In the old days of radiology, covering nights was a straightforward affair. One of the benefits of working at an academic institution was that residents would do the heavy lifting, but in most other instances, a radiologist had to be available to “cover” the emergency department. Sleep disturbances were to be expected, but considered part of the job.
This model, in which every member of the practice rotates through night call, still exists. The question is for how long? Information technology and a dramatic uptick in imaging in the emergency department (ED) have rendered this model untenable in small practices. And the widening availability of high-quality teleradiology services has made outsourcing an increasingly attractive choice for groups of all sizes.
Some advocates of the traditional approach, in which practice members handle night call, believe that outsourcing night coverage does nothing less than put the future of the specialty at risk. But other groups, often those on the smaller end of the spectrum, are undeterred. These groups employ a nighthawk or outsource to a nighthawk service and enjoy sleeping through the night, every night, without ever having to take call. Decisions in Axis Imaging News identified five night coverage models outside the academic model and explored the costs and benefits of each.
Model No. 1: The Offshore (in which the practice contracts with an off-shore teleradiology service to provide preliminary or temporary reads).
North Shore Radiologists (NSR) in the Chicago suburb of Skokie, Ill, covers a single hospital with eight radiologists. More than 2 years ago, the group signed up with Nighthawk Radiology Services, Coeur D’Alene, Idaho, a company that employs United States-trained, board-certified radiologists at its reading centers in Sydney, Australia, and Zurich, Switzerland. At that time, Nighthawk was the only game in town, according to Leonard Berlin, MD, a radiologist at NSR.
Before committing to a contract, Berlin contacted the group’s malpractice carrier, the Illinois State Medical Society Insurance Company, and advised it of the plan to employ an offshore company to provide night reads. The insurance company was skeptical at first because it felt that in the event of litigation, a plaintiff’s lawyer would pursue a local company instead of one that was based in Australia, where Nighthawk’s headquarters were located at the time. Theoretically, the doctor conceded the point but also insisted that Nighthawk would produce a radiologist for a trial if necessary. The insurance company gave them the green light without increasing the malpractice insurance premium. So far, it has been a moot point because there has not been any litigation concerning night reads, Berlin notes.
The price of the initial setup was minimal; hardware and software cost roughly $5,000. There is no annual fee to the group, and the hardware is the responsibility of the group. With a price of $55 per temporary report—usually CT but sometimes ultrasound or nuclear medicine—the group spends about $75,000 on the night service that covers them 7 days a week from 9 PM until 7 AM.
“We have eight radiologists, so that represents a loss in gross income of a little bit less than $10,000—in other words, $6,000 after tax dollars—a man. So everyone loves it,” Berlin says.
The overall volume of night studies has doubled since the group signed on for the service. Berlin attributed the growth to two factors: the general increase in CT utilization and the acquisition of the nighthawk service. Before Nighthawk was employed, an ED physician had to call a radiologist in the middle of the night and get permission to do a CT scan. Often, the call would wake up the radiologist, and being aroused from his or her slumber would rarely leave the radiologist in an agreeable mood, according to Berlin. As a result, the radiologist would not okay every scan, and often try to convince the emergency department doctor that the scan was not necessary or could wait until the next day. Now the emergency doctors bypass the radiologist, and getting the okay is virtually automatic, Berlin says.
Model No. 2: The Full-time Nighthawk (in which the practice employs a full-time radiologist to read every night).
With more than 850 employees spread across three divisions, Radiological Associates of Sacramento (RAS) is the largest private radiology practice in Northern California. It illustrates why size matters when it comes to handling night call internally.
“We are large enough that we can do it internally,” says David Seidenwurm, MD. “We have enough radiologists and staff people and infrastructure that we can manage it ourselves.” In total, RAS has more than 60 credentialed radiologists that cover six hospitals, 11 offices that they own, plus five where they read. With those numbers, call was spread widely enough to prevent a serious negative impact on quality of life. The initial teleradiology startup cost a decade ago for software, hardware, and setup was about $200,000. RAS employs three full-time employees who support the PACS, and roughly a third of their time is dedicated to night reads.
Six months ago, the practice was able to spread the call even more thinly when it brought on a full-time partner who prefers a steady diet of night call. In addition to the occasional partner with a nocturnal predilection who volunteers for a stint of night duty, all partners fill in the night coverage gaps, which are now quite intermittent. “We have the full spectrum of personalities in our group, and there are some people who would rather be boiled in oil than work a night-owl shift,” Seidenwurm says. “And there are some people who find that shift a most relaxing and pleasant way to spend the evening.”
If a physician chooses to work extra nighthawk shifts, the group tries to accommodate them. Sometimes that means modifying a nighthawk station to make it more comfortable with amenities like a well-stocked refrigerator, cable TV, comfortable seating, and recliners.
The benefits to this approach are twofold. “We haven’t made ourselves dependent on anyone outside of our organization. We maintain control of our practice,” Seidenwurm says. “The main benefit is that you remain the master of your destiny. You maintain your autonomy, you maintain your control, you maintain your relationship with your hospital, you maintain your relationship with your referring physician, in a very direct way you maintain your integrity as a radiologist.”
Over the past year, the night volume has increased by 10%. Seidenwurm attributes that increase to imaging becoming the dominant triage technique in American medicine. Seidenwurm believes that there is a lot of pressure on physicians to make decisions quickly, and imaging helps with that. “Radiology adds value. They want it early and they want it often,” Seidenwurm says. “If they know they’re not waking you up, they know you’re already working, there’s not the same barrier. If it’s available, they will use it.”
Model No. 3: The Nighthawk Service Line (in which the practice develops its own nighthawk service and offers it to other practices).
In the fall of 1997, Puget Sound Radiology and Radiology Associates merged, forming Radia, the largest private practice radiology group in the Pacific Northwest. The size of the Washington-based group justified creating a new position: a full-time nighthawk. The group’s radiologists welcomed the paradigm shift. Until that point, both groups handled nights by assigning three radiologists to night duty. Those doctors were woken up during the wee hours to provide reads and the sleep-interrupted radiologists were often tired and nonfunctional the next day, according to Jeffrey Robinson, MD, medical director at teleRadia, a subgroup of Radia that handles nighthawk duties.
“It wasn’t done as a profit-making [venture]. It wasn’t even done to break even. But it was done as a sustainability issue,” Robinson says, discussing the adoption of the full-time nighthawk. “We saw it as an efficiency measure, not necessarily a cost-saving measure.” The group focused on covering its own hospitals for the next few years. Then it received a phone call from a small hospital that was covered by a single radiologist. The small hospital was in negotiations with a new emergency department physician who agreed to accept the position on one condition: he wanted a radiologist on call. The veteran radiologist was not willing to commit to being on call 365 days a year.
Through word of mouth, the small hospital had heard that teleRadia did remote work, so it called Robinson and asked if the group could cover its nights. He agreed and has since received many requests for night coverage. teleRadia now provides nighthawk service for 25 hospitals, and the coverage has become a source of revenue for Radia, an obvious benefit that may not have been present in the early years of the service. Since the overnight coverage was not set up as a business, there was minimal attention paid to accounting in the early years, according to Robinson. The group did not know if the nighthawk service was losing or making money. As the service kept growing, one of Radia’s partners insisted on improved accounting and that is how the group found out that the service was profitable.
There have been costs associated with creating the service as well as costs for maintenance, but Robinson does not offer exact figures. However, he does say that starting the nighthawk service cost significantly more than $1 million to get the necessary imaging network up and running.
To set up the service, the group had to buy PACS workstations, network equipment (hubs, routers, and switches), and a PACS system that had all of the functions of a traditional PACS with one major difference—the group did not need an archiving component because its customers handled that. After continued growth, the group also needed to buy real estate. When teleRadia began, reads were conducted in a radiology department in a hospital. As it grew, the group decided to build a reading center. The calls and new contracts kept coming, and now the group has two reading rooms and a pool of five full-time radiologists that take turns covering the two-person night shift. That is a significant change from the single, underutilized radiologist who served as the first nighthawk more than 8 years ago.
teleRadia conducted roughly 70,000 reads last year, an increase of 50% from the previous year and a 100% increase from 18 months ago. The benefits of the nighthawk service are not solely financial. The system also helps day radiologists because it is utilized for load leveling. Quality of life for the group’s 55 radiologists is improved because doctors have to work nights only if they volunteer. Lastly, its nighthawk service has been a source of marketing for the group. “It’s like the UCLA football team, it doesn’t necessarily say very much about the university, but it’s a vehicle for publicity,” Robinson says.
The group charges its customers by the read for nighthawk service and offers both preliminary and primary reads. Clients who want evening and weekend coverage incur an additional monthly charge, which reflects the difficulty of staffing, Robinson says. Nighthawk customers that require only a handful of reads are also charged an additional monthly fee. “If you have one reading a week, then what you need is not a reading service. What you’re really hiring is a standby service. You’re paying someone to be there,” Robinson says.
He believes that there will be an increased demand for primary reads from teleRadia’s nighthawk service in the future. Robinson also predicts that more nighthawk customers will request night and weekend coverage. The past success of the nighthawk includes one more benefit. It has enabled Robinson to support a group he holds in high esteem, the rural radiologist.
“Rural radiology is very hard. Those guys work very hard and it’s hard to survive. I’m not interested in making a living off the backs of rural radiologists,” Robinson says. “I don’t want our health care system to evolve to six mega-radiology groups across the country and nobody else in the field. I’m all for making things work for the solo practitioner out in the small towns. For that reason, I probably charge a lot less than the commercial services because they have a different mission.”
Model No. 4: Final Nighthawk Reads (in which the practice outsources final reads to a United States-based teleradiology company).
Until 4 years ago, Florida Radiology Consultants (FRC) handled its own overnight coverage, with the 11 radiologists taking turns covering the overnight shift. Factoring in physicians on vacation, it seemed like the partners were on call once or twice a week, says Joe Tienstra, MD, a radiologist at FRC. Picking up between zero and two calls a night, the shift was sometimes a non-issue because there would not be any calls. At other times, it was a sleep-disturbing nuisance. When a read was required, the image would be sent to the on-call radiologist at home, who would have to wait patiently for the slow download to be completed. After reading the image, the radiologist called the ED physician with the results and then made two more calls. One was to the hospital to get more information, including the number assigned to the patient. The next call was to the dictation service.
About 4 years ago, there was an explosive growth in overnight reads and the on-call doctors were often up all night. By the time the morning rolled around, the radiologist had not slept a wink, so they would pass out once day coverage relieved them and arrive at work at noon or later. Needless to say, that physician often felt jet lagged and exhausted and was unable to operate at peak performance levels.
Three years ago, the group, which covers a hospital with three locations, hired a nighthawk service, Virtual Radiologic Consultants, Minneapolis, to cover the 11 PM to 7 AM shift. The system held up to Hurricanes Charlie and Wilma and was a big help to the group during these critical times. While residents in the area did not have Internet or phone service, the hospital service never went down, which was a big relief. “After one of those things hits and comes through, you have so many personal issues and office issues to take care of, the last thing you want to do is worry about who is going to be up all night reading cases,” Tienstra says.
The overnight coverage, for which FRC would overread in the morning, went relatively smoothly for about 2 years. The one problem? Weekends. One of the emergency departments that FRC covers is the busiest between Tampa and Miami. Even though each hospital has one radiologist working nights on the weekend, the radiologist often would be overwhelmed. The morning physician would sometimes have to work well into the afternoon finishing cases from the previous night. So, the group asked their nighthawk service if they would consider conducting final reads on the weekends. Their nighthawk provider was interested, but acquiring the necessary credentialing from the hospital took a few months. After all the paperwork was completed, the workload of the weekend, day radiologists changed significantly. “I don’t have the overwhelming burden of the previous night’s CT scans to wade through before I even get to [the current] day’s work,” Tienstra says.
The nighthawk service began providing final night reads last November. They are $20 more expensive than the $50 preliminary reads. In addition to covering weekends, the service also provides final reads on days before big holidays and that has a positive effect on radiologists’ quality of life. Overall, the night reads average out to about $1,000 per night or about $350,000 per year, a cost that the hospital shares.
Model No. 5: The Traditional Democratic-with-a-Modern-Twist (in which each practice member rotates through night call using a state-of-the-art teleradiology hookup to their house).
Newport Harbor Radiology Associates (NHRA) in Southern California has 23 radiologists and all but seven take night call. Its model has not changed since the inception of the group; members take turns handling the overnight with one exception: technology allows the on-call physician to read from home. Currently, the nighthawk arrives at the single hospital the group covers at 5 PM and stays until the work is done. This typically takes 5 hours. When the decks are cleared, the radiologist goes home and covers via teleradiology using their personal computers until the next morning. The doctors often have the opportunity for some shut-eye during the night and can catch up on sleep during the day before heading back to the hospital for another 5 o’clock shift. On-call shifts are usually 1 week long.
The cost to implement this program is minimal. Most doctors already have a computer at home as well as an adequate monitor, and the software is provided by the hospital. The biggest expense is the radiologist, a cost that some other practices feel is prohibitive. But many advocates of this traditional solution feel that it is the most forward-thinking option available.
“I think it’s very shortsighted for groups to use nighthawk services,” says Michael Brant-Zawadzki, MD, FACR, a radiologist at NHRA. “There is an economic model that on the short end suggests there are economic advantages to outsourcing night call because you don’t have the expense of an FTE—we have a full FTE that takes night call—as opposed to one that reads prelims at a lower rate. On the short end, that seems like an economic advantage, but it’s not a long stretch to say, Gee, the price of getting a reading at 2 AM is 75% of what it is during the day. Why not set up a system that’s 75% during the day as well?’ In essence, what outsourcing night call does is devalue radiology. It turns radiology into a commodity. The long-term economic view of outsourcing night call is that it’s self-defeating if not self-destructive to radiology as a profession as opposed to a commodity.”
Brant-Zawadzki is an outspoken proponent of groups handling their own night call, and he does not pull any punches. He believes that coddled physicians who do not want to take night shifts are partially to blame. From a business point of view, he thinks that outsourcing does not make sense because it takes away some of the primary competitive advantages. For NHRA, those include being tuned into the hospital, being able to provide continuity of care with the patients the next day, and being able to talk to the other physicians. Once a group says that the advantages work only during the day, the argument loses some of its punch. NHRA also likes to tout the fact that it offers modality subspecialization during the night. It takes pride in being part of a hospital practice where its work and skills are evaluated by the entire staff—in NHRA’s case, more than 1,000 doctors—every 2 years. “If we then say, Well, that works until 10 o’clock at night, but after that anybody can do this job, it takes away from that competitive advantage,” Brant-Zawadzki says.
Although the future of nighthawk services is yet to be determined, night reads are on the rise. North Shore Radiologists’ numbers are a good indicator of that. Before signing on with a nighthawk service 2 years ago, NSR averaged 1.5 emergency cases between the hours of 9 PM and 7 AM. When the nighthawk service went into effect, the number of cases began to rise immediately. Today, their average has risen to four for the same time period—an increase of almost 300%.
Some radiologists attribute the growth to young ED physicians weaned on imaging technology and accustomed to being able to order CT scans since the beginning of their careers, and uncomfortable practicing medicine without imaging tools. Advancing technology also has increased dramatically the applications for CT. Unlike a decade ago, CT is now ordered to detect kidney stones or a pulmonary embolism. Moving forward, the new 64-detector CT scanners likely will play an important part in diagnosing myocardial infarction, according to Berlin. As these units are being installed across the country, it is likely they will add to the rise of the number of total scans performed overnight. “Bottom line: the number of CTs ordered will continue to go up and up and up,” said Berlin in an e-mail.
Each group will need to keep this in mind as they assess which model will meet their needs for night coverage.
Stephen Krcmar is staff writer for Decisions in Axis Imaging News.