[g.giancaspro_108]

We had facilities try to provide that level of service to us, giving us only the current exams and not the priors.  We did not accept that and required them to send the priors and the reports.  
I would suggest that you advise your client to send the priors and the reports.

[Zuleyka]

I am of the opinion you cannot practice radiology safely or correctly without the priors.

[nuhahussein320]

We require our techs to send the most recent relevant priors to our tele company, but it requires the tech to actually find the prior and do it; it isn’t automated for us. Every now and then they may not get a prior study of different body part but overlapping coverage; however, it hasn’t really affected care much other than backing off a followup recommendation (e.g. pulmonary nodule called on CT chest that is stable from a CT T-spine study years ago)

[talia784]

As a trainee, one of the corporate telerad groups covered our nights and never got priors (images or reports, I believe). Their reports were very frequently very bad due to the complexity of our cases and the subtlety of findings that a prior (and EMR access that I had) would easily illuminate. Not on them.
 
My current practice has a setup where a site we cover has a tech that must manually send a prior, if there is one, for me to see either the images or the reports. They remember less than 50% of the time. I can in theory call them, but I can’t at times when I’m slammed. I very much agree with TripleJumper — this is just bad medicine. Acceptable on paper, but bad.

[ruszja]

Our tele providers have always required relevant priors to be sent. Doesn’t always happen, particularly on stroke codes.

[william.wang_997]

You will start getting requests for comparisons if you don’t have priors. Tough to give a good report without priors.

[kmh0667]

You sound like a lawyer. Would a rad read a study without a prior from the Emergency room???
 
Of course they would- they should not sit on emergent findings. Example, ruptured aorta, pneumothorax. It is the responsibility of your hospital to send the priors. The teleradiologist cannot hop on a plane 5 states away and look at a prior he/she did not know even exits. Easy question. Lets see someone spin it the other way of course.

[toumeray]

Agree, OP sounds like a lawyer, be careful what you say folks. Dont want to feed these scumbags for free. Even if working medmal defense, they should be paying for expert witness services like we would pay for counsel. I doubt if you went on a law forum they would help you as much as some rads are helping them here.

[visguf]

BTW, the OP is me, and NOT I am not a lawyer. I’m a tech guy (PACS Manager) and not a rad.  And I’m asking because sometimes we get clients that refuse to send prior reports. Most of them are OK with the request to ask for prior images, but these are sent manually – as many of you have stated – and many times the relevant priors are forgotten.
 
The problem I see out there is that techs, most of the time, have access to priors via their own PACS systems and it’s relatively easy for them to send prior images to us (they find the priors, initiate a move and select our AE from their list). The same is not possible – most of the time – with prior reports. There’s no easy way that I’ve seen with many of the big EMR/RIS vendors out there to be able to send prior reports.
 
So, for some of our clients, we don’t get prior reports, and the chief information officer(s) say that they can’t authorize us getting all their reports because we only read a fraction of their studies. 
 
I just find all this ridiculous though. Aren’t we all trying to provide good healthcare? If we all agree that having prior images [b]and prior reports[/b] is in the best interest of the patient, then why security officers continue to put roadblocks in here?

[jonhanse_770]

Forgive the directness but why are you advising clients if you have no idea about something as basic as this?  <sigh>
 
Never make asumptions. Base your decisions on facts
 
PACSMan

[visguf]

Wow, never would have expected such a disrepectful answer in this forum.
 
Why do you say I’m assuming? What am I assuming? And when you say “as basic as this”, what’s “this” referring to? 
If by “this” you mean the need to have access to prior images and reports, I guess the answer is not that clear given the amount of answers in this post.

[lisa.kipp_631]

To give you an answer – the rad will do their best. I often compare to outside studies without the report and will state that in my comparison section. Ive also called some concerning findings that turned out to be stable when a prior came to light (14mm appendix, vert occlusions, early osteo that was just degen). Whatever system youre in should strive to give rads as much info as possible, I would consider it a big deal.

[g.giancaspro_108]

I appreciate your concern on this topic.  
Unfortunately YOU want to provide good healthcare, the doctors want to provide good healthcare, but neither of us are in control.  The non-doctor administration is in control and they do not care [b]one bit[/b] about patient care.
We have had success on this issue (receiving prior reports and prior images) only by demanding it as a group and no one would read the studies without them, and to a lesser extent reminding administration that they were legally vulnerable because they had documented themselves refusing to support sending prior reports and studies. 
I hope you succeed in this.
 
 
 

Quote from Anibal J

BTW, the OP is me, and NOT I am not a lawyer. I’m a tech guy (PACS Manager) and not a rad.  And I’m asking because sometimes we get clients that refuse to send prior reports. Most of them are OK with the request to ask for prior images, but these are sent manually – as many of you have stated – and many times the relevant priors are forgotten.

The problem I see out there is that techs, most of the time, have access to priors via their own PACS systems and it’s relatively easy for them to send prior images to us (they find the priors, initiate a move and select our AE from their list). The same is not possible – most of the time – with prior reports. There’s no easy way that I’ve seen with many of the big EMR/RIS vendors out there to be able to send prior reports.

So, for some of our clients, we don’t get prior reports, and the chief information officer(s) say that they can’t authorize us getting all their reports because we only read a fraction of their studies. 

I just find all this ridiculous though. Aren’t we all trying to provide good healthcare? If we all agree that having prior images [b]and prior reports[/b] is in the best interest of the patient, then why security officers continue to put roadblocks in here?

[toumeray]

Im sincerely apologize for using the word scumbag, I thought you were a lawyer based in the verbiage and original post. I have nothing against PACS guys, the scumbags was directly used to describe lawyers, as lawyers are generally speaking scumbags. But you dont seem like one, my mistake.

As for the original question, now I will give you my opinion. Based on what you described it sounds like there is an issue with getting the reports to cross over electronically since Im guessing they are not saved in PACS but in RIS/EMR. I wonder if as a possible solution the technologist could physically print the report, scan it and upload load it as an image series to PACS, then begin the pacs transfer? Perhaps you have thought of this and apologize if there is some issue with this as well.

I have seen many techs print cds and I have looked at the printed cds for family members etc. the reports usually come with the images in these cases, can the tech just print a cd then use the information on that to upload the images and report to the seperate tele pacs system?

Having both images and reports for prior exams is optimal, but Im not sure I would go as far as to say it is substandard care. It is commonly done at many places and although it does not excuse it, it does make it seem hard to argue that not uploading the reports is a violation of standard of care.

As for the information officers argument, I can see the merits of it as well tbh. They are supposed to only provide necessary information on the patients being treated, as per HIPAA requirements. Uploading all of the reports which Im guessing means literally all of the patients in the EMR/RIS means uploading a lot of information that is not being used for patient care (ie patients without any recent scans needing the use of the prior reports). That is a HIPAA violation 100%

[visguf]

We have thought and discussed using different avenues to upload the reports, and there are ways, except they’re very cumbersome, taking too much time for the techs, and error prone. That’s why we have not done it again, nor much at all in other contracts. We have tried printing to a virtual printer, exporting to PDF, saving screenshots, and then uploading to our PACS either by adding the “electronic” copy of the report to the images, or doing some other sort of transfer… and the amount of errors we found and slowness in the process was just too much.

As for the 100% HIPAA violation, I can see that, but I thought that the HIPAA violation would occur if unwarranted (and untracked) access to a patient’s record was done. Just having access to the data doesn’t necessarily make it a HIPAA violation. Now, of course, if you have access to more data then there’s higher chances you’ll actually access the data than if you didn’t have the access to begin with.

Anyway, I was looking to this forum to hear what other telerad practices were trying. It’s unfortunate that there’s no easy/efficient solution to be able to retrieve prior reports from EMR/RIS repositories/DBs in the same way that we can prior images via DICOM Q/R.

[toumeray]

“As for the 100% HIPAA violation, I can see that, but I thought that the HIPAA violation would occur if unwarranted (and untracked) access to a patient’s record was done. Just having access to the data doesn’t necessarily make it a HIPAA violation. Now, of course, if you have access to more data then there’s higher chances you’ll actually access the data than if you didn’t have the access to begin with.”
 
This seems pretty reasonable and maybe this needs to go above the information security officers head, ie head of his section or even CMO.  Can be brought up as a patient safety issue.  I misunderstood the meaning of uploading reports.  If it just means there is access to the reports, but in practice only the relevant reports would be accessed (those with current studies to be read) I don’t see a problem.  Moreover, it’s essentially exactly the same way EMR is accessed, possibly even by telerads.  EMR’s allow access to any patient that has interacted with the health system in any way, to any provider that is part of the system (sometimes even the telerads).  And the EMR gives more information not less compared with a prior report. Obviously the provider would only access the information that is relevant, which is a small fraction of the total information they technically have access too.  Could present it like that.

[g.giancaspro_108]

This seems to be a fairly nationwide (if not global) issue.  Some of the people in our realm are very coding savvy and perhaps someone could be a superhero and write a small program to automatically retrieve reports from RIS and insert them into into the PACS, even if it means converting them to a DICOM image.  Where are the HL7 masters?

[visguf]

The issue here is that every system is different and there’s no real standard. There’s  a query interface that’s stipulated by HL7 (with QRF segments) but I have only seen one vendor implement such a thing, and only for orders, not for reports. No other big vendor has this interface. That’s the issue. 
 
So, I guess my real answer here is that everybody’s struggling with the same issue, and that some telerad practices put their foot down and will not read without access to prior reports/images, while others will try and hope for the best. OK, just wanted to confirm that I was not missing something obvious. 
 
Thanks to (almost) everybody for very useful and thoughtful responses.

[ruszja]

Quote from Anibal J

The issue here is that every system is different and there’s no real standard. There’s  a query interface that’s stipulated by HL7 (with QRF segments) but I have only seen one vendor implement such a thing, and only for orders, not for reports. No other big vendor has this interface. That’s the issue.

 
If your clients RIS is not ancient, it should have the capability to send HL7 report messages. How to trigger such a message being sent, how to route it to your system and how to mate it with the images, yeah, that may be a bit more complicated.
As for HIPAA, there is no violation. The law has exemptions.
 
[i][i]Treatment[/i] is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.[/i]
 
Of course, you are going to have a business associate agreement that covers that.

So, I guess my real answer here is that everybody’s struggling with the same issue, and that some telerad practices put their foot down and will not read without access to prior reports/images, while others will try and hope for the best. OK, just wanted to confirm that I was not missing something obvious. 

 
As a tele practice, you write it in your contract as a deliverable from the client. If they dont provide images and priors, you send them a notice that they are in default. If they dont cure the deficiency in whatever timeframe the contract spells out, you cancel the service.

Look at page 579 of the ACR teleradiology white paper:
 
[link=https://www.telemedecine-360.com/wp-content/uploads/2019/02/2013-ACR-Teleradiology-white-paper.pdf]ACR White Paper on Teleradiology Practice: A Report From the Task Force on Teleradiology Practice (telemedecine-360.com)[/link]