As teleradiology evolves, it changes dramatically, plays growing role in practice

Teleradiology has morphed over the last decade, from an adjunct to the practice of radiology to an essential practice- enhancing technology for groups large and small.

Editor's note: Over the past couple of months we've watched the evolving world of teleradiology and thought a way to capture some of its features would be a series of vignettes written by those most involved.

The writers of these vignettes, all of them commissioned before the acquisition of NightHawk by Virtual Radiologic, were asked to answer two questions: How has teleradiology changed over the past decade, and what impact has it had on the practice of radiology? Not all stuck precisely to the format, but all provided interesting answers that will give you a sense of how differently teleradiology is being viewed, even among its most active practitioners.

-John C. Hayes

TELERADIOLOGY HAS MOVED FROM ADJUNCT TO ESSENTIAL ELEMENT OF PRACTICE

Teleradiology has morphed over the last decade, from an adjunct to the practice of radiology to an essential practice- enhancing technology for groups large and small.

For large practices, it has facilitated the ability to provide subspecialty radiology coverage to a large geographic footprint. In addition to providing a higher quality subspecialty interpretation within a practice or group of practices, teleradiology has also supplied a tool to help hospitals and radiologists practice more efficiently, resulting in timelier subspecialty imaging coverage. For the small practice, teleradiology is now more than an adjunctive tool facilitating night call coverage; it is a tool to tap into a subspecialty resource whenever there is a need.

Teleradiology’s decade-long impact on the medical landscape is multifactorial. It has facilitated subspecialty coverage of radiology practice landscapes unachievable in an analog world. It has made subspecialty reads increasingly possible around the clock and has allowed radiologists to focus on the development of subspecialty expertise within a practice by delivering imaging studies regardless of the patient location. Most important, teleradiology has helped radiologists keep the patient first in delivering high-quality service to all patients under their care, at that moment, regardless of geographic location within a practice envelope.

Arl Van Moore, M.D., FACR
President, Charlotte Radiology,
Charlotte, NC

Teleradiology changes reflect technology, market shifts

The evolution of our teleradiology practice reflects changes for radiology practices in general. Advanced Medical Imaging Consultants (AMIC), the teleradiology group in which we are partners, has a unique twist on teleradiology. On the professional side, we offer a full-service, subspecialized radiology group to hospitals, imaging centers, and clinics in Colorado, Wyoming, and Nebraska. We also supply a smorgasbord of imaging IT services, from radiology IT consultation to PACS and image storage provider.

AMIC began this service over a decade ago in an effort to help sites which otherwise had trouble finding radiology coverage. Initial issues included expensive storage, low and costly bandwidth, last-mile connectivity, additional workstations, and DICOM conflicts. Reading was tightly centralized because of workstation cost and data transmission limitations. At the time, however, radiology was less specialized. A typical CT had fewer than 60 images and 50-MB digital mammograms weren’t even part of the discussion.

Data storage is now cheap and can be dispersed in a grid or a cloud, high-bandwidth and last-mile issues are less significant, and diagnostic workstations are inexpensive. These factors have allowed for dispersed reading, improved efficiency, and time shifting as options even for small groups. On the other hand, exams are significantly larger, more complex, and more numerous. As a result, advanced image processing and subspecialization have become the norm rather than the exception, and the number of stat exams as a percentage of overall volume continues to increase.

In the beginning, many sites simply appreciated consistent, high-quality coverage. Today, however, radiology is a commodity-with quality assumed-and clients focus almost entirely on cost and turnaround time. While these things are easy to quantify and certainly have some bearing, quality is more difficult to measure. A good teleradiology practice, though, will always obtain relevant priors and may spend hours on the phone discussing patients and their presentations. In today’s world of radiology, it’s attention to details such as these that makes the difference between a teleradiology company and your teleradiologist.

J. Raymond Geis, M.D.,
Medical Director, Imaging Informatics
Chris Fleener, M.D.,
Codirector, Outreach Imaging
Advanced Medical Imaging Consultants
Fort Collins, CO

Once a solution to an acute radiologist shortage, now an integral part of practice

Teleradiology emerged in the early 2000s as a solution to an acute radiologist shortage that coincided with increased demand for 24/7 imaging interpretations. By outsourcing nighttime on-call duties, radiology practices were able to better serve the needs of hospital emergency rooms and effectively gain additional FTEs during daytime hours.

This synergistic relationship continued to evolve, and teleradiology grew beyond its traditional-and very narrow- definition of remote off-hour reads. Today, teleradiology is a tool that helps local hospitals and radiology practices meet the market demand for expanded access, improved quality, and reduced costs. A select few teleradiology firms, such as vRad, have been able to offer 24/7 subspecialty coverage and, in our case, even the workflow technology necessary to integrate subspecialist reads with onsite physicians. Ultimately, this has resulted in improved patient care and increased efficiencies.

The industry continues to evolve, and healthcare reform has accelerated the pace of change. Radiology practices will need to offer a wide range of subspecialists and technology with the sophistication to seamlessly manage workloads and improve turnaround times while facilitating effective communication between all physicians on the care team. As we look to the future, technology will continue to serve as an enabler for enhanced radiology services. Along the way, the need for partnerships with seamless integration between virtual radiologists and onsite radiologists will be key to optimizing radiology’s role in healthcare.

Rob Kill, CEO,
Virtual Radiologic

Large practice uses in-house teleradiology to meet all contract needs

Wake Radiology employs 58 subspecialty radiologists practicing in a multicounty region of central North Carolina. We staff several local hospitals by virtue of exclusive contracts, some of them many decades old. We have historically provided “in-house” 24/7/365 radiologist coverage at the largest of our contracted hospitals, 800- bed WakeMed in Raleigh.

The suburban and rural hospitals we staff are covered by our group onsite (seven days week) and we use our own after hours in-house teleradiology service overnight. Our radiologists cover all shifts, including five dedicated trauma radiologists onsite at WakeMed plus our evening suburban/ rural hospital enterprise-wide teleradiology service.

As a result, we have never used a contracted teleradiology service. This may sound old-fashioned, but we believe that our obligation as an exclusive provider requires us to provide the service and not outsource it to an unrelated entity. Notwithstanding trends to the contrary, given our size, it somehow seems contradictory to ask for exclusivity only to turn around and contract with a third party. We certainly understand the advantages of outsourcing in rural and low-volume/low-intensity environments, and we are not critical of those who contract teleradiology for those purposes.

Dr. Robert E. Schaaf
Managing Partner, Wake Radiology
Raleigh, NC

Present at the beginning, a teleradiologist looks back wistfully

I look back on the past 10 years rather wistfully, but not because of some regret over what teleradiology has failed to achieve. Because I feel strongly that it has been hugely successful in freeing radiologists from the drudgery of being on call while offering rapid access to skilled radiologists and subspecialty readings-while personally benefiting from it financially as well.

No, my sense of regret stems from my ability to see where we will be 10 years in the future. I’m sure many settlers in the early West who had escaped the crowded industrialized East nonetheless saw the advantages of the coming of the steam trains. But just like the Native Americans, they didn’t realize how much the West and their lives were about to be changed.

I am no Luddite; rather I’m an enthusiastic adopter of new technology, having, with my business partner, started a teleradiology company in the early days. But we should remember that the Luddites were actually skilled textile workers whose jobs were being disrupted by industrialization. And it may be a bit of idealization, but they were losing a pastoral lifestyle as that revolution overtook them, as will we.

Teleradiology has allowed for the transformation of radiology into an easily tradable commodity and with that, the intrusion of large, profit-driven corporations into what previously had been a collegial environment of physician owners. The trend now is more and more of physicians becoming employees of hospitals or large corporate health systems rather than independent practitioners. And with that comes the inevitable loss of freedom, intellectual independence, and, of course, income.

However, it is impossible to embrace the future if our arms are laden with regrets and memories of the past. So, even as we expand our own teleradiology company, I am looking forward to many new opportunities. Just as someone had to sell liquor to the railroad workers and Newport mansions to the robber barons, I am looking forward to selling yachts and Gulfstreams to those new CEOs.

Eric Trefelner, M.D.
Cofounder, NightShift Radiology
Columnist, Diagnostic Imaging

From a crude way to cover call to a strategy for radiologist efficiency

Ten years ago teleradiology was a crude and rudimentary way to cover call, relying on downloads via dial-up connections that could take hours. Fortunately, the evolution of high-speed connections began enabling data transfers in a matter of minutes, creating a tremendous opportunity to expand radiology consults and accommodate the huge data sets resulting from other technology innovations.

Today, radiologists can be sent and easily share thousands of images with minimal wait time and a high level of security provided by HIPAA. The result is a vast improvement in patient care through increased consultation among specialists, subspecialists, and colleagues. Getting the right physicians together is the right thing for patient care, and though those physicians can’t always be in the same room, the same hospital, or even the same state, teleradiology has made such consultations possible.

Its impact on the profession of radiology? Teleradiology was integral to the development of a total PACS solution. Teleradiology is effectively an extension of the radiology team, whether our interactions take place on a computer screen on the fourth floor of a hospital or across the country. Teleradiology has facilitated improved efficiency and subspecialization within radiology. It helps support the growth of practices through more efficient staffing. Teleradiology also improves the efficiency of individual radiologists. Small groups of radiologists can join together to offer services, including subspecialty coverage, to multiple hospital sites, thus decreasing turf battles among radiology groups and encouraging collegiality. Getting the right images to the right radiologist helps us provide the best possible patient care.

Timothy Myers, M.D.,
Senior Vice President, Chief Medical Officer,
NightHawk Radiology Services

Teleradiology brings dramatic changes to sprawling Wisconsin practice

Our group, Radiology Associates of the Fox Valley, covers multiple hospitals that span a wide geographic area. Some of the smaller ones are more than an hour away. Before the advent of teleradiology, patients requiring CT or ultrasound imaging often had to be transferred to a major facility, or a hard copy of the study had to be sent by bonded courier to a radiologist at one of the major hospitals. When first-generation teleradiology systems appeared, patients who needed imaging could be medically and surgically managed at the smaller facilities. This was a significant milestone, particularly during the middle of January in Wisconsin.

The first teleradiology systems were set up at the larger hospitals, so the radiologist on call still had to drive in to read remote cases. Their computers had little in the way of hard drive storage, so floppy discs were used to store images. A CT of the abdomen and pelvis required two separate floppies that had to be continually swapped for the radiologist to view the full study.

The next big step was the ability to read images from home. While this cut down on driving to and from hospitals, we still had multiple radiologists covering multiple hospitals. And we still drove in for big trauma cases when the surgeon wanted to be able to sit at the monitor with the radiologist. It soon became apparent that a dedicated radiologist who was awake covering all our hospitals was better than three or four radiologists working intermittently all night-as well as during the day before and after call.

National teleradiology services started appearing at this time to help radiologists, particularly those in smaller groups, ease some of the after-hours imaging load. Our local physicians told us the only way they would endorse this approach was if we provided our own nighthawk service. After a six-month trial, we and our referring physicians concluded that the patients and hospitals are better served with teleradiology by the same radiologists with whom they have developed strong relationships during regular hours.

Since then we have gone to three teleradiology shifts for all our hospitals, 24/7. Teleradiology has also opened up subspecialty reads for even smaller and more distant hospitals and has become one of the services we provide that stands out the most. It has actually brought new business from hospitals that want this same personalized level of service.

Fred Klein, M.D., President
Radiology Associates of the Fox Valley
Neenah, WI

Practice-based teleradiology approach has benefits over business-based option

Over the past 20 years or more, teleradiology has evolved from a tool that improved quality, service, and cost-effectiveness in healthcare into a process that can elevate costs and sometimes decrease quality and service.

Let me explain. Initially we viewed images remotely to consult with colleagues on difficult cases, monitor examinations in progress, and provide subspecialty interpretation region-wide. But over time, teleradiology evolved from a tool employed within a practice to facilitate coverage into a business-driven outsourcing strategy that could be used as a market-consolidation tool. Among the potential negative consequences of this phenomenon are fragmentation and predation.

To counter some of the negative aspects of this model, we developed a practice-based teleradiology system in which the radiologists who read remotely remain completely integrated into the practice as a whole. The advantages of this arrangement are derived primarily from the spectrum of clinical practice in which our radiologists participate. For example, a radiologist who interprets an emergency brain CT might be more familiar with the late complications and likely evolution of any abnormalities detected than a radiologist who is familiar only with the hyperacute phase of brain injury.

In addition, the practice-based teleradiology model is unlikely to result in predation. This is due to at least two crucial differences between the structures of business- based and practice-based teleradiology services. A business-based teleradiology service owes its primary fiduciary responsibility to its owners and investors. A teleradiology service grounded in a medical practice is oriented toward patient care and the professional responsibilities of physicians.

For these reasons and others, a practice-based teleradiology service is the most likely teleradiology option to provide high-quality, reliable service without the potential negative consequences of outsourcing with a business-based service.

David Seidenwurm, M.D.
Chair of the Diagnostic Division
Radiological Associates of Sacramento
Sacramento, CA