Ten years ago, the possibility of teleradiology promised more than it delivered. There was not enough bandwidth, memory, or speed to transmit and reconstruct images in a timely and accurate fashion; image quality was still a challenge. But as we entered the 21st century, these problems were solved. Add the evolution of PACS, RIS, and EMRs and the digitization of health care is inevitable if not yet complete.

This has meant opportunities have become available to help meet rising demands for care while preserving employee quality of life and improving the bottom line. Teleradiology is one of those services, and it is finally beginning to deliver what it has always promised. Radiologists really can complete readings across town or around the globe (restrictions now being more regulatory than technical).

As quality has improved over the past decade, teleradiology services have expanded from a support service to a business partner, the extent of which is determined by need on an institutional basis. The majority of radiology groups, however, use teleradiology in some form. A 2003 study reported that 67% of all radiology practices in the United States said they use the service.1

Most often, these contracts include preliminary reads for nighttime services, but more frequently, they also are encompassing final reads, subspecialties, and other fractional needs. Indeed, some in the industry worry that these companies may become direct competitors to radiologists and radiology groups. But the leading teleradiology providers and their clients brush aside that concern, citing business practices and partnerships that ultimately serve to benefit patients. With a burgeoning number of imaging procedures and a shortage of radiologists to read them, your teleradiology provider should be a valuable collaborator.

An Extension of Staff

According to one Merrill Lynch report, teleradiology providers estimate there could be a shortage of about 15,000 radiologists by 2020.2 This compares with growth in imaging of approximately 8% annually through 2010, according to another report by William Blair and Company, LLC.3

With advances in technology and reconstruction, the increase in actual images is even greater. Reading time of the final report can increase with complexity, and having a preliminary read can shorten that time. Radiology groups are likely to turn to teleradiology to help handle the surge in cases. “Many radiology groups we have talked to are looking for someone to handle the overflow of studies they cannot get to,” said Scott Giordanella, director of marketing with NightHawk Radiology Services, Coeur d’Alene, Idaho.

Sean Casey, MD, CEO and cofounder of Virtual Radiologic, Minneapolis, agrees that mid-sized to large practices are expanding nighttime preliminary reads to nighttime final reads as well as daytime overflow and subspecialty finals. “It’s inefficient to have two radiologists read one study,” said Casey, explaining that in larger institutions the on-site rereading of the preliminary teleradiology reports from the previous night can number 30 to 50 and take up a significant portion of daytime on-site radiologists’ work.

At the opposite end is the economic restraints of hiring specialists to perform only a small portion of exams, a greater issue for smaller and rural institutions than for academic institutions and large hospitals. “They may find teleradiology for subspecialty reads more affordable, especially if they don’t have someone in-house with those capabilities. It’s hard to hire a radiologist to read just 10% of studies, as a pediatric radiologist might do,” said Casey.

Casey feels the same principle is applied to nights, which is the primary need for most institutions. “Most people don’t have a full work volume at night, and it’s inconvenient to staff,” said Casey.

Mount Sinai Hospital in New York City found a need for overnight staff even with residents available. “We didn’t feel we had the critical mass or enough faculty to provide the service in-house at night without impacting the day schedule,” said Zvi Lefkovitz, MD, the hospital’s vice chairman of radiology. Even if a daytime staff member covers the on-call shifts, that physician is not available the next day (“or is very tired,” said Lefkovitz). Weekends, vacations, leaves (both sudden and planned), and holidays may also be covered by teleradiology services.

The use of teleradiology expands staff beyond the direct assistance; it is also a significant recruitment tool. Many institutions report it is easier to hire radiologists when they are not required to work nights, weekends, or holidays. “It’s very difficult to find night people,” said Lefkovitz.

Teleradiology can step in where radiologists cannot be recruited, not only at night but also in smaller communities and rural areas where institutions have a difficult time finding personnel. “I do see teleradiology services playing a role in the field of program development for those in rural or remote areas that don’t have the opportunity to bring subspecialists in but have the ability to provide those services,” said Marty Khatib, JD, RT(R), imaging director of Mercy San Juan Medical Center, Carmichael, Calif.

Recruitment Ramifications

“You could say that with the shortage of radiologists, any large company that pulls radiologists away is stealing talent,” said Scott Giordanella, director of marketing for NightHawk Radiology Services, Coeur d’Alene, Idaho. You could say that, but it wouldn’t really be accurate since most physicians cite teleradiology’s benefit to recruitment more so than its competitiveness.

“It is a great recruitment and retention tool because it allows you to offer a unique balance between professional and personal life to radiologists. At the same time, because its main focus is on evening hours, it is not necessarily the most attractive situation for radiologists,” said Marty Khatib, JD, RT(R), imaging director of Mercy San Juan Medical Center, Carmichael, Calif.

Zvi Lefkovitz, MD, vice chairman of radiology at Mount Sinai Hospital in New York, feels that teleradiology providers can offer a lifestyle that matches particular needs, such as those of radiologists who are parents of young children or caregivers for older relatives.

Those who want to travel as well as those who want to stay at home can also find careers in teleradiology. NightHawk uses both centralized reading and at-home models, with centers in Sydney, Australia, and Zurich, Switzerland (the latter was chosen by physicians already working for the company). The physicians are born and trained in the United States, but are interested in living outside the country. “It’s about a 50-50 split in physicians working from home or going overseas. The interest is very large in going abroad. I hear living in Sydney is quite spectacular,” said Giordanella.

This lifestyle, however, is unique, and Lefkovitz doesn’t believe that radiologists interested in academia and private practices are competing for the same jobs. “Radiologists who want to work in an academic or private practice environment do not form the same pool of talent from which teleradiology providers pull,” Lefkovitz said.

The same can also be true in finding radiologists to work where none can be found, such as during night hours and in rural communities. If a physician does not want to live in a certain area, then the teleradiology service is not drawing that talent away. Rather it can help to extend staff and create efficiencies.

“For those who work with us on the technical infrastructure and build a network between their facilities and load balance across their radiologists and route subspecialty studies, they can realize a great improvement in efficiency; although they have not actually hired a new radiologist, they have certainly improved the staffing situation,” said Sean Casey, MD, CEO and cofounder of Virtual Radiologic, Minneapolis.

This means smaller numbers of radiologists can handle greater volumes, alleviating some of the staffing shortage challenges as well as improving the quality of the radiologist’s work life. However, teleradiology will make it easier to find that talent. “Quality of work life is much better when the radiologist can count on being able to leave and know there is a very competent resource out there that will maintain the same level of quality and efficiency they are used to. So it is a very good retention and recruitment tool,” Khatib said.

—R. Diiulio

Improvements to Productivity

One of the general effects of expanded staff is improved productivity. “Teleradiology can help to improve throughputs and lower costs, especially in a post-DRA [Deficit Reduction Act of 2005] world,” said Ken Rardin, president and CEO of Merge Healthcare, Milwaukee. He notes that centers are also expanding hours to increase volume.

“It has made our overall operations more efficient during the evening hours because [our teleradiology service] has numerous radiologists at night who can respond to multiple emergency cases simultaneously, which permits load balancing similar to our daytime operations,” said Khatib. Mercy San Juan uses Virtual Radiologic. Faster reads mean shorter times to treatment.

“If the MRI is not running, it’s expensive so anything to improve productivity while lowering costs will be considered. Clinics are open 7 am to 7 pm rather than 8 to 5. Some clients are even thinking of staying open on Sundays,” said Rardin.

“The overnight read provides the referring physician with a board-certified preliminary read, which I believe is a slightly higher level of quality—despite the quality of our residents—because it is a board-certified physician. So it is an improvement in quality and enhances our turnaround time,” said Lefkovitz.

Before an imaging study can be reimbursed, however, it must undergo its final read. CMS dictates this occur in the United States, limiting teleradiology final reads to those provided by domestic radiologists. But even if teleradiology provides only the preliminary read (which is about 85% of the market, according to Rardin), the signing physician still saves time.

10 Factors to Look for in a Service

  1. Quality, including an excellent peer review process and clear reporting
  2. Customer service
  3. Technical integration capabilities (including PACS, RIS, and voice recognition systems)
  4. Electronic reporting
  5. Sound IT infrastructure ensuring reliable operations and having built-in failover capabilities
  6. The location of the radiologists (ie, US-based, which is a regulatory issue for final reads and an emotional issue for others)
  7. Access to interpreting radiologists
  8. Reputation
  9. References
  10. Competitive pricing (of course)

Merge now offers a preliminary read designed to save the radiologist performing the final read a significant amount of time. The Consult PreRead goes beyond the emergent need to include prior comparisons as well as measuring, annotation, and transcription of the current image interpretation. Merge’s technology integrates with the facility software to transfer relevant information, such as a patient’s prior history and images.

Rardin cites a company study that compared radiologist reading time of an MRI of the spine with and without the preliminary Consult PreRead. “The lumbar MRI took the radiologist 15 minutes to read on his own but 6 minutes with a preliminary read,” said Rardin. A client of Merge rated the quality of the reports 4.85 out of 5.0, a figure that was higher than those performed internally.

Subspecialty reads also can help to improve quality and turnaround, particularly since the interpretation is completed by an expert. “The more you do, the more efficient you get,” said Casey. This is true of all subspecialties including mammography, pediatrics, virtual colonography, nuclear medicine, and cardiac, one of the fastest-growing areas.

Virtual Radiologic has seen an interest in cardiac imaging and expects growth in this area in the future, particularly once CMS reimbursement decisions are finalized. As a result, the company has invested in the remote 3D reconstruction technology, trained 22 radiologists to level II certification (ACC), and hired radiologists from cardiac imaging fellowship programs. “To provide the service round the clock 365 days a year requires an up-front investment,” said Casey.

These economics can hinder smaller centers from beginning their own programs, but teleradiology companies are willing to help where needed. “They can outsource that work to us,” said Giordanella, who also notes the company offers consulting services to radiology groups starting up new services.

Enhancements to Quality and Efficiency

Consultative services can help a facility to implement new programs with greater efficiency. One such area is technology. Many teleradiology companies offer technology solutions to provide users with the ability to transmit images efficiently as well as integrate with standing systems such as PACS, RIS, and EMRs. Health care providers who want to implement in-house teleradiology services can therefore benefit from a teleradiology provider’s technology even if the image interpretations are not completed by the teleradiology radiologist.

“We are able to help improve the efficiencies of a private practice by using the same tools we have,” said Casey. For instance, a practice that covers five hospitals with disparate systems is a sizeable institution but may not be able to subspecialize adequately because of technical challenges. “The neuroradiologist on staff has to read images outside of his specialty because the systems aren’t integrated across the facilities. We can provide a scaled-down version of the same software we use to cover 800 hospitals to cover those five,” said Casey. The radiologist doesn’t have to jump between systems or travel between hospitals, thus increasing efficiency.

NightHawk and Merge also offer technology services. NightHawk’s Talon Clinical Workflow Solution integrates workflow and disparate systems over standard DSL or cable modem Internet connections to provide users with workload balancing, single work list, and reporting capabilities. The solution also comes with quality control personnel who can serve as administrative assistants to handle tasks such as pulling priors.

“There is a need for greater breadth in business services, including revenue cycle management, marketing services, contract negotiations, and other things of that nature,” said Giordanella. Client demand for services, such as billing and revenue cycle management, drove NightHawk’s decision to acquire Midwest Physician Services, LLC, this past summer, which provided the foundation for NightHawk Business Services. “Our clients are looking at us as partners and not just another vendor offering preliminary interpretation at night. Our doctors become part of the staff representing the group,” said Giordanella.

Collaboration Rather Than Competition

Of course, with teleradiology providers holding a bigger role, some fear that they may eventually become competitors rather than collaborators. “I think there is global concern. What I interview medical students and ask them their concerns, it is one of the most prominent questions,” said Lefkovitz.

While Lefkovitz doesn’t fear competition in well-populated areas, he does feel smaller communities may have a greater risk. “Say two or three physicians have a contract with a small hospital and the institution is not happy with their service. That is where I feel a leading teleradiology provider could take away that business,” said Lefkovitz.

Leading teleradiology providers, however, have stated that their business practices do not encourage this type of competition. “We have run into situations where hospitals have contacted us for help, asking us if we can handle all of their radiology needs, but we do not want to bite the hand that feeds us so we will contact the radiology group,” said Giordanella. The goal is then to help the radiology group where they need it and develop a more stable relationship with the hospital.

For instance, if the hospital is displeased with the radiology group’s turnaround time, the teleradiology service can provide additional doctors to handle volume where needed or provide preliminary reads that shorten interpretation time for the signing physician or even provide final reads.

Merge’s Rardin stresses that the teleradiology provider’s customer is the radiologist. “Our service is complementary,” said Rardin.

Virtual Radiologic also focuses on radiologists as clients. “We have made it our mission to assist radiology groups and not compete with them. We don’t think it is in the patient’s best interest to displace local radiologists,” said Casey. He suggests that in areas where this has happened, later analyses show that patient care has suffered.

Competition within the market itself will help to shake out those who do not have the resources needed to support a large and successful business. While many cite the low barriers to entry, others note there are higher barriers for growth. “Companies want to grow and increase revenue, but the more customers and services you bring on, the more resources you need,” said Giordanella.

These restrictions are leading to consolidation among teleradiology providers as well as decisions by smaller companies to stay out of the subspecialty and final read markets. But as others expand their services, evolving into business partners, teleradiology is delivering on its promises.

Renee Diiulio is a contributing writer for Axis Imaging News. For more information, contact .


  1. Steinbrook R. The age of teleradiology. New Engl J Med. 2007;357:5-7.
  2. Galluci T, Lang C. Initial opinion Virtual Radiologic Corporation. Merrill Lynch. December 26, 2007.
  3. Daniels RS, Blaschek K. Equity research for Virtual Radiologic Corporation. William Blair and Company LLC. January 2, 2008.