Sample Xray image of the spine viewed on a non-diagnostic monitor compared to the same spine viewed on a diagnostic monitor.

For the purposes of this article:

Teleradiology refers to the practice of a radiologist interpreting medical images while not physically present in the location where the images are generated.  The teleradiology service may be performed by hospital employed radiologists, a single contracted radiology group, or multiple radiology groups.  Many health systems have multiple hospitals interconnected and utilize a shared reading service across multiple sites. 

PACS (Picture Archiving and Communication System) refers to the computer system used to store and display radiology and cardiology exams.

Client refers to the radiologist group’s customer.  This could be a large health system, hospital, stand-alone emergency care center, urgent care center, breast center, or clinics; with which the radiologist group has a legal contract to perform imaging exam interpretation.

Who is the target audience?  Who should care about this?

Patients, Radiologists, Healthcare C-suite CEO, CMIO, CIO, CISO, CMO of Radiology, Health Care Legal Counsel, Medical Imaging Managers and Directors, PACS Administrators, Medical Physicists, Risk Analysts, Patient Advocates, Hospital Risk Management, Medical Malpractice Attorneys.

 

Exposing the increased risk to patients!  We must address the use of non-diagnostic monitors during the interpretation of radiology and teleradiology exams.

As a medical imaging technology advisory firm, we are seeing an increase in radiology groups offering teleradiology services to their clients.  While teleradiology services do provide a win-win relationship for both the radiologist and the client, there are significant considerations that must be addressed prior to the implementation of teleradiology services.

Over the years, we have advised and educated hospitals, radiology groups, radiologists, orthopedic providers, clinic managers, and PACS administrators as to the differences in diagnostic displays versus non-diagnostic displays.  And then we watched in horror as they go online to purchase cheaper monitors because they believe the picture quality should be good enough for reading exams.  Just because a monitor is 4K does not mean the monitor should be used as a diagnostic display.

So what’s the problem?

Many radiologists and orthopedic physicians are using non-diagnostic monitors to view and interpret exams.  This is a blatant disregard for patient safety!

When radiology became a digital technology governing bodies established important guidelines and requirements for reading exams via calibrated diagnostic displays.  Many of the recommendations and requirements are to ensure consistent image display from monitor to monitor and over time.   These standards are in place to improve patient safety and to minimize errors.  The potential for errors to occur increases significantly when a non-diagnostic monitor is used to interpret exams.

What’s the difference?

Diagnostic monitors have performance standards designed for the accurate display of medical images.  There are important subjects to cover which include: luminance, contrast, pixel pitch, uniformity, power stabilization, calibration, DICOM GSDF, auditing reports, maintenance, warranty, and support roles (vendor, site, physicist).   When discussing diagnostic monitors, it is also important to identify regulatory topics: FDA 510k filing for Diagnostic Monitors, ACR recommendations for monitors, and industry guidelines.  In our next post, we will go in-depth on the specific details of such topics including how to implement a quality program and hardware standards for diagnostic monitors.

Does it really matter?

Here is a real-life example of a teleradiology situation that happens every day:

Example:

Patient Amy has a chest cold with a cough, and her doctor orders a chest x-ray to rule out pneumonia. When Amy arrives at the hospital imaging center, she sees the best technology in use. The chest x-ray is acquired on a brand-new digital radiography system and within seconds the images are available. The study is transmitted from the x-ray machine to a million dollar PACS. The hospital contracts with a radiology group that has specialized reading. This specialized reading assures Amy that her images are being read by a radiologist that is highly trained in specific anatomic and diagnostic concerns. The study hits an “UNREAD” reading worklist in the PACS and then one of two scenarios happen:

Reading Scenario A:

Jeffrey Radiologist is covering the evening shift from home; and views the images using his personal laptop, which coincidentally doesn’t have virus protection running. Jeffrey Radiologist is enjoying picking up the evening shift from home because he can sit on the patio watching his kids playing in the back yard on a sunny evening. The sunlight is causing glare on the laptop, and the kids are playing soccer. You get the picture (loud, distracting, and the radiologist can’t clearly see the images on the screen). According to the notes in PACS, this is just to rule out pneumonia, which is easily discernable, and Dr. Jeffrey quickly reports the exam as negative. However, he inadvertently missed multiple tiny lung nodules. There are several reasons he missed it: the glare from the sunlight, the distraction from the kids, and the laptop monitor wasn’t capable of producing enough luminance to distinguish between the white and gray levels to see the early telltale signs of lung cancer.

Reading Scenario B:

Julie Radiologist, in the same practice, receives the notice on her reading worklist and proceeds to read the case from her simulated reading room at home.  The simulated reading room is like a sanctuary.  The room is darkly lit with controlled ambient light.  Julie is reading exams on a high performance and secured workstation with calibrated diagnostic monitors.  Julie’s monitors are calibrated according to the ambient light in the room to ensure accurate visualization of all anomalies.  Dr. Julie Radiologist clearly sees no pneumonia, and she easily sees the lung nodules on her diagnostic calibrated monitors.

Both scenarios occur every single day in health systems across the country. Thankfully, radiologists usually catch these missed anomalies during the comparison of older exams to new exams, albeit sometimes months and years later. When radiologists find these anomalies on old exams they will typically perform an addendum to the previous report, to correct the error or add the additional findings.

Non-Diagnostic Example of a Spine Xray viewed on a non-diagnostic monitor.
This is a sample image of an xray of the spine viewed on a non-diagnostic monitor.

As compared to this image:

Diagnostic Example of a Spine Xray viewed on a diagnostic monitor.
This is a sample image of the same xray of the spine viewed on a diagnostic monitor.

Can you see the difference?

Why does this happen, and who is responsible?

The client, the radiology group, and the radiologists themselves are equally to blame.  The client and the radiology practice often leave the purchasing decision up to the discretion of the practicing radiologist to determine which monitors to use at home while providing these teleradiology services.

Solution:  Put it in the contract!  Radiologist reading workstations and monitors should be addressed within the radiologist service contract with the client.   A proper contract should:

  • State that both onsite and teleradiology interpretation of exams must be performed from calibrated and managed diagnostic medical imaging displays.
  • State that the monitors must be diagnostic medical displays as marketed by the manufacturer.
    • To take the requirement a step further the radiologist may be required to use the exact same manufacturer, model, and support system used by the client (if the client is a health system with in house reading). This will establish consistency in image display, performance, auditing, calibration, and support.
  • State that the reading monitors must be calibrated on a schedule; daily, weekly, quarterly.
  • State that the reports from calibration, the physicist, and the auditing must be delivered on a quarterly if not monthly basis to the client to ensure stability and consistency of the monitor performance.
  • Define who will be responsible for purchasing the monitors and workstations for radiologists at home use.  Do not leave it up to individual radiologists within a group.
  • Define who will be providing the installation, calibration, performance standards, auditing, upgrades, testing, validation, and support of the monitors.

What do the radiology groups care about? Costs. Period.

I know it sounds harsh, but it’s true.  When they have to purchase medical displays, radiologists and radiology administrators seem to only care about the cost of the medical displays.  Diagnostic medical displays have a moderately higher cost then clinical review monitors and a significantly higher cost then commercial off the shelf (COTS) monitors.  Perhaps, they should look at it from a different perspective.

Teleradiology Example: Cost of Monitors vs. Cost of Litigation.

Radiologist Income From Working 1 Evening Shift of 4 Hours per Week 

Evening coverage in a rotation during peak time = $300/hour + bonus  time off

  • $300 x 4 hours x 50 weeks: $60,000
  • 5 Year Total Income working 4 hours per week: $300,000

Cost of Diagnostic Workstation

  • Cost of tax deductible PACS workstation + diagnostic monitors = $10,000 – $50,000 (depending upon configuration)
  • 5 Year Adjusted Gross Income: = $250k – $290k with diagnostic equipment.

Cost of Non-Diagnostic Workstation and Monitors

  • Cost of workstation and non-diagnostic monitors = $1,000 – $5,000 (depending upon configuration)
  • Lawsuit for missed diagnosis = $1million – $20million
  • Getting your name in the paper = Priceless.
  • Tarnished reputation for using non-diagnostic monitors (lost revenue from referrals or patient reviews, the practice looks cheap, poorly managed, and trying to save a buck and missed a cancer diagnosis) = Priceless.

What should the radiology group and radiologist care about when using non-diagnostic displays?

  • Cost of poor reputation for using non-compliant technology
  • Increased costs of missed diagnosis (false negative reports)
  • Increased costs of litigation
  • Increased risk of errors in diagnosis
  • Increased patient safety risk in radiology
  • Increase in false negative reports (missed a finding)
  • Decrease quality scores in radiology
  • Decreased patient safety
  • Decreased patient trust
  • Decrease in accurate and consistent interpretation of radiology exams
  • Decrease in patient satisfaction in radiology

Why do diagnostic medical imaging displays cost more than regular off the shelf displays?

There are several factors that contribute to the costs of medical displays such as the following:

  • Research and development
  • Specialized technology to maintain display performance over the warranty period
  • Strenuous testing to meet performance standards
  • Regulatory compliance
  • FDA requirements
  • Marketing and consumer education to ensure appropriate use of the technology to provide care

Patients trust their providers, providers should honor that trust.

Patients trust hospitals and physicians to use the best technology to diagnose and treat their illness, no matter where the care is being provided. Radiology and teleradiology are no exception to this quality standard.

Patients and referring providers must be able to trust the quality of the radiology report, therefore, interpreting providers should include the workstation identifier (hostname) and monitor calibration report reference # in the diagnostic report.  This will allow the patient and even the patient attorney to request and receive the calibration report for the monitors that were used during the interpretation of their exam.   This process will help to ensure patients are receiving the highest quality care in radiology.

As consumers and patients are becoming more informed, the use of non-diagnostic displays in radiology will undoubtedly cause an increase in legal liability for the interpreting physician and their clients.

 

Stay tuned…  In upcoming posts we will detail how to include diagnostic workstations and monitors in your radiology quality program!  

 

Contact us today to request assistance in reviewing your medical imaging hardware for compliance and risk assessment.

 

Additional Resources:

https://www.healthcaretechsolutions.com/product-category/monitors-displays/ 

https://www.millerandzois.com/malpractice-lawsuits-against-radiologists.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2999012/

https://www.nolo.com/legal-encyclopedia/medical-malpractice-misdiagnosis-delayed-diagnosis-32288.html

https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Elec-Practice-MedImag.pdf

https://www.acr.org/-/media/ACR/Files/Practice-Parameters/rad-digital.pdf?la=en

https://www.fda.gov/media/95527/download

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