Medico-legal issues Medico-legal issues in Teleradiologyin Teleradiology

Aditya DaftaryAditya Daftary

Teleradiology SolutionsTeleradiology Solutions

TeleradiologyTeleradiology

• Needs no introductionNeeds no introduction

• Teleradiology is a means of Teleradiology is a means of electronically transmitting electronically transmitting radiographic patient images and radiographic patient images and consultative text from one location consultative text from one location to another*to another*

*http://www.radiology.uiowa.edu/MoreRAD/Teleradiology/Tele.html

Goals of TeleradiologyGoals of Teleradiology• Providing Providing timely consultative and interpretative timely consultative and interpretative

radiologic services radiologic services • Making radiologic consultations Making radiologic consultations available in medical available in medical

facilities without on-site radiologic supportfacilities without on-site radiologic support• Facilitating radiologic interpretations in Facilitating radiologic interpretations in on-call on-call

situationssituations• Providing Providing subspecialtysubspecialty radiologic support as needed radiologic support as needed• Enhancing Enhancing educational opportunities educational opportunities for practicing for practicing

radiologistsradiologists• Promoting Promoting efficiency and quality improvementefficiency and quality improvement• Providing interpreted images to Providing interpreted images to referring providersreferring providers• Supporting Supporting telemedicinetelemedicine• Providing Providing supervisionsupervision of off-site imaging studies of off-site imaging studies

Medico-legal Issues in Medico-legal Issues in TeleradiologyTeleradiology

• The good news:The good news:– A lot of it is still unclearA lot of it is still unclear

• The bad news:The bad news:– We’re dealing with lawyers!We’re dealing with lawyers!

Conceptually simpleConceptually simple

• Imaging data acquired at one siteImaging data acquired at one site• Network transmits images to a Network transmits images to a

serverserver• Data can be reviewed and Data can be reviewed and

interpreted at a remote siteinterpreted at a remote site• Report generated and transmitted Report generated and transmitted

electronically back to the parent siteelectronically back to the parent site

Many a slip….Many a slip….

• QualificationQualification• Liability and InsuranceLiability and Insurance• Radiologist dutiesRadiologist duties

QualificationQualification

• Varies Varies – Country (US, Singapore, UK)Country (US, Singapore, UK)– StateState– InstitutionInstitution

• Law can be a little vagueLaw can be a little vague• Best to be safe: full qualification in Best to be safe: full qualification in

geographic area and institute for geographic area and institute for whom one is interpretingwhom one is interpreting

QualificationQualification

• Medical board certification:Medical board certification:– USMLE/LMCC/recognized MBBSUSMLE/LMCC/recognized MBBS

• Specialty qualification:Specialty qualification:– ABR/RCPS/FRCRABR/RCPS/FRCR

• Subspecialty qualification:Subspecialty qualification:– Certificate of added Qualification (CAQ)Certificate of added Qualification (CAQ)

• LicensureLicensure• CredentialingCredentialing• CMECME

Medical Liability Medical Liability Insurance: Why?Insurance: Why?

• Establishment of a physician-patient Establishment of a physician-patient relationshiprelationship– No case examples, but probably YESNo case examples, but probably YES– You are being consulted and you are getting paid!You are being consulted and you are getting paid!

• Jurisdiction for accountabilityJurisdiction for accountability– Where do you get prosecuted? Texas or India?Where do you get prosecuted? Texas or India?– May not be teleradiologist, but definitely parent May not be teleradiologist, but definitely parent

hosp/grouphosp/group– UK-Europe: Primary/alternative siteUK-Europe: Primary/alternative site– No case examplesNo case examples– Not too many people going to put themselves on Not too many people going to put themselves on

the line for you!the line for you!

Liability InsuranceLiability Insurance

• Covers one against possible litigationCovers one against possible litigation• Find someone willing to insure off site/off Find someone willing to insure off site/off

country reading: not much experiencecountry 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 On site group to get clearance from their

insurerinsurer• Teleradiologist must have coverageTeleradiologist must have coverage• Terms of coverage must be very clearTerms of coverage must be very clear

Medical Liability: Medical Liability: RadiologistRadiologist

• The teleradiologist is as liable as any The teleradiologist is as liable as any other radiologist in the given settingother radiologist in the given setting– Technical issuesTechnical issues– Interpretation and missesInterpretation and misses– CommunicationCommunication

Medical Liability: Medical Liability: TechnicalTechnical

• Much of this is now redundant, but there are a few Much of this is now redundant, but there are a few areas:areas:– Image acquisitionImage acquisition

• Digitized radiographsDigitized radiographs• Unsupervised ultrasoundUnsupervised ultrasound• Patient motionPatient motion• ContrastContrast

– Image transmission/viewingImage 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, Appropriate viewing stations: mammography,

radiographs, MPR needradiographs, MPR need

– Patient privacy, data encryptionPatient privacy, data encryption– Preliminary versus final readPreliminary versus final read

Medical Liability: Medical Liability: Interpretation and Interpretation and

CommunicationCommunication• Teleradiologist has a duty to communicate Teleradiologist has a duty to communicate

as effectively as any other radiologistas effectively as any other radiologist• Typical communication by written reportTypical communication by written report

– Reports to includeReports to include• Patient demographics, procedural details, relevant Patient demographics, procedural details, relevant

findings, impression (unless short)findings, impression (unless short)

– Preliminary reportsPreliminary 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 Must provide information to deal with immediate

carecare

http://www.acr.org/s_acr/bin.asp?CID=541&DID=12196&DOC=FILE.PDFhttp://www.acr.org/s_acr/bin.asp?CID=541&DID=12196&DOC=FILE.PDF

Medical Liability: Medical Liability: Interpretation and Interpretation and

CommunicationCommunication– Non routine communicationsNon routine communications

• Situations:Situations:– Findings needing immediate interventionFindings needing immediate intervention– Discrepant from prior reportDiscrepant from prior report– Unexpected, but serious findingsUnexpected, but serious findings

• Direct conversation best; others (fax, pager. Direct conversation best; others (fax, pager. email etc) less reliableemail etc) less reliable

• Must be documentedMust be documented

Medical Liability: Medical Liability: Minimizing ErrorMinimizing Error

• Preliminary reports to include relevant Preliminary reports to include relevant issues, small details not necessaryissues, small details not necessary

• Call when in doubt/something seen laterCall when in doubt/something seen later• Ask for additional/repeat imaging as Ask for additional/repeat imaging as

neededneeded• Recommend appropriate clarification Recommend appropriate clarification

studiesstudies• Everyone misses…have a good QA Everyone misses…have a good QA

system in placesystem in place

SummarySummary

• Teleradiology is an excellent empowering Teleradiology is an excellent empowering technology which enhances patient caretechnology 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)Do not compromise patient care (primum non nocere)– Appropriately qualified radiologistsAppropriately qualified radiologists– Clear contracts and insurance a must to cover Clear contracts and insurance a must to cover

liability issues liability issues – Efficient communication in a clinical settingEfficient communication in a clinical setting– Quality assurance programmeQuality assurance programme– A very friendly lawyer!A very friendly lawyer!

Questions?Questions?