Discrepancy in radiological reporting is a complex issue and the causes of discrepancy are numerous,
well recognised and often inter-related3,4.
Radiologist specific causes include faulty reasoning,
lack of knowledge (particularly when working outside an individual’s area of specialty expertise),
failure of perception or poor communication of findings.
System related factors are also important and a number of causes are recognised – staff shortages (with over reliance on locum radiologists),
combined with excess workload,
inexperience of staff and insufficient or inaccurate clinical and/or previous radiological information3.
The demand for access to radiology services continues to increase year on year in the UK.
Due to its high diagnostic accuracy and increased availability,
CT has experienced a rapid expansion in its roles both in and out of hours; a growth of 141% in CT scans was reported in the USA over a 10 year period5.
Unfortunately,
the increased diagnostic imaging workload has not been matched by an increase in reporting radiologists.
This is a situation which is particularly acute in the UK,
but is also recognised worldwide.
Service challenges have led to the development of other reporting models – registrars often provide the first tier of reporting,
however increasingly hospitals have been looking at offsite/outsourced radiology reporting solutions,
particularly during antisocial hours and weekends.
Outsourcing is now widely used in the UK,
but it is a worldwide phenomenon with remote reporting hubs in India,
Australasia,
Europe and the USA6,7.
Our study incorporated 4931 patients from 108 UK radiology departments.
It explored in detail factors that might be related to increased major discrepancy at the level of the provisional (initial) radiology report on review by a CT auditor.
When compared to an onsite consultant there was a statistically significant increased risk of major discrepancy and major discrepancy with harm in an offsite/outsourced CT report,
this finding was consistent in both surgical and pooled data.
Major discrepancy was also found to be more likely in the surgical group; registrars had a major discrepancy rate intermediate between onsite consultants and offsite reporting radiologists.
These findings are also reflected in failure of compliance with the major discrepancy audit standards.
Offsite reporters narrowly missed the non-surgical major discrepancy standard (standard <5%,
achieved 5.2%) but also missed the surgical major discrepancy (standard <5%,
achieved 12.7%) and pooled (standard <5%,
achieved 8.7%) standards.
Both registrars and onsite Consultants were able to meet the recommended provisional report standards for major discrepancy.
The overall major discrepancy rate (patient came to harm) standard was also missed in the surgical group (standard <1%,
achieved 1.5%).
These results raise important questions and there are no immediate or straightforward solutions.
The RCR supports the European Society of Radiology (ESR) statement that defines teleradiology (transmission of radiological patient images from one location to another) as a ‘medical act that must have the same level of guarantee,
in terms of quality and safety as compared to standard medical acts.’8
After the audit,
The Royal College of Radiologists (RCR) updated its teleradiology guidance setting out standards for the sharing of imaging data and for outsourcing reporting outside of the local healthcare organisation9.
The standards set out in this document are those that the RCR believes best serve the population of the UK and should be taken into account by UK healthcare providers and commissioners when considering outsourcing image reporting to teleradiology companies.
The standards recommend that:
- There should be clear and transparent systems in place for rapid,
secure transfer and review of images and,
where necessary,
storage of patient data.
- Reporting must be to the same standard independent of where and by whom the data is reported.
- The same person should interpret the examination and issue the report to the referring clinician and should be clearly identified,
with the results communicated and integrated into the base hospital’s radiology information system (RIS),
picture archiving and communications system (PACS) and electronic patient record (EPR) in a timely manner.
- Teleradiology should be part of an integrated radiology service,
and be subject to the same governance framework as the rest of the service,
with all participating radiologists working within a clearly documented quality assurance framework in line with RCR guidance.
The RCR is also looking to update its Standards for Interpretation and Reporting of Imaging Investigations,
taking into account the latest innovations in informatics to ensure that patients get what they want from their radiology report,
be it generated onsite or offsite.
While outsourcing companies structure their out of hours services differently,
there is recognition by them of the importance of access to prior images and reports and of conversation with the referring clinician as part of the justification process.
One outsourcing model calls for collaboration between radiologists on duty for difficult cases and second opinions; it also allows increasing subspecialisation.
There is evidence that the Government is beginning to take action to tackle the shortage of radiologists with the recruitment of 300 more radiologists for NHS England10.
However,
the reality for the foreseeable future is that the quality of radiological reporting both in and out of hours would likely see benefit from development and harmonisation of best practice between teleradiology companies and closer collaboration between on-site radiology providers and teleradiology reporters,
including collaborative audit,
and potentially access to discrepancy and surgical meetings for feedback.