My dilemma: I am a radiologist at a pediatric hospital with multiple satellite ultrasound sites. Though most ultrasounds can be performed at the satellites, a small subset of advanced ultrasounds are only scheduled at our main hospital where a radiologist is available to scan. Recently, a family expected to schedule a complex scan at our satellite location near their home, so they understandably had questions when they were told to drive 2 hours to the main hospital instead. Is the quality of ultrasound services different? Would the radiologist scan if they traveled to our main hospital? Could they get the same study at a local non-pediatric, small community imaging center? They wanted answers! It was challenging to explain why it was worth their time to make such a long drive to get a “better” study. This led me to ask, what is the right answer at a time when teleradiology is commonplace?
Challenges and Potential Solutions of Teleradiology in Ultrasound
1. Retaining Clinical Context
Problem: Typically, radiologists interpret exams solely based on the images. However, additional patient history that was not in the original order and physical exam findings can be of tremendous value. For example, a sonographer might image a cutaneous vascular lesion compatible with a hemangioma. If a pediatric radiologist were present to ask additional questions, they would learn that the hemangioma only just appeared in the 2-month-old patient a couple of weeks ago, is rapidly growing, and is one of multiple cutaneous lesions concerning for infantile hemangiomas. Additionally, they could look at the color of the lesion and see if it blanches upon compression. Such additional historical and physical information warrants a recommendation in the ultrasound report for an abdominal ultrasound to assess for hepatic hemangioma involvement. If this clinical context is lost, then the full value and specificity of the superficial ultrasound could be lost as well.
Solution: If a radiologist is not present in-person for scanning or image review, the sonographer must know what questions to ask and what additional information might be helpful to the radiologist. Sonographers can add extra history and physical exam findings directly into the PACS technician notes, via institutional communication tools like Microsoft Teams, or on scanned worksheets. A radiologist might even talk directly with the family over the phone or ask the sonographer to include a picture of the patient in the medical record of the patient.
2. Optimizing Image Quality
Problem: The ability of the radiologist to provide image quality control is diminished when working remotely. There is more responsibility on the sonographer to optimize imaging and to recognize pitfalls independently. To this point, for example, consider a sonographer imaging a joint with concern for effusion and septic arthritis. However, she may not realize that the gain was set too low. Cartilage would look anechoic like joint fluid instead of the normal speckled hypoechoic appearance in cases such as this. Therefore, the images would look like there was a joint effusion when in fact there was no joint effusion at all.
Solution: Radiologists must provide feedback, ideally in real time, to sonographers. Standardized protocols, as well as in-person on-the-job training with experienced sonographers and radiologists, are also needed for sonographers to function independently at remote sites. In this case, the sonographer should ask a radiologist to review the images in real time so they can identify such mistakes, affording the sonographer opportunity to rescan the patient before they left.
3. Understanding Variability in Practices Between Institutions
Problem: Teleradiologists read for multiple sites, all with unique workflows and varying levels of sonography expertise. As a pediatric radiologist, I read pediatric studies from both pediatric and adult hospitals. There is a wide variety in the experience of the sonographers, as I learned recently when I opened a pyloric ultrasound exam only to realize that the sonographer had incorrectly imaged the gastroesophageal junction instead of the pylorus. I subsequently learned that this site did not have pediatric sonographers or pediatric sonography training.
Solution: As a radiology team, we must provide additional resources to support sonographers if they are to assume more responsibility. At my institution, radiologists are available for questions 24 hours a day, 7 days a week to sonographers before, during, and after image acquisition. Additionally, we provide a free, CME-accredited, internet-based didactic series for optimizing pediatric imaging technique. We also solicit topic ideas from our affiliate institutions so that we can elevate the quality of imaging at all sites. When one person or one site has a particular ultrasound question, there are often many others with the same struggle.
In conclusion, teleradiology in ultrasound is here to stay. Our responsibility going forward is to optimize it, support our sonographers as they become more independent, and understand that while we as radiologists may not physically be there, there are many technological advances that we can leverage to optimize imaging.
Dr Lauren May, MD, is a pediatric radiologist at Nemours Children’s Health in Wilmington, DE. Her primary interests are in ultrasound and medical education. She can be contacted by email, Lauren.May@nemours.org.
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