Which Niche?
By Aine Cryts
Radiology Today
Vol. 22 No. 6 P. 24

What will teleradiology look like in a post-COVID world?

On February 29, 2020, Washington was the first state to declare a state of emergency in response to SARS-CoV-2. Florida and California would follow suit on March 1 and March 4, respectively. Along with its declaration, California’s order instructed health care providers to prioritize care for the sickest patients, and many other states would make similar decisions about care access.

On March 10, “[d]eeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction,” the World Health Organization decided that COVID-19 should be referred to as a pandemic. The US Centers for Disease Control and Prevention (CDC) defines a pandemic as an “event in which a disease spreads across several countries and affects a large number of people.”

Flip the calendar forward approximately nine months to December 31. That’s when the CDC reported a record 3,764 deaths due to COVID-19 in a single day. In May 2021, NPR revealed that the virus had claimed more than 7 million lives across the world, more than double the reported number of 3.24 million.

On December 28, San Francisco’s ABC 7 News reported that area hospitals were starting to reschedule some elective surgeries. Eighteen months after the start of the pandemic, increasing numbers of Americans are getting vaccinated against the potentially deadly virus. In response, the United States is opening up again. President Joseph Biden fell just short of a goal to have 70% of adults get at least one vaccine dose by July 4.

While Western countries, such as the United States and the United Kingdom, have achieved success with vaccination programs, the virus continues to claim thousands of lives each day in India and Brazil, CNN reports.

COVID’s Impact on Teleradiology
Tarek Hanna, MD, associate director of the division of emergency and trauma imaging and an associate professor at Emory University School of Medicine in Atlanta, says the two greatest impacts of the pandemic on teleradiology include a change in perception about teleradiology and its accelerated adoption. Hanna is coauthor of a December 2020 article in the American Journal of Roentgenology about the emerging challenges and opportunities in the evolution of teleradiology.

With the dawn of the pandemic and the need to prevent spreading the virus while ensuring radiologist coverage, many diagnostic radiologists turned to interpreting studies from home. “More practices, both academic and private, engaged in greater amounts of off-site work and accelerated technology deployment, [which includes] home workstations and the infrastructure necessary to support them,” Hanna says.

He defines teleradiology as diagnostic imaging that’s interpreted in a location that’s physically remote from the site of image acquisition. Within the practice of teleradiology, Hanna characterizes intraorganizational teleradiology as the interpretation of cases by radiologists where they’re employed but where the images were captured at a different physical location. By way of contrast, there’s also extraorganizational teleradiology, where exams acquired by a different entity than the radiologist’s employer are read.

Radiologists are continuing to work both on site and as part of teleradiology coverage for their practices. Hanna advises employers to be mindful about supporting radiologists who are reading from home to maintain a work-life balance and “not let work creep into what was previously off-time.” When a radiologist is reading exams from home, it’s easy for this line to be blurred, Hanna cautions.

Carolynn DeBenedectis, MD, an associate professor of radiology at University of Massachusetts Medical School in Worcester, says there are clear benefits for radiologists when they read remotely. For example, it can create a stable workday with the same hours but more time to interpret studies, since the 30-minute drive to the hospital can be spent working.

Still, the teleradiology experience is different for each radiologist, she concedes. DeBenedectis observes that she’s more productive when she interprets studies at a remote location where she doesn’t have as much interaction with students. That said, a great deal depends on the radiologist’s home environment. She adds, “If they have three kids at home, [the radiologist] isn’t going to increase their efficiency.”

In addition, working remotely can cause relationships with colleagues to fray. Thus, it’s important for radiologists to continue to invest in those relationships, DeBenedectis advises. “It becomes very easy to be ‘all business,’ and radiologists may miss out on the social aspects of being at work.”

Access Is a Priority
While teleradiology allows radiologists from most specialties—with the notable exceptions of breast imaging and IR—to interpret exams from home or any remote location, being accessible to discuss a patient’s presentation is a must. “Teleradiology doesn’t work ... if the radiologist is in a ‘black hole.’ [Radiologists] need to be engaged with the clinical picture. Being amply accessible [is important],” DeBenedectis says.

Dominick Pernice, RT, administrative director of imaging services and cardiac catheterization at St. Charles Hospital in Port Jefferson, New York and St. Catherine of Siena Hospital in Smithtown, New York, agrees that being available for consultations with referring doctors is important. Efficient call centers that facilitate access to radiologists can help solve this problem, he says.

Pernice notes another challenge with teleradiology: Radiologists aren’t easily accessible for urgent procedures and communication with technical staff. “It’s easier to [have the radiologist] on site and be able to walk over to speak with the technologists.”

Access for underserved populations is also important. Kristen DeStigter, MD, FACR, cofounder of Imaging the World, a nonprofit organization that integrates low-cost ultrasound programs into remote health care facilities that lack radiologists, other skilled personnel, and imaging equipment, says teleradiology will continue to play a role in improving care delivery for the underserved. DeStigter is also chair of radiology at the Larner College of Medicine at the University of Vermont.

Hanna and his coauthors also discuss the role of teleradiology in humanitarian efforts with organizations such as Doctors Without Borders. Specifically, they point to the role of teleradiologists, who need access to high-quality images in order to perform well. Improvements in training for radiographers and using CR instead of traditional plain film can help, they wrote.

In addition, teleradiology can help address care access issues in the United States. Hanna and colleagues point to potentially serious deficiencies in access to subspecialized radiology services for many patients in rural and urban areas. For example, they encourage practices to embrace the lessons learned about the role of teleradiology in Montana in the treatment of acute stroke.

Licensing and Credentialing Challenges
Andy Colbert, a New York–based senior managing director at Ziegler, an investment bank with experience in the health care sector, is optimistic that credentialing and licensing for radiologists will be less challenging going forward. “If there’s one thing that COVID-19 did, it accelerated this concept that we can all do [our work] from anywhere. I think it created a more virtualized business economy … the concept of state lines is kind of irrelevant,” he says.

The ACR maintains a list of teleradiology licensure requirements across the 50 states. The following are requirements from a variety of states:

• In Alabama, in order to interpret diagnostic imaging studies for patients in the state, the physician has to hold a full license to practice medicine in Alabama or an Alabama license to practice medicine across state lines.

• In Alaska, a full, unrestricted license is required; a notable exception is for a “curbside” opinion that’s provided at no charge to a state-licensed physician.

• In Rhode Island, a full, unrestricted state license is required if the radiologist reads directly for a patient; the license isn’t required if the radiologist is consulting for a physician who’s already licensed in Rhode Island.

• However, in most states, including geographically vast states with large populations, such as California, Florida, and Illinois, a full, unrestricted state license is required.

The lack of uniform licensing requirements among states results in a “tremendous administrative paperwork burden,” Hanna and his coauthors wrote in their article. They argue that these barriers result in practice inefficiencies and restricted access to emergency and specialty care, particularly in rural areas. For example, states have many different requirements regarding postgraduate medical training, criminal background checks, and continuing education for physician licensure, according to the authors.

The Interstate Medical Licensure Compact offers a possible remedy, per Hanna and colleagues. Released for consideration in 2014, the compact offers an expedited pathway for physicians practicing in multiple states to secure licensure. The ACR weighed in during the development of the compact; also expressing support are the American Medical Association and the Council of Medical Specialty Societies.

The compact includes 30 states, the District of Columbia, and the territory of Guam. In these locations, physicians are licensed by 43 different medical and osteopathic boards. Additional states are introducing legislation in their state houses to facilitate adoption of the compact.

While Hanna and colleagues note that 80% of physicians meet the criteria for licensure through the compact, heavily populated states such as California, Florida, New York, and Texas don’t participate. Imaging volume is high in these states, they note, and the lack of participation by these states limits the compact’s value.

Correcting Bias
Hanna says there remains a bias against teleradiology in some parts of the country. Specifically, he says, “the practice of teleradiology is inherently perceived as facilitating the commoditization of radiology. Now, I think this was much more the case a decade ago, but it persists. The COVID-19 pandemic and workflow changes associated with it have mitigated the issue somewhat. But I think it remains a headwind.”

Samir Shah, MD, FACR, MMM, vice president of clinical operations at El Segundo, California–based Radiology Partners, a national radiology group with more than 2,800 radiologists across 33 states, observes that teleradiology has existed for about 20 years. “Two decades ago, teleradiology leveraged utilization of unified worklists and voice recognition technology to keep up with the explosion in imaging that suddenly became a 24/7 round-the-clock phenomenon,” he says.

Shah expects the increase in imaging to continue to grow in the next two decades because “imaging continues to be the foundation of modern diagnosis in medicine.” Putting on his futurist cap, he believes teleradiologists “will champion and pioneer AI to manage [the] triage of cases, determining the best radiologist to read the ‘next’ case—the one with the right subset of license, credentials, study type, specialty, current modality mix, productivity/load, time remaining, site preference, likelihood of error, and factors we haven’t even fathomed as of yet.”

Specifically, he points to Radiology Partners’ MATRIX Teleradiology, the group’s teleradiology business, which was designed with the goal of collaborating with onsite radiology practices to optimize patient care. According to Shah, one of MATRIX Teleradiology’s differentiators is the use of peer learning in quality assurance. He explains that this translates into greater participation among radiologists and increased contributions to the quality assurance process. Shah says this nonpunitive approach benefits all of his colleagues.

Radiology leaders need to ensure that teleradiology provides the same high-quality, customized service and accessibility to referring physicians as on-site radiology. “Conversely, the worst thing we can do is to move diagnostic imagers off site and then make them inaccessible to the rest of the health care team, which creates frustration, leads to worse patient care, and promotes the misconception that teleradiology is a problem,” Hanna says.

— Aine Cryts is a health care writer based in the Boston area.