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Original Research |
1 Department of Radiology, University of Colorado Health Sciences Center,
Denver, CO.
2 Research Department, American College of Radiology, 1891 Preston White Dr.,
Reston, VA 20191.
3 Department of Diagnostic Radiology, Yale University, New Haven, CT.
4 Department of Economics, Yale University, New Haven, CT.
5 Yale School of Management, New Haven, CT.
Received September 21, 2004;
accepted after revision September 27, 2004.
Address correspondence to J. H. Sunshine.
Abstract
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MATERIALS AND METHODS. In 1999, the American College of Radiology surveyed 970 practices by mail. A response rate of 66% was achieved. Responses were weighted to represent all radiology practices in the United States. Data from nine questions specifically designed to profile the use of teleradiology were analyzed using descriptive statistical methods and multivariate regression analyses.
RESULTS. Seventy-one percent of multiradiologist practices had teleradiology systems in place, using them to interpret 5% of their studies. For solo practices, corresponding statistics were 30% and 14%. Ninety-two percent of multiradiologist practices with teleradiology systems used them for preliminary on-call interpretation. Other major uses included consultation with other radiologists (20%) and primary interpretation of studies (18%). Ninety-five percent of multiradiologist practices with teleradiology systems used them to interpret CT, 84% used them for sonography, 69% for nuclear medicine, 47% for MRI, and 43% for conventional radiographs.
CONCLUSION. Teleradiology had already become a fixture in most practices by 1999, though it was used for only a small fraction of image interpretations. Its widespread presence positioned teleradiology to become a key element of radiology practice nationwide.
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In 1999, the American College of Radiology (ACR) conducted a large-scale survey of diagnostic radiology practices that included nine questions on teleradiology. The answers to these questions provide a detailed picture of the state of teleradiology in 1999. Although administered in 1999, the ACR Survey of Practices still represents one of just a few comprehensive sources of information about the use of teleradiology in clinical settings, and to date these data have not been formally disseminated to those in the radiology profession. Survey data from other sources, such as that produced by the Association of Telehealth Service Providers, are periodically released and, although they are useful in describing telemedicine activity in the United States overall, they do not provide extensive detail on the use of teleradiology [6]. The 1999 ACR survey fills this void and thereby makes an important contribution to the improved understanding of teleradiology and the impact it has on the quality and practice of medicine today.
This article presents a comprehensive portrait of the characteristics of teleradiology systems of radiology practices as obtained from the 1999 ACR Survey of Practices. Teleradiology was defined in the survey as "the transmission of images from an originating medical facility (e.g., a hospital) to another location or to a distant site within the same facility. Thus an intrafacility image communication system counts as teleradiology." The topics covered by the survey include the extent of teleradiology use by practices; the sites of teleradiology transmission and the types of originating and receiving facilities; the purposes for which teleradiology was used; imaging techniques and image capture methods that were used in conjunction with teleradiology; use of PACS; and credentialing and other related issues for those practices with teleradiology systems in place.
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In brief, a 65-item questionnaire was mailed to 970 randomly selected U.S.-based radiology practices from a list of approximately 3,000 in May 1999. Information about how this list was developed is described in an earlier article [7]. Four follow-up mailings were subsequently conducted between June and November 1999. Seven hundred eight responses were received, and approximately 90 of those were excluded because they were either incomplete or duplicates or were provided by respondents outside the target group (e.g., residents in training). The result was a final response rate of 66%. The final number of unweighted practices used for analysis was 645.
Statistical and Data Analysis Methods
Responses were weighted so that weighted statistics would be representative
of the answers that would have been received if all practices in the United
States had been surveyed and responded. Weights were determined according to
28 strata based on four census regions and seven practice size categories (the
latter were measured by the total number of full- and part-time radiologists
at the time of the survey). These strata represented only those practices that
reported performing some diagnostic radiology services;
radiation-oncology-only practices were excluded. Additional information about
how weights were applied to responses is presented elsewhere
[7].
Data from sample surveys are subject to sampling variability. The usual measure of sampling variability is the standard error (SE). There is a 95% probability that the true value of a population parameter (such as a population mean) lies within approximately 2 SEs of the corresponding statistic for a sample drawn from a normal population. For percentages in tables, the SE (in percentages) can generally be approximated by taking the square root of p(1 - p)/n, where p = percentage and n = unweighted sample size. Besides percentages, other descriptive statistics that are reported are means (averages), percentiles, and counts. We used chi-square analysis (degrees of freedom = 1) to assess the association between two nominal variables [9, 10], namely, the association between having PACS and using teleradiology for primary image interpretation.
The information in this article is based on the responding practices' interpretations of the survey questions. For example, a practice was recorded as "academic" because it checked "primarily academic" as its practice type on the survey's list of practice types.
Practice characteristics that were used in the analysis include type and size of practice, geographic region, type of general practice settings served (such as hospitals only or nonhospital sites), practice location (such as whether the practice was located in a main city of a large metropolitan area or rural area), and practice ownership.
Practices that contain more than one diagnostic radiologist are referred to as "multiradiologist practices," and it is on these practices that most of the analysis of this article is focused. Practices containing only one member are referred to as "solo practices." In this article, we limited the analysis of solo practices because the number of solo practices that responded to the 1999 survey was low, making the results of cross-tabulations with other practice characteristics statistically unreliable. In the descriptive statistics tables, estimates for solo practices are presented as estimates for a separate type of practice.
When information about practice location is discussed in the text and tables, the types of locations are center city or suburb of a large metropolitan area (area population > 1 million); center city or suburb of a smaller metropolitan area (area population, 50,000-1 million); nonmetropolitan city, town, or rural area (area population < 50,000); and varied locations, no one type is principal (area population not specified). Also, "any outside ownership" is defined as "complete outside ownership" or "partial outside ownership."
We report key findings from regression analyses—namely, logistic regression and multiple regression analysis: logistic regression to determine what practice characteristics could predict a dichotomous dependent variable (such as whether a practice had a teleradiology system in place), and multiple regression analysis to determine what practice characteristics could predict a cardinal dependent variable (such as percentage of all procedures for which teleradiology is used).
Generally, results of regression analysis provide better information about which relationships among variables are real and meaningful than do tables containing descriptive statistics because regression analysis measures the effect of each variable after statistically controlling for the effect of all other variables included. We used explanatory (independent) variables (such as practice type, size, census region, general practice setting served, and location) that were found to be important in earlier published analyses [11-15]. In regression analysis, the category with the highest number of data points was designated as the referent category. Regression measures the likelihood of a significant effect from each practice characteristic (positive or negative) compared with the effect of the referent category. Referent categories used for each practice characteristic included "nonacademic private radiology" for practice type, "South" for census region, "both hospital and nonhospital settings" for general practice settings served, and "center city, smaller metropolitan area" for practice location.
We included the square of the practice size variable (i.e., [practice size]2) in each regression model. We did so because the association between practice size and the dependent variable perhaps is better approximated by a curve than by a straight line; for example, a characteristic may be most common for medium-sized practices rather than for small or large ones.
The regression analyses were conducted on all multiradiologist diagnostic radiology practices. Because the descriptive characteristics are reported in tables, they are not emphasized in the text. Selected results of the regression analyses are reported in table format, and those that are considered major are also reported in the text. Generally, logistic regression analysis was restricted to dichotomous variables for which the rate of occurrence was between 10% and 90%, because regression can add little further information if nearly all practices have the same characteristic.
For any analysis involving the practice characteristic "general settings served," responses in which the calculated total number of settings served by a practice did not fall within 80-125% of the self-reported total were excluded to minimize error resulting from invalid or missing data. Generally, categories of multiradiologist practice characteristics with fewer than 20 responding practices are not presented in the descriptive tables (e.g., "government" and "other" categories are not included under "practice type"). Some select categories of low cell size were included because of their potential interest—results from solo practices are presented despite the fact that analyses were based on only 19 responses. Solo practices were not included in the regression analyses.
Data analyses were conducted with SAS statistical software (release 9.0, SAS Institute) and Excel software (release 2002, Microsoft). If a finding was statistically significant, it is reported as such. We used a p value of less than or equal to 0.05 as the measure of statistical significance.
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Among those diagnostic radiology practices with teleradiology systems in place at the time of the survey, teleradiology was used for only a small fraction of interpretations (mean, 7%; Table 1). Multiradiologist and solo practices with teleradiology systems used them for 5% and 14% of their interpretations, respectively. The mean percentages of interpretations for which teleradiology was used in academic and nonacademic multiradiologist practices were 14% and 5%, respectively. However, after controlling for other characteristics using multiple regression, none of the set of practice variables used in the regression model was significantly associated with the percentage of procedures for which teleradiology was used.
Image Transmission and Originating and Receiving Facilities, by Practice Characteristic
Approximately 40% of practices' teleradiology systems transmitted images
only beyond an individual facility, 41% transmitted both beyond and within a
facility, and 20% transmitted just within a facility
(Table 3). Statistically
controlling for the effects of the other characteristics of a practice, the
likelihood that a practice with a system transmitted images only beyond a
facility significantly increased with increasing practice size, but the
increase was smaller among larger practices than among smaller practices
(Table 2). The converse was
true regarding the likelihood that a practice transmitted images both within
and beyond a facility (Table
2). Also, relative to practices in the center city of smaller
metropolitan areas, practices in all locations except rural areas were more
likely to transmit images beyond a facility only, other practice
characteristics being equal.
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Overall, multiradiologist practices with systems listed hospitals as an originating facility in the overwhelming majority of cases (94% of practices with systems) and offices in a few instances (15%) (Table 3). Statistically controlling for the effects of the other characteristics of a practice, the likelihood that a practice transmitted images from an office significantly increased with increasing practice size, but the increase was smaller among larger practices than among smaller practices (Table 2). Other practice characteristics being equal, factors decreasing the likelihood of transmitting images from an office included location in the Northeast or West (relative to the South) and, by definition, practices serving only hospitals.
Far the most common receiving facilities for multiradiologist practices with systems in 1999 were homes (86% of practices with systems), followed by hospitals (43%) and offices (17%) (Table 3). The likelihood that a practice transmitted images to a hospital or office significantly increased with increasing practice size, other practice characteristics being equal, but the increase was smaller among larger practices than among smaller practices (Table 2). On the other hand, the likelihood of transmitting to a home decreased with increasing practice size, other practice characteristics being equal, but the decrease was smaller among larger practices than among smaller practices.
Purposes for Which Teleradiology Was Used
The overwhelmingly most common purpose for which multiradiologist practices
reported using teleradiology (Table
4) was for preliminary on-call findings (92% of practices with
systems). Other less common uses included consultation with other radiologists
(20%), primary interpretation (18%), and monitoring studies performed at
another site (16%). Systems were rarely used for consultation with referring
physicians (7%) or for peer review (3%).
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Logistic regression showed that, relative to private nonacademic groups, academic practices were more likely to use teleradiology for primary interpretation of studies and consultation with other radiologists, and less likely to use it for on-call preliminary interpretations, other practice characteristics being equal (Table 2). The likelihood that a practice used teleradiology for primary interpretation of studies, monitoring studies performed at another site, and consultation with other radiologists significantly increased with increasing practice size, other practice characteristics being equal, but the increase was smaller among larger practices than among smaller practices. In contrast, other practice characteristics being equal, the likelihood of using teleradiology for on-call preliminary interpretations decreased with increasing size for practices having up to approximately 30 members, after which it increased.
Techniques Involved in Teleradiology
Ninety-five percent of multiradiologist practices with teleradiology
systems used the systems to interpret CT, 84% used them for sonography, 69%
for nuclear medicine, 47% for MRI, and 43% for conventional radiographs
(Table 5). Relative to
nonacademic private radiology practices, academic practices with teleradiology
were, other practice characteristics being equal, more likely to use
teleradiology for conventional radiographs and less likely to use it for
sonography and nuclear medicine (Table
2). Other characteristics being equal, relative to practices with
teleradiology in the South, practices in the Northeast with teleradiology were
less likely to use it for conventional radiographs, MRI, and nuclear medicine.
Practices with teleradiology in nonmetropolitan cities or towns, other
characteristics being equal, were less likely than those in the center city of
smaller metropolitan areas to use teleradiology for conventional radiographs,
MRI, sonography, or nuclear medicine.
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Image Capture Methods
A direct interface was used most often to capture CT, MRI, sonography, and
nuclear medicine images; conventional radiographs were most often digitized
for teleradiology systems; and images from fluoroscopy and angiography were
captured with direct interface and by digitizing film with similar frequency
(Table 6). Video camera was
rarely used to capture images for any technique.
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PACS and Teleradiology
Fourteen percent of all multiradiologist practices with teleradiology
systems in place had a PACS system; 52% had no PACS system, and 34% had no
PACS system but had plans to install one
(Table 7). None of the solo
practices with teleradiology systems reported having a PACS system, and only
3% of them had plans to install one. Logistic regression analysis showed that,
other practice characteristics being equal, academic practices were
significantly more likely to have a PACS system in place than nonacademic
private radiology practices (statistics not reported in tables). Also, other
practice characteristics being equal, the likelihood that a practice using
teleradiology had a PACS system increased with increasing practice size, but
the increase was smaller among larger practices than among smaller practices.
Using chi-square analysis, we found that practices performing primary
interpretation of studies with teleradiology tend to have PACS more often than
practices that do not use teleradiology for primary interpretation.
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Credentialing, Hospital Competition, and Other Related Issues
Eighty-eight percent of multiradiologist practices with teleradiology
systems in place reported that the radiologists using teleradiology were
credentialed at all sending facilities, whereas 5% reported that they were
not, and 6% did not respond to this question
(Table 8).
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Sixteen percent of radiology practices with teleradiology systems in place reported that the hospitals they served had been offered teleradiology services by a competing practice or party; moreover, one third of practices with systems did not know if a rival offer had been made. Of those multiradiologist practices reporting that teleradiology services had been offered to hospitals by other parties, 15% reported that the hospitals had accepted such an offer, 83% reported that they had not, and 2% did not know (statistics not reported in table). However, only relatively few practices responded to this question, making the results difficult to interpret.
Most multiradiologist practices using teleradiology (82%) did not report whether each of their members was licensed in all states served by their systems; only 10% of such practices reported that all members were licensed in each originating state, and 8% reported that they were not (statistics not reported in tables).
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Academic practices varied from other practices in that they used teleradiology much more for primary interpretation of studies (and several other uses) and much less for on-call preliminary findings. This implies that academic practices were technology leaders in terms of using teleradiology as an integral part of daily practice rather than primarily for night and weekend coverage. Possible explanations may be that academic practices tend to be larger [17] and may serve a higher number of settings and geographic locations. More fundamentally, perhaps the role of research and training in academic practices facilitates earlier adoption of technology.
Not surprisingly, teleradiology played a greater role in the practice of larger groups than in smaller. Similar to academic practices, teleradiology was used in larger practices more for primary interpretation of studies, monitoring studies performed at remote sites, and communication with referrers and other radiologists, and less for on-call preliminary findings. This indicates that teleradiology addresses disadvantages associated with practice size in different ways. Specifically, teleradiology helps to overcome challenges inherent in larger practices such as geographic separation, specialization, and diversity of practitioner skill. On the other hand, teleradiology also addresses one of the major challenge associated with a small practice—after-hours coverage.
It is difficult to draw generalized conclusions regarding the role that practice location plays in the use of teleradiology. Practices in the center city of large metropolitan areas were similar to those in nonmetropolitan cities and towns in that they had a relatively low likelihood of having a teleradiology system in place, but this was not true of practices in rural areas. Also, regression analysis showed no statistically significant effects of practice location on the percentage of studies for which teleradiology was used by practices with systems in place. Obviously, more factors affect this relationship than were investigated in the study. Because this study was undertaken when teleradiology was in a relatively early stage, the technology may not have diffused enough to permit accurate inferences regarding its ability to address challenges related to practice location.
Compared with multiradiologist practices, solo practices were less likely to have teleradiology systems in place, but those that did have teleradiology used it for a higher percentage of studies. Solo practices also used teleradiology less for on-call preliminary interpretation and more for primary interpretation and consulting with other radiologists. Thus, it appears that, relative to multiradiologist practices, solo practices lag in terms of acquiring teleradiology; but once they invest in the technology, solo practices appear to use it more extensively than multiradiologist practices. This is consistent with the notion that smaller practices may be somewhat more risk-averse and financially limited in terms of investment in leading-edge technology, but they are also more flexible and can fully adopt the technology more quickly once they have committed to it. The absence of PACS and plans to acquire PACS among solo practices may reflect financial constraints vis-à-vis this relatively expensive form of teleradiology or may also reflect lack of relevance in a solo practice.
It is not surprising that the technique most commonly associated with teleradiology is CT, because it is already acquired in a digital format and is the technique probably most frequently used after hours that requires an immediate interpretation by a radiologist. CT has also been shown to be the technique most commonly associated with PACS [18]. It is also not surprising that teleradiology is only rarely used with fluoroscopy and angiography, because both of these procedures typically require the on-site presence of a radiologist.
The prevalence of PACS was lower than that of teleradiology systems and was associated with the use of teleradiology for primary interpretation of studies. This is consistent with the idea that practices that have incorporated teleradiology into the workflow enough to use digital images for primary interpretation of studies are likely also to want to store and retrieve images in digital form. Alternatively, the higher prevalence of teleradiology systems may simply indicate that teleradiology represents an earlier phase on the pathway to digital imaging.
Implications for the Future
The high percentage of practices using teleradiology in 1999 for on-call
preliminary findings and for receiving images at home indicates that initially
the primary use of teleradiology was to ameliorate the burden of one of the
most onerous aspects of radiology practice, after-hours call. This also
portends the rapid proliferation of nighthawk services
[4]. These are now becoming
more widespread. The increased availability of board-certified radiologists at
any hour—a service that is increasingly expected of radiology
practices—seems to be a universally applauded benefit provided by
teleradiology [19].
A related problem that teleradiology has the potential to address is the radiologist workforce shortage [7]. This ability may provide further stimulus to radiology practices and referring physicians and organizations to establish teleradiology services. However, new evidence indicates that the radiologist workforce shortage may be easing [20]. Nevertheless, once the technology and infrastructure of teleradiology are in place, they are unlikely to be removed even if the workforce shortage pressures leading to their installation have diminished. Therefore, although teleradiology development may have been spurred on by what might prove to be a temporary shortage, teleradiology is likely to continue to have profound effects well into the future.
Other new dilemmas that teleradiology may present include ones involving privacy of personal medical information, the ability to ensure high quality, malpractice liability, and reimbursement. The Health Insurance Portability and Accountability Act of 1996 is directed to the privacy issue, although it is unclear how it will affect the nature of the teleradiology systems that are being implemented. Traditionally, quality of practice has been addressed through certification and accreditation, by the threat of legal repercussion, and through contractual and informal relationships with referrers. By adding another layer of complexity, teleradiology may blur lines of accountability, especially when an individual provides a preliminary interpretation on behalf of another practice. In a ddition, teleradiology may increase financial complexity—for example, with problems such as compensation for preliminary interpretations and determining responsibility for funding infrastructure improvements [21].
The issue surrounding teleradiology with perhaps the greatest potential impact on domestic radiology practice is that of international teleradiology. Although this was not addressed in the 1999 survey, reports now indicate that non-U.S.-based radiologic interpretation is rapidly becoming available throughout the United States [4]. Currently, state and federal programs do not reimburse non-U.S.-based physicians who practice medicine remotely in the United States [22]. Nevertheless, a small number of practices reported in this survey that at least some of their physicians were not licensed or accredited at the institution or in the state where the images were originating. A large number of practices (82%) did not respond to the question about states, indicating that no images or few images were being transmitted out of state (most likely, we believe), that they did not know the answer, or that they were unwilling to share such sensitive information. Regardless, in the face of tremendous cost pressures and a tight labor market, non-U.S.-based image interpretation will likely evolve under growing regulatory surveillance that promotes quality interpretation and patient care and also under greater cost-consciousness.
Such issues have been foreseen by the radiology profession. In 2003, the ACR established a task force to address issues of licensure, credentialing, quality, reimbursement, liability and jurisdiction, and ethics surrounding teleradiology [23]. The task force released its report in April 2004, outlining the issues and providing guidance to the college for future policies. The report maintains that interpretation quality and patient safety should remain the highest priorities of those providing, receiving, and paying for the service.
Strengths and Limitations of the Study
Strengths and limitations of the 1999 ACR Survey of Practices have been
discussed in detail elsewhere
[8]. In brief, the principal
strengths of the survey include large sample size, intensive follow-up,
receipt of a relatively large number of responses, and sophisticated weighting
to make the responses more representative of all radiology practices in the
United States.
Principal weaknesses of the survey include limitations inherent in sample surveys, such as ambiguity in the wording of survey questions; sampling error; coverage error; and nonresponse error. Question ambiguity was minimized by asking about issues relevant to the target population and providing reasonable responses, although terms were largely self-defined and responses self-reported. Coverage error was probably most pronounced in the area of government practices (few of which were part of the sample frame) and practices that contained no ACR members (which were not reached by the sample frame). Response rates were similar to other surveys of practices conducted by the ACR [12] and were maximized by conducting four follow-up mailings. However, there was a near total lack of response from radiation-oncology-only practices.
Questions in the teleradiology section of the survey may be at above-average risk for misinterpretation by respondents because of the novelty of terminology associated with this relatively new technology. Attempts to minimize this ambiguity included defining teleradiology at the outset of the survey section and avoiding technical language that may not be familiar to radiologists.
Because most of the present study is based on responses from practices with teleradiology systems in place, certain categories are represented by relatively few respondents. These include solo practices, government practices, and "other" multiradiologist practices, practices that functioned only in nonhospital settings, and practices operating in multiple types of geographic locations. This was in part due to the relative low number of responses from practices with these characteristics, but relatively low prevalence of teleradiology systems in these practices also contributed to the low number of responses. However, characteristics that were likely the most germane to the use of teleradiology appear to have been fairly well represented.
Because of the rapid advancement and diffusion of the technology [24, 25], teleradiology use by U.S. radiology practices may have significantly changed since the time this survey was administered. Indeed, the very definition of teleradiology has become more refined as the technology has evolved. For example, a Web-based system transmitting nondiagnostic quality images to referring clinicians could have reasonably fit the definition given in the survey, although such a system that does not include image interpretation probably would not now be considered teleradiology. Questions of current interest may have been excluded from the study. Furthermore, the survey may not have perfectly anticipated deeper implications such as dissolving interstate and international borders, creating opportunities for competition, and eliminating personal interactions and relationships.
However, this study provides a comprehensive picture of the state of practice at the end of the century that can be used as a benchmark for future results and help delineate the evolution of teleradiology. Specifically, results from the 2003 ACR Survey of Radiologists will provide updated information on the use of teleradiology and will build on the foundation set by the 1999 survey.
Conclusion
Although teleradiology was being used for only a small percentage of
diagnostic examinations at the time of the survey in 1999, it had already
become a fixture in most practices. Teleradiology has the potential to
revolutionize many aspects of the practice of radiology by breaking down
certain traditional barriers of practice group, locality, and space. To the
extent that they improve efficiency and patient care, such advancements should
be wholeheartedly embraced. However, some long-held safeguards are also at
risk of being brushed aside in the rush to embrace this technology. Care must
be taken to distinguish barriers from safeguards and to preserve key elements
of the profession, such as quality, responsiveness, and responsibility.
Acknowledgments
We wish to acknowledge the assistance of those who responded to the survey.
Without the participation of these individuals, statistics generated from
these survey data could not have been disseminated to the profession. The ACR
thanks them for their time and effort.
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