TELERADIOLOGY By Robert Alvarez Jonathan Caprino Sara Desanto Josh Gonzalez Angelica Sukel A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah April 25, 2025 ii THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Robert Alvarez Jonathan Caprino Sara Desanto Josh Gonzalez Angelica Sukel This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Tanya Nolan, EdD Chair, School of Radiologic Sciences ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist ______________________________ Dr. Robert Walker, PhD Director of MSRS iii THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Robert Alvarez Jonathan Caprino Sara Desanto Josh Gonzalez Angelica Sukel This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date April 25, 2025 ______________________ April 25, 2025 ______________________ April 25, 2025 ______________________ April 25, 2025 ______________________ April 25, 2025 ______________________ ____________________________________ Robert Alvarez ____________________________________ Jonathan Caprino ____________________________________ Sara Desanto ____________________________________ Josh Gonzalez ____________________________________ Angelica Sukel iv Abstract Teleradiology has been an ever-growing, sometimes necessary element of radiology departments across the globe. Modern computer networking has provided the ability to access and interpret medical imaging internationally while allowing radiologists to do so remotely, creating flexibility for an often essential component of healthcare. While many of the advantages of teleradiology can be readily appreciated, it is crucial to analyze the challenges it currently faces. The available literature demonstrated both the successes and barriers of teleradiology; however, these qualities are never, if rarely, compared. This qualitative literature review compared the advantages and disadvantages of teleradiology to provide insights to the medical community on those areas that work, those that are challenging, where information is needed, and recommendations that promote a more efficient system for future considerations. The participants of this study are Sara DeSanto, Robert Alvarez, Angelica Sukel, Jonathan Caprino, and Josh Gonzalez. The key results of this literature review include how radiologist shortages negatively impact patient care, how the availability and expansion of teleradiology services depend on the global area, how departmental variations affect teleradiology services, and how the advantages of teleradiology services outweigh the disadvantages. In conclusion, it was discovered that the advantages of teleradiology services outweighed the disadvantages and the availability of teleradiology directly relates to the global location. However, teleradiology is constantly expanding globally, and as it expands, more research can be done to assess whether the advantages still outweigh the disadvantages of providing this medical service. v Table of Contents Chapter 1: Introduction ....................................................................................................... 1 Background ....................................................................................................................1 Statement of the Problem .............................................................................................. 2 Purpose of the Study ..................................................................................................... 5 Research Questions ....................................................................................................... 6 Nature of the Study ....................................................................................................... 7 Significance of the Study .............................................................................................. 8 Definition of Key Terms .............................................................................................. 10 Summary ...................................................................................................................... 12 Chapter 2: Literature Review ............................................................................................. 14 Documentation ............................................................................................................. 16 Advantages of Teleradiology ....................................................................................... 16 Disadvantages of Teleradiology ................................................................................. 20 Barriers of Teleradiology ............................................................................................. 24 Worldwide and Departmental Variations .................................................................... 26 Effects of Radiologist Shortages .................................................................................. 30 Summary ...................................................................................................................... 34 Chapter 3: Research Method.............................................................................................. 36 Statement of the Problem ............................................................................................. 36 Research Questions ...................................................................................................... 38 Research Methods and Design(s)................................................................................. 38 Population .................................................................................................................... 40 Sample.......................................................................................................................... 42 Materials/Instruments .................................................................................................. 48 Data Collection, Processing, and Analysis .................................................................. 50 Assumptions.................................................................................................................52 Limitations ...................................................................................................................52 Delimitations ................................................................................................................54 Ethical Assurances .......................................................................................................54 Summary ......................................................................................................................54 Chapter 4: Findings ............................................................................................................56 Results ..........................................................................................................................56 Evaluation of Findings ................................................................................................. 59 Summary ...................................................................................................................... 60 Chapter 5: Implications, Recommendations, and Conclusions ......................................... 61 Implications.................................................................................................................. 61 Recommendations ..................................................................................................... 655 Conclusions .................................................................................................................. 67 vi References .......................................................................................................................... 69 Appendices ......................................................................................................................... 75 1 Chapter 1: Introduction This literature review was composed of a group that focused on the major themes of teleradiology: its advantages and disadvantages, radiologist shortages, barriers, and the various departments affected around the world. Multiple scholarly and peer-reviewed sources to support each theme and to identify any gaps in our research were applied. We also researched the overall positive and negative effects on patient care, the ability of radiologists and healthcare workers to overcome barriers within the field, and the correlation between radiologist shortages and varying departments in radiology. Background Teleradiology is a large, sometimes necessary, component of radiology departments across the globe. The interdependence of radiology departments and teleradiology systems across geographic locations has created a carefully balanced network designed to improve patient care. As teleradiology continues to grow and become more essential, it is important to understand its advantages and disadvantages. Positive impacts of teleradiology have been appreciated, such as improved turn-around times and better access to subspecialty reading (Anawade et al., 2024). Radiologists that utilize remote reading also report improved satisfaction and increased productivity (Petscavage et al., 2022). Perhaps the most significant advantage of teleradiology is its ability to bridge gaps of rural healthcare, in that it provides timely radiology reporting in urgent settings (Hanna et al., 2020). 2 While these benefits may be evident, each has its own drawbacks. Reading times have improved, but there has also been an increase in malpractice claims with teleradiology (Mezrich, 2024). Radiologists that read off-site can be more prone to communication errors with on-site providers and technologists, causing confusion and patient care delays (MacFarlane, 2019). Geographically remote or rural locations can suffer from underdeveloped infrastructure resulting in those same time-sensitive readings becoming difficult to obtain (Hadian et al., 2024). These areas may also be burdened by substantial startup costs (Madej & Sasiadek, 2023). As teleradiology continues to grow and become more essential, it is important to understand its advantages and disadvantages, and how they relate to each other. Evaluating the pros and cons of remote reading can provide valuable insight to the medical community for informed decision making on this important aspect of patient care. Having found both strengths and weaknesses through the literature, we have decided to further explore these topics to better understand how teleradiology impacts the modern world. Statement of the Problem Teleradiology has become an integral part of today’s healthcare field, offering both opportunities and challenges in its delivery of image interpretation. As the radiologic field continues to grow, it is necessary to evaluate its impact on the healthcare system. To achieve a fair evaluation, it is important to assess the challenges and gaps in knowledge of teleradiology, as well as highlight its successes. Malpractice, financial costs, interpersonal communications, and infrastructure limitations are issues that negatively impact teleradiology. Radiologist shortages create both an issue for image interpretation on-site as well as an advantage of remote reading. Knowledge gaps present 3 a challenge for understanding geographic and socioeconomic disparities, as well as the long-term impacts of teleradiology on the healthcare industry. The advantages of teleradiology are significant and reach far beyond the borders of the United States. The utilization of teleradiology has increased productivity by breaking the boundaries of distance and time by allowing teleradiology services to be offered after-hours and overnight (Hanna et al., 2020). This allows practitioners to receive image interpretation promptly. This service is critical when addressing radiologist shortages and improving patient care in areas of low socioeconomic status (Abdulwahab, 2019). Teleradiology has also helped in enhancing the work-life balance for radiologists, with many reporting increased productivity and job satisfaction due to the flexibility of working from home and the added time given to them due to not having a daily commute (Petscavage et al., 2022). However, teleradiology is not without its drawbacks and disadvantages. Since the inception of teleradiology, there has been an increase in malpractice claims associated with teleradiology services, which may be attributed to a lack of communication between the reading radiologist and the referring practitioner (Mezrich, 2024). Additionally, the cost associated with teleradiology, particularly the startup cost, could be very costly and difficult to achieve for some healthcare facilities, particularly those in low-income neighborhoods (Madej & Saiadek, 2023). As teleradiology grows, barriers to implementation include inadequate networking infrastructure, especially in low socioeconomic countries. Unreliable internet connections and frequent power outages in many regions play a large role in the 4 efficiency of their teleradiology services (ACR, 2022). Furthermore, a lack of quality communication between remote radiologists and on-site healthcare providers may lead to misunderstandings and potential errors in patient care (McFarlane, 2019). The adoption of teleradiology globally can be dramatically affected due to resource limitations. In Poland, for example, the high cost of hardware, software, and services provided by teleradiology companies can cause significant challenges (Madej, 2023). In contrast, countries like the United States and India have successfully implemented to cover after-hours services and provide valuable services when needed. As those services are further integrated, the increasing problem of radiologist shortage still remains a critical issue with some countries, reporting alarmingly vast ratios of radiologists to population (Omofoye, 2024). The ongoing problem of radiologist shortages has led to significant delays in image interpretation which, in turn, has led to the potential to compromise patient care. Teleradiology is the potential solution to this problem, allowing for expedited image interpretation and faster results for countries that would otherwise not have this option. In conclusion, while teleradiology offers numerous benefits in addressing radiologist shortages and improving access to specialized services, it also presents significant challenges that must be addressed. As the medical field and the need for these services continue to grow, it is essential to continue to develop strategies to overcome barriers to implementation, improve quality control measures, and maintain effective communication between the reading radiologist and the on-site clinician. By doing so, 5 teleradiology can continue to play an important role in increasing the efficiency and quality of radiologic services worldwide. Purpose of the Study The purpose of this literature review is to expand the current knowledge of the effects of teleradiology - both positive and negative - on radiologists, allied health workers, and patient care by analyzing the available literature. These key themes will be evaluated in depth, demonstrating where certain patterns and data either conflict or intersect, and how they aid in addressing the overarching research topic: Expanding the knowledge base of teleradiology with the aim of increasing the efficiency of future practice. To achieve this goal, the study will assess the following: ● The impact of teleradiology on diagnostic efficiency in relation to turnaround times and accessibility to subspecialty interpretation. ● Challenges in terms of communication, both interdepartmental and interprofessional. ● Constraints on required infrastructure and financial needs for startup and maintenance. ● The effect of teleradiology on radiologist shortages and its implementation in various healthcare environments. ● Gaps in the literature involving socioeconomic inequities, geographic disparities, and security risks inherent in global departmental variations. 6 It is important to understand past and current trends in this discipline to better identify future practices that will aid in optimizing policies and workflows, as well as alleviate any burdens of teleradiology where indicated. Central to implementing best practices, it is vital to address key arguments. These include debates such as whether teleradiology has an overall positive or negative effect on patient care, the ability of radiologists and allied healthcare workers to overcome barriers, and the correlation between radiologist shortages and varying departments in radiology. To answer these questions, gaps in literature must also be identified. Currently, these gaps involve the geographic scope of research, how socioeconomic status can affect access to teleradiology, and international security limitations. Research Questions 1. How does the implementation of teleradiology services affect patient care outcomes in rural and underserved areas? 2. What are the challenges and successes of global teleradiology implementation across varying socioeconomic backgrounds? 3. To what extent does teleradiology alleviate radiology shortages in terms of quality and timeliness of diagnostic services? 4. What are the advantages and disadvantages of teleradiology in regard to effectiveness of healthcare delivery, provider workload, and patient satisfaction? 5. What are the legal and ethical implications of cross-border teleradiology services, particularly in terms of licensure and patient privacy? 6. What role does teleradiology play in addressing health disparities, especially in terms of access to specialized radiologic services? 7 7. How does the use of teleradiology affect the work-life balance and job satisfaction of radiologists? 8. How does the integration of teleradiology impact healthcare systems, in terms of interdepartmental communication and collaboration? 9. What strategies can be employed to standardize the education and continuing professional development of teleradiologists across different countries and regions? Nature of the Study The study presented provides a comprehensive literature review examining teleradiology and healthcare systems' current state and global impact. The design that was utilized is qualitative, utilizing a systematic review approach to bring together and analyze existing literature on teleradiology. The primary sections and constructs that were explored in this study are the advantages and disadvantages of teleradiology, barriers to teleradiology implementation, the impact of radiologist shortages on teleradiology services, global variations in teleradiology practices, and effects of teleradiology on patient care and healthcare delivery. The method that was chosen integrates with the study's purpose of exploring the current information on the effects of teleradiology on radiologists, allied health workers, and patient care. A qualitative literature review was the most optimal choice for this research topic as it allows for an exploration of multiple issues surrounding teleradiology and its implementation and impacts. Data collection involved a systematic search of peerreviewed studies published within the last decade, sourced from reputable medical journals and databases. Some of the key search terms include “teleradiology”, 8 “advantages”, “disadvantages”, “barriers”, “international”, “U.S.A.”, “medical-legal”, and “socioeconomic”, among others. Studies were selected based on criteria involving peer review, geographic region, socioeconomic factors, healthcare facility policies, and medicolegal issues. The procedure used to analyze the information gathered in the literature review was a systematic, transparent, and flexible process. This process helped identify recurring themes, patterns, and gaps in the current information that was gathered. This approach, as described by Thomas and Harding (2008), leaves room for the integration of the findings from multiple qualitative studies that provide new insights and interpretations. This chosen strategy is supported by Foundational research literature. Booth et al. (2016) emphasizes the value of systematic literature reviews in healthcare research for organizing evidence and supplementing practice and policy. Additionally, Pare et al. (2015) highlights the importance of rigorous literature reviews and information systems research which is relevant to the technological aspects of teleradiology. This research design allows for a comprehensive understanding of teleradiology's current state, its challenges, and its potential routes in the future. By combining existing knowledge and identifying gaps in the literature, the study aims to contribute valuable information and supplement future practices and policies in teleradiology. Significance of the Study Assessing the many facets of teleradiology can provide insight into best practices for these systems. The purpose of this study is to understand the impacts of teleradiology on healthcare outcomes, whether they are inherent in healthcare systems, such as policy, workflow, licensing, and shortages, or factors that are outside of those bounds, such as 9 stress, communication issues, and access to rural areas or areas with suboptimal infrastructure, among others. Through a review of the literature, it was found that each of these topics has its strengths as well as challenges. The significance of this study is to highlight and provide suggestions to further refine the strengths of teleradiology, in the hope of continued positive patient outcomes. Conversely, and perhaps more importantly, the study aims to identify the challenges, pitfalls, and knowledge gaps of teleradiology. Currently, there is little information on international security and socioeconomics and how they affect teleradiology. This is compounded by the lack of breadth in global research. By addressing the gaps in knowledge through literature review, it is hopeful that new research will be conducted to bridge those areas. In this way, these difficulties can be brought to the attention of the larger medical community, and therefore solutions can be put forth to increase efficiency. This review of the literature may bring forth policy changes that outline more efficient communication protocols between providers and remote readers to reduce patient care delays and promote exam appropriateness; spur the creation of more accessible pathways for interstate and international credentialing and licensure; establish guidelines for down-time procedures which can be especially useful in rural or lowincome areas; foster change in purchasing strategies to drive down costs; and create a better understanding of teleradiology as a whole, through analysis of its component parts. Our literature review provides a means for strengthening and optimizing challenging aspects of teleradiology, promoting those areas which work well, and to inspire positive change through recognition of the many components of teleradiology and their interdependence. 10 Definition of Key Terms Teleradiology: interpretation of medical images transmitted over electronic networks for diagnostic purposes (Merriam-Webster, 2025). PACS (Picture Archiving and Communication Systems): computer systems which aid in transmitting images to multiple, disparate physical locations (Picture Archiving, 2025). Radiologist Shortage: The global issue of insufficient radiologists to meet the growing demand for imaging services. Turnaround Time: The time taken from the acquisition of an image to the interpretation and delivery of the report, which is a critical metric in teleradiology (NHS). Image Interpretation: The process of evaluating images to differentiate between normal and abnormal anatomy and the creation of reports detailing those findings, which is the main function of teleradiology (Medicine, 2025). Rural Healthcare: The implementation of medical services in remote or underserved areas, where teleradiology may not be readily available. Interventional Radiology (IR): A subspecialty of radiology that uses imaging guidance to perform minimally invasive procedures (Uvaradweb, 2020). Barriers to Teleradiology: Obstacles that hinder the delivery or effectiveness of teleradiology services, such as infrastructure limitations, cost or communication issues. Medicolegal Considerations: Relating to both medical and legal aspects of practicing teleradiology services across different jurisdictions (Merriam-Webster, 2025). Accreditation and Licensure: The process of ensuring that teleradiologists are adequately qualified across different regions or countries (Accreditation, 2022). 11 Patient Care Impact: The effects of teleradiology on patient outcomes, the speed of diagnoses, and the treatment selected for the patient. Cost-effectiveness: The economic impact of implementing and maintaining teleradiology services compared to traditional radiology practices while attempting to keep costs as low as possible (Thompson, 2023). Quality Assurance: Measures and protocols that ensure teleradiology interpretations meet certain specified requirements (Hashemi-Pour & Gillis, 2024). Workflow Optimization: Strategies to improve the efficiency of teleradiology services (Admin, 2024). Global Variations: The differences in teleradiology services that affect practices across healthcare systems across the country. Systematic Literature Review: research process involving selection and appraisal of research to answer a question or questions (Library Guides, 2025). Quantitative Research: collection, analysis, and interpretation of numerical data (Bhandari, 2023). Qualitative Research: research that evaluates and provides insight into real-world problems (Tenny, 2022). Chi-Square Test: statistical for discerning the difference between expectations in data and actual outcomes (Tenny, 2022). Reflexive Thematic Analysis: methodological approach to qualitative research that requires introspective analysis of the researcher for critical reflection of the research process (Reflexive, 2025). 12 Mixed-Method Research: integration of both quantitative and qualitative research methods (Mixed Methods, 2025). Summary The above literature review explores the impact of teleradiology on healthcare delivery, focusing on its advantages, disadvantages, barriers, and effects on radiologist shortages. The study's purpose is to inform the reader of current knowledge on teleradiology’s effects on radiologists, allied health workers, and patient care by analyzing available up-to-date information. Key points include: Assessing the advantages of teleradiology including its improved access and efficiency across domestic and international boundaries, as well as the quality-of-life enhancement for remote radiologists. Disadvantages and barriers will also be analyzed pertaining to high start-up costs, socioeconomic burdens, communication errors, and medicolegal issues involving pertinent patient data. The study will also evaluate the global impact of radiologist shortages, and how variations in radiology departments around the world impact efficiency. The proposed research plan involves: 1. Conducting a comprehensive literature review of peer-reviewed studies from the past ten years. 2. Analyzing data on teleradiology’s impact on patient care, radiologist work-life balance, and healthcare delivery efficiency. 3. Evaluating the global variations in teleradiology implementation and effectiveness. 13 4. Identifying gaps in current research, such as socioeconomic factors affecting teleradiology access and international security limitations. 5. Organizing findings to provide recommendations for optimizing teleradiology practices and addressing current challenges. This study focuses on providing insights to the medical community on the aspects of teleradiology that are successful in improving patient care and worker satisfaction, while also highlighting current issues with the system at large and bringing attention to gaps in knowledge through the literature. Subsequent studies may use the information provided here as a basepoint to launch investigations into knowledge gaps while also expanding the teleradiology knowledge base. Furthermore, this research and any inspired future studies have the potential to affect real-world change in radiology departments by adopting successful strategies outlined in this review and gaining understanding on how challenging aspects of teleradiology can be improved. 14 Chapter 2: Literature Review In recent decades, teleradiology has become more common in radiology departments worldwide. With this increase in use over the years, much literature has been written detailing the advantages and disadvantages of teleradiology. The aim of this review is to expand current knowledge on the effects of teleradiology - both positive and negative - on radiologists, allied health workers, and patient care by analyzing the available literature. It is important to understand past and current trends of this discipline to better identify future practices that can aid in optimizing policies and workflows, as well as alleviate any burdens of teleradiology where indicated. Central to implementing best practices, it is vital to address key arguments. These include debates such as whether teleradiology has an overall positive or negative effect on patient care, the ability of radiologists and allied healthcare workers to overcome barriers, and the correlation between radiologist shortages and varying departments in radiology. To answer these questions, gaps in literature must also be identified. Currently, these gaps involve the geographic scope of research, how socioeconomic status can affect access to teleradiology, and international security limitations. To better evaluate these questions, arguments, and gaps, this review will be organized into key themes that were derived from patterns found during the synthesis of the literature. Criteria used for obtaining the literature and subsequently formulating key themes included peer-reviewed studies authored in the last ten years from medical journals. Key terms used for gathering data were teleradiology, advantages, disadvantages, barriers, international, U.S.A., medicolegal, and socioeconomic, among 15 others. Limitations of the review may include the time frame and geographic range of studies gathered. Of these themes, the advantages of teleradiology will be addressed, such as increased imaging efficiency by transcending both geographical and temporal boundaries (Hanna et al., 2020). This efficiency also allows for better access to subspecialty reading and faster turn-around times (Anawade et al., 2024). Disadvantages will also be discussed; it was found that there has been an increase in the number of malpractice suits since the adaptation of teleradiology (Mezrich, 2024). Additionally, initial start-up costs can be prohibitive (Abdulwahab, 2019). Related to disadvantages, another key theme discussed will be barriers to teleradiology. Of these, institutional policies and policies at other levels can be restrictive to workflow and efficiency (Rangachari et al., 2021). Another aspect of the review will focus on radiologist shortages. In the literature, a link was found between staff shortages and patient outcomes and satisfaction. Furthermore, shortages were correlated with several other factors, including hospital ownership, location, and size (Winter et al., 2022). Global variations within radiology departments and their structuring of teleradiology will also be examined. The development of multilanguage systems and strong networking infrastructure reveals challenges when working internationally (Hadian et al., 2022). These key themes will be evaluated in depth, demonstrating where certain patterns and data either conflict or intersect and how they aid in addressing the overarching research topic: Expanding the knowledge base of teleradiology with the aim of increasing the efficiency of future practice. 16 Documentation The literature search strategy that we implemented to expand current knowledge around teleradiology consisted of working as a group and using different resource methods to locate appropriate sources from around the world. These sources included Google Scholar, Journal of the American College of Radiology, PubMed, Weber State University Library, and the Journal of Radiology and Medical Imaging. These sources provided us with a diverse idea of what information we wanted to focus on for this scholarly paper. The terminology we used to find these articles included "telemedicine," “department,” “radiology,” and “barriers,” all allowing us to find appropriate, relevant peer-reviewed information. Our primary focus was to review many articles both within the United States, as well as worldwide to assess the differences that each country experiences and if any differences in healthcare around the world affect teleradiology. We will also compare how telemedicine in radiology will affect other departments in healthcare and if it is beneficial to patient care. Advantages of Teleradiology The advancement in the utilization of teleradiology has offered many advantages to those involved in receiving and providing healthcare. Teleradiology was utilized well before the occurrence of the pandemic when COVID-19 took over the world. Since COVID-19, teleradiology has grown in its usage and has proven to help many aspects of healthcare. The areas where teleradiology provides its advantages are shown by the increase in the overall work-life balance of radiologists, the care provided to those who live in more rural areas, and the overall increase in the speed and accuracy of diagnosing pathology for patients. 17 Radiologists are the physicians in charge of reading imaging studies and providing their findings so other physicians and healthcare workers can provide necessary and timely treatment for patients. If radiologists are not at their best and feel the negative effects of the pressure, stress, and long hours required of them, patients can suffer. “Addressing burnout and promoting physician wellness is a strategic imperative for leadership across the country so that clinical operations are not compromised. Burnout is present in 49-72% of diagnostic radiologists (1, 2, 3, 4). Burnout may manifest as disruptive physicians, apathy, emotional exhaustion, and depersonalization, and in some cases, leaving the workforce” (Petscavage et al., 2022). All of these examples highlight the importance of mitigating radiologist burnout. Again, the stressors and pressure experienced by healthcare professionals can be immense, and the utilization of teleradiology helps alleviate some of that pressure. One major advantage of the implementation of teleradiology is shown by the level of employee satisfaction of radiologists. “Radiologists who joined third-party teleradiology providers, meanwhile, enjoyed improved quality of life owing to a greater autonomy in scheduling work-fromany-anywhere capabilities” (Reeves, 2023). A way that has led to radiologists enjoying a better quality of life is the fact that “Hybrid work from home solutions allow faculty autonomy and flexibility with work-life balance, improving wellness” (Petscavage et al., 2022). Further evidence showing the benefits of teleradiology and the level of satisfaction related to the work-life balance of radiologists is represented in the following comments related to working remotely due to the usage of teleradiology: - “100% I am more focused and productive at home. There are few distractions, and I can focus on tasks uninterrupted” (Petscavage et al., 2022). 18 - “I have an extra 90 minutes of productive time/day between 6 am and 6 pm because I have no commute” (Petscavage et al., 2022). - “Yes, the flexibility that allows would be invaluable to me. Time savings that I can use to spend time taking care of my kids or allow me to fit exercise into my day has been so important to my well-being” (Petscavage et al., 2022). Another aspect of healthcare where teleradiology has been an advantage is in relation to the underserved patient population and those patients that experience hardships due to their geographical location from their healthcare facility(s). Sometimes, it can be challenging for patients to merely make a doctor’s appointment and/or show up for their appointment/procedure due to the distance they have to travel to their healthcare facility. “Teleradiology can help increase imaging efficiency and mitigate both geographic and temporal discrepancies in imaging care” (Hanna et al., 2020). In respect to geographical limitations, the use of teleradiology provides care to those who have limited or no access to healthcare. “In a variety of health care situations, such as acute stroke, outcome disparities between patients in rural and urban settings are substantial, and telemedicine has been harnessed in an attempt to mitigate these care discrepancies” (Hanna et al., 2020). Not only do some patients have difficulty receiving treatment due to their location, but some might also suffer from a lack of resources, i.e., staffing at healthcare facilities and their hours. “Teleradiology may be part of the solution by providing contemporaneous around-the-clock imaging services to rural areas and providing subspecialty diagnostic imaging interpretations to these underserved patients at their local hospitals” (Hanna et al., 2020). 19 More advantages of teleradiology have been evident in regard to the time it takes for physicians to diagnose, the accuracy of a diagnosis, and an overall increase in patient care. “Teleradiology solutions are often used to cover after-hours and overnight services to provide contemporaneous interpretations for the growing volume of time-sensitive emergency department and in-patient diagnostic examinations” (Hanna et al., 2020). Furthermore, “MTMS provides real-time interaction using several modes (video, audio, and text) and offers a display of radiographic images, image annotation tools, an archiving and retrieving system, real-time interaction, and an audio reporting feature. The developed system is particularly useful in providing immediate diagnosis for a remote medical care center. The system provides remote consultation in such a way that both the referring physician and radiologist can review the same image and discuss it with each other through the dialog window using various modes” (Al-Safadi, 2016). Not only is it important to have a timely diagnosis, but it is also essential to be accurate in the diagnosis. “The use of multimedia with an interactive consultation environment is a valuable strategy that yields a better diagnosis and clinician satisfaction” (Al-Safadi, 2016). Since teleradiology provides a more timely and accurate diagnosis, patients are receiving better care. It is important to further highlight the importance of the speed and accuracy teleradiology provides for Radiologists. There are many moving parts involved when a patient is seeking care. A patient has to be seen by their physician, orders for tests/procedures need to be placed, and patients need to schedule additional appointments related to their initial visit. Once the patient has completed their tests/exams, they still have to wait for physicians to go over imaging, exams, etc., in order for the patient to seek treatment. If it takes extra time for a 20 physician to review the images/exam due to a lack of staff or expertise, a patient could miss a critical window in their care. Teleradiology has provided answers to all of these problems that burden patients and healthcare professionals. As stated by Abdulwahab (2019), teleradiology provides radiology services for rural areas, solves radiologists shortage, removes the delay in the interpretation of imaging, decreases the workload on radiologists, improves patient care, and removes the need for patients to travel to receive services and care. Disadvantages of Teleradiology Teleradiology is not without “its detriments, and it presents challenges not only in terms of technology and regulatory and/or administration hurdles but also introduces unheralded risk-management issues” (Mezrich, 2024). Some of the challenges in terms of technology, regulatory, and/or administration hurdles are “the expenses of installing a teleradiology system, teleradiology system maintenance, technical issues, legal jurisdiction of teleradiology system, medical license, and certified practitioners in different countries, overseas and non-certified practitioners, accreditation of teleradiology services, limited access to obtain a previous study and patients’ history, training teleradiologist is required, and limited communication with clinicians” (Abdulwahab, 2019). There are also challenges with the reimbursement of teleradiology services for patients who have Medicare. The expenses of installing a teleradiology system, as well as system maintenance, can be very costly. It can take a network of specialists to do the maintenance, and sometimes, the availability is limited in rural areas and developing countries. The average start-up costs of teleradiology services must take into effect medical imaging equipment maintenance, telecommunication and internet services, 21 radiologist fees and compensation, software licensing and subscription fees, administrative and support staff salaries, compliance and regulatory costs, insurance premiums, marketing expenses, and training costs. Depending on the hospital or healthcare system, this could be too costly. In the “Polish context, one of the limitations concerns the cost of the required hardware and software (advanced computer, medical computer display, high-speed internet connection, etc.)” (Madej & Sasiadek, 2023). Another issue that arises in Poland is the “relatively high prices of services provided by teleradiology companies, which are increased by the profit of the company, overhead costs, etc.” (Madej & Sasiadek, 2023). Because of this concern, many medical facilities in Poland agree to only use teleradiology services when a radiologist who is already employed at the institution is able to read that exam. Technical issues can also have a major impact on the availability of teleradiology services due to some complex issues that can take a while to fix and cause a delay in medical services. Teleradiology services can also be limited in emergency radiological examinations. “Transferring images consumes time, which is crucial in emergency patients, e.g., with trauma and stroke. In these patients, treatment is often started based on the instant oral opinion of the radiologist. Therefore, in emergency conditions, it is better to have an onsite radiologist” (Madej & Sasiadek, 2023). Legal jurisdiction issues can arise when there are certain rules and regulations in one country but do not apply to another. For example, overseas radiologists might be able to work in their country utilizing teleradiology without a medical license, but in the country where the images need reviewing may require a medical license. Therefore, in these circumstances, those providers may not be able to work for legal reasons. There is a need for accreditation for 22 teleradiology services, but this costs money and time. This also applies to radiologists' credentials in different states. For full services with a final reading, the radiologist needs to be licensed and credentialed in the remote institution’s state as well as insured for medico-legal liability. Medicare payments for teleradiology services have “historically faced a number of billing-related challenges from Medicare, as well as challenges related to contracting and credentialing with hospitals and healthcare organizations” (Rangachari, 2024). According to the ACR task force on international radiology, “payment for radiologic interpretations and subsequent reports that are rendered by international teleradiology is appropriate if the following criteria are met and the person interpreting the examination and submitting the report to the referring physician are one and the same” (Allen, 2024). 1. The person rendering the report is licensed in the state and credentialed as a member of the medical staff at the institution performing the examination and receiving the report. 2. The person performing the interpretation and rendering of the report is available for Consultation. 3. The report meets the guidelines for diagnostic reports issued by the ACR. 4. The ACR Technical Standard for Teleradiology is met. Another big concern is the limited access to a patient's history and previous studies, which can lead to wrong diagnosis. Remote radiologists may not have access to the same electronic medical records system as well as access to patient comparison imaging, which can be detrimental to patient care. Radiologists need specific training to utilize teleradiology services, which again cost money and time. The teleradiologists also 23 usually do not have access to communicate with the patient’s local clinician to understand the case, which is a major limitation (Abdulwahab, 2019). The “Lack of faceto-face interaction with clinicians may contribute to misunderstandings, and incomplete contact information may frustrate or delay communications” (Abdulwahab, 2019). According to a study that compared retrospective malpractice claim data between teleradiology and non-teleradiology cohorts, it was found “that during a 12-year period, teleradiology malpractice claims involved greater clinical severity and resulted in higher median indemnity payments that radiology claims generally. Specifically, they found that death of the patient occurred more often in teleradiology cases (35.6% in the teleradiology cohort compared with 19.7% in the radiology cohort) and that the median National Association of Insurance Commissioners clinical severity scale was higher for teleradiology claims (7 vs.5)” (Mezrich, 2024). This data suggests that teleradiology can place radiology groups and facilities at a substantially greater risk of liability. However, this study did have some limitations, including the database used may not be nationally representative and does not provide information into the training and qualifications of the radiologist, providing teleradiology services compared with radiology groups. The qualifications and training of the teleradiologist are particularly important because if this was not considered during this study, that could reflect a greater contributing factor to liability claims. There are improvements that can be made to teleradiology services to make them more accessible and affordable. Making teleradiology services available at a lesser cost, decreasing the number of teleradiology system breakdowns as well as adding 24 accreditation programs for teleradiology globally will improve teleradiology services globally. Barriers of Teleradiology Adjacent to disadvantages in teleradiology are barriers. While disadvantages detail some of the negative aspects of a functioning teleradiology system, barriers describe a situation in which the pitfalls are too great to overcome for an efficient program to emerge. Essentially, teleradiology networks facing barriers suffer greatly reduced quality and functionality. These barriers typically stem from foundational issues, one such being reliable and sustainable networking infrastructure. One of the tenets of a successful teleradiology program is the application of a reliable network infrastructure, where stable internet connection and high transmission speeds are paramount. As stated in the ACR–AAPM–SIIM Technical Standard for Electronic Practice of Medical Imaging, “Dictation tools, internet access, and other reference tools should be readily accessible and easy to use during image interpretation” (ACR, 2022). With the global adoption of teleradiology services, some low-income and middleincome countries still struggle with readily available internet access. A common theme was the lack of adequate internet infrastructure. In Ethiopia, network infrastructure challenges create issues with a consistent internet connection. As a result, healthcare workers are forced to consolidate their efforts because of this instability; "As a solution, we have centralized the internet access in one room only...” (Nigatu, 2024). This bottleneck greatly reduces output, creating patient care delays. Additionally, intermittent internet service causes a fragmented network of hospitals and facilities that participate in 25 teleradiology programs, further reducing efficiency (Nigatu, 2024). Other parts of the continent suffer connectivity issues as well. Frequent power outages in South Africa make for an unstable environment for consistent remote reads (Schoeman & Haines, 2023). Additionally, in Iran, low bandwidth was a common problem for adequate image transmission (Maher, 2018). These foundational issues inhibit a truly efficient teleradiology service. While network infrastructure is vital for a sustainable remote reading model, interpersonal communication is another key component. Even with optimal connectivity, ineffective communication, and lack of communication protocols thereof, it can prove to be a barrier for an otherwise well-functioning system. Mismanagement of conflict and communication can ultimately lead to delays in patient care or even delivery of unnecessary procedures, which can include unneeded radiation exposure. Some healthcare facilities inadvertently place the responsibility of order appropriateness on the technologist. Situations arise when ordering physicians may pressure technologists to perform scans that may not be indicated. Lacking an on-site radiologist and not being able to reach a teleradiologist for advice on proper exam protocol puts radiographers in a predicament where they feel they must perform scans as ordered by a superior. A radiographer who participated in a focus group in South Africa stated, "... now you cannot get a radiologist, and the doctor is here, and you must decide if you are going to do this patient” (MacFarlane, 2019). Another radiographer is quoted as saying, "We just scan, the doctor dictates.” Technologists do not just feel these frustrations. Ordering physicians sometimes comes into conflict with teleradiologists when seeking advice. In the same focus group, a 26 referring clinician says, "When you call, they get angry, and they (radiologist) say you are sitting with the patient there, what is your clinical judgment, why can't you do the scan, you do not have to call for all of them” (MacFarlane, 2019). For these scenarios, it is important to have ordering protocols in place that are specific to each healthcare facility to avoid ambiguity that leads to miscommunication and conflict. Even when communication protocols are optimized, some clinicians feel a diminished sense of trust when reviewing reports from radiologists who read remotely. The rapport that is typically built through face-to-face contact, image review, and consultation with on-site radiologists is reported as lacking when a radiologist is not physically present (Fatahi, 2019). Patient care may suffer from delays in treatment and possibly misdiagnosis by the referring clinician if a certain level of trust with a radiologist cannot be attained. Also, in regard to communication issues, it was found that teleradiologists who work extramurally offer little to no insight into departmental workflow. It is typical in rural communities that local radiologists advocate for changes that benefit patient care (Davidson, 2023). Being disconnected from these communities can be a barrier to better healthcare access. When a teleradiologist does not participate within the community, it can be not easy to understand their specific health needs and to adjust radiologic protocols accordingly. Worldwide and Departmental Teleradiology Telemedicine is a newer field in healthcare that has rapidly grown due to the effects of COVID-19 and, in return, has brought about other subtypes, including teleradiology. Throughout the world, radiology is an ever-growing and expanding field of medicine vital to diagnosing and managing patients. Shortages of radiologists throughout the world lead to a lack of timely care for these patients who may not have direct access 27 to suitable care. Through teleradiology, imaging can be sent throughout the world with a system known as PACS (Picture Archiving and Communication Systems) to be assessed by the best-trained physicians, allowing for proper diagnosis and treatment. This is well demonstrated in countries such as the United States, where highly trained radiologists are not readily available to evaluate patients' images, whether in the evening or in a rural area, and these patients would otherwise not be treated in a timely manner. There have been studies done on the benefits of radiologists from India covering ICU imaging throughout the evenings for United States hospitals due to the shortage of radiologists during evening hours. It was found that this is “advantageous because of speedy and accurate reporting of clinical images, continuous availability of teleradiologists for consultation purposes, and a consequent decrease in the number of missed findings, rapid initiation of life-sustaining therapies, reduction in the mortality and ICU length of stay and lowering the costs for critically ill patients” (Rao, 2023). Intensive care units require the utmost diligence when assessing imaging of patients due to patient instability, and therefore, radiologists who are not tired, distracted, or overworked. Time is of the essence with certain diagnoses as well, demonstrating the importance of thorough and accurate reporting to allow enough time for on-site practitioners to intervene and prevent a patient's condition from worsening quickly. Bringing in outside radiologists, specifically from other countries, to relieve the burden placed on already overworked radiologists is essential to the safety of patients and has been proven to ease the burden on radiologists in the United States. In Poland, another study was done to showcase the benefits of teleradiology in healthcare. Throughout Europe, there is a growing problem of an insufficient number of 28 physicians, with radiology as one of the leading deficits (Madej, 2023). Again, found in more underdeveloped and small-town areas, the number of radiologists is not adequate for the patient input they are receiving. Although “funding for imaging studies for patients is widely available and imaging equipment in Poland is improving despite some shortages, the main barrier is identified in the number of specialists capable of assessing the exams” (Madej, 2023). With the help of teleradiology, these understaffed areas in Poland would infinitely benefit, allowing more time to review imaging and see more patients. There is currently a 171-day wait for patients hoping to get an MRI done, as well as a 59-day wait for computed tomography imaging, which delays treatment for possible life-threatening conditions that may be at play (Madej, 2023). Hiring outside radiologists to read these images and get results back to their patients sooner would provide better healthcare and fill otherwise empty positions due to geographical problems. The benefits of teleradiology in rural and less populated areas are shown to be beneficial for the streamlined efficiency of outpatient imaging. However, inpatient evaluation can be just as time-sensitive. Neurology is an extremely time sensitive department that relies on the medical personnel that are staffed to be watchful of their critical patients. Strokes must be managed rapidly to prevent any extra brain damage that happens as each second passes. In order to administer treatment to these patients quickly, a CT of the brain must be completed and assessed within a timely manner, and findings must be communicated to the provider. Recombinant tissue plasminogen activator (rtPA) is one of the life-saving treatments that must be “administered to patients within a threehour window of onset to show improved survival and outcome” (Misra, 2005). When a 29 radiologist is readily available to read these stat imaging series, it streamlines the time from onset to treatment and will provide a greater outcome for the patient. Not only are the neurological floors crucial to have radiologists ready to assess imaging, but the emergency department is also a vital area of the hospital, constantly needing extra help. Emergency rooms are constantly packed with patients waiting to be seen, with holidays and natural disasters normally increasing the influx of patients. All types of injuries and conditions may be demonstrated in the ER, so it is imperative that the radiologists staffed to read the images are well versed in multiple specialties, whether CT, ultrasound, or MR based. Musculoskeletal, gastrointestinal, neurological, and cardiac imaging, as well as many other specialties, all require a radiologist who has extensive training in that field because so many disease processes have multiple patterns that must be recognized. “Considering the severity of trauma, stroke, and other critical illnesses in patients admitted to the ED, delays in diagnosis and treatment can have serious consequences. Thus, timely and accurate interpretation of patient images is critical. However, the number of full-time radiologists in the ED with specialized training is limited, especially during off-hours and holidays” (Kalyanpur, 2024). Teleradiology aims to solve this issue by easing the burden of staff radiologists and helping with the caseload. It also allows specialized radiologists more opportunities to find jobs where their main skills are showcased, such as a neuroradiologist who excels in neurological findings and recommendations. More skill sets among these radiologists make it less likely for errors to occur and allow peer feedback on unusual presentations. Overall, 30 teleradiology has benefits for departmental diversity and can be applied worldwide, easing the strain on hospital staff and to better serve its community and patients. Effects of Radiologist Shortages The shortage of radiologists is a growing issue affecting clinical institutions in the United States and globally. Demand for radiologic imaging examinations is increasing, and the resources to meet that demand still need to be met. Factors such as advancing technology, aging populations, the increasing number of prevalent diseases, and the need to increase cancer survival rates leave little room for delayed image interpretation. Unfortunately, this is precisely what is transpiring. Global studies have shown that in countries such as Nigeria, there is one radiologist per one hundred thousand people. The United Kingdom has eight and a half radiologists per one hundred thousand people (Omofoye, 2024). These numbers have deemed the situation in some countries to be a global emergency. A study by the Journal of Health and Sciences asked one hundred and six radiologists worldwide for information on image volume and characteristics. These radiologists practiced in different socio-economic environments and were affiliated with different educational institutions. The radiologists were asked to report the total number of examinations performed and the total number of unreported results. Out of the hundred and eight, forty-six radiologists responded entirely to the surveys. Thirty out of forty-four respondents reported they had sixty-eight percent of unreported examinations in their facilities (Omofoye, 2024). Seven days post-imaging, forty-eight percent had unreported brain and head CT scans, fifty percent had unreported chest CT scans, and fifty-nine percent had unreported chest radiographs (Omofoye, 2024). 31 This extensive delay in image interpretation frustrates referring physicians waiting for results and delays patients' diagnoses and treatment. The frustration of not having radiologists available to interpret images leads to physicians with inadequate image interpretation training interpreting images due to a lack of options. A study written in the Journal of Radiography showed that physicians in low-resource settings, specifically in state-funded hospitals, had poor image interpretation services, long radiology turnaround times, some up to three months for a CT scan report, and compromised patient management due to delays in obtaining imaging reports (Kerrera, 2024). The study found that most medical students do not have the proper image interpretation training during medical school. As a result, the responsibility of interpreting these images is placed on inadequately prepared physicians, which could result in misdiagnosis and mistreatment of patients. In some severe cases, a patient’s prognosis can change from manageable to terminal in the process of waiting for a report. In one particular case, a respondent commented, “It took up to 6 months to get the report, and it was a cancer patient” (Kerrera, 2024, p. 562). Due to cases such as the one previously mentioned, physicians mentioned the need for improved preparation of image interpretation. Physicians mentioned that the training they received needed to be adequate and specific. Most participants emphasized the need for additional training to better prepare for in-life situations. Furthermore, most reported they had limited on-the-job support. This type of need not only reflects diagnostic imaging but also spills into Interventional Radiology. Interventional radiology (IR) is a subset of radiology crucial in a clinical setting. Many referring physicians depend on Interventional radiology to provide minimally 32 invasive treatments to improve patients' lives. Most rural areas are smaller but tend to be poorer and have more chronic health conditions. Many rural areas have a high rate of tobacco use and obesity. In a study by the American Journal of Radiology, in 2022, rural areas showed twenty-three percent higher annual mortality compared to urban areas. Interventional radiology and the procedures that Interventional radiologists provide are essential to treat these diseases. The lack of Interventional radiologists results in a deficit that cannot be filled. Interventional procedures provide value to hospitals by reducing costs and length of stay. Due to this critical lack of services, the American College of Radiology (ACR) and the Society of Interventional Radiology (SIR) formed a joint task force to investigate and help correct the issue in smaller rural areas. The ACR and SIR have put together specific remedies, such as improving procedural training for diagnostic radiology residents, developing practice models and financial arrangements to recruit and retain IR physicians, leveraging the value that IR provides to hospitals, and emphasizing for hospitals to consider a partnership between radiology groups and independent IRs (Findeiss, 2022). The ACR and SIR encourage continuing training for residents and physicians in rural areas to provide specialized procedures typically performed in large hospitals. By emphasizing these improvements, steps could be taken to fill the drastically needed void. As these necessities are recognized, the need for services such as teleradiology is growing. In recent years, teleradiology has grown considerably, and for good reasons. Teleradiology has helped in optimizing patient care and has helped fill the void for hospitals that require available radiologists. As teleradiology expands and evolves into 33 intra-organizational and extra-organizational services, it relieves the urgent need for referrers to have reports read and patients to have treatments earlier. Teleradiology allows for after-hours staffing and additional hospital and radiologist reimbursement. Through its inception, teleradiology has grown from fifteen percent in 2003 to forty-four percent in 2007, fast forwarding to 2019, when the ACR performed a survey that showed that eighty-four percent of the radiologists that responded actively performed teleradiology services (Hanna, 2020). Studies show that teleradiology helps decrease disparities in medical care during the weekends and after-hours by providing the needed services. The shortage of radiologists presents a critical challenge in healthcare systems worldwide. The growing demand for radiologic imaging and insufficient resources to meet the demand has created a global emergency in many countries. This shortage manifests in alarming statistics, such as the high percentage of unreported examinations and extended delays in image interpretation, which can significantly impact patient diagnoses and treatment plans. Through all these challenges, teleradiology emerges as a promising solution to bridge the gap created by the shortage of radiologists. Its rapid growth and evolution demonstrated its potential to optimize patient care. As we look forward, it is clear that a combination approach combining improved training, strategic recruitment, and technological solutions such as teleradiology will be essential in addressing the global radiologist shortages. 34 Summary Our literature review focuses on the significant themes of teleradiology: its advantages and disadvantages, radiologist shortages, barriers, and the various departments affected. In our research, we found that radiologist shortages can directly affect the availability of teleradiology services as well as affect patient care (Omofoye, 2024). There was also a direct correlation between the shortages of radiologists and Interventional Radiology (IR) availability (Findeiss et al., 2022). We also found different barriers to teleradiology services, including the limited availability for individuals in rural areas due to low incomes and/or no internet service (Nigatu et al., 2024 & Maher, 2018). One of the gaps we identified was the lack of research, specifically on teleradiology services in the United States. To address this, we expanded our research to include not only the United States but also other countries. We also noted gaps in our research that provide the exact costs of establishing teleradiology services in a medical facility or hospital. While there is research that outlines the various costs involved in developing teleradiology, the exact dollar amount remains elusive (Madej & Sasiadek, 2023). This literature review provides a strong foundation for our questions on how teleradiology affects patient care and whether its advantages outweigh its disadvantages. We found that there was supporting literature on the advantages and disadvantages of teleradiology services and how each correlates with the effects on patient care. Overall, with all our research, it appears that teleradiology services do offer a lot of advantages, including quicker readings, especially during the COVID-19 pandemic, as well as the 35 increase in availability of teleradiology services due to radiologist shortages. However, with these advantages also come disadvantages. Even though teleradiology services can offer a quicker reading, it may not always be the most accurate, as the patient’s history or prior images may not be available (Abdulwahab, 2019). This can directly affect specific departments. In an emergency setting, not having direct contact with the patient and provider, as well as the patient’s history and prior films, can harm a patient’s overall diagnosis (Madej & Sasiadek, 2023). 36 Chapter 3: Research Method Statement of the Problem Teleradiology has become an integral part of today’s healthcare field, offering both opportunities and challenges in its delivery of image interpretation. As the radiologic field continues to grow, it is necessary to deeply evaluate its impact on the healthcare systems, considering its advantages, disadvantages, and barriers within implementation across numerous global sources and medical departments. The advantages of teleradiology are significant and reach far beyond the borders of the United States. The utilization of teleradiology has increased productivity by breaking the boundaries of distance and time by allowing teleradiology services to be offered after-hours and overnight (Hanna et al., 2020). This allows practitioners to receive image interpretation promptly. This service is critical when addressing radiologist shortages and improving patient care in areas of low socioeconomic status (Abdulwahab, 2019). Teleradiology has also helped in enhancing the work-life balance for radiologists, with many reporting increased productivity and job satisfaction due to the flexibility of working from home and the added time given to them due to not having a daily commute (Petscavage et al., 2022). However, teleradiology is not without its drawbacks and disadvantages. Since the inception of teleradiology, there has been an increase in malpractice claims associated with teleradiology services, which may be attributed to a lack of communication between the reading radiologist and the referring practitioner (Mezrich, 2024). Additionally, the cost associated with teleradiology, particularly the startup cost, could be very costly and 37 difficult to achieve for some healthcare facilities, particularly those in low-income neighborhoods (Madej & Saiadek, 2023). As teleradiology grows, barriers to implementation include inadequate networking infrastructure, especially in low socioeconomic countries. Unreliable internet connections and frequent power outages in many regions play a large role in the efficiency of their teleradiology services (ACR, 2022). Furthermore, a lack of quality communication between remote radiologists and on-site healthcare providers may lead to misunderstandings and potential errors in patient care (McFarlane, 2019). The adoption of teleradiology globally can be dramatically affected due to resource limitations. In Poland, for example, the high cost of hardware, software, and services provided by teleradiology companies can cause significant challenges (Madej, 2023). In contrast, countries like the United States and India have successfully implemented to cover after-hours services and provide valuable services when needed. As those services are further integrated, the increasing problem of radiologist shortage still remains a critical issue with some countries, reporting alarmingly vast ratios of radiologists to population (Omofoye, 2024). The ongoing problem of radiologist shortages has led to significant delays in image interpretation which, in turn, has led to the potential to compromise patient care. Teleradiology is the potential solution to this problem, allowing for expedited image interpretation and faster results for countries that would otherwise not have this option. In conclusion, while teleradiology offers numerous benefits in addressing radiologist shortages and improving access to specialized services, it also presents 38 significant challenges that must be addressed. As the medical field and the need for these services continue to grow, it is essential to continue to develop strategies to overcome barriers to implementation, improve quality control measures, and maintain effective communication between the reading radiologist and the on-site clinician. By doing so, teleradiology can continue to play an important role in increasing the efficiency and quality of radiologic services worldwide. Research Questions 1) How does the implementation of teleradiology services affect the patient care outcomes in rural and underserved areas? 2) To what extent does teleradiology alleviate radiology shortages, and how does it impact the quality and timeliness of diagnostic services? 3) What are the advantages and disadvantages of teleradiology in regard to effectiveness of healthcare delivery, provider workload, and patient satisfaction? What are the primary barriers to implementing effective teleradiology services in low- and middle-income countries, and how can these be overcome? 4) How does the integration of teleradiology impact healthcare systems, in terms of interdepartmental communication and collaboration? Research Methods and Design(s) Teleradiology has rapidly evolved into a significant component of modern healthcare delivery. Given its extensive integration into clinical practice, there are numerous advantages as well as potential drawbacks associated with this technology. To comprehensively explore the multifaceted aspects of teleradiology, it was imperative to curate a selection of scholarly and peer-reviewed literature systematically. The process 39 involved meticulously evaluating a wide array of articles, ultimately filtering out those that did not contribute substantially to the research objectives. This rigorous literature selection was conducted to thoroughly address key questions and illuminate the principal themes surrounding the application of teleradiology. The initial step involved identifying a pertinent topic within the realm of medical imaging in healthcare. Given the extensive application of teleradiology, we opted to delve deeper into this subject. Our research unveiled numerous advantages associated with teleradiology, which we thoroughly examined and articulated. Upon reaching a consensus on the topic, we initiated an extensive review of scholarly and peer-reviewed literature to inform our research. Additionally, we encountered several challenges and barriers regarding its implementation and the implications for patient care. Notably, teleradiology has been demonstrated to enhance the work-life balance of radiologists, contributing positively to various aspects of healthcare delivery. Considering its global utilization, we found it essential to address the diverse regulations and legal frameworks governing teleradiology across different states and countries. Researching peer-reviewed articles as a group effort is a highly effective strategy for defending a thesis for several reasons. First, collaborating with others allows for the pooling of diverse perspectives and expertise. Each group member may have different strengths—some might excel at critical analysis, while others may be better at synthesizing information or identifying gaps in the literature. This collective knowledge enhances the overall quality of the research, making it more robust and comprehensive. Second, group discussions can lead to deeper understanding of complex topics. When individuals engage in dialogue about the articles they’ve read, they can clarify concepts 40 for each other, challenge assumptions, and uncover new ideas. This collaborative environment promotes critical thinking and can lead to insights that an individual might not achieve alone. Additionally, working as a group encourages accountability. While conducting research, group members can keep each other on track, share responsibilities, and ensure a thorough review of relevant literature. This shared commitment can enhance motivation and discipline, making the research process more efficient and effective. Finally, group research fosters skills in communication and presentation. When it comes time to defend the thesis, members will have had the opportunity to practice articulating their ideas and arguments in front of peers, honing their ability to respond to questions and engage in critical discussions. In summary, researching peer-reviewed articles together enriches the research process, strengthens the defense, and prepares everyone involved for a successful presentation of their findings. Population Initially, our research concentrated predominantly on the United States. However, during our first discussion following the preliminary phase of our investigation, we collectively recognized the necessity of incorporating insights from international contexts in order to comprehensively address the topic of teleradiology. Our research encompassed a diverse array of countries, drawing information from the United States, Iran, Saudi Arabia, Zambia, Canada, Poland, India, Ethiopia, and South Africa. Notably, one of the articles referenced a survey distributed across 46 European countries, from which we extracted relevant statistics from 36 responding nations. In addition to these various geographical contexts, we emphasized the significance of examining specific subpopulations. We deemed it crucial to explore data pertaining to small and rural 41 communities, as defined by the U.S. Census Bureau and the U.S. Department of Agriculture. Information regarding low-resource settings was also integral to our analysis. Furthermore, we incorporated insights from the American Board of Radiology and the American College of Radiology to strengthen our findings. The population from which we gathered information is highly appropriate for several reasons. First, by including a wide range of countries—such as the United States, Iran, Saudi Arabia, Zambia, Canada, Poland, India, Ethiopia, and South Africa—we ensure a comprehensive understanding of teleradiology practices across diverse healthcare systems and cultural contexts. Each of these nations presents unique challenges and advancements in medical imaging, which enriches the overall analysis. Moreover, the inclusion of data from 36 out of 46 surveyed European countries allows us to capture a broad spectrum of opinions and experiences within the European context, offering robust comparative insights. This diverse geographical representation helps identify trends and variations in teleradiology implementation, enabling us to draw more generalizable conclusions. Additionally, our focus on subsets of specific populations, particularly small and rural areas as defined by the U.S. Census Bureau and the U.S. Department of Agriculture, addresses significant gaps in the existing literature. These regions often face unique healthcare challenges that differ markedly from those in urban environments, making it essential to understand their particular needs in the context of teleradiology. Finally, incorporating information from respected organizations such as the American Board of Radiology and the American College of Radiology adds credibility and depth to our research, ensuring that our findings are grounded in recognized 42 standards and practices in the field. By utilizing this diverse and relevant population of information, we can provide a more nuanced and comprehensive view of teleradiology on a global scale. Sample The research conducted involved various sampling methods and participant selection processes as outlined in the articles reviewed for our paper. Below is a summary of the sampling strategies utilized across these studies. In the article titled "The Effects of Real-Time Interactive Multimedia Teleradiology System," participants included two categories of users: eight physicians and three radiologists, all of whom were female. Notably, a significant majority (73%) had between three to five years of experience. The study "Novel Training Approach to Improve a Cohort of Radiographers’ Image Interpretation Skills of Trauma Chest Radiographs" focused on radiographers employed at eight public hospitals in the Copperbelt Province of Zambia. These hospitals represented three distinct levels of care and services—Level 1 (L1) to Level 3 (L3). L3 hospitals are large training facilities with full-time radiologists, employing more than ten radiographers, and serving populations exceeding 800,000. They provide extensive services including internal medicine, general surgery, pediatrics, obstetrics, gynecology, intensive care, psychiatry, as well as training and research opportunities. In contrast, L1 and L2 hospitals lack full-time radiologists and generally have limited access to digital radiology (DR). At the time of the study, an L2 hospital offered services similar to L3 but employed between six and ten radiographers and served populations of 200,000 to 43 800,000. L1 hospitals, on the other hand, are district facilities employing no more than five radiographers, catering to populations between 80,000 and 200,000, and providing a narrower range of services such as medical, surgical, obstetrical, and diagnostic care. The participating hospitals included Hospital 1 (L3; 15 radiographers), Hospital 2 (L3; 13 radiographers), Hospital 3 (L2; 6 radiographers), Hospital 4 (L2; 6 radiographers), Hospital 5 (L2; 6 radiographers), Hospital 6 (L2; 6 radiographers), Hospital 7 (L1; 4 radiographers), and Hospital 8 (L1; 4 radiographers). The article "Landscape of Rural and Remote Radiology in Canada: Opportunities and Challenges" examined the state of rural and remote radiology within Canada, identifying both opportunities and challenges within this context. Another study, "Difficulties and Possibilities in Communication Between Referring Clinicians and Radiologists: The Perspective of Clinicians," utilized qualitative research methods involving data gathered from interviews with clinical physicians at a university hospital. This research included four focus group discussions with a total of 22 physicians (9 women and 13 men) from various specialties including internal medicine, abdominal surgery, and orthopedic surgery. The informants were recruited through departmental announcements and participated voluntarily, with ages ranging from 32 to 63 years (median age of 41) and experience spanning from 4 to 34 years. In the article "Interventional Radiology Workforce Shortages Affecting Small and Rural Practices: A Report of the SIR/ACR Joint Task Force on Recruitment and Retention of Interventional Radiologists to Small and Rural Practices," a qualitative research approach was employed. Data were collected through semi-structured 44 interviews, providing deeper insights into the factors influencing radiographers’ ability to deliver imaging services in rural areas of Zambia. Notably, Zambia, located in Southern Africa, has a population of approximately 18 million and is administratively divided into ten provinces, with Lusaka and Copperbelt being primarily urban. The remaining provinces are predominantly rural. The article "Radiology Image Interpretation Services in a Low-Resource Setting: Medical Doctor's Experiences and the Potential Role of Radiographers" also adopted a qualitative approach using a descriptive phenomenological design. This design allowed for an in-depth exploration of medical doctors' experiences with radiology image interpretation without external biases. Participants were selected from three state-funded hospitals in Namibia, consisting of medical officers and interns who were engaged in referring and utilizing imaging services. Only those with a maximum of three years of experience in their respective hospitals were included, as they were deemed more likely to make interpretation errors. Thirteen participants were purposively recruited to represent various medical subspecialties, ensuring diversity in experiences and maximizing variation. Data collection continued until concept saturation was achieved, meaning that no new insights were being revealed. The article titled "Maintenance of Certification for Radiologists: An Overview of European Countries" involved outreach to the national radiological societies of European countries as listed on the European Society of Radiology (ESR) website. This included certain countries geographically situated in Asia that are ESR member societies and participate in ESR activities, thereby considering them under the umbrella of “Europe at large.” A total of 46 European countries were contacted, resulting in a substantial 45 response rate; 37 out of 46 national radiological societies (approximately 80%) provided feedback, as illustrated in Figure 1. The responses are summarized in Table 1. Among the 37 responding countries, 22 (59%) reported having mandatory requirements for maintaining a radiologist’s license to practice, while 15 countries (41%) indicated that such requirements were not enforced. The examination revealed a median license validity period of 5 years, with a range between 1 and 7 years. In terms of Continuing Medical Education (CME), the median number of points required annually was 40, varying from 8 to 57.6, with an interquartile range of 30. Additionally, eight countries reported supplementary requirements, which included practicing clinical radiology, attending quality meetings or clinical audits, and completing additional courses such as radiation safety training and advanced medical training. The list of all responding countries includes Albania, Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Kazakhstan, Kosovo, Latvia, Lithuania, Luxembourg, Malta, Montenegro, Netherlands, Norway, Poland, Portugal, Romania, Russia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey, United Kingdom, and Uzbekistan. In another study, "Evaluating Health Disparities in Radiology Practices in New Jersey: Exploring Radiologist Geographical Distribution," researchers identified physicians practicing in at least one location in New Jersey and categorized them into diagnostic and interventional radiologists. Using U.S. Census data from 2021, the median household income and population size for each county were recorded. Counties were stratified into three income categories based on their median household income: the top one-third, the middle one-third, and the bottom one-third. The study utilized Microsoft 46 Excel (Microsoft, Washington, USA) to perform chi-squared analyses and descriptive statistics across these subgroups, examining proportions and ratios. A key analysis involved calculating the ratio of the population size to the number of radiologists in each county, serving as a surrogate marker for disparities and standardizing to account for varying population sizes. The article "The Need for Improved Telecommunication and Collaborative Practice Among Teleradiology End Users in a Rural District of South Africa" documented data collected at both the central teleradiology site and the remote radiologist reporting site. Teleradiology end users and referring clinicians from satellite hospitals were invited to participate in the study, with written informed consent obtained from all participants prior to the interviews. Focus group interviews were conducted separately with two groups of end users: the radiographers (N=6) and referring clinicians (N=12). A research assistant attended two focus group interviews to facilitate the process. The article titled "The Growing Role of Telemedicine: Possibilities and Regulations Concerning Teleradiology in Poland" provides an analysis of access to radiology healthcare services in Poland, framed within the context of both international and national legal provisions related to the right to healthcare. Another important study, "Malpractice from Afar: Teleradiology May Increase Malpractice Risk," examines retrospective malpractice claim data from a national insurer database, comparing outcomes between teleradiology and non-teleradiology cohorts. In the article "Telemedicine in Neurology: Underutilized Potential," researchers explored three distinct case studies. At the University of Maryland Medical Center, a pair 47 tilt and zoom camera with remote site control facilitated 50 stroke consultations between 1999 and 2001. Of these, 23 consultations were conducted via telemedicine, while 27 were managed through traditional telephone conversations followed by patient transfer. Notably, two of the telemedicine consultations were aborted due to technical difficulties. Additionally, a study in Swabia connected seven rural hospitals with a centralized stroke unit through video conferencing, allowing 153 patients to be assessed via teleconsultation. This method made a relevant contribution to the diagnostic workup, CT assessment, and therapeutic recommendations in over 75% of cases. Finally, an educational teleconferencing initiative between the Sanjay Gandhi Post Graduate Institute of Medical Sciences in Lucknow and SCB Medical College in Cuttack, which are 1500 km apart, engaged faculty members and residents from both institutions. The article "Barriers and Facilitators Experienced During the Implementation of Web-based Teleradiology Systems in Public Hospitals of Northwest Ethiopia: An Interpretive Description Study" employed a purposive sampling method, involving indepth interviews with seventeen participants, including hospital managers, physicians, emergency surgeons, and radiologists, conducted from March to May 2023. A reflexive thematic analysis, using an abductive coding technique at the semantic level, was utilized to interpret the data collected through semi-structured interviews, which were held both face-to-face and virtually. This data was transcribed, translated, and analyzed using Open Code version 4.02 software. Trustworthiness of the findings was secured through prolonged engagement, reflective journaling, and review by coauthors. The article "Mitigation Tactics Discovered During COVID-19: Long-term Report Turnaround Time and Burnout Reduction Benefits" provides insights from a 610-bed 48 Level 1 Trauma academic medical center and its affiliated community hospitals. The center's academic radiologists serve the main trauma facility and several outpatient imaging centers, while community practice radiologists cover other sites. The workforce includes 50 academic practice radiologists, 31 residents, and six fellows spread across various subspecialties. Daily procedural attending is required in all divisions except thoracic radiology, managing a variety of procedures, including myelograms, arthrograms, liver biopsies, and barium studies. Lastly, the article "Radiologists' Experiences and Perceptions Regarding the Use of Teleradiology in South Africa" presents a qualitative study that sought to make the tacit knowledge of radiologists explicit. Researchers conducted an online electronic survey to gather insights into the experiences and perceptions of radiologists regarding remote reporting. The survey invitation was distributed by the RSSA to all radiologists registered with the Health Professionals Council of South Africa (HPCSA), reaching a total of 583 members at the time of the study. Among these participants, 448 were employed in private practice, 127 in the public sector, and eight worked in both areas. Overall, these articles collectively highlight the expanding role of telemedicine and teleradiology, examining the legal, clinical, and practical implications across various healthcare contexts. Materials/Instruments The overall theme of the research revolves around the importance of effective training and data analysis methodologies in the field of radiology. It highlights the significance of collaborative learning experiences, such as the use of face-to-face training 49 combined with modern communication tools, to enhance the skills of radiographers. Additionally, the focus on rigorous data analysis methods underscores the need for systematic and unbiased approaches to extract meaningful insights from qualitative research. Together, these elements illustrate a commitment to improving medical practices and ensuring high-quality healthcare outcomes through targeted education and analysis. The findings from one study reinforced the importance of integrated training strategies and effective data analysis. Data were collected at the central teleradiology site and the remote radiologist reporting site. Teleradiology end users from these locations, as well as referring clinicians from satellite hospitals, were invited to participate in the study. Written informed consent was obtained from all participants before the interviews commenced. Focus group interviews were conducted separately for each group of end users, specifically with radiographers (N = 6) and referring clinicians (N = 12). According to Creswell, focus group interviews ideally involve groups of between six and eight people. At the time of data collection, three radiologists were working at the reporting site; however, only one was available for a face-to-face interview. A semi-structured interview guide was utilized to collect data, featuring similar open-ended questions for all groups. All focus group interviews were conducted by the researcher. Krueger and Casey suggest that the quality of the data collected is significantly influenced by the interaction between the researcher and the participants during these interviews. The researcher's role as the interviewer was to ensure that participants did not dwell on irrelevant experiences, steering them back to the primary research questions. This was achieved using probing questions. Additionally, the 50 researcher clarified questions that participants found challenging by providing familiar examples. A research assistant was present at two of the focus group interviews to take field notes, which were later compared with the audio recordings of the interviews. All interviews were audio recorded with the permission of the participants. Data Collection, Processing, and Analysis The research utilizes a qualitative thematic analysis method to organize findings systematically from existing literature about teleradiology. Thematic analysis is a commonly used qualitative research approach to detect and document patterns (themes) within qualitative data. Researchers developed themes from the literature in an inductive manner instead of using pre-set categories. Data Collection Process The study collected data through a systematic review of peer-reviewed journal articles published during the previous decade from reputable medical and radiologic science databases, including PubMed, Google Scholar, the Journal of the American College of Radiology, and Weber State University Library. Search Strategy & Inclusion Criteria The research data included terms like "Teleradiology," "radiologist shortages," "barriers to implementation," "AI in radiology," "healthcare disparities," "radiology workflow," and "medical-legal aspects of teleradiology." 51 The time frame was studies published from 2013-2024. The research exclusively used peer-reviewed journal articles along with systematic reviews and meta-analyses. We did not include conference abstracts, opinion pieces, or studies without peer review in our selection. Appendix A contains a PRISMA flow diagram which shows the count of studies that were identified and filtered out through the selection process. Data Processing and Thematic Categorization Researchers read and reread studies multiple times to pinpoint recurring concepts and each study received descriptive labels that identified its significant excerpts. The coding process created overarching themes by analyzing patterns and similarities and examining contradictions. The themes were then re-analyzed to verify their connection to the research questions. Out of the 56 records screened, nine were excluded by human analysis. For 19 of the remaining 47 records, reports were sought for retrieval; all reports were received, and all were deemed eligible for this literature review. Identified Themes and Their Application The examination revealed several primary themes, which included the advantages of teleradiology, the disadvantages and challenges of teleradiology, the impact of radiologist shortages, and future trends and innovations in teleradiology. One advantage of teleradiology was the faster turnaround times for imaging interpretation, increasing access to subspeciality readings. Another advantage of teleradiology was the improvement of work-life balance for radiologists. It was discovered that teleradiology has many disadvantages and challenges. They included limited access to complete patient history, higher malpractice risks and miscommunication issues, cost and 52 maintenance burdens for hospitals, barriers to implementation, infrastructure and connectivity issues in low-resource settings, legal and licensure obstacles in cross-border teleradiology, and the lack of knowledge of telehealth practices by healthcare providers. Many things impact radiologist shortages, including increased workload leading to burnout, use of international radiologists for coverage, delays in patient diagnosis and care, legal and ethical considerations, HIPAA regulations, licensing requirements across jurisdictions, security threats, and challenges with patient consent procedures during digital imaging transmission. Future trends and innovations in teleradiology include the integration of artificial intelligence for automated diagnostics and blockchain technology for secure radiology data exchange. The growth of teleradiology services addresses healthcare needs in global regions that lack resources. This study implements a structured thematic framework, enabling our researchers to synthesize literature that provides deep insights into the multifaceted aspects of teleradiology adoption and implementation and its future possibilities. This also systematically structures the literature in a way that answers research questions and reveals current knowledge gaps. The themes establish the groundwork for evidence synthesis, which supports conclusions about best practices, barriers, and future directions in teleradiology. Assumptions This literature review assumes the published, peer-reviewed journal articles selected for research are valid and unbiased. Limitations While the research collected strived to include relevant data by limiting articles for selection to have been published within the last ten years, the rapid pace of computer 53 technology advancement may outdate the findings of older publications. Kalyanpur (2014) notes in their work the concern for lengthy file transmission times when dealing with larger studies such as CT and MRI. The FCC's measurement of the average data transfer rate in 2014 - the time of publication - was 31 megabits per second (Mbps), which had tripled from 10 Mbps in 2011 (FCC, 2015). In the FCC's thirteenth report on broadband services, the average download rate was found to be 467 Mbps, a dramatic increase in ten years' time (FCC, 2024). Through this comparison, it can be reasoned that internet transmission issues do not have the same concern as ten years ago. However, it must be stated that connection stability may vary depending on geographic location and infrastructure integrity. As noted by Schoeman & Haines (2023), intermittent connectivity hindered consistent radiology report generation in South Africa. It must also be stated that while this literature review assumes no bias, there is potential for its existence. For instance, in the article "Malpractice From Afar: Teleradiology May Increase Malpractice Risk", it is indicated that the increase in malpractice arises more from emergency and cerebrovascular cases than teleradiology as a whole (Mezrich, 2024). A narrowed focus on specific facets of teleradiology can skew perceptions on larger issues. Additionally, when working with qualitative analysis, limitations must be recognized that are inherent in the study design. Many of the studies collected utilized interviewing techniques which can be concerning for observation bias. One such bias is the observer-expectancy effect, in which a participant may change their behavior to be more agreeable to the researcher's end goal. This has the potential to produce unreliable information from participant testimony. 54 Delimitations Studies were selected based on appropriateness for the research questions, with the main themes being the advantages and disadvantages of teleradiology, as well as its effect on healthcare access both socioeconomically and geographically. To streamline the research process and to ensure quality data were being collected, specific criteria were used to obtain pertinent resources. Selecting a date range within the past ten years was one method of delimiting sources to maintain relevance. Peer-reviewed articles were also selected for their validity within the medical field and providing a strong methodological framework which establishes credibility for the research. Ethical Assurances Ethical standards were maintained by ensuring selected sources were accurately represented and attributed. As the literature review involved no human participants, IRB approval was not required. Summary The literature review used qualitative analytic techniques to further explore and reveal themes related to the advantages and disadvantages of teleradiology, and to answer questions on its impact to healthcare systems in a wide array of socioeconomic and geographic settings. This method of research was optimal for the goal of gaining a deeper understanding of teleradiology and how it affects modern medicine, as well as inform future research decisions (Tenny, 2022). A collaborative effort utilized the strengths of each researcher to maximize efficiency of literature selection and evaluation. This included strategies for selecting an appropriate population, which required expansion to include international studies, and identifying the various sampling methods and 55 instrumentation used in those same studies. A qualitative thematic analysis method was utilized to collect, process, and analyze the data as it is most suitable for detecting and deconstructing data to more easily demonstrate common themes within the body of literature (Rosala, 2025). The review delimited studies by selecting those within a specific date range and choosing articles that were peer-reviewed. It was presumed that the published research obtained is valid and unbiased, however limitations to the data do exist. While specific date ranges were taken into account, relevancy of older articles may still invalidate issues of computer technology, while projecting subspecialty focus onto larger issues can skew perceptions. There is also bias inherent in qualitative study designs, such as the observerexpectancy effect. Despite these limitations, it was found by the researchers that the overall quality of the collected materials was suitable for evaluation and reporting. 56 Chapter 4: Findings This chapter presents the key findings from our systematic literature review on teleradiology. This mixed-method study explores and merges research on teleradiology and its impact on radiologists and allied health professionals throughout the healthcare industry. Our research questions focused on teleradiology’s impact on patient care outcomes, integration across healthcare systems, alleviation of radiologist shortages, advantages and disadvantages, implementation barriers, legal and ethical implications, effects on health disparities, radiologist work-life balance, departmental workflow, communication between professionals, and standardization of education and training. Results Our systematic review revealed several key themes related to teleradiology: Advantages of Teleradiology Our systematic review revealed several key themes related to teleradiology. The advantages of teleradiology include improved access to radiologist services, especially in rural and underserved areas. Additionally, remote reading allows for quicker interpretation of imaging studies, particularly for after-hours and emergency cases. Teleradiology also enables access to subspecialty radiologists regardless of geographic location, which is crucial for providing specialized care. Furthermore, radiologists report improved job satisfaction and productivity due to the flexible work arrangements offered by teleradiology. In a voluntary, anonymous study of 981 members of the Association of Academic Radiologists (AAR) in April 2024 showed that out of 205 respondents, 73% participated in remote work. The top benefits reported were work-life balance, flexibility, 57 and reduced commute time. From those radiologists participating in remote-work 89% reported an increase in well-being (Belfi et al., 2025). Furthermore, flexible scheduling was offered to 46.4% of the participants, with 91% reporting an increase in well-being from having a flexible schedule option (Belfi et al., 2025). Disadvantages and Challenges However, teleradiology also presents several disadvantages and challenges. Communication issues, such as the lack of direct communication between remote radiologists and on-site clinicians, can lead to misunderstandings that may affect patient treatment. Teleradiology services are not offering avenues that a Radiologist can communicate with referring clinicians (Abdulwahab Alahmari, 2019). The disadvantages of direct communication can have a direct correlation to an increase in malpractice claims. As stated earlier in this literature review the the data between teleradiology and non-teleradiology practitioners found that during a 12 year period teleradiology malpractice claims involved greater severity and resulted in higher indemnity payments occurred more often than general claims done by Radiologist (Mezrich, 2024). This obstacle creates limitations on patient treatment and directly affects patient outcome. To combat the higher incidence of malpractice claims The American College of Radiology (ACR) White Paper on teleradiology emphasizes that teleradiology must “maintain all appropriate licenses and should be in good standing with the appropriate state medical board” (Silva et al., 2013). The amounts covered should meet all local requirements, satisfy contractual obligations set by the facility, originate from a rated courier, and can be verified up request (Silva et al., 2013). The technology-dependent nature of teleradiology can be problematic, particularly in low-resource areas where stable internet 58 connections and solid IT infrastructure may not be readily available. Moreover, the high startup and maintenance costs can be prohibitive for some healthcare facilities. Impact on Radiologist Shortages Radiologist-to-population ratios vary widely across countries, with some facing severe shortages. A 2025 study published in the Journal of the American College of Radiology projected that the number of Radiologists is expected to increase by 25.7% between 2023 and 2055. In contrast the study found that imaging needs are projected to increase 16.9% to 26.9% by 2055 (Christensen, 2025). This trend suggests that the current Radiologist shortage is likely to continue for decades without any changes implemented. Disparities that are found throughout regions such as Singapore which have a discrepancy of 7.6 radiologists per 100,000 population, despite a growing number of radiologists from 370 in 2018 to 446 in 2022 (Goh, 2023). Other regions such as Europe which maintains a concentration of 13 radiologist per 100,000 population, United Kingdom which reports 8.5 radiologist per 100,000 population, Brazil mainly Sao Paulo having 10 radiologist per 100,000 inhabitants, and Malaysia which reports particular shortages in rural settings (International Radiology Societies Tackle Radiologist Shortage, n.d.). Teleradiology allows for the efficient distribution of workload, which can potentially lead to alleviating local shortages. Remote reading enables round-the-clock radiological services, addressing staffing gaps and providing 24/7 coverage. This capability is particularly beneficial in areas where maintaining a full-time radiology staff is challenging. Teleradiology services offer solutions such as geographic barrier elimination, workload balancing, rural health support, and with the implementation of remote consultation it can enforce subspecialty expertise access. 59 Effects on Patient Care Teleradiology can lead to timely diagnoses and treatments due to faster turnaround times. However, some studies raise concerns about the quality of remote readings compared to on-site interpretations. Research indicates that remote radiology interpretations might miss essential patient context that on-site radiologists can access which may affect diagnostic accuracy. Despite these challenges, teleradiology has the potential to reduce healthcare disparities by improving access to specialized services in underserved areas. This improvement in access is crucial for ensuring equitable healthcare delivery across different regions. Evaluation of Findings Our findings indicate that teleradiology offers significant benefits in terms of improved access to radiological services, faster turnaround times, and potential alleviation of radiologist shortages. However, these advantages are balanced by challenges related to communication, technology dependence, and potential quality concerns. The impact of teleradiology on patient care appears to be largely positive, particularly in underserved areas. However, the increased risk of malpractice claims and potential communication issues highlight the need for careful implementation and ongoing quality assurance measures. The global adoption of teleradiology varies significantly, influenced by factors such as technological infrastructure, regulatory frameworks, and economic resources. 60 This variability suggests that strategies for implementing and optimizing teleradiology services need to be tailored to specific contexts and healthcare systems. Our review also revealed gaps in the literature, particularly regarding the longterm impacts of teleradiology on radiologist workforce dynamics and the standardization of education and training for teleradiologists across different countries. Summary This systematic review has provided a comprehensive overview of the current state of teleradiology, its impacts on healthcare delivery, and the challenges associated with its implementation. While teleradiology offers promising solutions to many healthcare challenges, particularly in addressing radiologist shortages and improving access to specialized services, it also presents unique challenges that require careful consideration and management. Teleradiology is a field that is growing and expanding and will evolve. The research indicates that this evolution will be generally positive but will have obstacles to overcome. 61 Chapter 5: Implications, Recommendations, and Conclusions As previously discussed, this literature aims to expand on the knowledge surrounding teleradiology and how it may be beneficial versus hinder radiologists and their ability to care for patients throughout the world. Multiple facets in teleradiology prove to be a dilemma and impede the execution that would benefit many small or understaffed hospitals due to shortages of radiologists, communication barriers, and availability in off hours. Through analyzing these benefits, shortcomings, worldwide differences in practice, and negative features, recommendations can be provided to better implement teleradiology and improve the efficiency and quality of care throughout hospitals worldwide. Implications The implications of teleradiology as analyzed in this systematic review are in-depth, addressing its advantages, challenges, and impact on healthcare delivery worldwide. This thesis addresses the research questions individually, draws conclusions supported by the findings, and situates the results within the context of the study's problem, purpose, and existing literature. Impact on Patient Care Outcomes in Rural and Underserved Areas Teleradiology has demonstrated significant potential in improving access to radiological services for patients in rural areas. By providing adequate imaging interpretation even in subspecialty fields, it bridges the gap that exists between geographic disparities in healthcare delivery. For example, teleradiology has been crucial in reducing treatment delays for critical procedures, such as strokes, where time is a vital 62 component in providing lifesaving treatments like recombinant tissue plasminogen activator (rtPA) within a three-hour window of onset (Misra, 2005). However, fundamental issues with infrastructure, such as unreliable internet connections and frequent power outages in regions like Ethiopia and South Africa, blunt its effectiveness (Nigatu et al., 2024; Schoeman & Haines, 2023). This leads to the conclusion that teleradiology enhances patient care outcomes but requires an invested infrastructure to ensure consistent delivery of imaging services. Challenges and Successes of Global Implementation Across Socioeconomic Backgrounds Globally, teleradiology has been successfully implemented in high-income countries like the United States and India to address after-hours imaging needs. In India, radiologists provide overnight coverage for U.S.-based hospitals, improving ICU efficiency and reducing mortality rates (Roa et al., 2024). However, socioeconomic disparities create barriers to implementation in low- and middle-income countries. Factors such as high start-up costs for hardware, software, and services are problematic for many facilities, as seen in Poland (Madej & Sasiadek, 2023). Additionally, legal jurisdiction issues complicate cross-border implementation due to varying licensure requirements (Silva et al., 2013). In conclusion, while teleradiology bridges gaps in healthcare access globally, targeted investments are needed to address socioeconomic inequalities. Alleviation of Radiologist Shortages The global shortage of radiologists remains critical, with some countries reporting alarmingly low ratios. Nigeria, for example, has one radiologist per 100,000 people 63 (Omofoye et al., 2024). Teleradiology mitigates these shortages by redistributing workloads across geographic areas. Remote reading allows for continuous radiological services and provides subspecialty knowledge where maintaining a full-time staff is difficult (International Radiology Societies Tackle Radiologist Shortage, n.d.). However, this solution does not fully resolve workforce shortages without equal efforts to train more radiologists. Examining these facts leads to the conclusion that teleradiology alleviates local shortages but cannot fully address global workforce deficits without additional training initiatives. Advantages and Disadvantages Regarding Healthcare Delivery Teleradiology offers faster turnaround times for imaging results and improved work-life balance for radiologists through remote work options (Petscavage et al., 2022). It also amplifies access to subspecialty expertise regardless of location. However, communication gaps between remote radiologists and on-site clinicians can lead to misunderstandings that affect patient care. Malpractice claims associated with teleradiology have been found to involve greater clinical severity compared to traditional radiology practices (Mezrich, 2024). In conclusion, the advantages of teleradiology outweigh its disadvantages when systems are optimized for communication and quality assurance. Interdepartmental Communication and Collaboration Teleradiology creates a new communication pathway between radiologists and referring clinicians. Lack of face-to-face communication can lead to delays or misinterpretations. For instance, referring physicians may feel a diminished sense of trust 64 when reviewing reports from radiologists (Fatahi et al., 2019). Standardizing communication protocols is essential to minimize any issues. In conclusion, effective communication strategies are critical for optimizing the collaborative potential of teleradiology. Limitations Affecting Interpretation - Technological Constraints: Outdated internet infrastructure in low and middleincome communities limits applicability to regions with advanced connectivity. - Observer Bias: Qualitative studies relying on interviews may reflect participant bias or researcher influence. - Geographic Scope: Comprehensive data from certain regions like Latin America remains sparse. The findings align with the study’s purpose by addressing teleradiology’s dual impact on healthcare efficiency and equity: - Significance: Teleradiology addresses critical challenges such as radiologist shortages while improving access to specialized care. - Contribution to Literature: This study fills gaps by comparing global implementation across socioeconomic regions. - System Utilization: Recommendations for standardized education frameworks and improved IT infrastructure directly address identified shortcomings. Implications for Practice 65 1. Healthcare Systems: Teleradiology reduces health disparities by extending specialized care to underserved areas. 2. Radiologist Training: Standardized global education programs to ensure consistent quality across all regions. 3. Policy Development: Policymakers should incentivize investments in infrastructure for low and middle-income communities while addressing legal barriers like cross-border licensing. 4. Technology Integration: Universal platforms like PACS streamline image sharing and improve diagnostic accuracy. Recommendations The recommendations that we feel should be implemented to provide for a better future with the use of teleradiology include findings from our research and literature review. Certain barriers and disadvantages towards teleradiology in hospital systems throughout the world include the diversity in education for practicing radiologists. The differences in educational background may provide variable knowledge amongst radiologists and limit the adequacy of reports, including recommendations that are communicated back to the referring physician. To staunch this variability, standardized expectations in education must be implemented to ascertain that all radiologists have equal ability to produce a sufficient report.“With the aid of teleradiology, ICUs can quickly and accurately evaluate radiological images with immediate access to experienced and subspecialty trained radiologists with great expertise in particular fields” (Rao, 2023). Worldwide criteria or testing for all radiologists will ensure that 66 expectations are met and hospitals need not worry about the adequacy of the report received. The field of radiology is so vast and requires a wide range of knowledge about different organ systems, resulting in many radiologists choosing a specialty to work in. The specialty that is chosen is where a majority of their work is and allows them to be masters of their field. Teleradiology that is implemented worldwide may require a radiologist to either be well versed in one specialty or, within a small hospital system, the staff radiologist may be expected to cover the entirety of the hospital's imaging. Expectations must be clearly distinguished before teleradiology with a staff radiologist is implemented to ensure that the staff that is assisting is competent in whatever studies that will be evaluated. A neurological intensive care unit that needs assistance with reads in the evenings is best suited with a neuroradiologist who is proficient in the complexities that are found in these cases and is confident in communicating with the provider that is present to assist in guiding diagnosis and treatment. Teleradiology “enables many smaller hospitals who struggle to maintain adequate off-hour and specialist coverage to quickly provide round the clock, high-quality interpretations” (Rao, 2023). The interpretation of images is extremely important in the diagnosis and treatment process, however, if the path of communication is hindered, it affects the quality of care that patients receive. “Some of the challenges faced during tele-reporting of a few cases where interpretation time exceeded the limits of compliance included [a] lack of pertinent prior images [and] slow image transmission” (Rao, 2023). A consistent and methodical program used for sending and retrieval of images will streamline the process of transferring data to radiologists that are across the globe and allow for proper 67 interpretation that is easily accessed by the referring provider. In the case of a stroke, a timely diagnosis must be made to ensure treatment is begun on that patient immediately to ensure the best outcome. Using a system such as PACS throughout all hospital systems around the globe will allow all imaging, including from other hospital systems, to easily be acquired and reviewed by the provider seeing the patient. A detailed history can be obtained with these images and comparisons may be made to rule out pathological changes. The transmission of images to providers will be more straightforward and require less data to be modified in order to fit new imaging systems guidelines. The consistent use of one program, such as PACS, will allow for seamless transfer and interpretation of imaging throughout many hospital systems and improve their ability to work together. Conclusions Recommendations to implement teleradiology effectively begin with addressing the barriers that are evident in the field. The shortage of radiologists throughout the world creates a demand for the occupation and provides opportunities for assistance in filling positions. After hours shifts in the nighttime may be filled through radiologists across the globe, who will consequently cover these positions and do so while maintaining a preferred daytime schedule. Effective communication between providers after reading exams can be streamlined through the use of effective communication systems. A consistent archiving system for the analysis and recovery of images throughout the hospital systems across the globe provide consistent and speedy reporting of clinical images. Accurate and timely diagnosis is advantageous to both hospital staff and patients, all the while streamlining the diagnosis and treatment process. Proper execution of a 68 consistent teleradiology service will address problems associated with radiologist shortages and shortcomings within the imaging field. 69 References Accreditation, certification and licensure. Radiology | U of U School of Medicine. 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