Teleradiology in the Crosshairs

	The reading room serves as 24x7 headquarters for Radiology Associates of Fox Valley self-developed teleradiology service

Originally hailed as a practice-extending boon for overworked radiologists, teleradiology has faced increasing fire and fury in the last 12 to 18 months. As the major players grow larger, swallowing other teleradiology providers and building affiliations with local practices, rad practices are concerned that they, too, may be bait for teleradiology companies.

In the February issue of the Journal of the American College of Radiology, David C. Levin, MD, of the department of radiology at Thomas Jefferson University Hospital in Philadelphia, cautioned of "the serious negative consequences [of outsourcing night and weekend call]. These include the likelihood of commoditization of the field, lowering of fees, displacement from hospital contracts, greater encroachment by other specialties and lowering of quality."  

Teleradiology proponents, however, refer to greater access to subspecialized care, expedited turn-around time and improved quality. Plus, the ability to balance radiologist workload extends efficiency and cuts costs, they argue.

Both camps make valid points. The growing size and increasing aggressiveness on the part of some teleradiology companies have sparked fear in radiologists' hearts and wallets. And many clinicians are hesitant about working with unfamiliar teleradiologists. But there are ways to leverage the concept with services tailored to local needs.

Patient-centered service

Gem State Radiology, a 25-radiologist practice in Boise, Idaho, considered the teleradiology route about a decade ago when the local hospital began to acquire hospitals and the volume of night work increased. After meeting with internal and external stakeholders, the practice decided teleradiology didn't fit its business model. "We believe we're integral to patient care in the community. Like emergency physicians and trauma surgeons, we cover nights and weekends. We determined that we would be a can-do department," recalls Radiologist Tim Hall, MD.

Radiology Associates of Fox Valley, a 28-radiologist practice in Neenah, Wis., has embraced a do-it-yourself model that involves some teleradiology.

When a host of commercial teleradiology offerings burst onto the radiology scene a decade ago, the practice analyzed its night-call routines and realized it was suffering from inefficiency and overlap. Film-based radiology required that the practice staff multiple physicians at night, so that they could be available for on-site interpretation and procedures. Teleradiology, the radiologists believed, might provide a more efficient, cost-effective model.

"We presented the idea to physicians at the six hospitals we served at the time and they uniformly told us they would hate it. There was no acceptance for an outside source," recalls Fred Klein, MD, president. The practice solved the dilemma by developing a rudimentary internal nighthawk service.

Other successful teleradiology models driven by local needs needs include Arkansas Children's Hospital in Little Rock. Several years ago, the radiology department faced a critical staffing shortage with several concurrent retirements and multiple overlapping medical leave periods. "We knew if we didn't do something to reduce the weekday and evening shift load, the remaining subspecialist pediatric radiologists would be difficult to retain," recalls Charles James, MD, medical director of pediatric radiology. However, clinicians voiced a fair amount of resistance to the teleradiology model.

James assuaged physicians' hesitations about working with unfamiliar, offsite radiologists by tapping into known resources. Part one of the plan centered on a small pediatric teleradiology provider, which employed a subspecialized pediatric radiologist previously on staff at the hospital. Part two entailed equipping a former trainee with a PACS workstation. She read a subset of neonatal intensive care unit (NICU) and pediatric intensive care unit (PICU) studies from home for two days a week for two years. Physicians in those departments had worked with her, which increased their comfort level with teleradiology, says James. To further boost clinicians' confidence, James tasked an onsite pediatric radiology fellow with listening to teleradiologists' voice clip impressions before NICU rounds.

Teleradiology can be a practice builder. Over the last eight years, the teleradiology service at Radiology Associates of Fox Valley has grown by leaps and bounds. Since launching teleradiology, the practice has added two hospitals to its services and expanded teleradiology hours from 10 p.m. to 8 a.m. to round-the-clock service.

Turn-around time: The ultimate service

One of the criticisms of teleradiology is that it can distance a radiology practice from referring physicians and the local community. "This is clearly a valid point," says Marty Khatib, JD, RT, director of imaging services at Mercy San Juan Medical Center of Carmichael, Calif. However, "nothing satisfies a referring physician like high-quality reports and rapid turn-around time. They override anything else you can do to address the need for sustainable quality in a patient-centered environment."

Mercy San Juan employs a hybrid teleradiology model for emergency department (ED) imaging, combining on-site radiologists with local, off-site radiologists and outsourced teleradiologists to deliver an actual final report turn-around time of less than 45 minutes for ED imaging. Khatib argues that teleradiology is intrinsic to the patient-centered ED. Departments can't predict future demand, he explains, but they can utilize teleradiology to respond to demand on the fly and enable precise load-balancing for ED imaging.

Radiology Associates of Fox Valley manages its overnight workload by scheduling one radiologist to the night shift and designating two others as backups for procedures.  

Expediting patient flow not only satisfies physicians and patients, it also benefits the organization's bottom line, says Khatib. "It's in the institution's best interest to expedite throughput and reduce length of stay in the ED."

Meanwhile, Klein says the practice's commitment to internal teleradiology helps it maintain a competitive edge. "We picked up two hospitals in the last few years. Providing our own internal nighthawk was a significant factor in the decision-making process." And James of Arkansas Children's Hospital insists that the practice's 18-month teleradiology stint helped the practice retain staff during a severe radiologist shortage.

Nuts & bolts and IT

Like any radiology or IT project, launching a teleradiology service requires a well-designed contract. "The contract is extremely important. It should be detailed and include compliance mechanisms to satisfy the Centers for Medicare & Medicaid Services and the Joint Commission," says Khatib. Organizations should incorporate quality metrics in the contract, establishing a clear peer review process and a structure for ongoing performance monitoring. Other critical contractual considerations include the ability to load balance studies to subspecialists and provision of immediate access to interpreting radiologists as needed.

James notes that it's critical for practices to define their teleradiology needs. As an academic facility, Arkansas Children's Hospital can draw on its resident pool for the mainstay of teleradiology—overnight emergency reads. His division needed final interpretations on a subset of day and evening studies to keep the worklist manageable. James carefully spelled out the hospital's needs for its teleradiology providers and established expectations, including a mechanism for critical results notification and peer review processes.

As grueling as contract negotiations may be, business complexities may pale in comparison with informatics challenges. At Radiology Associates of Fox Valley, technical infrastructure poses the single teleradiology Achilles' heel. Serving nine hospitals, radiologists contend with three disparate RIS/PACS, which translates into three distinct workstations and an ever-changing posse of passwords. The practice has evaluated software that promises a global view of multiple RIS/PACS; however, the still-developing technology is not quite ready for prime time, says Klein.

Teleradiology is here to stay, and there is no ideal practice model. Practices can develop successful programs by tweaking the service to meet their needs. The key is to carefully evaluate the decision and balance the needs of referring providers with radiologists' goals. After assessing the local landscape and surveying stakeholders, practices can contend with the details, and develop an internal system or devise a tight contract with an outside service. Alternately, they can decide that the model does not fit their community.