Teleradiology: Radiology Narrows the Distance in an Instant

Technology is taking the distance out of medicine and there is no better example than teleradiology. With the assistance of revved-up computers and speedier telecommunication technology such as WANs (wide area networks), high-quality digital images are acquired, sent electronically to radiologists just about anywhere around the globe and integrated seamlessly into workflow for diagnosis. In many cases, completing an imaging report used to take days - now it takes minutes.

While landline and satellite-transmitted telehealth is far from a new concept, radiology has by far exceeded any of the other "teles" in medicine. "Teleradiology is probably the most developed of all the subsets of telemedicine," says Jeff Bauer, Ph.D., senior vice president of Superior Consulting Co.

Bauer attributes improved bandwidth to teleradiology's growth. "As bandwidth increased, T1 lines became more affordable and the government started providing subsidies for putting broadband linkages between rural and urban hospitals. Bandwidth started coming into rural America and it was more attractive for vendors to develop products for teleradiology," explains Bauer.

Teleradiology also is fully reimbursed, clinically proven and relatively inexpensive to implement and operate, says Jon Linkous, executive director of the American Telemedicine Association.

"There are services popping up now that provide hospitals after-hour services and they are done typically by teleradiology," explains Linkous. "At the same time, as hospitals do that, there are medical centers that are looking to outsource all of their imaging services and do it on a contracted basis to a vendor. Plus, looking at it on the reverse side, there are hospitals that have fairly sophisticated imaging centers that become [an expert] source for smaller clinics."


THE REVERSE SIDE

The University of Iowa Healthcare System, a 769-bed facility in Iowa City, supports eight rural community clinics in Iowa with no on-site radiologists. Providing coverage all day, every day, the institution employs 32 radiologists who can read images on eight separate workstations. Out of its 225,000 imaging exams read annually, 10 to 15 per day are sent from off-site CT (computed tomography) and ultrasound systems.

The bulk of the images are CT, says Brian Mullan, M.D., associate professor, vice chair of education and director of clinical PACS at the institution. "With ultrasound, who does the scan and how well they do it is critical to the images that are generated. Generally we'll have no idea who the tech is or what their level of skills are. If there is an emergency and they are looking for a very specific thing, we will do that, but we can only offer a limited report," explains Mullan.

Before a clinic signs on, Mullan says their equipment is examined for possible upgrades. "If we don't feel that the equipment is up to our standards - that we are not willing to interpret off of - then we have discussions with them to upgrade their equipment," clarifies Mullan. It also is mandated in the contract that a clinic must integrate their equipment with Iowa's system so that the images go directly in their archive. Teleradiology images blend into workflow and are presented in the exact same way as the studies from within the facility.

Previously, Iowa's radiologists read images on a separate monitor in another room. Disrupting workflow, Mullan says radiologists were more adept to finish the hospital's caseload before looking at the studies from the rural clinics. "Now, unless I look at the top and see the hospital identification number on it, I don't know where it came from," says Mullan.


GLOBAL IMAGES

Teleradiology's recent growth and acceptance has been fueled by the many companies that provide nighthawk coverage. Since staffing a radiology department at night is costly, and on-call hours are burdensome, these nighthawk companies "lessen the load" by providing off-site interpretation and consultation services. The trend has proven itself as a cost-effective alternative to leveraging the increasing volume of images and waning number of physicians - without jeopardizing diagnostic quality.

Improved bandwidth has recently allowed these companies to provide teleradiology services day and night. "The word 'tele' is almost an insult to the teleradiology system of today," says Sean Casey, M.D., president of Virtual Radiologic Consultants of Eden Prairie, Minn. "Probably a better word for [teleradiology] is remote networked radiology," poses Casey.

Virtual Radiologic connects 25 U.S. board-certified, fellowship-trained radiologists with U.S. practices and hospitals in 30 states (although they are licensed in 40) using a very redundant teleradiology infrastructure. "We have a RIS [radiology information system] that filters exams according to what each radiologist is qualified to read. The radiologist who has 10 licenses is only going to have on his list the 10 states that he is allowed to cover - and only the hospitals within those 10 states in which he is credentialed," explains Casey. He says that licenses generally range from $300 to $1,000, depending on the state. Renewals for all the licenses each year could tally up to $20,000 per radiologist.

"Our radiologists have a broadband connection that is typically a cable modem with a backup line that is typically a high-speed DSL [digital subscriber line]. Some of the radiologists will put in a T1 line as well. The weakest link is usually a single Internet connection coming out of the hospital. It's their choice if they want to have a backup Internet connection that they can switch over to if there is a power outage," explains Casey.

The radiologists reside in various locations for many reasons, including the 2003 blackout that struck the U.S. Northeast and Ontario in August, leaving 50 million people without power. "Since our radiologists are dispersed all over, the company did not experience any problem in providing coverage during that blackout," notes Casey.


BALANCING THE CHECKBOOK

Teleradiology is not a plug-and-play business. A radiologist cannot morph into a teleradiologist as easily as images are transmitted online. Issues such as proper licensure, credentialing and most of all, malpractice insurance, are bridges one must first cross.

As teleradiology went mainstream, the American College of Radiology established a set of standards, including state licensure and credentialing, requiring that physicians providing teleradiology coverage be licensed in both transmitting and receiving states, as well as credentialed at the institution that sends the image. Malpractice insurance is a little more complicated.

"Liability coverage is all over the place," says Superior Consulting's Bauer. "It is subject to state law and states have different rules and regulations. It is in a bit of a mess right now and working itself out … just not in a particularly pretty fashion."

Ask a teleradiology entrepreneur the same question and the matter may be a little closer to heart. "The insurers do not understand teleradiology and medicine crossing state lines," says Patrick Barron, chairman and chief executive of Palmaris Imaging of St. Louis, Mo. Palmaris employs 13 radiologists who work eight- to 12-hour shifts in "state-of-the-art" reading rooms to provide 24-hour remote coverage to hospitals in eight different states.

Barron calls teleradiology a tough but rewarding business. Created to help augment the radiology practices in the country, Barron insists that his biggest challenge - and bill - is medical malpractice insurance. "It's beyond ugly. I now pay $888,000 per year for liability coverage. The insurance companies are charging us a premium above everybody else in the marketplace because it is teleradiology," contends Barron.

In 2002, the Institute of Management and Administration in New York issued a report that found one recent quote of $225,000 per year for covering 90,000 reads, an amount equal to approximately $50,000 per full-time radiologist, assuming each FTE read approximately 20,000 exams per year.

Insurers are more willing to address exposure if it's intra-state, says Mary Stone, healthcare risk management consultant and president of Locum Tenems Consulting in Atlanta.

It's more of a risk issue than it is an experimental issue, argues Stone. "If a claim were to occur, how is it going to be filed and which venue is responsible? There are such things as valid medical claims. But as many as we are seeing, in which some are frivolous, it's possible that [malpractice lawyers] will position the claims as to get more money," explains Stone. Suits can be filed in the state where the teleradiology claim is located, the state where the patient resides, or the state where the teleradiology firm is incorporated to do business.


MAKING THE CONNECTION

When the legal issues are resolved and various systems are integrated - such as the PACS (picture archiving and communications system), RIS and dictation software - a hospital can develop a stable and profitable teleradiology program. Odessa Medical Center, a 300-bed facility in Odessa, Texas, that performs more than 105,000 radiology exams annually, just celebrated its first-year anniversary as a filmless/paperless institution and is about to celebrate the inauguration of its filmless/paperless satellite clinic, Pecos County Memorial Hospital in Fort Stockton.

According to Jess Dalehite, M.D., chief of radiology, compressed CR, CT and ultrasound images will be sent over from the clinic and immediately available and archived for radiologists in Odessa. "It's basically a hub-and-spoke network that is duplicated all over the country. What you need to do is establish the main PACS [eMed Technologies Corp.'s PACS and teleradiology system are installed at Odessa] as the main infrastructure system in the hub and work on your spokes one at a time," says Dalehite.

There will be no radiologists at the 100-bed off-site clinic and reports will be electronically integrated into the system using Agfa Healthcare's Talk Technology. Dalehite admits the integration of their PACS, dictation software and IDX Systems' RIS was extremely challenging, but allows for a quick turnaround time. Digital dictation is becoming an important component of many teleradiology systems today. Iowa's Mullan explains that the institution will soon eliminate its cumbersome transcription service used for teleradiology reports with the complete integration of Dictaphone's Powerscribe.

As the venture continues, Odessa plans to install eMed's newest teleradiology offering, eMed.net. Dalehite describes the product as "have monitor, will travel," since it works like a thin-client diagnostic workstation. "All I need is a good diagnostic monitor and a broadband Internet connection and I can read from the surface of the moon," says Dalehite.


SAVING LIVES

While teleradiology isn't ready for the surface of the moon, at least not yet, transmitting images overseas has proved to be a clinically powerful, reliable and secure method of improving patient care. Teleradiology systems are being widely implemented and dispersed throughout the military for these exact reasons. The Army's Surgeon General, Lieutenant General James B. Peake, established the Army PACS Program Management Office (APPMO) in March 2001 to complete the digitization of radiology services - at the same time improving the efficiency of radiology services within the Army Medical Department, and the standard of care to patients.

As of now, any of the major U.S. Army medical centers can receive images of medically evacuated patients in Europe via teleradiology methods. Some of these patients have been sent to the Landstuhl Regional Medical Center in Germany from military operations in Afghanistan and Iraq for emergency treatments, and for further transfer back to medical centers in the U.S. The Army uses MedWeb's All-In-One-Server to connect all of its major medical centers in the United States to major tertiary care Army medical centers in Europe, Korea, and Hawaii. Landstuhl sends images of "MEDEVAC" patients to locations such as Walter Reed Army Medical Center in Washington, D.C., and Dwight David Eisenhower Army Medical Center in Fort Gordon, Ga. (just to name a few).

Including the ability to preplan surgical procedures and supportive care plans ahead of time, the benefits of the program are many, says Robert deTreville, Army PACS manager of APPMO at Fort Detrick, Md.

"Healthcare providers at deployed hospitals and clinics can 'reach back' for medical expertise at medical centers not normally available in austere deployed environments like Afghanistan, Kosovo and Bosnia," deTreville says. "In doing so, we have avoided some medical evacuations that were not really necessary. Any time we can do this saves a tremendous amount of resources and reduces the level of risk to medical evacuation aircraft and pilots."

The Army's aggressive program to digitize all sites is expected to be complete by the end of 2007, and MedWeb is not the only teleradiology system the Army uses. "We have a superlative constellation of teleradiology systems in the Great Plains areas using IBM's teleradiology system with GE Medical Systems' Radworks software as a subcomponent. We also use Agfa Healthcare's teleradiology product in the North Atlantic region. In addition, 25 sites in Europe and 17 sites in South Korea use teleradiology to improve the turnaround time from up to 21 days under the previous film-based radiology services model to overnight interpretation using the digital services model," says deTreville.


AT THE END OF THE DAY

Edmund Franken, Jr. M.D., professor of radiology at the University of Iowa Healthcare System, has seen teleradiology mature from rather simple devices used in the mid-1980s to more complex systems used today - and he has embraced the technology from the start. "I've lived through eras where we had to make compromises for image quality. Now, the difference between plain film and digital images does not deplete one's diagnostic ability. As years passed, technology has improved so that now radiologists do not jeopardize convenience for image quality," says Franken.

But it will never replace traditional radiology methods, reflects Franken's colleague, Mullan. "One of the limitations we found in teleradiology in all places is that there is still a human component of what a radiologist does in the consultant world. We discuss with clinicians not only what study needs to be done, but now that it's done, what does it mean? Where do you go next with it in order to tie the whole package together? When you are just doing teleradiology, just looking at the image and sending the report back, you have lost that," says Mullan.