Telemedicine services in radiology include the provision of remote radiological services by using information and communication technologies. Usually, radiographs or radiographic images (hereinafter image material) captured at one place are examined at another remote location and results and opinions are given.

The primary goal of introducing telemedicine services in radiology is to make radiological examinations more accessible in isolated and hard-to-reach areas, such as islands and rural areas and health institutions without competent staff.

A medical doctor indicates the need for a radiological examination. If the indicated and medically justified radiography can be performed at the location where the indication was made (availability of a medicine radiology engineer and a radiological device), and a radiologist who would examine the image material and give a written result and opinion is not available, or if he cannot deal with the required opinion because it is of a subspecialist nature, the recorded image material can be sent to a teleconsultant who then sends back the results and his opinion.

Contemporary radiology has become almost entirely digital. This means that all radiological image material (from conventional radiographs to CT, MR and ultrasound examinations) are in the digital format. Similar development can be observed in Croatia. Digitalization of image materials represents a necessary and unavoidable prerequisite in radiology in telemedicine. In addition, in order to maintain standardized conditions of recording, exchanging, viewing and storing radiographs, it is necessary that they are in the format prescribed by the DICOM standard (Digital Imaging and Communications in Medicine). In addition to the file format, the DICOM standard defines how images are transmitted in computer networks and stored on different media. When developing radiology systems in telemedicine, it is necessary to abide by all the guidelines of the DICOM standard in all the steps comprised in providing a teleradiological service, not just the file format.

In order to store and access pictures in the radiological system in telemedicine, a central or distributed PACS(Picture Archiving and Communication System) needs to be established including all protection systems (backups, authorized access) and in line with the DICOM standard. The development, maintenance and improvement of PACS for the needs of radiology in telemedicine falls within the competence of the Croatian Institute of Telemedicine, which the latter can perform in cooperation with independent contractors.

In order to facilitate the smooth sending and connecting of radiological queries, test results and opinions in telemedicine, in addition to PACS, the Radiology Information System(RIS) is required, with all the functionalities enabling authorization, production ofmedical reports in a standardized format, drawing up of working lists, making of appointments, access to earlier radiological examinations, but also connecting to other different large medical systems and databases, like the ones in primary health care, in order for the radiologist to have as much information as possible while interpreting test results.

There is another prerequisite for the functioning of radiology in telemedicine – a computer network infrastructure with a sufficient data transfer speed for all radiological examinations which are planned to be done via telemedicine.

All the medical documentation produced by using the radiology system in telemedicine has to be available to all the persons comprised in the telemedicine network centres and the computer systems connected with it.

In facilities where there is a referring health professionalwho requests a radiological telemedicine service, or where this facility is envisaged, and where there are also several radiological modalities, there must also exist a local network infrastructure via which images will be sent into the radiology system in telemedicine. The setting up and maintenance of the local computer network of individual facilities included in the operation of radiology in telemedicine (referring professional and teleconsultant) falls within the competence of such facilities according to the conditions and instructions given by the Croatian Institute of Telemedicine. The pictures and medical report with the radiologist’s opinion have to be given to the patient on an optical medium (a CD or a DVD) upon the completion of his radiological telemedicine services; it this is not possible, it has to be enclosed to the patient’s medical documentation, which is the obligation of the referring health professional. The reasons for this are manifold: on one hand, there is a lack of interconnection between individual health facilities in Croatia and of a global national information system dedicated to health, as well as the lack of standards and legal regulations. On the other hand, there is a need for availability of medical documentation of a patient in case of his/her treatment in several health institutions or when a second opinion is needed. In addition, all images and related medical reports and opinions of radiologists produced by using radiology in telemedicine have to be stored for as long as this is prescribed by the legal regulations in force.

From the technical point of view, the introduction of radiology in telemedicine takes place in 4 basic stages:

  1. digitalization of local radiology departments/wards with a complete radiological business process,
  2. introduction of communication infrastructure and connecting of locations,
  3. integration of radiological solutions in telemedicine into an institution’s business processes, 
  4. central system with logic control of image material and medical report exchange among institutions.

Radiology in telemedicine offers a series of advantages. The basic advantage was mentioned at the beginning: the availability of radiological examinations in isolated and hard-to-reach areas. This is especially important in medical emergencies. In addition to the improved quality of health services by using radiology in telemedicine, and telemedicine generally speaking, significant savings in health can be expected because patients no longer have to travel to another location to have a radiological examination, which is even more pronounced in case of control check-ups and repeated examinations. Moreover, the number of days spent on sick leave is reduced. There is no longer a need for employing a part-time radiologist in that area and paying for his travel expenses or potential accommodation expenses. The central system with logic control of image materials and medical report exchange ensures a continuous availability of radiological images to all institutions included in the telemedicine system. This allows for immediate accessibility of image materials if a patient is treated in another institution, which is especially important for emergency interventions. In addition to the mentioned advantages, there is a possibility of comparing new image materials with the old ones, and the patient might notneed to be exposed to x-ray if the required image material already exists. All of the mentioned advantages result in substantial savings in both time and money which would otherwise be needed for a diagnostic procedure. This is especially true of double and multiple diagnostic procedures. By introducing radiology in telemedicine, especially on Croatian islands, the level of quality of health services is raised, thus also contributing to tourism and making it safer, more attractive and more competitive. Finally, there is a trend to connect health on the international level by introducing telemedicine services in radiology, which makes the Republic of Croatia a potential provider of such services to other countries too.