Even critics say there are situations where teleradiology providers offer lifesaving support in the ER.

David C. Levin, MD

The issue of teleradiology in emergency rooms took on added urgency earlier this year when David C. Levin, MD, of the department of radiology at Thomas Jefferson University Hospital in Philadelphia, wrote an article in the February issue of the Journal of the American College of Radiology criticizing radiologists for “abdicating” their responsibilities by outsourcing night and weekend coverage.

“It sends out a bad message about the importance of radiologists,” said Levin. “They’re saying we’re very important to patient care, but that’s only between 8 am and 10 pm—after that we’re letting someone else do it. And we don’t know that person or how qualified that person is.”

It’s not that Levin dislikes the technology—he actually goes to great lengths to defend it. “I think it’s great,” he said. “If the emergency room is going to use it to transmit images to the radiologist at home, that’s OK. What I don’t like is when tele-radiology is used to outsource the images to some nighthawk company a thousand miles away.”

Impact on Patient Care

In his article, Levin argues that using nighthawk services damages radiology as a profession, but also has an adverse impact on patient care. There are a number of reasons why this is so, he says.

For example, Levin says that the business model of nighthawk companies requires teleradiologists to read studies as quickly as possible.

“These companies make money through fast reads,” Levin argued. “The higher the volume of reads, the more money they’re going to make, which means there is going to be pressure on these radiologists to read as many cases as they possibly can. It’s axiomatic—the faster you read, the more likely it is you are going to make a mistake.”

Another drawback in using teleradiology in the emergency department, Levin says, is that it hinders contact between radiologists and patients. “In our hospital,” Levin said, “if a radiologist has a question about how a study has been done, or what the protocol is, or what the ordering physician is looking for, he can talk to the patient and ask questions like, ‘Where do you hurt?’ Certainly, a teleradiologist is not going to talk to a patient.”

While Levin has well-documented qualms about the use of teleradiology in the emergency department, Patrick Browning, MD, head of Sutter Medical Group’s medical imaging group, says the use of a teleradiology service to handle Sutter’s overnight emergency reads is all about providing excellent patient care.

California-based Sutter Medical Group comprises nine different facilities, in which 300,000 to 350,000 imaging exams are carried out annually. According to Browning, the facilities send anywhere from 60 to 100 studies to StatRad every night.

Sutter actually had to switch teleradiology services in 2010 because, Browning says, Sutter’s need for overnight coverage was not being met by Radisphere, its previous provider.

“The decision to go with the prior provider had been made without full knowledge of how things were going to work,” Browning said. “So a number of unexpected facets to the overall delivery of imaging in the ER had developed, and we decided to reevaluate what our needs were and that a change would be the best for everybody.”

That change meant that Sutter switched to StatRad Teleradiology—a company that has, Browning says, “become experts in overnight emergency radiology since they basically practice that as their sole profession—they’ve become very good at what they do.”

Specifically, Browning says Sutter is very happy with the quick turnaround times they get from StatRad—on the order of 20 minutes—as well as the overall accuracy of StatRad’s reports.

“Twenty minutes is a good turnaround time for acutely ill patients,” Browning said, “and the quality of the overall radiology interpretations is such that our emergency room doctors have a high degree of faith in those interpretations that come from StatRad.”

Quality Assurance

Quality assurance is, of course, a major consideration for any hospital that contracts with teleradiology services. With that in mind, the American College of Emergency Physicians (ACEP) has developed guidelines addressing the use of teleradiology in interpreting images in emergency departments. According to ACEP, initial radiological interpretations of imaging exams have “profound implications” for the way emergency physicians make decisions. Consequently, emergency physicians should “demand” that nighthawk services should:

  • Make interpretations available on a timely basis after completion of the study. In addition, the radiologist must be available, in real time, by phone for discussion and/or consultation with the treating emergency physician.
  • Require that the radiologist providing the service should be licensed in the state where the images are performed. The radiologists should meet the same credentialing requirements as radiologists within the local health care facility, such as board certification.
  • Ensure that the original, as well as the final interpretations, must be documented in writing and be made a permanent part of the patient’s medical record. This documentation is necessary in the event that the local radiologist changes or disagrees with the original interpretation.

Every hospital usually has some kind of quality assurance mechanism in place, Levin says, whether it’s a risk management committee, a rad-peer program, or some other kind of quality assurance program. “It’s much less likely to happen in teleradiology,” he argues. “Many companies claim they have these quality assurance programs. I’m not sure I believe it.”

Levin questions whether teleradiology companies are able to meet some of those demands that ACEP says hospitals should be requiring of them. For example, Levin says that there is unlikely to be much discussion between teleradiologists and emergency department physicians. “In most hospitals, if you have a radiologist reading a study and he has a question, or wonders why the study is being done, he can call the referring physician,” said Levin. “Theoretically, the teleradiologist can also do that, but it’s going to be unlikely because teleradiologists are trying to get through as many cases as they can—they may be reading for 10 or 15 hospitals.”

But Browning points out that it was the ability and willingness of a StatRad radiologist and a Sutter ER physician to talk to each other that may have saved a patient’s life when he walked into a Sutter emergency room earlier this year.

According to Browning, a patient about 50 years old had presented himself with abdominal pain. The emergency room physician ordered an abdominal CT, and the interpretation of that study from a StatRad radiologist had a notation that a partially visualized abnormality was possibly present in the right lower lobe of the patient’s lungs and that another CT might be worthwhile because the possibility of a pulmonary embolism couldn’t be excluded.

The emergency room doctor, questioning that interpretation, called the radiologist to discuss it. “Her response,” Browning said, “was ‘Yeah, I think there’s something there.'” The physician ordered a CT pulmonary angiogram, which revealed a large right lower lobe pulmonary embolism that was the cause of the patient’s symptoms.

The emergency room doctor called the teleradiologist after the interpretation of the second study was obtained, Browning recalls, and he told her, “‘You just saved this guy’s life—I was just about ready to send him home.’ So that’s the kind of difference they can make.”

Teleradiology in Rural Settings

There are some instances in which the use of a teleradiology service for emergency departments can be justified, Levin says, particularly in the case of small rural hospitals that simply can’t afford their own radiology coverage of emergency services.

Brenda Hamilton is CEO of such a hospital—Parkway Regional Hospital in Fulton, Ky. The hospital is a 70-bed facility located in southwest Kentucky right on the Tennessee border. It carries out about 13,000 imaging studies annually.

When Hamilton started working at the hospital, vRad provided it with teleradiology services after hours and on weekends and holidays. Since then, the hospital has contracted with vRad to provide it with close to 24-hour coverage, 7 days a week, except for about 16 hours that are covered by an in-house radiologist.

“It’s very difficult for small rural hospitals to afford a full-time radiology practice within such a small organization,” said Hamilton. “In fact, there are probably many small rural hospitals that don’t have any in-house coverage at all.” The challenge, she says, is providing her hospital’s patients with quality care in such an environment.

And that’s where a company like vRad comes in. “Depending on the modality of the imaging test, vRad is going to have a specialist reading that test,” she said. “In a small rural area like ours, you can’t afford all those specialists, but you can get them through teleradiology.”

As for her emergency department, “vRad is my radiologist after hours,” she said. “They enable us to provide urgent care for our patients. If we have major accidents or trauma, we can stabilize even the most critical patients and do CTs any hour of the day or night to get appropriate reads on our patients.” And the fact that vRad meets or exceeds its guaranteed 30-minute turnaround times, Hamilton says, means that the hospital can provide high-quality emergency services.

While both Hamilton and Browning are pleased with the companies they?ve contracted with to provide then with teleradiology services, Levin points out that the problem Sutter had with its previous provider represents another potential disadvantage in hiring these companies?sometimes hospitals just aren?t happy with the quality of coverage they receive.

?That?s why it?s really important to go with a high-quality company,? said Browning. ?If it doesn?t work out, I?m going to be held responsible for having them as a partner and for having had them read all of these studies overnight. Hiring a bad company is always going to reflect badly on your group?s day-to-day operations.?

It?s also important, Browning adds, to include emergency room physicians in deciding which teleradiology company to partner with. ?One of the things I did before hiring StatRad was to poll ER docs about StatRad,? he said. ?It was important to include them in the decision because they really do become the face of the radiology department overnight and their level of service has a dramatic impact on your turnaround times, confidence, and patient care.

Michael Bassett is a contributing writer for Axis Imaging News.