Remote Reading: Practice Extender, Not Practice Extinction

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Virtual Radiologic’s remote reading workstation
Ten years ago, the American College of Radiology surveyed nearly 1,000 practices as to their utilization of teleradiology. They found that 71 percent of multi-radiologist practices had teleradiology systems in place, while 30 percent of solo practices had deployed remote reading systems.

“Teleradiology had already become a fixture in most practices by 1999, though it was used for only a small fraction of image interpretations,” wrote the authors of the survey (Am J Roentgenol 2005; 185:24-35). “Its widespread presence positioned teleradiology to become a key element of radiology practice nationwide.”

Fast-forward a decade and remote reading is part of the day-to-day routine of the majority of practicing radiologists. Most groups manage diagnostic image interpretation for multiple sites; including hospitals, clinics, free-standing imaging centers and other specialty practices.

Technology—the proliferation of high-speed data lines, the widespread availability of low-cost high-performance workstations and a boom in digital imaging and PACS adoption—has both propelled and enabled the expansion of teleradiology. In addition, referring clinicians are ordering diagnostic imaging in ever-increasing volumes, further fueling the growth of remote reading.

Uncertainty and doubt

However, this distance between the interpreting radiologist, the patient and the referrer has led some to question the role of teleradiology.

“The clinical interaction may be lost when outsourcing work,” says Steve Field, MD, chairman of the Royal College of General Practitioners in an article in the August 2008 issue of the British Medical Journal. Field’s worry is that outsourcing this relationship can jeopardize effective communication between specialists.

“Prior to teleradiology, radiologists were protected in their practice sinecures by a variety of barriers to competition and had wide latitude to look at life according to their own viewpoints and self-interests,” wrote James H. Thrall, MD (Radiology 2007; 244:325-328). “It is likely that major consolidation in the practice of radiology will be fostered by means of teleradiology to achieve benefits of scale, provide more timely service, provide access to subspecialist clinical expertise, and better match supply with demand.”

A legitimate concern among some radiologists is that the explosion of remote reading will lead to a commoditization of their skill set.

“The trend toward commoditization is accelerating because of globalization, increased information exchange, and technological developments, all of which are currently applicable to medical imaging,” wrote Eliot L. Siegel, MD, and Bruce I. Reiner, MD (J Am Coll Radiol 2009; 6[3]:167-170). With the widespread adoption of teleradiology, universal information technology standards (such as Health Level 7, Integrating the Healthcare Enterprise, and DICOM) and PACS, medical imaging has all of the prerequisites to fulfill this commoditization trend.”

Thrall sees remote reading as offering a double-edged sword to radiology.

“If the practice of radiology is defined narrowly as the interpretation of imaging examinations, the specialty indeed risks becoming commoditized to the degree that outsourced teleradiology services have taken over a growing fraction of radiology work,” he wrote (J Am Coll Radiol 2009; 6[2]:73-75). “However, if the practice of radiology is defined more broadly and comprehensively, it is clear that radiology is not a commodity, and that teleradiology, rather than being the instrument of commoditization, can be an important tool for the enhancement and optimization of providing imaging services to patients.”

Delivering quality care, everywhere

The overarching benefit of widespread internet access, PACS and the development of remote-reading only radiology practices is that the capability exists to provide a quality diagnostic image interpretation anywhere, at any time.

“These powerful tools are already giving small and rural radiology practices access to subspecialty interpretations that they might not have had access to previously,” observed William G. Bradley, Jr. MD, PhD (Radiology 2008; 248:337-341). “Small radiology groups without fellowship-trained subspecialists can now contract out for subspecialty interpretations to provide the higher level of service increasingly being demanded by subspecialty clinicians.”

Virtual Radiologic, a Minneapolis-based remote reading firm has successfully applied this model both in the United States as well as overseas. The company recently signed an agreement with Arabia and late last year inked a technology and interpretation deal with Pro-Laudo, a Brazilian teleradiology group.

“In Brazil, an acute shortage of radiologists in non-metropolitan areas poses socio-economic inequalities in healthcare delivery,” says Felipe Nirenberg, MD, co-founder and CEO of Pro-Laudo. “Now, we can devote our full attention to providing customers with quality patient care, and realize more quickly our growth potential.”

Several time zones away, Virtual Radiologic successfully negotiated a multi-year agreement with Lion City Radiology of Singapore to provide preliminary interpretations of CT and MRI studies for its affiliates in Singapore and the United Arab Emirates (UAE).

According to Vas Metupalle, MD, managing director of Lion City, the partnership allows his group to expand its service offerings in both Singapore and the UAE.

“We can now provide the round-the-clock coverage and high quality subspecialty expertise that our clients in Singapore and UAE demand,” he says.

Greg Rose, MD, president and CEO of Bellaire, Texas-based NightRays says he has seen a 33 percent growth in new client contracts for his practice over the past year. One of these clients, Associated Radiologists in Jonesboro, Ark., selected the group to provide subspecialty and other interpretative services.

“After evaluating several key players in the teleradiology field, we felt that our best option was to move forward with NightRays,” says John B. Lieblong, CEO and administrator of Associated Radiologists. “NightRays has an impeccable record of providing quality service, efficiently, and provided a customized solution to meet our radiology needs.”

Franklin & Seidelmann Subspecialty Radiology is a subspecialty radiology interpretation provider in the U.S. serving imaging centers, in-office practices, radiology groups and hospitals.

“When it comes to radiologist staffing, it is getting more challenging to appropriately staff with the full breadth and depth of radiology expertise needed to support all modalities and physician specialties,” says Peter D. Franklin, MD, co-founder and medical director of the Cleveland-based firm. “A single staffing model just doesn’t adequately support physician and patient needs anymore. Imaging facilities are using a blend of onsite and virtual staffing models to get the right mix of general and subspecialty interpretation expertise to ensure physician satisfaction, increase referrals, improve patient outcomes, mitigate malpractice exposure, and support new revenue streams as a result of high-end modality purchases.”

Lighthouse Diagnostic Imaging of Lone Tree, Colo., is a practice that has put this virtual model into place.

“To offset losses from DRA cuts in reimbursements and to increase our referrals and market share, it made sense to utilize a subspecialty teleradiology model which is more cost-effective than hiring full-time multi-subspecialist positions that would probably be underutilized at times,” says Mark Forte, MD, medical director and CEO. “We have seen an increase in referrals for neuro and spine imaging, as well as an increase from orthopedic surgeons in our community.”

Bradley sees that the trend for further growth in teleradiology is favorable, given current market forces.

“Given the opportunity afforded by off-site teleradiology to connect subspecialist clinicians with subspecialist radiologists, use of this technology is likely to increase,” he wrote. “While there may be an element of commoditization with off-site teleradiology, patient care will be improved—and this should always be our highest priority.”