The audit about the accuracy of interpretation of emergency abdominal CT reports, which was published earlier this month in Clinical Radiology and reported last Wednesday by AuntMinnieEurope.com, raises concerns that all teleradiology companies providing out-of-hours reports, all departments using their services, and all National Health Service (NHS) organizations in the U.K. planning to implement regional out-of-hours solutions based on remote reporting should take seriously.
The quality of a report is not related to the reporting radiologist's location, Dr. George McInnes said.The audit analyzed data from 109 U.K. departments out of 188 who were asked to contribute, looking at 2,568 surgical and 2,363 nonsurgical cases -- the first 50 of each from every participating hospital from 1 January 2013. It found a statistically significant major discrepancy rate in reports issued by remote radiologists when compared with local consultants and even with local specialist registrars. The consequence of such discrepancies might result in unnecessary procedures including surgery for some and delay in diagnosis and/or treatment in others.
While recognizing that the provision of this outsourced service is necessary to plug the gap between demand and provision on a local level throughout the country, the audit drew the conclusion that: "It is clear that both the seniority and location of the reporter can have a significant effect on the accuracy of emergency CT reporting and hence patient outcomes."
Telemedicine Clinic (TMC) welcomes the publication of this audit, which recognizes the complexity of providing an out-of-hours service while acknowledging the need for such a service in the absence of sufficient local resources.
The relevance of the findings of the audit to our service is clear and our analysis of the audit results is as follows:
Case discussion, quality of referral, and reporting from different time zones
The authors highlight the higher rate of discrepancies in reports by radiologists who are not based in the referring hospital and conclude the "location of the reporter" can affect quality and patient outcomes. TMC acknowledges the remoteness of the reporting radiologist and the potential lack of close clinical correlation might affect the quality of the report, but does not agree the "location" of the radiologist must inevitably adversely affect the quality and accuracy of the report. The client hospitals for which TMC knows it provides the best service are those where there are clearly defined rules on who can make referrals so a specialist registrar (SpR) in radiology, or above, discusses the case with TMC radiologists.
Calls from very junior doctors where pertinent information is lacking and the rationale for scanning at night is questionable leads to inappropriate scanning and potential reporting discrepancies. The availability of pertinent previous imaging and reports is key to accurate reporting and TMC has rules in place to ensure these are available as they would be to a local radiologist.
TMC's main on-call reporting center is located in Sydney, Australia. We believe that, particularly with regard to complex abdominal scans, after detailed discussion between a senior referring clinician and the TMC radiologist, and with the provision of relevant previous imaging where available, the location of the radiologist can be an advantage, especially if that radiologist reporting cases scanned during the night is only working for TMC and is in a time zone where they would normally be awake at the time of the report.
Uninterrupted radiologists
As every radiologist knows, interruptions during the process of reporting complex scans lead to errors. When TMC identified this as a factor in discrepancy levels, action was taken to roster radiologists so a separate radiologist took calls from referring clinicians while others reported scans. This also gave the radiologist answering the calls more time to extract and record pertinent data on the referral and to act as a more effective gatekeeper just as a local radiologist would do, and as our clients expect us to do.
Radiological competence
Not all our radiologists are U.K. based or trained, which gives us a greater pool of talent from which to choose. However, all TMC radiologists are on the General Medical Council's specialist register, undergo appraisal and revalidation, and have passed a rigorous set of test cases before being accepted as part of our team. We do not employ radiologists who fail to reach this standard.
Audit/peer review
Our current policy is to have 10% of out-of-hours reports peer reviewed, meeting the standards of the U.K. Royal College of Radiologists (RCR). From January to November 2016, 8,937 cases were reviewed blind by a second experienced radiologist prior to comparison of the reports. The discrepancy rates in 2016 show 5% minor disagreement, less than 2% moderate disagreement, and no major disagreements, which is in line with rates in the published literature. Although this peer review cannot take account of subsequent clinical and surgical findings, the discrepancy rates do not raise concerns.
Learning from discrepancies
When discrepancies are found at peer review, they are brought to the attention of the radiologist concerned and discussed at a "learning from discrepancy" meeting run according to RCR recommendations from Sydney and by teleconference to other on-call radiologists. Our radiologists thus reflect on their discrepancies and learn from them. If problems persist, then further action is taken, rarely if necessary by terminating the contract.
Subspecialization
By economy of scale, teleradiology companies are better placed than individual hospitals to increase the level of subspecialist expertise in their service. With regard to this audit, this could mean a service that includes gastrointestinal radiologists. However, the emerging subspecialty interest of emergency radiology might be a model of subspecialization that better meets the needs of our client hospitals.
Exposure of radiology trainees to on-call experience
The paper correctly points out there is a risk that outsourcing might reduce the exposure of radiology SPRs to on-call work. With its directly employed radiologists, bespoke software, and experience at double reading and peer review, we are convinced that TMC is actually better placed to support trainees in providing a service than local consultants who are trying to sleep. This is an area where there is great potential and indeed support from the RCR and TMC would welcome approaches from enthusiastic partners.
Market penetration 2013 vs. 2016
The audit took place in early 2013, auditing reports from 109 hospitals when TMC had four U.K. on-call clients. Between January 2013 and December 2016, TMC's client base has increased considerably. In January 2013, TMC reported only 344 cases compared with 4,285 cases in January 2016.
Key points
- The quality and accuracy of the report is not related to the location of the radiologist reporting it, but to the quality of the referral, the availability of pertinent information, and the ability of the reporting radiologist to accurately interpret the images.
- Reporting from different time zones when consultant radiologists report during their daytime together in a team can have a positive impact on emergency reporting quality.
- Given the current and inevitable future gap between radiology demand and capacity in the U.K., outsourcing is here to stay.
- Involved only as a minor player at the time of the audit in 2013, TMC's internal peer review has not suggested a level of discrepancy to match the finding of this audit. Taking into account the data from this audit and learning from discrepancies as recommended by the RCR, we believe we are well placed to provide a timely and accurate service to meet future needs.
- TMC welcomes this comprehensive audit and where we do not already do so, we will willingly apply recommendation made in the paper in the anticipation of a repeat audit to show the effect of any changes.
- TMC enthusiastically endorses the need to support trainee radiologists and encourages departments to engage with us on how this might be achieved.
Dr. George McInnes is the U.K. medical adviser at the Telemedicine Clinic and consultant radiologist and clinical director at Poole Hospital NHS Foundation Trust, U.K.
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