Going the Distance
By Kathy Hardy
Radiology Today
Vol. 21 No. 6 P. 22

Teleradiology helps maintain COVID-19 safety precautions.

In radiology, the six feet necessary to practice social distancing doesn’t only apply to capturing images. It also means finding a safe way to work in a crowded reading room with colleagues wearing masks. At a time when staff could be reduced due to illness or simply need to work remotely, teleradiology is one option for increasing the physical space between personnel while managing a growing volume of often complex COVID-19 caseloads.

“You can more effectively separate staff from each other with teleradiology,” says Ezequiel Silva III, MD, FACR, medical director of radiology at Methodist Texas Hospital in San Antonio. “Practices that might have had five radiologists working in a hospital now have only two working in the hospital, with the other three at home.”

Many health care facilities are relocating staff due to COVID-19. Reading rooms can become crowded as radiologists and technologists interact on cases. In some instances, there is a designation of staff to work solely with positive patients, while other personnel focus on patients whose matters are non–COVID-19 related.

“There’s also a concern for radiologists and technologists aged 65 and over, who are in the demographic more at risk for having significant effects of the virus,” Silva says. “You may want to remove those individuals, out of a precaution for their health. We need to keep staff safe.”

In addition to reducing the number of radiology staff in one location, teleradiology also offers hospitals and imaging centers a way to separate COVID-19 patients from the general patient population—the heart attacks and broken bones that occur regardless of a pandemic. Whether these changes last beyond the pandemic remains to be seen, but it is becoming clear that COVID-19 has changed the teleradiology landscape and will continue to do so.

“It’s still so early that we don’t have hard data to show the full effect of COVID-19 on teleradiology,” Silva says. “We’ll know later in the year what changes were implemented in practices. For now, we’re looking at effectiveness and learning best practices.”

Silva is the current chair of the ACR Commission on Economics, but in 2012 he chaired the ACR’s task force on teleradiology. During that time, he was the lead author of a whitepaper on teleradiology practice, reviewing the landscape at that time to determine what role remote reading could play in the field, as well as guidelines for use. Without a crystal ball, Silva says, those involved in the paper could never have imagined how useful a study involving remote reading would become nearly 10 years down the road.

“We recognized even then that teleradiology was a growing area of our specialty,” Silva says. “We knew that teleradiology had value as a practice model, and it was time to explore this avenue. We also recognized the need to create standards for a teleradiology practice. What we didn’t anticipate was that there would be a pandemic mandating everyone to keep a safe distance from each other.”

In the whitepaper, the task force outlines the following four guiding principles, which should be a part of all teleradiology efforts:

• Patients are the primary focus.
• Teleradiology services supplement an onsite radiology practice.
• There is a need for one unified professional standard of quality for teleradiology providers and onsite radiology entities—separate standards for remote and onsite radiology does not meet the criteria of best patient care.
• Teleradiology should be incorporated into local operations of hospitals or imaging facilities in regard to safety and quality, assimilating into the usual medical staff credentialing and privileging process.

Eliminating Adoption Hurdles
Even with the immediate need for distancing, there are hurdles to adopting a teleradiology model. Technology can be a challenge, for example, both from a sufficiency and an expense perspective.

“Switching from a facility-based radiology practice to remote reading is not as simple as going home, turning on your computer, and getting to work,” Silva says. “It requires a robust infrastructure. You need a certain monitor that supports high-resolution image quality, you need enough bandwidth to manage large file sizes, and you need an effective method of communicating with staff.”

A cloud-based solution can ease the burden of hosting the myriad large files generated via radiologic imaging modalities, says Dhruv Chopra, CEO of Collaborative Imaging. His company currently has solutions that provide support to 60 hospitals from one viewer.

“With a cloud-based system, you can maintain all your hospitals on one platform, and you’re able to deploy the network more quickly,” Chopra says.

Of particular importance is the interface between radiologists and technologists, Silva says. The radiologist may, for example, see something on an ultrasound image that requires reimaging, possibly from a different angle. Working remotely can result in a communication barrier.

“It could be difficult if the technologist has to locate me off campus,” he says. “Or, if the technologist needs to call a radiologist, there could be an impact on care if it’s not someone they’re used to working with. Onsite relationships are important, too.”

Chopra credits cloud technology advancements with allowing real-time, monitored communication between technologists and radiologists in a secure, integrated process.

“Technologists can now easily relay information to radiologists in real time via a technologist portal that enables them to converse regardless of location,” Chopra says. “The ability to resolve issues, such as a radiologist needing a comparison that wasn’t available or a tech relaying that a referring physician wants to be called at a particular number with the result, is embedded in the workflow. As soon as a radiologist interprets the study, the referring physician information is available to them for the next step of action.

“In addition,” Chopra continues, “the technologist has real-time visibility into the status of their studies, can edit information, or upload additional documentation. The technologist can also utilize integrated instant messaging tools at any point to communicate with the radiologist who will be reading the particular study.”

In the past, there has been some resistance on the part of referring physicians to accept teleradiology as a viable alternative to a traditional reading room setting. But, again, that’s changing as the need to socially distance comes into play.

“With COVID-19, the idea of reading images remotely from the hospital has become more acceptable,” Chopra says. “You don’t want all your radiologists, referring physicians, everyone involved in a case, to become ill because they’re all working in the same room.”

He believes that this is another positive aspect of cloud-based systems—all physicians involved in a patient’s care can view images virtually, together, with the touch of a button. This type of access allows for staggered shifts and 24/7 coverage, without exposing radiologists to a large group setting. This type of system also allows cases to be virtually directed to radiologists who are focused solely on COVID-19 cases.

“You can have radiologists in eight states but all on one platform,” Chopra says. “You can direct help to different locations as needed. If a hospital in New York, where there is a significant number of COVID-19 cases, needs coverage, we can get them help in a matter of hours.”

Economic Concerns
One obstacle that has been moved to the side, at least temporarily, is the matter of Medicare reimbursement. On March 6, 2020, the Centers for Medicare & Medicaid Services (CMS) instituted a temporary emergency broadening of access to Medicare telehealth services in response to the COVID-19 crisis. Medicare providers may now use telehealth technology when providing various services, including teleradiology, to patients.

“This is helpful during the pandemic, as facilities are scrambling to find solutions to the need for social distancing,” Silva says. “What we don’t know is what will happen going forward, once the pandemic is over.”

Chopra notes that economics are a factor in considering the expansion of teleradiology during the COVID-19 pandemic, but radiology groups need to look at the long term to ensure their survival. In teleradiology, having radiologists reading remotely from one state becomes an issue when images come from a different state. Relaxing requirements at this time can help with the licensing issue, but not necessarily reimbursement.

“Will this facilitate a more permanent relaxing of CMS codes? No one knows for sure,” Chopra says. “But even if that were the case, it still doesn’t mean there will be reimbursement. Medicare will reimburse, but maybe not commercial insurance providers, each with separate contracts. Not all teleradiology patients are on Medicare.”

There is also a concern regarding a reduction of revenue. With COVID-19, elective procedures have been postponed to avoid potential exposure from patients who have the virus. Hospitals and imaging centers are taking a financial hit, as elective procedures bring in more revenue than emergency and ICU cases. Radiology practices need to identify how to increase volume in the absence of outpatient work.

“That’s where teleradiology can help,” Chopra says. “You can create a center of excellence for reading just COVID-19 cases. Also, with many temporary medical treatment locations being established by the Army Corps of Engineers and National Guard, there is a greater need for teleradiology to meet imaging needs in these remote locations.”

He says users can also establish separate subspecialty imaging centers for more traditional radiology needs. With more people working from home, there are more home-based accidents, such as slips and falls, which are considered the “bread and butter” of radiology.

AI Assistance
A new tool that could play a role in assisting with subspecialty needs is NinesAI, a recently FDA-cleared medical device for use by radiologists in emergent cases of intracranial hemorrhage (ICH) and mass effect—the changes that occur around a brain tumor—two time-sensitive and life-threatening conditions. This AI device is designed to be used in triage situations.

David Stavens, PhD, and Alexander Kagan, MD, site chair of radiology at Mt. Sinai West and Mount Sinai Morningside in New York, cofounded Nines, a radiology-as-a-service teleradiology solution, in 2017. Combining medicine and engineering, Kagan reached out to Stavens, the former CEO of the online learning platform Udacity and the cofounder of the AI technology used by Stanford University’s self-driving car team.

“Nines was developed as a way to help radiologists deal with burnout stemming from an increased volume of cases to be read,” Stavens says. “The presence of COVID-19 is making the situation even more dire, as hospitals are seeing an increased patient caseload. They’re also looking for ways to divide staff to address non-COVID–related cases. Our software can assist with that.”

NinesAI uses a prioritization method to assist in identifying ICH and mass effect in emergent cases. As Stavens explains, radiologists typically receive images in the order in which they were captured. However, this “first in, first out” method doesn’t take condition severity into account.

“With our software, radiologists receive an emergency alert telling them if there is a study they need to look at right away,” he says. “This increases the odds that severe conditions will be identified first. Radiologists can be notified of a potential life-threatening brain bleed in 15 seconds and begin reviewing the case immediately. With intracranial hemorrhage, for example, researchers estimate that the 30-day mortality rate ranges from 35% to 52% with only 20% of survivors expected to have full functional recovery at six months, and approximately half of this mortality occurs within the first 24 hours.”

While NinesAI did not come about as a result of COVID-19, an area where this solution may now have greater relevance is in patients under the age of 50 who contract the virus. Hospitals are reporting cases of stroke and blood clots in this younger demographic; strokes and trauma are causes of ICH and mass effect.

What’s Next?
Just as other industries are adapting to operational changes brought on by COVID-19, health care is taking steps to be safe, conduct good practices, and remain financially viable.

“This situation happened almost overnight,” Silva says. “We’re currently testing a lot of models that we have not had a chance to test before. Through lessons learned, we’re keeping what works and ditching what doesn’t work. From a teleradiology perspective, there are efficiencies that will be gained and practices that we will keep.”

Teleradiology is growing within the telehealth space. With that, another aspect to consider is the patient side of a switch to telemedicine in general.

“Once the pandemic is over, will patients still want to drive to a doctor’s office?” Silva asks. “There are some fields, such as radiation oncology, where regular interaction with patients is important. We have to consider whether or not we want to lose that. Our focus needs to remain what’s best for patient care.”

“I don’t think we will go back to the way it was,” Chopra adds. “I think hospitals will want to keep this high level of functionality and turnaround times.”

— Kathy Hardy is a freelance writer based in Phoenixville, Pennsylvania. She is a frequent contributor to Radiology Today.