Eight point mantra for quality in teleradiology

Addressing to what Dr Sona said in her article on Challenges in teleradiology in India, Dr Arjun Kalyanpur, MD, CEO and Chief Radiologist, Teleradiology Solutions, Bangalore shares his insights on quality in teleradiology reporting

Teleradiology has become firmly established as a powerful clinical paradigm within healthcare delivery that permits radiology reporting to be performed rapidly and efficiently as well as providing access to radiologic expertise where/when it might otherwise not have been available, in an era of crippling radiologist shortages. However, for teleradiology to provide continuing benefit, it must be supported by quality reporting, or else its value proposition ceases to exist. How can teleradiology providers ensure that they deliver consistent quality to their clientele, and through them to their patients? And how can a hospital or imaging center that is looking for a teleradiology provider decide which service really and truly represents a quality performer? Here are eight key processes that define quality in teleradiology, and can/will distinguish the quality teleradiology provider from the rest.

Selection and training process: An important part of the growth of a teleradiology practice as new radiologists are added to the team, is to adhere to stringent recruitment processes that include not just vetting the CV but also conducting a baseline reporting quality check. Given that teleradiology presents a wide variety of reporting challenges such a process ensures that the aspirations of the radiologist are matched with the quality standards and processes of the teleradiology organisation.

Reporting standards and checklists: It is necessary for a teleradiology provider to develop clear internal standards, checklists and reporting templates to ensure that quality is maintained in day-to-day reporting. These should be available for each modality, and ensure an internal standard of reporting that forms the bedrock of teleradiology reporting operations.

Robust peer review: At the heart of any successful teleradiology practice is a strong peer review process. This essentially means review of both the examination and the report by an independent radiologist with a score assigned for error/discrepancy. Whether this is by way of external third party audit (as in the form of feedback from client radiologists) or internal peer review process, this is the true pulse check of quality and defines the organisation’s performance improvement, or lack thereof. The core philosophy behind such a process involves objectivising error evaluation (the American College of Radiology’s Radpeer scoring process is the current benchmark) and ensuring that the peer review process is consistently followed. It is all too easy in the midst of busy day to day work to let what may be perceived as “non-essential” processes slip or slide, and ensuring continuous focused attention on them is key to optimising teleradiology performance.

Rigorous data tracking mechanism: Coupled with peer review is the need for effective data collection from this process, which captures the information that is needed to provide the quality insights. The best way to ensure that steps 1 and 2 follow in sequence is to have a technology based solution for the same. In the case of our organisation, our teleradiology workflow platform Radspa also contains a robust quality assurance portal which allows for peer review to be assigned, performed and objectively scored. This data is continuously captured and subsequently extracted and sorted based on all the relevant parameters, namely based on error grade, referring client, radiologist etc etc.

Analytical approach: It is important to analyse the data effectively by asking the right questions that allow trends to be captured/identified. For an individual case, how could the error have been avoided? Is a particular member demonstrating a pattern of error on say, CT pulmonary embolism studies? Or is there a particular modality, such as CT angiography where the group as a whole has a higher error rate? Is the error pattern indicative of an individual performance issue or is there a systemic issue involved? Such trendspotting of error patterns can help to identify and address training or operational needs for the group, or to provide specific feedback to an individual. Here again, an effective online QA management and analytics portal such as Radspa can greatly help a teleradiology provider to detect and address such trends.

Couple the learnings from peer review analysis with teaching/training: As suggested by the previous step, the output from the data analysis is only effective if it is used to generate training material to benefit the individual radiologist as well as the entire group. It is necessary to capture the relevant images to illustrate the teaching point as well as to identify the specific learning insight that is gained from the retrospective analysis of the error. This process is key to transforming learning to teaching, which is at the heart of all quality improvement. The fundamental philosophy is (or should be) that the error of one should translate into a learning for all.

Learning philosophy: This last point is part of EQ or Emotional Quotient development. When a radiologist joins our group, in my initial interaction/orientation with them, my key message/request to them is to submerge individual ego in the larger purpose of learning and growth. For quality improvement to occur, it is important for the individual radiologist, however senior or experienced, to be receptive to feedback, to accept that everyone is capable of error and to be open to learning from it as well. I believe that my own greatest learnings have arisen out of my errors, and am candid in sharing my errors/misses with the rest of my colleagues, as I feel that quality assurance, to be effective, must be seniority-agnostic!

Communication and accountability: A teleradiology provider must audit itself not just on the quality of its reports but on metrics such as report turnaround time, and equally important, the level of communication on any critical finding of acute clinical significance. Ultimately in radiology, diagnosis is only 50 per cent and the other 50 per cent is clear communication. Therefore tracking of such communication is important to ensure that the organisation is compliant with protocols. Further, sharing of all such metrics in an open and transparent manner with the client is in the interest of building trust and ensures that any issues that arise are discussed and addressed to mutual satisfaction, on an ongoing basis.

Teleradiology, given its outsourced nature, has traditionally been held to a higher quality standard than in-hospital radiology. And in a competitive industry such as teleradiology represents, the differentiator must be quality and not cost. The hallmark of true quality is introspection and insight, and any teleradiology provider of substance must be willing to go the extra mile and spend the extra hours needed to gain the meaningful insights that can genuinely facilitate improved quality of performance. Hence the critical importance of a structured quality assurance program/process for a teleradiology service provider. The ultimate goal is to learn from one’s errors in order to prevent further such incidents. In teleradiology no less than anywhere else, as the aphorism goes, an ounce of prevention is far better than a ton of cure.