Day for Night, East for West
Teleradiology permeates the specialty as practices cross state, regional, and global boundaries to purchase and practice radiology How did a 2000 lecture tour in China spawn a teleradiology revolution? For William G. Bradley, MD, PhD, FACR, the idea for an international business evolved from a reading that he did nine years ago in the Far East. Thanks to PACS and the Web, Bradley, who is now chair of the radiology department at the University of California, San Diego (UCSD) Medical Center, interpreted an MRI of the brain in China and then called the neurosurgeon in the United States. “It was the middle of the night back in Long Beach, Calif, and the middle of the afternoon in China,” Bradley recalls. “At that point, it occurred to me that with PACS and the Internet, you don’t have to be up at night anymore—which is the worst thing about being a radiologist.” That, he adds, was the genesis of the first after-hours teleradiology coverage provider. After returning from Asia, Bradley mentioned the idea to friend and colleague Paul Berger, MD. With PACS, increased Internet bandwidth, and lossless images fueling the digital transformation, the idea took hold. Berger nurtured the concept, eventually starting a company with a name that became generic in the industry and synonymous with nocturnal radiology. “What we started was simple,” Bradley says. “You moved to Sydney. You moved to Zurich—and you worked during the day.” At present, he reports, 26% of US hospitals are covered by the original company, and 55% of hospitals are covered by one of its 40 competitors. Over time, and through the adoption of PACS, many traditional radiology practices have embraced teleradiology, not just as customers, but as providers of daytime coverage for contracted hospitals and long-distance and after-hours coverage for rural hospitals and small radiology practices. Today, for example, UCSD is not only a client of the original after-hours coverage provider, but is also a purveyor of subspecialty teleradiology services. Each day, UCSD radiologists perform 50 to more than 100 teleradiology interpretations; Bradley expects this service line to generate revenues of $1.5 million in 2009. When taking on a new hospital client, many radiology groups, such as Radiology Consultants of Iowa (RCI) in Cedar Rapids, keep a close eye on the windshield factor, preferring to contract only with hospitals no farther away than a two-hour drive. Kathryn Epley, RCI’s chief administrative officer, presides over the 27-radiologist RCI group and takes pride in the company’s ability to offer both distance readings and on-site services with a personal touch. With the continuing rise of subspecialization, high-end MRI, and interventional procedures, Epley points out, it is tough for small, rural hospitals to retain enough radiologists with all the necessary credentials and skills. The highly dispersed population centers of Iowa mean that RCI primarily deals with critical-access hospitals (of 25 or fewer beds) outside its urban home base. When Epley arrived four years ago, most of those hospitals still had film-based radiology services, and turnaround for routine studies could take days. To make matters worse, radiologists had to spend time traveling to those hospitals to provide on-site coverage, even for studies that could have been interpreted via PACS (if it had been available). With the help of an IT committee of four radiologists and a new CIO, Joe Moore, RCI selected a PACS in 2005 and began visiting outreach hospitals. “The most precious resource we have is the doctors’ time,” Epley says. “For them to be driving to outreach sites is a poor use of their time if they can do that same work in a remote reading room.” Realizing the dream of providing networked, real-time radiology service for all of the contracted outreach hospitals was not easy, but Epley and her staff made steady progress. “Our vision required that those hospitals develop a stronger relationship with us, in terms of trusting us to purchase their PACS through us, which was a real leap of faith,” Epley says. “Since that time in 2005, every one of our 10 outreach hospitals has come onto what we call RCI Net. We provide a completely turnkey digital system because most of these hospitals don’t have the IT infrastructure necessary for PACS. We also provide 24/7 reading within our group because we have radiologists working all three shifts.” With those pieces in place, multislice CT, MRI, digital mammography, and more all became portable. From signed contract to go-live date typically takes about 90 days for RCI, in a feat that it has been able to duplicate many times. When small hospitals did not have the RIS in place to place electronic orders properly, the RCI IT committee worked with a programmer to write a mini RIS that fits the bill. Using voice-recognition software (with the vast majority of reports edited by the radiologists), turnaround time has been dramatically reduced—to minutes, in most cases. So far, Epley has no plans to expand outside Iowa. While she has not specifically avoided crossing the border, she says that there is still plenty to be done within the state. Joseph Racanelli, MD, is president of Radiologic Associates, New Windsor, NY, a 16-radiologist group that covers four hospitals and four imaging centers in New York. Like UCSD, Racanelli’s group uses teleradiology to fill its own gaps while also providing teleradiology services for others. For example, Racanelli contracts with a New York-based after-hours service to handle his group’s overnight readings. “In the beginning, we had to use more radiologists than we needed because we did not use teleradiology,” he says. “That was the big problem in staffing. Some places would be dead quiet and others were getting killed, and having radiologists driving around is not economical.” Radiologic Associates currently offers teleradiology services in the surrounding county up to 35 miles away, under a limitation that is largely in place due to hospital desires. “Most every hospital wants a body on the ground,” Racanelli says. “They like to have somebody sitting there for face time to work with the technologists, but instead of having two or three radiologists there, we send one. The overflow is handled via PACS and teleradiology.” If Racanelli found a potential client that did not require the on-site presence of a radiologist, offering teleradiology services in other states would definitely be a realistic option for the practice. “It would not surprise me if we ended up jumping state lines,” Racanelli says. “More of our business will be handled over the computer, rather than having a radiologist sitting somewhere.” In a change of attitude that is further opening the door to remote practice, Racanelli says that he increasingly is seeing a willingness on the part of clinicians to talk with radiologists by telephone. “We’re at the point where the referring clinicians who used to walk in the door and go over cases are getting comfortable with calling and going over the cases,” Racanelli explains. “I get phone calls all the time asking me to look at a case. The caller is in one place and I’m in another—and it really doesn’t matter where we are, because we can both bring up the case at the same time. That used to be the big thing: somebody had to sit there when the doctors came by, but now, that’s not so much the case.” Regulatory Barriers One other limitation on expansion is state licensing. The good news is that gaining another license is usually just a matter of turning in the paperwork, paying the fee, and waiting the required six to nine months. Beyond marketing services to other areas, gaining the first out-of-state teleradiology client is often a matter of mining old contacts. “The way it works is that you may have a friend from residency in Texas who says that he has some extra work,” Racanelli says. “Even though you may be far away, he may ask if you want to do it, rather than having the hospital two counties away do the extra work.” At RCI, tailoring services to fit each situation is largely a function of geography and mission. In keeping with its strict two-hour–drive policy, RCI provides a medical director for every hospital’s radiology department, and that director attends all the medical staff’s meetings. “There is a lot of teleradiology out there, but those people are distant, and they rarely come on site,” Epley says. “The local physicians don’t know them, and that makes a difference. Our physicians attend the meetings, and they are there with the local referring doctors to answer questions. If we start expanding outside of more than about a two-hour–drive radius, we are going to lose the ability to do that.” Epley foresees a day when RCI could partner with other radiology groups, providing them with the technology that her team has developed and starting a joint venture. She is quick to point out, however, that any such move would have to be nonpredatory. “We don’t want to go into hospitals to boot out the radiologists who are there,” she explains. “That’s not our design. We could provide some top-quality service that they may not be able to provide because we have 27 doctors, the technology, and the culture that makes it all work well.” Pushing the Boundaries While US-trained physicians residing abroad currently perform readings for cases originating in the United States at night, it is still uncommon for US radiologists to interpret exams that originate outside the country. The barrier is mostly reimbursement. Bradley explains that while European radiologists complete training similar to that of US radiologists, they only garner about half of what US doctors would be paid for a typical night reading. Indian physicians get approximately 10% of what US radiologists earn. “It does not really pencil out for us to read for anyone other than the US practices, because they just don’t pay enough,” Bradley says. “Other radiologists around the world are not paid as much as US radiologists, so there is no incentive for us to read at night for them.” Subspecialty daytime teleradiology is another matter. According to Bradley, world-renowned UCSD musculoskeletal radiologist Donald Resnick, MD, gets enough per case from Portugal to make it worthwhile. “I have been doing MRI teleradiology since 1984,” Bradley says. “Initially, it was all MRI. After I moved to UCSD, where everything is subspecialized, I limited my teleradiology to neuroradiology.” Bradley points out that another reason that radiologists trained abroad do not read for US providers is that they do not take the US boards, leaving doubt that they are trained to the same standards. Some countries try to get around such prohibitions through the practice of ghost reading, Bradley says. He explains, “There is a risk, usually addressed to India, that you will have one US-trained radiologist surrounding himself with 10 Indian-trained radiologists, cranking through cases at hundreds an hour” that are actually being read by radiologists without US training or board certification; the cases are then signed by the US-trained radiologist. “The Indian-trained radiologists could be in the United States or in India. That’s called ghost reading, which is illegal. It’s a possibility, and that is one of the inherent risks of teleradiology,” Bradley says. Bradley believes that a dozen US teleradiology entities have sent radiologists to the United Kingdom, France, India, Israel, and Australia. Because final readings for Medicare cases cannot be performed outside the United States, coverage providers outside the country provide so-called wet readings in the middle of the night, and a local radiologist does the final interpretations the following morning. “There is an inherent double reading of every case, which is an opportunity for quality assurance,” Bradley says. “The next morning, the local doctors are rested. They have all the films, including films not sent in the middle of the night (because we’re only concerned with emergency findings). We compare the night reading to the final reading. At UCSD, we have been doing this since we started with night-coverage service. If there is a discrepancy, half the time, the coverage provider is right, and half the time, we are right.” Most radiology groups that use after-hours services have fewer than 10 radiologists, and therefore are not subspecialized. “If they are going to see one pulmonary embolism a month, they might miss it,” Bradley says. “Ideally, the local radiologist would read the case without seeing the wet reading and would then compare his or her reading to the night interpretation. In fact, the local radiologists often know what night service said, so it is not a true comparison of reading capability, but it could be set up that way.” Thanks to several different coverage services throughout the country, the idea of nighttime subspecialty teleradiology coverage has spread rapidly. In Bradley’s opinion, the after-hours market is just about saturated, but there is still opportunity to be found in daytime subspecialty readings. The advantage of daytime readings, he says, is that they can be based in the United States and, therefore, can be final readings. Bradley describes daytime readings as the focus of the new push. He says, “Nighttime is pretty much saturated. There are too many companies competing for the business, and the price is dropping, but if you can get a good subspecialist radiologist to read, you can save yourself. Let’s say that a group needs half of a bone radiologist. Rather than hiring someone like that, who would rather be doing 100% bone radiology, it can hire a subspecialty-coverage company.” Bradley continues, “It will then do the subspecialty readings with fellowship-trained radiologists. I also see this, really, as an opportunity for academic radiologists to get more business—and we can use teleradiology to help train our fellows. We can use it to supplement the cases that our fellows see, so it is a win–win all around.”