Get Over the Guilt: Leverage Teleradiology to Improve Hospital Service
Teleradiology has come a long way from its origins in the 1980s, when physicians would snap a photo of a film and transmit the image across telephone lines. Remote review, once a last-resort option, is now a commonplace service employed by hospitals and practices alike to handle stat cases at night or difficult subspecialty cases. Particularly in the past year, however, nagging questions have arisen that might give those practices that use these services pause: Does a practice that avails itself of off-site coverage leave itself vulnerable to a Trojan-horse attack by the teleradiology provider? Will the practice be subjected to greater legal liability? Does it erode the service that a radiology practice provides the hospital? In an interview with, the president of one hospital-based radiology practice put the above concerns in context and maintained that a good teleradiology provider can, in fact, improve service to the hospital. Leonard Berlin, MD, FACR, chair of radiology, Rush North Shore Medical Center, Skokie, Ill, says, “If I got an involved or complex neuroradiological study, in the old days, I’d have to pack the films up and mail them to someone. Now I can send them in 3 minutes and get a consultation. When I do that, I’m offering a better service to my local hospital.” Berlin says that, initially, the benefits of teleradiology were felt mostly by Rush’s radiologists. This is a familiar story to practices that got in on the ground floor. “We were an early customer of NightHawk,” he says, referring to NightHawk Radiology Services, Coeur d’Alene, Idaho. “At the time, we were looking around, and they were the only ones in the business. The other companies didn’t have track records yet.” Right away, contracting with a teleradiology provider took pressure off the group’s radiologists and gave the practice leverage in competing for new staff. “It provides a more comfortable practice situation for the radiologist, because in the morning he or she is awake and bright and cheery: theoretically, more accurate,” Berlin says. “It also is easier to recruit a radiologist when I tell him or her I have NightHawk coverage,” he notes. “That’s a competitive advantage. We have a very well-trained radiologist doing wet reads. With NightHawk, you know they will be read by someone who knows what they’re doing.” With improvements in connectivity, teleradiology companies have moved into final reading and daytime subspecialty services, also a boon to practices, Berlin says. Not only can the radiologist read with greater confidence by gaining immediate access to a subspecialty radiologist, but the practice is able to provide greater breadth of subspecialty expertise. The Price of a Good Night’s Sleep Berlin’s group is part of a 240-bed, community-based hospital in an academic system; the practice consists of eight radiologists. From 9 PM to 7 AM every night, NightHawk takes over while the radiologists get some much-needed rest. “Overnight, the studies are sent to NightHawk in Australia for preliminaries, and when we come in the morning, we provide the permanent reads,” Berlin says. “We pay NightHawk out of our pockets.” Is that fiscally harrowing? Not when procedural volumes are constantly on the rise, Berlin says. “We probably average three or four cases a night,” he notes. “Volume has grown, and it grew as a result of teleradiology,” Berlin states. “Whatever minimal guilt the doctors may have felt about waking the radiologists up in the middle of the night, they don’t have now. Our bill runs about $100,000 a year, which works out to $12,000 or $13,000, pre-tax, for each radiologist during the course of the year. We consider that money well spent.” This is not to say that teleradiology services come without hazards of their own. Quality assurance (QA) is always an issue when contracting with outside providers. “We do our own QA, obviously, and NightHawk does it, too,” Berlin says. “We run about 1% to 2% discrepancies between the temporary reading and the permanent reading, which is consistent with our own readings and within national averages. Fortunately, we’ve never had a situation where there’s been injury to a patient.” It is, however, conceivable that a misreading could be catastrophic, Berlin notes. One example is a subarachnoid hemorrhage. “The worst-case nightmare would be the patient who has a subtle, inconspicuous, or barely discernable bleed in the brain, the NightHawk radiologist reads it as normal, and we check it out at 7 AM and realize what’s going on—only to learn the patient died an hour ago,” he says. “Fortunately, we haven’t encountered that, but could it happen someday? Of course.” In the event of a malpractice lawsuit, all parties involved are potentially liable. The law is fairly clear as to the responsibility of the practice. “We’d have what’s called vicarious liability, because we’ve contracted with the company,” Berlin says, “but there’s no specific carveout in malpractice law for teleradiology. Obviously, the person responsible for the reading is going to be held liable, but lawyers go for the deep pocket.” Berlin notes, however, that no case involving teleradiology has reached the appeals-court level so far. Friend or Foe? An even more alarming question is whether radiologists are shooting themselves in the foot by helping to grow teleradiology businesses. Strong, tangible benefits on the practice end of the equation make contracting with NightHawk-style providers appear to be a win-win, but as the companies gain strength, they are compelled to seek new ways to expand their businesses. Could that growth potentially undermine conventional practice models? There are the numbers to contend with: 23 teleradiology companies now provide services to around 50% of US hospitals; another 25% are considering jumping on the remote-reading bandwagon, according to an audience polled at the 2007 Economics in Diagnostic Imaging conference in Washington, DC. Two teleradiology firms, NightHawk and Virtual Radiologic, Minneapolis, are now traded publicly. All of them are vying against one another for the business that they need to continue to grow: in such a saturated market, only the strong will survive. “Where are they going to get the customers?” Berlin asks. “Well, they’re now providing day service. When you need a consultation and you don’t have the subspecialty radiologist you need, they’ll do it for a fee.” The companies know just what audience to target when marketing new dayhawk services: administrators. “They’re going to hospital presidents,” Berlin says, “and the presidents say, ‘We could hire a dayhawk service and go from eight radiologists down to two.’“ Of course, it’s nowhere near an epidemic. Berlin had heard of just a few cases in which a teleradiology provider replaced a radiology practice. Are these isolated, case-specific incidents or harbingers of a new trend? The concern, according to Berlin, is whether practices have made it too easy for someone else to invade their turf. He says, “There have been several cases where radiologists have been replaced by dayhawks, but when you look at the details, it is possible that the groups may have been responsible for giving less than optimal service. It’s intuitive to believe that if the radiology group is a good group, why would any hospital president consider throwing them out? It has raised concern among the radiology groups, because if the hospital is operating at a loss or only marginally, hiring a nighthawk company to replace some of its radiologists who may be salaried could improve their bottom line. Nobody feels immediately threatened, but there is a dark cloud on the horizon. I’m not pessimistic, but we should be cautious and aware.” Squandering the Edge Ironically, the best way for a practice to protect its turf is to improve service—the principal reason that most groups bring on teleradiology providers in the first place. The situation, however, is not as paradoxical as it seems. Radiology groups will always have one key competitive edge over the teleradiology firms they contract with: the benefit of being on-site, in person. In many cases, it is possible that potential advantage is currently being squandered. “Doctors like to see and talk to radiologists,” Berlin says. “Providing the best possible personal service is the way to fight back. When there was an x-ray taken and the patient’s doctor wanted to see the x-ray, the radiologist and the doctor used to chat in front of the viewbox.” Because improvements in technology have stripped much of the personal contact from physician-radiologist interaction, radiologists are missing out on an opportunity to assert themselves as the logical choice for day reading. “There’s not much traffic in the x-ray department these days,” Berlin says. “If personal contact is decreasing, theoretically, down the road, an internist might think, ‘I rarely see Lenny Berlin anyway. What’s the difference if he’s here or in Australia?’ In the future, they could interface via video, so what should the doctor care?” For the most part, in today’s climate, teleradiology’s primary purpose is bolstering service—but that’s not to say it couldn’t evolve into something else, Berlin warns. “We’ve been very pleased with our teleradiology services, but it’s important to mention these caveats,” he says. “There are two sides of the coin. We have to be careful not to trade short-term gain for long-term pain.”