Examine | Teleradiology: Country-Time Teleradiology

Expanding access to quality healthcare in rural America

For the approximately 60 million residents who live in rural communities throughout the United States, accessing quality healthcare can be challenging.

Major advances in technology are helping to alleviate the inequities in healthcare caused by geography. For example, telemedicine enables rural facilities to take advantage of the skills and knowledge of medical professionals in other locations – even more so now that feasibility has increased significantly as the cost of equipment and bandwidth has fallen.

Teleradiology is one of the most widely used forms of telemedicine and can bring rapid access to subspecialty radiologists capable of reading the most advanced imaging studies to rural community hospitals – many of which have no night coverage for emergency departments, or even worse, no local radiology resources at all.

Despite the fact that more than one-fifth of the population lives in rural communities, they suffer from a lack of diverse providers – only 10 percent of physicians practice in those areas, and there are half as many specialists per 100,000 people compared with urban communities. One reason medical professionals are scarcer in these areas is due to a higher retirement rate among doctors and new graduates preferring larger urban communities. Recruitment and retention continue to pose a challenge.

As a result, residents in rural areas may have to travel hours to an urban area to receive specialized healthcare, which means time away from their families and jobs. Many members of rural communities are farmers, so time away from home can mean less income for them. Furthermore, inclement weather in certain parts of the country – for example, snowstorms in the Midwest – can result in a patient not accessing care at all. 

Expanding access to high quality healthcare is a key tenet of current healthcare reform mandates, and telemedicine, specifically teleradiology, is a critical component to the future of quality healthcare in rural America.

Dakota Imaging LLC is based in Aberdeen, S.D. The closest major metro areas are Fargo, N.D., and Sioux Falls, S.D., both of which are about three hours away. There are very few radiologists in South Dakota – only 70 to cover more than 75,000 square miles – and the majority of them are located in the three largest cities. Many of Dakota Imaging’s seven radiologists – two of whom are part-time – relocated to the area during a major targeted recruiting effort in the mid-1990s when the largest hospital in the area found itself suddenly with no radiology resources. 

The practice provides service for a total of 14 medical facilities and performs approximately 90,000 exams every year.  Dakota Imaging uses Avera St. Luke’s Hospital in Aberdeen as a base, and the other 13 facilities it services are spread across a two-hour, 100-mile geographical area.  


The Digital Age Improves the Delivery of Care

When the current partners first started practicing in Aberdeen, they would try to reach as many of the outreach hospitals as possible. Each day, one of the radiologists would take one of several different routes around the coverage area, sometimes spending four to five hours driving. It was terribly inefficient and difficult to cover such a wide geographical net.

In addition, each day at 3 p.m., multiple couriers from the outreach hospitals would arrive at Avera St. Luke’s and literally drop off bags and bags of films. The radiologists on duty would switch into rapid gear mode and read films as fast as possible. The reports were typed up overnight, and the first radiologist to arrive in the morning would sign all of them – sometimes a couple of hundred – before the couriers would pick them up and deliver them back to the hospitals. As a result, turnaround times could be 48 hours.

Since then, significant advances in technology, along with government grants, have enabled the majority of the facilities to digitize their systems and install PACS, as well as film scanners and eventually advanced imaging equipment such as CT and ultrasound. The outreach hospitals then began sending images digitally to Dakota Imaging, allowing the radiologists to more quickly provide reports, as well as to spread the imaging volume out over the whole day.  Turnaround times went from 48 hours to 24 hours to 30 minutes in many cases.


Stretched Too Thin as Volume Increases

Over a period of several years, Dakota Imaging grew and evolved, and became so busy that the radiologists found it difficult to maintain a healthy work-life balance. Being on call for the Avera St. Luke’s emergency room was manageable, but as the outreach hospital sites began producing more and more complicated studies, such as CTs and ultrasounds, the off-hours volume for Dakota Imaging began to rise significantly. The radiologist on call was getting woken up more frequently, often staying up all night and then working a full shift the next day.

The volume was becoming too much for the six full-time radiologists, and recruiting additional radiologists to work in rural South Dakota was a major problem. New radiologists coming out of residency and fellowship programs located in metropolitan areas want to stay in metropolitan areas, especially the young radiologists. 

The breaking point came when one of the radiologists found himself with 26 CTs to read after midnight with a busy next morning looming ahead. The partners realized this was contributing to a less-than-desirable work environment and decided to partner with a teleradiology services provider. The practice evaluated multiple national teleradiology providers, eventually signing on with Eden Prairie, Minn.-based Virtual Radiologic (vRad) in January 2008.

vRad provides nighttime coverage every night of the week for Avera St. Luke’s, as well as to 10 of the outreach hospitals. Rather than fighting the nighttime coverage issue, Dakota Imaging has been able to keep the group the same size without having to worry about recruiting additional partners to handle the volume. They also have the peace of mind that patients even in their smallest, most rural hospitals are receiving high-quality reports delivered in the quick turnaround times (average is less than 20 minutes) necessary to deliver care.


Around-the-Clock Specialty Care

In the past, rural facilities would read their own studies because that was the only option, especially at night. Even after systems were digitized, a lot of the smaller hospitals Dakota Imaging services were still being staffed by local family practitioners during the night who had enough knowledge to read the plain films and simple CTs.

Now with vRad available to provide the interpretations, these local family practitioners can stay at home for much-needed sleep and have a nurse practitioner or physician assistant handle the cases. This has provided some of the rural hospitals more freedom with their staffing needs and allowed them additional budget flexibility. Having robust nighttime radiology coverage is also a significant positive for these community hospitals in recruiting additional staff, as the family practitioners do not have to be on call all the time. 

Because teleradiology enables rural facilities to utilize the skills and knowledge of radiologists in other locations, nighttime emergency department patients at Dakota Imaging’s outreach hospitals have access to more subspecialty expertise than they otherwise would.

With a large teleradiology provider such as vRad, these rural patients, depending on the time, have access to 30 to 65 radiologists – the majority of whom are subspecialty trained – every single night. A victim of a car accident at 2 a.m. on a rural road in South Dakota where the next major town is two hours away can have their brain CT scan read within 18 minutes by a neuroradiologist sitting in San Diego – a scenario unheard of 10 years ago.


Bottom Line: Improved Patient Care

The bottom line: if a patient has an accident or is experiencing some other sort of trauma and does not have access to relatively quick imaging, patient care can be significantly impacted. In rural South Dakota, the next town may be two hours away – so advances in technology have resulted in an amazing improvement in the level of patient care Dakota Imaging can provide to rural communities.

And in the face of increasing imaging volume and recruiting challenges, partnering with a teleradiology services provider that delivers consistent, quality patient care with quick response times anywhere at anytime is crucial. It provides Dakota Imaging’s radiologists an improved work-life balance and the ability to focus on current business and possibly add additional rural medical facilities – without increasing the size of the practice. 
 
References
National Rural Health Association, “What’s Different about Rural Healthcare?”, www.ruralhealthweb.org

Physician Characteristics and Distribution in the U.S., American Medical Association, Pg. 137, 2008

– Stephen Peters, MD, is president of Dakota Imaging LLC in Aberdeen, S.D. Direct questions and comments to editorial@rt-image.com.