October 20, 2008

Filling a Void — Subspecialty Teleradiology’s Universe Is Expanding
By Dan Harvey
Radiology Today
Vol. 9 No. 21 P. 10

The move toward subspecialty interpretations represents a significant trend in the maturation of teleradiology. Increasing acceptance is driven by substantial challenges presented by radiology’s development.

“One of those challenges is matching the suitable reader with the right study and then achieving this appropriate matchup as much as possible,” explains Scott Seidelmann, president of Franklin & Seidelmann Subspecialty Radiology Inc, a provider of teleradiology services. But such an idealized marriage of need with expertise doesn’t happen as often as hoped because of economics and location. Those challenges lend themselves well to the teleradiology solution, Seidelmann points out.

Teleradiology services can effectively address these issues by providing customers with a network of subspecialty radiologists who can be deployed on a part-time, as-needed, or even full-time capacity. More often, healthcare enterprises recognize the dual benefits the arrangement fosters: On one hand, subspecialty reads have a positive impact on patient care; on the other, it increases referring physician satisfaction (and, in turn, referrals) and bumps up revenue, which supports a business’s sustainability in a highly competitive marketplace.

Market Drivers
Observers point to a full suite of converging factors that drive the growing need for subspecialty teleradiology, including the ever-growing number of outpatient imaging facilities, the ongoing advancements in imaging technology (and the resulting increase in data volume), as well as business considerations such as economics and differentiation from competition.

Then, of course, there is the ever-present radiologist shortage. “When you look at subspecialty reads specific to teleradiology, you first need to consider what has driven the need for subspecialization in the radiology field in the first place: The number of procedures has grown far faster than the number of radiologists, a situation promulgated by advances in technology,” says Seidelmann. New advancements have subsequently led to new imaging modalities and increasingly complex applications.

“With that comes increasing demand from consumers for the latest, most noninvasive diagnostic procedures, as well as from physician specialists, including orthopedic surgeons, neurologists, and pediatricians, among others,” Seidelmann adds. “Such specialists look to radiologists that have a corresponding comprehension of a specificity.”

In addition, with new imaging developments, radiologists have become overwhelmed by the increasing amount of volume that simply surpasses the amount of knowledge they can effectively master. “Radiology has become so complex that no single radiologist can be expected to know it all and do it all,” says Seidelmann.

The situation is similar to what took place in the field of surgery, he explains: “Today, a heart surgeon doesn’t want to do knee surgery, while an orthopedic surgeon can’t be expected to perform heart surgery. Radiology has now specialized to that degree.”

“When talking with our client group, I can tell that some of their doctors feel pushed to do these interpretations, and they aren’t comfortable with the situation. Many would rather have an expert do the reading,” says Scott Giordanella, director of marketing for NightHawk Radiology Services, the pioneering teleradiology company.

Accessing the Expertise
But the radiologist shortage also brings with it a relative scarcity of subspecialist or fellowship-trained diagnostic readers, and healthcare facilities face the prospect of competing for the most highly specialized experts, says Greg Rose, MD, PhD, founder, president, and CEO of NightRays, a teleradiology service provider that offers subspecialty reads. Some of these facilities simply can’t compete.

Further, he says, the traditional radiology model doesn’t optimize the use of existing expertise. Ideally, each case that a hospital or imaging center sees should advance to the appropriate level of expertise. But that doesn’t always happen within the traditional radiology model. “Instead, because of the shortage of radiologists, the field is just trying to keep up,” says Rose.

But subspecialty reads via teleradiology help offset those issues. Also, they enable general radiologists to do what they do best while being supported by available experts. The new paradigm benefits the subspecialists as well, says Seidelmann. Subspecialists, by nature of their education and ambition, need to handle a certain volume level to maintain competence in their particular area. “That’s why it is hard for a neuroradiologist or musculoskeletal radiologist to work in one place. Typically, they won’t have access to enough cases,” he says.

Other Factors
As far as economics, due to legislation to reduce medical imaging costs and a decline in reimbursement, smaller imaging facilities and hospitals have needed to increase their referrals. Subspecialty reads help them accomplish this, as well as separate themselves from the competition.

But the most important economic factor is that subspecialty reads, as offered by teleradiology services, make the concept affordable to a range of customers, no matter their size. Once outside urban areas and large hospital systems, there may be high-priced radiologists whose salaries surpass a facility’s revenues. “Obviously, that doesn’t make sense,” says Seidelmann. “The great thing about teleradiology is its variable costs. A facility doesn’t have to hire a radiologist at $600,000 or make them a partner or share technical revenues with them when you really only have half an FTE’s [full-time equivalent’s] worth of volume. You can contract with a teleradiology service provider and send perhaps 10 cases per day. If volume grows, then you might consider bringing on a subspecialist full time.”

Increasing Acceptance
Something that has allowed subspecialty reads to be supported is the political acceptance, says Rose. “People now realize that it is perfectly all right if a radiologist is not located within the facility. As things move forward, I think that radiology groups, small hospitals, and outpatient imaging centers will become much more focused on how much of their practice truly needs to be located on site and how much can be done off site.”

He anticipates that, in the future, many organizations will position as much as two thirds of the practice off site. “The remaining on-site radiologists will typically be procedure-type radiologists and leadership figures,” Rose says. “Essentially, they will provide the physical presence as custodians of the practice and be involved in issues related to politics, quality of service, and hands-on care. But actual percentage will hinge upon what is specifically required within an organization.”

Hand-in-hand with that, he adds, some smaller facilities will transition to the point where they only have intermittent on-site subspecialty care. “The rest of the work will be sent to teleradiology services,” he adds.

Furthermore, the transition will occur within environments with the most advanced communication advantages. “Improved communication will exist among local clinicians and radiologists via technology such as Web cams,” Rose says.

As Seidelmann points out, such environments will represent a “decoupling” between who needs to be on site and how images are read.

Who Benefits
In the meantime, subspecialty reads are especially benefiting the smaller healthcare organizations (the rural hospitals and outpatient imaging centers) as it provides them with the highly trained experts who they otherwise couldn’t recruit or afford. “Right now, we see the biggest need in the small practices, especially in rural areas, specifically the one- to five-person operations,” says Rose.

To compensate for those needs, NightRays advances a combination approach. “We offer our customers fellowship-trained radiologists, as well as radiologists who have garnered expertise in a subspecialty over a long period of time, on the ground, and can cover a range of specific areas,” says Rose.

But Giordanella perceives that subspecialty-read needs are not limited to just those small, out-of-the-way facilities. Rather, he believes that just about any facility—with the possible exception of the large academic centers and maybe the conglomerated healthcare organizations—can benefit from subspecialty teleradiology solutions. “Many facilities need the kind of backup that subspecialty teleradiology provides, and a good teleradiology service will be as flexible as possible in meeting their needs,” he says. “The bottom line is that it advances better patient care.”

Right now, the specific subspecialty areas most in demand include women’s imaging (mammography and breast MRI), musculoskeletal (MSK), neuroradiology, cardiac imaging (particularly CT angiography), nuclear medicine, and pediatrics.

Indicative of the growing need for subspecialty reads in teleradiology, Franklin & Seidelmann added 31 subspecialty radiologists to its staff in 2007, which increased its number to more than 100. “When we started out seven years ago, we delivered neuro and MSK reads to outpatient imaging centers, hospitals, and radiology groups, and we’ve since expanded. Now, we find that the strongest demand comes from medical staff and referring physicians that require specific expertise,” says Seidelmann.

Recruiting Talent
Compared with their customers, teleradiology companies have a relatively easy time recruiting the expertise. “We’re in contact with 1,500 client hospitals, and I understand the difficulty they have in recruiting fellowship-trained physicians, especially if these hospitals are small, rural facilities,” says Giordanella. “That’s where we can help because it’s easier for us to recruit.”

Subspecialists enjoy a high degree of autonomy and job security, and they can work anywhere they want because of the work environment teleradiology offers.

“Our radiologists can do interpretations in locations such as Sydney, Australia, or Zurich, Switzerland, as well as anywhere within the United States. Thus, we have been able to recruit the most highly skilled radiologists,” says Giordanella.

Most importantly, in such a virtual workplace environment, the experts can focus exclusively on their particular areas of interest. They’re assured that they will get to do the kind of studies they’d most like to read. “As a result, many of these subspecialists reach out to us, knowing that we have subspecialty needs as expressed by our customers,” says Giordanella. “In turn, we know that we are attracting the best radiologists, as they come to us with the highest levels of training from the best medical schools in the nation. We consider ourselves quite fortunate to attract that caliber of physician.”

Giordanella anticipates a consolidation of factions where both on-site and off-site radiologists work together. “More and more facilities are going to be asked to provide subspecialty work and, at first, they might struggle with this. But by tapping into a network of experts the teleradiology companies can provide, they will equip themselves with a long-term solution to meet the growing needs for subspecialty reads. Even with a radiology shortage, companies such as ours can provide the supplemental services that will take care of the extra work that needs to get accomplished.”

— Dan Harvey is a freelance writer based in Wilmington, Del., and a frequent contributor to Radiology Today.