Teleradiology is still considered an emerging field. At the same time, it’s becoming more firmly entrenched due to substantial demand driven by a shortage of radiologists, burgeoning utilization of imaging technology, and the increasing number of images in CT and MRI studies.

“Depending on what you read or who you talk to, there’s anywhere from an 11% to 17% increase each year in radiology volume,” says Mark Bakken, president of The Radlinx Group, a nationally known teleradiology service provider headquartered in Irving, Tex. “In addition, study sizes are increasing. We’re not dealing with just plain film anymore.”

As teleradiology evolved, it became increasingly viewed as a viable solution. Evolving with it was concern that teleradiology may become potential competition for local radiology groups. With more and more facilities turning to teleradiology, observers began wondering whether teleradiology could even supplant local radiology groups and on-site radiologists.

Teleradiology companies answer that fear with a fairly firm “no.” Even more, they indicate that competition seldom exists. Rather, the emergence of teleradiology has been driven by trends that foster an atmosphere of collaboration and cooperation.

Fears surrounding possible competition and replacement had been expressed by organizations such as the American College of Radiology (ACR). Those fears appear symptomatic of the anxiety normally aroused by new developments.

“At first, because teleradiology was something new, people imagined the worst. But now I think they see that it will augment local radiologists more than it will replace them,” says Arl Van Moore, Jr, MD, FACR, vice chair of the ACR’s Board of Chancellors. “I don’t think you’ll ever be able to replace radiologists on the ground.”

Augmentation Is the Key
For one thing, any attempt to replace local radiologists simply wouldn’t reflect good business judgment, according to Bakken. “Companies intending to compete with radiologists on the ground will end up broke,” he says.

The key word, as many teleradiology companies assert, is augmentation. Currently, the sound teleradiology business model supports the needs of local radiology reading groups, according to Bill Franz, vice president of development for Montara, Calif.-based NightShift Radiology. “As our company is owned by radiologists, we look at ourselves as a radiology group and, therefore, as an extension of our client radiology groups,” he says.

Both Bakken and Franz report that competition between local radiologists and teleradiology doesn’t exist. Further, they anticipate that serious competition is unlikely, at least for the coming decade.

The major rule for teleradiology companies, Bakken states, is not to compete against the radiologists on the ground or buck existing infrastructure. It would be folly to think otherwise, he believes. Existing infrastructures and relationships give traditional radiology groups a huge competitive advantage.

Competitive Disadvantage
“You can’t take on traditional radiology groups because you’re not only competing against local radiologists, you’ll also be taking on all of the people the radiologists have already developed a relationship with, such as surgeons, referral staff, subspecialists, and hospital administration,” Bakken says. “No hospital will go with a company they don’t know. Hospital CEOs may as well just fire themselves, if that’s the direction they take.”

It seems the same could apply to a teleradiology company CEO who thinks about trying to supplant local radiologists. “Any business model that goes against existing infrastructure is dead on arrival,” says Bakken. “Teleradiology would always lose. You may have the greatest radiologist in the world reading for you, but hospitals will always go with the local physicians.”

As such, Bakken recommends that teleradiology companies work with—and not against—the existing radiology infrastructure. “That’s rule No. 1, 2, and 3,” he says. “Teleradiology is purely a tool to augment existing practices because physicians are busting at the seams with study volumes.”

Sean Casey, MD, president, CEO, and founder of Virtual Radiologic Consultants in Minneapolis, agrees with Bakken’s take. In competition between locals and outsiders, locals would have the advantage. “Local radiology groups are the incumbent,” he points out. “They have the preexisting relationships with referring clinicians and the hospitals. They’ve developed a reputation.”

Casey points out that the collaborative approach is more workable because there will always be the need for a radiologist to read on site. “There are local procedures, conferencing needs, on-site consultations, and local quality control that require someone serving in the role as on-site chairperson,” says Casey.

Economic Advantage
Casey adds that local radiologists have an economic advantage as well. If it ever came down to a teleradiology company taking on local radiologists, the teleradiologists would have to absorb the additional equipment costs needed to provide their service. Essentially, a teleradiology company would have another layer of technical expenses for items such as Internet service, bandwidth, hosting, and software. “Basically, they’d have a PACS and a RIS—a whole IT department that needs to be funded,” explains Casey. “This is redundant to what the hospital already funds locally. If you read locally, you don’t pay redundant costs. If you read remotely, a portion of your professional fee goes toward paying for technical infrastructure.”

Therefore, Casey says, as it stands now, teleradiology service providers could never underprice local radiologists. “The only thing they might be able to compete on is a higher level of service,” he adds. “But in saying that, I don’t want to give the impression that there is competition occurring, because it just isn’t happening.”

As far as the service issue, a teleradiology company may be called in if a local radiology group suddenly deserted a hospital, or if a local reading provider was seriously understaffed, says Casey. Franz cites a hypothetical situation: A hospital that contracted a local company may experience dissatisfaction because the company doesn’t have sufficient manpower and, as a result, provides suboptimal service. “Theoretically, a teleradiology company set up to provide services 24/7 could contract directly with that hospital and provide its services,” Franz says.

However, in such situations, both Franz and Casey suggest that collaboration—rather than competition—would prove the more effective approach. “It would be better for all concerned parties to work together to improve the level of service,” says Casey. “When you think about it, that’s exactly what we already do with our night business.”

As such, Virtual Radiologic Consultants doesn’t bid against local radiology groups for hospital contracts. “Our business model is to partner with local radiology groups,” says Casey. “We have a few hospital clients, but they are basically paying the bill. A radiology group invited us in and then got the hospital to agree to pay the bill. In no way did we come in and bid against the radiologists.”

Move Toward Day Hours
A more concrete trend than competition is the move by teleradiology companies to increase service coverage into daytime hours. Off-hour coverage remains the bread and butter of teleradiology, but some companies are expanding services as overflow starts to pour into daytime hours. Some teleradiology services now provide daytime interpretations for inundated radiology groups or hospitals that have a hard time recruiting enough radiologists to meet reading demands.

Daytime reading represents a perceivable shift, says Franz. “So-called ‘nighthawk’ services started out as night, and then went into weekends,” he says. “Now, based on customers needs, some servicing has moved into the day. Radiology groups have asked for additional services.”

“Daytime is our biggest growth area,” reveals Bakken.

The daytime trend is still characterized more by collaboration than actual competition. Teleradiology groups doing daytime reading only enhance the services offered by local radiology groups. “It always comes back to augmentation,” remarks Casey.

Casey reports that his company only does a small amount of day business (approximately 3% of its total volume, he says), and it’s mostly confined to the Midwest, where the radiologist shortage is most keenly felt. “Our customers are radiology practices, and we provide them whatever services make them more competitive in their market, to make their local contract more secure,” he says. “It is merely accommodating their needs, not an aggressive search for day business.”

NightHawk Radiology, based in Coeur d’Alene, Idaho, the company that pioneered the “nighthawk service” concept, has even added a daytime division. “Earlier this year, we acquired DayHawk Radiology Services, which is now our day division,” reports Jon Berger, NightHawk’s vice president of sales and marketing. (Berger’s father, Paul Berger, MD, founded the company.) “There’s a definite trend to assist local radiology groups in this way, and I think the trend will continue.”

Another strong trend Berger sees is an increasing investment in technology on the part of teleradiology companies. He says his own company invests a significant amount of its resources into software applications and networking technology that enable the transmission of larger data sets and more images very efficiently across a wide network, he says. “This enables very quick turnaround time and ultimately results in a higher level of quality patient care,” he says. “As we do more and more cases, our turnaround times have become less and less. Investment in technology for teleradiology companies is something else I expect to see continue.”

Another trend more tangible than competition is teleradiology accommodation of subspecialty needs, particularly for daytime reading. One increasingly evident advantage of teleradiology, Van Moore says, is that smaller hospitals gain access to more subspecialty expertise. “If you’re in a one-man or two-man hospital, teleradiology offers an avenue to utilize subspecialty expertise,” he says. “For instance, if you have a complex neurology case, you can refer that to a teleradiology practice, to have one of their radiologists read the case. This applies to musculoskeletal and other specialties.”

Berger also sees that trend. “Part of delivering efficient, high-quality patient care involves getting specialty cases to the physicians who have an expertise to be able to do this in the most efficient way,” he says.

Looking Ahead
Most observers expect the augmentative approach to stand for at least several decades. “Maybe things will change in about 20 or 30 years,” says Bakken, “but, for right now, collaboration is only being bolstered.”

Mindy Goldsmith, PhD, director of imaging services at Wadsworth Rittman Hospital (WRH) Health System in Wadsworth, Ohio, an organization that is implementing nighthawk services, envisions a future development that could create at least one scenario where teleradiologists could become competitors to local groups. It involves the evolution of the American healthcare system and a potential socialized medicine environment.

“If our current system goes bankrupt, say in about 20 years, the government may arrange medical care in terms of ‘regions.’ Patients would see a nurse first and, if deemed sick enough, then go to a ‘regional’ medical center for care,” she explains. “In that case, my hospital and those around me would probably shut down or become clinics. The regional center for this area would be the Cleveland Clinic. The government wouldn’t pay for all of us to have MRI machines if the regional hospital has one already. Cardiologists would perform all cardiac interventional procedures, vascular surgeons would perform all vascular imaging, and so on. The ‘hands on’ radiologist would be virtually replaced. That’s the only scenario that involves competition that we can see.”

Stuck in the Middle
In the meantime, the system will foster collaboration, which suggests resolution of all problems. However, as typically happens, new systems and technology introduce new considerations that generate other problems. Goldsmith says that when WRH Health System goes with a nighthawk service, collaboration between a local radiology group on one side and a nighthawk service on the other put pressure in the middle. She raises an issue that groups and hospitals should address before taking the step to the nighthawk solution.

As Goldsmith recalls, the Wadsworth system contracted with a local radiology group to read at three hospitals and several imaging centers. Because of the resulting volume and insufficient manpower, the group spread itself thin. “Some of their radiologists retired, and recruiting became an issue. The group held off as long as they could before it finally gave up and hired a nighthawk,” she relates.

As a result, the Wadsworth system and the local group will contract with I-RAD, a nighthawk service in Pittsburgh. The arrangement will introduce new workload considerations. “For me it creates a logistical nightmare, because I now need different protocols for when to send to I-RAD and when to send to the local radiology group,” explains Goldsmith. “I also have to get I/S involved to assist in setting up the proper interface to I-RAD.”

In addition, she says, all I-RAD radiologists will have to be credentialed at WRH. “So it creates a tremendous amount of work for a radiology manager and the hospital administration,” she says.

Here to Stay
Despite the logistical problems at Wadsworth, it’s clear that teleradiology companies are becoming firmly entrenched in the healthcare landscape. Such companies can provide support that alleviates the increasing reading burden placed on radiologists and local radiology groups in the evening, weekend, and even daytime hours.

Further validation is provided by the fact that, as Berger reveals, an increasing number of high-quality radiologists view teleradiology as an accepted career path. More importantly, he says, teleradiology companies increasingly provide more efficient capabilities for remote reading. “It’s a win-win-win situation, for all of the radiologists involved, for the customers served, and for the patient receiving the high-quality care. Also, there is no added cost to the patient or the healthcare system.”

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