Hospitals and referring physicians make no bones about it—they want musculoskeletal studies interpreted more often by radiologists subspecializing in musculoskeletal anatomy. The same is true with images of the heart—more frequently, providers are insisting that the radiologist who reads those views be highly expert in cardiac work. The reason for this trend is simple: Radiology customers are increasingly coming to appreciate the value of subspecialized radiologists’ attention in support of efforts to improve surgical and therapeutic outcomes.

“In order to enhance their management of patients, our customers are requiring definitive, detailed reports from radiologists who have superior understanding of not only pathology but also surgical-medical options,” said Jeffrey D. Robinson, MD, an emergency-department specialist with Radia Inc, Seattle, one of the largest radiology and vascular surgery practices in the Pacific Northwest.

The physicians most eager to receive interpretations by subspecialty radiologists include neurosurgeons, orthopedists, and urologists. “They no longer want us to report back with generalized observations about the abnormalities we notice in the images we’re looking at,” Robinson said. “Now, they want us to state everything in as much specificity as possible, coupled with rich descriptions of the pathological relevance of our findings so that the range of possibilities is narrowed.”

As Steve Duvoisin, CEO of Inland Imaging, Spokane, Wash, put it, “Evolving technology is resulting in radiologists reporting a greater number of incidental findings, many of these in the lungs. Naturally, in response, pulmonologists want unambiguous reporting about those findings. The best way that this will happen is if the reporting comes from a subspecialty radiologist.”

Duvoisin contends that this is equally true for oncologists, another class of physician expressing a desire for subspecialized radiology support. “More and more, oncologists are turning to radiology groups that have a breadth of oncological expertise,” he said.

Former University of Maryland department of radiology chairman Philip A. Templeton, MD, FACR, who is now president and CEO of Templeton Readings LLC, Sparks, Md, suggested that a wish for continuity of experience drives at least some of the interest among physicians for subspecialized interpretations. “These doctors very often come out of residency accustomed to receiving advanced subspecialty reads provided by the academic institutions where the training took place,” he said. “Then, when they go out into the community to begin practice, they want the same kind of imaging interpretations that they had access to previously.”

After Hours, Too

Another reason for the rise in subspecialty demand is that some radiology groups and imaging centers have been aggressively promoting their ability to provide high-level expertise as a means of achieving a marketplace advantage over their rivals.

“For the most part, everyone now has the same modalities and patient-related services, which leaves only the quality of the report as the key competitive differentiator—and the quality of the report is directly tied to the expertise of the radiologist,” said Frank Seidelmann, DO, co-founder and CEO of Franklin & Seidelmann Subspecialty Radiology, Beachwood, Ohio, a national subspecialty radiology interpretation provider that serves imaging centers, orthopedic practices, hospitals, and radiology groups around the country.

Importantly, diagnostic imaging enterprises that offer subspecialty interpretations soon discover that demand does not confine itself to regular business hours. Customers—hospitals, most prominently—frequently call for subspecialty radiologist ministrations at night and throughout the weekend. Duvoisin said that after-hours subspecialty service represents a formidable challenge for most radiology practices, because providing it requires certain lifestyle adjustments—or lifestyle sacrifices, if you will—that ultimately affect the dynamics of the entire group. Inland Imaging, he said, has opted to address the problem by developing an in-house night-read system. “This approach affords us control over both service and quality while allowing the majority of our radiologists to enjoy an attractive lifestyle,” Duvoisin said. “With more than 70 radiologists and six vascular surgeons on our team, we have the available physicians to make our [night-read] system work well.”

Ranks Are Small

Inland Imaging long anticipated that the need for subspecialty interpretation would grow, so it has recruited radiologists with this in mind. The group’s size and pleasant location make recruitment easier than might otherwise be true, given that the ranks of subspecialty radiologists from which to choose are comparatively small anyway.

Seidelmann said that the radiology shortage is still an issue with subspecialists. “For example, as of 2006, there were only 1,930 American Board of Radiology-certified neuroradiologists in the United States, according to the American Board of Medical Specialties,” he relayed, noting several reasons why there aren’t more subspecialists. “One of those reasons is that the additional training required to be a subspecialist acts as a disincentive. A physician must pass a test to earn a Certificate of Added Qualification in Neuroradiology, which is granted for 10 years. To maintain the credentials as a Board Certified Neuroradiologist, the physician must take a Maintenance of Certificate Examination every 10 years. The neuroradiologist must participate in an ongoing continuing medical education program, to be allowed for re-examination every 10 years. The CME program requires 50 credits in neuroradiology and two self-assessment examinations per year.”

A second reason is the difficulty of building or maintaining subspecialty expertise once trained in a particular discipline, since most traditional imaging organizations do not see sufficiently high case volume requiring subspecialty interpretation. “Expertise is achieved after a radiologist interprets 10,000 to 15,000 cases in a dedicated subspecialty area,” Seidelmann said. “After gaining expertise, the subspecialist must then read 8,000 to 10,000 cases per year in order to maintain that level of expertise. However, the typical imaging facility does not produce anywhere near those numbers of subspecialty studies. With musculoskeletal, for instance, the typical facility generates less than 1,000 MRIs of joints annually, which must be shared across several radiologists. The same thing is happening in neuroradiology and cardiac imaging. So, what often happens is that the subspecialist, to be productive, is made to interpret all kinds of cases. That then leads to a loss of his or her edge as a subspecialist.”

For many groups and imaging centers caught in this bind, the answer is some combination of nimble staffing and use of teleradiology services. “Teleradiology has created opportunities for imaging facilities in any location to access subspecialty expertise,” Seidelmann said. “It is also the ideal solution for facilities encountering problems finding local subspecialists, or even for radiology groups that need complementary subspecialty staffing support. Teleradiology is an efficient and cost-effective way to provide high-quality reports and consultations from subspecialty experts when an imaging facility does not generate enough subspecialty volume to merit hiring a full-time on-site subspecialist.”

New Products

Paul Berger, MD, is founder, chairman, and CEO of NightHawk Radiology Services, Coeur d’Alene, Idaho, considered by many to be the grandfather of all teleradiology organizations. Started in 1994 to address a manpower shortage, the company today is staffed by more than 70 US-trained, Board-certified radiologists operating from various domestic and foreign facilities; all interpretations are made by alert, awake, expert physicians in real time during the receiving NightHawk center’s local daylight hours, Berger explained.

“In the future, we expect to see much more interest in subspecialty teleradiology,” he said. “A big driver of that is going to be the ongoing advances in technology. Digital already has largely taken over, and we can now securely move images anywhere in the world in minutes or even seconds. Even sites that don’t have PACS can be connected online easily and start benefiting from a teleradiology solution.”

Among the solution options is NightHawk’s Talon product, a proprietary workflow technology service. Talon features intelligent image distribution that routes images via the Internet to the appropriate physician and then creates worklists for those transmitted studies. “The processes built into Talon ensure that scans are evaluated by the most qualified radiologist on staff and in the timeliest manner,” Berger said. “The system can quickly and easily integrate into an existing practice. It limits administrative work, and it enables radiologists to better track the number and timing of studies. This, incidentally, makes it possible to better maintain and evaluate proper staffing levels.”

Templeton Readings also offers teleradiology technology, the newest of which is set to roll out this month, and is geared toward those radiology groups and imaging centers not quite ready to commit to a full-service teleradiology contract. The pay-as-you-go product is called Radiology Expert Opinion.

“It’s an Internet-based, quality assurance-oriented consult service,” Templeton explained. “It will be most useful for radiologists in solo practice or in small two- or three-person groups that need only infrequent teleradiology support. For example, if you’re reading 100 or more cases per day and you get stuck on one of them, you can get the help you need with a couple of mouse clicks rather than having to stop, look through several reference books, or try to find someone in your group who isn’t too busy to talk to you about it. Radiology Expert Opinion helps the customer make the right diagnosis and complete the report with the requisite level of specificity, but it also serves as an educational experience. We think that many users will welcome the way the service mitigates some of their medicolegal risk. But, most importantly, it will result in patients receiving better care. That should make referring physicians happy enough to not send their patients elsewhere.”

Radiology Expert Opinion is being offered through a partnership that Templeton Readings established with Neurostar Solutions Inc, Atlanta, a software and services company that provides delivery of radiology services through a proprietary virtual radiology network. “The way we’ve set things up, the customer is spared installing a virtual private network router on-site so that images can be sent to a server somewhere for reading,” Templeton said. “And because it’s not a full-scope teleradiology service, the customer also does not wait for months and months while the teleradiology provider arranges for hospital privileges. Radiology Expert Opinion allows the customer to go online by whatever method is already in existence for them, go to our Web site, log in, request a consult, enter a credit card number, and download the custom-developed Neurostar software, which permits secure transfer of customer images to our server. Then, one of our expert radiologists renders an opinion and provides a consult.”

Attractive Proposition

From the perspective of the organization providing teleradiology, a main advantage of such a service is that it allows the group to project itself virtually anywhere on the globe. But that can be a two-edged sword. “If you’re able to extend your skills far and wide, so can the next group—and that discourages many groups from offering teleradiology services,” said Robinson, who serves as medical director of Radia’s teleradiology enterprise, which goes by the name of teleRadia.

Robinson also speculated that groups able to offer teleradiology choose not to because they fear having their services perceived as a commodity—and reimbursed accordingly. “They worry that the improved quality of care made possible by subspecialized reading would be supplanted by the quest to provide reads that are the cheapest in price,” he said.

Another drawback for teleradiology—and the one that can make or break client satisfaction—is that by its very nature, it does not permit face-to-face interaction of radiologist and customer. According to Robinson, teleRadia overcomes that problem by emphasizing other types of physician-to-physician contact. “We’re very liberal in our communications and interactions with the referring physicians, even though we’re on site with only some of our clients and most of our work is conducted remotely,” he said.

Despite the limitations, teleradiology that is used to promulgate subspecialty services remains an attractive proposition. Certainly those organizations offering it think so. One reason they do is that it is not very difficult to attract subspecialized radiology talent. “We have many more applicants than we have positions for,” Berger said. “Besides, our goal is to not focus on recruiting the superstars of subspecialty radiology, but on attracting good, solidly talented subspecialists who also can handle general work. We in teleradiology are not competing directly with the local radiologists for personnel, because what we offer is a completely different lifestyle. The doctors in our model have a tremendous amount of job flexibility—they can go anywhere and work largely on their own terms.”

Seidelmann’s prediction is that teleradiology will grow because more practices dedicated to interpreting subspecialty cases will spring into existence. He said, “Subspecialty radiology expertise delivered by teleradiology allows the targeting of referring physicians who have been underserved by radiology.”

With or without the boost of teleradiology, more practices dedicated to subspecialty work are on the horizon because improving the quality of patient care while making that care more cost-efficient is really what matters most. Said Berger, “The focus on subspecialized interpretation is absolutely a good thing all the way around.”

Rich Smith is a contributing writer for Axis Imaging News. For more information, contact .