The recent COVID-19 pandemic has resulted in many institutional, state, and/or federal directives requiring social distancing and/or sheltering in place. This has caused widespread closures and meeting cancellations around the world and increased the need for virtual alternatives to in-person meetings. This article reviews how to effectively participate in, present, and manage online meetings during this pandemic. Radiology-specific scenarios where teleconferencing plays a vital role will also be discussed.
Online conferencing (often referred to as web-based conferencing, virtual meetings, or webinars) was commonplace in clinical care and among professional societies and industries before the COVID-19 pandemic. However, many academic institutions may still find themselves unprepared in switching to virtual communication. This includes moving to remote patient encounters (telemedicine) and transitioning various traditional “in person” meetings, such as multidisciplinary tumor boards, daily operational huddles, and trainee-attending radiology sign-outs to the virtual realm. Quickly getting up to speed with online conferencing is imperative to protect both the health care workforce and patients from unnecessary exposure that may be generated by in person meetings during a viral pandemic.
There are a variety of platforms available for hosting teleconferences that are relatively straightforward as a participant to use. However, a deeper level of understanding is needed for those planning, hosting, and presenting in such venues. This review will build on central tenants of web-conferencing described by Lewis et al1 with a focus on scheduling, planning, presenting, and managing virtual meetings in radiology-specific scenarios.
Basic Tips for Online Conferencing
Tip 1: Basic Tips for Scheduling Online Webinars/Meetings for Busy Radiologists
One of the most challenging but key items to the success of any conference is scheduling. This is especially difficult given the unpredictability of clinical schedules, varying work hours, different time zones, and scheduling conflicts between conference participants. A popular solution is a simple web form called “Doodle Poll” (www.doodle.com;Doodle Ltd. Zurich, Switzerland)2,3 that allows potential participants to choose available time slots, minimizing back-and-forth emailing to determine availability.2,3
A single conference coordinator should create and distribute the poll and collate the responses. Once the meeting date and time are established, an invitation to the participants can be sent from the webinar application or from the user's calendar invite tools (Figs. 1 and 2). It is helpful to send reminders in advance of an online conference.
Common pitfalls include inadvertent cycles of meeting cancellations and invitations often associated with updates to the details for teleconference connection. Care should also be taken if using a participant's online calendar availability to book a meeting, as there may be inaccuracies regarding true participant availability. For example, radiologists may not routinely block their calendars during patient care activities, often causing inadvertent scheduling of meetings during that time frame.
Tip 2: Teleconference Basics
A guiding principle to remember is that a virtual meeting is not simply an “in person” meeting online. Previous studies from the field of business consulting have shown that virtual meetings often fall short in meeting expectations and reaching goals, secondary to such unique problems as poor participant focus secondary to simultaneous performance of tasks unrelated to the meeting.4 Proposed solutions, such as live video of all participants throughout a meeting, meeting agendas circulated in advance, and incorporating tasks assigned to meeting participants, have been shown to increase participation. Many platforms offer such interactive tools as real time polling, break out rooms for small group work, and huddle boards (Fig. 3). Other tools include the ability to have multiple presenters, to readily switch between presenters, and to securely share files between participants during the meeting. Indeed, some may now find that virtual meetings and their unique tools can result in meetings that are more effective than conventional “in person” meetings.
Tip 3: Tips for Participants
Participants may elect to “dial in” to the conference with a telephone or use their computer's audio. Cellular phone applications often automatically enter the conference code and participant PIN if accessed via the phone's calendar invite. However, this information must typically be entered manually for desktop (“landline”) phones. Meeting participants must be careful to choose to join the meeting audio via either the computer (eg, headset, desktop microphone, and computer-connected speakers) or the phone, but not both (Fig. 4). If both options are used, a disruptive feedback echo can occur. Meeting participants should also be comfortable with how to “mute” their phone, or to use “speaker phone,” to avoid inadvertently disrupting the meeting, and to avoid being accidentally disconnected from the meeting.
If Internet connections are poor, an alternative approach can be used with an audio only teleconference. The participants may interact simultaneously on documents via their own computer if the document is shared on a platform, such as Google Docs (Google, Mountain View, California). Google Docs and other similar platforms allow for simultaneous editing online by multiple collaborators or participants.5 Participants can “follow along” with the host, simultaneously editing or otherwise making suggestions in the document during the meeting.
Tip 4: Tips for Presenters
A trial run a few days in advance of the meeting is highly recommended to minimize technical issues and to avoid unexpected surprises. Experienced meeting hosts or moderators, if available, should guide novice presenters through the presentation process in advance of the live event.
It is recommended that presenters disable all pop up and sound notifications. This includes notifications of individuals who are joining or leaving a meeting. The primary host may also set up a “welcome” message for participants. Participants should be notified at the beginning of the meeting/conference that they will be automatically muted to avoid background noises. In this setting, the host should direct participants whether they should virtually “raise their hand” (a feature offered by some platforms), type questions/comments into the chat function, or individually unmute to speak, to interact with the host and participants during the conference.
If there are many participants (eg, 20 or more), it is often best to have a separate person be a moderator to monitor for “hand raising,” and comments being submitted via chat and/or being sent to an email address set up for the meeting. The moderator can screen, collate, prioritize, and present questions/comments to the presenter(s) during designated question and answer sessions.
Most online conferencing platforms include a participant list or gallery view. This essentially automates the process of “roll call,” although participants may remain anonymous by not entering their unique id. In such cases, a manual “roll call” may be necessary to avoid confusion regarding who is participating. Of note, most platforms allow hosts to export the participant list into a spreadsheet.
Tip 5: Screen Sharing in the Health Care Setting
If a radiologist is presenting from a computer workstation setup for reading cases, they will most likely be working with multiple monitors. In this setting, it is important to carefully choose the correct monitor for presenting and to only display material meant to be shared. This will avoid unintentionally sharing inappropriate material, such as the host's email, or HIPAA-related items, especially if the radiology picture archive and communication system (PACS) or HIMS software is running in the background. Therefore, it is strongly advised, when possible, to shut down all nonrelevant programs during an online conference.
Challenges to Online Conferencing
Several challenges may be encountered during online conferencing, both technical, and participant related.
Technical issues occasionally encountered during the initiation of a webinar session include distribution of an incorrect dial-in number, sudden failure of the hosting platform, loss of internet connectivity and limited internet “bandwidth,” occurring most often during times of “surge” internet use. Surge” issues have been particularly problematic during the current pandemic as worldwide internet usage has drastically increased. Scheduling conferences during “off peak” times can be helpful.
Difficulties may also be encountered when “passing the controls” between presenters (eg, switching who is sharing their screen). This process differs between various online conferencing platforms and practice in advance of the actual conference/meeting is encouraged.
Another factor is the difference in size of the monitors being used for presenting and viewing the presentation. Participants may be viewing screens as small as those on a mobile phone or as large as a 30-in. (or larger) monitor. If a presenter is using a large monitor, they should try to avoid putting too many items on the screen being presented, or minifying the presentation, to the point that those on smaller screens can no longer participate meaningfully. This is a particularly important consideration for radiology-based webinars, given the primary emphasis on images.
Challenges related to online participants themselves include participants joining in from locations with loud background noise, and failing to mute a call and consequently causing disruptive audio feedback. Participants also need to remember to identify themselves when speaking, particularly if they are not identified on the platform. Premeeting instructions can help minimize these problems.
Lastly, with the recent marked increase of online conferencing, there has been an increase in the incidence of “Zoombombing,” a practice where uninvited guests attend an online meeting/conference, sometimes forcibly taking over presentations and screen sharing offensive content. To avoid such intrusions, it is recommended that hosts/presenters always set a meeting password and consider enabling a waiting room where the host can screen participants and choose to allow them to participate.
Best Practices for Online Conferencing/Teamwork in Radiology-specific Scenarios
Clinical Operation/Crisis Operations
Online meetings and “virtual teams” have the advantage that they can be set up very rapidly because participants do not need to gather to a common location. This is particularly helpful for crisis situations where team members may be physically distanced and unable to meet centrally, such as in the setting of the current pandemic.
An example is a virtual “centralized” command center with information resources and working documents available online to facilitate disaster planning as well as day-to-day management of a radiology department during a crisis. Key members might include the department chair, the vice chair of operations, the administrative clinical operations director, division chiefs or directors, nursing and technologist supervisors, and the residency program director. Regular virtual “huddles” of the command center team could be held online to discuss such issues as the evolving status of a disaster, the management of newly arising challenges, and the redistribution of resources, thereby facilitating rapid decision making. Following such virtual meetings, these team members could then disseminate information and decisions more widely to local groups, either in person or online.
Online tools have been developed that facilitate the creation and operations of such virtual teams. For example, the Microsoft Teams platform (Microsoft Corporation, Redmond WA) (Fig. 5) incorporates real-time multiparticipant online face-to-face video and/or audio conferencing and screen sharing, threaded discussions, systems to store and disseminate online files, and the ability to integrate multiple applications including spreadsheets and project management software. This platform can be used to host online meetings, facilitate discrete discussion threads, and host documents for sharing such as dashboards. Other tools can be used in combination to provide the same benefits or to augment those provided by a platform, such as Microsoft Teams. These include shareable cloud-based storage software, such as Dropbox (Dropbox Inc., San Francisco, CA) or Box (Box, Redwood City, CA), multithreading messaging software, such as Slack (Slack, San Francisco, CA), and group audio/video conferencing software, such as Zoom (Zoom Video Communications, San Jose, CA), Google Meet (Google, Mountain View, CA), Webex (Cisco Webex, San Jose CA), or Skype (Microsoft Corporation, Redmond WA). It is helpful to contact one's institution's IT team to identify which software a given organization has access to use.
During the current pandemic, centralized radiology command teams have managed such diverse issues as identifying and deploying on-site skeleton crews, deferring nonemergent imaging and image-guided procedures to decrease the presence on-site of nonessential staff, redesigning workflows to facilitate off-site work, deploying resources to facilitate off-site work, and holding large-scale online information sessions/townhalls to maintain communication with a geographically dispersed workforce. Such a structure can continue to be used during the recovery process, such as for the development of workflows to handle a “new normal” of social distancing (ie, reconfigured radiology waiting rooms and imaging control rooms) and to manage expected postpeak pandemic surges in imaging.
Outside of a crisis, such online, centralized, management structures can be used to improve and standardize operations, and to improve cohesiveness, of a geographically dispersed radiology department that may be operating multiple imaging centers. Benefits may include increased employee engagement, improved communication between staff, and a more positive work culture.
To effectively implement such systems, it is important to establish that all participants/sites have the right software tools and sufficient online access/bandwidth. Institution computers that will be used should be checked that they have the right software installed and that they have been updated to the current version. Tests should be made that such systems are not inadvertently blocked by institutional security software. The primary meeting site hosting the presenters should have sufficiently up to date hardware for good video and sound capture to allow for remote sites to adequately “see and hear.” Similarly, remote sites need to have sufficiently capable hardware to permit adequate participation.
It is also helpful to send to all potential participants pre-event emails that include instructions about how to participate, as well as how to access a recording of the session afterward. Postsession emails should sum up the most significant points, include a link to a recording of the presentation, and copies of any slides that were presented (often best in the portable document format, or “pdf,” which allows for slides to be seen on a wide variety of devices).
Multidisciplinary Patient Care Conferences
Multidisciplinary care conferences have now become virtual at many institutions because of the current pandemic. The choice of the appropriate combination of software that is needed to present information depends on the spectrum of health information to be shared and can include, for example, radiology studies, pathology slides and specimens, intraoperative photographs, other procedure imaging (eg, colonoscopy/endoscopy, endoscopic ultrasound, bronchoscopy, etc.), and conventional slide presentations. The combination of software can, therefore, include radiology information software, hospital information software, PACS, and associated viewer software, medical specialty viewing software, slide presentation software, and software for specific document types, as well as online conferencing software. The chosen conferencing platform should be able to support passing control of the screen to different participants to allow multiple individuals to present from their own computers when needed, and these individuals need to be comfortable with efficiently and rapidly accessing and displaying such information.
A major benefit of web-based conferencing is the ability for individuals to participate regardless of location, who would not have been able to do so otherwise, such as clinicians at satellite facilities. Online conferencing also may increase the range of potential participants to those not typically included, such as nursing or social work, because of the lower barrier to participation.
It is important that the meeting organizer make sure that the chosen web conferencing platform has been approved for use for displaying patient care information by their institution, and that it is sufficiently secure and HIPAA-compliant (see below for crisis induced regulation relaxation). Similarly, all participants should be participating in such a way that HIPAA privacy rules can be observed.
It can be helpful to have access to a multimonitor reading station as the host radiologist. One of the monitors (typically that in the center) can be chosen as the shared display “portal,” and the other monitors can be used as places to “stage” information from a variety of supporting software programs. Information can then be brought into the “portal” as needed, and quickly slid out of the way when no longer required. It is important to consider the relative difference in size between the display “portal” and the potential size of the screen being used by an attendee. Images, in particular, should be sufficiently enlarged on the “portal” display so that they are easily viewable by attendees.
From a technical standpoint, if the radiologist is presenting from a home computer, it is imperative to ensure that the user's institution VPN access is functioning and network speed is adequate to handle large volumes of data if PACS is being accessed remotely. In addition, the radiologist should decide in advance if they would like to use locally downloaded virtual meeting software on their home computer versus running the meeting software via a VPN web browser. Depending on an institution's VPN setup, the VPN may not allow downloaded software to screen share programs accessed via the VPN, such as PACS. This should be tested in advance of the conference to allow for alternate plans to be made.
The benefits of teleradiology have been well known to the radiology community and radiology has set the example for teledermatology,6 telepsychiatry,7 and telepathology.8 Still, there are many specialties that are just now realizing that digital initiatives are important for disaster preparedness. For example, videoconferencing for direct patient care (telemedicine) for many outpatient “visits” is now being performed to decrease contagion exposure risk. It has been speculated that this new “normal” for telemedicine clinic “visits” may set a precedent that will persist beyond the current pandemic, particularly for those patients for whom the logistics of face-to-face clinic visits are particularly difficult.
It is important to note that because of the unique situation of the COVID 19 pandemic, there has been a relaxation of HIPAA protection requirements specific to telemedicine.9 The Health and Human Services Office for civil rights announced that it will not penalize physicians practicing telemedicine for breaches in HIPAA regulations during the pandemic and, therefore, essentially any video sharing platform may be used in the care of patients, despite absence of a patient data-compliant platform. Specifically, it states “OCR will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA rules against covered health care providers in connection with the good faith provision of telehealth during the COVID-19 nationwide public health emergency. This notification is effective immediately.” Additionally, the site HealthIT.gov provides technical information on telehealth,10 and there are discussions regarding billing for telemedicine services which are actively ongoing at the time of submission of this article.
In radiology, the biggest potential use of telemedicine currently is in interventional radiology. Telemedicine can be used to do interventional radiology consultations, screen patients, obtain consents for procedures (with digital signatures), answer patient questions, and guide patients in preprocedure preparations, all well in advance of presenting to the interventional suite. In addition, telemedicine can be used to follow-up with patients once they have left the radiology department. An important efficiency consideration is that with this technology, patients can be “visited” by a radiologist during down time between procedures. Telemedicine may also improve access to interventional services; an example is patients living in rural areas. Using telemedicine, the need for travel could be limited to just the procedure itself. This approach would also benefit those patients who may have difficulty in making or keeping face-to-face appointments, such as the elderly, those with very debilitating chronic illnesses, and those with difficult job conditions.
Outside of disasters or the current pandemic, telemedicine can also be leveraged to develop an enhanced patient facing strategy, similar to that outlined in the American College of Radiology's Imaging 3.0 initiative (www.acr.org).11 For example, radiologists could visit online with patients in advance of an imaging study to determine if the ordered imaging studies are appropriate. During such visits, radiologists could answer patient questions, make sure patients are adequately prepared for the examination, and address expectations. An example might be a discussion of the relative risk of radiation risk from a given radiology procedure. Postprocedure, the radiologist could discuss with patients the significance of their imaging findings.
Preparatory virtual visits may be particularly helpful for the pediatric population where parents are often unaware of what examinations, such as voiding cystourethrograms, may entail. By “walking” a family through a procedure, parental anxiety can be allayed and compliance potentially increased.
There are many logistical factors to consider for such scenarios. These include, but are not limited to, level of IT support for the radiologist, selection criteria regarding which patient visits are candidates for telemedicine, nature of the computer equipment and internet service to which a given patient has access, and acceptable hours for making such online visits. If vital signs or laboratory results are needed, a “hybrid” approach may be required. A full discussion of this emerging field is beyond the scope of this article.
The pandemic has challenged resident education in ways never seen before. Most radiology departments in the United States have seen 50% to 70% or more12 reductions in case volumes, significantly impacting resident education. The Accreditation Council of Graduate Medical Education (www.acgme.org) has developed staged responses to the COVID crisis where stage 1 is minimal to no impact on education and stage 3 is significant impact resulting in a need to suspend educational activities.13 Many programs are operating in stage 2, where education can still occur but is significantly impacted. Programs initially struggled with methods to provide this education while adhering to social distancing requirements. Many have turned to online approaches, which can include web conferencing, which they have used in different ways, some of which will be discussed below.
“Instruction at the Reading Station”/“Case Sign-Outs”
At many of our institutions, conventional “in person” case sign-outs and reviews are no longer being conducted because of current social distancing guidelines. However, case sign-outs can still occur virtually using a variety of approaches including the use of real-time teleconferencing and screen sharing.
Trainees and faculty may designate in advance a specific time for virtual readouts. Alternatively, these sessions may be set up on an as-needed basis if users have access to a common HIPAA-compliant virtual platform that is integrated within their desktop software. For example, institutions with MS teams can initiate real-time chats between users and launch screen sharing with audio capabilities on demand. This eliminates the need for a designated meeting ID and password and the need for formal participant invitations. Another advantage is that if last-minute scheduling changes should occur for either faculty or trainee, the meeting information does not need to be recirculated to include new participants. Nonintegrated software can still be utilized but may require emailing of meeting sign-in information between the trainee and the radiologist.
Another approach is that trainees can dictate preliminary drafts using voice recognition, assign them to the reading physician, and use conventional email to notify radiologists when they have completed review of cases. The radiologist, using a remote reading station, can review the cases and contact the trainee with points of instruction via online conferencing software, telephone, or email.
There are several different approaches that can be utilized for didactic instruction, building on the specifics that have already been described. Some of the approaches are as follows:
- Live streaming
Trainee conferences may be given live during the program’s typical conference time. This type of presentation is best suited to didactic lectures, especially those with interactive discussions, although case-based formats or interactive games can be presented in this manner as well. The presenter should use a platform that will allow their computer screen to be visible to the participants. Depending on the circumstances, the presenter may be alone or may be presenting to both in person and virtual audiences. In such a mixed audience, the presenter should repeat any questions posed by an in-person participant so that the question can be heard also by the virtual participants, and vice versa. In real-time sessions, saving questions until the end of the session can limit disruptions. Questions may be emailed to the lecturer after the live session to facilitate continued discussion or clarify teaching points.
For case-based education sessions, an interactive audience response system can increase audience engagement. This can be done via products, such as Diagnosis Live (Radiological Society of North America, Oakbrook, IL), Poll Everywhere (San Francisco, CA), or Kahoot! (Oslo, Norway). Such software allows participants to answer questions posted by the host in real time, though the questions typically need to be incorporated into the software in advance of the presentation. Some conferencing platforms include polling functions, which can be used in an interactive manner. A drawback of real-time audience response systems is the time taken for each question to be shown, answered, and reviewed. Although this increases audience engagement, the use of this approach often decreases the amount of material that can be covered in a given session.
Another consideration is whether to record a didactic session. Most online conferencing platforms offer this capability, though institutions may put restrictions on whether this capability can be used. Recording a session allows webinars to be viewed later, making them an enduring resource.
Finally, if enduring materials (recordings, FAQs, copies of slides) are created, a well-organized online repository is necessary. This can be as simple as a set of shared folders utilizing cloud-based storage (eg, Box or Dropbox), a shared team site (Microsoft Teams), an institutional intranet website, or a shared drive to which trainees have been given access.
- Flipped Classroom
Flipped classroom web-based conferences can occur on a voice-only call platform or one with screen sharing capabilities. Typically, a flipped classroom involves discussion of print and/or video material circulated well in advance of the discussion session (eg, journal articles, presentation slides, recorded videos of lectures, or a combination of these). In this circumstance, a voice-only platform may be sufficient to adequately discuss the subject matter. However, screen sharing is suggested when interactive use of the source document and supplemental materials is considered likely.
- Prerecorded lecture with live question and answer session
Lectures that have been previously recorded can be hosted on a web-based platform, followed immediately by a real-time, live online moderated question and answer session. Many are available from societies, such as Radiological Society of North America, the American Roentgen Ray Society, and the Society of Advanced Body Imaging (SABI). The moderator can be the original speaker or a different content expert. This method is of particular value for bringing subspecialty expertise to small- and medium-sized training programs. Alternatively, an open-source lecture can be shared with a training group, followed by a facilitated discussion with faculty at the local institution via online conferencing.
Considerations for Individual Radiology Training Programs
Often, a combination of these above strategies may be used to meet a given program's educational needs depending on such factors as the range of expertise of a local training program, the nature of a crisis, and so on. For example, during the current pandemic, many of our institutions have suspended all live resident and interdisciplinary conferences and decreased clinical rotations for residents. An example of a combination approach would be replacing resident conferences with a combination of CME lectures purchased by the program and offerings from the Association of Program Directors in Radiology (APDR), which launched a virtual noon lecture held 2 times per week. These can be supplemented with occasional local faculty presenting a live streaming conference.
National and international radiology societies have had to variably modify many of their annual meetings given challenges of the COVID pandemic, including travel restrictions and social distancing guidelines. Some have canceled their meetings, whereas others (ie, the American College of Radiology) have quickly pivoted to offer meetings virtually and are using live streaming technology to deliver the content of their annual meeting in real time during the scheduled sessions. Other societies have chosen a hybrid approach, such as the Association of University Radiologists, who has chosen to postpone some of their meeting to the following year and offer some content virtually to Association of University Radiologists members.
Many societies have made their resources freely available to members and training programs. This includes recorded videos of lectures from the APDR (www.apdr.org), the American College of Radiology (www.acr.org), American Roentgen Ray Society (www.arrs.org), and SABI (www.scbtmr.org). The APDR has dedicated a page on their website to links to the many online educational offerings radiology societies have provided for trainees during this pandemic (https://www.apdr.org/trainees/online-education-resources). Other academic groups, such as the Disease Focused Panels of the Society of Abdominal Radiology and the SABI, are offering live webinars at no charge, including a question and answer session, frequently recorded for later viewing. A summary of these resources can be found in Figure 6.
One substantial challenge faced by radiologists, trainees, technologists, and administrators is the loss of interpersonal interactions in the age of social distancing and telecommuting. To combat this growing sense of isolation and decrease in morale, many departments are turning to web-based platforms as a means of restoring some level of interaction. During such sessions, participants are encouraged to use their web cameras to allow others to “see them.” Meetings can be in a variety of contexts, ranging from informational town halls, to opportunities to “touch bases” with a small group of team members, or “coffee clubs” for a brief social interaction. Other novel examples include virtual “happy hours,” meet and greets for newly matched residents, and even virtual graduations.
This review describes how radiologists can effectively participate, present and manage online conferences which have become commonplace during the social distancing directives of the current COVID 19 pandemic. It is important for the radiology community to be ready to utilize a variety of web conferencing tools and applications and to be familiar with common tools, tips, and pitfalls to aid in the transition to virtual communication. Scenario-based medical and radiology applications such as administration (focusing on crisis management), multidisciplinary patient management conferences, telemedicine, radiology resident “read outs,” didactic education sessions, and even socialization during this time of forced social distancing were discussed. Online tools for video conferencing, teams, education, scheduling, chats, huddles, document sharing, and messaging continue to evolve, and knowledge of these advances is important to support the practice of radiology particularly during these difficult times.