By many accounts, teleradiology now ranks as telemedicine’s largest field. It’s interesting, then, to imagine how the earliest radiology subspecialists in the 1930s would have reacted to a prediction that one day, a radiologist in daytime Australia could interpret a real-time image of a nighttime accident victim in Chicago. Not surprisingly, it was virtually impossible for the physicians to visualize a complex web of virtual readings.

Fast forward 70 years and realize that we live in that world, that environment, that virtual realm of possibility. And companies are growing, launching service-based organizations to quell the tide of the radiologist shortage and entice physicians with promises of an improved quality of life. Some companies are using this technology abroad, others stateside. Although the clients vary in size from private, rural imaging centers to urban, 600-bed hospitals, those who have signed up for these services all agree on one thing: There is no turning back on our digital revolution.

Efficiency and Quality: Finding the Balance

Even with society’s rapid conversion to digital imaging, the American College of Radiology (ACR of Reston, Va) estimates that the increase in radiological scans is growing three times faster than the current available pool of radiologists. The ACR-concerned about the quality of outsourced overseas images-has set up a Task Force on International Teleradiology to ensure that quality standards and patient privacy meet or exceed those within the United States. Other critics simply fear the job losses that overseas outsourcing could bring.

Many have estimated the number of total US jobs lost as a result of offshore outsourcing. The US Bureau of Labor Statistics (BLS of Washington) pegs the number at 4,600 in the first quarter of 2004; Forrester Research (Cambridge, Mass) estimates 315,000 service jobs have moved offshore since 2000.

Forrester also predicts that by 2015, 3.3 million jobs will have moved offshore. However, the BLS also reports that by 2010, as the current generation of baby boomers retires, the American workforce could be hit by a shortage of more than 10 million workers.

For rural facilities that would otherwise require a traveling radiologist, teleradiology can be a boon for access to equal healthcare. Advocacy groups, such as the National Rural Health Association (Kansas City, Mo), aim to improve the health of rural Americans with equal and appropriate healthcare services. Supporters of teleradiology believe that outsourcing increases the standard of quality for US patients and enables hospitals to remain consistent with the growing level of demand. Furthermore, proponents claim that well-rested radiologists, like most individuals, make fewer mistakes.

“There is a global shortage of radiologists. However, there is a relentlessly increasing demand for radiological services driven by the aging population. Whenever there is low supply and high demand, it’s a seller’s market. Radiologists can literally pick their jobs now,” says Douglas Kiviat, MD, chairman of the Radiology Department at the Brooklyn Hospital Center, a member of the New York-Presbyterian Healthcare System. “Most radiology employment ads now clearly state, ‘This job offers nighthawk coverage,’ as a way of improving recruitment.”

Offering Solutions

The radiologists who sign up to work for these private, service-based companies look for an improved quality of life and financial incentives. For example, many of the companies offer radiologists specialized nonemergent opportunities from imaging centers in combination with emergent opportunities. Also, these companies are managing and providing all necessary licensing, privileging, and global malpractice.

The goal behind American Teleradiology (Edgewater, Md) is to diversify its staff of US-based subspecialty-trained radiologists to create low-cost solutions to the growing need for medical imaging services.

The company offers both emergent and nonemergent reads with a network of strategically placed radiologists from Maryland to Hawaii. The company’s subspecialized doctors provide a 24-hour turnaround for nonemergent reports. A patient’s time-critical emergent report is completed within 20 minutes. The nonemergent reports are fully dictated and ready for billing, whereas with emergent reports, a physician reviews each case the following morning.

Some companies, including American Teleradiology, allow radiologists to provide readings from a home computer. Likewise, Virtual Radiologic Consultants (VRC of Minneapolis) gives its physicians the choice of working from their professional home-based offices or the reading room at the company’s headquarters. According to its Web site, the company offers its services to hospitals and private practices for those “seeking to restore quality of life for their overworked radiologists in a reliable, efficient, and economical manner.” Founded in 2001, the company employs board-certified radiologists in multiple time zones and processes about 300,000 studies per year. Licensed in 50 states, it plans to open a new reading facility on the island of Maui in Hawaii.

Although working from home has its perks, the Health Insurance Portability and Accountability Act of 1996 (HIPAA) can throw a kink into a pajama-clad radiologist’s plans. To comply with all HIPAA privacy rules, both American Teleradiology and VRC provide their physicians with a separate home computer and state-of-the-art equipment.

Founded in 2001, NightHawk Radiology Services (Coeur d’Alene, Idaho) is one of the largest companies providing nighttime readings to clients across the country. The company’s core is led by board-certified, American radiologists who work out of a reading facility in Sydney, Australia. The team of credentialed and privileged physicians who relocated and are employed by NightHawk work during the day hours in Australia to read electronically sent digital X-rays, CT scans, MRIs, and other medical images of nighttime patients in the United States. The US hospitals send encrypted patient scans to NightHawk via a HIPAA-compliant, secure virtual private network. Within seconds, the company’s AutoRad workflow software routes the scans to the radiologist with the most appropriate medical specialty and workload. That software also matches the patient’s location with a physician who is licensed in that particular state.

In a world with a radiologist shortage, how does NightHawk convince American physicians to become expatriates? “Our career path is different from any other group. Physicians can customize their schedules as they want to, teach, or take time to travel back and forth to the United States,” says NightHawk VP Chris Huber. He adds that a new NightHawk office will soon open in Zurich, Switzerland, to cover all time zones.

“Our physicians see things that some radiologists in a group practice do not. For example, a doctor in a major hospital might see a pulmonary embolism twice a week. Our physicians might see that six to seven times per night,” Huber explains. “And small, rural hospitals that need a traveling radiologist can have world-class radiology done in the middle of the night.”

By recruiting highly trained radiologists, he says, the company is able to offer premier subspecialty expertise.

“Our goal is to support radiology group practices. Our strategy is inexplicably linked to the success of our clients,” Huber notes. “We have a healthcare crisis, an aging population, and declining reimbursement. With subspecialization, our efficiency model can keep radiologists as busy as they want to be. We have to find a way to stem rising healthcare costs.”

Technology Helps Recruiting

One recruitment philosophy that all radiology companies agree on is that nighthawk services-whether offered from US soil or abroad-is a prerequisite to recruitment and retention of radiologists.

The Brooklyn Hospital Center is a not-for-profit, acute-care, 653-bed teaching institution located in New York City’s largest borough. When Kiviat assumed responsibilities as chairman of the Radiology Department nearly 2 years ago, one of his first goals was signing a contract with NightHawk Radiology Services.

Of course, signing the NightHawk contract did not come without a few roadblocks from the hospital’s management, many of whom were hesitant of such services based on earlier misleading reports about some companies hiring unlicensed physicians. Kiviat persisted, highlighting the need for this service, not to mention the credentials and training of NightHawk’s physicians.

“The CVs of these doctors are very impressive. They have a ‘dream team’ of radiologists. We had to show [management] that this was progress, this was survival,” Kiviat says. “Once it went into effect, especially in the emergency room, there was no turning back. It has led us to be able to recruit and retain radiologists.”

Before implementing teleradiology, the hospital used in-house services. “The network was extremely slow, and doctors were literally up all night,” he remembers. “Eventually, the images [moved] faster, but you still had to wake up the doctor at night to give a verbal order to the technologist. But sometimes there were mistakes with that method.

“I did the numbers, and [teleradiology] saves us money,” Kiviat continues. “With a nighthawk service, you don’t have to worry about giving the doctor the next day off. In the past, you would have to hire one extra radiologist because of the previous doctor’s night hours. Hiring a nighthawk service makes economic sense because you’re not giving each radiologist compensation days off.”

The hospital monitors the type-written reports for any variances, but there have been very few to none in terms of discrepancies, he says. “We also keep in mind that this is a preliminary report. In the morning, we do the official report and look at the films again.”

The hospital’s original plan was to use NightHawk’s services for emergent cases only. “We literally changed that plan within a few days and now use it for inpatients and outpatients between 8 pm and 8 am. In the interest of patient care, every patient who receives a CT scan during the night hours has their case reviewed by NightHawk,” he notes.

The hospital recently signed a contract for extended “dayhawk” coverage and has used the service on a case-by-case basis. “For instance, if a doctor is stuck in a snowstorm for a few hours and can’t make it in to work, we don’t want that CT scan sitting around for 2 hours,” he says.

Realizing that teleradiology was increasing efficiency for CT scans, the hospital plans to add MRI review soon. For example, in the event that a scheduled MRI takes longer than planned, the hospital is hesitant in this “seller’s market” to excessively tire the radiologist. “In that case, yes, we’re going to NightHawk it,” Kiviat explains. “We don’t want to keep the radiologist past his or her shift.”

Kiviat also notes that pathology is another growing subspecialty field for teleradiology. “It certainly makes economic sense in a digital age in which people send out images all the time,” he says. “Anytime you can send out digital images and draw on amazing specialists is beneficial. It’s easier to send electronic slides than to send hard copies; plus, it is safer because the slides won’t be lost in the mail. I don’t think it will take away anyone’s job. You’re drawing on resources where you can get the best of the best. The World Wide Web is one of man’s greatest inventions.”

A Well-Rested Radiologist
Is a Happy Radiologist

The slogan behind VRC is “Give us 90 nights, and you’ll forget you own a pager,” but that’s not entirely true for the full staff of radiologists at Phoebe Putney Memorial Hospital (Albany, Ga). A 450-bed, acute-care facility serving more than 26 counties in southwest Georgia, the hospital contracted with VRC in early 2004 after earlier attempts with two other service providers.

“In the past, my emergency room [physicians] would be hollering, ‘Where are my reports?’ because it was taking longer than 30 minutes sometimes,” says Jerry Whitley, PACS coordinator at the hospital. “VRC provides excellent turnaround time. We had used a service outside the United States, but it took extra time with image transfers-sometimes 25 to 50 minutes. Having VRC locally in the states has [improved] our read time to 8 to 15 minutes.”

The hospital uses these services from 8 pm to 7 am but has no plans to use daytime services. The radiology department uses VRC for approximately 20?45 reads per night for CT, ultrasound, MRI, and X-rays. The hospital has seen a 35% rise in imaging in the past year due to the increase in diagnostic services, such as multi-slice CT, Whitley explains. This increase is due in part to the aging population; he predicts that teleradiology will help the medical field cope with such growing numbers.

Whitley is pleased with the nighttime services, but he points out the benefits of the in-house radiologists. “We have a full radiology staff. We use VRC only during the night because when a radiologist works a night shift, you generally lose him [or her] for two days,” he says. “Economically, having staff fresh allows you to have a more efficient staff.

“However, VRC gives us access to several radiologists and is able to give us a faster turnaround time because they can provide multiple doctors,” Whitley continues. “We gain access to radiologists that we normally might not be able to afford to have on staff. This field also will help that small, 50-bed hospital that can’t afford to have four or five specialists on staff. And VRC can share these resources across many hospitals.”

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Elaine Koritsas is a contributing writer for Medical Imaging.

Atlanta’s Star

Established in 1999, Neurostar Solutions (Atlanta) is an imaging solutions company that provides services to both small group practices and large hospitals. The company’s product is built on a single Web-based communication channel that promises seamless workflow and secure compliance to meet HIPAA standards.

One private practice that has contracted with Neurostar is Georgia Lung Associates (Austell, Ga), which offers a range of pulmonary diagnostic services, including CT, ultrasonography, and echocardiography. In fact, it is the only community-based practice in the United States to be approved as a testing site for the National Lung Screening Trial, which is sponsored by the National Cancer Institute (Bethesda, Md). As a small practice, it does not employ a full-time radiologist; instead, the facility contracts with Neurostar.

“The service is good and dependable,” says Crystal Bishop, RT, a CT technologist with Georgia Lung. “The office chose Neurostar because it is more efficient, the image quality is good, and it’s easy to use. Most everything we do is scheduled and not urgent.”

Georgia Lung averages about 25?40 scheduled CT scans per day. When Bishop starts the CT scan, the first image of the patient is scanned immediately to Neurostar. She says that a concise, computerized report is typically faxed back to her office within 24 hours.

-EK