Outsourced remote radiology reporting has increased in recent years along with an increased ability for radiologists to report from home.
But while this can speed up the delivery of reports, there are some risks both for the hospital and the private teleradiologist. Dr Emma Green explains how some of these risks may be mitigated.
UK NHS trusts are allowed to procure the reporting services of compliant private teleradiology suppliers covering a range of reports including backlog, urgent and second opinion referrals.
Due to Covid-19, radiology is not new to remote working. However, outsourced remote radiology reporting has been increasing in hospitals over recent years and can offer completion of reports 24/7, allowing for a greater volume of imaging to be undertaken.
A 2018 Care Quality Commission report1 indicated that 76% of hospitals trusts in England were outsourcing radiology at this time. A subsequent 2021 report from the Royal College of Radiology (RCR)2 showed that UK outsourcing of radiology reporting in 2020 had increased to a cost of £128m compared to £81m in 2018.
With the full impact of Covid-19 not reflected in this report, it is likely that outsourcing will have increased further although the 2021 report3 does not include the outsourcing costs in isolation, so there is currently no comparable data.
With recognised shortages in the NHS consultant workforce for radiology and the increasing use of radiology for diagnostic purposes, it is unsurprising that trusts are increasingly outsourcing this work to meet the demand for reporting.
There are, however, some medicolegal risks both for the trust and for the teleradiologist and we have noticed a trend in associated claims.
In 2019 and 2020, these claims featured in the top 25 UK claims by cost and we anticipate this trend will continue.
A 2020 report published by Getting It Right First Time4 and a 2021 report by the Parliamentary and Health Service Ombudsman5 highlight a number of areas where it was recognised that outsourced remote reporting might contribute to systemic problems.
It is important to also highlight that, while there is an accepted reporting error rate for radiologists between 3-5% for plain film radiographs and higher for cross-sectional imaging,6 this has been shown to increase with off-site reporting to between 8.7%-12.7%.7 This shows the importance of ensuring there is a robust system to allow for learning from errors.
Some of the problematic areas identified by the reports above and seen in cases managed by Medical Protection include:
Many systems do not allow image sharing between hospital trusts. This can result in previous imaging being unavailable and leaves the reporting radiologist exposed to potential risk. It can also result in further imaging being suggested, which may be unnecessary.
Radiology request forms are only as good as the level of detail included on the form. If important clinical detail is not included and face-to-face communication cannot occur, the reporting radiologist may be clinically disadvantaged.
Remote reporting can also result in the loss of the communication with other healthcare professionals either through the traditional multidisciplinary team or passing ‘corridor consultations’. This can result in lost opportunity to seek further clinical correlation or secondary reviews of reports.
Similarly, receiving clinicians are unable in most cases to contact the reporting radiologist or do not have the same working relationship as those co-located in the hospital environment.
This can result in reports being interpreted incorrectly, especially when the report contains ambiguity, lacks suggested further management or an unexpected finding is not reported in a way which highlights potential serious pathology.
So how can private teleradiologists supplying reports to NHS trusts through third party suppliers reduce their risk?
Firstly, while remote reporting may be undertaken for NHS trusts, the work will require separate, individual indemnity for radiologists. Those undertaking remote reporting should ensure they are aware of the indemnity requirements and contact their medical defence organisation if they are unsure.
While many of the problems cannot be solved by individual clinicians alone, those involved in remote radiology reporting should adhere to the RCR reporting standards.8
Some of the key areas that can assist teleradiologists in reducing risk include:
Ensuring report wording is unambiguous. This is especially important for those reporting for a company and not directly alongside the referring clinician when it may not be possible to tailor a report to the professional background of the requesting clinician.
So use plain English, avoid acronyms, abbreviations, colloquialisms and explain any medical terminology which is unusual, localised or subject to interpretation.
This is where the lack of knowledge of the status of the referrer should be taken into account to provide a clear report.
When reporting images, the report should consider pertinent previous radiology, clinical information and lab/histopathology reports. This can be a barrier for those reporting remotely for a third-party without access to patient records.
The report should therefore consider whether knowledge of results would change the report and whether the information needs to be obtained.
When imaging reports identify unexpected significant clinical findings or life-threatening emergencies, reporters should comply with local reporting mechanisms.
This is a key area which can result in claims or potential criticism and we have seen claims relating to delayed diagnosis of cauda equina as a result of poor reporting pathways.
Teleradiologists should ensure, if they are providing their service to a company, that they are satisfied there are robust reporting mechanisms and be aware of the referral pathway before undertaking the work.
If a clinician cannot satisfy themselves that the pathway is adequate, the risk of a claim increases and it is likely that some responsibility will be attributable to the radiologist as well as the organisation.
Those reporting for external organisations or taking on additional reporting workload should consider the increased risk of errors associated with working above contracted hours as well as the increased risk associated with reporting during night hours.9
Clinicians should ensure they are satisfied that the remote radiology companies to which they are contracted facilitate a service which is subject to quality assurance.
This should include access to and participation in REALMS meetings and relevant continuing professional development.
Quality assurance should also include discrepancy reporting in line with RCR standards with at least 5% of reports being reviewed.
This ensures that colleagues undertaking remote reporting are subject to the same scrutiny and can learn from the peer reviews undertaken of their work.
Medical Protection recognises the important role that teleradiology plays in the evolving picture of medical practice, especially since Covid-19.
But, with rising numbers of claims, those providing this service should familiarise themselves with the expected standards, consider ways to ensure that reports are easily understood, and ensure all relevant information and unexpected findings which require action are clearly communicated to the provider.
Dr Emma Green (right) is a medico-legal consultant at Medical Protection
1. Care Quality Commission: 2018; Radiology Review; A national review of radiology reporting within the NHS in England.
2. Royal College Radiologists: 2020: Clinical radiology UK workforce census 2020 report.
3. Royal College Radiologists: 2021: Clinical radiology census report.
4. Getting It Right First Time 2020: Radiology GIRFT Program National Speciality Report.
5. Parliamentary and Health Service Ombudsman: 2021: Unlocking Solutions in Imaging: working together to learn from failings in the NHS.
6. Maskell G. Error in radiology-where are we now? Br J Radiol. 20199.
7. Howlett D et al. The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit. Clin Radiol: 2017 Jan; 72(1): 41-51.
8. Royal College Radiologists: 2018: Standards for interpretation and reporting of imaging investigations: second edition.
9. Patel A et al. Radiologists Make More Errors Interpreting Off-Hours Body CT Studies during Overnight Assignments as Compared with Daytime Assignments. Radiology 2020; 297: 374-79