Examine | Teleradiology: Viewpoint: Prelim to Final?

Teleradiologists: Remember back in the ‘90s when we would moonlight in little towns on the weekends? Hospitals called us at the local hotel at 2:35 a.m. and we would put on our clothes, schlep down to the elevator, drop in the car, and head over to the hospital.

We’d truly wake up after about two heavy metal songs on the radio – just in time to arrive at the doctor’s parking lot. The radiology tech would identify us by our “bed-head” and guide us through the department to the viewboxes like cows to a vaccination.

For a few minutes, we would stare blankly at the head CT on the viewbox. “Negative. Thank you for this interesting consult.” And with that, we would drive back to the hotel and collapse on the bed like a starfish on a clam until the next call.

We’ve come a long way since then. Things got more organized at the end of the century. Some radiologists with vision saw the utility (and money) in gathering up all these little one, two, and three cases a night and spending their night reading them as prelims.

Most of these groups were handwriting and faxing as fast as they could, since about one-third of the cases were “no active disease” (NAD) head CTs, negative deep vein thrombosis (DVT), or only had one or two findings and required little writing.

Most groups had no real radiology information system (RIS), dictation system, archiving, access to prior images/reports, quality assurance system, or backup, but the money was flying in since prices were high and the deliverables were low, namely “NAD.” While there were indeed some high quality outfits, lower quality was acceptable since, after all, “it’s just a prelim.”

There are three basic types of teleradiology reports:

A number of factors have kept most after-hours reports in the prelim status to this day. These factors are of variable validity, but over the years, there has been an evolution of the industry in the areas of politics, economics, awareness, and technology that have increased the move toward around-the-clock final or pre/fin reports.

Several factors in the industry today – from bias against after-hours radiologists and turf wars, to billing concerns and technical aspects of the read – continue to drive both the use of prelims and the use of finals.

*Stigma about after-hours radiologists

Prelims: The onsite radiologists don’t trust the after-hours reads enough to let them be finals without overreading. There was, and still is, a pervasive stigma about the quality of work done by after-hours radiologists.

I have heard radiologists say, “What kind of a radiologist do you think has to work after hours?” “They do night work because they can’t handle a day job.” “Must be because they don’t get along with people.”

Finals: As more radiologists discover the freedom of working from home, the stigma has all but vanished. In fact, many subspecialized radiologists have found they can do more of what they love by becoming teleradiologists reading their subspecialty from numerous facilities.

Disillusioned by negative hospital experiences, increasing numbers of talented radiologists are exiting the hospitals in droves to sit at home reading cases. The negative stigma about working at night further erodes, and people work swing and partial shifts.

Very few radiologists still work the entire shift of 5 p.m. – 8 a.m. Many families find they get more time together working with this lifestyle – plus day/night shifts can be rotated.

Prelims: The continuity of care issue arises when the number of radiologists reading final cases balloons to the point that clinicians don’t feel familiar with individual radiologists.

Finals: This is an adaptation process as the same number of radiologists are still doing prelims for the ER, while the rest of the hospital clinicians are used to seeing only the final reads from their radiologists. This part of the conversion process is usually not significant, once it is explained that the radiologists are already fully credentialed at the hospital providing reads in the ER.

Prelims: While only a fraction of ER cases have priors of the same body part, the final read should include a comparison with that study. Most vendors were/are not set up to receive these cases.

It has also been suggested by some that for a prelim, a prior comparison is not needed and sending or looking for the prior slows things down. It is not simple to match up priors in a RIS, and some engineering is required on the part of the teleradiology vendor.

Finals: Now that some services are offering reads with a comparison study, the referents are seeing the benefits, and this is motivating more teleradiology services to provide this.

Prelims: While most prelim reports are simply on fax paper, the final reports must somehow get into the hospital’s RIS and this requires some degree of engineering.

Finals: Reports can be faxed into many RIS, but for high volume facilities, this can be time-consuming and a point of failure. An increasing number of teleradiology vendors are providing HL7 messaging, which allows reports to go directly from the teleradiology vendor’s RIS to the client’s RIS.

Prelims: It is much faster to get through a case without a prior. There is no additional fee for comparison to a prior, so it has been traditionally resisted.

Finals: Competition pressures have caused teleradiology groups to begin offering this service. Also, ER doctors love getting final reports throughout the night.

Prelims: If the case is read as a final, some paperwork has to be completed/submitted on behalf of the teleradiologists regarding their physical locations where the case is read.

They must be physically located in the United States for final reads since the payer cannot be reliably sorted out before the case is read. The initiation of this paperwork has been traditionally met with resistance by some hospital credentialers and, therefore, has occasionally been dropped at that point.

Finals: There is growing pressure to push this through the various offices. The resistance to the paperwork is being progressively reduced with discussions of the advantages final reads bring to the facility.

Prelims: There is the sometimes real concern that if the teleradiology group starts doing final reads, they could take over increasingly more final reads.

Finals: These fears are becoming less common as various reputable, long-standing groups continue to operate within the bounds of their agreements without predatory behavior. Non-compete clauses usually appear in contracts involving final reads.

Prelims: Teleradiology groups are engineered to provide rapid turnarounds on reports. For prelims, a 30-minute maximum is expected but these groups can also generate fast final reports, which could cause pressure on the local radiology group to change their level of performance.

Finals: Newer contracts contain language that matches the expectations for the local group.

Prelims: It costs more to get final reads at night than prelims.

Finals: This is not true if you add all the elements; it takes more time to dictate out what is usually about two to four times as much text. There is added exposure now that all the liability is on the teleradiologist, and it takes more time to review and discuss the comparisons.

Also, the clinicians often call the teleradiologist who read the final to go over the case. Because the usual market upcharge for finals versus prelims does not make up for these costs, exposures, and time, most teleradiology vendors just want to do prelims.
 
Indeed, it is a slightly higher charge for the final versus prelim report, but consider this: If the teleradiologist charges an additional $20/CT to do a final instead of a prelim, and you elect to just go with prelims, you are effectively reading those CTs the next day as finals for $20 a piece, taking most of the liability, doing the “go over the case,” and taking time away from other higher paying work you could be doing.

In my opinion, if you ask a teleradiology company to convert to final reads or start out that way – a reputable teleradiology group that operates with integrity, has no hidden competitive agenda, wants to work with you, and preserve your interests – they will come back to you with more than a price list.

They should volunteer discussions about stability of the onsite practice and whether the radiology group is currently concerned about the hospital trying to replace them. The reputable teleradiology vendor would not feel comfortable beginning a relationship that is headed towards the hospital approaching them later to take over the contract.

Instead, they would want to put themselves in alignment with the local radiology group, so that option is not available. If you approach a teleradiology vendor requesting final reads after-hours or even during the day, and they do not volunteer a non-compete clause and ask about the likelihood the hospital will try to approach them for a takeover, then they may be trying to keep their options open.

However, some perfectly honorable teleradiology companies wouldn’t even dream of executing such a plan and therefore not even mention it during negotiations; they may need a little prodding. Various influences are motivating onsite radiology groups to move from prelims to final reads after-hours.

The result of this move is a net financial gain and lower malpractice exposure for the onsite radiology group, increased availability of the onsite radiologists for activities other than over-reading cases, faster average turnarounds for the hospital, higher accountability for the reads done at night, more complete diagnosis of the patients in the ER, and a lower financial gain for the teleradiology vendors depending on how they charge.

— Greg Rose, MD, PhD, is president and CEO of Bellaire, Texas-based NightRays Teleradiology. Questions and comments can be directed to editorial@rt-image.com.