U.S. luminary weighs pros and cons of radiology outsourcing

Although the globalization of everything from transcription to equipment assembly permeates medical imaging, radiologists need not fear that outsourcing will threaten their jobs, according to Dr. James Thrall, radiologist-in-chief at Massachusetts General Hospital.

In the opening session of the RSNA meeting in December, Thrall explored unresolved issues associated with global teleradiology and identified safeguards against the exportation of radiology jobs.

Teleradiology is a fact of life for a growing proportion of U.S. practices, according to Thrall. Up to 30% of group practices use teleradiology for off-hours coverage. The best data on the use of overseas radiology suggest that no more than 15% of this work is transmitted outside the U.S. for interpretation, however.

Many U.S. radiologists still feel threatened by the possibility of outsourcing. The magnitude of those fears became apparent to Thrall in 2003 after news coverage of his department's work on a teleradiology research project in Bangalore, India.

"Suddenly, we were on the front page of The New York Times, and every radiology resident in the country thought that I was destroying their career opportunities," he said.

In reality, radiologists are concerned about the quality of global teleradiology services and the ability of the profession to control it, he said. Evidence suggests global teleradiology performed by radiologists at midday overseas can be more competent than work by weary U.S.-based radiologists at night. The medical literature has established a strong relationship between medical mistakes and long working hours.

"Rested radiologists make fewer mistakes," Thrall said. "Outsourcing can address this quality issue."

Outsourced radiology is handicapped by technical problems, however. Because of PACS limitations, remote site readers are not likely to have access to prior exams, medical records, imaging processing services, and consultations with attending physicians and patients. The U.S. group practices that contract for these services may not be fully aware of the qualifications of the radiologists who remotely perform their late night readings.

In terms of radiology turf, Thrall argued that foreign competition is a nonissue. Global teleradiology is controlled by U.S. radiology groups or academic radiology departments, he said. Their offshore providers must be board-certified in the U.S. and licensed in the states where the imaging that they interpret is performed. They also must have malpractice insurance. The growth of outsourced radiology is limited by Medicare's ban against payment for services performed.

A loophole in this scheme is the possibility of shadow interpretation by foreign-trained radiologists who interpret studies under the authority of a board-certified radiologist, according to Thrall.

"This loophole has not yet been exploited, but it surely will be explored," he said.

Compared with the 30,000 radiologists in the U.S., Thrall estimates that no more than 100 radiologists provide remote site teleradiology from outside the U.S. Fewer than three of these practitioners are based in India.

Despite their small numbers, offshore teleradiologists pose some risk to their U.S. peers, Thrall said. The reputation of radiology is potentially threatened if U.S. healthcare administrators come to believe that medical imaging interpretation is a replaceable commodity. Radiologists could also lose their negotiating leverage over hospital administrators if radiology coverage can be accessed easily through outsourcing.

Patient privacy is difficult to protect when imaging is transmitted for interpretation, Thrall said. Many groups that outsource a portion of their imaging volume have yet to decide how to properly tell their patients that their studies have been transmitted to a foreign land for interpretation.

"Under the control of radiologists to improve their practices, globalization may be all right," he said. "But other physicians, hospital administrators, and even entrepreneurs may co-opt the control of globalized radiological service, if it is proven that outsourcing works too well."