Teleradiology: the perks, pitfalls and patients who ultimately pay.

• Author: Barlow, Coryell L.

1. INTRODUCTION II. TELERADIOLOGY--A BRIEF HISTORY III. QUESTIONS RAISED BY TELERADIOLOGY A. Who Is Responsible? 1. Teleradiologist a. Standards Governing Radiologists b. On-Site Versus Working from Home c. Equipment Guidelines and Standards d. Intangible Interpretation Factors 2. Teleradiologist's Employer 3. Treating Physician 4. Hospital's Liability a. Ostensible Agency b. Non-Delegable Duty Doctrine IV. JURISDICTION AND SERVICE OF PROCESS V. CONCLUSION The business side of medicine is driven by profits. Changes have been implemented to achieve this goal of profits through the utilization of such things as electronic medical records, e-prescriptions, the increased use of generic drugs, and the reduction in the number of diagnostic imaging and blood tests ordered. A less well-known area of change is teleradiology, the ability of healthcare providers to transmit radiological images, like X-rays, CT Scans and MRIs, from one location to another for diagnostic or consulting purposes. The premise is that a radiologist can diagnose images remotely from anywhere in the world as long as there is a phone or internet connection. This allows a medical facility, regardless of its size, to have a radiologist on call at any hour to quickly review diagnostic studies, without having to employ such a specialist on premises. The business advantages of teleradiology are obvious, but who is responsible when something goes wrong? While teleradiology services are usually set up as independent contractors, can the healthcare provider escape liability for the malpractice of a radiologist who is not an employee of the hospital or urgent care center? The complex and sometimes far-removed relationships that teleradiology creates can make ascertaining who is liable and how to seek legal redress uncertain. This article will address the myriad legal issues that arise with the use of this technology in the practice of medicine.

   Financial Disclosure

   The authors have received no financial aid for the writing of this article nor do they have any financial interest in the topic.

   Annie was rushed to the emergency room of a rural hospital complaining of an intense headache. The emergency room doctor ordered a CT of her brain to determine the cause. As is the case with many smaller facilities, the hospital did not have a radiologist on site to interpret and discuss with the treating doctor what the test revealed. The hospital, however, had a contract with an off premise teleradiology company. Digital versions of the films were immediately dispatched to that service, which, in turn, sent the scan to one of its radiologists in California. She returned a written report indicating a small mass in the patient's brain, possibly a tumor, but not a life-threatening one.

   Annie was discharged with pain medication and told to schedule an appointment with a neurologist. She returned to the medical facility four hours later in excruciating pain. The same ER doctor ordered a CT angiography to obtain a more detailed image of the brain. (1) The physician again sent the images to the teleradiology company, who forwarded the study to a different radiologist in England. This radiologist also detected the small mass but noted a cloudy ring around it. The ER doctor, finding no cause for concern from the second radiologist's evaluation, again discharged the patient.

   The following morning, Annie's father - aware she had been to the hospital--checked in on his daughter. Unable to reach her by phone, he rushed to her house and found Annie unconscious at the bottom of the stairs. She was transported to the same emergency room, where she was now diagnosed with a ruptured brain aneurysm. Annie was in a coma for seven weeks and sustained permanent brain damage. Tier sensory skills are impaired; she cannot drive and has difficulty processing language, leaving her unable to function on her own. Had either teleradiologist been able to discuss their findings with the ER doctor, Annie's condition may have been prevented. The mass was actually a fusiform aneurysm (2) and the ring was a buildup of fluid causing pressure on the brain, which can be fatal if left untreated. With no interaction among the physicians, each doctor assumed that someone else was putting the puzzle pieces concerning Annie's problem together, leading to the devastating consequences she experienced.

1. INTRODUCTION

   The face of medicine has changed dramatically over the last several decades. The days of doctors making house calls and hospitals being non-profit centers catering to the needs of the local community are gone. Healthcare is a business with the bottom line being the focus of much attention. Providers clearly understand their priorities--offering "high quality goods and services people want, at affordable prices." (3) For instance, profit margins have been increased by converting to electronic medical records. This system allows physicians to treat more people since they spend less time inputting data. Office personnel can process claims much faster, making these workers more efficient. (4) Hospitals are utilizing less-costly generic medication, streamlining their staff, and offering less overtime to employees. (5) Others are eliminating unnecessary diagnostic imaging and blood tests. For example, not every person with back pain needs an X-ray or MRI when physical therapy will abate most spinal complaints. (6) Teleradiology, a little-known byproduct of the digital age, is another cost-saving measure that offers a number of medical and financial benefits.

   Teleradiology is a branch of telemedicine, the exchange of medical information via electronic communication. (7) Teleradiology enables healthcare providers to transmit radiological images, like X-rays, CT scans, and MRIs, from one location to another for diagnostic or consulting purposes. (8) The premise is that a radiologist can diagnose images remotely from anywhere in the world as long as there is a phone or internet connection. (9) This allows small healthcare providers that do not employ a radiologist on a 24-hour basis to send their films for immediate interpretation by an imaging specialist at a distant location. (10) Other advantages include reducing costs, allowing radiologists to be more productive by not having to travel, enabling hospitals to serve their patients better, and providing access to radiological specialists in certain subsets of diagnostic imaging. (11)

   Until recently, healthcare providers only used teleradiology services in emergencies. (12) However, the concept of providing long-distance medical services is not new. Closed-circuit television systems were developed for the medical care of boat passengers as early as the 1960s. (13) The rise of the computer-facilitated store-and-forward method (14) simplified operations by eliminating the need for all parties--patients, providers, and other support staff--to be present at both sites simultaneously. (15) With the advent of digital imaging, teleradiology became possible, but different practices for how these images were stored made displaying them on various machines complicated. (16) A standard for storing digital images was created in 1993 and was widely accepted by image machine manufacturers, creating uniformity among these entities. (17)

   Teleradiology systems became commercially available in the 1980s, but their quality, adaptability, and enlargement capabilities were limited in handling a growing amount of work. (18) Thus, high costs and low performance hindered their widespread adoption. (19) However, changes in computer technology and performance, medical imaging, and the birth of the Internet created an economical and functional platform for realizing teleradiology on a large scale. (20)

   Just before the start of the twenty-first century, pure teleradiology companies flourished, taking advantage of differences in time zones such that a doctor in England could monitor the graveyard shift in California. (21) The software necessary to interpret various types of images became inexpensive, and with the availability of personal computers, the radiologist was able to work from home for several teleradiology companies. (22)

3. QUESTIONS RAISED BY TELERADIOLOGY

   1. Who Is Responsible?

   The advantages of teleradiology are obvious, but who is responsible when something goes wrong? The complex and sometimes far-removed relationships teleradiology creates can make ascertaining who is liable and how to seek legal redress uncertain. Parties involved, at a minimum, are the teleradiologist, the employer (which may be a hospital or an independent contractor), the treating physician, and the hospital with whom the teleradiology company has contracted.

   1. Teleradiologist

      The most obvious place to begin when investigating liability is with the individual reading the images. Setting aside jurisdictional questions, if the teleradiologist has malpractice insurance, an individual has some form of redress for the harm caused. In addition, the teleradiologist presumably has not only the training and skill to read the images but also adequate equipment on which to read them.

      Coleman v. Meritt offers an example of a malpractice claim against a teleradiologist. (23) In Coleman, a teleradiologist's delayed diagnosis of a ruptured stomach ulcer was alleged to be directly responsible for Ruth Lacey's death. (24) Lacey went to a hospital for a CT scan and then returned home. (25) The hospital forwarded the images to a teleradiologist who reported nothing life-threatening. (26) Still in pain, Lacey went to the emergency room the following day where doctors detected a ruptured ulcer, but emergency surgery did not save her life. (27) A lawsuit alleged that free intraperitoneal air (28) was visible on the images, indicating an emergency. However, when the teleradiologist viewed the images, they were not the original images. Rather, they were "digitally transmitted images on his office computer...