In the United States, teleradiology is considered an external service that provides medical image interpretation, as well as an integral part of radiology services, particularly for smaller establishments. As Johnson (2010) resorts, “teleradiology was one of the first successful and practical “telemedicine” initiatives” (p. 1052). Being originally implemented as a tool to overnight service demand, the specialized software transmitting radiological images enables radiology practices to face the unexpected illness or recruiting difficulties. New models of the radiology services are currently developing to involve both night and day provision of radiology expertise between well-established institutions. Such an initiative is especially beneficial for pediatric radiology departments that traditionally focus on radiologists who need to conduct a technical expertise for various purposes. Although the invention implies mostly technical monitoring, teleradiology raises important legal, ethical, and practical debates, including confidentiality, competence, technological reliability, and data security (Ashcroft and Goddard, 2000). These issues can be considered in the context of radiological practice to make recommendations for establishing professional and teleological practice.
History of Teleradiology
Teleradiology has been analyzed for almost half a century and is considered the component of a broader concept – telemedicine – associated with the provision health care services distantly (Thrall, 2013). Major progress in development of computer systems and telecommunications, as well as advances in capturing digital information, has fostered the ability to implement telemedicine methods in an efficient and affordable manner.
In 1876, Alexander Graham Bell was pioneer in developing telephone systems, as well as a trigger of telemedicine development and assurance of distant communication between patients and providers, between stakeholders and physicians (Thrall, 2013). In 130 years, new methods and channels of communication have been explored in numerous applications of telephony devices. Specific attention requires extensive exploration of broadcast and closed circuit television as a precursors of teleradiology, transmitting medical images in 1960s (Thrall, 2013). In 1970s and 1980, telemedicine devices were gaining momentum, with increased interest in digital transmission of information. At this point, Thrall (2013) focuses on a store-and-forward approaches that have now become the foundation for teleradiology. According to the U. S. legislature, a licensed medical practitioner is eligible for conducting any medical procedure, involving the consideration of imaging studies (Johnson, 2010). The restrictions to procedure performance imposed by non-certified physicians are monitored by credentialing limits at individual and institutional levels. Generally, U.S. healthcare institutions do not confine the physicians’ ability to evaluating their patients’ medical images.
The rapid growth of popularity of using telemedicine technology dates back to the early 1990s, when Medicaid division of the U.S. Department of Health and Human Services made a decision to invest into medical imaging research. Before the changes in 1993, an overnight physician could present a quick interpretation of image in medical notes (Johnson, 2010). Then, the radiologist wrote a final report, but both the physicians and radiologists could bill for the services. Moreover, there should be additional services for communicating and settling disagreement between physician’s medical notes and the official report, which resulted in misunderstanding and legal violations. In addition, the 1993 HHS provisions lead to commercial insurance companies and HHS department itself to pay for the first submitted bill, creating new timing advantages (Johnson, 2010). The new forms of teleradiology continued expanding, but there were a number of licensing challenges for its further progress.
Due to the fact that telemedicine implies transmitting patient images across the states and abroad, a number of licensure constraints arise. In particular, the issue unveils whether a physician must be licensed in the country he/she is located, or the licensure procedure should cover the state in which telecommunication connection takes place. Such a controversy imposes certain risk on patient protection. In 1994, the American College of Radiology suggested that physicians who analyze teleradiology images should obtain a license for delivery of radiology services (Gobbins, 2002; Gobis, 2001). In addition, the College of American Pathologists recommended that a physician must be licensed in the state of his/her location (Gobbins, 2002). However, in case a physician has to deliver patient images to patient from other states, it should have to undergo both in-state and several out-of-state licensing procedures, as well as pay all registration fees (Gobis, 2001). In this respect, receiving multiple licenses is definitely burdensome. With regard to the above-presented challenges, several liability issues come to the fore. To begin with, great concern is connected with considering inappropriate licensing with malpractice (Berlin, 2010). Second, there are a number of problems connected with the legal shortcomings of interstate commerce.
In the 21st century, the medical community also focuses on licensure in a global context, which points to even greater difficulties with promoting this technology. Considering state legislation in the United States provides different solutions to the licensure issue. For instance, some states have accepted legislation corresponding to the ACR standards that require licensing in both obtaining and transmitting jurisdictions (American College of Radiology, 2013). Other states admit the possibility for out-of-state physicians to use teleradiological devices under restrictions of a specialized license. Finally, there are states that have adopted exceptions to the limitations, ignoring the need to introduce licensure to out-of-state physicians.
Within global perspectives, the adherence to the ACR standards is crucial for meeting the needs of international community. Besides, the transmission technology is closely associated with the globalization of process across the world. Further expansion of teleradiology will lead to the development of integrated health care institution that would control all processes through online and telecommunication networks (Alexander, 2007). The integration trends can complicate the licensure procedures because of the necessity of establishing new standards for all practitioners. This process is quite time-consuming because countries using this technology should reconsider their own legal and licensing issues, including registration fees, taxation, and ethics.
Traditional Radiology vs. Teleradiology
Numerous cases of radiological communication emphasize the inability of radiologists to accurately present information about patients through traditional reporting. Specific attention requires malpractice in terms of patient care that is presented by Berlin (2010). The scholars’ observations focus on the pitfalls of interpretation of radiography through emergency department physicians. The failure to diagnose and communicate the results of the radiological images becomes the result of 80 % of malpractice cases (Berlin, 2010).
Managing medical records is challenging in its own sense, but the emergence of computerized reporting and teleradiology contributed to the problem. Confidentiality and security issues referring to the increased threat of inappropriate disclosure of records, violation of privacy, illegal access to patient data, and verification problems should be addressed consistently. At this point, White (2002) insists on the idea that data security issues should be premised on privacy, authenticity, and integrity to protect patients from illegal use of information transmitted by telemedicine devices. Additionally, physicians should carefully reconsider the above-presented concerns and establish a greater control over the incoming information. Understanding the basic teleradiologic technology is vital for a physician to conceive the strengths and weaknesses of its application. Therefore, the role of physicians is confined to demonstrating proper American College of Radiology standard for specific diagnostic procedures that are transmitted via teleradiology.
The technical difficulties of remote teleradiology have been considered, and the practice of technologists who have been trained and qualified in the United States is now accepted as well. However, the challenges of licensure, reimbursement and credentialing determine whether telemedicine providers who were trained overseas are allowed to compete with the radiologists who complete training in the United States. Moreover, the definitions of out-of-state practice differ considerably and, as a result, there are no specific regulations and standards put facilities and technicians in serious danger (Cannavo, 2012). As a result, both technologists and physicians cannot reach a consensus about common standards that should be settled for conducting teleradiology practices.
Factors of Perpetuation
Advancements in computer technology and telecommunication
Although technological progress in telecommunications has opened new possibilities for transmitting digital images, ethical and legal concepts relating to innovation are contestable. As an example, White (2002) explores the limited practice guidelines relating to teleradiology in the UK. At this point, the point is that the current legislature fails to address equally the ethical and legal issues as it does other medical practices. Looking through the perspectives of such countries like the United Kingdom, Australia, and New Zealand highlights the potential gaps in the U.S. licensing issues, as well as those relating to patient care, responsibility, liabilities and duty.
Reconsidering legal and ethical background of telemedicine technologies implies the creation of new norms and standards for licensing health professionals. The common standards for nursing and medical licensures have become universal in all states, and physicians must graduate from nationally accredited educational programs to pass nursing licensure examination (Center for Telemedicine Law, 2003). Despite the existence of basic standards, there are considerable differences in filing and administrative requirements that can create challenges for health care professionals who seek to establish practices in several states. The limitations can be eliminated as soon as licensure options are reconsidered.
Improvements in Quality of Care
Electronic medical record (EMR)
Electronic medical recording of information radiologic images is an important condition ensuring security and protection of patient. However, introducing electronic reporting should be transparent, and physicians should be liable for the information they provide about the patient.
The failure to communicate and interpret digital images can lead to more lawsuits against radiologists and technologists. As a result, they should be more attentive to the issues relating to the use of teleradiology. In particular, “the radiologic technologists as a very important quality assurance, quality control role with respect to teleradiology” (Sabatini, 2009, p. 2). Understanding the consequences of inadequately transmitted information is vital producing a good image.
Engaging several stakeholders into the process of transmitting radiological images can contribute to accurate distribution of responsibilities. Coordination and constant interaction will also minimize the risk of inaccuracy and breach of patient confidentiality.
Physicians cannot base their decisions on radiologists’ readings because it can have profound consequences for radiologists who distribute distorted information. U.S courts are inclined to impose greater responsibility on hospitals that can lead to obstacles in developing teleradiology and other technological advances in medical service. In order to solve this issue, Center for Telemedicine Law (2003) advises two solutions – corporate liability and administrative compensation. The first option, defined as corporate liability, is premised on the fact that most powerful party concerned is product manufacturers because they take the most beneficial position for internalizing costs and improving the quality of medical services. The second option focuses on developing administrative compensation networks for victims of cyber malpractice in a medical setting.
One the one hand, the uniformly developed standards for telemedicine activities can lead to conflict situation between the states because of the fact of retaining the authority of individual states to establish behavioral, educational and competency requirements (Gobis, 2001). On the other hand, “a national licensure system with uniform requirements and a centralized data would permit physicians to practice anywhere in the U. S. without multiple license applications” (Gobis, 2001, p. 4). Despite the challenges created under the uniform governing, it is highly recommended to reconsider the requirements of separate state to eliminate malpractices and inconsistencies in telemedicine laws. It will also reduce the time on documenting the compliance with numerous interpretations of state laws.
Each medical establishment should develop a powerful protection strategy that seeks to improve organization’s information security through introducing good practices and eliminating the consequences of poor practices. At this point, HIPAA introduces a foundation for developing relevant organizational behavior that focuses on the accountability practices, but not on technology (Alexander, 2007). Hence, the main scope of supporting information security management programs lies in developing a set of skills, knowledge for insuring accurate information transmittance is vital for designing such information system as teleradiology. Under the provision of HIPAA, the radiologists and product manufacturers of teleradiologic equipment should be liable for the quality of information transmittance. In addition, HIPAA suggest that both physician and radiologist are responsible for privacy of the data they received about patients.
In case of malpractice of physicians and radiologists, the providers of teleradiology services should also be accountable for the quality of equipment and products they offer. Hence, efficient defense mechanisms should be employed to protect radiologists accused of malpractice in teleradiology information interpreting (Ottenwess & Taweel, PLC, 2013). In order to avoid malpractice, both technologists and radiologist should undergo enhanced education and training.
First major lawsuit involving Teleradiology
The bias of teleradiology information is underscored in the lawsuit filed by Robert Eversole II whose wife died three days after she was delivered to the Winchester Medical Center emergency department. According to the case, the doctors spent eight hours to receive a radiologic image of the patient to have asserted that the scan shows no deviations. The radiologist also approved the information, but the patient was still getting worse. Soon after, the doctors resorted to surgery to have found out that all abdominal organs are not supplied with blood. The case reveals the evidence of severe negligence and inappropriate interpretation of the information delivered by radiologists.
In order to manage the cases of malpractice and inaccurate data use, the law firm of Ottenwess, Allman & Taweel, plc, has focused on representing diagnostic imaging providers and radiologists (Ottenwess, A., & Taweel, 2013). In particular, the attorneys can consider the cases of provider’s encounter with legal barriers, as well liability and reimbursement issues relating to telemedicine procedures. Due to the fact that teleradiology ensures the flow of patient data across state borders, the Detroit attorneys can provide sufficient guidance to radiologists according to state laws controlling medical and licensing practice.
The legal and ethical implications for radiological communication refer to the cases of malpractice at hospitals. At this point, Berlin (2010) introduces examples of communication failure premised on inaccurate radiology results interpreted by physicians. Specific attention requires the case happened in California when a 58-year-old woman suffered from misinterpretation of physician’s results by radiologist. As a result of negligence, the patient was diagnosed with carcinoma in eight month after examination. Malpractice and negligence served the basis for lawsuit filed against radiologist’s failure to communicate with the physicians.
Global market demand for telemedical services is predetermined by economic changes. As a result, the international case study of legal and economic consideration in telemedicine refers two operational models, including “Nightwalk” and malpractice liability (McLean & Richards, 2006). According to the first model, both providers and those who apply telemedicine are equally liable for the quality of the medical services (Center for Telemedicine Law, 2003). In contrast, Indian operational model suggests that providers can avoid malpractice liability because of deeper price discounts. Hence, hospitals that rely on outsource services should pay closer attention to these differences to avoid conflict situations.
Teleradiology for the Future
On the one hand, teleradiology has a number of benefits in terms of efficient time management provided the standards for these services are uniform for all states. In addition, technologists should be regarded as obligatory stakeholders participating in the information exchange and should take a full responsibility for possible malpractice and negligence. The presence of the third party simplifies the process of information transmittance. All three actors – radiologists, technologists, and physicians should adhere to international standards because it contributes to faster data processing.
Lack of universality and common legislature for the teleradiology services does not ensure safety and confidentiality to patients. Besides, equipment and human factor cannot guarantee absolute accuracy of information. Therefore, the physicians cannot fully rely on the information they read from radiologic images. Rather, they should introduce new checking mechanisms to respond to legal and ethical issues.
The emergence of teleradiology has raised a great number of ethical and legal issues. To begin with, the U.S. government fails to recognize uniform guidance for licensing physicians and radiologists who are engaged into telemedicine services. Second, the presence of individualized state laws for licensing often leads to serious consequences. In particular, physicians should undergo a number of licensing procedures that can allow them to act at an interstate level. However, such a system hampers the quality of provided services because of great amount of time spent on multiple licensing. Finally, technologists should be involved into the process of licensing and information transmission to increase the quality and accuracy of the teleradiologic images. Such an approach requires developing new training programs that can enhance communication between the established stakeholders.
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