APPENDIX 1
Memorandum by the Royal College of Radiologists
(MT06)
1. The Royal College of Radiologists is
an organisation whose object is to advance the science and practice
of Clinical Radiology and Clinical Oncology. The Royal College
of Radiologist would be willing to speak to the issues raised
in this memorandum. It is pleased to supply information to this
inquiry which covers several areas integral to the practice of
these specialties.
2. The remit falls into four main headings
which are listed below A-D.
A. The utilization of Telemedicine (including
telecare) and its future potential for improving services
B. The recommendations of the Healthcare
Industries Task Force (HITF) Report, published 17 November 2004.
C. The speed of, and barriers to, the introduction
of new technologies.
D. The effectiveness and cost benefit of
new technologies.
3. Items A, C and D are of great interest
to the RCR and comments are included as follows:
A. THE UTILISATION
OF TELEMEDICINE
(INCLUDING TELECARE)
Our evidence relates to teleradiology a major
component of telemedicine:
Teleradiology
— Teleradiology is the electronic transmission
of radiological images from one geographical location to another
for the purposes of interpretation and consultation.
— locality of service—transfer
of images from a remote area to a major centre;
— direct patient care—transfer
for expert opinion;
— out of hours imaging—transfer
to home or abroad to an alternative time zone; and
— out-sourcing from the NHS to
cope with workload, back logs etc.
There are, however, many issues of risk and
potential problems associated with teleradiology which are enumerated.
These can be considered under a number of headings.
A1. PROFESSIONAL
REGISTRATION
The Radiologist must be licensed to practice
within the UK, have liability insurance and be subject to the
same controls as UK Radiologists, such as annual appraisal and
five yearly revalidation.
A2. RADIATION
PROTECTION
All examinations must be subject to the same
controls demanded by the Euratom Directive and the Ionising Radiation
(Medical Exposure) Regulations in order to optimise radiation
safety.
A3. COMMUNICATION
— The legal record of an imaging examination
is the radiological report. There must be sufficient linguistic
capability to ensure that the report is accurate and that nuances
of the language are recognised. In particular variations of normality
must be properly recorded and not ascribed to disease. Abbreviations
used in the report should be commonly recognised by both the reporting
Radiologist and the Clinician.
— Although the written report is the
legal record there must be the opportunity for direct discussion
between the reporting Radiologist and the referring Clinician.
— The opportunity to discuss the findings
with the patient may be lost by processes of teleradiology.
A4. CONSENT
There must be clear and explicit consent by
the patient for transmission of images out with the referring
hospital. There must be sufficient security for the transfer of
demographic personal data.
A5. TEAM
WORKING
Much of clinical care now occurs on multi-disciplinary
teams. The role of the Radiologist in informing clinical management
in this environment could be lost through teleradiology.
A6. QUALITY
OF CARE
Transfer of images may compromise access to
previous investigations and reports and access to full clinical
information. Commercial viability may depend on high reporting
rates. There is evidence that reporting accuracy deteriorates
with sustained high workload.
— Continuity of care and out-of-hours
services. Several investigations and procedures require a "hands
on" approach. It is important that teleradiology does not
compromise the delivery of these services.
— Disease prevalence may be different
in different countries and therefore differential diagnoses inaccurately
reported for the country of origin.
— Deskilling of local staff may compromise
local service delivery.
A7. EDUCATION
AND TRAINING
Transfer of images from training departments,
either for whole subspecialties or "simple investigations"
may compromise the exposure of home trainees for this case material.
A8. Downstream Costs
Teleradiology may generate significant downstream
costs:
— Additional investigations consequent
upon inexperience, insecurity, incomplete information or different
imaging practices.
— Clinicians responding to reports
of normal variance or pseudo lesions.
— Requirement for review of images
by home radiologists in uncertain reports.
— Perverse commercial incentives for
teleradiologists to suggest further imaging.
— Fear of litigation. Defensive medicine
is potentially more likely if the Radiologist is removed from
the clinical environment.
A9. TEAMWORK
The provision of Imaging Services relies heavily
on teamwork (radiographers, radiologists, oncologists, physicists,
etc). It is recommended that where teleradiology is used it should
be undertaken with the close involvement of the local department
of Clinical Radiology and staff thereof. The service must enjoy
their confidence and enhance their ability to deliver clinical
care.
A10. PRACTICAL
EXAMPLE: FAST
TRACK MAGNETIC
RESONANCE IMAGING
(MRI) SERVICE
The Department of Health has recently commissioned
a Fast Track Magnetic Resonance Imaging (MRI) Service with the
Independent Sector. The MR images are obtained in mobile units
supplied by Alliance Medical and the images are sent to other
European Centres for reporting.
A summary of the service as experienced in radiological
centres around the country is attached as an Appendix. A full
audit of the project is now under way which is being undertaken
jointly by the RCR and Department of Health.
This project has led to numerous enquiries and
critical comments from patients, clinicians and the press. In
response the Royal College of Radiologists issued the following
statement:
"The Royal College of Radiologists
welcomes any new initiative to improve patient care and will do
all it can to make sure such ventures are a success. Any new initiative
to improve patient care will present challenges and, whilst much
can be achieved, it is inevitable that there will be teething
problems. The RCR has been in discussion with the National Patient
Safety Agency to ensure patient safety is paramount while working
closely with the Department of Health to monitor the progress
of the project and improve the service through continuous appraisal
as it develops."
C. THE SPEED
OF, AND
BARRIERS TO,
THE INTRODUCTION
OF NEW
TECHNOLOGIES
C1. THE
PACE OF
CHANGE
It is debatable whether any area within medicine
is changing so quickly as diagnostic radiology and radiotherapy.
The newer scanning techniques are evolving so rapidly that machines
rapidly become outdated. Tumours are better defined and sophisticated
radiotherapeutic techniques allow the tumour to be treated to
a higher dose with less morbidity. Furthermore, the newer machines
have a much greater repertoire; this means that they need to handle
an increasing number of patients per annum.
C2. BARRIERS
The finance for new machines can be difficult
to come by. Although there has been a welcome expenditure by the
NHS for capital purchase, this has not been matched with adequate
revenue to run the systems at anything like full capacity.
One new technique, Positron Emission Tomography
(PET scanning) has been largely overlooked in this country, compared
with the mainland Europe and the USA. Indeed in the last couple
of years it is clear that there are several advantages on combining
PET with Computed Tomography (PET/CT). It is hoped that there
will soon be full funding (capital and revenue) to disseminate
this important technique throughout the UK.
D. THE EFFECTIVENESS
AND COST
BENEFIT OF
NEW TECHNOLOGIES
D1. COST-EFFECTIVENESS
STUDIES
Although the NHS Health Technology Assessment
(HTA) Programme often considers studies concerning imaging, few
such studies get funded often because the technology changes so
fast (see point C1 above) or because the capacity to perform the
necessary research is not available. A case in point is PET (see
point C2 above). Many enquiries were made as to why there was
so little PET in the UK. The HTA committees asked for evidence—but
there were virtually no machines from which to obtain the evidence.
Thus no progress is made.
D2. COST
BENEFIT
Numerous research studies have shown that the
use of high technology imaging often provides increased confidence
about the clinical diagnosis and leads to faster throughput of
patients in expensive hospital beds. What is not so often assessed
is the obvious benefit to the patient in terms of morbidity—reduced
need for surgery, invasive investigations replaced by non-invasive
outpatient procedures, etc.
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