Clinical quality management in telenuclear medicine

Abstract

A new subject of huge economic interest is being born: telemedicine. Dedicated journals are emerging, literature is expanding and societies of interest are being created [1]. Web-based e-medicine is increasingly becoming a strategic tool in health care delivery worldwide [1,2]. There is a scarcity of specialized medical expertise in distant rural regions of emerging countries as well as among human communities living apart, e.g. in the Navy, or in remote places in harsh physical environments, e.g. the Arctic or Antarctic. In such geographical regions with low population densities, where, for instance, "circuit riders" have been travelling from small town to small town in order to interpret imaging findings among all sorts of other tests, rapidity and competence of expert reading may be increased by distant access to medical data [3].Practical e-medicine applications include the follow-up of rare clinical conditions (telefollow-up), the seeking of a second opinion by rural (teleconsultation) or navy doctors (navy telemedicine), expert diagnosis of dermatological conditions (teledermatology) [4] and distant reading of radiological (teleradiology) or nuclear medicine images (telenuclear medicine). Moreover, continuous medical education programmes (tele-education) [5] may be based on evaluation of clinical or dermatological cases (dermanet) [6] or on live surgical procedures (telesurgery) [7]. Clinical applications have been described in the monitoring of cardiac parameters (telemonitoring or telecardiology), in the monitoring of under-served populations (telehomecare), in the surveillance of daily living activities in elderly people in nursing homes using an infrared motion detection system (telesurveillance) [8], in the screening of diabetic retinopathy using digital fundus photography, etc.Besides the broad concepts of "telemedicine" and "internet medicine", a ready-to-use "tele-terminology" covering diverse aspects of medical expertise is emerging, with original terms such as telespecialist, teledoctor, teleexpert, telepresence, telehealth and evidence-based telemedicine. These terms are partially self-explanatory with regard to technical potential. However, several fundamental questions relating to clinical quality considerations remain without satisfying answers. In telenuclear medicine, the problem lies mainly in the dissociation between the acquisition of clinical and imaging data by a local doctor and their interpretation by a distant expert.In traditional bedside or ambulatory medicine, the physical proximity and the human relation between doctor and patient are important, resulting in the provision of relevant information via the clinical history and physical examination that may be essential for study interpretation. Functional imaging is sensitive to all sorts of disturbances. FDG scans, which are subject to all manner of possible causes of false positive and false negative results, are but one prominent example. A simple bone scan may raise as many questions as it answers. Such a scan performed in a you...