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Commentary |
1 Department of Radiology, Massachusetts General Hospital, White Bldg. 270C, 55 Fruit St., Boston, MA 02114.
Received September 6, 2007; accepted after revision November 3, 2007.
Address correspondence to G. W. L. Boland
(gboland{at}partners.org).
Keywords: radiology practice • teleradiology
The past few years have witnessed a phenomenal growth in teleradiology services, fuelled largely by the desire of radiology groups to outsource off-hour radiology interpretations in the hope of making their practices more attractive, particularly in a tight labor market [1–3]. Off-hour coverage had become particularly onerous to hospital radiology groups because emergency department doctors were ordering more and more studies at night, depriving radiologists any chance of a peace ful night's sleep. Very quickly, the term "night hawk" entered the radiology lexicon as an in creasing number of teleradiology companies took advantage of the market, and thousands of hospitals in the United States now out source off-hour imaging interpretations [4, 5]. It is somewhat surprising that so many hospitals, so quickly, have allowed their radiologists to cede their off-hour responsibilities given that referring physicians usually prefer to have their own radiologists interpret off-hour images [6]. Despite initial reluctance, however, emergency department physicians have now mostly accepted unfamiliar medical practitioners providing radiology interpretations at night, perceiving them to offer equivalent and sometimes superior customer service levels compared with their own radiologists. This state of affairs has clearly been a big "win" for the teleradiology companies and, it seems, at least for now, the radiology groups [2, 4, 5, 7, 8].
If the market for these nighthawk services was restricted to off-hour operations, then radiologists, perhaps, might have secured for themselves a long-lasting lifestyle benefit. However, a new radiology "dayhawk" market is emerging, based primarily on the commercial success of nighthawk teleradiology services, which threatens the very existence not just of some radiologists' lifestyles but even their jobs. Having experienced the service advantages of outsourced off-hour teleradiology, referring physicians and hospital administrators are now asking why their radiology groups cannot deliver the same levels of service for daytime radiology operations [9]. Given that many groups are understaffed, some have reluctantly agreed to outsource an increasing number of day time interpretations to the acquisitive teleradiology companies, which have built the logistic infrastructure to respond rapidly to this new dayhawk market. In other words, radiologists, by readily outsourcing their off-hour responsibilities, have inadvertently created a competitive dayhawk market for radiologic services.
The speed with which competition has been introduced into the radiology market has caught some radiology groups by surprise, some of which have already lost either part or all of their existing franchise [2]. Furthermore, due to the success of the commercial tele radiology companies, larger entrepreneurial radiology groups have been encouraged to enter the market. They have the added advantage of being able to provide some on-site hospital coverage—a hospital will usually need some radiology daytime presence—while transmitting the majority of images elsewhere, wherever the majority of their group is located.
The radiology market is therefore entering an intense phase of consolidation, and smaller radiology groups, particularly those deemed to deliver poor customer service, are at significant risk of losing out [2]. They are at a particular disadvantage because they often cannot offer the full range of subspecialty services that increasingly are being demanded of them [9]. Consequently, some radiologists can no longer assume long-term job security because their core value proposition can now be outsourced. Although many groups have responded accordingly and have either maintained or improved the quality of their services, the tide has turned on those groups who have used the tight radiology job market to leverage their own self-interests [2]. These groups face a very uncertain future.
From the referring physician's perspective, the implications of radiology outsourcing and consolidation have yet to be fully realized, but in all likelihood, it will mean even less communication between themselves and their radiology colleagues—likely a loss for both parties. This trend had already started after the widespread implementation of institutional electronic image and report distribution, giving caregivers less reason to communicate with their radiologist colleagues. However, their continued desire to discuss complex and difficult cases with radiologists is inevitably challenged if the reporting radiologists are out of state or country [6, 8]. The referring physician will, in all likelihood, never have met the off-site radiologist, inhibiting the necessary trust and camaraderie required be tween clini cal colleagues to facilitate clinical decision making. Radiologists there fore risk losing their professional status among their peers as referring physicians dis engage and begin to see them as commodities rather than clinical colleagues—a profound loss for radiologists.
Considering the significant increase in teleradiology over the past few years, it is perhaps surprising that patients have, for the most part, been completely unaware that their images could potentially be outsourced to relatively unknown remote professionals. Most patients probably assume that local radiologists, known and presumably trusted by their health care facility, interpret their images. Patients would likely have significant concerns if they knew that hospitals were not only outsourcing their images but that these same hospitals are sometimes challenged to appropriately credential and monitor a large number of distant radiologists, whose quality assurance programs (peer review) may not be transparent to the host organization.
Maybe this would all be moot if patients could be reassured that remote radiologists could just as easily provide equal or superior interpretations as their local radiologists. For nighthawk services, this can be assumed, perhaps, because teleradiology is ideally suited to emergency department radiology whereby referring physicians are often simply asking for a preliminary report based on a binary decision (e.g., is there a fracture or not?). In reality, however, when it comes to the dayhawk business, studies are usually more complex, requiring comparison with old studies and reports, and many studies, ideally, would require the radiologist to access other pertinent clinical information (blood work, pathology, and surgery reports among others) before an accurate report could be generated [2].
However, there are still too many technologic obstacles in the dayhawk busi ness that must be overcome before tele radiology companies can honestly claim that their reports are consistently of equal or higher quality than those of on-site radiologists [2]. Without access to the hospital information system, the radiology information system, or the PACS, it can be hard if not impossible for the remote radiologist to have timely access to the perti nent prior clinical data necessary to generate an accurate report—far from ideal from the patient's perspective. Most teleradiology companies are not integrated with hospital information systems and have to resort to a system of faxes, e-mails, and telephone calls if their reporting radiologists request addi tional clinical information, an inherently inefficient process [2].
Despite this deficit, as patients become more informed they may, paradoxically, generate an even greater demand for teleradiology services. Knowing that some teleradiology companies could provide almost immediate access to subspecialty radiologists who may not be available locally, many patients may well lobby their health care facilities to give them access to these services. If patients become more demanding, commercial teleradiology companies may even start marketing second opinion services directly to patients, bypassing the health care facilities altogether. Teleradiology companies will compete on cost and quality, and it will then be up to the patient to decide how to value these services. However, given the current lack of integrated technologic platforms, it is far from certain that patients can ensure they will indeed obtain a quality product. Patients could now expose themselves (rather than their hospitals) to suboptimal radiology reports.
Fortunately, some entrepreneurs, including Microsoft, have recognized that patients, as they seek greater choice in their medical and radiologic care, will ultimately need to have their full medical records electronically available as they move from one caregiver to the next [10]. The company is developing software products that permit medical facilities to transmit, across secure networks, patient medical records into virtual medical record repositories, which can then be accessed and available to the patient or caregiver at anytime, anywhere. Remote radiologists could then have access to all the pertinent clinical information, just as if they resided within a hospital network.
Teleradiology may then, and only then, have reached its ultimate promise of being able to connect patient images and clinical data seamlessly to expert radiologists wherever they are—a likely big win for patients. It will finally be left up to the legal and regulatory bodies to remove their barriers once they are confident of the quality of the radiologists and their output. Given the uncertainties of validating radiologists' standards, qualifica tions, and ex per tise from distant lands, it is far from certain that the regulatory bodies will, or even should, do so.
Patients, on the other hand, may make the decision for them and contract directly with teleradiology companies, bypassing the tradi tional health care process altogether. So, although teleradiology still has much to offer, radiologists, referring physicians, tele radiology companies, and patients face a fu ture full of uncertainties and risks. As tele rad iology comes of age, it is not yet clear who will end up as the ultimate winners and losers.
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G. W. L. Boland Visibility of Radiologists: Helping to Secure Your Future Am. J. Roentgenol., May 1, 2009; 192(5): 1373 - 1374. [Abstract] [Full Text] [PDF]
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