Outsourcing is hot; don’t get burned

Teleradiology and the outsourcing of imaging studies continue to proliferate, but that doesn't mean they are always the right answer. Questions often arise over risks and rewards related to the practice, and how those risks and rewards vary among different practice models.

"Outsourcing is a topic we [radiologists] need to understand well if we are to make informed choices about the future of radiology, our practices, and our own careers," said Dr. Richard B. Gunderman, an associate professor of radiology at Indiana University.

Many hospital operations have been outsourced for years, including billing, payroll, cafeteria, laundry, housekeeping, and medical transcription. More recently, hospitals and imaging clinics have begun outsourcing after-hours interpretations. As of 2005, 20% of all U.S. hospitals were using after-hours radiology services.

Gunderman recently published an outsourcing primer that explores the nature of outsourcing and also defines and discusses the subtle distinctions between outsourcing, offshoring, offshore outsourcing, and inshoring (JACR 2008;5[8]:893-899).

His paper includes guidelines for radiology practices contemplating outsourcing, including an examination of outsourcing risks and risk mitigation. Risks are presented in the context of a hypothetical rural hospital with two general radiologists who wish to outsource neuroradiology, mammography, and overnight emergency studies.

Risks include outsourcing the wrong studies, outsourcing too many studies, choosing the wrong vendor, legal factors, and resistance from in-house physicians.

Risk mitigation involves:

• carefully reviewing the purpose of the outsourcing venture and specifically designating which studies are outsource candidates;

• performing dry runs to see which imaging studies need to be outsourced and how many are likely to be involved;

• seeking references for potential vendors and evaluating their approaches to workflow, billing, malpractice, and performance standards; and

• verifying that potential vendors are economically stable and pose no legal risks.

The most costly aspects of outsourcing are not financial in nature, Gunderman said.

"As an increasing percentage of radiologic services are outsourced, radiology itself may undergo undesirable changes," he said.

One such change is the loss of patient contact and the opportunity to build patient-physician relationships. A related problem concerns loss of continuity of care. A patient's ongoing imaging studies may be interpreted by different radiologists, none of whom sees the process evolve over time.

Outsourcing and related offshoring, offshore outsourcing, and inshoring practices play important roles in the evolving global marketplace, and often promote valuable competition and innovation, Gunderman said.

"Yet outsourcing per se is not necessarily a good thing, and in some cases, its risks and costs may outweigh its benefits," he said. "Radiologists need to understand these in both the short and the long term."