Feature | October 29, 2008 | Richard R. Rogoski

Teleradiology’s Growth Comes of Age

Teleradiology’s growth garners both praise and blame.

Greg Rose, M.D., says NightRays is increasing its staff of specialized radiologists to cover the increasing demand for specialty reads.

Greg Rose, M.D., says NightRays is increasing its staff of specialized radiologists to cover the increasing demand for specialty reads.

The rising tide of teleradiology services is being heralded by some as a breakthrough in radiology that will ultimately improve the quality of healthcare and provide new jobs for U.S. radiologists.
Others, however, place part of the blame for a shortage of radiologists on the growth of teleradiology. And the use of foreign-based teleradiologists to do preliminary reads at lower costs has raised concerns over the quality of these reads and whether U.S.-based radiology service providers or the healthcare organizations that contract for these services can be held liable for reading or diagnostic errors.
It will take years before all the clinical and legal questions are answered. But the one thing that everyone does agree on is that teleradiology will continue to reshape the radiological landscape.
Growing trends
The healthcare profession, in general, has been slower than corporate America in adopting more efficient and cost-effective IT solutions. But with the growing acceptance of RIS/PACS, radiologists now have more options in how they can collect, store, read and exchange images. Teleradiology became a logical and natural progression in the use of this new technology. “All teleradiology is saying is that we can apply Internet and bandwidth technology to solve the problems of efficiencies, quality and costs,” indicated Scott Seidelman, president and CEO of Cleveland, OH-based Franklin and Seidelman Subspecialty Radiology (F&S).
Arl Van Moore, M.D., president of Charlotte Radiology in Charlotte, NC, and the current president of the American College of Radiology (ACR), says higher bandwidths and increased CPU power, especially, have been driving teleradiology. “About five years ago it became more affordable and more acceptable,” said Dr. Moore.
According to Dr. Moore, every radiological subspecialty is growing under teleradiology with the exception of digital mammography, which requires extremely high bandwidths to accommodate the larger images.
Interestingly, Seidelman believes that to a large extent, radiologists themselves are driving the growth of teleradiology subspecialties. “Radiology is moving toward individual body parts, paralleling what’s going on in surgery, for example,” he said.
With referring physicians wanting more complete and detailed images from a variety of scanner types, there is a growing demand for specialty radiologists who, for example, can read and interpret breast, neuro or cardiovascular images, Seidelman says.
But according to a 2006 study conducted by F&S, 23.4 percent of radiologists who responded said subspecialty coverage was less than adequate given the requests from referring physicians. “They aren’t getting the specificity and depth of report they want,” noted Seidelman.
A field in transition
It has been reported by a number of research groups and publications that the demand for imaging procedures is outpacing the number of radiologists by 3 to 1 and predictions indicate a 140 percent increase in annual imaging procedures for Medicare patients by 2020. Additionally, it is estimated that up to 20 percent of the U.S. image interpretation business — worth up to $15 billion per year — will soon be provided through teleradiology.
The inability to find enough qualified, specialized, on-site radiologists has forced many hospitals and radiology groups to rely on teleradiologists.
To meet this growing demand, radiology service providers like Bellaire, TX-based NightRays are beefing up their teleradiology staff. “While NightRays is a 24-hour general teleradiology service that offers preliminary, final and ‘pre/fin’ reports, we have found the need to continue to increase our radiologist staffing with special expertise to cover the increasing requests for breast MR, MSK, peds, neuro and mammo studies,” said Greg Rose, M.D., Ph.D., NightRays’ president and CEO.
There are still opportunities for general radiologists, but with the field subspecializing as much as it is, many radiologists are finding greater personal and professional satisfaction working as a teleradiology specialist. “If you’re a neuroradiologist, you don’t want to go to a rural hospital and read musculoskeletal images,” Seidelman said.
But this could further erode the quality of healthcare offered in rural areas, says James Backstrom, M.D., chief medical officer of Pittsburgh, PA-based Foundation Radiology Group. “As the pool of radiologists gets less and less, rural areas, especially, will get less qualified radiologists,” he noted.
But while there might be fewer on-site radiologists in these areas, there are still qualified teleradiologists available when needed — 24 hours a day, 365 days a year, says Dr. Rose. “Because subspecialists would rather read more of their subspecialty, they are attracted to teleradiology where they can fill their day with such interpretations from a variety of facilities. Together, this has allowed the smaller and/or rural general radiology practices to bring subspecialty radiology to their facilities through teleradiology. Indeed, there are reports of a worsening radiologist shortage, but this seems to be mostly due to new radiologists being progressively less attracted to on-site, rural positions. The number of radiologists moving to teleradiology seems to be increasing. Perhaps this evolving manpower issue will drive the staffing of fewer on-site radiologists and allow more work to be done by teleradiology services which can be more efficient in the face of increasing study volumes.”
As the line between traditional radiology and teleradiology disappears, radiologists are presented with more options. Among these, according to Dr. Rose, is the conversion of hospital radiologists to teleradiologists. Driving this particular movement are three major factors, he notes: lifestyle, politics and finance. “Lifestyle changes are profound with teleradiology. No driving to and from work, live anywhere you want, your own office with your own stuff, generally more flexible schedule, personal matters can be more easily attended to, and usually an efficient reading system.
“Indeed, hospital politics are a necessary evil, but it seems most radiologists don’t want to deal with them. A teleradiology company generally manages the whole practice and the radiologist just reads the cases. They are generally not involved in contract negotiations, equipment purchase, HR issues, billing matters or legal issues. It has been termed a ‘clean radiology job,’” said Dr. Rose.
He added, “Financial pressures from the DRA (Deficit Reduction Act) have driven down reimbursements for various studies. On-site radiologists report more ‘non-revenue generating’ activities and feel bogged down by inefficiencies due to being on-site.”
Still, Dr. Rose believes that a balance between on-site radiologists and teleradiologists can be achieved. “I think radiology would have been a combination of on-site and off-site manpower from the start if we could have done it,” he said. “Indeed, the ACR is likely evaluating how they can be of service in guiding the redistribution of on-site and off-site reads in a fashion that preserves the quality, integrity and spirit of this great specialty.”
Safeguarding quality
Reports show that the DRA has eliminated up to 30 percent of federal reimbursements for readings, prompting some traditional radiology groups to increase procedure volume or to add teleradiology services to bolster their bottom lines.
But reduced reimbursements are also exacerbating the current shortage of radiologists, which, says Dr. Backstrom, will get worse.
In an effort to educate the public and Congress about the role of radiologists and the need for adequate reimbursements, the ACR is rolling out a nationwide branding campaign called the “Face of Radiology.”
Interestingly, this campaign does not target teleradiology companies that try to cut costs by using foreign-based readers, but self-referring physicians — those specialists who own their own imaging equipment and may not be ACR-accredited.
Shawn Farley, public relations manager for the ACR, says self-referrals are one reason cited for the increased number of imaging tests ordered. And too many unnecessary tests expose patients to unnecessary levels of radiation, he says.
Plus, non-radiologist physicians who read their own images may not know how to interpret them correctly, thereby increasing the risk of errors, Farley says.
He also points out that from 1998-2005, the non-radiologists’ share of in-office MRI and CT imaging doubled and tripled respectively. These physicians also received more than double the amount of Medicare dollars paid to radiologists during the same period, translating to approximately $4 billion.
When the campaign’s launch was announced, Dr. Moore stated: “It is important that radiologists make their role in patient care known so that patients are aware of radiology’s tremendous contribution to their well-being, and can choose to receive care from the physicians most qualified to provide it.”

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