TSR Guidelines for the Practice of Teleradiology: 2021 Update*

Diagn Interv Radiol 2021; 27:504-510 GENERAL RADIOLOGY © Turkish Society of Radiology 2021 COMMENTARY

TSR guidelines for the practice of teleradiology: 2021 update*

Mustafa N. Ozmen ABSTRACT Oğuz Dicle This update of Turkish Society of Radiology’s (TSR) guidelines for the practice of teleradiology Utku Şenol is intended to provide a reference framework for all parties involved in delivering imaging services away from the immediate vicinity of the patient. It includes relevant definitions and Üstün Aydıngöz general principles, features organizational modes and qualifications of the practicing parties, lists technical issues, and addresses such management and legal aspects as archiving and documentation, security and privacy, reliability, responsibilities, quality inspection and improvement, reimbursement and accountability.

uidelines in the form of standards for the practice of teleradiology in Turkey were first published in 2010 (1). This decennial update was prepared in consideration of G the evolving nature of imaging technologies and medical informatics as well as the changing character of the patients’ and public’s demands. These guidelines have been prepared with the aim of providing advice on the appropriate use of teleradiology applications, thereby increasing the impact of their contribution to public health. They comprise recommendations and are not intended to fill legal gaps. They are prepared—and expected to be implemented—with a view to highlighting a patient-oriented and good clinical practice approach. The application of other requirements and prerogatives not defined in these guidelines, specific to any clinical situation, is at the discretion of the responsible physician who performs or oversees the radiological service or renders its interpretation. Provided that they are carried out in accordance with guidelines, teleradiology allows the reporting of radiological examinations in a shorter time, renders this process possible independent of time and place, facilitates easy consultation when necessary, and makes possible continuous training and assessment/appraisal processes. Thanks to teleradiology, users in different locations can view radiological images simultaneously. Teleradiology is a means of maintaining health service without interruption during disasters and other extraordinary circumstances (2–6). The use of teleradiology should not diminish the radiologist’s responsibilities for the supervision and management of the entire process of radiology service, which comprises steps to select the most appropriate examination for the patient, to make the examina- From the Department of Radiology (M.N.Ö.  [email protected], Ü.A.), Hacettepe tion at the most appropriate time and with the pertinent protocol, to prepare the patient University School of Medicine, Ankara, Turkey; for the examination, to select and prescribe the appropriate contrast material when its Department of Radiology (O.D.), Dokuz Eylül University School of Medicine, İzmir, Turkey; use is beneficial, to perform the examination in a way that minimizes the harm, especial- Department of Radiology (U.Ş.), Akdeniz University School of Medicine, Antalya, Turkey; On behalf of the ly radiation, to the patient and staff, to provide on-site supervision and quality control Turkish Society of Radiology’s Imaging Informatics of the examination, to evaluate the images from the examination in light of clinical and Education and Research Group. laboratory information and previous examinations, to communicate the imaging find- * These guidelines were endorsed by the TSR Executive Board on May 15, 2021. ings by preparing a report that includes differential diagnosis and recommendations, and to archive the patient’s radiological images and report with appropriate methods. The Received 24 May 2020; accepted 26 May 2021. radiology report is an intermediate yet integral product of this service. Teleradiology ap- Published online 24 June 2021. plications should be carried out in a way that ensures the integrity of these steps at the DOI 10.5152/dir.2021.20570 highest possible degree.

You may cite this article as: Özmen MN, Dicle O, Şenol U, Aydıngöz Ü. TSR guidelines for the practice of teleradiology: 2021 update. Diagn Interv Radiol 2021; 27:504-510 504 Definitions Outsourced teleradiology service mod- responsible for the patient and submitted el: Teleradiology applications in which the as a written report. This service is not nec- Telehealth: All services and information radiological examinations obtained in an essarily limited to a single episode of imag- exchanges that can take place, regardless institution are evaluated by way of a con- ing; it can be in the form of comparatively of location, throughout the life of a target- current or nonsimultaneous service to be evaluating the examinations performed on ed individual relevant to their health pro- received from outside the institution. the patient at different times. Alternatively, tection, disease treatment and disability Source radiologist: Onsite radiologist consultation may entail a phase or aspect of management by the use of information and who is required to be present at the sender the radiology service earlier than the image communication technologies. party and is responsible for patient commu- acquisition. Telemedicine: A subfield of telehealth nication and supervision of the radiological Secondary opinion: The billable service encompassing all applications whereby examination including the latter’s appropri- of rendering professional opinion by a ra- health services are carried out remotely ateness, vetting, and planning. diologist, different from the one that made through information technologies, regard- Teleradiology performed with diagnos- the primary reporting, performed upon the less of location. tic equipment: Teleradiology applications request of a patient, their legal guardian/ Teleradiology: A subfield of telemedi- performed onsite or offsite in personal of- relative or any other legitimate entity such cine comprising applications that allow the fice/home spaces via workstations with dias an insurance company, sports club, or digital transfer, storage, processing, evalua- agnostic monitors. legal firm. This is not a health service and tion, and reporting of radiological images Teleradiology performed with non-di- should be considered as an independent and related information to a different place agnostic equipment: Teleradiology appli- professional opinion on a specific subject from where they were obtained. cations that technically provide image and and not a radiology report per se. Social se- Sender party: The party that performs ra- other data sharing onsite or offsite in per- curity institutions are not expected to pay diological examinations and sends images sonal office/home spaces, via equipment for this service in patient-related payments. to another party along with related infor- with non-diagnostic monitors such as per- The price is borne by the party requesting mation for the purpose of reporting, con- sonal computer and mobile phone. the opinion. sultation or obtaining secondary opinion. Radiology service: The entire process Expert opinion for a legal prosecu- Receiving party: The party that writes that starts with the requisition of a radiolog- tion or administrative investigation: The reports for or is consulted on medical im- ical examination for the patient, including billable service of rendering professional ages. scheduling, admission, patient preparation, opinion by a radiologist, different from In-house teleradiology service model: vetting, examination, quality control, re- the one that made the primary reporting, Teleradiology applications performed si- porting, timely transmission of all relevant performed upon the request of a legal or multaneously or at different times by the output (including report and images) to the administrative body. This is not a health ser- employees of the institution using the insti- referring clinicans and archiving. vice and should be considered as an inde- tutional picture archiving and communica- Radiological examination: The section pendent professional opinion on a specific tion system (PACS) onsite or offsite. of the radiology service starting with the subject and not a radiology report per se. patient’s entrance into the radiology ex- The price, when applicable, is borne by the v amination room and progressing until the party requesting the opinion. Main points images obtained are sent to the PACS. This Preliminary (provisional) report: A fast, • On account of the evolving nature of imaging also includes quality check. concise and goal-oriented reporting that technologies and medical informatics as well Reporting: Part of the radiology service is mostly used in emergency departments as the changing character of the patients’ and whereby medical images are interpreted in and situations. After the provisional report, public’s demands, teleradiology guidelines light of clinical and laboratory information primary reporting is made by the same or followed in a country or territory need to be and put into an actionable text. (an)other radiologist(s). periodically updated. Primary reporting: The process of re- Addendum: Additional report created af- • Teleradiology guidelines should take into porting the radiological examination by an ter approval of the primary report, when a account the legal framework governing the practice of medicine in a country or territory, authorized radiologist who is responsible change, clarification or correction becomes while observing universal human rights. for the entire radiology service. necessary for any reason. Once the prima- Expert opinion: Opinion given by a ra- ry report is approved, it should be stored • Teleradiology should utilize contemporary data transmission, hardware, software, and diologist (with specific expertise on a sub- in such a manner that it cannot be altered. user interface technology, while ensuring ject), different from the primary reporting An addendum stands distinctly apart from, data security and patient privacy. radiologist, upon the requisition of the but also visibly along with, the primary re- • Teleradiology should not be misconstrued as latter. The opinion and the identity of the port in electronic patient records. Identity a means to diminish and devalue the central expert should be explicitly mentioned in of the approving radiologist and time (date, role of radiologists in the provision of imag- the report of the radiological examination hour:minute) of the approval should be ex- ing services for patients. in question. plicitly mentioned in the addendum. • Prioritizing the good of the patients in terms Radiological consultation: The billable Electronic signature (e-signature): A le- of health care, which is the most ancient and service of rendering professional opinion gal identity verification system in the form universally acknowledged principle of medi- by a radiologist, different from the one of electronic data, used for authentication cal ethics, needs to be the ultimate guiding principle of teleradiology. who performed the primary reporting, purposes in lieu of a wet signature in elec- performed upon the request of a clinician tronic/digital environment.

TSR guidelines for the practice of teleradiology • 505 General principles m. Continuous quality improvement and is suitable for such non-standard use a. The main purpose of teleradiology is should be an integral part of teleradiology may be employed as well. Teleradiology to provide the dissemination of qualified services. applications can be divided, according to radiological services for the benefit of pa- the properties of their components, into tients and society by using the opportuni- Modes of teleradiology three groups as those using diagnostic or ties provided by information technologies applications non-diagnostic equipment or a hybrid of and informatics. With the developing technology and busi- these two. b. The primary goal of teleradiology service ness models, the methods of teleradiology A third classification of teleradiology ap- provision is to make radiology processes diversified over time. Today, it is possible to plications is according to the purpose of meaningful as a whole and to design them classify the modes of various teleradiology service. The point of discrimination here in a way that ensures this integrity. applications under three categories, namely is whether the service is used for primary c. Teleradiology should not be used to com- the business model, the hardware infrastruc- reporting, expert opinion or radiological pensate for scarcity or absence of radiolo- ture or the purpose of service. consultation. In addition, as stated in the gists. With regard to their business model, tel- definitions section above, teleradiology d. A source radiologist should be present at eradiology applications can be divided into can also be used for generating preliminary the sender party who, in addition to their two as internal or external. Teleradiology (provisional) reports or addenda. Other aforementioned roles, is responsible for the applications in which the service is carried uses of teleradiology, which are not consid- timely communication of urgent or unex- out in-house involve images obtained from ered health care services, include reporting pected findings. Under such circumstances single or multiple institutional unit(s) by the in the form of secondary opinion or expert as disaster, extraordinary conditions and use of the infrastructure and evaluation by opinion for a legal prosecution or adminis- specific screening programs (e.g., screening the radiologists of the institution, usually trative investigation, and meeting educa- mammography), source radiologist may through a single PACS, inside or outside the tional demands. not be present. institution (at their office or other personal e. In-house teleradiology use should be living spaces such as home). Teleradiology Qualifications of the practicing focused on patient benefit and quality of applications can also be carried out by the parties service. same radiologist at another personal living In order to ensure that both service pro- f. Patients and their legal guardians are en- space such as home by continuing an imag- viders and receivers can produce health titled to have information about the out- ing assessment that the radiologist initiated care services meeting the established stan- sourced teleradiology service provided. within physical confines of the institution. In dards, implementation of individual and in- g. Teleradiology service should be carried such applications, access to patient clinical stitutional training, certification and accred- out in a manner that protects patients’ per- data is relatively easy and straightforward. itation procedures should be encouraged. sonal and health information within legal On the other hand, teleradiology applica- Radiologists involved in teleradiology and ethical frameworks. tions where the teleradiology service is out- services should be trained in the field of h. Reports and other relevant outputs pro- sourced are also quite common. Here, the teleradiology. The training for this purpose duced by the teleradiology service should produced radiological images along with should entail the technical requirements of be stored without loss and in an easily acces- clinical data are shared with an external ser- teleradiology, patients’ rights, legal regula- sible/retrievable way. vice provider, who ensures the review and tions governing the protection of personal i. Elements that play a role in providing tel- reporting of the radiological examination. data, ethical rules, and an awareness of the eradiology service (e.g., service provider Although this method generally increas- unintended consequences that might arise company, network environment used, cer- es the speed of radiology reporting, it can from wrong practices. tification, radiologist information) should be cause various problems as it significantly dis- There should be a sufficient number of included in the patient’s examination report. rupts the integrity of the radiological service. radiologists for the workload that the ser- j. Teleradiology service should be designed In terms of their hardware infrastruc- vice is supposed to cover. by the relevant institutions and parties in a ture, teleradiology applications can be way to at least maintain and preferentially performed with a diverse set of compo- Technical issues raise the health service standards and be nents. The main hardware components of Once acquired, radiological images are priced in a fair way that confers the labor teleradiology are the sending web server, stored in local or institutional archives therein its due value. institutional firewall, transmitter network, (PACS). Cloud-based archiving systems are k. Teleradiology service should be carried and reporting radiologist’s computer and also being used with increasing frequency out under the supervision and control of the monitor. Dictation and report output tools for this purpose. The conformity of data relevant public and/or private authorities. are among the subcomponents of this in- storage to the stipulations of the Turkish l. In education and research institutions, frastructure. Each of these components has Law (No. 6698) on the Protection of Person- the in-house or outsourced teleradiology application-specific requirements for image al Data should be assessed and ensured by services should not be allowed to inter- quality and patient data security. There may the organization where the teleradiology fere with education and research activities; be diagnostic and medical standards for service is utilized (7). Whenever there is out- precautions and/or regulations should be each component; an array of equipment sourcing of this service, the teleradiology established to ensure the obviation of such that, although not intended for this spe- service provider is obliged to ensure such interference. cific purpose, can nevertheless do the job conformity.

506 • July–August 2021 • Diagnostic and Interventional Radiology Ozmen et al. Teleradiology operations require an ap- standards. In such applications, the systems should be monitored and, when necessary, propriate network structure that provides belonging to both parties should work in updated regularly to ensure appropriate rapid data transfer in the broadband range harmony and there should be no manual image quality. while ensuring the confidentiality of pa- applications in the workflow. For example, tient data. The basic information system when the patient reports are created and Reporting console used in teleradiology operations should be sent and the report–patient matching is The screens on which the technologist designed taking into account the issues of done manually (in a setting whereby HL7 who performs a radiological examination, speed, back-up, security, reliability and con- communication is not used), this carries the the radiologist who makes the reporting fidentiality. risk of misfiling the report to the electronic in-house or by remote access, and the clini- In order for the radiologist at the receiv- patient record that is not the intended pa- cian who accesses the images are generally ing party to access the images without loss, tient’s. DICOM e-mail system or secure web similar. However, the screen on which ra- both data transfer and monitor characteris- services can be used for this purpose. diological evaluation and reporting is made tics need to comply with the recommend- 3. Integrating the Healthcare Enterprise is especially important in terms of spatial ed specifications. Requisition information, (IHE) supported protocols: IHE is a non-prof- and contrast resolution. These features are prior diagnostic images and all relevant in- it organization established to provide in- determined by the software as well as the formation in the patient’s electronic records teroperability in the health system. The characteristics of the monitor and graphics have to be accessible. IHE’s XDS (Cross-Enterprise Document) and cards (8–11). Workstation and screen fea- XDR (Cross-Enterprise Document Reliable tures can be listed as follows: Data transfer Interchange) integration profiles define the Data transfer in teleradiology can be safe performance of such data transfers. Workstation done in several different ways (3): When the information systems of both par- a. Graphics bit depth: The greater the bit 1. Virtual private network (VPN): This type ties support these protocols, data transfer depth that the card and display can sup- of transmission is the most suitable method occurs smoothly. Medical device manu- port, the greater the depth of gray, red, for remote access of the radiologists to the facturers and health informatics produc- green, and blue. For example, 16.4 million images obtained in their institutions, as it ers make sure that their products support colors can be featured in an 8-bit system, is usually required for out-of-hours remote many different IHE protocols with the main whereas in a 10-bit system this exceeds 1 assessments or pandemic or other disas- purpose of ensuring interoperability. billion. However, in the studies conducted ter situations. After establishing the VPN 4. Remote desktop access: This is an appli- so far, from the diagnostic standpoint, no structure of the institution, the radiologist cation that provides remote access (as with significant difference has been shown in remotely connects to the PACS, Radiology VPN) to all health data of the institution systems over 8 bits. Information System (RIS) and Hospital In- through a desktop device within the insti- b. Graphic card connection: Liquid crys- formation System (HIS) in the institution to tution. This can cause serious problems in tal display (LCD) or organic light emitting which he is connected, and performs the institutional data management and securi- diode (OLED) screens used in radiology works on the job list remotely as if in the ty. Healthcare institutions should not allow practice today work with digital data. For institution. Its greatest advantage is that such an approach by their employees and this reason, digital transfer of data from the it does not require the image and other should design and install secure connec- card, where digital data is produced, to the information to be copied and reproduced tion systems. It should be made clear that screen is the most suitable. For this pur- on another system. VPN also provides the employees and managers will face medico- pose, HDMI, DVI-D or display port connec- necessary security measures in the cyber legal problems in cases where institutional tion can be used. VGA or DVI-A connections environment. secure data transfer is not provided. Turkish are analog and inconvenient. If such a network will be used to report Law (No. 6698) on the Protection of Person- c. Image size: The number of rows and radiological examinations through an ex- al Data states that such an application can- columns of the image acquired and the ternal teleradiology institution such as in not be made without the approval of the image displayed is usually not equal. When the outsourced teleradiology model, it is institutional data controller (7). a 512×512 matrix image is displayed on a recommended to make necessary arrange- 3840×2160 pixel matrix screen, the need for ments and take precautions to eliminate Image compression interpolation naturally arises. A high quali- medicolegal problems that may arise due Image compression can be performed ty interpolation ensures that the image is to the institution’s access to all health data. using lossless or lossy methods. As the displayed without delay. The video card 2. Data sending (“DICOM push”) technique: name implies, there is no loss of image data should be high-end in this regard. The only data transferred are the medical in lossless compression. Data compression d. Imaging software: For proper reporting images (along with relevant information of can be performed lossy to reduce image of radiological examinations, the software patients) that are needed to be reported. transfer speed and archive requirement. should be compatible with the workflow The institution’s PACS-RIS-HIS system can Under the supervision of a responsible ra- steps of the radiologist, and should include send relevant data to the teleradiology sys- diologist, many lossy or lossless compres- many features that facilitate the radiologist’s tem. This system is mostly used in situations sion methods can be used that will not lead work. Some of these features are as follows: where reporting is outsourced to an exter- to degradation of clinical diagnostic image i. Comparative (prior or otherwise) nal organization. The transmission of imag- quality (8). Compression methods and ra- examinations and/or image series es and data and reception of the issued re- tios to be used for different imaging stud- should be able to be opened at the port are carried out in accordance with HL7 ies provided by the responsible radiologist same time.

TSR guidelines for the practice of teleradiology • 507 ii. There should be a customizable work of photons the receiver (eye or light meter) Therefore, pixel and screen size are mean- list. The users should be able to open encounters. ingful in terms of image evaluation. the examination they want to access Ambient luminescence is the level of light A pixel size larger than 0.21 mm is not desir- and even the series within the exam- reflected off the device when it is turned able in diagnostic monitors. In non-diagnostic ination. off. Minimum luminescence is the lowest monitors, this upper limit value is 0.3 mm. iii. There should be image hanging op- level of light that the device emits when it The screen size has an upper limit, espe- tions (“hanging protocols”) that take is turned on. The sum of these two values cially for the proper evaluation of its periph- into account many features such as the forms the “effective minimum lumines- eral areas. Bigger screen is not necessarily diagnostic method evaluated, person- cence”. This value is expected to be at most better. The most appropriate diagnostic al preferences, and imaging sequences 1 cd/m2 on diagnostic screens (at most 1.2 image evaluation should be made from a obtained, and optional changes should cd/m2 in mammography monitors). Maxi- distance of approximately 60 cm. In order to be easily made. mum luminescence is the highest light lev- avoid peripheral evaluation problems from el. This value, which was formerly defined this distance, a 4:3 aspect ratio screen with iv. Zooming, panning, windowing, trian- a diagonal length of 80% of this distance is gulating, rotating, and creating a mir- as the “contrast ratio”, is now defined as the required. Hence, a 21-inch medical monitor ror image should be possible. “luminescence ratio” and is obtained by di- viding the maximum luminescence value is generally used. The pixel size of such a v. The desired information about the into the effective minimum luminescence. monitor with 3 MP (1500×2000) pixel count patient and the technique should be This value should be above 350:1 on diag- is around 0.21 mm. displayed on the image, and all im- nostic screens. For this reason, the bright- age-related information and intro- ness calibration values of medical screens Appropriate layout of the reporting console duced markings (annotations) should are usually set to 350–400 cd/m2 and au- 1. Workstations used in radiology units be made invisible when necessary. tomatic calibration is continuously run in should be planned with at least three vi. The image should be able to be re- the background to maintain this value for monitors. Apart from one standard infor- corded in different formats including a very long time. Since such a calibration is mation screen, systems containing two 4:3 DICOM, and, if necessary, the recording not possible, non-medical monitors require aspect ratio, 21–24-inch, pixel size of less should be stored by deidentification manual measurements at regular intervals. than or around 0.21, preferably 3 MP med- (i.e., anonymized). Medical monitors usually have very high ical screens that can operate on at least 8 vii. A calculation tab should facilitate rel- brightness values. In order to maintain bits should be designed. Medical monitors evant measurements. constant brightness throughout the life of should have automatic calibration software viii. Other aspects of the user interface the device, the maximum brightness value and hardware. All workstations should be (such as mouse button function assign- can be reduced to the values given above, calibrated to the same level and different ments) should also be customizable. thereby achieving this level of efficiency for workstations should be able to display the a long time. same image with the same gray scale prop- Screen It is desired that the gray scale level of erties after calibration. a. Display technology: Almost all dis- the screen is parallel with the DICOM part 2. In remote use, 8-bit monitors, with a plays today are produced with LCD or 14 GSDF (gray scale display function) lev- pixel size of less than or around 0.21 mm, OLED technology. There are different pan- el. A deviation of up to 10% in this value is minimum luminescence value below 1 cd/ 2 2 el technologies in LCD screens and their acceptable. Medical displays can calibrate m , brightness over 350 cd/m , preferably “TN” feature is not suitable for radiologi- system responsiveness within this range. less than 27 inches (recommendably with a cal use. It can, however, be used as a third However, the response curve of most diagonal diameter of 24 inches) should be screen to access patient information. LCD non-medical displays (LCD or OLED) pro- used. It should be kept in mind that these screens with “IPS” and “VA” features are duced today is very similar to the DICOM screens cannot maintain their calibrations suitable for radiological evaluation and GSDF and does not significantly affect the for a long time and that DICOM GSDF mea- do not create a difference in brightness, diagnostic quality (12, 13). It is also known surements or calibrations should be per- contrast and color depending on the that some non-medical professional mon- formed manually at least once a year. viewing angle. itors have manual calibration software, al- 3. For mammography reporting, equip- The light source in LCD displays can be though not like medical monitors, where ment to be used either in the radiology unit cold cathode fluorescent (CCF) or light this is done automatically. or at the remote reporting point should be emitting diode (LED). LCD screens with CCF c. Pixel and screen size: These are the fac- at least 5 MP medical monitors. sometimes have a warm-up time of 30 min- tors that determine the spatial resolution. 4. When designing the reporting console utes, while LCD screens using LEDs do not Often medical monitors are described as and environment, workplace ergonomics have such a problem. 2, 3, or 5 megapixel (MP) by the number rules should be observed (14, 15). Optimum b. Luminescence: It is a combination of of pixels they contain. These values make ergonomic conditions are mandatory for brightness and contrast and is important sense, as these monitors are in a 4:3 aspect the most effective reporting by the radiol- in selecting a screen for radiological imag- ratio and are usually 21–24 inches in size. ogist. Therefore, appropriate ventilation, ing. Although brightness is only the level However, non-medical monitors are now- ambient lighting and sound levels, suitable of photons emitted by the light emitting adays often in 16:9 aspect ratio and come table and chair, proper dictation and com- source, luminescence is related to the level in a wide variety of sizes and resolutions. munication systems should be provided.

508 • July–August 2021 • Diagnostic and Interventional Radiology Ozmen et al. Archiving and documentation “Ghost reporting”, which does not include Responsibilities Provided that other relevant require- the true identity of the reporter, is a serious All radiologists serving in teleradiology ments in these guidelines are met, primary misconduct and should not be allowed un- applications in Turkey should have a spe- reporting teleradiology applications should der any circumstances. cialization diploma that enables them to meet the sender’s archiving rules, as well as An approved report document should work as a Radiology Specialist in the Repub- the rules on medical records of the institu- not be changed in any way. If any change lic of Turkey (1). tional, national or other domains served, or amendment is needed, there should be a The radiologist serving via teleradiolo- and all relevant legislation. clear record these changes such as “adden- gy should be authorized by the party they Images should be securely stored in one da” or “erratum/correction/amendment”. provide service for, should serve under con- Additions or corrections that will change of the parties for the period stipulated by tract and should have the necessary qual- the report content should be kept as a sep- laws, regulations or bylaws and in a way to ifications. These physicians should work in arate record; however, they should be read- meet the legal responsibilities of the im- a manner proper for fulfilling their profes- ily accessible through the original report. age sending party where the radiological sional legal responsibilities. For applications using teleradiology service process has started. There should The sender and receiving party employ- methods in capacities other than primary be a digital image storage policy and rules ees and the radiologists on both sides are reporting (such as emergency provision- agreed by both parties and announced in responsible for the quality and timeliness al or preliminary report), mechanisms in writing that will meet legal requirements. of the radiological examination. The func- which the teleradiology process is ade- For each examination, database records tions performed by radiologists and other quately documented should be established containing patient information, examina- employees in teleradiology services in each (1–3, 5). tion information and other pertinent in- procedural step should be clearly defined, formation, the times of the examination Security and privacy announced by mutual agreement, and all process and the identities of those respon- responsibilities of the radiological service In addition to honoring internationally sible should be kept. These records should process should be completely met. accepted basic medical values, teleradiol- The names and contact details of the tel- contain, as a minimum, the patient name, ogy systems should have network and eradiology staff of the sending and receiv- file number, name and type of the examina- software security protocols to ensure the ing parties should be accessible and veri- tion, the times of the examination steps, the privacy and confidentiality of patient data, fiable by the stakeholders of the process. examination performed and the identity observing relevant international health information at the sender responsible. Sim- standards and national legal regulations. Images archived on either side should meet ilarly, on the receiving side, the time the im- It should be clear which patient data will the legal requirements of the sending party. age is received, the reporting approval time be shared, under which conditions and with Where interpreted images are properly ar- and the identity information of the respon- whom, and precautions should be taken in chived at the sender side, they do not have sible parties at the receiving end should be order to restrict access to such data, grant- to be archived at the receiving end. Howev- recorded. Transmitted clinical information, ing such access to only a select group of au- er, if archiving is to be done at the receiving which is the basis for review and reporting, thorized persons. end, the archiving should meet the legal should be kept in an accessible form and Precautions should be taken to ensure archiving requirements at the sending side. preferably included in reports. data integrity against intentional or unin- How the records are kept should be stated Previous examinations and related clin- tentional corruption of data. These security in writing in advance. ical information of the patient should be measures should also be met in all sorts of Radiologists performing teleradiology able to be called at a rate suitable for the teleradiology applications such as remote should work in accordance with the laws, needs of the sender and receiver staff primary reporting by in-house employees, rules and regulations on the sending side. during the teleradiology service. remote primary reporting by outsourcing, The work plan and responsibilities of the In primary reporting with teleradiology, preliminary (provisional) report, radiologi- employees in the teleradiology service pro- the radiology report writing guidelines of cal consultation, expert opinion or second- cess should be arranged in a way that does the Republic of Turkey’s Ministry of Health ary opinion. not violate the working hours and personal and the Turkish Society of Radiology (TSR) rights determined by law. should be followed. Documents given for Reliability In cases where primary reporting is primary reporting purposes made with the National and institutional written policies made in the form of outsourcing, the or- teleradiology service should include the and procedures should be in place to ensure ganization requesting such service pro- names of the receiving and sending parties, the quality and continuity of the teleradiol- curement is responsible for the design of the identity of the source radiologist and ogy service. These should include backup the service in accordance with the laws of the reporting radiologist, the physicians systems of patient data, telecommunication the Republic of Turkey, relevant ministry making the request, clinical information, link failure contingency planning, fault tol- regulations, bylaws and communiqués, date and contact information. The identi- erance leeways and disaster plans. and the features specified in this guide. ty of the source and reporting radiologists In primary teleradiology reporting appli- The responsibility of complying with the should be explicitly placed in the docu- cations, measures should be taken to pre- rules specified in the contract framework ments, and a secure method such as wet vent data loss in case the service provider or for the provision of this service lies with signature or electronic signature should be information systems change or discontinue the contractor teleradiology company or used. the service for any reason (1–3, 5). organization.

TSR guidelines for the practice of teleradiology • 509 Quality assurance and Reimbursement and 5. Silvia E III et al. ACR White Paper on Teleradiol- ogy Practice: a report from the task force on improvement accountability teleradiology practice. J Am Coll Radiol 2013; Teleradiology practice should be consid- A reimbursement system should be es- 10:575–585. [Crossref] ered as part of the radiology service and the tablished to meet the services and efforts 6. Royal College of Radiology. Standards for the same quality criteria should be met as with provided in teleradiology applications. Provision of Teleradiology within the United Kingdom, Second Edition. 23 June 2016. onsite radiology services. Medical or technical errors that may 7. Republic of Turkey Personal Data Protection Teleradiology parties should have a writ- occur during teleradiology applications Authority. Law (No. 6698) on the Protection of ten plan for quality control, improvement should be insurable. Personal Data. Ratified 24 March 2016. https:// and patient safety. These plans should, as www.kvkk.gov.tr/Icerik/6649/Personal-Da- a minimum, comply with the institution- Ethical issues ta-Protection-Law. Accessed 11 May 2021. 8. American College of Radiology. ACR–AAPM– al quality policies of the receiving and All established principles of medical eth- SIIM Technical Standard for Electronic Practice sending parties, the national regulations ics, including those governing medical re- of Medical Imaging. 2017. and the guidelines announced by TSR. search outlined in the World Medical Asso- 9. Kagadis GC et al. Medical imaging displays and Teleradiology service provided by either ciation Declaration of Helsinki, should apply their use in image interpretation. RadioGraph- in-house employees or external service to the conduct of teleradiology practice. ics 2013; 33:275–290. [Crossref] 10. Compton K, Oosterwijk H. Requirements for In the outsourced teleradiology service providers should meet all of these quality medical imaging monitors (part I). https://ote- requirements. model, patients or their legal guardians chimg.com/publications/pdf/wp_medical_im- Quality metrics should regularly monitor should be explicitly advised on the nature age_monitors.pdf. Accessed 11 May 2021. patient safety and best diagnostic and ther- of service they are provided and their in- 11. National Electrical Manufacturers Association. apeutic practices. Teleradiology process formed consent to the outsourcing of their Digital Imaging and Communications in Med- icine (DICOM). Part 14: Grayscale standard dis- radiological procedural consultation or should comply with evidence-based guide- play function. 2011. lines. As with all health care processes, tel- evaluation should be obtained and stored. 12. McIlgorm DJ, McNulty JP. DICOM. Part 14: eradiology practice should be monitored in Otherwise, all institutional procedures gov- GSDF-calibrated medical grade monitor vs a terms of efficiency, effectiveness, safety and erning informed consent of the patient or DICOM part 14: GSDF-calibrated “commercial cost effectiveness. their legal guardian should apply (16). off-the-shelf” (COTS) monitor for viewing 8-bit dental images. Dentomaxillofac Radiol 2015; In cases where teleradiology is applied Conflict of interest disclosure 44:20140148. [Crossref] for the generation of a preliminary (provi- MNÖ, UŞ, and ÜA are shareholders of Helcon 13. Salazar AJ et al. DICOM gray-scale standard sional) report, the quality criteria required Health Informatics and Consultancy Inc. OD has no display function: clinical diagnostic accuracy of by emergency radiology applications relevant conflict of interest to declare. chest radiography in medical-grade gray-scale and consumer-grade color displays. AJR Am J should be met. References Roentegenol 2014; 202:1272–1280. [Crossref] Certification procedures showing telera- 14. Harisinghani MG, Blake MA, Saksena M, Hahn PF, 1. Turkish Society of Radiology Board of Qualifi- diology accreditation, licensing and related Gervais D, Zalis M, da Silva Dias Fernandes L, Muel- cation and Standards. TSR Standards for the ler PR. Importance and effects of altered work- training for teleradiology service provid- Practice of Teleradiology [Turkish]. 9 April 2010. place ergonomics in modern radiology suites. ers or employees of teleradiology services 2. Ranschaert ER et al. Comparison of European Radiographics 2004; 24:615–627. [Crossref] (ESR) and American (ACR) white papers on should be prepared and implemented by 15. García-Lallana A, Viteri-Ramírez G, Saiz-Men- teleradiology: Patient primacy is paramount. J the relevant institutions. diguren R, Broncano J, Dámaso Aquerreta J. Am Coll Radiol 2015; 12:174–182. [Crossref] Ergonomía del puesto de trabajo en radiología For teleradiology service providers, there 3. European Society of Radiology. ESR White Pa- [Ergonomics of the workplace in radiology]. should be an independent institution or per on Teleradiology: an update from the tel- Radiologia 2011; 53:507–515. [Crossref] entity that evaluates the quality of service eradiology subgroup. Insights Imaging 2014; 16. World Medical Association. WMA Statement 5:1–8. [Crossref] in terms of radiological examination and on the Ethics of Telemedicine. 2017 (Amend- 4. European Society of Radiology. ESR teleradiol- reporting components, and audit reports ed 2018). https://www.wma.net/policies-post/ ogy survey: results. Insights Imaging 2016; wma-statement-on-the-ethics-of-telemedi- should be submitted regularly (1–3, 6). 7:463–479. [Crossref] cine. Accessed 11 May 2021.

510 • July–August 2021 • Diagnostic and Interventional Radiology Ozmen et al.