24/7 Coverage: The New Norm
Teleradiology has reshaped the delivery of imaging services across the board, but it has had a particularly strong impact on around-the-clock coverage. Hospitals are demanding 24/7 imaging service as the expected level of patient care, partly because an attentive emergency department generates business in surgical suites and elsewhere. Even for very small rural hospitals, 24/7 image interpretation has become the new norm. That doesn’t mean that one 24/7 delivery model serves all, however. There are surprising levels of variety and dexterity in how after-hours services meld with daytime coverage. This variety is determined by resource availability on one hand and by institutional vision on the other. An important variable, which is sometimes the deciding factor in how facilities handle 24/7 coverage, is whether they deliver care in urban or rural settings. Urban North Carolina High Point Radiological Services is a nine-physician radiology group that reads for High Point Regional Hospital and Lexington Memorial Hospital in the adjoining North Carolina cities of High Point and Lexington. High Point Regional Hospital is a level III trauma center with 400 beds; Lexington Memorial Hospital has 100 beds. Nancy Holland, MBA, MHA, is practice administrator at High Point Radiological Services. “The 24/7 coverage is demanded by the hospitals,” she says. “Patients don’t choose when they get sick and a radiologist is needed.” On-site radiologists from High Point Radiological Services cover High Point Regional Hospital from 7 am to midnight and Lexington Memorial Hospital from 7:30 am to 5:30 pm seven days per week, Holland says. After 5:30 pm, the Lexington Memorial Hospital exams are interpreted at High Point Regional Hospital using a high-speed connection linking the PACS at High Point Regional Hospital to the PACS at Lexington Memorial Hospital. Between the two sites, High Point Radiological Services interprets about 200,000 studies per year, Holland says. From midnight to 7 am, neither hospital has on-site coverage. During these hours, a teleradiology service is used for preliminary interpretations, Holland says. If emergency-department physicians or other referrers have queries after cases have been reported, they talk to the teleradiologists by telephone. “The teleradiologists are more like partners for us,” Holland says. “If it’s something big, we have a local radiologist on backup call.” At Lexington Memorial Hospital, where the nighttime exam volume is lower, only the CT and radiography services are staffed by technologists, while at High Point Regional Hospital, a full range of modalities is staffed at night, Holland says. She notes that there is little demand for subspecialty interpretation at night at either hospital. While subspecialists are on staff at the teleradiology service, Holland says, “That’s not something we seek.” All night interpretations are stat, with a turnaround-time goal of 20 minutes, she adds. A serious issue associated with 24/7 coverage is that of who pays for it, particularly for the teleradiology piece. At High Point Radiological Services, the radiology group pays the teleradiologists and then bills for professional fees when final interpretations are done in-house the next morning, Holland says. Each hospital bills for its technical fees. “Using the teleradiology service is totally our expense,” Holland says. “Otherwise, we would have to staff it. It is more financially viable to partner with the teleradiologists than it would be for us to hire a partner.” A sometimes-touchy financial concern of 24/7 coverage is the amount of uncompensated nighttime care that occurs in emergency departments when uninsured patients seek attention, but can’t or don’t pay their bills. “The hospital is not compensating us for the uncompensated care. I hear a lot of rumblings about specialists wanting pay for being on call. We never ask to be supplemented in any way. That has helped in a lot of situations, because we realize that quality of service is what keeps referrers coming back,” she explains. Holland says that a key concept for 24/7 service delivery is having the hospital’s care team work as a group to decide on the appropriate service levels. “Last year, we had a request for 24/7 nuclear-medicine coverage, which most hospitals don’t provide. The radiologists worked with the nuclear-medicine staff to figure out what was an emergency and what wasn’t. We came up with two studies considered emergencies: gastrointestinal bleeding and suspected pulmonary embolism,” she says. “The hospital was pushing to get more procedures on the list. We had physician-to-physician conversations. We found, most times, that procedures could wait until the next day.” In other words, don’t try to offer everything to everybody at night if you want to operate in the black. Rural Idaho At Syringa Hospital and Clinic in Grangeville, Idaho, teleradiologists do all the interpretation, days, nights, and weekends. The 16-bed hospital has no radiologists on staff. This teleradiology-only model is becoming increasingly common for small, rural providers, perhaps because it works if the service is well designed. Kyle Kellum, RT(R), is radiology manager at Syringa Hospital and Clinic and is one of four technologists who operate the imaging equipment, which includes CR, CT, ultrasound, mobile mammography, and mobile MRI. The hospital completes about 6,000 imaging studies per year, Kellum says. For archiving and Internet access, the hospital has deployed a PACS, which also autotransmits all imaging to the teleradiology service. When reports are completed, they show up online on a special Web portal installed by the teleradiology provider. Syringa Hospital and Clinic has four physicians and five physician assistants or nurse practitioners on staff, Kellum says. He estimates the number of referring physicians at about 25. “We have a physician or a midlevel person in the emergency department at all times,” Kellum says, specifying that the midlevel staff member is a nurse practitioner at Syringa Hospital and Clinic. “There’s not a lot at night, but when it rains, it pours.” Technologists are at the hospital until 6 pm weekdays and until 7 pm on weekends; after that, they are on call. Kellum says that the emergency department’s cases include people who have met with farming and sports accidents, along with many people injured using all-terrain vehicles. “We also get a lot of fishing accidents from people falling and breaking both arms when they slip,” Kellum says. Syringa Hospital and Clinic operates an outpatient clinic in the nearby village of Kooskia, where it plans to install radiography equipment. It also has opened a new women’s clinic, just across the street from the hospital, that does bone densitometry. Kellum says that his next goal, if he can convince administrators to do it, is to replace mobile MRI with an in-house system. “It’s a huge investment, and it’s tough to have the hospital say, ‘OK,’ when there’s no proof it would pay out, but I feel, absolutely, that it would,” he says. “I think we could increase our volumes by 50%.” He says that the mobile MRI system now handles about 300 studies per year. Even in its rural location, Syringa Hospital and Clinic faces competition from another hospital 20 miles away, and this is one reason that Syringa Hospital and Clinic offers 24/7 care. The hospital picks up cases that it would otherwise miss, Kellum reports. “If a patient comes in with right-upper-quadrant pain at 2 am and it’s determined that it’s gallstones, because we are able to provide ultrasound, we keep that business, and the gallbladder surgery is done the next day at our facility,” Kellum says. “It’s been beneficial, from a radiology/ancillary perspective, to support the core services the hospital offers.” Kellum says that he can’t judge how much the hospital might lose in uncompensated emergency cases. He says that patients without insurance know that they won’t pay and come in at night for a sore throat, whereas people with insurance know that a night emergency-department visit might result in a bigger copayment than a daytime physician-office visit would. “There’s no way I can prove our 24/7 coverage is profitable, but I can tell you that because we have it, people are coming into our hospital. We do gain that business we wouldn’t obtain if we didn’t have it,” Kellum says. He notes that the hospital pays its teleradiology service a per-scan fee that the hospital then bills to patients or payors at a higher rate. “We’re able to bill a global fee to recoup. Instead of the teleradiologists billing the patients, they bill us at a set contracted fee; then, we put a fee into the exam with a hospital markup,” he says. Because Syringa Hospital and Clinic relies on teleradiologists for all of its interpretations, Kellum says, choosing a teleradiology provider had to be done with extreme care. “There’s huge competition out there,” he observes. “We had another group, and we had problems with the reports being read on time and with the quality. I would say, when it comes to teleradiology, don’t settle for the cheapest. Definitely do the research. Get in writing the turnaround times you expect. That was the biggest pitfall that I had. There was nothing to hold them to, and we were in it for a lot of money.” With the current provider, he says, the turnaround for routine cases is 24 hours, with 12 hours for expedited cases, 30 minutes for stat cases, and 20 minutes for hyperacute problems. Moreover, Kellum says, the current provider offers subspecialty service, which is a huge plus for a small hospital like Syringa Hospital and Clinic. The teleradiology-only model does have drawbacks. “Because we have no radiologist, we’re not doing biopsies or interventional procedures,” Kellum says. “We are working on the possibility of doing breast biopsies with ultrasound, and CT-guided biopsies, by contracting with an area radiologist. That is still in the very early stages, but it has the potential to bring in revenue.” Rural Minnesota The Murray County Medical Center in Slayton, Minnesota, might be about as rural a setting as there is for a hospital. “Our town has 2,500 people, and we’re in the only county in the state of Minnesota that does not have a stoplight,” Sandy Stokesbary, RT(R), says. Nonetheless, Murray County Medical Center, which has 16 beds, operates its emergency department 24/7. “It’s surprisingly busy,” Stokesbary says. “It can be anything: a car wreck, a domestic case the police bring in, chemical abuse, a baby who spikes a fever, or someone who falls at the nursing home. The elderly also get frightened at night if they can’t breathe well.” Stokesbary is Murray County Medical Center’s radiology manager. She says that the hospital offers 24/7 care as a service to the community. “It’s a critical-access facility, so it has to,” she adds. The medical center relies on teleradiologists for interpretation. There are no radiologists on staff. A mobile nuclear-medicine unit comes periodically in conjunction with the visits of a local cardiologist, Stokesbary says; the unit’s images are sent to Sanford Health, a hospital in nearby Sioux Falls, South Dakota, for interpretation. Images from the mobile MRI service that comes twice a week, as well as from a mobile ultrasound unit, are transmitted to Murray County Medical Center’s PACS. From there, they go to the teleradiologists, Stokesbary says. Murray County Medical Center’s relationship with Sanford Health (one of two large hospitals in the region) involves more than sharing radiology services. Stokesbary says, “Sanford Health gives us access to specialists and group buying power. It’s one of our first directions for advice or referral of patients, but we’re not bound to refer.” Murray County Medical Center has three technologists on staff (including Stokesbary). The hospital also is affiliated with two technologist-training programs, Stokesbary says. The radiology department provides radiography, ultrasound, and CT exams. It is open from 8 am to 5:30 pm on weekdays and on Saturdays from 9 am to noon. The rest of the time, the technologists are on call. “We also have a locum-tenens technologist who does a long weekend for us,” Stokesbary says. “She gives us three nights per month: just enough to keep your sanity.” Biopsies and interventional procedures are referred to Sanford Health or to a hospital in nearby Worthington, Minnesota, Stokesbary adds. All interpretations done by the Murray County Medical Center teleradiologists are final. There is subspecialty interpretation available through the vendor as well, Stokesbary notes. The typical turnaround time is 24 to 36 hours, but emergency interpretations are done in 20 minutes to an hour. “The service is very flexible and tailored to what we need,” Stokesbary says. If a referring physician has questions, a teleradiologist is consulted, she adds. “Yesterday, we had chest imaging done on an inpatient and he was to go to another facility for another procedure. They needed the report on his chest this morning, but they didn’t have it, so we called the teleradiology vendor. They changed it to stat and I had the report in half an hour. You have a person you can talk to,” Stokesbary says. She notes that the payment arrangement with the teleradiology service gets complicated because the teleradiology vendor itself bills government payors such as Medicare and Medicaid. “Everything else, our billing office bills for,” she says. For studies for which the hospital bills the professional fee, the teleradiology service is reimbursed on a fee-per-study basis, she says. She says that the teleradiology arrangement has worked well for the hospital during the year that it has been in place. “The teleradiologists were really helpful during the training period, and they have very patient and excellent customer service. They’re on top of it,” Stokesbary adds. A rural hospital is not like a large institution, where everyone has a defined role, Stokesbary notes, and the broader roles of employees include the provision of 24/7 services. If a patient needs lifting, a technologist might have to pitch in, for example. “You can’t be a stinker and be well received in a small hospital,” she says. “We’re an interdepartmental team. That is key; it’s the golden rule, really.” Urban Washington Kennewick and its sister cities, Pasco and Richland, lie at the confluence of the Snake and Columbia rivers in south central Washington. Together, according to Trevor Smith, director of medical staff services at Kennewick General Hospital, the three cities contain about 250,000 people, making them the fastest-growing area in the state. Every month, about 2,500 of these residents show up in Kennewick General Hospital’s radiology department for diagnostic exams. Kennewick is a not-for-profit facility administered through a hospital district with an elected board of directors, Smith says. It receives taxpayer support. It is licensed for 101 beds, and plans for a second hospital are in the works. Kennewick General Hospital also operates a mammography clinic and an outpatient imaging center off-site, but only during the daytime, Smith adds. To meet the needs of its patients, the hospital contracts with a local radiology group to keep four radiologists on staff, Smith says. For its 24/7 coverage and as a supplement during busy times of day, the hospital relies on a teleradiology provider, which it has been doing for the past five years. The teleradiologists do preliminary interpretations only. Final reports are issued the next day by the Kennewick General Hospital staff radiologists. During the off hours, a staff radiologist is on call. Smith says that the teleradiology provider is paid by the radiology group, which bills for professional fees. When the dual-service arrangement of both staff radiologists and teleradiologists was first proposed, Smith says, physicians at Kennewick General Hospital were skeptical. “They wanted to make sure there was shoulder-to-shoulder contact with the radiologists and that the teleradiology was secondary. With the support of the medical staff, we were able to give it a preliminary run, and it has since done quite nicely.” Smith says that the hospital’s emergency department is busy, and that following best practices has been key to its success. The 24/7 coverage, she adds, “is enhancing our service line.” Turnaround times for the teleradiologists, she says, are less than 30 minutes. If biopsies or interventional procedures are needed at night, the on-call radiologist will come in, she adds. In fact, she calls collaboration between the staff radiologists and the teleradiologists an important factor in providing 24/7 imaging. “It’s not detached at all, and I would encourage others to look at that,” she says. “That’s been a nice branch of our service. It’s essential for a high level of patient care.” Collaboration throughout is what makes 24/7 imaging work, Smith says. “In order to be successful, all parts of the organization need to be on board with the model. They weren’t on board initially, but the dual-service combination sets us apart and continues to,” she says. “We have now had buy in from the stakeholders.” Urban New Jersey LibertyHealth provides health services through two New Jersey hospitals across the Hudson River from New York City. Jersey City Medical Center is on a 15-acre campus overlooking Statue of Liberty Park and Meadowlands Hospital is 10 minutes from the Lincoln Tunnel. Edward K. Poon, MD, is chair of the radiology department at LibertyHealth and oversees imaging at both hospitals. According to Poon, the two hospitals have a combined capacity of about 350 beds. Poon says that 75% of the imaging is interpreted at Jersey City Medical Center, which is a level II trauma center and a teaching affiliate of the Mt. Sinai School of Medicine. Meadowlands features all private rooms and holds ACR accreditation in mammography, CT, MRI, and ultrasound. Poon says that volume at the two hospitals is about 150,000 imaging studies per year. To interpret them, the hospitals contract with Jersey Liberty Radiology, a 10-person practice. Both hospitals share a centralized PACS, Poon adds. From 11 pm to 7 am, imaging studies are read by a contracted teleradiology group. The teleradiologists essentially are used to cover the emergency departments. Emergency traffic makes up 95% of the night work, Poon says. Poon notes that the teleradiology provider bills by the case. “It’s mainly for the radiologists, now, that we have to provide 24/7 service,” he says. “The coverage is not needed to the point where we would ask one of our own staff to stay up all night. There’s not enough work to have one person stay up all night.” The staff radiologists are assigned on-call duty, and interventionalists have a separate on-call schedule to provide services 24/7, Poon says. Within 30 minutes of receiving studies, the teleradiologists do preliminary reports, which the staff radiologists overread. The reports are downloaded from the Internet to the night physicians and nurses, Poon says. “The technologists can call, or the teleradiologists can call them,” he adds. “For the emergency-department physicians or referrers, it’s pretty smooth; the quality is good.” The hospitals are glad to have the night service, Poon says. “This is something that they like. The feeling is mutual.” Poon offers insight on teleradiology-vendor selection, saying, “We didn’t want a very large group, and we didn’t want a very small group.” In either case, quality could suffer, Poon says, perhaps because the large group would be too bureaucratic and the small group would be unable to meet demand surges. “We went with a medium-sized group,” he says. “It’s turned out to work very well for us.” Remote California Barstow, California, sits on the high desert midway between Los Angeles and Las Vegas. Barstow Community Hospital has 34 physicians on staff, is licensed for 56 beds, and has 250 employees. It’s too big to be rural and too isolated to be urban. Jack Johnson, PhD, is radiology director and director of outpatient services at the hospital. He contracts with a three-person radiology group that staffs the hospital. Modalities provided include CT, MRI, radiography, nuclear medicine, ultrasound, mammography, and bone densitometry. From 5 pm to 7 am and on weekends, Johnson says, Barstow Community Hospital relies on a teleradiology service. The teleradiologists do final interpretations, including subspecialty services, and bill by the study. “The hospital agrees to pay for the service,” Johnson says. He reports that between 60,000 and 70,000 studies are conducted annually, and 30% of those are handled through teleradiology. Only rarely do the teleradiologists read MRI exams. Those studies are sent to a different teleradiologist (a physician friend with outstanding skills), Johnson says. He estimates that the hospital does 15 to 20 MRI studies per week. Imaging studies go directly from the modality to radiology workstations at the hospital. At night, studies are transmitted using a virtual private network to the teleradiology service. Barstow Community Hospital also has an online mini-PACS that the teleradiologists can log into if needed, Johnson says. For critical findings, the teleradiologists consult directly with Barstow Community Hospital’s emergency-department physicians, Johnson says. The hospital does not have an in-house PACS. Instead, Johnson himself has designed a system of servers that he describes as a colocated PACS. He says that he built the system with off-the-shelf technology for about $1,500. “The archive is backed up three times, twice off-site and once on-site,” he says. “That eliminates the cost of a total PACS. I have found it to be more streamlined, cost effective, and secure.” The colocated PACS is only for use by referring physicians, Johnson notes, but from it, the referrers can access images and reports or listen to dictated reports. Johnson says that the teleradiologists the Barstow hospital uses, for the most part, have final reports back within 30 minutes. He notes that Barstow lies at the junction of two major interstate highways and that, as a result, the hospital gets lots of accident cases. Patients who can’t be handled at Barstow are sent by helicopter to a hospital east of Los Angeles. “By the time the patient arrives, the PACS in Loma Linda has our study and the report,” Johnson says. Johnson says that from a financial point of view, the 24/7 coverage that the hospital offers does no more than break even. “With uncompensated cases, we take our hits like everybody. The teleradiologists get paid, regardless,” he says. “There’s no money being made. The intent is not to make money. We like to provide the service.” Service is the focus of all hospitals, large and small, when they provide 24/7 imaging, no matter how they accomplish it. Service keeps patients returning, keeps physicians referring patients, and keeps caregivers along the whole spectrum employed. For hospitals of all sizes, 24/7 radiology has become the new norm. Teleradiology providers have made this happen with offerings that are both flexible and capable, with subspecialty reporting being part of the new norm, too. George Wiley is a contributing writer for Radiology Business Journal.