Teleradiology has gone global. Driven by the explosion in night-call coverage and a concomitant slump in the radiology workforce, the idea of sending images around the world has taken a new twist. Entrepreneurs and individual radiologists are seeing the potential to exploit global time differences as a way to turn night duty into day.

It’s an attractive image to many radiologists: the thought of sipping a cool drink under a palm tree on some idyllic island before flipping open their laptop to read incoming studies. No more graveyard shift, euphemistically referred to as “night call.” No more haggard days after busy nights reading films and fielding phone calls.

What used to be a casual on-call duty has become an on-site necessity. Clinicians want access to radiologists 24/7, and short-staffed radiology departments and practices are finding it increasingly tough to comply.

“Night call is totally different than it was 10 years ago,” said Dr. Brian Wistow, a community radiologist with Sutter Gould Medical Group in Modesto, CA. “There are lot more things that radiology is doing in the middle of the night: fast CT scanning for trauma, appendicitis work, renal stone workup. What that means is that someone is up all night.”

The trend toward heavier night-call duty is developing at the same time that many radiologists are seeking to cut back or even work part-time. Others, near retirement, would rather quit altogether than work the graveyard shift. Young doctors entering the specialty expect to work short weeks and have access to the best technology while doing so. To ease the load, private groups in some areas have banded together to share the night shift for their respective practices. But that still means somebody is staying up all night.

While contracting with nighthawk services to handle overnight cases is not new, the idea of exploiting time differences as a way to eliminate nighttime duty is. The shift means that the radiologists handling cases are working during their own daytime hours. As a result, with the exception of the occasional interventional procedure, the local radiologists can set their alarm clocks for morning without losing sleep or too much revenue in the process.

The handful of new companies that have set their sights on capturing night-call contracts by employing the time zone model see their business appealing to a wide range of customers. It’s a gamut that runs from solo practitioners in small towns to universities like Yale.

“The solo doctor may only have one scan a night from the ER to cover, but it’s enough to wake him up every night,” said Dr. Arjun Kalyanpur, a Yale radiologist who practices in Bangalore, India and has formed Teleradiology Solutions, one of the new global teleradiology service companies. “He doesn’t have big bucks to spend on having a nighthawk do it for him. But a service that contracts with multiple groups would be ideal because it would be cost-effective.”

The other end of the spectrum is represented by university hospitals like Yale, Kalyanpur said, which handles heavy volumes of scans during the night and could use the backup help. In between are radiology groups that serve smaller community hospitals and manage five to 10 studies a night.

“Essentially, the radiologists in these groups are taking turns, but it means one person is run pretty ragged during the week he’s on call,” Kalyanpur said.

All of these groups could benefit by getting off the night-call merry-go-round and concentrating on their daytime practices, he said.

Testing The Concept

Kalyanpur has already tested the concept of providing night-call services from Bangalore, a region that Newsweek magazine has called “the Silicon Valley of Asia” because of its high-tech infrastructure. Over a two-week period, Kalyanpur read CT studies acquired from 102 consecutive patients scanned at Yale.

The studies were transmitted from the Yale PACS workstation to a secured Web-based server. Using a 128-Kbps Internet connection, Kalyanpur downloaded the scans from the Web server to a standard personal computer. The average time to send a preliminary verbal report back to Yale was 30 minutes. A final written report averaged 40 minutes. Kalyanpur presented a paper outlining the results at the American Society of Emergency Radiology meeting in San Francisco in April.

Although some findings differed between the radiologists at Yale and Kalyanpur, none resulted in a change in patient management, he said.

“One of the things those changes demonstrate is that when people are reading under difference circumstances, they get different results,” he said. “The person who is reading in the ER is doing 16 things at once. He’s being interrupted to go do an ultrasound, and somebody else is showing him a plain film. And then the phone may ring.”

By contrast, the radiologist interpreting scans from afar is more focused. Proponents of offshore teleradiology say that increased diagnostic quality may be one of the side benefits of the service.

“It makes sense that if you’ve got dedicated people reading during the daytime, the overall quality is going to be better than if you are reading the same scans after being awakened several times during the night,” said Dr. Paul Berger, who heads Nighthawk Radiology Services (NRS), a company based in Coeur d’Alene, ID, that provides on-call coverage from Sydney, Australia, using a team of two U.S.-trained radiologists.

The only downside to outsourcing night call is that some calls do require an on-site presence. And even with redundant, reliable systems, networks sometimes crash. That means having a backup pool of radiologists available just in case.

“The remote radiologist cannot provide all the services that the on-site radiologist can,” Kalyanpur said. “But if you split the work, you can increase the efficiency of each operation.”

Staffing Crisis

As the field of radiology copes with a staffing shortage that hovers around 20%, the advantages of outsourcing night call could include easier recruitment and retention. That shortage that won’t be alleviated anytime soon, said Dr. Chip Truwit, director of neuroradiology at the University of Minnesota and chair of radiology at Hennepin County Medical Center in Minneapolis.

“It’s going to be at least seven years before we have anywhere near enough people to meet the demand,” he said. “It takes that long to bring people through the academic system and to gear up residencies. And there is little hope on the horizon that the residency numbers are going to get better; they are dwindling rather than rising.”

The staffing crisis combined with the increasing burden of night call have converged at a time when adoption of PACS and advances in telecommunications technology make global teleradiology feasible, Truwit said. Those trends spurred him and two university-based colleagues to form Virtual Radiologic Consultants (VRC), a company that is already fulfilling night-call contracts with U.S.-trained radiologists in the south of France. Dr. John Haaga, chair of radiology at Case Western Reserve University and director of radiology at University Hospitals of Cleveland, spotted the same trends earlier this year.

“Within two to five years, the manpower shortage will get worse,” he said. “Radiologists can work harder and be more productive during the daytime hours, but if you have a strenuous night call, that makes it very complicated. We think we can provide a situation that’s a true win-win for radiologists, because most would love to give their night call away.”

Haaga harbors hopes that radiologists will want to shift that business to Global Nighthawks, the business he and colleagues will formally launch at the RSNA meeting in November. Haaga believes outsourcing night call appeals on a deeper level than simply avoiding sleep loss.

“Most people with a reasonable-sized group will have someone take the next day off after being on night call,” he said. “So they basically lose an FTE to their own schedule. Global Nighthawks is a convenient and efficient way for people to provide a service that’s required, and they actually recover an FTE in their practice.”

In addition, he said, at a time when recruitment and retention of radiologists is at a low ebb, being able to tell prospective radiologists that night call is not required is a plus.

“If a radiologist is considering equivalent situations and one of those situations has no night call, that is the job they are going to take,” he said.

The issue has particular relevance for radiology department chairs like Haaga, who sees a direct tie between the radiology shortage and the survival of university centers.

“If radiology is going to survive in the long term, university centers have to have an ability to generate more income,” he said. “It’s easily overlooked that we in academics could pack our bags and go into private practice, and the specialty would collapse in five years because no one is training radiologists. As a profession, it would be very irresponsible if a mechanism isn’t found to somehow ensure that the economic mission continues.”

Developing revenue-generating businesses like international teleradiology is thus a natural for academic sites seeking to bolster the bottom line. As compared with freestanding teleradiology companies, the stature and reputation of universities adds credibility to the service, he said.

“Universities have the best international connections, relationships, and the ability to carry out quality assurance and oversight,” he said. “It’s what we do on a daily basis. It’s a perfect niche market for academic centers and affiliated sites.”

Do It Yourself

Global teleradiology is an opportunity not only for radiology entrepreneurs, but also for individual practices. Wistow believes that overseas teleradiology has the potential to rejuvenate radiology practices with long-standing partners who may be looking for a way to ease out.

“In our practice, we’ve all been here 15 to 20 years, and we’re beginning to look at ways to wind down our practice over time,” he said. “We don’t necessarily plan on staying in this community long-term. The ability to divide the practice up and to have the flexibility to move somewhere else for part of the year is compelling.”

Wistow is not alone in indulging what some might call wishful thinking. Dr. Mark Fritze is part of an 18-member radiology group in Kansas that has had similar thoughts since it implemented a Fuji PACS.

“It’s a Web-based system, so theoretically you could read images from anywhere in the world. That made me wonder if we couldn’t read in another time zone,” he said. “I think that a person covering night call from overseas could eliminate about 90% of our night call between 11 p.m. and 6 a.m. That would be a huge plus. Night call is such a detractor from the quality of practice and quality of life.”

And despite the competitive pricing that these newly emerging nighthawk services may offer, outsourcing still means revenue out the door, Wistow said.

“If the goal is to keep your group intact, you don’t want to be giving up revenue,” he said. “So people are hesitant to use a nighthawk service when it means you lose that business.”

Berger of NRS offered a counterpoint to that argument.

“There’s a huge cost to the radiologist to provide night coverage-and only part of it is economic. You have to pay somebody to do it,” he said. “But if you outsource that and redeploy your radiologists, you can become more efficient during the day and may even be able to take on more business.”

Complicating Issues

Regardless of whether one seeks to provide night-call services or outsource them, interest in setting up teleradiology networks is at an all-time high. After giving a presentation on teleradiology infrastructure at the 2000 RSNA meeting, Patricia Kroken of Telemedix was besieged by radiologists interested in pursuing a teleradiology business overseas. Some were international radiologists seeking to capitalize on the staffing shortage in the U.S. Others were U.S. community radiologists like Wistow and Fritze.

But before setting their sights on do-it-yourself international teleradiology, radiologists need to know the pros and cons of establishing a global business, Kroken said. Issues of taxation, licensure, infrastructure, and technical support need to be considered. For international radiologists seeking to read films from the U.S., there are credentialing issues as well. A related issue is malpractice insurance for teleradiology, requirements for which may vary among countries.

“It sounds pretty glitzy and glamorous to say, ‘We’re going to be the crew that reads in a foreign country for a couple of weeks or months,’“ she said. “But there are apt to be all kinds of logistical problems, and this is just the kind of thing that doctors hate to hear.”

Data security is another issue, although that concern is due more to new Health Insurance Portability and Accountability Act regulations than to any danger involved in transmitting images across continents, Truwit said. Whether they use teleradiology or not, practices and hospitals will need to comply with the HIPAA requirements. That means new consent forms that inform patients that their images or other medical data may be shared by telephone or on the Internet with whatever medical consultant their physician needs to work with in diagnosing and managing their case.

On the financial side, groups that are considering do-it-yourself teleradiology may face double taxation issues, according to Chris Huber, network director for NRS in Idaho.

“When you’re talking about going overseas, especially placing radiologists for a short period of time, taxation issues between the U.S. and the host country need to be considered,” he said.

In terms of licensure, many states in the U.S. require physicians to be licensed in a state in order to read the images of patients who reside there. This is less of an issue for radiology practices that simply seek to export their physicians so as to better manage their own cases. But it has caused complications for companies that seek to attract business from practices in more than one state.

Infrastructure Tips

The technological ease of simply sending images can be deceptive, as the four entrepreneurs now vying for night-call business have found. The first consideration is the technical infrastructure: While it’s true that images can be read on standard PCs and even sent over the Internet as e-mail attachments, few who hope to do significant business are setting themselves up that way.

Instead, dedicated lines and virtual private networks that permit high-bandwidth transmission of encrypted data are the norm. Typically, radiology groups that contract with these companies are required to make a minimal investment in compatible software.

In the case of NRS, the cost to upgrade averages about $100 per site, according to Huber. The group or hospital is responsible for maintaining the Internet connection and facilitating outbound traffic. NRS provides uptime guarantees, international service level agreements, and round-the-clock management of its network.

Both speed and network security are critical to running an offshore teleradiology business, as is 24/7 technical support, Huber said.

“Infrastructure is more than just technology, although technology is a big part,” he said. “When you use the Internet to transfer such big image files, you need both redundancy and reliability of the network. We’ve been tinkering with our network to ensure that we have just that.”

NRS benefits from the teleradiology expertise of its founder. In the 1990s, Berger spearheaded one of the earliest teleradiology practices in the U.S. while at the helm of Long Beach Memorial Radiology Group in southern California.

The Idaho company has been managing a number of interstate coverage contracts while readying its network for overseas operations. Its Sydney-based radiologists are credentialed and board certified.

The NRS network can handle a nightly caseload of more than 150 scans. While much of the network protocols and transmission scheme is considered proprietary, Huber said that most images arrive in Sydney from the U.S. in about two minutes.

“Our goal is to provide 30-minute turnaround on preliminary reports for our customers,” he said. “If we can provide that, we’ll be doing better than most groups can achieve on their own.”

Helping Hand

In Cleveland, Haaga’s Global Nighthawk service has been providing nighttime coverage for the University Hospitals campus since April. The company is also basing its offshore operations in Australia, using U.S.-trained radiologists who are credentialed at the university. The company is already looking at expansion sites in other countries.

Like VRC, NRS, and Teleradiology Solutions, Haaga’s team seeks to secure service contracts with radiology groups. There are no plans to bill for their interpretation services themselves or to try to capture local practices’ business.

“We contract with the radiology group,” Haaga said. “The on-site relationship with referring physicians is very important, so we do what we can to assist the radiologist. We don’t want to come between the radiologist and the referral base.”

It takes about five seconds to send an image between Cleveland and Australia over Global Nighthawk’s virtual private network. Haaga anticipates that once the service is formally launched, preliminary report turnaround time will be between 15 and 20 minutes—much shorter than the average time for a resident to read and report on a case on-site, he said.

In Minnesota, VRC offers a full range of interpretive services, including use of its three-dimensional imaging lab.

For its infrastructure, VRC installs a high-quality teleradiology system at the contracting hospital or practice or makes use of existing systems if compatible. The radiology group carries the costs to maintain Internet connectivity, but VRC covers all other costs as part of the contract.

“Almost every practice now can install a box and have DICOM output,” Truwit said. “Maybe not for their plain films but certainly for CT, MRI, and ultrasound. Almost any high-quality PC is able to transmit and present images quickly and efficiently.”

Using a DSL line, imaging studies are being sent from Minnesota to France in less than five minutes, he said.

“We can do perfusion imaging for stroke in the middle of the night, something that other groups are not quite ready to do,” he said. “Since it’s DSL or better, it’s very fast. And using an Internet telephone makes it very easy to communicate.”

In addition to rotating its own team of three radiologists to read scans in France and other locales, VRC is also actively recruiting other U.S.-trained radiologists interested in an international proposition. It may be possible for radiology groups that contract with the company to become a part of the larger business by buying an equity stake.

Within the next few years, Truwit predicts, the handful of companies now poised to capture night call will have more business than they can handle.

“It’s a new age for radiology,” he said. “Three years from now, the playing field will be totally different. We’d like to believe we’ll still be part of it, but we’re not naive enough to think things aren’t going to change. It just takes someone to put the first foot forward, and that’s what we’re trying to do.”

For More Information…

Nighthawk Radiology Services
Dr. Paul Berger
866/400-4295

Virtual Radiologic Consultants
Dr. Chip Truwit
877/785-4669
virtualrad.net

Global Nighthawks
Dr. John Haaga
216/844-3858

Teleradiology Solutions
Dr. Arjun Kalyanpur
www.radiologist-nighthawk.com