When we started in ’97, we were one of the early pioneers in this field,” says Wilson Wong, MD. “Back then, you could count with your hands how many companies were doing teleradiology. Now every Tom, Dick, and Harry is trying to get involved. We don’t know what is going to happen.”

Wong, a radiologist, is founder and president of Teleradiology Diagnostic Service (TDS), an Arcadia, Calif-based company that night reads ED cases for about 65 California hospitals. Wong says he worries not only about competition but about the interpretive quality of teleradiology generally, about susceptibility to lawsuits, and about the huge image volumes from multislice, high-end CTs that leave him scrambling to upgrade his firm’s data transmission capacities.

“We’re pretty well established with most of our clients,” Wong says, “but now the market is getting smaller and smaller. The only way to expand is to go get somebody else’s client…The small [teleradiology] company may have problems. I don’t see us as a small company anymore, so we’re going to be OK.”

So much has night-reading teleradiology taken off, that there is a spillover now from nighthawking, as this nighttime interpretation for a fee is called, into daytime reading. Daytime teleradiology services provide daytime interpretations for radiology groups that are swamped or for hospitals that cannot find radiologists because they are too small or too remote to attract them. The current shortage of radiologists in the United States has helped the teleradiology companies to grow, and nobody seems to question that the teleradiology companies have indeed made a lot of otherwise sleepy on-call radiologists a whole lot happier.

But, as they say, there are issues. And Wong’s short list contains only a few of them.

James Borgstede, MD, is a practicing radiologist in Colorado Springs, Colo. But Borgstede is also chairman of the Board of Chancellors of the American College of Radiology (ACR). From that high-placed chair, he can see the big picture, and, like Wong, he is worried.

Borgstede makes clear when he voices these concerns that he is speaking on behalf of himself, not on behalf of the ACR. The ACR’s essential concern with nighthawking is that the radiologists doing the reads be trained, certified, and licensed at the hospitals they read for.

“I think we are going to see more and more use of teleradiology, and I think there’s going to be a greater and greater temptation to use nighthawk services,” Borgstede says, “but I think we have to be very careful that we don’t commoditize radiology… If we as radiologists endorse after-hours teleradiology services, we become a commodity rather than a consultant, and pretty soon the clinicians will say all you are is interpreters of examinations, you’re not our consultants anymore.”

Furthermore, Borgstede says, nighthawks could easily morph into daytime readers – which they are already doing – and attempt to capture radiology groups’ practices or key segments of them.

“If they could provide the service at night, why couldn’t they provide the service during the dayand why couldn’t the hospital use some sort of mid-level health care provider, a physician’s assistant or a radiology assistant, and just leave the local radiologist out of the picture?” Borgstede asks. “I don’t think that’s optimal patient care.”

Indeed, spokespersons for large nighthawk services interviewed for this story all say they will consider daytime interpretation in those cases where a local radiologist is not available. All insist, however, that they are supercareful not to intrude on the local radiologist’s turf.


Borgstede is also concerned that the globalization that has already occurred with night reading overseas could lead to a more general globalization of interpretation, and perhaps not just by American radiologists. “I think nighthawking is clearly the leading edge of globalization,” he says. “I hope it’s not the leading edge of commoditization.”

Already there are stories that everyone seems to have heard about foreign “ghost readers” who interpret for overseas American radiologists who then sign the reports. Borgstede calls the ghost-reading accounts “all hearsay and innuendo,” but he says such a scenario is not impossible. “In theory, could they be providing ghosted reports? I guess they could, but the College clearly opposes that. You hear rumors, but nobody is going to say they ghost their reports.”

The larger concern, of course, is not the ghost readers of today, if any, but the foreign radiologists of tomorrow who may in a decade or two be reading the imaging studies of American patients routinely. The ultimate commoditization nightmare is one in which images would flow in to some offshore radiological sweatshop where radiologists’ pay would be a fraction of what US doctors charge.

For now, such a scenario is mostly poo-poohed. The barriers against it are significant. Medicare will not pay for examinations interpreted on foreign soil, a factor that forces nighthawk companies that read overseas to restrict their work to preliminary reports.

Another barrier to interpretation ever being done by foreign doctors is the building concern over American patient health information being sent overseas, as mentioned by consultant Pat Kroken.

Kroken, who runs Healthcare Resource Providers out of Albuquerque, NM, says there is no question that foreign entrepreneurs are eyeing the US radiology market and that some would probably offer nighthawk services. But she says there is already a “big hue and cry” over the exportation of patient data involved in billing and coding, a lot of which is done overseas.

“In terms of HIPAA (Health Insurance Portability and Accountability Act), if you’re sending the information over there, you’re the one on the hot seat [if there is misuse],” she says. But she says proposed bills that would ban sending health care information overseas altogether probably will not pass. While the nighthawk services do not have the clout to scuttle the bills, big insurance carriers that use offshore billing and coding services probably do, Kroken says. “The insurance companies will fight because they send tons of private health care information overseas.”

But Kroken says the concern over outsourcing and the fact that US laws may or may not be enforceable in foreign countries will continue as a barrier to non-US certified doctors reading imaging examinations of American patients. “These companies really aren’t using foreign doctors as far as I know,” she says. “That is very controversial. But the hospitals will want the radiologists boarded and licensed in the United States, and referring clinicians will be more resistant. I’m not saying it wouldn’t happen, but if it happens, it will happen with great resistance.”

But other radiology experts say that the pressures of globalization and financial incentives will eventually break down the resistance to foreign doctors doing interpretations on American patients.

William G. Bradley, MD, PhD, FACR, is chairman of the Department of Radiology at the University of California at San Diego (UCSD). He is also a teleradiology pioneer, having been instrumental in the formation of NightHawk Radiology Services, where he is still an academic advisor.

Bradley says foreign entrepreneurs with an eye to foreign ghost reading have approached him. “An Indian talked to me. He said, Send one of your boys over, I’ll make him 10 times more efficient.'”

Bradley says he turned down that proposal. He agrees that the licensing and certification barriers are too significant to allow interpretations by non-US radiologists. “I don’t know of anybody in the United States using foreign readers,” he says. But he says inevitably that will change and the barriers to interpretation by foreign doctors will fall.

“I was a spokesman at the World Congress on Radiology,” he says. “The papers from other countries were the same quality as ours. It’s becoming a single world. We’re just a couple of steps away from [certification] reciprocity. At some point there will be a common Board and world standards.”


The concern enunciated by the ACR’s James Borgstede that teleradiology services might supplant local radiologists, seems to be widespread.

David Estle, MD, is president of Chatham Radiology Group, a seven-man practice in Savannah, Ga. Chatham contracts with a radiology group in Atlanta to cover its night reading at five hospitals. The Atlanta doctors do the preliminary reports, Chatham doctors overread them the next day. Chatham’s relationship with the Atlanta doctors has been good, Estle says, but he says groups like his need to be aware of whom they are dealing with when they make arrangements for night reading.

“Technology is a two-way street,” he says. “You can bring other people in, but if you take that help they can steal your business. The hospitals don’t care. Once you start creating partnerships, other things can happen. Those kinds of things do go on.”


While they are creating concern among their industry brethren, the nighthawking companies seem to be doing a robust business and then some.

“We have been growing by 100% annually,” says Jon Berger, vice president of NightHawk Radiology Services, LLC (NRS). The company is based in Coeur d’Alene, Idaho, but it has a big software support staff in Milwaukee and the bulk of its radiologists are day reading from Australia and to a lesser extent from Switzerland.

Berger says NRS is now night reading for more than 600 American hospitals in 46 states, but with nearly 6,000 hospitals out there, he says there is plenty of room for the company to grow. “There is a tremendous need for the type of services we provide,” he adds.

NRS has recently merged with DayHawk Radiology Services, an affiliated company that has been folded into NRS. “It became apparent it would work better if it was all under one organization and using one technical platform,” says Berger. “The impetus was to raise the level of service and expand the hours of coverage.”

Kroken says the biggest hurdle for a teleradiology company is getting the infrastructure in place to route all the images and patient worklists to the night (or day) readers. The company must also get its radiologists licensed and certified in the states where they read. The companies must put the technical equipment in place to get reports quickly back to clients. Only with reports can treatment decisions be made by clinicians. “Without the appropriate infrastructure, it just won’t work,” Kroken says.

Berger says NRS has devoted huge resources to handling these needs. “Most of our doctors get licensed in from 40 to 50 states,” he says. “We have 35 staff people who just focus on licensing.” Another 15 staff people just write software to let the images and reports flow back and forth across the oceans and to interface the company’s PACS/RIS system seamlessly with client hospitals’ imaging equipment, he says. NRS, he says, has about 30 radiologists stationed in Sydney and six in Zurich. It also uses a few radiologists stationed in the United States.

NRS has been so successful, says Berger, that it recently caught the eye of an investment group called Summit Partners, which has agreed to invest enough to “take NightHawk to the next level.”

Berger says NRS also surmounted the difficult hurdle of finding malpractice insurance for all its radiologists, including those offshore. “The organization and the physicians are insured by an A-rated company,” he says. “The client does not have to worry about our doctors being covered.”

Berger says NRS has paid close attention to federal outsourcing legislation that might impact it. “From our point of view, our exposure has been mitigated,” he says. “The legislators don’t want to prevent what we do from happening. They don’t want to hurt organizations that are helping people.”


Kroken, however, says that potential legislation limiting offshore outsourcing does pose some risk to companies like NRS that have mounted big international operations. Some teleradiology companies take that point of view also.

“We are 30 miles from DC,” says Robb Vaules, chief operating officer for American Teleradiology Nighthawks Inc (ATN), Annapolis, Md. “It’s no coincidence that we [are paying keen attention] to what the federal legislators are doing and on what the states are doing too… We’re seeing down the line a pretty definitive road that offshore will have to be done onshore, so we just started from that point.”

ATN requires its radiologists to read during the night from America, says Vaules, and all 10 of them do. ATN now reads for about 100 hospitals in 15 states, says Vaules, with another seven states about to be added. The attraction of nightwork for the radiologists, he says, is that they never have call because they are doing other people’s call. They also work a week-on/week-off schedule that allows them recreational time or time with their families.

“It’s a quality of life issue,” says Vaules. “They understand the future of radiology. Some are just born nighthawks.”

Like other nighthawk companies, ATN is mounting a daytime teleradiology operation. But Vaules says the company absolutely will not replace existing radiology groups.

Virtual Radiologic Consultants Inc (VRC), headquartered in Minneapolis, is a third supplier of teleradiologic night reading services on the national level. According to chief operating officer Lorna Lusic, VRC’s strategy has been to let its radiologists live and read from overseas if they want to. “One is in Hong Kong, one in Brazil, another in Germany, one in Malta, one in France, and one in Australia,” she says. But the rest of the VRC’s 28 total radiologists read from the United States, she says. She says the company reads for about 250 hospitals in 40 states.

“We do believe the distributive approach is prudent,” she says. “We don’t know what the future will bring as far as legislation.”

Lusic says VRC has deployed a centralized PACS/RIS from which all its radiologists call up the cases they are reading and send back the reports they complete. Lusic says the system is “a virtual reading room environment” where any VRC radiologist can quickly consult with any other VRC radiologist on the system.

“Our doctors are within basically seconds or minutes able to consult and communicate through our central hub,” she says. “This is something our radiologists find extremely important.”

Lusic says that VRC radiologists, like those in other teleradiology companies, are reading mostly emergent CT scans “with some MR, some ultrasound, some nuclear medicine, and very little plain film.”

VRC is just now “rolling out” daytime services and the issuance of final reports if such reports are specified by clients, Lusic says. She says the company has no intention of replacing existing radiology contracts. She agrees there is increasing competition from other nighthawk services, but she adds, “We’re not seeing a slowdown in the need for nighttime services. It’s increasing as we get more visibility.”


One driver of the increasing demand for nighthawk services may be the increased emphasis by patients in using emergency departments as a point of contact for health care.

That is what Teleradiology Diagnostic Service’s Wilson Wong maintains. “The ED landscape has undergone huge changes,” he says. “The caseload is going up 10% to 20% per year because patients find they can get care faster by just going to the ED.”

He says the increase in emergency cases puts a burden on caregivers because so many ED cases are eventually written off without payment. “Most radiology groups get squeezed because they outsource to people like us, but they don’t get paid for it. Sooner or later something has got to give.”

Wong also says the huge data volumes from multislice CT scanners have created problems for TDS. “We used to look at a CT of the chest, it was 64 images. Now it’s close to 1,000 images per case. Even at 5 seconds per slice, that is still a lot of [transmission] time. We are having to increase our bandwidth and set up more computers.”

The irony is, Wong says, that in the ED setting “it may not be that more slices are better…We want to address the clinical situation right there and then, and not every nodule that may have been missed.”

Like the ACR’s James Borgstede, Wong says he is worried that the commoditization of imaging that occurs with teleradiology may eventually push down reimbursements. “The general fear is less pay,” he says. “If the charge now [for a night read] is $50 to $60 a case, that’s not going to last.”

It may be, as many radiologists admit they believe, that in the long term, radiologic studies will become a global commodity, shifted for interpretation to the lowest bidder whether that interpreter is an American or a foreign doctor.

Says Chatham Radiology’s David Estle, “In some way, shape, and form, it is going to happen. Radiology groups will just have to be ready to deal with it.”

UCSD’s William Bradley calls teleradiology “a paradigm shift.” It may turn into a huge one.

George Wiley is a contributing writer for Decisions in Axis Imaging News.