Radiology must confront outsourcing challenges

Teleradiology has apparently come of age. Imaging examinations can be sent via high-speed connections to anywhere in the world, at increasingly low cost. Teleradiology also appears to be a profitable business. Take, for example, the services emerging to cover the night shift for U.S. radiologists. Teleradiology Solutions and TeleDiagnosys Services are just two of the many enterprises in the field, both offering this service from a base in India.

The existence of these firms shows that the concept of outsourcing radiology reporting has become acceptable to patients, referring doctors, and insurers. Is this the beginning of a revolution in radiology?

Teleradiology places the in-hospital radiologist in direct competition with all other suppliers of radiology services worldwide. It is a near-perfect example of international free trade. Laws of free trade economics dictate that radiology reports are best written in the country with the cheapest labor. Outsourcing radiology services to intelligent, motivated, and well-trained radiologists who can do the work for a tiny fraction of the cost benefits everyone, according to macroeconomic principles. Rich countries receiving cheaper radiology services will have excess money to spend on other goods and services.

Predicting the future does not need bold thinking. Teleradiology will continue to evolve, and radiology services will be almost completely outsourced. After all, more than 90% of conventional x-ray, MRI, CT, and ultrasound examinations could potentially be handled in this manner. Factors that currently limit outsourcing, such as licensing issues and a relative lack of well-trained radiologists in relevant low-wage countries, can and will be resolved.

Hubs will emerge in low-wage countries to handle the bulk of global radiology reporting needs. These centers will develop an unrivaled concentration of expertise as a result of their high throughput of cases. It may be possible, for example, to have radiologists who read MR studies of the inner ear and nothing else. They will also set high quality controls such as compulsory double reading.

How will this affect the way we practice radiology? What will hospital radiologists' role be in this "new" radiology?

First, it is important to stress that a radiologist's job entails more than making a report. Radiologists are responsible for the entire chain of diagnostic imaging processes in patient care. They play a key role in multidisciplinary conferences, where they can explain the relevance of imaging findings in their correct clinical context. Radiologists also manage the workflow and quality assurance of an imaging department. In short, they spend an estimated 70% of their working time acting as an imaging consultant and only 30% writing radiology reports.

If the task of writing radiology reports is to be outsourced, we radiologists should focus more on our role as imaging consultant, which defines our "added value" in patient care. Greater emphasis on the diagnostic management of individual patient care will, in fact, make our work more challenging and rewarding. In-hospital radiologists will also control the quality of radiology outsourcing, maintaining an existing responsibility for quality in the entire diagnostic imaging chain. It is critically important that outsourcing be operated as a service between in-hospital radiologists and teleradiologists.

Coding and billing systems will clearly have to be adapted. Most reimbursement systems are based on a fee-per-report basis and take no account of radiologists' activities as imaging consultant. This made sense in the past, because radiology reporting and clinical activities leading up to the report were performed by a single radiologist or team. But outsourcing separates these activities. The price of radiology reports will probably fall steeply when outsourcing takes off. Radiologists working under a fee-per-report scheme will be hit by a double whammy: They will be producing far fewer reports, and those they do write will be reimbursed at a much lower unit price.

Outsourced radiology is likely to become reality in the near future, and radiologists need to accept this fact. Our response should be to emphasize our role as imaging consultants and retain control over the entire diagnostic imaging chain. This means direct management of any outsourced reporting and interaction with contracted teleradiologists. We should also reconsider the appropriateness of fee-per-report reimbursement schemes. It is our own responsibility to make our added value visible to our colleagues, our patients, the general public, and reimbursement agencies.

PROF. PATTYNAMA is secretary-general of the European Union of Medical Specialists (UEMS) radiology section and a professor of radiology at Erasmus University Medical Centre in Rotterdam, the Netherlands.