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For other articles and previous issues click here. May 30, 2005 Offshore
Reading The American College of Radiology guidelines largely reflect what’s happening in international teleradiology. The scary stories you’ve heard are pretty much just stories. Most radiologists reading studies overseas for stateside facilities were trained in the United States and licensed in the state where the study originated—which is what the guidelines recommend. In 2003, the American College of Radiology (ACR) set up its Task Force on International Teleradiology to examine major issues in the growing practice of offshore radiology reading—the electronic transmission of radiological images to be interpreted outside the United States. Specifically, the task force was created to investigate concerns about quality assurance, privacy and security, and fears about loss of jobs to outsourcing and work being routed to so-called “radiology sweatshops.” Task force members recently completed their work. The recommended guidelines were published in the “Report of the ACR Task Force on International Teleradiology” that appeared in the February issue of the Journal of the American College of Radiology. The findings and recommendations weren’t surprising, as the questions surrounding offshore teleradiology were already obvious and widely known. Despite all the expressed qualms about the practice, the ACR isn’t exactly opposed to teleradiology. In light of the current radiology workforce shortages and mushrooming number of images needing to be read, the organization believes teleradiology could help provide access to quality radiologic interpretations at night and during weekends—times when shortages are keenly felt. Indeed, international teleradiology has been able to advance due to shortages coupled with developments in computer technology that make outsourcing a viable and attractive option. “It has clearly been established that teleradiology may help provide better care in a timely manner,” says Arl Van Moore, Jr, MD, FACR, the task force chair and a radiologist with Charlotte Radiology in North Carolina. Still, obvious and important questions had to be addressed. For the concept to work—both from a client and provider standpoint—certain substantial criteria must be met and logistical considerations must be confronted, says Moore. “The concern many share is that because this is outside of the country, where there is no jurisdiction, it is very difficult to know what is going on,” he says. “You’re dealing with different countries, governments, and cultures.” To date, those problems appear far more hypothetical than real, but the ACR is taking a proactive approach. The task force’s recommendations are intended to ensure that radiologists performing image interpretations overseas meet the training and professional standards of U.S.-based radiologists. Among its guidelines, the task force recommended that physicians reading studies transmitted outside the United States be licensed in the states where the studies originated, be credentialed and afforded privileges by the healthcare institutions contracting them, and have liability insurance. Preliminary Statement The ACR gave clear indication of the direction it was headed when it released a preliminary position statement in 2004. At the time, the organization stressed that physicians working internationally should meet or exceed the same standards met by U.S.-based physicians. Specifically, they must: • be licensed to practice medicine in the state where the imaging examination is originally obtained (In addition, they should possess the medical or other licensure required within the jurisdiction of the interpretation site.); • be credentialed as a provider and maintain appropriate privileges in the U.S. health facility where the examination is done; • have appropriate medical liability coverage for the state in which the examination was obtained; and • be responsible for the quality of the images being interpreted. Further, physicians practicing outside the country must subject themselves to the jurisdiction of all applicable U.S. state and federal laws. They should maintain licensure appropriate to delivery of radiologic services at both the transmitting and receiving sites. Also, radiology groups, hospitals, and other entities in the United States should enter into contracts for interpretation of imaging exams with only those physicians who meet the criteria. The findings in the 2005 report were essentially an expansion of the recommendations made in the ACR’s earlier stated position. All along, the main message has been that even though international teleradiology could help address the workforce shortage, the quality of patient care must not be compromised. In its report, the task force indicated that international teleradiology should be performed consistent with the ACR Technical Standard for Teleradiology. Physicians should independently interpret teleradiology studies initially read outside the United States and provide the official authenticated written reports. Any group that obtains final interpretations from overseas should ensure that physicians providing interpretation have proper liability coverage, state licensure, and credentials. All physicians who provide imaging interpretations should regularly participate in the on-site quality assurance process and be involved in documenting that process. The quality guidelines state that the assurance program must be equivalent to or exceed that of the service hospital. All physicians who render interpretations on emergent cases should be immediately available for consultations. For nonemergent cases, interpreting physicians should either be available for consultations or make arrangements to communicate their findings. All physicians who contract with radiologists or radiology group practices to interpret imaging studies outside the United States should know that such an arrangement is subject to U.S. privacy laws and regulations such as HIPAA. The ACR also indicated that U.S.-based practices that contract for teleradiology services should probably expect to be held jointly responsible for any HIPAA violations resulting from those services. Reaction One reason so many people are on board is because the issues were already evident. “These were questions first raised five years ago, when teleradiology was just starting,” says Mark Bakken, president of The Radlinx Group, a teleradiology provider headquartered in Irving, Tex. “Everyone was asking about the need for credentials and licensing.” Some comments about the guidelines provided revealing insights about the practice of international teleradiology itself and its application in a business model. Sean Casey, MD, founder and CEO of Virtual Radiologic Consultants (VRC), a Minneapolis-based provider of on-call teleradiology services, says some fears may be unfounded, as inherent safeguards can come into play. “I think there’s a little hysteria involved,” he says. “At this point, some of these fears are more imagined than real.” Casey believes radiologists practicing overseas—specifically U.S-based radiologists—will have little reason to violate HIPAA regulations or become involved in any illegal activity. “They’re not going to become a fugitive from justice just because of a radiological reading,” he says. In addition, any business involved in the practice would want to ensure that appropriate licensing and credentialing were in place—from a practical and common-sense standpoint. However, the ACR task force recommendations may turn out to be merely a moot consideration, as offshore reading—as the practice is envisioned by some investors and overseas companies—may not even fly for long. From a business prospective, many unknowns exist. Looking at it as a businessman, Bakken believes the potential challenges and legal risks currently make the offshore reading model unviable and undesirable. He reports that his company currently doesn’t—and most likely will never—engage in offshore reading. To help illustrate his reasons, Bakken explains how international reading can be differentiated into two kinds of business models. One model involves companies that employ licensed U.S. physicians who have moved overseas. Bakken calls that the more workable model, which is certainly true because NightHawk Radiology Services, a pioneer in teleradiology, already operates under such a model. NightHawk has a central reading service in Sydney, Australia, and is developing a second in Switzerland. All its radiologists are licensed to practice in the state where clients’ exams originate and have malpractice insurance. It’s basically been operating for years under what have recently become the guidelines. The second model involves nonresident radiologists residing and licensed in countries such as India and China. This model can offer an economic advantage, as overseas radiologists can be paid much less and the savings are passed onto the clients or stateside providers. Still, that is less workable—and perhaps will never be entirely feasible. “That model is really struggling because, currently, it is the hardest to get off of the ground,” Bakken says. Liability Questions Unresolved Issues If something goes wrong, where would liability fall, Bakken asks. “Who would get sued—the facility doing the outsourcing, the referring physician, the overseas physician, the company providing the service? It’s a big unknown.” Most likely, he says, it won’t be the overseas physician who gets sued. Rather, it would probably be the company that provides the service. But right now, nobody really knows what is going to happen. Bakken doesn’t like the unknown element it brings into a business. “Who will end up holding the bag?” he asks. “If you’re a malpractice lawyer, and all you want to do is find the easiest pocket, would you sue the people who hired that physician? But the physician is the one who missed, so would you go after him? The argument is that a lawyer looking for the cheapest way to get the job done quickly will go stateside for the money. But this hasn’t been tested.” The second major concern involves HIPAA compliance. “I hadn’t seen this one coming, but now I am seeing it coming hard and fast,” Bakken says. “I don’t care who you are and where you are, malpractice doesn’t cover HIPAA compliance. If you send patient information overseas, there are no HIPAA regulations. That is what state legislatures are focusing on. Now, you’re not only talking about not being sued; you are talking about potential jail time. That may sound over the top, but if you’ve got an overzealous prosecutor who wants to show that he’s really enforcing HIPAA, the stateside clients will be the first ones they go after.” The third concern involves connectivity. “Even with current technology such as broadband, when you move things over lines, you’re only as strong as your weakest switch,” Bakken says. “So, the further you go, the more switches you go through. When you go overseas, you have more and more switches and more things can go wrong. There is a far greater level of shutdown in the international coverage market than there is with U.S.-based coverage.” Moore says some liability concerns can be addressed by relocating U.S.-based radiologists to do the overseas reading. “If you have U.S.-based trained radiologists who has moved from one country to another and provides the same service they would at home, then it’s less of an issue,” he says. This is a strategy VRC has integrated into it operations. Some of the company’s U.S. radiologists have moved overseas to read from remote locations such as Hong Kong, Brazil, Germany, France, and Australia. VCR finds this workable and prudent. Bakken readily acknowledges the sensibility of this strategy. Still, he feels a human factor can cause it to capsize. Relocation overseas is a significant life change that requires considerable adjustment. Doctors living abroad are asked to accept much and give up even more. “One problem with this strategy—and I have heard this repeatedly from the doctors who have worked overseas—is that, after awhile, living abroad gets old. So, getting people to move on a wholesale level has been a real challenge. In the end, you’re asking a lot of radiologists…” Possible Legislative Impact However, these bills have generated strong opposition and may not be passed. “My guess is that the Clinton bill is going to die,” says Bakken. One reason is pressure from insurance companies who are already sending a great deal of healthcare information overseas. Still, the defeat of the legislation is not a given. Future Directions Bakken likens the field to the “wildcatting” era in the oil industry or the PC revolution. However, teleradiology has advanced—and will continue advancing—at a much faster clip than the two examples. “Since 2000, this business has evolved at steroidal speed,” says Bakken. “It has gone through all of the standard migrations of any business, but it has experienced in about five years what most businesses will experience in 20 or 30 years. People have struggled with how to manage and structure this business. Everyone has different ideas. There’s no standard yet. Typically, in a new industry, one company will have their model and another will have their own model. In 15 years, there will be one generally accepted model. Meanwhile, we’re going through the process of determining what will be that model. It will probably be a blend of various types.” “I think this will be a viable solution if all of the parameters that we addressed are met,” says Moore. “Clearly, unanswered questions remain, particularly about liability and jurisdiction, and most of them revolve around the legal aspects. If things are going right, people won’t be worried about it. But if something goes wrong, people will try to look for someone to blame or to take the responsibility. That’s where the issue has gotten more complex.” In its recently published report, the ACR task force outlined and then addressed what it felt were the most important issues currently generated by the practice of offshore reading. “However, the most significant issues could change over time, as this is still an evolving practice,” Moore says. — Dan Harvey is freelance writer based in Wilmington, Del. He is a frequent contributor to Radiology Today. |
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