Teleradiology for remote consultation using iPad improves the use of health system human resources for paediatric fractures: prospective controlled study in a tertiary care hospital in Italy

European health systems are under severe budgetary constraints, while having to respond to the challenges of an ageing population, rising expectations of citizens, and a steady decline in the number of health personnel [1, 2]. All these factors have set e-Health high on the European political agenda: the eHealth Action Plan 2012–2020 - Innovative healthcare for the 21st century[2] is strengthening European commitment in the implementation of e-Health services since they are believed to have the potential to both reduce cost and improve the quality of health care. Due to the predominant digital character of medical imaging, radiology is on the forefront in this e-Health scene [3].

Injuries are one of the primary causes of morbidity in children [4, 5]. According to existing epidemiological data, about a quarter of children suffer from at least one injury every year [4‐6]. Incidence of fractures range from 2 to 3.6 per 100 children a year [4‐7], with one-third of boys and girls expected to suffer from a fracture before 16 years of age [6]. Fractures also represent a considerable economic burden to families, with high health-care related costs and lost parental working time [8‐10].

Most cases of fracture access hospital care through the emergency department. Based on the case characteristics and on existing local guidelines, the emergency department staff contact an orthopaedic specialist for support and advice. Usually, this remote support relies on a verbal description made by the emergency department staff or on a written description made by the radiologist. However, clinical practice has showed that a description of the X-ray is not enough for proper decision making in orthopaedics and often does not substitute for viewing the actual images [8, 9]. This is particularly true for non-displaced or minimally displaced fractures [12].

When orthopaedic specialists lack the X-ray image for remote consultation they may decide to travel to the hospital to view the image, or decide to base their opinion solely on the X-ray description. The first option implies additional costs for the health services (cost of the orthopaedic consultancy), while the second option implies a possible risk of misdiagnosis and improper case-management [12, 13].

Implementing teleradiology for remote X-ray consultation into standard clinical practice has the potential to improve this communication. Remote X-ray consultation could enable the on-call orthopaedic specialist to establish the management plan more accurately and more rapidly with a possible benefit both for the patient (speeding up of case-management) and for the health services (better use of health services resources).

Although a number of pilot experiences exist, and experiences are rapidly growing in this field, remote X-ray consultation on mobile devices for on-call specialist services in Europe is still not a wide-spread practice. Literature in orthopaedics has so far mostly concentrated on the use of digital cameras for acquiring a digital copy of the plain X-ray image, and on the use of either Multimedia Messaging Services (MMS) or image-transfer [11‐14]. Studies were generally small in sample size, and MMS have in most instances failed to show an acceptable accuracy and reliability for diagnosis, with a misdiagnosis risk reported within the range of 15 to 40% [15‐17]. Moreover, the use of either MMS or emails to transfer patients files is not complying with the international regulations and standards on data privacy and integrity, and may be open to litigation. The European legislation, similarly to the United states regulation, requires that the images are transferred securely and are accessed only by authenticated users [3, 18, 19].

Alternative methods for remote consultation are needed for optimising the use of resources in emergency departments. In this prospective study we evaluated the impact of remote X-ray consultation using a mobile device (iPad) on orthopaedic consultations for children with bone fractures in a tertiary care paediatric hospital in Italy.

Forty-two children were enrolled in the study. Characteristics of cases are described in Table 1. Among the forty-two enrolled children, 23 (54.7%) presented with a fracture of the upper limbs, 13 (30.9%) with a fracture in the lower limbs, 5 (11.9%) with a fracture in the clavicle, and one with a suspected fracture of the pelvis. Overall, 25 (59.5%) children were diagnosed with a simple fracture, 15 (35.7%) children with a wedged fracture, and 2 (4.7%) children with a complex (displaced) fracture.

The number of in-hospital consultancies by the orthopaedic specialists was 32/42 (76.1%) when no X-ray was provided compared to 16/42 (38%) when the X-ray was provided through the iPad, p < 0.001 (Table 2). No significant differences were observed among different orthopaedic specialists (p = 0.1).

With teleradiology in 14/42 (33.3%) cases services such as surgery and plaster room could be immediately activated for case management, compared to no service immediately activated without teleradiology (p < 0.001).

With the standard approach (only verbal communication, no X-ray provided), the average time for decision making on case-management of fractures was 56.2 ± 16.1 minutes compared to 23.4 ± 21.8 minutes when the X-ray was provided (p < 0.001).There was no statistically significant difference in quality of images using iPad compared to the dedicated PACS, as rated by the independent radiologists (respectively 9.89 ± 0.37 K = 0.92 vs 9.91 ± 0.30 K0 = .96; p =0.79 (Figure 4). Similarly, there was no statistically significant difference in diagnostic confidence using the iPad compared to using the PACS (respectively 9.91 ± 0.32 K = 0.95 vs 9.92 ± 0.31 K = 0.92; p = 0.88).

This study was a pragmatic evaluation of the impact on in-hospital orthopaedic consultancies of providing the X-ray for remote consultation through an iPad in addition to the standard approach (verbal communication only). Results showed that after having direct access to the X-ray for remote consultation orthopaedics switched their minds from "go to the hospital" to "stay home", halving the number of in-hospital orthopaedic consultancies for paediatric fractures, and significantly speeding up the decision making on case management.

This study suggests that providing access to the X-ray for remote orthopaedics consultation may have a large impact on the organisation of care, decreasing the need for the orthopaedic to come to the hospital, and facilitating a more rational and efficient use of the health system resources. Potentially, although this was not formally evaluated in our research, it may also decrease the costs for care. Specialist orthopaedics are paid more for their on-call consultancy if they come to the hospital rather than if they work from home. In our setting, net cost for the in-hospital orthopaedic consultancy is 28.54 euro/hour (with an average of approximately 3500 consultancies per year, and an average duration of each consultancy of 1.8 hours, range from 30 minutes to 6 hours), whereas if the on-call orthopaedic provides the consultation only from home the cost is approximately 20 euro for the whole shift (usually 12 hours). Therefore the estimated total difference in expenditure for the hospital when implementing simple systems for remote X-ray consultations may add up to several thousand of euro a year.

Additionally, the recent economical crisis has imposed restrictions in the health workforces [1, 22, 23]. There are fewer orthopaedic specialists and these frequently need to cover the services on-call at night or during the weekend. In many instances even if called at night, the specialist is not exempted from working on the following day. Requiring a specialist to come back to the hospital just to view an X-ray, because this is not available for remote consultation, may appear outdated compared to the actual large use of web-based services in the general population.

Although teleradiology is a very rapidly growing field, to the best of our knowledge, there are no other studies in orthopaedics on systems for remote X-ray consultation ensuring adherence to international standards on data privacy, image quality, and data integrity. As already described, most studies in orthopaedics have evaluated MMS. However, with MMS data security is not ensured (for example, with MMS data usually stored in an unprotected server of the provider) and data integrity is problematic (e.g. sharing files of large dimension is often difficult, and image resolution may be automatically lowered by the system) [15‐17]. Other systems for data transfer, such as Dropbox or email are regarded as potentially unsecure if they are not built on a dedicated system. The vision of the European eHealth Action Plan 2012-2020[1] is to utilise and develop eHealth to address several of the most pressing health and health systems challenges of the first half of the 21st century, including the need to increase sustainability and efficiency of health systems. This study aimed at filling gap in research in regards to innovative simple eHealth systems for orthopaedic consultants. A possible limitations of this study include the cost of the technology used. In the future, other systems may be tested and compared to Aycan OsiriX PRO or iPad, evaluating both accuracy in diagnosis and cost. For example, future systems for remote X-ray consultation may utilise smart phones with large screens, which are sometimes preferred to an iPad due to their portability.

Remote X-ray consultation through an iPad should be considered as a means to reduce the need for in-hospital orthopaedic consultation, and potentially decrease costs for the health system and families. In the future, alternative systems less expensive than Aycan OsiriX PRO should be further developed and tested.