"TReBREIZH: Teleradiology for Public-Private Integration and Quality of Care in Brittany”
"TReBREIZH: Teleradiology for Public-Private Integration
and Quality of Care in Brittany”
With a shortage of radiologists, teleradiology is emerging as an innovative solution for maintaining quality of care. The interview with Dr Morcet and Dr Eugene, key players in the TReBREIZH project, reveals the challenges and benefits of this unique initiative in Brittany. They share their vision of complementary teleradiology, aimed at strengthening the physical presence of radiologists and facilitating collaboration between the public and private sectors. By focusing on diagnostic reliability and uniformity of practice, TReBREIZH is striving to meet regional needs while ensuring optimum patient care.
What is teleradiology and how does it improve radiology practice?
Dr Morcet: "From our point of view, teleradiology is a tool for making up for the lack of radiologists physically present in medical facilities. Unlike standard practice, our aim is to maintain the presence of radiologists in these care establishments. Teleradiology is only used when their physical presence is not possible.
Dr Eugene: "It is essentially a 'band-aid' on the demographic difficulties encountered in the medical field."
Dr Morcet: "Exactly. What sets us apart from other teleradiology solutions is that our priority is to maintain the availability of care through the physical presence of radiologists. We aim to facilitate the integration of radiology teams into healthcare structures. That's the very essence of our approach.
Dr Eugene: "Ideally, we won't need TReBREIZH when we have enough radiologists physically present. To take part in TReBREIZH, you need to already be established somewhere, whether in a public or private medical imaging centre, with activity representing at least half the time in a physical structure."
What are the benefits of the tools at your disposal in terms of diagnostic accuracy for your radiologists?
Dr Morcet: "Before adopting Telemis, we were experiencing difficulties with other competing solutions, notably because of image visualisation problems linked to their cloud infrastructure. However, since we migrated to Telemis, given that the majority of TReBREIZH's users already work with this tool, viewing images has become much simpler. This effectively translates into an easier diagnostic process."
Dr Eugene: "Rather than talking about diagnostic accuracy, I prefer to talk about diagnostic reliability. The prior integration of TELEMIS in Brittany has enhanced the reliability of our diagnoses."
Dr Morcet: "As a corollary, the use of Telemis offers a significant advantage in that it provides us with a teleradiology working environment similar to the one we use face-to-face in our establishments.
We work with Telemis for our activities in the hospital or in private radiology practices, using this tool for our own patients. When we switch to the TReBREIZH platform, we continue to use the same Telemis platform. This consistency in our working environment is of paramount importance."
How does using the solution encourage collaboration between the public and private sectors, and what does this mean for users?
Dr Morcet: "What sets us apart is our desire to establish cooperation between the public and private sectors at a territorial level, given that we all share the same patient population pool. We all have the same objective: to recruit radiologists for our various facilities. We know that the possibility of using teleradiology is crucial to attracting new radiologists.
That's why we worked together to find a legal structure that would enable us to work together in the interests of patients, whether they come from public or private establishments.
So we set up a "Groupement de Coopération Sanitaire" (GCS = Sanitary cooperation group) under private law, which makes it much easier for us to operate. Our two-headed administration is made up of an administrator (representing the private centre) and a deputy administrator (representing the public centres), as well as decision-making colleges.
These colleges include the applicants, grouped together in a Plateau d'Imagerie Médicale Mutualisé (PIMM =The shared medical imaging platform) for public institutions, and the private medical imaging centres. When it comes to decision-making, each college has equal weight in the vote, with a 50/50 split.
We have a real desire for decisions to be taken on a shared basis and for each college to have equal weight in the decision-making process. This collaboration has also enabled us to set up a medical committee where we discuss our working methods. This enables us, as colleagues in the private and public sectors, to share our practices and harmonise our protocols. In addition to its use for teleradiology, the TReBREIZH tool has enabled us to strengthen our links and develop a network between us."
So, for you, is this really the main impact of the project between health establishments throughout Brittany?
Dr Morcet: "For the moment, yes. We've opted for a cautious start to ensure a good match between the number of requests from requesting establishments and the number of radiologists available. We currently cover the T5, T6 and T7 territories. Our aim is to encourage communication and exchanges to develop TReBREIZH throughout the region. For the time being, these regions are working well in daily routine."
Dr Eugene: "It's also about building mutual trust between two worlds. In the beginning, there was perhaps a certain distance, even mutual distrust. However, as time went by and we worked together, this trust was established. This story illustrates how, when both parties trust each other, long-term projects can be realised. This creates a zone of convergence where the private and public sectors work together for the benefit of patients. By not compartmentalising these two worlds, we benefit our patients."
Could you give us an overview of the feedback you've received on using the tool?
Dr Morcet: "Before Telemis, we had problems viewing examinations and retrieving history. These problems have now been ironed out. What's more, we found that practices varied from one structure to another, whether private or public. Some sites assigned a radiologist specifically to the teleradiology shift, while at others it was the radiologists who were already doing their face-to-face work who were also interpreting for TReBREIZH, so it was sometimes difficult for requesters to contact us. We therefore received some negative feedback on this subject. Setting up a regulator was an important step in streamlining these processes and preparing them in advance. This task is now carried out by another person, which considerably reduces the number of negative feedbacks.
We still have some way to go in terms of our commitment to providing interpretations within 48 hours. Sometimes we exceed these timescales slightly, as we are busy with other tasks and don't always think about dealing with the backlog of tests. It is important to note that we only carry out scheduled examinations, without consulting specialists directly, for example. We must therefore be vigilant in this area. As far as the quality of our reports is concerned, I think that applicants are satisfied. We also endeavour to entrust the interpretation of examinations to specialists according to their skills".
That's the basic idea behind your organisation, isn't it? Namely, to guarantee an interpretation by a specialist in a specific field for each examination.
Dr Eugene: "Perhaps not for all cases, but there are general criteria accepted by all radiologists, whether for standard X-rays or abdomino-pelvic computed tomography (APCT). However, in certain cases, our aim is indeed to ensure optimum quality. I think the important thing is really the quality and proximity of the service. We try to provide specialised interpretation as much as possible. In terms of proximity, I sometimes receive emails about an examination that I have interpreted for a neighbouring hospital.
In these cases, they may ask for further information, additional explanations, or even immediately consider taking the patient to the CHU. I see this as positive feedback.
The only point where we sometimes run into difficulties is that our approach differs somewhat from that of commercial teleradiology companies. Sometimes, for example, we refuse examinations when we know that a previous interpretation has already been carried out and that it sufficiently answers the question asked."
Is your approach, which you describe in terms of quality and proximity, both the origin of your project and its raison d'être?
Morcet: "Sometimes we receive examinations for which there is no medical prescription, especially when it comes to standard imaging. In these cases, without notes, there's no interpretation and no prescription. It's a way of showing that our aim is not to perform medical procedures. As far as proximity is concerned, we favour a local approach. Claimants know us. They can put faces to names. It's not an anonymous radiologist somewhere far away who does the interpretation.
In fact, for you, teleradiology is not a goal in itself, but rather a means of providing more complete, extensive and high-quality care at regional level for patients?
Dr Eugene: "Perhaps not necessarily 'more' complete, but rather 'more extensive', as we said at the outset, because there is a need. Our intention is simply to meet that need. Ideally, we would prefer to have radiologists present in these health establishments. However, it's essential to guarantee a supply of care, so we're trying to fill that need by relying on every player, whether public or private. This makes the situation more accessible and achievable for patients, rather than having to close facilities."
What is remarkable about TReBREIZH's approach is that it is agnostic, mixing the public and private sectors while reinforcing the regional aspect. The name itself is a good illustration of this objective.
Dr Morcet: "Yes, as we said earlier, teleradiology is more of a band-aid, as my colleague pointed out. Ideally, we would prefer not to need this kind of solution. If one day TReBREIZH is no longer needed because there are enough radiologists, we will be very happy. We have also tightened the criteria for integrating radiologists. For example, a radiologist who only does locums will not be able to take part in TReBREIZH. A minimum amount of face-to-face work in a facility is a prerequisite for inclusion. What's more, we require them to have almost daily experience and practice of cross-sectional imaging in their establishment".
So you're essentially asking them to be involved in cross-sectional imaging in the field as a prerequisite for joining TReBREIZH?
Dr Eugene: "Yes, because we've noticed that as a radiologist practising face-to-face, you're aware of the additional tasks such as sorting requests, checking allergies, etc. On the other hand, when you only do teleradiology, everything seems to be prepared and ready to be interpreted. However, in reality, a great deal of sorting and checking has been done beforehand. This is something that radiologists working in the field are very familiar with. So the prerequisite for joining TReBREIZH is to have experience in this area. Without this experience, you can't fully carry out the work of a radiologist".
So TReBREIZH is not an opportunity?
Dr Eugene: "Exactly. Another aspect to consider in terms of quality concerns the requests for reviews that sometimes come from peripheral establishments, in particular certain GHTs (Terriotial Hospital Groups), which are general hospitals, so to speak, attached to the CHU. Sometimes there is no radiologist or the radiologists available are not based in the area. In such cases, many clinicians at the university hospital would ask for images that had already been interpreted to be re-read, which was quite time-consuming for us.
There was no billing and no time dedicated to this. By setting up TReBREIZH in these hospitals, we were able to reduce the number of readings carried out by the CHU radiologists. The respiratory technicians at the CHU know the radiologists who interpreted the examinations within TReBREIZH. All in all, this helps to improve the reliability and quality of the service. These are small improvements, but they are important nonetheless".
Is the number of interpretations by TReBREIZH growing? Is it stabilizing?
Dr Morcet: "At the moment, it's stable because we haven't taken on any new applicants. To be able to accept new applicants, they need to have enough teleradiologists. So we're in a routine phase. We hope that the arrival of Telemis will make our teleradiologists much more satisfied with our tool. Previously, because of the difficulties encountered, many were discouraged. Now we don't have that slow-moving obstacle any more. The Telemis tool, which enables us to interpret examinations in excellent conditions, is attracting more and more of them. However, we are all very busy with our own face-to-face activities. Given the demographics, there aren't more and more radiologists, so we have to remain cautious. Before taking on new applicants, we need to make sure we can meet demand."
Going back to the Telemis tool, could you give us your opinion on the installation of the software in your establishment?
Dr Morcet: "As far as installation is concerned, I have to say that you excel at Telemis. The installation of your equipment is really well managed. As soon as you decide to install something, we know that it will be done, so we can trust you. We have been using Telemis for many years outside of TReBREIZH, and have always had good support for upgrades and other technical aspects. We haven't encountered any major difficulties in this area.
The problems arise more upstream, when it comes to signing the agreements and managing the administrative and political aspects. But once these aspects are sorted out, I think everything goes very quickly on your side."
In one of your LinkedIn posts, I noticed that you emphasised the closer links between the city and the hospital, specialisation and proximity of interpretations. Could you expand on this point?
Dr Eugene: "This merger has brought together two worlds, that of the private sector and of the public sector. And, in practical terms, I think there is a clear advantage for patients in having a common image base. All those taking part in TReBREIZH have access to the examinations that have been carried out. It is possible to search for previous images within TReBREIZH. For patients, this also means that they are directed to the right care channels. For example, if a patient undergoes imaging as part of TReBREIZH, interpreted by a radiologist specialising in women's imaging, such as the one at CIM Les Cèdres, and is diagnosed with endometriosis, she is likely to be referred quickly to the appropriate care. Ultimately, this benefits patients. These closer links between town and hospital are not just abstract concepts, but translate into tangible benefits."
Can we discuss the implementation of the PIMM?
Dr Eugene: "We are not the first to set up a PIMM in France. What's innovative about TReBREIZH is this partnership within the same entity of the GCS of TReBREIZH, where both parties have equal value in choices and decisions. The PIMM was a means we used to make this additional burden attractive. In reality, TReBREIZH, whether in the private or public sector, adds a little extra workload to each of us every week.
But to make that workload attractive to already busy radiologists on both sides, particularly the public side, I needed something to attract them, and the additional remuneration certainly helped. The PIMM allows us to adapt the standard remuneration for practitioners. It also enables me to attract younger radiologists who wouldn't be eligible for self-employment. In fact, radiologists in France have the right to work on a freelance basis within the hospital, but this is mainly open to more experienced radiologists who already have a certain amount of professional experience. With the PIMM, we can recruit post-internship assistants who need to be remunerated and who can therefore benefit from the principle of "working more to earn more".
Dr Morcet: "In our various establishments, we are keen to recruit young colleagues. It is important to ensure that teleradiology structures do not become more attractive to them than face-to-face activities. Above all, we want to encourage new radiologists to join public or private structures, and the possibility of practising teleradiology as part of a public/private partnership is an undeniable attraction.
An additional comment: We have the support of the FHF, the URPS MLB and the ARS Bretagne. We have institutions working with us and supporting us.
On the Telemis side, the Managing Director of Telemis France, Mr Jean-Baptiste Guillot, expressed his satisfaction with the collaboration with the health establishments for the successful implementation of TReBREIZH. He salutes the courage of Dr Morcet and Dr Eugene in their vision for the future of healthcare in Brittany, by resolutely tackling the shortage of radiologists.