24/7 Coverage: The New Norm

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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: