Frank Seidelmann, DO, is co-founder, CEO and the force driving the success of Franklin & Seidelmann Subspecialty Radiology, Beachwood, Ohio. He ensures the company and radiologists stay on the cutting-edge of advanced modality and interpretation trends. Seidelmann brings a wealth of experience in radiology with subspecialty expertise in MRI and neuroradiology. With more than 15 years' experience in interpreting MRI cases and functions as a consultant on difficult cases for radiologists and clinicians around the country, he has lectured on MRI, both nationally and internationally

RT Image: There seems to be a lack of understanding about subspecialty radiology. Can you explain what subspecialty radiology means today, and how it is improving healthcare?

Frank Seidelmann: The field of radiology has dramatically expanded its information knowledge base and imaging capabilities with the advent of MRI, multi-detector CT and PET\CT. The advanced imaging capabilities of these modalities now provide the ability to image patients to the molecular level. As imaging modalities have expanded the capabilities of demonstrating disease processes, the necessary information to become a subspecialist has increased significantly. At the same time, the areas of subspecialization have narrowed, developing what we call "hyper-subspecialists."

Neuroradiologists have progressed from using angiography, myelography and CT as their primary tool, to using MRI imaging with advanced pulse sequences, including diffusion, perfusion, spectroscopy and functional imaging. Neuroradiologists are also now specialized in brain, head and neck and spine imaging. MRI has expanded the information content to be a musculoskeletal radiologist.

Prior to the advent of MRI, radiologists specializing in orthopedic radiology used plain film X-rays and arthrograms as their primary tools. The field of orthopedic imaging (musculoskeletal imaging) progressed from primarily the imaging of osseous structures, and indirect imaging of articular joint spaces, to direct imaging of soft tissue processes including muscles, tendons and ligamentous structures, with direct visualization of hyaline and fibrocartilaginous structures. Musculoskeletal radiologists are also now becoming hyper-subspecialists of specific anatomic areas and joints. These hyper-subspecialty musculoskeletal radiologists have greater specific expertise in shoulder, elbow, wrist, hip, knee and ankle/foot imaging.

Other examples of modalities that are driving the need for subspecialty radiologists include multi-detector CT imaging and PET/CT. CT is leading the way in fields of cardiac imaging, including cardiac angiography, other vascular imaging and virtual colonoscopy, and PET\CT has expanded our capabilities in oncological radiology.

Clinicians are now demanding precise, in-depth content in their reports in order to provide definitive and precise information to better manage their patients. In order to fulfill the needs of clinicians, radiologists are becoming hyper-subspecialists, with in-depth knowledge, combined with the experience of reading thousands of cases of a specific area of the body. Subspecialty radiology is improving healthcare by providing more definitive and accurate interpretations which result in improved patient care and medical outcomes, as well as reducing overall healthcare costs, helping to minimize malpractice risk and reducing the need for second opinions and over-reads.

RT: What factors have driven radiologists to subspecialize?

Seidelmann: There are three main drivers behind the growing need for subspecialty radiologists.

The first driver is modality advancements. In the early days of radiology, imaging was limited to X-rays, which were enhanced by contrast administration. These were the days of "bone and barium" and angiography. In the mid-1970s, however, the advent of computer technology, coupled with X-rays with computer technology, produced cross-sectional imaging provided by CT.

The mid-70s also saw the advent of ultrasonography, again providing cross-sectional imaging. Also in the 1970s, prior to the advent of CT, there were vast areas of the body that could not be adequately imaged, including the brain, soft tissue structures of the head and neck and areas of the chest, including the mediastinum and hilum. Radiologists were limited in their ability to evaluate abdominal organs and retroperitoneum, including retroperitoneal lymph nodes. Radiologists had no role in imaging of soft tissue structures of the extremities.

The development of MRI technology and ultrasonography required radiologists to greatly expand their knowledge base in anatomy and pathologic processes. The revolutionary development of multi-detector CT continues to expand the capabilities of the radiologist, while correspondingly increasing the amount of knowledge and experience necessary to be a true subspecialist. The knowledge base of anatomy, pathophysiology and biochemistry, coupled with the ever-increasing imaging capabilities of these modalities is requiring radiologists to increasingly narrow their area of expertise, while expanding their knowledge in their specific subspecialty area, creating the need for "hyper-subspecialists."

A second factor is the change in how healthcare has been delivered in the 1980s and leading into the 1990s. In the 1970s and in the early 1980s, radiology was limited to hospital settings. The advent of MRI spawned the development of diagnostic outpatient imaging centers by entrepreneurial owners and created a new market segment for diagnostic services. Innovation and new medical imaging modalities will continue to drive new market segments and the need for "hyper-subspecialists."

Finally, clinician interpretation requirements are increasingly demanding. Healthcare facilities are becoming highly competitive, seeking out referrals from clinical specialists. A healthcare facility no longer necessarily differentiates itself merely by the technology, but rather by coupling technology with detailed reports, answering the clinical questions of the specialists.

Healthcare facilities are now driven to compete for hyper-subspecialized clinicians including neurosurgeons, head and neck surgeons, spine surgeons, neurologist, rheumatologists, orthopedists with specific areas of subspecialty expertise, oncologists, podiatrists and chiropractors. Radiologists will find themselves in a turf battle with cardiologists and gastroenterologists providing reports to primary care physicians. If radiologists do not or cannot keep up with the increasing demands for subspecialty interpretations, clinicians will be forced to compete with radiologists in providing interpretations.

RT: What does it take to be a subspecialty radiology expert?

Seidelmann: A radiologist should have a certification by the American Board of Radiology or the American Board of Osteopathic Radiology. Radiologists then complete a fellowship in the area of subspecialty expertise. Certain areas of subspecialty expertise are eligible for certificate of added qualifications.

Advanced training, however, also needs to be coupled with experience. To be a true "hyper-subspecialist" a radiologist needs to combine academic and training experience, with experience of reading a high number of cases in a narrowed area of expertise. High-end modalities, such as 3.0 Tesla MRIs and multi-detector CT imaging, are requiring additional training and experience. Gaining "hyper-subspecialty expertise" means reading thousands of cases per year in a very narrow area of subspecialty information.

RT: What differentiates your practice vs. other teleradiology groups, and what are the value-added benefits of engaging Franklin & Seidelmann's network of subspecialty radiologists?

Seidelmann: We consider ourselves a virtual subspecialty radiology group that uses teleradiology as a means to distribute information, images and reports from clinicians to the radiologists with the appropriate expertise. Teleradiology does not define who we are, but is a tool or system that allows us to distribute studies to the appropriate radiologists throughout the United States. The differentiation that sets Franklin & Seidelmann (F&S) apart is the ability to develop and provide "hyper-subspecialists." It is the ability of F&S to provide a high volume of cases in a specific area of interest to the radiologist, which maintains their level of expertise.

We have a number of key differentiators, such as a virtual network made up entirely of dedicated, experienced, subspecialty radiologists (i.e., musculoskeletal, neuroradiologists, body, PET, etc.), with a narrow and deep focus of expertise, providing detailed interpretations that meet the needs of today's demanding specialized clinicians. F&S radiologists "speak the language" of clinicians, are highly accessible for consultation and peer collaboration, thus providing a "team approach" to medicine. Our clients receive a subspecialty radiology report every time.

F&S also maintains a high level of quality and consistency across interpretations through training, education and utilization of a standard internally developed lexicon that provides the direction for report format, terminology, depth of clinical focus, etc., and a rigorous quality control process.

Each radiologist interprets between 12,000 and 16,000 studies annually in their area of specialization, enabling them to continually build upon their existing level of expertise. Although there are no clear statistics available, most general radiologists read in the range of 1,000 to 3,000 subspecialty studies annually.

In addition to these differentiators, we have a sophisticated, secure, scaleable radiology workflow system called AccuRad™ developed specifically for F&S to ensure fast distribution of information, images and reports between clients, radiologists and referrers. Clients may receive their reports via automated fax or encrypted Web URL. Referrers may also receive automated fax report delivery directly. Our value-added services include modality selection and protocol development consultation, credentialing assistance, a client support call center and information technology and marketing support. We prefer to help our clients with all aspects of their imaging business if we can, because if they are successful, then so are we.

RT: What makes delivering virtual subspecialty radiology expertise difficult, and how have you overcome the challenges?

Seidelmann: There are three key requirements for a virtual subspecialty business model: 1) finding qualified subspecialty radiology experts, 2) getting multi-state licenses, and 3) developing the appropriate operational and technology infrastructure and support organization to distribute information and images.

We have been fortunate to attract the leading subspecialists of our profession who we have found typically through referrals. Since the subspecialty expert is really the differentiating factor and the hardest individual to find, we believe in moving the images to the expert rather than moving the expert to where the images are. This is why our radiology workflow system is critical. Using a combination of RIS, PACS, dictation and manual workflow processes, we are able to systematically create a routing process by which the work is matched up to the appropriate radiologist based on licensing, area of expertise and availability.

We have made significant investments in staffing and infrastructure to improve the speed, scalability and reliability of image transmission, as well as in credentialing software, client support software and Internet-based phone systems and communication tools. In short, our entire infrastructure is designed to accelerate report turnaround and communication processes.

RT: How can all imaging service providers utilize subspecialty teleradiology?

Seidelmann: An imaging service provider can choose to use F&S subspecialty interpretation services on demand (pay-per-study only when needed), for a specific modality or type of study (i.e., spine studies), or for subspecialty vacation coverage, or to handle all of their subspecialty interpretations. If an imaging center is targeting a new physician group, such as neurosurgeons, and doesn't have enough volume to merit paying for a full-time, on-staff neuroradiologist, the center can utilize the Franklin & Seidelmann network to cost-effectively build this physician base.

RT: Why should your clients utilize subspecialty interpretations as a marketing tool?

Seidelmann: For the most part, everyone now has the same modalities and the same patient-related services. The only competitive differentiator left is in the quality of the report, which is a direct result of the expertise of the radiologist. Subspecialty interpretations are a great way to target new referrals. For example, podiatrists can be targeted with MR subspecialty interpretations of the foot/ankle.

Ways in which you can target new physicians is by asking them what level of clinical details they require from their radiology interpretations. Let them know what your radiologists are capable of providing. Show them sample reports. Offer to do comparison reports at no charge to get their referrals. Have your subspecialty radiologists do a lecture for the physicians to explain the benefits of your reports. These are the compelling reasons to engage a subspecialist.

RT: What challenges do radiologists face today?

Seidelmann: The toughest challenge is keeping up with the necessary education required to meet clinicians' interpretation demands and new modality applications. Radiologists need continual education and must have the ability to "talk the same talk" and be collaborative with clinicians. Otherwise, the clinicians will continue to do their own interpretations, not primarily with the goal of generating new imaging service revenue, but because they cannot get the reports they need from radiologists.

RT: How do you attract and retain subspecialty radiologists?

Seidelmann: We find subspecialty experts by word of mouth and through the American College of Radiology Web site. Our radiologists go through an extensive evaluation before we determine if they are a good fit with Franklin & Seidelmann Subspecialty Radiology.

What attracts and retains F&S radiologists is the chance to work with a leading team of experts who are highly collaborative with each other, and each receives a high volume of quality studies in order for them to build upon their expertise and earn appropriate compensation.

Additionally, they get to live anywhere they want in the United States, and we provide them with job security, a dynamic support organization and technology and operational infrastructure. The subspecialty expert role is very gratifying knowing you are an expert at something. This allows you to do the job better and faster and have fewer worries about malpractice.

RT: How has teleradiology changed over the years, and where do you think subspecialty teleradiology is headed?

Seidelmann: With the advances in RIS/PACS technology and reduction in broadband costs, more radiologists are able to distribute images, information and reports. This is enabling many individuals to start teleradiology practices. The challenges they will run into are the operations and support infrastructure development.

Radiology reading strategies are changing. What is evolving is a three-legged approach, in order to offer the most effective reading strategy tailored to the imaging providers' needs. It is a combination of radiology interpretation providers. The first leg is the on-site general radiologist to handle injections, X-rays, ultrasound, CT and some subspecialty reports that will amount to 70 percent of the cases. The next leg is made up of "hyper-subspecialty" experts (by modality/body part) needed to support specific clinicians who will typically operate virtually and will make up about 20 percent of the report volume. The third leg is the traditional teleradiology or nighthawk providers to handle the night time/emergency reads for about 10 percent of the volume.

The shortage of radiologists is going to continue, and the demand for subspecialists is even greater. The use of teleradiology systems to transmit the work to where the hard-to-find subspecialists are located will increase and these systems will continue to decrease in cost and to improve in quality. The subspecialist is the focal point and systems should support the distribution process. Various communication tools will also help radiologists and clinicians collaborate more effectively (i.e., instant messaging, VoIP, Skype, etc.).

— RT Image