Remote teleradiology is an option for facilities that need the advantages of teleradiology at  reduced cost: remote radiology coverage, reporting with dictation and transcription, consults, access to radiology images by referring physicians, and so on. Implementing remote teleradiology forms a partnership between us and your facility that should be clearly understood by all concerned. 

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Teleradiology
What is teleradiology?
Why do we want teleradiology?

Our Teleradiology Partnership
What does Miner Miracles LTD provide?
What do we need to provide?
What steps are required to implement Remote Teleradiology?
What is our cost for Remote Teleradiology?

HIPAA Compliance
What security is applied to our patient data?
What HIPAA compliance procedures are in place?

Integration
What is a VPN connection?
What safeguards are in place for our network?
Which modalities can send studies to Remote Teleradiology?
Which studies can we forward to teleradiology?
What is DICOM?

Workflow
How many studies can we send?
What happens to our studies after we send them?
How long are our studies available?
How are reports transcribed?
How do we get reports from our radiologist?

Radiologist Access
Do you provide an image viewer?
Can our radiologists use their existing image viewer?
Can our radiologists manipulate the images?
Can our radiologists report their findings?
Can our radiologists use dictation?
Can you suggest a radiologist for our facility?

Accessibility
Can only our users see our studies?
How do we assure that only the right person can see their studies?
Should each user have a separate login?

User Assistance
What documentation is available for reference?
Who can our users call for assistance?

Teleradiology

What is teleradiology?
Teleradiology is the application of modern communications, storage and display technology to the secure transmission of medical diagnostic images.

Why do we want teleradiology?
Teleradiology can answer many needs within the medical community.

For the hospital ..

• Many facilities cannot support a full-time radiology staff. These facilities can now have access to qualified radiologists during regular hours, after-hours, and holidays. Studies can be returned with normal or stat scheduling at any time.
• For facilities that can support radiology staff, the hospital can add flexibility to radiology tasks and after-hours support. They can also offer specialty reads and consults that may not be available otherwise without prolonged delay.
• For facilities that cannot support any radiology staff, teleradiology providers may offer the only solution available to answer their needs. These providers offer multiple specialties, stat turn-around, after-hours coverage and direct billing.
• For facilities with limited radiology coverage, availability of fast radiology reporting will translate to higher patient retention rate.

For the patient ..

• Quicker availability to radiology services, especially for after-hours requirements.
• Wide variety of specialty coverage and consults.

For the radiology department ..

• More flexible work hours.
• Easier access to after-hours and specialty reads.
• Quicker compilation of read reports and consults.
• The ability to receive annotated images with the report.

For the radiologist

• More flexible work hours.
• More flexible work locations.
• After-hours coverage without getting in the car.
• Improved efficiency - more reads per hour.
• The ability to read for multiple facilities regardless of location.

Our Teleradiology Partnership

What does Miner Miracles LTD provide?
We provide the means and expertise to implement teleradiology at a reduced cost.

• Internet connection bandwidth to handle upload and download of your studies.
• Incoming Cisco PIX VPN access to our central servers.
• Secure temporary storage for your studies. Long term storage is available at an additional charge.
• A central Internet address for your users to download your studies.
• Image viewer and reporting software.
• Assistance in installing and testing your VPN connection. VPN hardware, software and installation services are available for an additional charge.
• Interface assistance in modifying your DICOM compliant modalities so they can send studies to our servers.
• Installation and maintenance of user accounts in accord with your directives for access and privileges.
• Telephone-based training, one session per group, with remote control for your technologists, transcriptionists, radiologists and referring doctors. On-site training is available at an additional charge.
• Detailed operation manuals in MS Word format.
• 8-5 Mon-Fri help desk user assistance. 24/7 user assistance is available at an additional charge.

What do we need to provide?
Your assistance will be required to implement remote teleradiology.

• Executed annual contract with payment.
• Provide a reliable broadband Internet connection.
• Have your IT person contact us to understand the VPN connection and test requirements.
• Have your modality maintenance people contact us for assistance in adding our servers as a DICOM device and sending test images.
• Provide a list of all users: first and last name, email address, and function.
• Set up training sessions with your technologists, transcriptionists, radiologists and referring physicians.
• Help us track and correct any problems that could arise to assure your satisfaction.

What steps are required to implement Remote Teleradiology?
The following steps are usually required to implement remote teleradiology in your facility.

• Complete and execute our annual contract.
• Set up and maintain a VPN connection to our servers on your LAN.
• Add our servers as a DICOM device on each of the modalities that will send images to teleradiology.
• Decide which users can access your studies and what role each user will assume.
• Provide training access to your user groups: technologists, transcriptionists, radiologists and referring physicians.
• Assist in defining and tracking any problems which may arise to assure your satisfaction.

What is our cost for Remote Teleradiology?
The annual contract for remote radiology is $6,900.00 per year for 10,000 studies per year and up to 40 users. Larger studies volumes and numbers of user logins are available at an additional charge.

HIPAA Compliance

What security is applied to our patient data?
Our network head end is isolated to teleradiology/remote PACS. It is fire walled to expose only those ports required for this application. Our servers operate Linux OS that is modified to exclude any known hack accesses. The head end is physically located in an area with double layer access control, strict access control procedures and locked in a separate enclosure with each server individually locked to prevent access. The operating software is keyed to the network connection which prevents installing the servers in a new location. All patient data stored on our servers or your workstations is encrypted. Data transmission using VPN is encrypted using 3DES. All other study input to our servers uses TSL encryption. Transmission between our servers and the client workstation is encrypted using 128 bit SSL. All user functions are tracked and logged in permanent files and provide audit trail capabilities. Any report marked as Final will be retained in the system indefinitely.

What HIPAA compliance procedures are in place?

• Administrative Safeguards
  Policies and procedures that include regular risk analysis and activity review
• Workforce Security
  Policies and review procedures to assure access on a strictly need to know basis
• Information Access Management
  Policies and procedures to authorize data access
• Security Awareness and Training
  Awareness training programs for all employees advise safe procedures for email, protection from malicious attack, login monitoring and password management
• Security Incident Procedures
  Respond and report procedures for incidents of security compromise
• Contingency Plans
  Data backup and disaster recovery procedures
• Evaluation
  Periodic technical and procedure review
• Business Associate Agreements
  Contractual agreements for security provisions
• Facility Access Controls
  Access control procedures to limit physical access
• Workstation Security
  Proper location of workstations to prevent unauthorized viewing
• Device and Media Controls
  Procedures for data stored on any type of media
• Access Controls
  Assures access only by authorized people or software
• Audit Controls
  Track all actions by people or software effecting data
• Integrity
  Protect data from unauthorized alteration and control destruction
• Person or Entity Authentication
  Verify that the individual is who they claim to be
• Transmission Security
  Encryption and other measures prevent unauthorized access of data while in transmission

Integration

What is a VPN connection?
VPN stands for Virtual Private Network. This refers to a network in which some of the parts are connected using the public Internet, but the data sent across the Internet is encrypted, so the entire network is virtually private. An example might be a company network where there are offices in different cities. Using the Internet the offices merge their networks into one network. The data is encrypted to insure that only the offices can see the data on the Internet link.

What safeguards are in place for our network?
Router controls severely limit the amount of data that can be transferred from our network to yours over the designated port(s), providing a connection that is virtually one-way, from your network to our servers. Fully excluding transmission from our network to yours is not possible, since TCP/IP and DICOM are two-way connection protocols.

To further protect your network, the network using VPN is isolated to teleradiology/remote PACS and fire walled to expose only the ports required for those functions.

Which modalities can send studies to Remote Teleradiology?
Any "DICOM transmission ready" modalities can forward studies to our servers. Your maintenance person can install our servers as a listed device using three parameters: IP address, AE title and port number. We will do the same thing for your modalities on our servers, then study transmission is available.

Which studies can we forward to teleradiology?
You decide which studies you wish to forward to teleradiology. Please bear in mind that the annual study volume is limited, typically 10,000 studies per year.

You can decide to forward all CT studies, all digitized films, or have your technologists decide which studies they will manually forward.

What is DICOM?
The introduction of digital medical image sources in the 1970's and the use of computers in processing these images after their acquisition led the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) to form a joint committee in order to create a standard method for the transmission of medical images and their associated information. This committee, formed in 1983, published in 1985 the ACR-NEMA Standards Publication No. 300-1985. Prior to this, most devices stored images in a proprietary format and transferred files of these proprietary formats over a network or on removable media in order to perform image communication. While the initial versions of the ACR-NEMA effort (version 2.0 was published in 1988) created standardized terminology, an information structure, and unsanctioned file encoding, most of the promise of a standard method of communicating digital image information was not realized until the release of version 3.0 of the Standard in 1993. The release of version 3.0 saw a name change, to Digital Imaging and Communications in Medicine (DICOM), and numerous enhancements that delivered on the promise of standardized communications.

DICOM is used or will soon be used by virtually every medical profession that utilizes images within the healthcare industry. These include cardiology, dentistry, endoscopy, mammography, opthamology, orthopedics, pathology, pediatrics, radiation therapy, radiology, surgery, etc. DICOM is even used in veterinary medical imaging applications.

At the application layer, the services and information objects address five primary areas of functionality:

• Transmission and persistence of complete objects (such as images, waveforms and documents).
• Query and retrieval of such objects.
• Performance of specific actions (such as printing images on film).
• Workflow management (support of worklists and status information).
• Quality and consistency of image appearance (both for display and print).

DICOM File Transmission

Transmission of DICOM studies is done with two separate files:

• Header File. This is a text file which provides all meta data related to the attached image. This data includes information on the patient, study, and specific settings for the image.
• Image File. Each image file is attached to a header file. Image files can be smaller than the attached header files.

Fully DICOM 3 compliant servers, including viewing workstations and diagnostic workstations, can all communicate with each other by simply applying standard DICOM communication protocol. To communicate between these systems, an operator must know:

• The Acquisition Entity Title (AET)
• The IP (Internet Protocol) address
• The port number used by the system for DICOM communications, usually port 104 for non encrypted transmission and port 2762 for TLS encrypted transmissions.

DICOM File Capture vs Native DICOM

Diagnostic systems, such as CT, MR or X-ray, can all transmit DICOM 3 images directly to a DICOM 3 compliant server. Almost all new systems can transmit DICOM 3 images directly without modification, although additional licensing and software upgrade fees may apply. Older systems cannot transmit DICOM 3 images directly without the installation of conversion hardware which captures the print output, converts the image to DICOM 3 and pushes the image to a server.

In addition to direct transmission, a digitizer (scanner plus workstation) can convert film images to DICOM capture files. Although this step entails more manual manipulation, it is often the most cost-effective means of transmitting images from older equipment. Digitizers also have the ability to convert films to digital files for digital storage.

Native DICOM 3 files are the images or image series transmitted directly by a DICOM 3 diagnostic system. These images are vastly superior to DICOM 3 capture studies from a digitizer or older diagnostic systems using conversion hardware. Native DICOM 3 images retain significantly more information and allow more sophisticated manipulation, such as 3-dimensional movement within the image. Depending on the type of diagnostic equipment, age and operator skill, many experienced teleradiologists will only accept native DICOM 3 files.

Workflow

How many studies can we send?
The typical annual contract involves 10,000 DICOM studies per year. Added study volumes are available at an additional charge.

What happens to our studies after we send them?
Your studies are stored in encrypted temporary storage on our servers and made available to the doctors for download. Unless you contract for long-term storage, these studies are eventually deleted to free storage capacity.

When the doctors download your studies to their workstation using an encrypted Internet connection, they are stored temporarily in encrypted form on their hard drive until they are deleted to free hard drive capacity.

How long are our studies available?
Your studies are stored for roughly 30 days, then deleted to free storage space. If you wish, we can make them available though our long-term archival for an additional charge.

How are reports transcribed?
The reporting component of the teleradiology software allows the radiologist to dictate a report for later transcription. These functions are connected to email, allowing each person in the chain to receive an email when something is waiting for their attention.

In practice, the radiologist dictates the report, then changes the study status to Dictated. An email is generated to the transcriptionist. The transcriptionist enters the web reporting access, types the report, changes the status to preliminary, then sends the report back to the server. The radiologist gets an email alerting that the transcription is complete, and marks the report as Final.

The initial dictation is saved on our servers as a sound file. Foot pedal actuation is available for the transcriptionist to allow easy control while typing.

How do we get reports from our radiologist?
If your radiologist uses our reporting feature, you login, download and print the report. If your radiologist uses another reporting tool, he will fax or send his reports.

Radiologist Access

Do you provide an image viewer?
We provide one of the most sophisticated image viewers available. The viewer is downloaded and installed automatically from our servers when the doctor logs in. Updates are automatically downloaded and installed.

Can our radiologists use their existing image viewer?
Our servers do not support DICOM query/retrieve. Your doctors have the option of downloading studies from our servers using our image viewer or having studies pushed to their servers where they can download studies using their image viewer.

Can our radiologists manipulate the images?
Our image viewer allows standard manipulation and annotation. Images can be attached to reports. It also offers advanced features such as series linking, single point linkage through multiple planes and planar reconstruction.

Can our radiologists report their findings?
We provide a complete reporting tool as part of our image viewer. Reporting can be done using dictation/transcription or typed directly into the reporting system. After reports are marked as final, they can be downloaded and printed for your records.

Can our radiologists use dictation?
The reporting tool supplied as part of our image viewer allows the doctor to use any microphone/sound card combination to dictate reports. The system will allow use of the Phillips SpeechMike™ without modification.

Dictation generates a standard sound file stored on the server for later transcription. At this time, we do not support voice recognition, although it can easily be used with our system. Create and edit the report using voice recognition, block/copy the report to our reporting tool, then save it on our servers.

Can you suggest a radiologist for our facility?
Miner Miracles LTD is not officially affiliated with any radiologist or group, but our work worldwide with radiology gives us access to some of the best in the business. Whether you need only nighttime services or full time service, we can suggest experienced professionals with excellent credentials.

Accessibility

Can only our users see our studies?
Your studies are strictly isolated in our systems. Only your users can see your studies.

How do we assure that only the right person can see their studies?
We typically allow your technologists and department managers to see all of your studies without restriction.

Further restriction is possible so that referring physicians and radiologists can only see their studies. These restrictions are at the discretion of the technologist who generated the study.

Should each user have a separate login?
Assignment of your user accounts is your decision. We highly recommend individual accounts for each user where possible, but there may be situations where doctors work as a group and individual logins may be impractical. In these cases, HIPAA appears to allow group logins as long as the group assumes responsibility for tracking user activity that provides a comprehensive audit trail.

User Assistance

What documentation is available for reference?
A complete users manual is available for download from our servers. The document is in MS Word format.

Who can our users call for assistance?
Your users can call Miner Miracles LTD for assistance 8-5, Monday through Friday. 24/7 user assistance is available at an additional charge.