Teleradiology: An Increasingly Important Issue for Canadian Radiologists

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Technology is a queer thing. It brings you great gifts with one hand, and it stabs you in the back with the other.

Charles Percy Snow, Baron Snow of Leicestershire (1905–1980), physicist and novelist

No doubt, like me, many of you received material in the mail that advertised the availability of teleradiology services, or you have been solicited to sign up with one of the several teleradiology companies to provide interpretation services for one of these companies, which are in the process of expanding their presence in Canada. Until fairly recently, teleradiology was seen as more of an issue affecting our colleagues south of the border, but this is changing rapidly. Canadian radiologists will have to decide how they wish to deal with the changing landscape and assess how much impact teleradiology may have on their practices.

Over the past 25 years, radical changes in imaging technology have permitted increasingly facile transmission of images from one facility to another, making the viewing of images even from very distant sites a practical reality. This clearly has many advantages, in that centers that do not have radiologists on site can now obtain expert radiologic opinion that might otherwise have been unobtainable or obtained only after a significant delay. This also allows a single radiologist to provide services to a number of smaller centers, therefore, making access to radiologic opinions practical where otherwise it may simply have not been a sensible or efficient undertaking. Each year further refinements in technology make this a technically simpler and more straightforward undertaking, with one limitation after another being gradually overcome.

The story is not entirely that simple, because there are also risks and problems associated with teleradiology, and Canadian radiologists will have to learn to cope with these issues. Among these problems is the fact that radiologists outside of a jurisdiction can theoretically provide competing services. For instance, radiologists from the other side of the world who can work during the day can provide nighttime coverage. All of this may be helpful to local radiologists who are not interested in providing nighttime service, but it also means that income will be lost. In addition, it can be difficult to control the quality of the teleradiology services. Although the training and quality of interpretations may be excellent, it becomes an issue to determine if specific accreditation should be required to allow teleradiology services to be provided in this way. The provision of poor quality interpretations not only would not be helpful but may be detrimental to the patient population being served. Should radiologists have to obtain a license in the jurisdiction where the teleradiology images are being generated? Should preference be given to teleradiology services that have licensed Canadian physicians on their staff as opposed to those with foreign physicians? Should physicians from abroad who are performing teleradiology be expected to write Canadian examinations such as the LMCC or Royal College examinations? It is also not always possible for referring clinicians to review imaging with teleradiology physicians, although more and more services are attempting to be able to do this telephonically, and the relationship that is often built up in an institution between members of a radiology department and referring clinicians either cannot be developed by teleradiology or is more difficult to develop.

Another issue alluded to above is the impact on physician income. In some jurisdictions, for example, the United Kingdom, foreign radiologists have underbid the usual fee structure within the United Kingdom and essentially do the work at a reduced rate. It may be tempting to accept substandard radiology in this situation if budget pressures are high on funding authorities. Taken together, all of these issues may well slowly erode the autonomy of radiologists and our ability to control how radiologic services are provided.

Many provincial radiology associations are aware of these issues, and a considerable increase in the amount of dialogue has been noticeable in the past year. Some radiology associations have suggested that the exportation of imaging to be interpreted outside the province (even within Canada) should be significantly restricted or even banned. This is a potentially difficult issue that could lead to considerable acrimony. Clearly, a great deal of open discussion among the provincial associations is required if we are to avoid a siege mentality from developing among these provincial jurisdictions. Although teleradiology may solve many problems and provide considerable opportunities, it also potentially may create a number of serious difficulties and be damaging to the specialty if not handled in a careful and thoughtful fashion.