Teleradiology should focus more on improving patient outcomes

2012 12 10 12 52 33 551 Boland Giles 70

Radiology groups that continue to use teleradiology to outsource off-hours reading risk sending the message that they are organizing patient care around what's important to the radiology group rather than the patient, referring physician, or organization. It's time to rethink teleradiology.

Teleradiology has been around for decades, but its initial use was limited to military and niche demonstration projects. Then, as computing power grew and bandwidth costs declined in the 1990s, medical innovators began to wonder about a world in which images could be "beamed" almost instantaneously from anywhere for medical opinions, thereby bringing first-world medical expertise to "a local hospital near you," so to speak.

Dr. Giles Boland.Dr. Giles Boland.
Dr. Giles Boland.

This vision for teleradiology, however, has never really taken off. Radiologists are generally very reluctant to outsource what they perceive as their value proposition (namely, a radiology report). This is understandable, considering that for many the report is their sole income source; therefore, less reporting translates into lost income, as least in the fee-for-service environment (interestingly, busy radiologists in the U.K. are often quite supportive of outsourcing reporting within their capitated and salaried milieu).

Furthermore, there is undoubtedly an element of medical protectionism, given the state medical licensing laws and reimbursement structures that prevail in the U.S. Finally, the myriad of proprietary electronic operating platforms usually cannot "talk" to each other. Even today, it requires sophisticated IT expertise to integrate HIS, RIS, and PACS between institutions. If there existed a truly open, transparent, nonprotected, and patient-centric environment (as is the case with many nonmedical business models), the vision of millions of images being seamlessly transmitted to institutions of excellence for subspecialty reporting might have been realized.

Off-hours reporting

What really took off, however, as we all know, was an explosion of off-hours reporting throughout the first decade of the 21st century. Depending on your point of view, what transpired was either a boon to radiologists or has put the very nature of our profession at risk.

On the plus side, this form of teleradiology has delivered fast, mostly accurate reporting to emergency room (ER) physicians who need to triage patients in a time-critical environment. Better to have a quick report generated from distant lands than to have to try and justify (sometime argue) with a sleep-deprived local radiologist as to why the study is needed in the first place. Besides, imaging has delivered such value to emergency care that ER physicians are demanding more and more of it, and generally rightly so.

It could be argued that it doesn't really matter where these studies are reported, as often it's only a simple binary question that is being asked (fracture or no fracture, appendicitis or not, etc.). In these cases, complex comparisons with prior imaging and reports may be redundant.

Comfort for radiologists

As a result, local hospital radiologists can now comfortably sleep the night away with the reassurance that the quality of patient care is, on the whole, upheld. As a bonus, given that most off-hours outsourced reporting delivers preliminary reports, most groups can even bill for the study by signing off the final report when they arrive fresh to work the next morning.

This dynamic has pervaded the majority of radiology practices over the past decade, particularly private-practice groups. Not offering this service has often been an impediment to recruiting new talent. There are also plenty of teleradiology providers, both academic and nonacademic, willing to offer their services, and why wouldn't they when they perceive an opportunity to leverage their skills and expertise?

Why should a radiology group, then, offer and deliver arguably the most unpalatable part of their job when they can so easily outsource it? Never mind that ER physicians and many other specialties are required to cover the off-hours. Perhaps if their work could be outsourced, they, too, would do the same. But the fact of the matter is that it cannot.

Shortsighted view

This viewpoint, however, is generally shortsighted. Radiologists have been among the highest-paid physicians in the U.S. What message does it send to our referring physician colleagues when we outsource the least desirable aspects of our trade?

Some radiologists answer by stating that they are simply taking advantage of the market. Some state that other specialty physicians have made their choices -- they could have chosen a specialty that didn't require night work. Others state that it is the only way they can keep up with the volume of day work.

Whatever argument (reasonable or otherwise) the radiologist tries to make, it generally falls on skeptical ears. When asked, ER physicians usually state they would prefer their local group to cover the night. Worse, when radiologists who outsource their off-hours responsibilities are asked the same question, they actually agree with them; ideally, the local group should report all imaging irrespective of when it was performed.

Few groups, however, have taken the bold strategic decision to "take back the night," recognizing that outsourcing off-hours reporting sends mixed signals to their stakeholders, potentially undermining the group's value proposition, and even sometimes affecting patient care. Some groups may be considering it, given the reimbursement climate and revenue shortfalls these groups are beginning to witness.

Services no longer required?

As a natural consequence of ceding off-hours responsibilities, medical colleagues and hospital administrations have now asked the question, "Why do we need this group at all?" Claims by local radiologists that they are critical to patient care between the hours of 8 a.m. and 6 p.m. may appear disingenuous when suddenly they are all too happy to outsource the reporting as dusk approaches.

A number of radiology groups across the country have lost their franchises altogether, as their medical colleagues and hospital administrations perceive they can find better value elsewhere. Paradoxically, the incoming groups often use teleradiology to manage some of their daily workflow, distributing the caseload across their network. Without realizing it, the exiting radiology group has inadvertently convinced its organization that the radiology value proposition can be outsourced during the day, too.

This, to be sure, is unfortunate for all parties involved and is usually a last resort. Often there are other factors contributing to the local radiology group's demise. Perhaps it had been unwilling to renegotiate its contract in good faith, or it had failed to participate in strategic growth opportunities with the hospital. Maybe customer service was poor, or larger groups had failed to fully subspecialize their workflow.

Whose interest?

These shortcomings get to the very crux of the issue. Does the group have the best interest of the patient and the organization at heart, or is it guided predominantly by self-interest? We, as radiologists, should be asking ourselves how and where we create value for patients and the organizations we serve.

If the employing organization believes it can achieve the same value at less cost from another group, why should it persist in supporting a group that it perceives as less valuable? It is only natural that the hospital and medical leadership will favor a radiology group that is able to collaborate and align its interests with those of the organization as a whole. Radiology groups should not be surprised if they are replaced when they are guided predominantly by self-interest and unwillingness to engage positively with their employers.

The usual response when radiologists lose their franchise is to become defensive, even incredulous. But such decisions do not often occur in a vacuum; honest, open-minded reflection will usually identify red flags from the preceding years -- situations that could, and sometimes should, have been handled differently.

This dynamic, however, is certainly not a one-way street. There are circumstances when a hospital organization has been solely driven by the financial bottom line: Where can it find the cheapest group regardless of quality? This scenario undermines its value proposition, too -- to deliver medical outcomes in the best interests of the patient and not the financial bottom line of the hospital.

Good patient care usually has costs; it's not about finding the "cheapest" radiology group. Much of what radiologists do, or should be doing, is not currently reimbursable; medical conferences and consultations, education, mentoring, quality control, peer review, customer service, committee assignments, leadership -- the list goes on. The problem for some hospital organizations is that they have been led to believe by our very own profession that a radiologist's value may be as simple as a reporting function.

On the other hand, if a radiology group truly understands how and where it creates value, then its franchise will almost always be secure. This usually means organizing the practice in the best interests of patient care and the organization's well-being. This, in turn, means embracing the less desirable parts of its responsibilities, including off-hours reporting.

Besides, it is becoming increasingly hard to argue that outsourced off-hours imaging has no impact on patient care. Most teleradiologists are now at a clinical disadvantage, as they cannot seamlessly access the host hospital's electronic medical record (EMR), which is increasingly being relied upon by hospital radiologists to garner the collateral clinical information necessary to generate a precise and accurate report.

Even if one believes that outsourcing off-hours reporting does not affect patient care, it still does not mitigate the perception that radiologists are "cherry picking" their roles and responsibilities. With such high salaries, radiologists should be going out of their way to fulfill all their expected responsibilities, lest they expose themselves to potential finger pointing and mistrust by their medical colleagues and hospital administrations.

Take back the night

Larger radiology groups should therefore seriously consider reorganizing their practice and "taking back the night." This will make an emphatic, positive, and progressive statement to their organization that they are willing to participate in the 24-hour operation of the hospital like most other physicians within their organization.

Smaller groups could, for example, collaborate with other local (not distant) hospitals to provide this service, which would mean ER physicians could, over time, get to know their local radiologists personally and build the trust necessary for optimal patient care.

It is doubtful that most radiologists relish the opportunity to be up reporting all night. However, creating meaningful value that your medical colleagues, hospital leadership, and patients can support means accepting the full range of expected responsibilities.

Teleradiology surely does still have a significant role, but perhaps not this one -- at least not as most groups currently envision it. Rather, it's time for radiology groups to ask themselves how they can use teleradiology in a more positive way, utilizing it in a manner that assists them to improve patient outcomes.

For some groups, particularly smaller ones, it may mean outsourcing some interpretations, especially when they have deficiencies in one or more subspecialties (pediatric or breast imaging, for instance). It may mean seeking second opinions for complex or problem cases. This use of teleradiology should not be about convenience for radiologists -- rather, it is about better outcomes for patients.

Groups that organize themselves around what's important to patient care and cover all their current expectations will be well-served and have a secure and bright future.

Dr. Giles Boland is a professor of radiology at Harvard Medical School and vice chairman of business development in the department of radiology at Massachusetts General Hospital.

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular vendor, analyst, industry consultant, or consulting group.

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