Teleradiology for Auction: The Radiologist Commoditized and How to Prevent It

Emerging Challenges and Opportunities in the Evolution of Teleradiology

OBJECTIVE. In recent decades, teleradiology has expanded considerably, and many radiology practices now engage in intraorganizational or extraorganizational teleradiology. In this era of patient primacy, optimizing patient care and care delivery is paramount. This article provides an update on recent changes, current challenges, and future opportunities centered around the ability of teleradiology to improve temporal and geographic imaging access. We review licensing and regulations and discuss teleradiology in providing services to rural areas and assisting with disaster response, including the response to the coronavirus disease (COVID-19) pandemic. CONCLUSION. Teleradiology can help increase imaging efficiency and mitigate both geographic and temporal discrepancies in imaging care. Technologic limitations and regulatory hurdles hinder the optimal practice of teleradiology, and future attention to these issues may help ensure broader patient access to high-quality imaging across the United States.

The Current State of Teleradiology Across the United States: A National Survey of Radiologists' Habits, Attitudes, and Perceptions on Teleradiology Practice

PURPOSE

To explore the current state of teleradiology practice, defined as the interpretation of imaging examinations at a different facility from where the examination was performed.

METHODS

A national survey addressing radiologists' habits, attitudes, and perceptions regarding teleradiology was distributed by e-mail to a random sample of ACR members in early 2019.

RESULTS

Among 731 of 936 respondents who indicated a non-teleradiologist primary work setting, 85.6% reported performing teleradiology within the past 10 years and 25.4% reported that teleradiology represents a majority of their annual imaging volumes; 84.4% performed teleradiology for internal examinations and 45.7% for external examinations; 46.2% performed teleradiology for rural areas and 37.2% for critical access hospitals; 91.3% performed teleradiology during weekday normal business hours and 44.5% to 79.6% over evening, overnight, and weekend hours. In all, 76.9% to 86.2% perceived value from teleradiology for geographic, after-hours, and multispecialty coverage, as well as reduced interpretation turnaround times. The most common challenges for teleradiology were electronic health record access (62.8%), quality assurance (53.8%), and technologist proximity (48.4%). The strategy most commonly considered useful for improving teleradiology was technical interpretation standards (33.3%). Radiologists in smaller practices were less likely to perform teleradiology or performed teleradiology for lower fractions of work, were less likely to experience coverage advantages of teleradiology, and reported larger implementation challenges, particularly relating to electronic health records and prior examination access.

CONCLUSION

Despite historic concerns, teleradiology is widespread throughout modern radiology practice, helping practices achieve geographic, after-hours, and multispecialty coverage; reducing turnaround times; and expanding underserved access. Nonetheless, quality assurance of offsite examinations remains necessary. IT integration solutions could help smaller practices achieve teleradiology's benefits.

Evaluating the Referring Physician's Clinical History and Indication as a Means for Communicating Chronic Conditions That Are Pertinent at the Point of Radiologic Interpretation

The clinical history and indication (CHI) provided with a radiological examination are critical components of a quality interpretation by the radiologist. A patient's chronic conditions offer the context in which acute symptoms and findings can be interpreted more accurately. Seven pertinent (potentially diagnosis altering) chronic conditions, which are fairly prevalent at our institution, were selected. We analyze if and how in 140 CHIs there was mention of a patient's previously reported chronic condition and if and how the condition was subsequently described in the radiology report using a four-item scheme (Mention/Specialization, Generalization, Common comorbidity, No mention). In 40.7% of CHIs, the condition was rated Mention/Specialization. Therefore, we reject our first hypothesis that the CHI is a reliable source for obtaining pertinent chronic conditions (≥ 90.0%). Non-oncological conditions were significantly more likely rated No mention in the CHI than oncological conditions (58.7 versus 8.3%, P < 0.0001). Stat cases were significantly more frequently No mention than non-stat cases (60.0 versus 31.3%, P = 0.0134). We accept our second hypothesis that the condition's rating in the CHI is significantly correlated with its rating of the final radiology report (χ(2) test, P < 0.00001). Our study demonstrates an alarming lack of communication of pertinent medical information to the radiologist, which may negatively impact interpretation quality. Presenting automatically aggregated patient information to the radiologist may be a potential avenue for improving interpretation and adding value of the radiology department to the care chain.

Comparison of European (ESR) and American (ACR) white papers on teleradiology: patient primacy is paramount

The ACR and European Society of Radiology white papers on teleradiology propose best practice guidelines for teleradiology, with each body focusing on its respective local situation, market, and legal regulations. The organizations have common viewpoints, the most important being patient primacy, maintenance of quality, and the "supplementary" position of teleradiology to local services. The major differences between the white papers are related mainly to the market situation, the use of teleradiology, teleradiologist credentialing and certification, the principles of "international" teleradiology, and the need to obtain "informed consent" from patients. The authors describe these similarities and differences by highlighting the background and context of teleradiology in Europe and the United States.

Teleradiology from the provider's perspective-cost analysis for a mid-size university hospital

OBJECTIVES

Real costs of teleradiology services have not been systematically calculated. Pricing policies are not evidence-based. This study aims to prove the feasibility of performing an original cost analysis for teleradiology services and show break-even points to perform cost-effective practice.

METHODS

Based on the teleradiology services provided by the Greifswald University Hospital in northeastern Germany, a detailed process analysis and an activity-based costing model revealed costs per service unit according to eight examination categories. The Monte Carlo method was used to simulate the cost amplitude and identify pricing thresholds.

RESULTS

Twenty-two sub-processes and four staff categories were identified. The average working time for one unit was 55 (x-ray) to 72 min (whole-body CT). Personnel costs were dominant (up to 68 %), representing lower limit costs. The Monte Carlo method showed the cost distribution per category according to the deficiency risk. Avoiding deficient pricing by a likelihood of 90 % increased the cost of a cranial CT almost twofold as compared with the lower limit cost.

CONCLUSIONS

Original cost analysis is possible when providing teleradiology services with complex statutory requirements in place. Methodology and results provide useful data to help enhance efficiency in hospital management as well as implement realistic reimbursement fees.

KEY POINTS

• Analysis of original costs of teleradiology is possible for a providing hospital • Results discriminate pricing thresholds and lower limit costs to perform cost-effective practice • The study methods represent a managing tool to enhance efficiency in providing facilities • The data are useful to help represent telemedicine services in regular medical fee schedules.

Bridging the text-image gap: a decision support tool for real-time PACS browsing

In this paper, we introduce an ontology-based technology that bridges the gap between MR images on the one hand and knowledge sources on the other hand. The proposed technology allows the user to express interest in a body region by selecting this region on the MR image he or she is viewing with a mouse device. The proposed technology infers the intended body structure from the manual selection and searches the external knowledge source for pertinent information. This technology can be used to bridge the gap between image data in the clinical workflow and (external) knowledge sources that help to assess the case with increased certainty, accuracy, and efficiency. We evaluate an instance of the proposed technology in the neurodomain by means of a user study in which three neuroradiologists participated. The user study shows that the technology has high recall (>95%) when it comes to inferring the intended brain region from the participant's manual selection. We are confident that this helps to increase the experience of browsing external knowledge sources.

Outsourcing to teleradiology companies: bad for radiology, bad for radiologists

Outsourcing night and weekend call to teleradiology companies has become a common practice among private radiology groups. While this may lead to an easier lifestyle, the authors discuss the serious negative consequences for radiologists and the specialty as a whole. These include the likelihood of commoditization of the field, lowering of fees, displacement from hospital contracts and outpatient reading contracts, greater encroachment by other specialties, and lowering of quality.

Radiology 2011: the big picture

OBJECTIVE

This article will take a big-picture view of the issues of utilization, cost, value, quality, innovation, self-referral, specialization, commoditization, competition, and corporatization and suggest how they are closely interrelated.

CONCLUSION

These issues may have a major effect on the practice of radiology. It may be both presumptuous and platitudinous to suggest that our profession currently faces some of the greatest challenges in its history.

From shared data to sharing workflow: merging PACS and teleradiology

Due to a host of technological, interface, operational and workflow limitations, teleradiology and PACS/RIS were historically developed as separate systems serving different purposes. PACS/RIS handled local radiology storage and workflow management while teleradiology addressed remote access to images. Today advanced PACS/RIS support complete site radiology workflow for attending physicians, whether on-site or remote. In parallel, teleradiology has emerged into a service of providing remote, off-hours, coverage for emergency radiology and to a lesser extent subspecialty reading to subscribing sites and radiology groups. When attending radiologists use teleradiology for remote access to a site, they may share all relevant patient data and participate in the site's workflow like their on-site peers. The operation gets cumbersome and time consuming when these radiologists serve multi-sites, each requiring a different remote access, or when the sites do not employ the same PACS/RIS/Reporting Systems and do not share the same ownership. The least efficient operation is of teleradiology companies engaged in reading for multiple facilities. As these services typically employ non-local radiologists, they are allowed to share some of the available patient data necessary to provide an emergency report but, by enlarge, they do not share the workflow of the sites they serve. Radiology stakeholders usually prefer to have their own radiologists perform all radiology tasks including interpretation of off-hour examinations. It is possible with current technology to create a system that combines the benefits of local radiology services to multiple sites with the advantages offered by adding subspecialty and off-hours emergency services through teleradiology. Such a system increases efficiency for the radiology groups by enabling all users, regardless of location, to work "local" and fully participate in the workflow of every site. We refer to such a system as SuperPACS.