1. Medico-legal issues in Teleradiology Aditya Daftary Teleradiology Solutions

2. Teleradiology Needs no introductionNeeds no introduction Teleradiology is a means of electronically transmitting radiographic patient images and consultative text from one location to another*Teleradiology is a means of electronically transmitting radiographic patient images and consultative text from one location to another* *http://www.radiology.uiowa.edu/MoreRAD/Teleradiology/Tele.html

3. Goals of Teleradiology Providing timely consultative and interpretative radiologic servicesProviding timely consultative and interpretative radiologic services Making radiologic consultations available in medical facilities without on-site radiologic supportMaking radiologic consultations available in medical facilities without on-site radiologic support Facilitating radiologic interpretations in on-call situationsFacilitating radiologic interpretations in on-call situations Providing subspecialty radiologic support as neededProviding subspecialty radiologic support as needed Enhancing educational opportunities for practicing radiologistsEnhancing educational opportunities for practicing radiologists Promoting efficiency and quality improvementPromoting efficiency and quality improvement Providing interpreted images to referring providersProviding interpreted images to referring providers Supporting telemedicineSupporting telemedicine Providing supervision of off-site imaging studiesProviding supervision of off-site imaging studies

4. Medico-legal Issues in Teleradiology The good news:The good news: –A lot of it is still unclear The bad news:The bad news: –We’re dealing with lawyers!

5. Conceptually simple Imaging data acquired at one siteImaging data acquired at one site Network transmits images to a serverNetwork transmits images to a server Data can be reviewed and interpreted at a remote siteData can be reviewed and interpreted at a remote site Report generated and transmitted electronically back to the parent siteReport generated and transmitted electronically back to the parent site

6. Many a slip…. QualificationQualification Liability and InsuranceLiability and Insurance Radiologist dutiesRadiologist duties

7. Qualification VariesVaries –Country (US, Singapore, UK) –State –Institution Law can be a little vagueLaw can be a little vague Best to be safe: full qualification in geographic area and institute for whom one is interpretingBest to be safe: full qualification in geographic area and institute for whom one is interpreting

8. Qualification Medical board certification:Medical board certification: –USMLE/LMCC/recognized MBBS Specialty qualification:Specialty qualification: –ABR/RCPS/FRCR Subspecialty qualification:Subspecialty qualification: –Certificate of added Qualification (CAQ) LicensureLicensure CredentialingCredentialing CMECME

9. Medical Liability Insurance: Why? Establishment of a physician-patient relationshipEstablishment of a physician-patient relationship –No case examples, but probably YES –You are being consulted and you are getting paid! Jurisdiction for accountabilityJurisdiction for accountability –Where do you get prosecuted? Texas or India? –May not be teleradiologist, but definitely parent hosp/group –UK-Europe: Primary/alternative site –No case examples –Not too many people going to put themselves on the line for you!

10. Liability Insurance Covers one against possible litigationCovers one against possible litigation Find someone willing to insure off site/off country reading: not much experienceFind someone willing to insure off site/off country reading: not much experience Will look at all qualifications to assess riskWill look at all qualifications to assess risk Costs increase with timeCosts increase with time On site group to get clearance from their insurerOn site group to get clearance from their insurer Teleradiologist must have coverageTeleradiologist must have coverage Terms of coverage must be very clearTerms of coverage must be very clear

11. Medical Liability: Radiologist The teleradiologist is as liable as any other radiologist in the given settingThe teleradiologist is as liable as any other radiologist in the given setting –Technical issues –Interpretation and misses –Communication

12. Medical Liability: Technical Much of this is now redundant, but there are a few areas:Much of this is now redundant, but there are a few areas: –Image acquisition Digitized radiographsDigitized radiographs Unsupervised ultrasoundUnsupervised ultrasound Patient motionPatient motion ContrastContrast –Image transmission/viewing Some modalities not DICOM compliant (PET)Some modalities not DICOM compliant (PET) Acceptable compression ratio for emergenciesAcceptable compression ratio for emergencies Appropriate viewing stations: mammography, radiographs, MPR needAppropriate viewing stations: mammography, radiographs, MPR need –Patient privacy, data encryption –Preliminary versus final read

13. Medical Liability: Interpretation and Communication Teleradiologist has a duty to communicate as effectively as any other radiologistTeleradiologist has a duty to communicate as effectively as any other radiologist Typical communication by written reportTypical communication by written report –Reports to include Patient demographics, procedural details, relevant findings, impression (unless short)Patient demographics, procedural details, relevant findings, impression (unless short) –Preliminary reports Time sensitive, limited by absence of prior etcTime sensitive, limited by absence of prior etc NOT complete reportsNOT complete reports Must provide information to deal with immediate careMust provide information to deal with immediate care http://www.acr.org/s_acr/bin.asp?CID=541&DID=12196&DOC=FILE.PDF

14. Medical Liability: Interpretation and Communication –Non routine communications Situations:Situations: –Findings needing immediate intervention –Discrepant from prior report –Unexpected, but serious findings Direct conversation best; others (fax, pager. email etc) less reliableDirect conversation best; others (fax, pager. email etc) less reliable Must be documentedMust be documented

15. Medical Liability: Minimizing Error Preliminary reports to include relevant issues, small details not necessaryPreliminary reports to include relevant issues, small details not necessary Call when in doubt/something seen laterCall when in doubt/something seen later Ask for additional/repeat imaging as neededAsk for additional/repeat imaging as needed Recommend appropriate clarification studiesRecommend appropriate clarification studies Everyone misses…have a good QA system in placeEveryone misses…have a good QA system in place

16. Summary Teleradiology is an excellent empowering technology which enhances patient careTeleradiology is an excellent empowering technology which enhances patient care Legal issues on teleradiology are still vagueLegal issues on teleradiology are still vague A safe strategy is the best strategyA safe strategy is the best strategy –Do not compromise patient care (primum non nocere) –Appropriately qualified radiologists –Clear contracts and insurance a must to cover liability issues –Efficient communication in a clinical setting –Quality assurance programme –A very friendly lawyer!

17. Questions?