2. Leonard Berlin, MD, FACR
Department of Radiology
Skokie Hospital, Skokie, IL
Professor of Radiology
Rush University Medical College
and
University of Illinois
Chicago, IL
6. 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
7. 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
8. The Virtue of International
Teleradiology
Potential to improve the quality and
timeliness of radiology services by providing
interpretations when local physicians
performing those services are unable to
provide immediate coverage.
9. 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
10. Virtues of Teleradiology
For 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
11. Virtues of Teleradiology
For 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
12. 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?
13. 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?
14. 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
16. The single biggest problem in
communication is the illusion that it
has taken place.
George Bernard Shaw
17. 2013 Survey of ACR Members
Regarding 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
18. In-Person Communication Between
Radiologist 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
19. 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
20. 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
21. 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
22. 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.
23. 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
25. 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
26. Incidentalomas
Site 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
27. The Radiologist’s Dilemma
As 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.
28. 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
29. 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)
30. 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
31. Standard of Care
• Usual and customary care in local community….
• Usual and customary care in national
community….
…under same or similar circumstances
i.e., How do other institutions, physicians
and radiologists deal with incidentalomas
32. 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 institution
Johnson, JACR 2011;8:762
33. 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
34. 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.
35. 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?
36. 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
37. 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
