Grid could easily transform the practice of radiology

In our last article, "Grid computing makes most of finite resources" (April, page 21), we discussed the technical aspects of grid computing and how it might be used to provide diagnostic radiology services. While we certainly don't possess a crystal ball, it seems self-evident that evolving computer-based technologies will have a radical impact on how radiology is practiced.

To get a glimpse of the future, we must first review how the practice of radiology has changed dramatically and irreversibly over the past decade. In the early 1990s, filmless radiology was a pipe dream for a few optimistic technophiles, with mainstream radiology expressing major reservations about the concept. Teleradiology was used solely to provide preliminary interpretation of emergency after-hours exams, largely to prevent radiologists from facing the harsh, cold night and allow them to remain in the comfort of their homes. While this instilled resentment in our technologist colleagues and perpetuated our undeserved reputation as "lazy radiologists," we embraced the technology as a means to improve our lives.

A few entrepreneurial academic institutions envisioned teleradiology as a revenue generator, an opportunity to compete for relatively lucrative CT and MR contracts from overseas, and a source of subspecialty second opinions for private-practice radiology groups. While the business model appeared to be both sound and timely, the economic bottom line faced technical limitations. They included difficult challenges associated with bandwidth, archiving, and system integration. A few savvy individuals made money, but most were left daydreaming of unrealized riches.

As PACS adoption increased and Web-based image distribution replaced closed proprietary PACS networks, the practical utility of teleradiology increased to the point where a new breed of radiologist was born, the nighthawk. This term refers not to some sort of predatory insomniac, but to someone who fulfills one of the following criteria:

- can't get a day job, so elected to temporarily fill the nighttime void;

- prefers the independence (and often extra time off) associated with late-night duty; or

- sees a potential financial opportunity in an expanding radiology practice environment.

Shortly after the nighthawk became recognized as a new species of radiologist, several interesting phenomena occurred. The radiologist supply/demand imbalance intensified, due to a combination of early retirements, decline in residency applicants, and increased demand for services. This resulted in an overall improvement in salaries, along with a perceived need to outsource on-call responsibilities to third parties. Entrepreneurs began seizing the opportunity and setting up nighthawk assembly lines. Currently, a small subset of these nighthawk providers are located in foreign lands, where the time zone differences enable radiologists to provide night-time coverage in the U.S., while working daytime hours abroad. Licensing and credentialing issues were the major impediment, and these were overcome through grit, determination, and assistance from professional credentialing personnel.

In short order, large teleradiology networks were established, ostensibly to enhance radiologist performance. The medicolegal aspects were largely, not entirely, circumvented by providing preliminary interpretations only. This teleradiology business model is thriving, as more radiology groups outsource after-hours responsibilities for a hefty price. Cost-justification can be accomplished through improved radiologist lifestyle and the simple fact that most radiologist groups are more profitable than ever before.

RADIOLOGIST GRID MEETS TELERADIOLOGY

While these large teleradiology providers fall far short of constituting a true "radiologist grid," they demonstrate how an expanded teleradiology network can provide profitability and job security for radiologists, while adding the flexibility of being able to work at home or another attractive location. Individual radiologists can have high-speed Internet connections installed in their homes with T1 lines, cable, satellite, or DSL. The contracting teleradiology company provides technical support, security, and a constant supply of business in return for a commitment of services, typically with a noncompete clause.

This setup has created a whole new breed of stay-at-home radiologists who enjoy the opportunity of working in their pajamas. These mavericks are freed from the rants of the hospital CEO, the politics of hospital-based radiology, and the requirement to work weekends and holidays. Instead, they can be considered a sort of mercenary, preferring to put destiny in their own hands, with an "eat what you kill" reimbursement model.

If we begin to introduce the radiology grid into this new teleradiology paradigm, a number of interesting and potentially frightening possibilities arise. Some of these are logical, intuitive extensions of how technology and its applications are evolving, while others are quite speculative.

Let's fast-forward to a hypothetical situation in the year 2015, where we find our good friend and colleague, Dr. Laurie, who is busy working in her high-tech Australian beachfront home. Laurie moved to the land down under 12 years earlier as a "hired gun" for a large teleradiology group. She fell in love with the area and decided to purchase property in Perth. Laurie spends her winters in Florida, her summers in Australia, her autumns in Maine, and her springs in Madrid. She has easily adapted to her lifestyle as a time-share radiologist by creating her own company: Have Radiology, Will Travel. This allows her to pursue her parallel loves of travel, real estate, radiology, and shopping.

She offers time-shares at her multiple properties to other radiologists within her co-op, which now totals 1562 radiologists and counting. The co-op slots individuals and groups of radiologists into an international radiology grid, linking computers into a single comprehensive network and database that spans five continents and 36 countries. By crossing time zones, the co-op offers 24/7 coverage ("The sun never sets on Have Radiology, Will Travel") to a myriad of customer groups: imaging centers, hospitals, medical offices, HMOs, and patient healthcare communes, which came into existence in 2012 after the advent of the national patient record database.

Last year, the co-op signed an exclusive imaging interpretation agreement with the AARP that is conservatively estimated to yield $40 million in annual revenues.

Laurie, an early adopter of the teleradiology business model, several years ago chose chest CT angiography as her designated superspecialty. She has international QA credentialing in both chest CTA and chest projection radiography, which includes thoracic computed radiography, direct radiography, dual energy subtraction, and tomosynthesis. While she doesn't sign on to the chest radiography queue frequently, she reads her required quota of 1500 exams per month to maintain licensing.

Laurie laughs when she thinks about the old days when a typical workday consisted of 80 to 100 cases, divided between all anatomic regions and modalities. She occasionally thinks about how strange it would be for her now to actually interpret an abdominal ultrasound or cardiac nuclear medicine study.

Typical shift

On a typical eight-hour shift, Laurie interprets 100 to 120 chest CTA exams, an impossible feat prior to the grid's evolution. This productivity is enhanced by the use of sophisticated decision support incorporated seamlessly into the interpretation process, including a radiology-oriented pithy summary of the electronic medical record, abnormal finding feature extraction, and computer-aided cuing and diagnosis. The 3D angiographic template takes her only a few moments to review and, coupled with the multiplanar reconstructions, helps her scrutinize the entire data set in less than three minutes.

After organizing the data into the structured reporting format and linking it with annotated images, she transmits the final report in about three and a half minutes (which happens to be her current speed based on productivity measures obtained from the grid database). If it weren't for the International Society of Digital Imaging's mandatory 10-minute breaks every two hours, her productivity might be even higher and she could afford to buy that property in Rio next month, instead of waiting until later in the year. In the beginning, the obligatory computer breaks were a real nuisance, but she now enjoys them. She uses the "rest time" to e-mail friends, review RSNA online, study MIRC cases in her CME queue, and trade stocks on the 24-hour international stock exchange.

Recently, while surfing the Web, she came across a listing for her old hospital-based job in Maryland. It saddened her a bit to realize that ever since the grid came into being, radiologists have been exiting hospital-based practices en masse. In 2015, only 11% of practicing radiologists are hospital-based, and this number has been shrinking exponentially. The grid's largest revenue growth over the past three years has been in the hospital sector, as more and more hospitals are forced to outsource professional interpretation services to offsite providers. In the beginning, everyone thought this was going to make radiology a commodity that went to the lowest bidder. But with savvy business practices and the focus on quality and added-value communication protocols, the reimbursement rates within Laurie's co-op remain high. The international QA database is instrumental in objectifying radiologist performance and is particularly well received by the growing patient healthcare communes.

The few radiologists left behind in hospital-based jobs are largely composed of governmental and private-practice general radiologists who did not foresee the radical radiologist superspecialization trend. After finishing up her shift, Laurie goes into the grid QA database and reviews her day, week, month, and yearly scores to date. Her communication score is 95 (on a scale of 1 to 100), her interpretation accuracy score 96, and her customer satisfaction score 92. She knows her customer satisfaction score would have been higher if Dr. Eliot hadn't "spoofed" her sign-on and injected condescending comments into one of her e-consults.

Laurie and Eliot have an ongoing bet over who would get the higher customer satisfaction scores, and she had beaten him 14 months in a row. While Eliot is a decent radiologist, his interpersonal skills are obviously in need of improvement. Consequently, while his referral base is eroding, Laurie's is expanding, largely as a result of the most recent updates of radiologists' scores on the Internet. In her designated categories, she has made the "top 100" list, one of the reasons the AARP decided to contract with her co-op.

After signing off the queue, Laurie e-mails her friend Diane, who is one of the co-op's marketing gurus. They had decided to vacation together next week and hadn't yet finalized plans. Diane wants sunshine and Laurie wants action. They decide to rent the company's charter plane and fly to Pamplona for the running of the bulls. That way, they can enjoy sun and action at the same time. Laurie takes a few moments to reflect on how her life has changed over the past 11 years. Change isn't really such a bad thing, she reasons, as long as you are properly prepared.

Are you properly prepared for the grid?

Dr. Reiner is director of radiology research and Dr. Siegel is chief of radiology and nuclear medicine, both at the VA Maryland Health Care System. Dr. Gutstein is a specialist in telemedicine in Coeur d'Alene, ID.