May 2013

Final Days for Preliminary Reads? — Not Completely, but Teleradiology Is Moving Toward Final Reads
By Beth W. Orenstein
Radiology Today
Vol. 14 No. 5 P. 26

Editor’s Note: Radiology Today is taking a look at the future of preliminary reads in radiology. This article, the first of two, looks at the radiologist perspective on these reads. The second article, appearing in our June issue, will focus on the hospital’s view.

A patient comes into the emergency department (ED) at 2 am complaining of abdominal pain. The physician on duty orders a CT scan to try to determine the cause of the patient’s pain. The teleradiology group providing night coverage reads the scan and tells the ED physician whether the patient has acute appendicitis, requiring surgery, or probably ate some bad guacamole and safely can go home and take some antigas medication.

In this scenario, the teleradiology group provided a preliminary report—a “wet” read for physicians who remember when films emerged from the processor and an interpretation was provided while the films were still wet. The report is preliminary because it focused on findings to be treated immediately by the ED physician. Pertinent positive and negative findings also are included. However, because prior reports or images frequently are not available in such situations, the next day an on-site radiologist will generate the final report with definitive follow-up recommendations.

Preliminary reads for emergency care basically have been a standard acceptable medical practice over the last decade as teleradiology groups provide more coverage at more hospitals and imaging facilities during off hours.

Greg Rose, MD, PhD, president and CEO of Rays Teleradiology in Littleton, Colorado, and CEO of EmCare Radiology Services, explains that when teleradiology groups first began providing after-hours coverage, the technology wasn’t available for providing more than preliminary reads. “The radiologists who were reading from remote sites didn’t have access to all the prior studies and prior reports, and we couldn’t easily send final reports directly into their RIS,” Rose says.

Technology-Driven Change
In recent years, however, competition in teleradiology has led to technology improvements that allow off-site radiologists to interface more easily with the facilities for which they read. As a result, more teleradiology groups can provide final reads, which has helped raise new questions about the role of preliminary reads. Some radiologists now wonder why every interpretation can’t just be a final read, questioning whether it’s double the work for one radiologist to provide a preliminary read at night and another the final read the next morning. Naturally, opinions on the matter vary.

“Over the years, I’ve noted that the choice of preliminary vs. final reads has been based on a number of issues, including financial, political, and personal,” says Rose, who personally believes final reads are right for some radiology groups and not others. “Some clients have revealed it’s a visceral decision that they can’t quite explain, and each member of a particular group making the decision may have a variety of weights given to each element. Radiologists in different stages of their career also choose differently.”

Hank Schlissberg, MS, MBA, chief client officer for Radisphere National Radiology Group in Cleveland, who believes every read should be the final one, sees the need for final reads as a quality issue. He believes patients should get the same standard of care regardless of whether it’s 2 am on Christmas morning and a teleradiology group is reading the emergency scan or it’s 2 pm on a busy weekday in the summer and an on-site radiologist is interpreting the images. He says that standard of care demands that radiologists reading after-hours report on everything they see that needs medical attention—whether or not that attention is immediate.

Besides, Schlissberg argues, having a preliminary read and a final read on every study done at night is needless extra work. “You don’t need two reads in today’s health care. It’s just not necessary,” he says. “We read all the time about the inefficiencies in the health care system, and this is a classic one that’s so solvable.”

One possible argument for a second interpretation comes with complicated exams with a very high error rate, Schlissberg says. “If it’s a study with a very high risk of error that could lead to patient mortality and morbidity, you’d want a double-blind review of the study or concurrence of the interpretation,” he says. “But that’s really something different—more of a second read than a preliminary vs. final read.”

Others argue that preliminary reads can speed and, thus, potentially improve care. For example, a preliminary read in a suspected stroke case could mean treatment is started sooner than if doctors wait longer for the more complete final report.

Two Views
Pat A. Basu, MD, MBA, chief medical officer for Minnesota-based Virtual Radiologic (vRad), says his personal preference, like Schlissberg, would be to provide final reads for all clients. “Theoretically speaking, I would prefer all contemporaneous final reads—one read and only one read period,” he says.

He agrees that having one radiologist provide a preliminary read off hours and another provide the final read during the day is inefficient. “If I spend time reading a CT scan at night and my brother, who is also a radiologist, spends more time reading the same scan the next day, that is time he could have spent caring for another patient,” he says.

However, Basu says, there’s theory and there’s reality, and the reality is that in some cases, for logistic or administrative reasons, only preliminary reads may be available “and in those cases, we cannot let the patient simply wait until the next day.” Some radiologists who work during the day are afraid that if they don’t do the final reads, they could become obsolete. They’re also afraid that if teleradiology groups were to provide final reads on nights and weekends, ultimately the hospitals would want the groups to provide coverage during the day and decide they no longer need their own radiologists. “It is one of the common fears I hear all the time,” Basu says.

Joe Moock, CEO of San Diego-based StatRad, says the issue of preliminary vs. final reads is just another of the many radiology turf wars. One reason on-site radiologists still prefer that teleradiology groups provide only preliminary reads “is that it helps them maintain control of their relationship with the hospital or department where they work,” he says. “They’re concerned that if their facility is outsourcing half the day to an outside organization and the reports it provides are no different from the reports its own radiologists provide, the differentiation between off site and on site can be blended more easily.”

The fear is unfounded with StatRad, Moock says. StatRad’s priority is to support local radiologists rather than try and take over hospital contracts. “So our day reads are limited to groups that need subspecialties or for smaller groups that need additional coverage for vacations or holidays,” he explains.

Moock says economics also plays a role. Medicare and private insurance companies can’t be billed twice for the same study—even if two different radiologists read it for different purposes. Final reads cost more than preliminary reads because they take more time to prepare. To maintain its share of the pie, the radiology group wants to have a hand in all reports that its department generates and be able to collect payment from them.

Quality Control
Rose says some radiology groups also believe they need to put their stamp on every exam as a quality control measure. “They deeply and truly are concerned with the quality of the work they provide and take a custodianship of their practice,” he says. “They feel it’s medically sound to have help with after-hours calls so they can preserve some semblance of family life but feel it’s their responsibility to review any radiology work done by the hospital.”

Michael Myers, MD, cofounder of California-based NightShift Radiology, sees another economic argument that favors keeping after-hours reports preliminary: If the teleradiology group performs preliminary reads while the hospital day-shift radiologists complete the final reads, staffing needs are easier to maintain and costs overall decrease. “If every report is a final report, it’s going to be more time-consuming, and you’re not going to be able to read as many cases in a night, so you will have to have more people and that’s going to drive up expenses,” Myers says.

The number of studies done at night is increasing, he says. Before cofounding NightShift in 2001, he worked at a hospital where the radiologists on call would have four or five cases per night and could catch some sleep in between. Now NightShift contracts with that hospital and does 30 to 40 cases per night. “The amount of night work has expanded tremendously with improvement in CT scanners and MRI scanners and ultrasound. Studies are more complex, too,” Myers says. Radiologists reading studies at night can turn them around faster as preliminary reports. If they had to make every one a final report, they couldn’t do as many, he says.

Moock notes that preliminary studies can be turned around quickly, which “means that they very positively impact patient care, especially in these night cases that typically are more time-sensitive cases.”

Besides, Myers sees no harm in waiting to make a full report as long as the STAT needs are addressed. “There is a difference between a preliminary and a final report,” he says. “A preliminary report has to address the issue of why the patient came into the ED—whether for abdominal pain or chest pain or whatever. You still have to read the study with the same intensity you would a final report, but your goal is to figure out what the acute problem is and whether it needs to be treated immediately. It’s not necessary for it to include a lot of the chronic, nonacute problems that you might put in a final report.”

Myers also likes the idea of a second pair of eyes reviewing the overnight reports. “Radiology is difficult even in the best of situations,” he says. “Humans are not nocturnal, and when you work at night, it’s not 100%. Having another pair of eyes looking at the same case the next day can make a big difference as far as quality of care. Patients like having their cases reviewed by two radiologists.”

Rose says preliminary reports afford the on-site radiologists a natural opportunity for quality assurance. “So it could potentially increase the reliability of your reports by having two people look at it,” he says. “Alternatively, if the teleradiology group is performing final reads at night, the two groups should strongly consider a modified quality assurance program that allows each group to overread a small fraction of each other’s work. I believe all radiologists, including myself, should welcome regular criticism of our work to keep our skills honed, whether we are teleradiologists or on-site radiologists. I read out cases for Rays and participate in the quality assurance program as much as any other radiologist. I believe we are better radiologists for it, and it is in keeping with a commitment to quality.”

Economic Arguments
A strong economic argument also could be made in favor of final reads, Rose says. “Speaking strictly financially, final reads are more cost-effective for radiology groups, especially in these days of reduced reimbursements,” he says. “If the on-site group overreads the exam in the morning and bills, say, $45 for the study and pays the preliminary readers $35, it’s as though the on-site group is reading CTs for $10 and taking all the liability. It’s just not financially sensible. Let the teleradiology group do the final reads and supplant your overread time with new work at a higher rate. This would translate to approximately saving your entire prelim cost.” Groups that let the teleradiology firms do the final reads can replace their readovers with more profitable work, Rose says.

Schlissberg believes that Radisphere’s business model of providing final reads should become the new standard and that eventually it will.

Basu says he’s seeing more movement toward final reads only, especially as a large percentage of new clients are asking for final reads. “It’s on the uptick, and I would encourage it,” he says.

However, he believes there will continue to be a place for preliminary reports, even if it’s smaller than it is now. “That’s why we offer both, and although we recommend final exams, we continue to offer preliminary reads as well to ensure patients are covered with the best care anytime and anywhere,” he says.

Myers doesn’t see preliminaries disappearing either. “It might be optimum if you could do final reads,” he says, “but I don’t think it’s practical, and I’m not hearing places asking for it.”

 Rose believes a small percentage of radiology groups probably will always prefer preliminary reads over after-hours final reads. “That’s the way they will always want to do business unless, over time, the culture in the group changes,” he says. “But more and more, the movement will be toward final reads and an alignment of style and quality between the daytime and nighttime groups reading reports.”

— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and frequent contributor to Radiology Today.