When a patient with a fractured leg arrives at Hartford Hospital in Hartford, Conn, a radiologist is on-site to read the films, whether it is three in the afternoon, or three in the morning. Radiologists at Hartford have been providing around-the-clock coverage for the hospital’s emergency room (ER) for the past 4 years. From Connecticut to California, more and more radiology groups are feeling pressed to provide 24-hour ER coverage, both to improve quality of care and to protect turf.
“Radiology is no longer an 8-hour-a-day job; it really is a 24-hour-a-day job,” says Paul Kamin, president of Memorial Radiology Medical Group (MEMRAD), a 52-member radiology group in Long Beach, Calif. MEMRAD provides coverage to eight hospitals in the Long Beach area and has offered 24-hour readings for the past 5 years.
TAKING THE LEAP TO 24 HOURS
When MEMRAD first looked at the question of 24-hour ER coverage, it operated in a situation typical of many radiology groups associated with hospital emergency rooms. If a patient came in during the night and needed radiography, the emergency room physician would read the film, make a diagnosis, and prescribe treatment. The next day, a radiologist would look at the films and either confirm or disagree with the ER physician’s assessment. “Some questioned the value of what the radiologist offered in terms of care after the fact, other than just reading the film and either agreeing or disagreeing,” Kamin says. “We were not really handling real-time care. There was some suggestion by ER physicians, not necessarily at our hospitals, but nationally, that they should be billing for these services since they were the ones who were actually reading the films. As a defense mechanism, we decided we were going to read films 24 hours a day.”
Similar concerns have prompted many groups to give serious consideration to around-the-clock ER coverage. “ER physicians in our facility were not talking about reading their own plain films, but they were beginning to have discussions about possibly doing ultrasound work in the emergency department,” says Stuart Markowitz, MD, chairman, Department of Radiology, Hartford Hospital. Radiology residents from Hartford’s residency program were already providing night ER coverage, but the Hartford group wanted to provide more experienced backup for these residents. “The residents who work nights are fairly junior and as technology advanced and the complexity of a tertiary care center advanced, there were procedures going on at night that were sometimes a little bit above the capabilities of the more junior residents,” Markowitz says. “To allow them in-house backup, we decided to put an attending radiologist on call in-house 24 hours a day.”
Radiologists at Hutchison Medical Center in Fort Oglethorpe, Ga, took a different approach. They no longer come into the hospital at night to read CT and ultrasound scans, as they did for many years. Now they read CT, ultrasound, MR, and nuclear medicine scans from their homes, which are linked to the hospital via a teleradiology system. Plain films are still read at the hospital the next morning. Turf battles have been averted by proactively establishing a good reputation with emergency room doctors and by arming themselves with plenty of data. “We have questioned the radiology performance of the ER physicians,” explains Joe Busch, MD, chief radiologist at Hutchison Medical Center. “In other words, what have they missed, what do they overcall, and what do they undercall? When they look at their numbers, they realize they need us.”
For radiology groups that decide they are going to provide 24-hour coverage, the first question to be answered is who will provide the coverage and how. Hartford Hospital radiologists made the decision to take turns providing night coverage. With 28 partners, they each work one night approximately every 4 weeks. Specialists in various areas such as pediatrics and interventional remain on call at home for special cases, while one radiologist spends the night at the hospital.
“Our night people work the next day,” Markowitz explains. “They do not get the next day off. It is not a night rotation. Each day, somebody works the night shift and the next day as well, so they work a double shift, with no loss of continuity.”
MEMRAD took a slightly different approach. Since the group covers eight hospitals, having a radiologist in each location 24 hours a day would prove too costly. A radiologist works nights at Long Beach Memorial Hospital, but the other facilities covered are equipped with a system the group patented and dubbed the Nighthawk. Stations at each hospital are equipped with a digitizer, in which analog films are placed and transmitted via high-speed transmission (T-1) lines to Long Beach Memorial. There the radiologist on call reads them. “Instead of someone at all the hospitals, we have one person spending the night at one hospital, taking care of eight hospitals,” Kamin says.
Originally, MEMRAD’s member radiologists took turns providing night coverage. Now, specific members of the group have daytime and nighttime coverage as part of their schedule, while everyone else works days only. “Our group happens to be very academic,” Kamin explains. “They have very diverse skills. They are not all [general] radiologists. It was difficult for everyone to handle the general nature of night call. About 3 years ago, we hired two people to staff nights full-time. Then we moved to four people. This year we are going to eight people. It will be part of their job. Nighttime radiology will be covered by members of our group who take calls every eighth night. This is just a small part of their rotation, but we will limit it to the people in the group who do it best.”
Kamin stresses the importance of having qualified people providing night coverage. “We wanted to make sure we could attract quality people with experience comparable to that of everyone else in our group,” he says. “In order to hire them, we felt that we had to make the job more palatable, giving them night work but offering work during the day as well.”
This was a concern for Markowitz’s group as well, and one reason it chose not to hire additional people to handle night duties. “We were afraid that if we went to some kind of nighttime rotation, there would be communication issues,” Markowitz says. “It is very hard, I think, to standardize the kind of care you provide when you have individuals who just cover your nights and do not interact much with the group during the day. It is hard to envision those individuals having the same investment in the practice as the daytime people do. Not that they are second-class citizens, but they tend to represent a different class of citizen in your organization. We were very concerned about that and for that reason have not gone to a night rotation or hired people specifically to cover those nighttime hours.”
Radiologists at Hutchison Medical Center also rejected the idea of hiring physicians specifically assigned to nighttime coverage. In the years before they installed a teleradiology system, Hutchison radiologists often drove to the hospital at night to read CT and ultrasound scans. “When CT first started in this hospital in the early ’80s, we came in during the middle of the night and read all the scans,” Busch says. “That meant getting in the car and driving down; I must admit that got old. But we did that for almost 10 years. We gave such good service that there were never any complaints or problems with encroachments on radiology services. When we started teleradiology, the perception was we were giving even better service.”
The seven physicians in Busch’s group are on call once a week. “A lot of doctors were afraid people would begrudge us because we would not come in anymore,” Busch says. “But the staff perception was ‘These guys can now read the ultrasound, CT, MR, and nuclear medicine scans all night long.’ And that is what we do. At night, we look at a lot of studies from our homes.”
BENEFITS OF NIGHTTIME COVERAGE
Hospital administrators have responded positively to 24-hour radiology coverage. “They in essence have full-time radiologists 24 hours a day, which most hospitals do not,” Kamin says of the response to MEMRAD’s Nighthawk system. “They like it in the sense that if a patient comes in at 10 pm, they can make a treatment decision right away. If the film comes in and the radiologist makes the primary diagnosis, and does not have to wait to consult with someone else, he will go ahead and dictate the case, so by the time the doctor comes in to make rounds, a report is available to him. It can speed up discharge time. The ER doctors like it because if they need someone to consult with about a case, there is someone readily available.”
Markowitz thinks a 24-hour presence can improve relations between radiologists and others in the medical community. “Over the years, radiology has always had a bit of a bad reputation in the medical community,” he says. “People used to think, ‘Like at the post office, they come in at 9, leave at 6.’ That is not true anymore; as a matter of fact, radiologists here work much longer hours than most of the other specialties and their frequency on call and working weekends is much higher than most of the other specialties. But there is still that sense out there that we are an elitist group and that we do not work that much. I think putting ourselves in the position where people see us here at 9, 10, or 11 o’clock every single night has begun to change the impression of what radiologists do, the quantity of work that they accomplish, and the degree to which they contribute to global patient care. So I think we are slowly beginning to change the attitude here on our campus.”
Busch thinks developing a close working relationship with ER physicians from the start can head off any attempts to encroach on radiologists’ territory. “Our relationship with the emergency room has always been outstanding,” he says. “They think we give them great service. And we have. That is one thing that has kept us away from radiology problems. When they came up here, they immediately went away. They did not go away at other places.”
SETTING UP A SYSTEM
Establishing around-the-clock coverage requires a substantial commitment from radiologists, in time or money. “Since we do not hire additional people [for nighttime coverage], we have not had to upsize our staff, so in reality, it does not cost us anything, at least not anything you can put on the bottom line,” Markowitz says. “Of course, it does increase each individual’s workload by adding these hours into the system. Because we have a large group, our nighttime coverage works out that each person is required to do it only a little more than once a month.”
MEMRAD found the costs of its Nighthawk system to be significant, with substantial outlays for equipment, T-1 lines, and additional personnel hired to help provide nighttime coverage. Originally, MEMRAD partnered with a technology vendor, which provided a lot of equipment free of charge. After 5 years, however, much of that equipment needed to be replaced, and the funds came from MEMRAD’s coffers. “I think it cost each one in our group probably about $25,000 to have this service,” Kamin says. “Maybe we built a Mercedes Benz, and there probably is a cheaper system. But we still think there is some potential business out there. We will probably spend some time trying to generate more revenue. We might go to other groups and try to develop other sources of revenue.”
These kinds of costs, both monetary and personal, make it difficult for smaller groups to provide nighttime coverage.
“Most people have teleradiology, but, unfortunately, what happens is they have only four or five guys in their group and they cannot provide the same service,” Kamin says. “You end up on call every fourth night and cannot work the next day, so it may be necessary to hire another person, which drives up the cost.”
Kamin sees a possible solution to this problem if several small groups join together to provide coverage. “I think you need a joint venture with other groups, if you can work together and not be afraid of that other group encroaching on your territory,” he says. “In the past, everyone has been afraid of other groups encroaching on their ground. In order to do this, you have to form partnerships, through groups either totally merging, or forming some kind of joint venture.”
Kamin also advises shopping around for equipment and comparing prices among vendors. Markowitz warns groups considering switching to 24-hour coverage to make a careful assessment of their goals and to be willing to give their full support to the program. “If you really are interested in radiology having a greater presence, and you really are willing to provide the same quality of care in the evening hours as you do during the day, and all of that is additionally geared toward preventing someone else from doing your work, then I think you have to try to mirror as much as possible the level of service you offer during the day,” he says. “You have to make sure you have quality personnel covering nights, very similar to the quality of people you use in the daytime. It is easy to shortchange yourself and hire cheap labor to work your nights for you. It is very shortsighted to do that.”
Markowitz also cautions against trusting residents to carry the burden of nighttime coverage. “Another thing that I see a lot of people doing is, say, ‘Our residents are here, so everything is covered for us,’ ” he says. “You have to remember that the emergency medicine physicians working out there are not residents. They are attending full-time emergency medical physicians. And if you put a resident on the front line to work with an attending physician, it is better than nothing, but not the same as having the attending there. Yet when you have a residency program, you have to make sure that your residents are exposed to that type of work, you cannot remove them from that setting. Residents need that exposure and training, but I think they need access to attending backup.”
Kamin and Markowitz think 24-hour coverage will become the norm, if not a necessity, for radiology groups in the future. “Many large groups are starting to offer this coverage,” Kamin says. “If small groups do not do this, they are going to lose business.”
Even Busch agrees that 24-hour coverage may be necessary at larger institutions. “If I were in a 400-bed institution with 12 radiologists and a booming, busy hospital all night long, I think there is real justification to have a radiologist there all night,” he says. “Then the radiologist brings value to the imaging that is going on all night long. He brings expertise to the case; it is just better medicine.”
Whether groups choose to provide a 24-hour presence at hospitals or not, Busch thinks the key to success comes down to what he calls the “three As of radiology”: availability, affability, and ability. He says: “You have to be there, you have to be friendly, and you have to know what you are doing.”
Cynthia S. Myers is a contributing writer for Decisions in Axis Imaging News.