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“Soon,” says Arl Van Moore, Jr, MD, “everybody is going to be able to practice in everybody else’s backyard.”
Moore is practice president at Charlotte Radiology, a private radiology group in North Carolina. He is also vice chairman of the Board of Chancellors of the American College of Radiology (ACR) and chairman of the ACR’s Task Force on International Teleradiology.
The ACR has a set of guidelines for the practice of tele-radiology that essentially requires teleradiologists to be board certified and properly licensed and credentialed in the locales where the images they read emanate from. They are also expected to have medical malpractice insurance and to provide quality, professional services.
The college is also working on international teleradiology guidelines that Moore says are needed but not yet in place. But when it comes to the sheer electronic movement of images taking place now, a big change for radiology in the past half decade or so, Moore says the college has not really focused on these changes.
“We in my practice move images all around for specialty reads. The college hasn’t really addressed this,” Moore says. He notes that teleradiology is proliferating rapidly but is still maturing as an industry and that its impact is “problematic.”
“The trend is a concern to those who are trying to build a practice in a community, and then to have those practice patterns disrupted because of this. The referrers you play golf with or see socially—those relationships are being disrupted for quality or economic reasons.”
 Arl Van Moore, Jr, MD |
For now, Moore says, the ACR is putting the emphasis on keeping teleradiology standards high within the practice of radiology itself. But on issues like teleradiologists interpreting for nonradiologists who own imaging equipment or teleradiology companies capturing whole segments of the image interpreting market, Moore says the college is gathering data.
“The ACR wants to see what the issues are, and as they become more thoroughly defined, it can act,” he says.
The trouble is that it is hard for data gatherers to keep up with what is happening on the ground. Earlier this summer, the ACR published a study on teleradiology practices from a survey done in 1999.1 Much has happened since that study was done. At the time of the survey, teleradiology was defined simply as transmitting images from a facility to another location, even another location in the facility. The survey found that 71% of multi-radiologist practices were using teleradiology for the interpretation of about 5% of cases. Most of those cases involved preliminary reads of on-call scans, which were occurring mostly at night.
When the big commercial teleradiology companies began to organize, at about the same time that the ACR survey was done, they retained this focus on emergency night reads, with the usual output being preliminary reports that were to be overread the next day. But now, with more and more companies organizing to vie for the teleradiology dollar and with radiologists in short supply, that ER night focus is shifting. Not only are the companies pushing day-reading services; they are also offering the final reports that those day services demand.
But it is a polychromatic landscape. Some teleradiology companies eschew day reads out of loyalty to their radiologist clients, and others are doing day reads but carefully choosing the clients they will read for. Still other teleradiology providers are gearing up to have their radiologists read for the many nonradiologist doctors who have put scanners in their clinics and who refer patients to them. The night readers are becoming dayhawks, but in carefully thought out ways that begin by targeting perceived segments of need.
PARTNER LOYALTY
Sean Casey, MD, is owner and founder of Virtual Radiologic Consultants (VRC), a major provider of teleradiology services that is headquartered in Minneapolis. VRC is licensed in all states, has clients in about 48 of them, and serves about 500 facilities using a staff of about 50 radiologists, Casey says. He says the company’s focus remains where it has always been—on providing emergency night reads for hospitals and radiology groups.
Casey says the shortage of radiologists has created a “huge market” for daytime teleradiology, however, and VRC has responded by offering around the clock coverage.
“We are providing daytime interpretation to meet what our clients are asking for,” he says. “We are a partner with the private practice radiology groups. If they ask us for daytime, we’d love to do it, but we haven’t been aggressively gathering day business. We don’t want to compete with our customers. We want to assist them.”
For the same reason—not competing with its radiology group clients—VRC has not pursued interpreting for nonradiology clinicians who have put scanners in their clinics, Casey says. “We have plenty of business in the existing market, and serving our current clients is our primary responsibility.”
He adds, “There’s no doubt that teleradiology tears down boundaries and creates competition, and that may be worrisome to some people. But radiology needs to be more worried about the shortage, so if turnaround and service drop, that won’t encourage clinicians to do their own imaging. Teleradiology is able to increase service levels and make it harder for the less qualified clinicians to do their own interpretations.”
Casey says he more than understands why teleradiology providers have their sights set on the daytime demand. He cites impediments, however.
“There are hospitals out there that have totally lost their radiology groups,” he says. “My belief is that having both on-site and off-site coverage is the ideal mix, but there is a need for at least some on-site presence.” Staffing needy hospitals with radiologists is not what VRC is geared up to do.
Another impediment is inadequate income from day reading, at least in Casey’s view.
“Funding is a challenge to daytime,” he says. “Any teleradiology provider is generally charging fees that are essentially considered professional fees, yet there is a need to pay all the company’s infrastructure from that. The hospital is collecting technical fees, which are supposed to cover the PACS and the RIS (radiology information system), but they don’t subsidize the infrastructure of the teleradiology provider. That exacerbates the daytime business model. It is extremely difficult for the teleradiology provider to read plain film at or around Medicare rates. When you’re talking about CT and MR, it becomes more possible.”
Casey says hospitals’ technical fees have given them a “cushion” with which they could pay radiologists beyond what radiologists get in professional fees. “But until the reality of the shortage sets in,” he says, “there is an unwillingness to subsidize the professional fee with the technical fee. Radiology is a profit center for them, and it subsidizes many other parts of the hospital. They are only slowly getting to the view that radiology might be profit neutral.”
There are pockets of need, like an extreme shortage of pediatric radiologists, that have caused VRC to target those markets, Casey says, but there again only a portion of that coverage could be outsourced, with some on site required.
The “temporal” shortage of radiologists at night has made the teleradiology companies specializing in night reads successful. “But the day model is generally more challenging,” Casey says.
DIVING IN
Nonetheless, some of the bigger teleradiology providers are going full steam ahead with plans to take on the most needy segments of the daytime market.
Gerald Johnson, PhD, CHE, is senior vice president for hospital operations for American Teleradiology Nighthawks (ATN), a Roanoke, Va-based company that has 12 radiologists on staff and another 30 contracted, to read for 67 hospitals around the country.
“We’re the number three night hawk, and we’re moving to the day business. That’s where the big need is,” Johnson says, adding that the company will “continue to grow the night service.”
ATN is just in the process of rolling out its daytime interpreting service, Johnson says, but he says the demand is definitely there. “Right now, I’ve got in excess of 20 small hospital clients standing in line waiting for us to offer day services.”
Johnson says ATN’s sales force is already promoting the day service. “If we do only 6% of hospitals, still that’s 300 hospitals,” he says. “The three major vendors are all looking to move toward the day service,” he says. “We think we’re ahead of the curve. We’re pushing it.”
Johnson says the goal is to provide supplemental coverage to radiology clinics and hospitals that have more daytime need than their radiologists on staff can handle, but more important, he says, ATN will provide complete coverage to small rural hospitals that cannot attract radiologists because of the shortage, or because there is not enough work to support a salary.
“If the rural hospital doesn’t have an existing radiology group, we’ll contract as the existing radiology group. We’ll place a radiologist on site and then a radiology assistant, and we’ll provide as a backup the teleradiology piece, where they have access to the specialty piece,” Johnson says, adding that on-site radiologists might be needed only 2 or 3 days a week in many rural locations.
He is betting that ATN can leverage its on-site coverage with its teleradiology coverage and achieve efficiencies that lead to profitability for ATN.
“We as a company will offer a pay incentive for the doctors who work for us that’s much different than what the small hospital can give them. At a small hospital, a radiologist might read only five or 10 cases, and he could read another five or 10 by teleradiology and get paid for that too. For us, they will get paid for what they read,” Johnson says. Doctors could rotate through small hospitals and read teleradiology cases too, making the whole venture profitable for all parties.
For small hospitals still stuck in the film era, Johnson says ATN has a “PACS initiative” to bring them digital. “We will put in a PACS and a RIS; we’ll send our team to do the install. Our IS (information services) will set everything up.” ATN will also install film digitizers. The equipment will reside at the client hospital but will belong to ATN.
What if a client becomes dissatisfied and wants to break its contract? “The equipment ultimately belongs to us,” Johnson says. “They can purchase it, or we’ll take it.”
But ATN clearly believes in its business model. “Teleradiology is the way of the future,” Johnson says. “The big teleradiology companies will absorb most of the rural market. Access to specialists will be available to everybody. That’s what the referrer wants; it increases the level of patient care.”
Johnson says there is no dearth of venture capitalists ready to back ATN’s daytime expansion. “We have private, eager investors. We haven’t had any problem finding the money we need. A lot of physicians are looking to invest their own money.”
LIMITLESS DEMAND
David Hunter, MD, looks at his teleradiology plan and sees a way to supply service to market segments crying for help. Hunter, himself a radiologist, says he likes to carry portable ultrasound to needy people in developing countries when he can get some free time. Four years ago, he formed a company, Visionary Radiology PC, to provide coverage for imaging centers and hospitals in Missouri and Illinois. Hunter made use of VRC radiologists to read for Visionary, and he himself read for VRC when he could.
In July, Hunter formed a second company, Allied Radiology Solutions PC, to provide “strictly daytime teleradiology.” He plans to use VRC radiologists to read for Allied too, and he has contracted with a headhunting service to find more radiologists for Allied.
Hunter said he talked to VRC about starting a daytime teleradiology service to cover for nonradiologists, especially orthopods, who had imaging equipment but no one to interpret. VRC, he says, declined to cover the market segment.
“It’s possible I will be taking business away from VRC clients,” Hunter says, “but it’s not unethical or unfair to do radiology for an orthopedic group. I’ve got no conflict of interest because it’s a business that VRC loses out on. They want the night coverage. I am very interested in ethics, but there is such an incredible shortage of radiologists out there. I recognize that stand-alone imaging centers, whether radiologists or nonradiologists, are trying to provide excellent care. If they have contacted me, there’s a reason they’re not using the in-town group. They may not feel the quality is there, or the group is too busy.”
Hunter says that he has been cold calling hospitals and imaging centers and that almost all of them say they need help. “I would say the demand is almost limitless. There’s a huge market. There could be 20 companies like Allied, and we could all be extremely busy.”
Hunter says that Allied will actually create profit for the imaging centers and hospitals it serves in the day. “They will collect the full technical fee and part of the professional fee, and pay us a professional fee that is less than the full fee,” he says. “They’re going to actually make money on us. We’ll be able to do a higher volume, and we’ll have efficiencies in our system. If you sit in hospitals, you get constant interruptions, but with Allied, we read case after case with no interruption. The only interruption is the call we make to the doctor on a dangerous finding.”
TELERADIA
 Jeffrey Robinson, MD |
Jeffrey Robinson, MD, is medical director of teleRadia, the teleradiology offshoot of Radia—a major Seattle area radiology group. Robinson says teleRadia now provides night coverage and an increasing amount of daytime coverage to eight area hospitals that Radia does all reading for. Another 16 hospitals scattered in rural areas around Washington state also use teleRadia’s services. He says in the last 2 years teleRadia’s daytime services have equaled its night coverage.
“We do remote diagnosis for many hospitals with our subspecialists. We have contracts with medical groups. We have three, and soon to be four, radiologists on every day, one person at night, and three in the evening, all on overlapping shifts. So far, our capacity is meeting demand, but we’ve never marketed our services. We haven’t had the capacity to grow that fast because we’re not a pure player. We have many initiatives of which teleradiology is only one, but it’s now considered one of our core product lines.”
Robinson says demand for teleradiology is still in the growth phase, with the volume of imaging overall outstripping both the growth of medicine and population growth. “A doctor can send a patient for a scan and then see another patient right away. It’s a more time-efficient way to practice medicine. But that’s not to say it’s cheaper. It means a lot more imaging dollars are spent.”
The sheer demand for imaging has forced radiology groups to turn to teleradiology, he adds. “It’s not that radiologists would rather be out on yachts than reading film. The radiologists are swamped. It’s a survival tactic.”
He says teleRadia does provide daytime coverage to imaging clinics run by nonradiologist clinicians. “It’s a politically sensitive issue, but the realities of life have made us decide to provide that coverage. Historically, our group has not had a lot of technical assets or imaging centers. We have been based on professional services and professional reimbursement. If an orthopod sends us an MR, we get the professional fee. If we don’t do it, that business will go out of state. It’s not a monopoly market.”
He says teleRadia is also preparing for new markets. “We are looking at CT angiography, and that’s going to be a big change. CTA is going to be huge in the ER&. If we can provide reliable diagnostic exams to say who has coronary artery disease, that’s going to be a huge benefit to reducing costs and increasing care. If a hospital embarks on ER CTA, we’ll be ready. We look forward to it.”
OKLAHOMA
Are You JCAHO’ed? |
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JCAHO, the Joint Commission on the Accreditation of Healthcare Orga- nizations, has never been shy about promoting itself, one reason it has been so successful. Now, for teleradiology companies and the hospitals that use them, JCAHO has adopted a procedural shortcut that may be an irresistible lure. Interest in JCAHO accreditation is running high among providers of teleradiology. According to Michael Kulczycki, the commission’s executive director for ambulatory care accreditation, JCAHO now has about a dozen teleradiology providers accredited. “Another four are in the pipeline for this year, and there’s interest from 30 more over the next couple of years.” JCAHO has not promoted itself to teleradiology companies either. “Other than interviews and articles, it’s all been word of mouth,” Kulczycki says. Of the teleradiology companies interviewed for the accompanying article, Virtual Radiologic Consultants is already JCAHO accredited, and American Teleradiology Nighthawks is quickly pursuing accreditation. So is Allied Radiology Solutions. The reason for the high interest is twofold. JCAHO accreditation by itself is a reassuring quality stamp when teleradiology firms are looking for clients. But the second reason for the interest is more compelling: If a teleradiology company has gone through the JCAHO process and cleared all its doctors, then that process may not have to be repeated for and by each hospital it serves. As Kulczycki puts it, “We have been trying to provide guidance to the customers of the teleradiology firms that they can rely on the licensing and credentialing of the teleradiology firm if it is JCAHO accredited.” As the JCAHO web site puts it, “It is not necessary for JCAHO accreditation purposes to maintain a complete credentials file for each provider or fully credential the provider using your hospital’s process.” Sarah Moore is vice president of The Medical Center, a 388-bed regional hospital based in Bowling Green, KY. Moore says the hospital was once contracted with a non-JCAHO accredited teleradiology company, but has now switched to a teleradiology provider that is accredited. “We did have to credential every teleradiology doctor in the past. Every time we met as a staff it seemed we had to credential a teleradiologist. The background checks had to be done on each and every physician, and the company might have 10 or 12 to 20 physicians.” Now, Moore says, because the hospital’s teleradiology provider is JCAHO accredited, the hospital does not have to go through the lengthy process of clearing each teleradiologist. The teleradiology company has already done that and had its process cleared through JCAHO. “That’s the beauty of the JCAHO standards,” Moore says. She advises hospitals to demand JCAHO accreditation from their teleradiology providers. “Particularly if you are JCAHO accredited,” she says, “that just raises the bar.” |
| —G. Wiley |
Another example of a practice model in teleradiology can be found in Oklahoma, where a unique communications network has been developed to serve rural areas, bringing them video, voice, and data over fiber optics and wireless channels. Teleradiology for rural hospitals is one of the services on this network, which is called OneNet.
Dean Fullingim, DO, is president of Diagnostic Imaging Associates Inc (DIA) in Tulsa, which has 12 full-time radiologists reading for 30 hospitals and a number of clinics, some in Tulsa but most in rural Oklahoma. “We take care of most of rural Oklahoma east of the I-35,” Fullingim says. DIA also covers clients in rural northeast Texas. DIA’s radiologists are on staff at all the rural hospitals it serves, but DIA physically covers only one of them, Fullingim says. Most of the images it reads are CT. “Any contrast would be covered by the ER physician,” Fullingim says. “A lot of the interventional radiology travel stuff comes to us in Tulsa.”
DIA operates its emergency coverage around the clock, with one or two radiologists working the night shift. Fullingim estimates DIA handles about 200,000 tele-radiology examinations per year in Tulsa and from the rural locations. DIA, which is owned by its partner radiologists, has viewing stations in Tulsa hospitals and another in Cushing. It acts as the PACS provider for its rural hospital clients, and it also operates a centralized RIS. Turn-around on its reports is about 6 hours, Fullingim says. For night stat reads, the report is faxed to the hospital directly.
An important part of DIA’s strategy, Fullingim says, is that it will not do night teleradiology as a carve-out. It demands all of a hospital’s coverage if it is going to do any. “My deal is, if I pay a radiologist, I want him working all day,” says Fullingim.
Fullingim credits the OneNet network with making the rural teleradiology possible. He says OneNet evolved to serve rural Oklahoma by stringing fiber-optic cable through abandoned oil pipelines. “Lots of rural Oklahoma has two 150 meg cables,” he says, noting that because the network is subsidized by the state a connection fee might be as low as $600 monthly.
Fullingim says if he could find more radiologists he could expand DIA’s coverage. “I grew up in rural Oklahoma, and my heart is there to help them,” he says.
CONCLUSION
Teleradiology may not be mature as a business, but it has clearly become an essential part of radiology. The question still is, What sorts of displacement will take place as teleradiology intrudes more and more into the daytime market? And how will it define itself internationally? VRC’s Casey says federal legislation is being mulled that could put constraints on the reading of cases by American radiologists stationed overseas. Some radiologists are also calling for national licensing so that the complicated business of accrediting and licensing telerads in multiple states and at multiple hospitals could be simplified (see sidebar).
“The biggest legal challenge I see is just getting licensed in all the states where we’ll do work,” says Allied Radiology Solutions’ Hunter. “A national license would really help the patients. If a doctor had his license revoked nationally, he’d be out of business. I think it would be a quality win-win for patients, doctors, and hospitals.”
It would clearly be a win for the teleradiology companies that have set their sights on the nationwide market.
George Wiley is a contributing writer for Decisions in Axis Imaging News.
References:
- Larson DB, Cypel YS, Forman HP, Sunshine JH. A comprehensive portrait of teleradiology in radiology practices: results from the American College of Radiology’s 1999 Survey. AJR Am J Roentgenol. 2005;185:24-35.
