self-defeating to argue that it is better to do nothing than something.

Werth, Damages; 1998:3650

Suggested Report

A nonspecific density (lucency) is noted in the upper pole of the left kidney. Although its cause is indeterminate, the likelihood that it represents a malignancy or other serious finding is thought

to be extremely remote