INTRODUCTION
In the present day, technological advancements and easy access to technological tools in healthcare facilities, along with the increasing integration of the internet and technology, have ushered in a higher quality of healthcare services. These developments have introduced various new applications into our lives (1).
Telemedicine refers to the provision of healthcare services through digital technology when the physician and the patient are physically distant from each other (2). The term “tele” has Latin origins, meaning distant, far away, or at a certain distance (3). The World Health Organization (WHO) defines telemedicine as the remote use of information and communication technologies for diagnosis and treatment (4). Telemedicine can be utilized in various fields such as teleradiology, teleconsultation, telesurgery, telegeriatrics, telehomecare, teledermatology, telepsychiatry, telepathology, and telerehabilitation, among many others (5,6).
Imaging techniques are an indispensable tool in modern medicine. One of the significant challenges in this field is the increasing number of diagnostic examinations. Consequently, radiologists find it difficult to allocate sufficient time for analyses. In our country, the number of radiologists is proportionally decreasing over time. This decline persists despite the rise in annual imaging procedures. Given the current conditions, it can be asserted that tele-radiology is the most effective method to cope with this problem. Tele-radiology enables radiologists to provide services without being physically present where the patient is, contributing to the development and continuity of healthcare services (7).
Pulmonary embolism (PE) is a frequently encountered and high-mortality condition in emergency clinics. The mortality rate is notably high, around 12%, not only in ambulatory patients but also in hospitalized individuals. Diagnosing PE may not always be straightforward. Challenges in obtaining computed tomography angiography (CTA), acknowledged as the gold standard for diagnosis, due to renal dysfunction and pregnancy, stand out as major difficulties in the diagnostic process (8).
One of these challenges is obtaining the report of the CT scan performed for emergency department (ED) physicians. The reporting process, at times, can take hours, leaving emergency physicians to manage cases without the radiology report. Consequently, emergency medicine physicians are able to accurately recognize findings indicative of PE in CTA images with high precision. Additionally, albeit rare, mismatches between clinically anticipated CT reports and erroneously reported results can occur, adding to the complexity of the situation (8).
Here, our aim is to present a case where pulmonary embolism was detected in CT angiography images, despite being reported as normal in the teleradiology report.
CASE PRESENTATION
A 70-year-old female patient presented to an external center with complaints of dyspnea. After evaluation there, she was referred to our ED for further imaging needs. Upon arrival, the patient had a Glasgow Coma Scale score of 15, and her neurological examination was unremarkable. She had no tachypnea, and there was no desaturation in room air. Vital signs were within normal limits, and she had no fever. The electrocardiogram (ECG) showed a normal sinus rhythm with no arrhythmias, ST-T changes, S1Q3T3 pattern, or bundle branch block. D-dimer was elevated at 2.77 (<0.55). Other tests (complete blood count, biochemistry, blood gas, and cardiac markers) were within normal ranges. Contrast-enhanced CT pulmonary angiography (CTA) revealed a filling defect consistent with emboli in the distal branch of the right main pulmonary artery (Image). Surprisingly, the teleradiology report provided via telemedicine reported the CT image as normal. The patient was admitted to the Chest Diseases inpatient service for further follow-up and treatment.
Image. Red arrow – Filling defect (thrombus) observed in the distal left pulmonary artery in the acquired CT angiography (CTA).
DISCUSSION
The Turkish Medical Association’s website highlights some potential negative consequences of the “service procurement” method actively applied in the field of radiodiagnostics in Turkey (9). Under the heading “Effects on the Number and Process of Reporting,” it is stated: “Another duty of radiologists is to dedicate the necessary time after appropriate imaging is performed to detect pathology in the images and contribute to the diagnostic process by creating an appropriate differential diagnosis list. However, in many hospitals in different cities, hundreds of films taken in a short period are pooled together, and distribution is made from this pool. In this system where payment is made based on the number of examinations, the situation of reporting hundreds of examinations in a short time arises. The number of reports written in a short time is well above the reporting reading standards recommended by international guidelines. This situation can lead to the oversight of existing pathology” (9).
Furthermore, in this article, under the heading “On the Nature of Teleradiology,” it is mentioned: “In societal emergencies and disaster situations such as the COVID-19 pandemic and earthquakes, remote reporting can be an option. However, performing routine healthcare services and radiological imaging through these companies disrupts the communication that is crucial between clinicians and radiologists. This communication gap can lead to missed diagnoses and unnecessary examinations, resulting in increased radiation exposure. Additionally, diagnostic monitors in hospital radiology units are screens specifically designed for this purpose from a technical standpoint and differ significantly from commercial monitors in the market. It is questionable whether the technical infrastructure used in the home environment for remote reading of reports utilizes this specialized equipment. This could be a factor affecting the diagnostic processes” (9).
In the same article, under the heading “Effects on Qualified Reporting,” it is stated: “Rapid reporting of a large number of patients in a short time leads to omissions in diagnoses and superficial descriptions of pathologies that require detailed characterization. This situation can result in the emergence of reports lacking in quality, leading to erroneous clinical management. Frequently, it necessitates obtaining a second opinion from in-house radiologists and/or repeating the same examination a second time due to suboptimal imaging, resulting in an increase in radiation dose. Additionally, the distance and communication gap between the radiologist and the report author prevent the second checks that the radiologist should perform after writing the report. This, in turn, can lead to erroneous reporting, causing serious problems in clinical workflow” (9).
In 2021, the Turkish Society of Radiology prepared a “TeleRadiology Guide” (10). Telemedicine is defined in this guide as applications where healthcare services are remotely conducted through information technologies independently of location. TeleRadiology, as a subset of Telemedicine, is described as applications that allow the transfer, storage, processing, evaluation, and reporting of radiological images and related information from the location where they are obtained to a different location digitally. However, legal responsibility regarding tele-radiology reports is not discussed in this guide.
Clinical manifestations of PE are nonspecific. The most common symptom is chest pain, often abrupt and pleuritic in nature, more commonly seen in distal pulmonary artery embolisms. Central pulmonary artery embolisms, on the other hand, may cause pressure and pain in the anterior chest, warranting differential diagnosis from acute coronary syndrome and aortic dissection. Shortness of breath is the second most frequent complaint, and a sudden increase in pre-existing dyspnea along with worsening oxygenation in individuals with known cardiopulmonary disease should raise suspicion of PE. In cases of large emboli, severe shortness of breath may be accompanied by a fear of death. Arterial blood gas (ABG) analysis may reveal hypocapnia, respiratory alkalosis, and hypoxia, although ABG can be normal in 40% of cases. In our case, the blood gas values were within normal ranges. Chest X-ray may be required to differentiate from other conditions, but in our case, a chest X-ray was not performed. ECG findings may include signs of right ventricular strain, such as T-wave inversion in leads V1-V4, S1Q3T3 pattern, and sinus tachycardia. In our case, the ECG was normal.
Most cases are brought to the emergency clinic after experiencing syncope. In the majority of these cases, when they are brought to the emergency clinic, blood pressure is normal or systolic blood pressure is not less than 90 mmHg. In our case, the patient presented to the outpatient clinic and had normal vital signs with no evidence of hypotension.
D-dimer, a fibrin degradation product, is often the initial test sought for many patients suspected of PE. In our case, D-dimer was requested, and the result came back elevated.
In the diagnosis of PE, CTA is now widely accepted as the gold standard. The resolution of new-generation multidetector CTA devices is excellent, capable of revealing even small thrombi that were difficult to visualize with earlier devices. Findings such as filling defects or signs of vascular narrowing can directly or indirectly indicate the presence of a thrombus. A negative CTA is crucial evidence for excluding the diagnosis of PE. In our case, a CTA was requested, and the evaluation was performed by emergency physicians before the radiology report was available. As a result of this assessment, a thrombus was detected in the distal right main pulmonary artery, and the patient was referred to the Pulmonary Diseases department. The patient was admitted to the Pulmonary Diseases Service for diagnosis and treatment. The teleradiology report received through the system, however, was reported as normal.
The error in the teleradiology report is not an uncommon situation for emergency physicians. Although the experience of emergency physicians often leads to resolving such situations without harm to patients and without clinical delays, this circumstance opens up discussions about the accuracy and legal responsibility levels of teleradiology reports.
During our literature and internet data review for this case presentation, we were unable to find any information, document, or source regarding the legal status of teleradiology reports.
CONCLUSION
We believe that advanced clinical studies are needed to determine the accuracy of teleradiology reports. This way, accuracy percentages of teleradiology reports can be revealed, and a transition to a more patient-centric teleradiology reporting system can be facilitated. Additionally, there is a need for legal and administrative studies that clearly outline the legal aspects of teleradiology reports.
REFERENCES
1.Official Gazette, Regulation on the Provision of Remote Health Services, issue: 31746. Accessed on February 3, 2024.
2.Lupton, D. Critical perspectives on digital health technologies. Sociology compass, 2014; 8(12):1344-1359.
3.Waller M, Stotler C. Telemedicine: a Primer. Curr Allergy Asthma Rep. 2018;18(10):48-54.
4.World Health Organization team. Consolidated telemedicine implementation guide. WHO Library Cataloguing-inPublication Data 2022.
5.Korkmaz, S., Hoşman İ.. Telemedicine Applications in the Healthcare Sector: A Research Including Dimensions of Telemedicine Practices. International Journal of Health Management and Strategies Research. 2018;4(3): 251-263.
6.İlhan B., Aslan D., Küçük U.Ç., Öztürk M., Aktepe H., Şengelen M. et al. Telemedicine. Aging and Telemedicine Applications. Ankara: Turkish Geriatrics Society, 2021:7-127.
7.Akçay, G., Özkaraca, O., & Güney, B. Remote Consultation Enhanced by Teleradiology Web Application Using Open Source Software: A Real Hospital Application. Health Academicians Journal, 2016:3(1),50-55.
8.Karalezli, A. Pulmonary embolism. Current Chest Diseases Series, 2018:6(2),16-35.
9.Turkish Medical Association Website. https://www.ttb.org.tr/haber_goster.php?Guid=00666ca6-6801-11ee-845f-ed4ebcc7b121. Accessed on February 3, 2024.
10.Turkish Society of Radiology Website. https://www.turkrad.org.tr/assets/DernektenHaberler-Pdf/Teleradyoloji-Kilavuzu-2021.pdf Accessed on February 3, 2024.
