Teleradiology, or remote radiology service, is the future of radiology. Information technology has been the genesis of radiology and nuclear medicine. Night-hawk services have changed the future of work for radiology. All but vascular and interventional radiology is protected from outsourcing. As radiology outsourcing moves to low-wage countries, revisiting the fee-per-report reimbursement scheme is in order. How can the in-house radiologist compete?\nBlockchain technology can assist with improving the truth for CT scans, MRIs and conventional radiographs. Blockchain technology gives radiologists and their patients truth.\nWhy are use cases so scarce?\nAre you trying to apply blockchain to healthcare? Having trouble finding concrete use cases? There\u2019s a simple reason for that.\nAre you protecting trade secrets or using innovation as a strategic advantage? Nondisclosure agreements (NDA) are the reason why you\u2019re unable to find specific use cases for a named company.\nHave you ever had a great idea, only to realize that someone else created the product, service or designed the interaction first? I think we all have experienced this at one time or another. A realization that is almost comical happens the more you\u2019re engaged in a field. You\u2019re unable to talk about the best ideas. Verbal agreements lead to confidentiality agreements which eventually result in nondisclosure agreements.\nAt some point, you grow your understanding of a topic from information to knowledge to strategy. It\u2019s at the strategy level where it gets dangerous. Why? This is the time where you have the knowledge\u00a0and\u00a0the ability to execute. Few leaders will reach out to an expert they don\u2019t think can deliver or whose ideas can\u2019t be realized. Frequently, leaders, championing innovation efforts are frustrated with the lack of specific or contextual examples with innovation. Recently this frustration has focused on the difficulty of identifying use cases that apply to blockchain in healthcare. It\u2019s not all grim; there is an upside. Here are two examples.\n\nA builder is building a new custom house; however, they are not able to talk about the design. If you were considering the development of a custom garage for your boat or plane, the good news is the builder's knowledge will transfer.\nA doctor designed a patient care program for a particular patient, and they are unable to discuss the name or specific situation of the patient. However, that doctor's knowledge and the themes applied will be useful if you\u2019re designing a new patient experience.\n\nAlmost all knowledge is transferable. Don\u2019t get hung up on the specifics \u2014 partner with a leader who can be trusted and has a track record. If they are engaged at the edge creating strategies for sustainable competitive advantage, board members will be quick to ensure their IP is protected. The organization won\u2019t want those competitive ideas discussed outside a small circle of individuals. That same professional courtesy will be extended when exploring new models for profitability, with your organization.\nTeleradiology for clinical applications\nRadiology is the science of high-energy radiation for the diagnosis and treatment of disease. Teleradiology extends this definition into the transmission of radiological patient images -- X-rays, CT scans and MRIs, for example.\nDiagnostic imaging modalities, the way a disease or illness is diagnosed by a doctor, vary based on clinical need. I\u2019ll briefly explain the seven of the major types of modalities used today.\n\nProjection (plain) radiography (X-ray): produced by transmitting X-rays through a patient. Film has been replaced by computed radiography (CR) and more recently by digital radiography (DR). Plain radiographs can be used to identify various types of arthritis and pneumonia, bone tumors (especially benign bone tumors), fractures and congenital skeletal anomalies.\nFluoroscopy and angiography: generated with a fluorescent screen, an image intensifier tube is connected to a closed-circuit television system. This type of special X-ray image is used to help identify abnormalities such as tumors, cysts and inflammations.\nComputed tomography (CT scan): CT scans use X-rays combined with computing algorithms to create an image of the body. Often used for urgent or emergent conditions including cerebral hemorrhage, pulmonary embolism (clots in the arteries of the lungs), aortic dissection (tearing of the aortic wall) and obstructing kidney stones.\nUltrasound (echo): used to visualize soft tissue structures in the body. Medical ultrasonography uses ultrasound in real time. This\u00a0imaging\u00a0technology is useful when observing changes over time. For example, heart valves and major vessels or monitoring changes in carotid arteries that may be a warning sign of an impending stroke.\nMagnetic resonance imaging (MRI): use powerful magnetic fields to align atomic nuclei with body tissues. Among all the imaging modalities, MRI scans give the best soft tissue contrast. MRIs help doctors to determine if tissues are healthy. They can be used to identify brain tumors, traumatic brain injury, developmental anomalies, multiple sclerosis, stroke, dementia, infection and the causes of headaches.\nNuclear medicine: uses radiopharmaceuticals administered into a patient. Positron emission tomography (PET) scans or single-photon emission computed tomography (SPECT) can be used to improve diagnostic accuracy. Nuclear medicine imaging is used to evaluate specific conditions relating to the heart, lungs, thyroid, liver, brain, gallbladder and bones.\nInterventional radiology (IR or VIR): vascular and interventional radiology are minimally invasive to the patient. Whether for diagnosis (angiography, looking at blood vessels and organs) or treatment (angioplasty, to widen obstructed arteries or veins) IR is used to identify the disease. Several uses for IR exist, including the diagnosis or treatment of vascular disease, renal artery stenosis and gastrostomy tube placements.\n\nTeleradiology\u2019s business case\nTeleradiology is the transmission of radiographic images from one location to another for sharing studies with other radiologists and physicians. The benefits of teleradiology mirror the benefits of telehealth. A doctor who needs the results of a scan can transmit that image to the West Coast or overseas to ensure a timely reading.\nThe primary benefit of blockchain technologies, when applied to teleradiology, is "truth," not "trust" by offering an integrity check on patient images. Yesterday, radiologists had to trust that images were accurate and unaltered \u2014 but they had no proof. Today, they have truth \u2014 immutable evidence that the images they are reading are unchanged.\nDoes this add value? You tell me. Let\u2019s assume you\u2019re a patient. When your doctor made a diagnosis on your image, would it matter to know with near 100 percent certainty that the image was unaltered? It would matter to me. Let\u2019s assume you can choose two providers to read your image. The first provider ensures that the image is unaltered. The second provider claims to have high security but offers no guarantees that the image is unaltered. Which provider\u00a0would you choose?\n\nTruth over the trust is the business care for teleradiology \u2014 patient image proof for treatment and diagnosis.\n\nAs a recent\u00a0study\u00a0found, 1 out of 20 (or 12 million) U.S. adults annually are misdiagnosed. Most patients won\u2019t gamble on their\u00a0health when the circumstances are severe enough to warrant a scan.\nImmutable patient images\nWe can expand the business case of teleradiology to include image transmission. By using blockchain technology, improved patient image immutability ensures that a provider can validate that the image and diagnosis are unchanged. Providers can verify that they are reviewing the latest copy and confirm the \u201cright\u201d image version was received.\nThis proof can be incorporated into the image display view for clinicians. For example, an image would have three statuses for "image validation:"\n\nConfirmed: A green check mark would appear if the image was validated and unaltered.\nUntrusted: A red \u201cX\u201d indicates the image had been manipulated.\nUnknown: A\u00a0gray\u00a0question mark could be used if there was a connectivity problem.\n\nIf a clinician was so inclined, he or she could select \u201cimage validation\u201d and view the patient image detail, which would include the following:\n\nVisual confirmation:\u00a0the "image validation" discussed previously.\nTransaction ID: blockchain address.\nHash: hash value.\nReceived: the date and time presented to the user.\nConfirmation: date and time the transaction was committed.\nVisual chart: illustration of\u00a0associated linked images.\nLocal stored: date and time with an internal reference number.\n\nTogether, these attributes present proof the image was unchanged. Using these principles, blockchain technology can create proof of the receipt and transmission of Digital Imaging and Communications in Medicine (DICOM) data. DICOM is a standard for handling, storing, printing, and transmitting information in medical imaging.\nA few myths debunked\nAre patient records stored on the blockchain?\u00a0No, the blockchain provides a check of the patient image (a\u00a0hash\u00a0similar to a\u00a0checksum\u00a0function) to ensure the record hasn\u2019t been tampered with. The patient image and data do not live in the blockchain.\nIs the blockchain able to handle these large record sizes?\u00a0A common misconception is that these patient images will be transferred to a blockchain. This isn\u2019t how it works. The patient image would be transferred to your existing image repository. Only the check or hash would reside on the\u00a0blockchain, not the image.\nDo blockchain projects in healthcare require significant changes to core technology?\u00a0No. The imaging workflow is not changed. To implement, simply add a new workflow that records the data source in a digital ledger. A basic check can then be used to verify that the data source is unchanged.\nDoesn\u2019t blockchain data need to be encrypted?\u00a0Nope. Remember the patient image is not stored on a blockchain, only the hash. Unless you hold the private and public key, you\u2019re unable to make use of the data. You would use the same standard security protocols for transferring data. There is a proposal from the MIT Media Lab to address the protection of personal data.\nIs additional infrastructure required to bolt on blockchain for encryption?\u00a0The short answer is no. Often, healthcare leaders who start to research blockchain mistakenly feel data needs to be encrypted. The data that is being transmitted to the blockchain isn\u2019t subject to HIPAA regulations; it\u2019s not protected health information. Remember, the image isn't being transmitted to the blockchain, only the hash.\nMIT does have an\u00a0active project\u00a0exploring a peer-to-peer network that allows users to share their data with cryptographic privacy guarantees. This would be useful when the patient learns their relative position in the group but learns nothing about other members \u201cdiagnoses.\u201d This\u00a0community-based\u00a0approach for data analytics could be leveraged to allow patients to conditionally share image diagnoses for the benefit of the crowd.\nThe Radiological Society of North America (RSNA), the\u00a0 American College of Radiology and the International Society for Magnetic Resonance in Medicine (ISMRM)\u00a0have lots of additional information on radiology. For a complete list of domestic and international radiological associations, Radiology.org is a great resource.\nThe path to implementation\nAre you thinking about applying blockchain technology for teleradiology? There are many ways to exploit the\u00a0benefits of blockchain technologies. Blockchain\u2019s characteristics of distributed, public, time-stamped and persistent establish proof, giving providers immutable proof that sensitive data has not been altered. When it comes to your health, would you rather have trust or indisputable truth that your patient images haven\u2019t been changed?