What’s Next for Teleradiology?

Author’s Note: I am honored to have been asked to comment on some of today’s key teleradiology issues. I hope you will find this useful in supporting some of your own observations and concerns regarding the industry.

I welcome supporting and opposing viewpoints, as they lead to reexamination of principles – which I believe is a worthwhile exercise. I hope this generates discussion among all participants in teleradiology so we can play our parts in preserving the greatness of radiology as teleradiology matures.


Teleradiology is the natural extension of radiology in the industrial age, and the  Internet has given it legs. There has been uncontrolled growth, and this has raised serious questions and concerns in a variety of areas. In a most general sense, how do we carry the good of the past into the good of the future?

While this is business, it is still medicine, and that means doing the right thing for the patient, something we all agreed to back in medical school. What will we, as founding fathers of this remarkable technology, do to navigate the teleradiology journey so we may stabilize this specialty for the next generation of radiologists, clinicians, administrators, and patients?

With all this power comes responsibility. Will we promulgate the importance of quality teleradiology to continue to motivate top-quality medical students to pursue this art? Or, will we self-engineer the demise of the overall payout through commoditization and disregard for quality?

Quality

There is no doubt about it: The need for teleradiology is on the rise, and we radiologists, clinicians, and administrators have a responsibility to shepherd it forward in a fashion that preserves its greatness and serves the patient.

As the shortage of radiologists worsens, there will be a continued increase in the need for quality coverage to fill the gaps. (See sidebar.) We are routinely approached by those needing teleradiology services who say it’s all about the price. Commonly heard phrases include, “You’re all basically the same, and we’re just looking for the lowest price,” and “Teleradiology is a commodity.”

Let’s get something straight. If we choose to use the word “commodity” correctly, then teleradiology is not a commodity because radiologists have a spectrum of skills and accuracy that impacts patient care and, indirectly, the reputation of those associated with this care.

Therefore, the teleradiology providers do not provide the same product everywhere and, as such, teleradiology is improperly termed a commodity. To label it as a commodity is to be dismissive or ignorant of the impact of good over bad radiology (or, perhaps, just ignorant of the definition of “commodity.”)

I hope you or your family or friends don’t need radiology at a hospital that chose their teleradiology group on price alone! The Deficit Reduction Act (DRA) took our money, but it didn’t take our reason or compassion. Patients still need quality care, and we should continue to provide the same level of care despite the current Dow Jones Average.

I caution onsite radiology groups who are proud of finding the cheapest teleradiology service against sharing this with their administration. If the administration hears your testimony that radiology is all the same and all that matters is getting the lowest price, is it a leap of logic for them to start reevaluating your cost?

Choosing quality over price makes sound business sense anyway. Most of the services’ fees only differ by about 10 percent. By choosing a cheap and lower-quality service where the radiologists rush through their studies to make up for their lower fees, they arguably incur more errors, including serious ones.

How long will it take for you to get your fee savings and reputation back with the additional unnecessary lawsuits and patient injuries due to employing a lower-quality service? How long will it take that patient to get vision back in that eye? “But Your Honor, they charged $2 less per CT than a quality provider!” Tell that to the family (or your own? or yourself?).

Every time you dictate a quality report or you select a quality teleradiology group, you support quality medicine.

There are a number of class acts out there doing quality work. Pick one, pay the extra 2 percent, join humanity, and kiss your mother with that mouth.

Competition

New teleradiology groups keep surfacing. It seems every time I pick up a radiology journal, there’s a new one with a snappy name that uses some permutation of “night”, “rad”, “rays”, “US”, “reads”, or “online.” (We’re NightRays, so we’re included.)

No doubt about it, the competitors are growing in number, but are they growing in competitiveness? What are they offering that the established or larger groups with infrastructure are not?

What do they offer that is actually important to those who have to go through enormous gymnastics to undo their current group, who is likely doing a decent job, and take a chance on the unknown new group and install them from scratch?

During the inquiry process, while some buyers of teleradiology indeed push the myth that all teleradiology service is about the same and the only real differentiator is price, this may be partly how they feel and partly their negotiation threat to urge the quality group to lower prices. They generally won’t consciously hire a service that will drive away business and flood them with lawsuits. 

While there continue to be potential clients who bounce from booth to booth at the Radiological Society of North America’s (RSNA) annual meeting like the flying monkeys in the Wizard of Oz, demanding, “Just tell me what you charge for a prelim CT; I don’t need anything else,” I see a change coming that may significantly adjust this information-gathering process and put the lower quality teleradiology services out of the competition.

A significant faction of the medical community that has to pay for the after-hours service would argue that it’s only a preliminary report and the onsite radiologists can usually clean up the mistakes the next day, so it isn’t important to have quality radiologists at night – just something minimum to cover the service.

This is actually a huge subject by itself, but I’m only covering one aspect of it. After-hours work is slowly migrating from prelims to finals. We are noticing this ourselves from current and new clients.

This has been primarily motivated by local financial and staffing pressures, but the administrators and ER doctors are weighing in regarding workflow and accountability. They want the job done and done right when it is sent, and not be forced to sort out a difference of opinion or “the rest of the details” the next day.

The onsite radiologists don’t want to spend their mornings double-reading CTs for a net few dollars when they could be getting caught up, reading more compensated work, and/or getting out earlier that day. A final read at night must now be a quality read since there’s no more next-day cleanup and the reading teleradiologist must be in the United States to satisfy Medicare restrictions.

Potential teleradiology clients can allow minimum quality at night and will likely have to reconsider quality, United States-based teleradiology providers (Medicare final reads) or else risk increased legal exposure, the wrath of the ER docs, and the potential loss of business due to a loss of confidence by patients.

This migration to finals after-hours should be edifying to the services currently riding out the price war and sticking with a quality approach.

Credentialing

Credentialing: the molasses of teleradiology, and the sometimes insurmountable barrier in convincing a facility to upgrade to a better solution.

Our credentialing and licensing office – God bless them! – deals with this issue daily and are the first to comment regarding interacting with various outside factions that, “at least a bean counter counts one bean after another, not the same bean over and over again.”

But only a few years ago, there was hope. It shone like its golden seal: JCAHO credentialing. Under LD.3.50, an opportunity to confirm a radiologist’s credentials once and for all. They got it. They understood the impossibility of a radiologist to “un-go” to medical school. Confirm primary source verification and be done with it.

But resistance to this process is resurfacing. The Center for Medicare & Medicaid Services (CMS) maintains that teleradiologists, even providing preliminary reads, are providing a “medical level of care” and must be individually credentialed and privileged through the medical staff process and approved by the board of directors.

CMS indicates that compliance with JCAHO’s LD.3.50 is not enough to ensure compliance with the Medicare Conditions of Participation (“COPs”) 42 C.F.R. 482.22. What about the National Practitioner Data Bank as a gold standard for primary-source information?

I wish I could put this issue to bed now but, at this time, we are still in discussion with various governing bodies, and I hope that once all the information is rationally laid out, a satisfactory resolution will appear.

Finals

I discussed previously the migration of prelims after-hours to finals. Are you a teleradiology service interested in this change? You’re thinking, just charge a few dollars more, scratch out “prelim” and crayon in “final?” ‘Fraid not.

The reason is: insurance. This is not a simple process, and if you don’t get it right from the beginning, you may find your unhappy client at the wrong end of the reimbursement stick. The main issue is final teleradiology reads provided by an out-of-state teleradiologist under certain payers.

While asked to comment on this issue, at the time of this publication, the most I can say is that this is indeed a problem and a simple solution does not currently exist. We are in the process of identifying the various providers who are balking at reimbursement for final reads from out-of-state teleradiologists.

We are working on an education process, including a layout of the accepted telemedicine environment in conjunction with the worsening shortage of radiologists for underserved areas or areas having difficultly recruiting onsite radiologists.

Cooperation

As long as there are livers to be stuck, aortas to be squirted, and abscesses to be drained, there will always be a place for the onsite radiologist. I have written before about the importance of teleradiology and onsite groups cooperating.

In addition to the obvious necessity of their physical presence for procedures, there is no substitute for their direct contact with hospital staff and patients. Their concerns are usually ours, too, and these “custodians of the practice” can be critical in lobbying for all radiology interests, such as quality, efficiency, and progress.

Teleradiology is an opportunity to amplify the great radiology performed by onsite radiologists and allow them to focus on their subspecialties and run the practice.

Consider small, rural practices. It is sad to see a radiologist retire and watch a lifetime of wisdom walk out of the hospital; however, it is even sadder for the remainder of the practice who must now begin the arduous task of finding a new radiologist who will work in their rural environment.

There is a worsening shortage of qualified radiologists, especially for rural America. Yet, there is hope for these small practices. Practices with enough onsite radiologists are now considering replacing their retirees with teleradiology. We originally called this the “extra-man” but have gradually come to call it the “X-man.” (See the “X-man Advantage” sidebar.)

There are occasional reports of teleradiology services attempting to “take over” onsite radiology groups. In my experience, these events are quite rare. Instead, what I am seeing are large, regional onsite radiology groups competing with smaller, nearby onsite radiology groups for their small hospital and imaging center contracts.

It would generally be the death of the reputation of a teleradiology company if it were to actually replace an onsite group. I cannot predict what may happen as more after-hours work is performed as finals and more routine work could be shuttled to the after-hours group.

My humble recommendation is to obtain a multipass, sterile biopsy of the integrity of a chosen teleradiology service before hiring them so you know you have someone interested in augmenting – not robbing – you. Work out all the details, including your turf concerns, with the teleradiology group and the hospital administration so it is never an issue. 

Environment

Teleradiology companies with infrastructure are designed to add radiologists and clients together, so why does it seem that every time you turn around, there is a new teleradiology company out there?

Why don’t radiologists just join one of the established companies? I think there is a frequent theme. “We can do it better and/or make more money by creating our own teleradiology service that cuts out the middle man.”

While I applaud the courage of radiologists going out on their own to create these new services and fully support and cheer those that provide quality care, it turns out that the “middle men” are critical service providers, such as technical support, credentialers and licensers, programmers, financial assistants for accounts receivable, and administrative leaders helping to guide the progress of the company and the industry.

Radiology is more than just faxing a report. Clients of teleradiology appreciate these services as they keep things moving smoothly and allow accountability. I believe this is why teleradiology companies with a solid infrastructure and such value-creating “middle men” are growing faster than “Bubba’s Teleradiology.”

The larger companies are finding that investment in all these “middle men” greatly improves the efficiency of the radiologist so they can focus on the tasks best handled by them, namely: dictating cases, discussing challenging cases with clinicians or fellow radiologists, and looking up information on hard cases.

Why force these highly paid experts to fix their own computers, do their own billing, update their Web site, see if their fax went through, and get hammered with technical calls halfway through each dictation when you can pay someone else to do the same for a tenth of the cost?

This reading environment is vehemently protected by those middle men who understand the importance of efficiency and concentration. In fact, the protection of this environment has been a significant draw of teleradiology for the radiologists who want to spend more of their day as an actual radiologist rather than a technician, secretary, computer-repair person or politician.

Let’s talk about the teleradiologist’s environment. These are general statements, and environments differ. Here are a few types of teleradiologist:

Regarding the radiologists who are augmenting their practice with teleradiology, this is most likely driven by two factors: diminishing revenue due to the DRA and interest in diversifying their business.

Groups that do this can be quite attractive to young radiologists coming out of residency or fellowship, since this offers the hospital environment along with the freedom and comfort of teleradiology. The most common environment is the teleradiologist reading from home working in a teleradiology company.

Here are a few items that make this job attractive (remember that some of these items make this job unattractive for others):

Reported negatives include:

Very few radiologists go back to an onsite hospital job, but there is a significant flux of radiologists converting to teleradiology. Now that even “stable” hospital radiology groups are being replaced, teleradiology is becoming the new “stable.”

Recruitment

Teleradiology companies and groups are generally looking for the best fit for their practice, which consists of a laundry list of qualifications other than speed. We find it interesting when a radiologist walks into our RSNA booth and the first thing they ask us – without eye contact – is, “What do you pay?”

What is the cost of a car? They aren’t all worth the same? My humble recommendation to those looking for any job is to start talking about all the great things you bring to and will do for the company and industry, and you will likely score a better salary.

I will now irresponsibly speak for all teleradiology companies when I say that there are many factors in how we choose radiologists. Of course, a radiologist must have the “goods” like accuracy and efficiency, but I would like to address a common misconception that explains why we additionally require our radiologists to be courteous, helpful, and patient.

”Teleradiologists don’t need people skills.”

Well, maybe they don’t have to brush their teeth or use foot powder, but they better have people skills or they will be replaced by those who do. The teleradiologist has limited connection with the facilities for which he provides reads.

There is no onsite daily glad-handing, bread-breaking or eye-to-eye contact. If he gets sideways with a tech, there are no next-day “apology doughnuts.” He cannot physically recruit the hospital staff behind him in times of conflict.

Without an onsite presence, he must endear the facility and all levels of staff to him through his voice on the phone and reports; that’s it! In times of conflict, the onsite perceived offendee is there to state his case to all, while the offsite faceless offender must wait for the verdict without opportunity to testify or even knowledge that he might need to.

Sure, your teleradiologist can read out a SLAP 6 shoulder, but how does he respond when he calls the floor at 2:35 a.m. to report a positive PE, is put on hold for five minutes, gets disconnected twice, no one speaks English, and then the nurse who finally picks up forces him to recite his resume for identification and after finishing with “Hobbies,” tells him to page the service to page another service to page the physician who doesn’t like being woken up?

The moment of truth! His response at this moment can make or break the contract. He needs people skills. Any group or company should be a team. Would the other members of your company or group lie down in traffic for you? Would you do it for them?

If not, each time sacrifice is needed, you may be left hanging – ergo your clients are left hanging, ergo they are no longer your clients. You then lose heart and begin searching for a better solution. Turnover.

A teleradiology service that hires those only interested in their own gain will have radiologists with little concern for others’ gain and will likely not put forth “non-revenue-generating” effort to help the rest of the team. A company (or person) is most commonly measured by how it or they respond when there are problems.

These are the times that are discussed when a reference gives a referral. If you have a team, you will survive those difficult times because members will pitch in to bridge the gap, and you will be lauded by your references for your cooperation; if you have individuals, there will be gaps and dissention, and you will be criticized.

To not end on that note, I suggest that picking personable staff members makes the work of others in the company more fulfilling, builds allegiance, reduces turnover, inspires all to “go the extra mile,” infuses stability, and supports an interest in bettering the art – it also makes company parties more fun.

Future

The most common question I am asked (besides, “How much for a CT prelim?”) is, “What is the future of teleradiology?” Answer: More. More images, more studies, and more types of studies. Here’s my best Nostradamus.

If we just extend the lines on the graph, then it is easy to see there will be more utilization of after-hours, daytime, and subspecialty teleradiology. Report turnarounds will drop as Internet speeds climb and compression algorithms improve.

Reports will become more accurate as radiologists and techs develop more user-friendly tools to share and look up hard cases. There will be advances in technology allowing faster, more reliable, helpful communication and reporting. Worklisting and study monitoring will improve. Health Level 7 messaging will simplify as more facilities move from prelims to finals.

Hardware prices will continue to drop, allowing easier access to improved backup solutions. Ergonomic computer input devices will become more commonplace, allowing the radiologist to work more comfortably and efficiently. OLED monitors are a variable distance away and may allow the creation of easily portable multimonitor workstations.

As teleradiology stabilizes, residency programs may more specifically tailor their curricula to meet the demand for trained teleradiologists. While there will continue to be a growing need for standard fellowship-trained radiologists in such areas as MSK, neuro, and pediatrics, more focused teleradiology-specific or ER teleradiology positions may open.

As groups migrate from prelim to final reads, teleradiology providers will likely migrate to a higher percentage of fellowship-trained radiologists, perhaps even allowing time for currently employed radiologists to complete mini-fellowships.

With continued growing acceptance of teleradiology, more rural groups may begin to staff some of their new positions with a teleradiology group. Credentialing may centralize and simplify, easing the burden of the credentialing process and, therefore, allow more radiologists to be credentialed at a given facility, which will improve acceptance of part-time radiologists.

A national association of teleradiology may surface with teleradiology-specific accreditation standards for all those individuals, groups, or companies wishing to publicly prove out their qualifications. By achieving these various standards, those seeking a teleradiology group can know a particular set of standards has already been determined by a third party.

This association might also include opportunities to confirm primary-source verification, licensing proof, and prior hospital affiliations, in addition to quality standards such as error rates and skill sets.

The hard questions include what will happen regarding billing issues for final reads out of state, credentialing issues, the overall competition in the market regarding fees, mergers and acquisitions of teleradiology companies, and the influence of the new U.S. administration.

This is an exciting time. For those of us concerned about the stability of radiology and teleradiology, I’m sure we all look forward to the day we can just focus on our job activities, instead of job security.


— Greg Rose, MD, PhD, is president, CEO, radiologist, physicist, and system architect of Bellaire, Texas-based NightRays (www.nightrays.com). Direct all questions and comments to editorial@rt-image.com.