Casting a Wider Net
By Beth W. Orenstein
Radiology Today
Vol. 20 No. 6 P. 18

Teleradiology has become much more than filling in coverage gaps.

Lao Friends Hospital for Children (LFHC) in Luang Prabang, the only children’s hospital in all of Laos, had no trained radiology personnel, no operational radiology equipment, and no digital radiology networks. In 2018, RAD-AID, a nonprofit organization of 10,000 radiology volunteers and supporters dedicated to bringing radiology to low-resource and medically underserved areas, partnered with Ambra Health to solve this problem. Erin McGee, Ambra Health’s manager of professional services, spent two weeks in Laos helping to install the Ambra cloud PACS solution at the hospital so that radiologists around the world could read images—largely CR and ultrasound scans from LFHC and CTs taken at the government hospital across the street.

“I helped to get the cloud installation set up and worked with the radiology team, the doctors and nurses, and people on the ground there to understand how to use the images and establish a workflow so that they could use our system in a way that made sense and was meaningful to them,” McGee says. “We did the cloud-based radiology software, Google did the infrastructure, and RAD-AID offered on-the-ground teaching and training.”

Since the system was put in place in August 2018, the hospital has been generating about 2,500 studies a month that are read by radiologists mostly in the United States but who could be sitting anywhere in the world. The LFHC project demonstrates the benefits of teleradiology and how it can bring modern health care to areas of the world that are underserved or difficult to reach.

However, teleradiology today is much more than this. Teleradiology is not only helping to fill gaps in overnight coverage and remote areas, as it did when it began growing in the 1990s; it is also bringing additional and specialty coverage to areas that already may have a full staff of radiologists.

“Teleradiology is no longer just a luxury service that helps with coverage gaps,” says Shannon Werb, president and chief operating officer of vRad, a MEDNAX company, and a supporter of RAD-AID. “It’s a value-added, and often necessary, service for any radiology group.”

Increasing Demand
Originally, teleradiology provided preliminary reads until an onsite radiologist could review the images and offer a final read. “It allowed patients to be previewed overnight, so to speak,” says Glenn Kaplan, MD, vice president of radiology strategy for Envision Physician Services. Today, he says, teleradiology services are able to provide first reads that are final reads 24/7 for remote sites and those in major urban centers. Given this ability, demand for teleradiology services is booming, he says. Envision has 900 radiologists in its practice, some who do teleradiology exclusively and some who do on-site and teleradiology. “Envision’s focus is on distributed radiology, which utilizes teleradiology technology to facilitate the integration of [the organization’s] on-site team with their offsite workforce, capitalizing on the strengths of each,” Kaplan says.

Kaplan says there are at least two reasons why demand for teleradiology services has been booming. One is that smaller or remote sites find it hard to attract radiologists. “We can staff it with one physician and send the rest of the volume offsite during the day and after hours,” he says. Second, he says, teleradiology can provide access to a large network of subspecialists, which is what everyone wants today. “If someone has a sports injury in a small remote town, the town is not likely to have access to a musculoskeletal [MSK] fellowship-trained radiologist. We can provide an MSK radiologist.” Another example is the push for neuroradiologists to read the images of suspected stroke patients. “That’s a huge area where we can fill gaps as well,” Kaplan says.

Physician shortages ebb and flow, “and, right now, we’re in the middle of an acute shortage,” Werb says. He agrees that the demand for subspecialty radiology is particularly strong and, given shortages, teleradiology can be the answer. “We’re able to connect those kinds of specialties that are harder to come by,” he says. “For example, finding neuroradiology coverage in deep night hours is a challenge, especially for a neuroradiologist who specializes in complex imaging. Even more challenging is complete pediatric radiology coverage, including overnight coverage. That’s harder because the population of pediatric radiologists is significantly smaller than the potential population of patients; as a result, it may be too difficult for a site to justify 100% pediatric subspecialty coverage 24/7.”

Subspecialty Coverage
The growing demand for teleradiology and subspecialty coverage in more remote sites is what caused Byron Christie, MD, a vice president of clinical operations of Radiology Partners in San Angelo, Texas, to change his career path. Christie had been a general radiologist and was the sole provider at a smaller hospital in Duncan, Oklahoma.

“I was a good general radiologist and could do some aspects of subspecialty care, but I couldn’t do it all,” he recalls. “I don’t think anybody can. I realized I needed to form a group, so I did.”

That was in 2006. In 2013, the group merged with Radiology Partners to further expand its teleradiology and facility-based capabilities. The group has grown to 25 radiologists covering 17 facilities spread over a wide geographic area in Oklahoma and Texas.

“We view ourselves as on-site teleradiology,” he says. “We offer a fully modern subspecialty radiology practice. We perform on-site fluoroscopy and IR and read from a common worklist which segregates the studies based on our skill sets so MSK radiologists read MSK studies and neuroradiologists read neuroradiology studies, etc.”

Christie believes teleradiology practices such as his are what providers are looking for in 2019. “It’s no longer standard of care to have one or two guys at a hospital providing general radiology reads,” he says. In keeping with Kaplan and Werb, Christie says, “Today’s health care providers expect a different level of service from radiology groups. They expect MSK experts to read their joint MRIs and neuroradiologists to read head CTs.” Also, Christie says, hospitals have invested in expensive imaging equipment that creates “new opportunities for innovation in care,” but they won’t get their return on investment if they don’t have radiologists who know how to use the more complex features of the imaging modalities.

Teleradiology Challenges
When teleradiology started, a fear arose that it would replace on-site radiologists. Because teleradiology has become an “addition to” as opposed to an “instead of,” that fear seems to have greatly dissipated. But it doesn’t mean that teleradiology isn’t without challenges.

What keeps Werb up at night is physician recruitment and retention. The number of imaging studies done annually in the United States continues to rise. Emergency department (ED) volumes continue to increase, and, as a result, EDs leverage imaging as a diagnostic tool, he says. Also, the country is aging, and an aging population typically increases the need for diagnostic imaging.

“Many of our customers see their volume increasing 20% year over year, and they’re having a hard time dealing with it, so they look to push more of it to us,” Werb says. “We’re seeing more clients coming to us for new or expanded coverage requiring us to partner with those clients in how to onboard new volume when new physician capacity can be made available.”

Samir Shah, MD, MMM, a vice president of clinical operations for Radiology Partners, says the Matrix group at Radiology Partners has had much less difficulty recruiting than many teleradiology groups thanks to a unique partnership—it’s an extension of the on-site practice. Still, the most difficult slots to recruit are for the overnight hours, he says.

“I’ve seen where people have a real awareness of some of the issues that can occur with their bodies when they switch their circadian rhythms, and that discourages people,” Shah says. Some people have worked overnight shifts for years without untoward effects, “but it takes a lot of discipline and self-regulation,” he says. Stationing physicians in Hawaii and Alaska can help because they can be desirable places to live and the time difference is such that they can work afternoons and evenings and largely cover the East Coast, where most of the US population is, Shah says.

Kaplan agrees: “It’s got to be people whose biorhythms and brains are converted over to reading at 3 am, and not every radiologist can do that type of work.”

In the past, teleradiology firms might have looked abroad for radiologists to cover overnight hours in the United States. But that isn’t a solution if they want their studies to be final reads, according to Shah and Werb; Centers for Medicare & Medicaid Services regulations require the teleradiologist to be on US soil to qualify for reimbursement for final reads.

Credentialing and Access
Another challenge is hospital credentialing. “The system that we use is completely broken, in the sense that each hospital site requires verification of the physician’s credentials,” Shah says. And many don’t have a system in place to verify credentials in a timely manner, he adds. The Joint Commission has a proxy document radiologists can use to verify that their credentials are legitimate, but a lot of hospitals don’t accept that document because they have antiquated bylaws. “They’re not fully prepared for telemedicine,” Shah says.

Kaplan also cites credentialing as one of teleradiology’s biggest challenges. Not only can the credentialing process take time, it can also be quite costly, he says, and hospitals have limited financial resources they can devote to getting it done.

The Interstate Medical Licensure Compact (IMLC) has made state licensing easier in the roughly 30 states that accept it, Werb says. “We can apply for licensure across the states with a single application and get multiple licenses for our physicians. We’ve figured out how to leverage that significantly.” However, the IMLC, a private corporation that is a joint agency of the compact’s member states, is completely voluntary; states are not required to participate.

Accessing relevant clinical history and retrieving prior studies are further challenges for teleradiologists, Kaplan says. “As a radiologist, it’s easier when you’re in the hospital where you’re reading because you can walk down the hall and talk to someone if necessary,” he says. “When you read remotely, it’s a little more challenging to be sure you’re getting more than just a simple history of pain or a headache and to track down what you might need. With access to prior studies, the patient’s clinical history often becomes more evident, allowing a more accurate interpretation, and many times eliminating the need for additional follow-up imaging that can be costly and time consuming to the patient.” Envision has had varying levels of success retrieving priors at different facilities, Kaplan continues. “A lot depends on how deep the integration we have with that hospital/facility. The deeper the level of integration, the easier the access to those prior studies.”

Broader Engagement
lifeIMAGE, a global network for sharing clinical and imaging data, recently announced a strategic partnership with swyMed, a provider of mobile technology solutions, to improve the ability of physicians to collaborate and coordinate care during a telemedicine encounter for stroke patients. lifeIMAGE currently supports more than 140 stroke centers within its US network. The partnership means care teams at trauma and stroke centers will have access to all relevant medical records, diagnostic imaging, and other critical clinical data before the patient arrives at their door, says Matthew Michela, president and CEO of lifeIMAGE. “It’s really upped the value of telestroke care,” he says.

Stroke diagnosis and treatment is highly time sensitive and requires a specialist. “This new strategic partnership addresses the data access and specialist shortage issues by offering immediate connectivity, even in the most bandwidth-challenged areas, to stroke specialists across the US,” Michela says.

Almost every day, a glance at the headlines seems to report a hospital closing or being swallowed by a larger health system in rural America. “There’s no question that’s going on within the larger health systems, academic institutions, and even amongst radiology practices,” Werb says. The closings and consolidations can leave rural areas without much-needed care. Many see teleradiology as the answer to this growing dilemma. “It is one way to address challenges in the rural market,” Werb says. “You want to support the people who are left in the rural communities because they need the same access to health care that larger urban centers can provide.”

This is a challenge for every specialty, not just radiology, Werb says, but radiology may be leading the way with its teleradiology services. Radiology has long been a leader and early adopter of telemedicine technology. “I expect that, in the future, we will continue to disrupt ourselves in a way that allows us to provide much better and highly differentiated services to our patients. Teleradiology, the act of reading remotely, will become more and more prevalent in how services are offered, even in large urban locations. This is less about finding the lowest cost and more about providing the best possible services. Radiology departments and large practices are all beginning to think this way,” Werb says. “If I provide services across a large geographic area, then I want to be sure that the services I deliver are consistent, and teleradiology can enable that.”

Kaplan agrees. “Teleradiology is going to be what enables our US health care system to engage and care for people in markets not only around the world but also domestically that have traditionally been underserved,” he says.

“Not only has teleradiology been used from the very beginning in rural areas to assist in delivering top-quality radiology care to small communities, but it will also evolve to provide more personal and integrated care to these hospitals as final reports become standard and as teleradiology delivers more specialized care to these rural sites around the clock,” Shah says.

— Beth W. Orenstein of Northampton, Pennsylvania, is a regular contributor to Radiology Today.