Diagnostic Imaging
September 2003

RADIOLOGY INFORMATICS

Wired radiology transforms imaging practice in U.S.

Technological advances and workforce shortage push teleradiology from night reads to daytime rural settings and beyond

More scanners producing more images and the continuing shortage of radiologists have created something of a crisis in radiology: images that are requested but risk going unread and unused, or worse, misread by the wrong people. Unlike in times past, however, teleradiology is jumping in to fill the gap.

Networks are springing up to redistribute the image interpretation workload. What was once a nighttime phenomenon has become a workflow solution. The result is a medically wired nation where the operating principle may soon be any image, any time, anywhere.

The original concept of teleradiology evolved in the late 1970s as a way for medical facilities lacking radiologists to obtain some level of diagnostic imaging consultation. The first analog camera-on-a-stick commercial systems were used almost exclusively for this purpose. As the image quality of these products improved, they spared many on-call radiologists night trips to the hospital and thus acquired the moniker of "on call" or "convenience" teleradiology. Twenty years after its introduction, teleradiology has come full circle. It is now being aggressively utilized to confront the national radiologist shortage.

The serious shortfall of radiologists in the U.S. shows no signs of diminishing. During a session on workforce issues at the 2002 RSNA meeting, Dr. Kimberly Applegate, an associate professor at Indiana University and current president of the American Association for Women Radiologists, and Dr. Carol M. Rumack, a professor of radiology and pediatrics at the University of Colorado Health Sciences Center, reported that the annual demand for radiology procedures is increasing by 3.5% to 5%, while the radiologist workforce is increasing by only 2%.

The percentage of complex multi-image studies is also increasing. Between 1995 and 2000, MRI examinations performed in North America and Europe increased by 19% and CT by 10%. Whereas these examinations seldom used to generate more than 40 images, today they generate hundreds of images.

StaffCare, a locum tenens firm in Texas, reported in its 2002 Review of Temporary Healthcare Staffing Trends that it received requests for 23,489 radiologist workdays, or 16% of the total number of locum tenens requests. The report noted that for every radiologist willing to work in this capacity, two additional radiologists could have been retained just to fill the requests made to this firm alone.

A survey conducted in December 2001 by U.S. Radiology Partners, a Dallas radiology management services firm, provides similar statistics. A 12% response to surveys sent to 2000 solo and group practice radiologists in 40 states revealed that staffing issues were the top two concerns for 55% of the 240 respondents.

Not only are there fewer radiologists to read an escalating number of images, but the adoption of on-call teleradiology has raised the expectations of the radiologists' clients-hospitals and referring physicians-with respect to the standard of care. Many hospitals expect their contract radiologists to provide 24/7 coverage. Referring physicians are demanding faster report turnaround time. Teleradiology, in addition to PACS, can be harnessed to meet these challenges.

NIGHTHAWKS TO THE RESCUE

Hospitals' rising expectations for round-the-clock radiologist coverage have created a burgeoning business opportunity for dedicated nighthawk practices. Their number is growing, and the number of staff radiologists within them is expanding. Speaking anonymously, most of the nighthawk practices say that their workload increases monthly. Radiologists at these highly competitive practices work from all parts of the globe.

This is quite a different scenario from the situation in the late 1990s, when only a handful of nighthawk practices existed. In February 2001, the largest national teleradiology practice filed for bankruptcy, having generated a revenue of only $85,000 the prior year. TeleQuest, launched with fanfare in 1995 as the first nationwide subspecialty radiology network in the U.S., failed to attract customers. It positioned itself as providing unprecedented access to some 300 subspecialty experts at five of the most prestigious academic medical centers in the country. It should have succeeded but may, in fact, have been ahead of its time.

Radiology practices faced significant economic challenges in the late '90s. Many were preoccupied by competitors' inroads on already declining revenue streams. TeleQuest was perceived as a threat that would undermine a practice's most financially lucrative patient base. And its market positioning inadvertently gave the impression that a local practice that retained its services lacked adequate internal expertise.

Nighthawk practices, existing and subsequent, took note. Practices that provide remote reading services today make a point of emphasizing that they read only studies requested of them by their clients. Their primary service is to provide second- and third-shift, weekend, and vacation coverage. But a new trend is emerging: The nighthawks are being pressured by some of their clients to read weekday day-shift examinations. More coverage is being provided for second-shift remote interpretation. And much of the volume from some clients' second shift is believed to be the unread overflow from the day. Nighthawk practices are gearing up to accept daytime reading.

A second major change is that most of these practices now prepare final reports, or their equivalent, in the style and format their customers use. The brevity of a "wet read" preliminary interpretation is no longer acceptable. The radiologists contracting the service may "produce" and bill for the final report, but for all intents and purposes, the work has been generated by the nighthawk. Radiology practices and healthcare facilities that contract for teleradiology services expect to receive an accurate, well-written, and comprehensive report that facilitates their own review of the case, which is ethically and legally necessary.

"Not only does a teleradiology service provide the opportunity for overworked radiologists to sleep at night, but we also allow them to be more efficient and alert the next day at work," said Dr. Sean Casey, president and director of Virtual Radiologic Consultants in Eden Prairie, MN. "It is the local radiologist's responsibility to verify the accuracy of our interpretation and the thoroughness of the report we generate, but the expectation is that we deliver a typed report that is almost as detailed as a final report."

Other teleradiology practices suggest that the service provides a jumpstart to a radiologist's busy day. VRC is a model of efficiency, streamlined by technology. The practice uses a customized radiology information system, a robust, scalable Web-based PACS that spans the globe, and speech recognition maximized with macros (see accompanying article). Founded in 1999 with five radiologists, the group has expanded to 15 radiologists credentialed in 40 states. To meet the demand, especially from clients requesting additional service during weekdays, VRC would like to add another 10 to 15 radiologists within the next three months. The shortage of radiologists and the cumbersome process of licensing them for multistate work are slowing down this process, however.

Both VRC and relative newcomer Templeton Readings in Baltimore report that requests for day coverage are frequently generated when a radiology practice loses colleagues, often in states with a hostile malpractice insurance climate. A healthcare facility may require a subspecialist but cannot cost-justify one based on volume. Or its volume may be erratic, and radiologists who are working to capacity cannot handle overflow exams.

The International Radiology Group has been providing centralized interpretation of films for remote clients since 1991. It offers 24/7 service with a steadily expanding workload. Average annual growth has ranged between 28% and 32% in recent years.

Dallas-based IRG initiated a teleradiology service in 1999, but it found the system unsatisfactory for its needs and abandoned it in 2000. In 2001, however, at the recommendation of its military clients, the group identified a more robust system-a teleradiology PACS that currently interfaces with over 26 different systems.

According to Brian Hall, chief operating officer, U.S. military hospitals and VA medical centers have been core customers of its daytime services and have been enthusiastic about the practice's adoption of digital image management technology.

PACS REPLACES CIRCUIT RIDING

The adoption of PACS in local practices or at the hospitals they serve is altering the traditional circuit-riding concept. Career circuit-riders who provided regular, albeit limited, services to rural hospitals are retiring. Because the shortage of radiologists in rural communities is especially acute, finding replacements is a difficult, if not impossible, process.

The bad news is that some rural hospitals can no longer offer interventional procedures. The good news is that the innovations of enterprise PACS are making it possible for some hospitals to offer a quality of service that did not exist in the era of circuit riding.

West Central Radiological Associates is a four-FTE radiology group that provides services to 12 widely dispersed hospitals and clinics in west central Minnesota. The practice is located in Willmar (population 20,000), the region's largest community. Until 2002, WRCA radiologists spent 40 hours per week traveling to facilities as far as 90 miles away. In the fall of 2001, the group dwindled to 1.25 radiologists, anchored by Dr. Barry Sewall.

WCRA has its home office in Rice Memorial Hospital, the state's largest city-owned hospital, which is a member of both the Minnesota Rural Health Cooperative and the Medisota consortium. The 136-bed Rice Memorial has a mission to make its specialized services accessible to smaller hospitals and clinics in its 14-county service area. It installed a PACS in late 2000 and was instrumental in developing a digital network connecting many of the hospitals served by the radiology practice.

Five of the outlying facilities that contract with WCRA are now wired. Two have converted to computed radiography for conventional imaging, with the remaining three scheduled to do so next year. (All three still print film for conventional images and send them to the WRCA office by traditional means via courier services.) DICOM modalities at each site have a direct connection to Rice's PACS. The mobile CT, MRI, ultrasound, and nuclear medicine units that provide service to many of the hospitals now travel to the nearest hospital with a T1 link to Rice and use this link to transmit all the images acquired that day. This process adds teleradiology turnaround efficiency to the hospitals that are not yet economically able to join the network.

Rice Memorial provides space, technical support, and most of the equipment for WCRA's offsite office, which contains two diagnostic workstations. These workstations are used exclusively for interpretation of examinations received from the remote hospitals. (Examinations performed at Rice are read at diagnostic workstations located in its own radiology department.)

"Rice's PACS and the filmless network developing in our region has not only improved turnaround, it has significantly improved the quality of our work environment. This, in turn, has helped us in recruiting radiologists," Sewall said.

Almost all diagnostic studies from the regional hospitals are sent to the central office, where radiologists are available for consultation and stat reports during the day. A teleradiology service covers nights, providing remote customers with the same timely response they receive during the day.

Sewall noted that referring physicians now have the ability to view their patient's examinations through the Internet. WCRA hopes to use the PACS for Web conferencing lectures to offsite physicians as well.

The radiologists still travel to outside facilities to perform procedures, but travel time is now less than 10 hours per week, a reduction of 75%. This means that Sewall and his colleagues have an additional 30 hours to actually do their jobs as radiologists, rather than as road warriors.

NEW PACS, NEW CLIENTS

In a very different scenario, Tacoma Radiological Associates Medical Imaging Centers, a large multispecialty radiology group in Washington, has expanded its regional scope of service solely because of the functionality provided by its newly installed PACS. TRA has two imaging centers served by PACS in Tacoma and one in an adjacent community.

TRA installed an enterprise PACS last year to improve workflow and efficiency for its staff, which also provides onsite radiology coverage for two of the largest hospitals in Tacoma and one in Federal Way. The PACS has provided TRA with two new unsolicited customers. One, an orthopedic center with an extremity MRI, wanted to contract only with an electronic practice that could provide rapid turnaround. The second, a new MRI center located 52 miles north, has a projected volume of 12 to 18 studies per day and would not ordinarily be a feasible account for TRA. But because of the enterprise orientation of the PACS, TRA guarantees a 30-minute report turnaround for STAT cases and a four-hour turnaround for all other MRIs. The new center is leasing both a RIS site license and a partitioned portion of the PACS archive, making it far more economical for the new center to become filmless.

"By virtue of its location, this new customer is not a competitor," said John Griffith, director of outpatient imaging. "We've acquired a partnership that would not have occurred without PACS."

DOUBLE BONUS FOR RURAL HOSPITALS

For the past six years, the University of South Alabama Medical Center has made a major contribution to the healthcare of rural Alabama residents who live between the Gulf of Mexico and Montgomery. According to radiology administrator Ron Ori, the rural hospital community in Alabama has struggled with acute shortages of radiologists and remains in dire need of radiology services.

In 1997, the USA Medical Center established an innovative, robust diagnostic teleradiology system for centralized reading, linking its two other hospitals. At the same time, the 44-bed Evergreen Medical Center, located 100 miles away, sought to increase its onsite radiologist coverage beyond eight hours a week. The USA offered to expand its teleradiology network. Evergreen acquired a film digitizer and established a T1 link, and the USA rural teleradiology outreach program was born.

"Because our state is so rural and our mission as a tertiary-care center is to serve outlying hospitals, teleradiology fits in perfectly," said Beth Anderson, chief operating officer at the USA.

Today the USA provides service to seven rural hospitals and two VA medical centers, and it intends to continue its outreach expansion efforts. Its 18 staff radiologists and 20 residents read an annual teleradiology volume of approximately 25,000 examinations in 2002, out of a total of about 200,000. A Web server makes images electronically accessible over the Internet for a short period of time to all authorized referring physicians. Most DICOM modalities are directly linked. Some facilities have replaced their film digitizers with CR readers.

The USA Medical Center purchased the teleradiology system, which grew by word of mouth and was expanded through the university's support. The USA provided the funding with the assumption that the system could be paid for through the professional fees obtained from the additional work. This was possible because the radiologists are employees, not a private practice, Anderson said. The USA pays for operating expenses, and each participating hospital pays for its own telecommunications costs and maintenance contracts.

WORKSTATIONS GALORE

The addition of the VA as a customer brought the addition of VA-specific Vista workstations. Radiologists and residents became multiworkstation-proficient quickly, according to Dr. Jeffry C. Brandon, associate dean of the USA College of Medicine and vice chair of radiology.

"The reading rooms are like a war room, with various workstations and monitors," Ori said. "We get exams nonstop all day, and the two or three radiologists who are assigned to teleradiology interpretation simply move between our workstations and those of the VA."

The USA Medical Center has stretched the teleradiology system to provide some PACS functionality among its four facilities by integrating Internet-enabled Web viewing. A PACS has been desired for years, but funding has not been available, Ori said.

The effect on rural radiology services has been profound. In addition to providing 24-hour service where none would otherwise exist, the department is also providing limited onsite support so that these hospitals are able to add fluoroscopy and interventional procedures.

"We want to assist these hospitals in providing the best quality of care to their patients," said Dr. Steven K. Teplick, a professor and chair of radiology. "Technology hasn't entirely replaced a hands-on radiologist. But it certainly has extended the resources of our department to provide a far-reaching level of assistance that could not otherwise be achieved."

MS. KEEN is a PACS consultant with i.t. Communications. She can be reached at itcommckeen@earthlink.net.