Some of you who read my writings may say that I find myself in hospitals and urgent care centers too frequently getting x-rays and other imaging scans. And those individuals would be correct! When you have family members that are accident-prone and add an older member of the family, gone are the days of our youth where seeing the inside of a hospital was a once every few year occurrence.
Most recently, we upgraded our semi-regular family outing to the urgent care
center for an excursion to the
emergency room of our favorite hospital. The family member in question had
x-rays taken at the urgent care center but needed a CT scan to diagnose the
issue further. So after an hour at the urgent care center, we made our way over
to the emergency room.
A (very) short time after checking in, a nurse
led us to a treatment room. Soon
after, my family member was taken to radiology for a CT scan. While waiting for
my family member to return, I started to think about our short visit to the
urgent center earlier. During our hour at urgent care, we had been checked in,
evaluated, x-rayed, and the physician concluded that further imaging was
necessary. What seemed strange was in thinking back as little as five years ago,
that visit would have taken a minimum of three hours. Less than an hour later,
after my family member was returned to the room, the physician returned and gave
us a diagnosis. Thankfully, it was nothing too severe or long-term. But before I
left, I casually asked one of the nurses about the on-call radiologist. She told
me that because of the time of day, and it was almost midnight at this point,
the technologist had sent the images to a third-party radiologist. Still, I
should rest assured because the physician at the hospital reviewed and agreed
with the findings.
Having suspected this was the case, I did a little
research the next day. Based on a July 2019 report* in the Journal of
the
American College of Radiology, based on 936 respondents, "...85.6% reported
performing teleradiology within the past 10 years and 25.4% reported that
teleradiology represents a majority of their annual imaging volumes." In the
same study, the radiologists noted: "...the challenges for teleradiology were
electronic health record access (62.8%), quality assurance (53.8%), and
technologist proximity (48.4%)." The conclusion of the report states, "Despite
historic concerns, teleradiology is widespread throughout modern radiology
practice."
So what are the concerns?
First, since the radiologist is offsite, most doctors do not have access to the
patient's previous medical records. Without those records, it becomes hard to
compare how a person's condition has changed over time. Though a hospital may
hire a local imaging group to read its images, that does not necessarily mean
that the radiologist is local. Many radiologists doing teleradiology in this
manner are US-educated but may live in India, Hong Kong, or anywhere else an
internet connection is available.
The lack of previous medical records
makes an accurate diagnosis more difficult and could require further unnecessary
and costly testing. Communication between the attending physician and the
radiologist is also more challenging when the radiologist is offsite. Gone are
the days of the radiology suite being next door to an emergency room, where the
attending physician could pop in and discuss a diagnosis. If progressive scans
are necessary to gauge improvement, it is possible to have an onsite radiologist
read the first image but have an offsite radiologist read the second scan.
Because most teleradiology businesses work with many hospitals and healthcare
systems, not every radiologist employed by the firm has access to the PACs or
RIIS system used by the originating hospital.
Lastly, some unfortunate
malpractice cases are being tried in the United States**. Because of
the immense
workload of the teleradiologists, a few imaging groups have had radiology
technologists call or communicate with the attending physicians instead of the
radiologist. In a few cases, this has led to incomplete or incorrect diagnoses
being relayed to the patients. From a survey conducted by the American College
of Radiology***,
"25% of respondents acknowledged being involved in at least 1
malpractice lawsuit involving failure of communication, with indemnification to
the plaintiff averaging $2 million." In most of these cases, both the
radiologist and the attending physician or hospital were liable.
So with all of these facts, why would a healthcare facility continue to use teleradiology?
As I noted in my story, time is the number one benefit of teleradiology. The
better offsite radiology companies have dedicated radiology specialists ready to
examine an image. For example, a patient presents in the emergency department
with a facial injury. A radiologist specializing in maxillofacial radiology will
most likely be able to read that image faster than an in-house general
radiologist who might have three leg images and a hand image to read before they
can look at the image of the patient with the facial injury.
The better
teleradiology businesses will only do a preliminary read of an image. This
preliminary read requires the attending physician to also read and make a
diagnosis based on the image. The result is a built-in second opinion on any
image. Because of this second opinion, patients can be more assured of the
findings.
Cost savings is also a significant factor in the decision to
outsourcing radiology. Instead of hiring an imaging staff to cover all hours, a
facility may only employ teleradiology during weekends and or nights. Or, as a
practice grows, use teleradiology services to accommodate the growing demand
until that demand can provide a positive ROI by hiring an additional in-house
radiologist.
Lastly, teleradiology provides better access to healthcare
in rural areas. With many rural hospitals closing, the void is being filled by
small outpatient or urgent care centers. These centers may have the ability to
take an x-ray; chances are they do not employ a radiologist to examine that
x-ray. In these instances, that x-ray is sent to a teleradiology group and read,
and the results can be returned to the patient within an hour. Without
teleradiology, these patients would typically be instructed to drive to a
regional hospital (on average 10.5 miles), where their time to treatment may
double.
So is outsourcing radiology a good or a bad thing?
Overall, I believe it is a good thing that will only get better with the advancement of technology. There will always be circumstances where human actions will cause errors, but as technology increases, the opportunity for those errors will decrease.
- * Rosenkrantz, Andrew B., Tarek N. Hanna, Scott D. Steenburg, Mary Jo Tarrant, Robert S. Pyatt, and Eric B. Friedberg. 2019. "The Current State Of Teleradiology Across The United States: A National Survey Of Radiologists’ Habits, Attitudes, And Perceptions On Teleradiology Practice". Journal Of The American College Of Radiology 16 (12): 1677-1687. doi:10.1016/j.jacr.2019.05.053.
- ** "Article - Failure Of Radiologic Communication: An Increasing Cause Of Malpractice Litigation And Harm To Patients". 2021. Appliedradiology.Com. https://www.appliedradiology.com/articles/failure-of-radiologic-communication-an-increasing-cause-of-malpractice-litigation-and-harm-to-patients.
- *** Kushner DC, Lucey LL, American College of Radiology. Diagnostic radiology reporting and communication: The ACR guideline. J Am Coll Radiol. 2005;2:15–21
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