Bridging the time difference between countries in teleradiology

Dr Arjun Kalyanpur

Late one night in the summer of 2003, a patient was wheeled into the emergency room (ER) at a hospital in Connecticut, complaining of severe right-sided abdominal pain. The patient, a middle aged male, was examined by the emergency room physician, who based on his examination, felt that the patient most likely had a kidney stone.

To confirm his diagnosis, the ER physician ordered a CT scan of the abdomen and the patient was taken to the Radiology suite for the scan. Twenty minutes later the phone rang in the emergency room. It was the radiologist calling to report that the patient did not have a kidney stone but actually had a ruptured appendix, resulting in an abscess, or a collection of pus inside the abdomen. Untreated, the patient would become septic and could get very sick. Based on the radiologist’s report, the patient was taken for surgery an hour later and was by morning recovering uneventfully in the postoperative suite.

This is a fairly typical US hospital scenario except for one thing. The unique feature of this story is that the radiologist who diagnosed the patient’s condition based on his interpretation of the CAT scan was not physically located in the hospital, as you might expect. Nor, for that matter, was he in the same town or even the same country. The radiologist, who made the diagnosis of perforated appendicitis, allowing the emergency treatment to be given to the patient in Connecticut, was reading the scan from Bangalore, India, half a world away.

The new millennium has brought with it a new paradigm, that of the global hospital. Today, as a result of the miracle of modern telecommunications, the diagnosis that saves a patient’s life in America can be made on the other side of the planet.

The benefits of this technology driven process are many. Foremost among these, we are far more productive and efficient when working by day than by night. Viewed in reverse, we are far more likely to make mistakes when awakened in the middle of the night to perform a task than if we perform the same task by the day. Consider the consequences, if the mistake in question could impact a human life. Physicians, by the nature of their work, are obliged to work the night shift upon occasion. Add to this the expectation that they work the whole previous day and the next day as well and you can imagine how their performance plummets during the night shift. Having been subjected to such rigorous hours of work during my internship year in the US, I can well attest to this.

In fact, the state of New York, in the year 1988, passed the Bell regulations, limiting the number of hours that physicians in training are permitted to work in continuity. This followed the tragic death of Libby Zion, an 18 year-old girl, in the emergency room of a New York Hospital. As a result of the efforts of her father, himself a legal expert and journalist, a New York grand Jury investigated the incident. The Jury found that overworked and sleep deprived resident physicians at the hospital committed grave errors of judgment that cost Libby Zion her life.

Many studies have shown the impact of sleep deprivation on the performance of physicians. It has been shown that the quality of patient care suffers, the physician –patient relationship suffers and the health and well being of the physician is impaired by sleep deprivation. In a series of tests, it was observed that well rested physicians consistently outperformed their sleep-deprived counterparts in tests of memory, concentration, math skills, EKG interpretation and anesthesia monitoring. In another study, the surgical complication rates were found to be 45 per cent higher among residents who had been on-call the previous night. 41 per cent of 145 residents surveyed in a study cited fatigue as a cause of their most serious mistake, and in nearly one-third of these cases, the patient died as a result of the error. Scary, wouldn’t you say?

What does this have to do with telemedicine, you ask? A simple concept, put to clinical use, is the answer. We here in India are wide-awake when the US is sleeping and so a night shift in the US is a day shift for us. By that token physicians working the “night” shift with US patients via telemedicine from India are actually working a day job and can provide a higher level of care than their counterparts in the US who are being awakened at 3 A M to do the same work–really a no-brainier, as they say in the US.

This today is a reality. Many emergency room physicians whom we work with are pleasantly surprised at how cheerful and responsive we are when they call hesitantly to discuss a report. This after having dealt with a less-than-happy US based radiologist who, having been awakened at an unearthly hour, is keen to return to bed at the earliest given opportunity.

An emergency physician at a hospital in Georgia once told me he could almost hear me smiling, when I spoke to him on the phone, a refreshing change from the response he was used to getting from his local radiologist. Of course, the radiologist groups themselves are greatly appreciative of our service given that it allows them to get their sleep and be productive the next day. Overall, service levels are therefore considerably higher when teleradiology is practiced well.

The effectiveness of the day-night time shift paradigm has been already well established by the information technology sector. Today, the healthcare sector is poised to use this to advantage as well. The telecommunications links are in place, the world has shrunk, and night can be turned into day benefiting patient care and ensuring the physician’s well being too.

The writer is CEO with Teleradiology Solutions, Bangalore.