This second survey sent to ESR members is more extensive and covers a wide range of topics and issues. A summary of the specific answers to the questions regarding these different topics is listed below.
Usage of teleradiology (TR)
The majority of the respondents (68.3 %) answered positively to the use of teleradiology (in- or outsourcing), whereas one third (31.7 %) answered that they did not use teleradiology (in- or outsourcing).
For outsourcing, 51.7 % stated that they did not use ‘TR outsourcing’, whereas 27.6 % indicated that ‘readings are outsourced from their backlog’, 23.4 % answered that ‘on-call readings are outsourced during nights and weekends’ and 6.8 % stated that ‘specialised readings are outsourced due to lack of experience’.
Almost half of the respondents (49.2 %) stated that both management and radiologists are involved in the decision-making process about outsourcing. One third (30.6 %) stated that solely the management decides on outsourcing. In addition, 13.7 % stated that the radiologists decide by themselves about when and how to outsource and about 4 % did not know about the decision-making process.
More than one third (32.5 %) of the respondents stated that their organisation uses TR insourcing, whereas 25.6 % stated it was used for ‘expert/subspecialty readings’, 21.5 % stated it was used for on-call purposes, and 13.8 % stated that work lists are being shared between private hospitals within the same hospital group. Almost a quarter (23.4 %) of the respondents stated that they do not use insourcing, and 8.5 % stated that they do not use in- or outsourcing at all, while 3.6 % stated that they did not know about the procedure.
There were 41.6 % that stated TR is not used for any other purposes, whereas 40.2 % responded that TR is used for providing expert opinions (business-to-business); 15.4 % stated that TR is used for teaching purposes, 12.1 % for scientific research, and 6,1 % for providing expert opinion directly to the patient. In addition, 8.3 % do not know about other purposes, and 0.6 % do not use TR at all.
For location, 44.1 % of the respondents stated that TR is used on a workstation in their hospital/department; 14.8 % stated that TR is used on a workstation located in the office of the TR company, 14.5 % responded that they use a combination of workstation, mobile device and own PC/laptop, and 1.2 % stated that they use a hospital-owned mobile device. Also, 12.7 % use TR at home on a professional workstation with equivalent performance to hospital PACS, 11.5 % use TR at home on their own computer, and 1.2 % use other private mobile devices (smartphone, tablet).
The vast majority of respondents (78.9 %) stated that TR reports are automatically incorporated in their PACS/RIS systems, whereas 17.8 % stated that the offsite radiologists communicate by phone, normal email, or other online technique (VOIP). Also, 12.4 % stated that offsite radiologists communicate via a secured e-mail system (e.g., DICOM-e-mail protocol adopted as a national standard in Germany or other third party secure Email systems) and 8.8 % stated that the offsite radiologist sends a report by fax, while 4.5 % stated that they did not know about the communication protocols used and 0.3 % responded that the offsite radiologists sends an SMS.
Additionally, 53.8 % of the respondents stated that the offsite radiologist can be contacted by phone on a 24/7 basis, and 10.6 % stated that the offsite radiologist can participate in multidisciplinary meetings from a distance using a secure online platform, whereas 9.1 % stated that the offsite radiologist brings visits to their hospital on a regular basis, and 7.9 % stated that the offsite radiologist is available for video-consultations, e.g., via Skype, GTM, or other software. Also, 16.3 % responded that there is no possibility to discuss the results with the offsite radiologist at all and 15.7 % do not know.
Furthermore, 64 % of the respondents stated that the referring clinician can contact the offsite radiologist, whereas 49.8 % stated that the radiographer contacts the offsite radiologist, and 48.3 % stated that local (onsite) radiologist contacts the offsite radiologist. According to 21.1 % of the respondents, the management contacts the offsite radiologist, and 13.3 % do not know about the procedure. Also, 2.1 % stated that the patient can directly contact the offsite radiologist.
Accessibility and quality assurance
For accessibility and quality assurance, 48.9 % of the respondents stated that the offsite radiologist has access to the PACS/RIS and, thus, is able to view prior studies and results, and 17.8 % stated that the offsite radiologist has access to all relevant patient information including electronic patient records and PACS/RIS. Also, 15.7 % responded that the offsite radiologist does not have access to PACS/RIS and prior studies cannot be viewed from elsewhere,and 7.6 % stated they do not know if offsite radiologists have access to prior imaging results and/or patient information.
Almost half (48.9 %) of the respondents stated that their organisation uses a quality assurance system for TR, whereas 32.6 % stated that they do not use a quality assurance system in their organisation for TR, and 20.6 % do not know whether their organisation uses quality assurance systems for TR.
Then 36.3 % of the respondents stated that they do not know what type of quality assurance systems are being used by their organisation for TR, whereas 26.8 % stated that offsite radiologists need to be registered in their country and need to follow the national guidelines for local accreditation, 16.3 % stated that double readings are made before sending the report and 14.5 % stated that random double readings are made by local radiologists. In addition, 13.5 % of the respondents stated that the offsite radiologist or teleradiology company needs formal approval of the medical staff/directors and 12.9 % stated that in their organisation the TR services are being audited on a regular basis and 9.8 % indicated other.
Satisfaction, advantages & disadvantages of TR
More than two thirds (62.7 %) of the respondents stated that they think that the referring doctors are satisfied with the TR services within their working environment, whereas 18.5 % stated that they did not know and 18.8 % stated that they believe that the referring doctors are unsatisfied with the TR services.
The majority of respondents rated ‘greater availability of radiologists’ as the most important advantage of TR, second is ‘faster turnaround time, clinicians get faster results’, ‘more easily availability of subspecialty knowledge’ is in third place followed by ‘improvement of the radiologist’s lifestyle’, ‘improvement of local radiologist’s workload’ and ‘the improvement of the overall quality of care’. Whereas ‘the improvement of the overall quality of radiology services’ seems to be the least accurate advantage to the respondents of the survey.
As regards the disadvantages of TR usage, ‘the offsite radiologists unavailability to participate in multidisciplinary meetings’ seems to be the most important disadvantage for the respondents of the survey. This is followed by ‘insufficient communication and contact with the offsite radiologist’ in second place, ‘insufficient contact with the patient’ in third place and ‘the insufficient access of offsite radiologists to clinical and/or historical patient data’ and ‘insufficient contact between the offsite radiologist and radiographers’ in fourth place. ‘Insufficient quality of reports’ and ‘patients feel unsafe / are insecure with TR’ mark the least relevant disadvantages according to the respondents.
Reimbursement, pricing, and competition
More than half (53.6 %) of the respondents stated that TR is not being reimbursed and that the hospital covers the costs, 23.4 % stated that they do not know whether TR is being reimbursed, 18.8 % stated that TR is reimbursed by a national or private health insurance, only 3 % stated that the radiologists pay for the TR services, 1 % stated that TR is only reimbursed in cases of ambulatory care and 0.3 % stated that TR is only reimbursed for scientific projects.
As regards the pricing arrangements, almost half (45.7 %) of the respondents stated that the hospital management is in charge of price negotiations. A quarter of the respondents (25.7 %) do not know who is in charge, 17.4 % stated that the negotiations are done by both management and radiologists, whereas 8.2 % stated that prices are fixed and non-negotiable in their country. Only 4.6 % of the respondents stated that the radiologists are in charge of the price negotiations and 3 % stated ‘other’.
According to 36.2 % of the respondents, radiologists earn additional private money through TR, whereas 30.3 % stated that radiologists do not get any additional payments through TR as it is included in the hospital/employee salary. Almost twenty percent (19.4 %) stated that they do not know how TR services are being paid for. More than ten percent (11.8 %) stated that TR increases their hospital salaries and 8.2 % stated that TR services are added to the total revenue/budget of the radiology dept. Only 3.9 % stated that TR services are used to fund a separate budget for the radiology team.
As regards the potential impact of TR on price competition, 32.9 % of the respondents stated that ‘TR is competitive and causing a downward pricing for radiology services’, whereas 29.6 % stated that ‘TR does not influence radiology prices’ and 30.3 % did not know about potential impacts on price competition. Also, 15.5 % stated that ‘lower pricing of TR companies enable hospitals to save costs via outsourcing’, and 1.3 stated ‘other’.
Potential threat by TR for radiologists
Almost thirty-five percent (34.9 %) of the respondents stated that TR is no threat for private/hospital based radiologists, whereas 30.9 % stated that ‘TR devaluates the radiology profession to a “commodity” that can be replaced’ and 20.7 % stated that ‘hospital managers are threatening radiologists with outsourcing and increasing the pressure on local radiologists’. In addition, 18.8 % stated that ‘commercial/private TR providers are even trying to replace local radiologists’ and 13.8 % fear that ‘younger radiologists will find fewer jobs in hospitals through TR services’. Almost one third (27.6 %) believe that ‘hospitals still prefer local radiologists for better services, although they could make savings with outsourcing’ and 7.6 % do not know if TR is a possible threat to local onsite radiologists.
Patient information and satisfaction
More than half (52.2 %) of the respondents stated that ‘patients do not know at all that TR is being used for outsourcing’ and 8 % stated that ‘the patients do not know that TR is being used for outsourcing, but the patients are aware that it is common practice to do so’, whereas 12 % stated that ‘patients are informed that TR services is being used for outsourcing but no approval by the patient is needed’ and 8 % stated that ‘informed consent by the patient is needed to use TR for outsourcing’, and 4.7 % stated ‘other’.
The vast majority of respondents (71.9 %) stated that they do not know if patients are satisfied with TR in their working environment, whereas 25.4 % stated that they believe that the patients are satisfied with TR and 2.7 % stated that they do not believe that patients are satisfied with TR.
Almost half (49.5 %) of the respondents stated that they do not know any cases where the patient refused TR, whereas 47.2 % stated that they never had the situation of patients refusing TR, and 3.3 % stated that they had the case where patients refused TR.
TR readings by non-radiologists
Almost sixty percent (59.9 %) of the respondents stated that they never experienced the situation of a ‘non-radiologist’ having to interpret the images due to unavailability of onsite radiologists, whereas 25.8 % responded that the referring doctors read the images, and the final readings are made by a radiologist in a later stage. Also, 5 % stated that the referring doctors read the images and no radiology report is made and 2.3 % stated that the radiographer does a preliminary read.
Cross-border/international TR and national/EU legislation
Almost forty-five percent (44.5 %) of the respondents are unaware of any existing legislative framework, regulations or guidelines, and 20.4 % stated that they do not know of any national rules in this regard. While 15.4 % stated that they are aware of the existence of national and European guidelines (ESR) and legislation (EU), whereas 13.2 % stated that they knew about the existence of the ESR guidelines (white paper) and only 3.5 % stated that they knew about ESR guidelines and EU legislation, and only 3 % stated that they knew about the existence of EU legislation.
More than half (55.3 %) of the respondents stated that all offsite radiologists need to be located in the country where the examination is performed and, thus, did not work with cross-border/international TR for FINAL readings (not preliminary or expert opinions). Also, 17.8 % do not know whether they worked with cross-border/international TR for FINAL readings (not preliminary or expert opinions). In addition, 10 % stated that images can be read from another country by a radiologist registered in the country of examination, 7.8 % stated that only for expert/research/scientific purposes, 6.7 % stated that images can be read from another country by a radiologists registered in any EU member state, and 2.4 % stated that indeed images can be read from another country by radiologists not registered in a non-EU member state.
As regards the EU legislation on the application of patients’ rights in the cross-border healthcare (Directive 2011/24/EU) regarding the registration of the offsite radiologist in the patient’s country, 42.3 % stated that they believe that the radiologist should still register in the country of the patient including radiologists working within the EU. Whereas 31.5 % responded ‘I don’t know’ and 24.3 % stated that the EU legislation regarding international TR in the European Union is clear to them and needs to be applied, but 2 % responded ‘other’.