This document summarizes the results of a survey on the current and future role of teleradiology in Europe. The survey found that while teleradiology is used by 65% of respondents primarily for in-house purposes, there is demand for EU-wide legislation and quality assurance frameworks to regulate cross-border teleradiology. Key challenges include the need for standards, legal uniformity, financial harmonization, and language barriers. Overall teleradiology is expected to grow with increasing radiologist shortages and healthcare costs, but concerns around quality, privacy and loss of control must first be addressed.

1. Dr. Erik R. Ranschaert
Radiologist
Jeroen Bosch Hospital

2.  to understand the current role of
teleradiology
 to be able to “map” the current usage of
teleradiology throughout Europe
 to be aware of the problems related to
teleradiology
 to be aware of and anticipate to the changes
in radiology dpts. due to telemedicine and
teleradiology

3.  Teleradiology (TR) is the electronic
transmission of radiographic images from
one geographical location to another for the
purpose of interpretation and consultation.
 Wide deployment of PACS in combination
with the overall presence of high-bandwidth
Internet have facilitated the transmission of
medical images for diagnostic purposes

4. Source: EC eHealthBenchmarking III report, April 2011

5.  PACS availability is 100% in Nordic countries
 Percentage of hospital PACS reaches 97% in
the Netherlands, 96% in Belgium and 95% in
the UK
 High availability rates are also found in
Austria, Portugal and Spain
 Only 25% French and 23% Greek hospitals
have a PACS
Source: EC eHealth Benchmarking III report, April 2011

6.  76% of hospitals have stand-
alone PACS
 23% of the hospitals have a
PACS integrated in a national or
regional network
 Most regional networks are in
Nordic countries and UK
 TR is mainly present in countries
with regional networks
Source: EC eHealthBenchmarking III report, April 2011

7.  TR has become part of regular workflow in hospitals
or hospital groups with geographically split
locations
 Integration of hospitals in regional or national
networks facilitates the use of teleradiology
 In smaller hospitals it is mainly used for off-hour
readings and emergency readings
 National and international commercial TR providers
have emerged in the past decade, facilitating the
outsourcing of diagnostic readings

8.  Extensive German nationwide
trauma network linking more than
850 care providers
 While Germany has enough capacity
for treating severe trauma based on
the number of hospitals in the
country, these are not
geographically distributed to
provide trauma care to all citizens
 TKmed aims to deliver teleradiology
coverage for these trauma networks
 It is Germany's first nationwide
teleradiology network to
incorporate advanced security
architecture

9. Peripheral Hospital or Hospital group Teleradiology company
Private Imaging Centre Hospital w/ split locations Commercial network
Outsourcing
Second Opinion Outsourcing
On-call readings
Commercial
TR services
TR
Outsourcing
On-call readings
TR T
R
•On-call radiologist‟s home •In-house distribution workload •Medical professionals
•On-call radiologist‟s home •Patients
•Emergency readings, expert National
In-house opinions Regional International
Copyright E. R. Ranschaert®

10. According to the ESR, teleradiology applications
should be distinguished as:
when providing a patient a
remote primary interpretation of an imaging study
 In this situation there is a more or less explicit patient-doctor
relationship
: when providing a second
opinion or a remote expert consultation.
 In this instance, the relationship is between two
professionals or institutions.

11.  The applications that are
being developed in a number of Member States
are different from
 Regional teleradiology is based on a network of
multisite PACS belonging to the same
organization or to a consortium
 Integration with Electronic Patient Record ensures
access to clinical information.
 the regional nature of these projects favours the
contacts between radiologists and prescribers who
know each other and share agreed protocols.
 it allows optimization of resource allocation and
homogenization of quality throughout a region

12.  Online survey held in 2011
 Purpose:
 map the current usage of TR in Europe
 evaluate the current and future opinion about TR
 Methods:
 Online survey, SurveyMonkey®
 Social media, e-mail, ESR website
 Online for 1 month (Sept – Nov 2011)
 368 participants from 35 European countries

14. Teleradiology is used by 65% of the respondents
 “other” types
 Second opinions (3%)
 TR company (3%)
 On-call and emergency
 Primary reporting from
home
 Mammography screening
 Research

15. Other reasons (8%)
 Only for emergencies
 To avoid working time
breaches
 For mammo screening

16.  …other:
 university to county hospital
 to hospitals within region
 to affiliated hospital
 to screening centre

17. Agree Disagree
Possibility to ask for second opinion 82% 6%
Availability of radiologists (calls ,emergency) 72% 10%
Temporary capacity problems 69% 10%
Workload & lifestyle 66% 15%
Possibility to sub-specialise 54% 16%
Improved quality of services 49% 24%
Improved cost-efficiency 44% 20%
Practice becomesmore attractive 38% 23%

18. Agree disagree
Insufficient information (clinical, images) 69% 17%
Insufficient communication 68% 15%
Impersonal 55% 21%
Insufficient QA 44% 24%
Complexity of logistics involved 38% 28%
Unstable/insecure 19% 48%

19. Agree disagree
Loose control over business 60% 17%
Reduced quality of reports 54% 24%
Danger for urgent diagnoses 51% 26%
Instability of jobs& income 49% 15%
Negative for training of residents 48% 29%
Reduced Q of patient care 48% 28%
Loss of radiological skills 34% 35%

20. Agree disagree
Clear national & EU legislation 81% 6%
Obligatory Quality Assurance system 78% 4%
Further implementation IHE profiles 66% 2%
Obligatory training in TR 66% 14%
Usage of “common” TR platform 61% 6%
Obligatory double readings 57% 17%
TR only by EU radiologists 51% 21%

21. agree disagree
Yes 65% 12%
Yes if pricing and reimbursement is regulated 60% 16%
No, TR should be organised within member state 35% 38%
Yes commercial imagebrokers should be allowed to do this 33% 38%
No, should be freely allowed as commercial service 14% 63%

22. Advantages of TR in general improves collaboration
greater efficiency
Reasons for outsourcing as part of planned workflow
for second opinions
for night readings
Advantages of outsourcing possible to obtain second opinions
availability for night calls and emergency readings
possible to solve temporary capacity problems
Disadvantages of outsourcing insufficient information (history, EPR)
insufficient communication with clinicians
Threats & dangers of outsourcing loose control over business, fear for reduction of value of work
reduced quality of reports
How improve Quality of TR? clear national & EU legislation
obligatory QA system
Should cross border TR be allowed? yes if regulated within EU
yes if pricing/reimbursement

23.  Analysis of qualitative data:
 80% has (strongly) positive opinion
 46% thinks its importance will grow
 20% mentions the need for further standardisation
+ a better financial and legal regulation

24.  A wide usage of teleradiology throughout Europe is
perceived, however mainly for in-house purposes
 There is great demand for adapted EU-wide legislation, price
regulation and QA framework
 Although there is a overwhelming positive attitude towards
TR, less than 50% thinks that its importance will grow

25.  The real boost of teleradiology didn’t take place yet
 most TR activity is in-house (1,2)
 in EU it accounts for ≤ 2% of all procedures, in USA ±20%(3)
 >50 % of revenues comes from UK and Germany
 The demand for TR services is largely depending on
the need for radiologists:
▪ number of radiologists is growing with ±2%
▪ volume of radiological procedures is a increasing at ± 4% CAGR (4)
Sources: (1)P. Ross presentation MIR 2011, (2)ETR survey, (3)Frost & Sullivan, (4) The Moran Company

26. 1. Infrastructure: PACS, regional network
2. Demand for radiologists
3. Political climate
4. Cost of healthcare
5. Acceptance of TR services by radiological
community and patients

27. INHABITANTS / RADIOLOGIST
IN 2010(*)
Shortage:
 mainly in UK and Germany
 less in NL and Spain
(*) numbers include residents in training
Teleradiology - AnIntegral Part of eHealth Agenda in Europe
2 Jul 2011, Som SainathanKamalasekar, Frost&Sullivan

28.  Political acceptance of TR varies per country
 outsourcing is accepted by the public inpatient sector in the UK,
Germany, Italy, Spain, Norway and Sweden
 outsourcing remains politically difficult in other countries e.g. France
 TR grows where Ministries of Health are pushing new targets
 In UK the government's cancer and stroke goals necessitate carrying
out images and scans 24/7, thus boosting teleradiology reporting
 In the NL the government wants to bring 1st line diagnostic imaging
closer to the patient (extramural facilities), this will probably boost
teleradiology reporting

29.  The 'Europe 2020 vision' is opening the way for e-health, as
it is believed to have the potential to reduce public
expenditure on healthcare
 There is a coordinated effort to overcome the current
barriers
 An additional stimulus is provided for implementation of
standards to support sharing of medical information (e.g.
XDS-I and IHE-XDS)
 Teleradiology is therefore very likely to become an integral
part of healthcare delivery across Europe

30.  e-Health Action Plan (2012-2020)
 Concerns expressed by ESR (May 2011)
 Teleradiology is not properly regulated in Europe. The ESR requests that
due consideration is given to the specificities of teleradiology in order to
ensure utmost patient safety
 Teleradiology should be explicitly defined as a medical act in order to
ensure quality of care and patient safety
 The same level of guarantee, in terms of quality and safety, must be
applied to these services as compared to “standard” medical acts

31.  Increasing costs + decreasing budgets for HC
 TR is perceived as a relatively low cost solution
 in Sweden TR is ± 40% cheaper than hiring a locum
 growing demand to capitalise on available technologies
 Based upon these assumptions the total
teleradiology market is expected to grow 14.5%
between 2010 and 2017(1)
(1)Healthcare Europa, Frost & Sullivan

32.  Fear that radiology will be reduced to a “tradable
commodity” instead of medical act
 Low support in radiological community for cross-border TR
 Considerable uncertainties about teleradiology regarding
legal aspects, privacy & security
Several key issues need to be addressed to improve
confidence in and acceptance of cross-border TR
Source: Thesis Dr. Peeter Ross, “Data Sharing and Shared Workflow in Medical Imaging” Dec. 2011

33. €
Patient
Language
Lexicon
QA
Copyright E. R. Ranschaert®

34. 1. Quality: QA framework including standards and regulations
2. Privacy and Security: EU-wide harmonisation of regulations regarding
protection of personal data for cross-border services.
Information privacy remains the greatest source of concern.
3. Standards (IHE): platforms allowing seamless integration of PACS and EPR
for TR purposes, further implementation of IT-systems that are IHE-
compliant
4. Legal: uniform EU-Legislation regarding TR as “Medical Act”, protection of
patient’s rights
5. Financial: moreflexibility needed in financial regulations proper to
socialized medicine, different reimbursement schemes need to be
harmonised/adapted
6. Language: semantic interoperability needs to be solved, e.g. international
lexicon, standardisation of radiological terminology, translation software

35.  Define Teleradiology as a medical act in its own right
 Establish uniform accreditation criteria for teleradiology
providers throughout the EU
 Stress the importance of the delivery of high-quality
healthcare according to patient International quality
standards
 Address the necessity of careful monitoring and auditing
of service providers
 Clarify that the legal organisation of teleradiology is the
responsibility of the member state where the patient
undergoes the imaging procedure or telemedical referral
 Guarantee that patients are fully informed (informed
consent)

36. New generation
PACS: Advanced TR Patient-centric : Handheld
platforms with new applications
Online image archive
other specialties functionalities
Online consultations M-Health
(contracting,
Multidisciplinary procurement) Second opinions Mobile Teleradiology
conferencing

37. Source: www.imedicalapps.com, 14 Nov. 2011

38. Social /
Financial Public Comparative demographic
responsibility policy quality indicators Connectivity changes
Engaged patient Empowered patient
• Patient empowerment is an increasing and undisputed fact
• Patients are more informed and thus more opinionated
• Informed patients will shop for healthcare providers that meet their specific needs and
expectations
• Informed patients want more customization and move convenience
Acknowledgements to Dr. Jan SchillebeekcxMIR 2011 Nice 40

40.  Patient becomes manager of own online image archive
 Images can be presented to and interpreted by any doctor/specialist
 Redundant imaging procedures can be avoided
 Potential for savings in healthcare expenditures
 Development of new services for patients offered via
websites and apps:
 Second opinions in radiology
 More direct communication with radiologists is likely to evolve
 Increased availability of radiologists is needed: online consultation,
social media

41.  TR in Europe is there to stay
and its impact will increase
 Several key challenges need “Replace „I‟ with „we‟
to be solved to improve the
acceptance of TR and
 A clear regulatory framework illnessbecomeswel
is required to enable the use lness.”
of cross-border teleradiology
 Radiology departments
should be prepared for the Swami
“Copernican revolution” in Satchidananda
healthcare

42. 1. Ranschaert ER, Barneveld Binkhuysen FH: European
Teleradiology now and in the future: results of a survey,
InsightsintoImaging, Acceptedforpublication
2. Barneveld Binkhuysen FH, Ranschaert ER: Teleradiology:
evolution and concepts, European Journal of Radiology 2011
78(2) 205–209
3. European Society of Radiology (ESR). ESR 2006 VII Telerad
white paper,myesr.org, 2006.
erik.ranschaert@gmail.com
www.ranschaert.be