New research showing that teleradiology services are highly reliable for emergency department (ED) off-hours CT is renewing debate about whether the benefits of teleradiology outweigh what some experts caution are considerable disadvantages.
Presented in March at the European Congress of Radiology (ECR), the retrospective study of more than 1,000 patients over a five-month period at the University College Hospital in London found a lower than 1 percent rate of serious missed interpretations. Staff and teleradiologists agreed in four out of five cases, with only insignificant discrepancies. Findings were also published in the August 2012 edition of the European Journal of Radiology.
“I don’t have any quality concerns about a teleradiology approach for emergency examinations,” said Joachim Hohmann, M.D., lead author of the study and a researcher in the imaging department at the University Hospital of Basel, Switzerland.
In the study of after-hours CT teleradiology service reports, CT studies comprised 437 women and 591 men with a mean age of 51 years and an age range of 0 to 97 years. Research was conducted between December 2009 and April 2010. The interpretations were conducted by a teleradiology service provider with offices in the U.K. and Australia. Exams were read in the U.K. location from 7 p.m. to 9 p.m., and from 9 p.m. to 8 a.m. in Australia. About half the studies involved the head and neck; most others were for the abdomen or chest. On average, between eight and nine studies were read per night.
All the reporting radiologists, teleradiologists and hospital staff had received equivalent training.
Results showed a small rate (0.8 percent) of proven serious misinterpretations by the teleradiology service provider, but this rate was lower than in comparable studies with preliminary in-house staff reports (1.6-24.6 percent), Dr. Hohmann said.
“The results of this study support the use of an outsourced after-hours teleradiology reporting service regarding the issue of quality concerns of such an attempt,” the authors concluded.
Nevertheless, some experts say significant obstacles exist to widespread use of international teleradiology in the U.S. and warn that reliance on teleradiology companies will drive down reimbursements and lead to commoditization.
Telemedicine in the U.S. has grown substantially since the mid-1990s when transmitting very large images first became feasible on a wide scale. While statistics are scattered, the American Telemedicine Association estimates that half of U.S. hospitals use some form of telemedicine and that teleradiology likely accounts for a large percentage of the usage. Smaller hospitals routinely send images to be read by specialists at large academic medical centers, and both hospitals and radiology practices use teleradiology providers for after-hours coverage. VRad, one of the largest teleradiology companies, reports 2,700 client facilities and 7 million reads annually.
While he acknowledges the usefulness of teleradiology for smaller hospitals and groups lacking subspecialty expertise, David Levin, M.D., professor and chairman emeritus of the Department of Radiology at Thomas Jefferson University Hospital, Philadelphia, said he draws the line after that.
“Even assuming that the teleradiologists in this study did a great job, I still think that outsourcing night calls is bad for radiologists,” Dr. Levin said. “My feeling is that it commoditizes the whole field. You’re saying to your physician colleagues, ‘We’re an important part of patient care, but only until 5 p.m. After that, we don’t really care what happens to the patients and we’ll let guys you don’t know read these studies.’ I don’t like the message it sends.”
That reliance on teleradiology companies will drive down reimbursements, said Dr. Levin, who was awarded the RSNA Gold Medal in 2009. “Right now, let’s say Medicare pays a radiologist roughly $70 to read an MR imaging exam,” he said. “These companies will read an MR imaging exam for $30 to $35. When the word gets out that a board-certified radiologist will read an MR imaging exam for $35, payers will ask why they should pay $70. The radiology community is unhappy that these reimbursements have been ratcheting down, but I think these teleradiology companies are part of the reason.”
Robert Novelline, M.D., a professor of radiology and director of emergency radiology at Massachusetts General Hospital, Boston, calls the research “a nice addition to the literature” and says it illustrates how dramatically radiology has been changed by access to high-quality transmission of images. But even though excellent images can be read half a world away, there are still significant obstacles to widespread use of international teleradiology in the U.S., he said.
The biggest hurdle is regulatory, he said. Credentialing and licensing requirements can often make it difficult to read studies in the next town, let alone in Australia or India. “If someone is going to read one of our CT scans, he or she has to be board-certified in the U.S., and have a Massachusetts medical license. In addition, that person must have passed all the credentialing requirements of the Massachusetts General Hospital,” Dr. Novelline said. “And in order to bill for the exam, it has to be interpreted on U.S. soil.”
Likewise, if Dr. Novelline reads a study remotely for another hospital, he also must be fully credentialed at that hospital. If the facility is in neighboring New Hampshire, he must also hold a New Hampshire medical license. Dr. Novelline predicts that the increasing use of telemedicine may eventually lead to national licensing, as state-based licensing becomes too unwieldy.
There’s more to quality of care than accurate reads, Dr. Novelline added. Unlike staff radiologists, teleradiology companies often aren’t in a position to influence the quality of the images, even though they’re taking legal responsibility for reading them. Nor can they offer the physical proximity often necessary to ensure exam quality.
“We cover several hospitals and our CT technology managers visit each of them to make sure the right protocols are being used,” he said. “We check the quality of every exam to make sure it’s done correctly and is diagnostic. This is one of the biggest challenges of a teleradiology practice—if the images aren’t of high quality, the reader could miss something. If I was reading a bad, non-diagnostic exam, I would need to have it repeated or arrange an alternative examination. It’s easy to do that if the patient and the technologist are on site right around the corner.”
Dr. Hohmann agrees that teleradiology poses a number of challenges and stresses that compromise is the best approach.
“Taking everything into account, my personal opinion is that we have no choice about whether we want teleradiology or not—it is already here. But we have a choice about how to use and regulate it to its full effectiveness and prevent patients from any potential harm,” Dr. Hohmann said. “That means we have to find reasonable compromises between the pros and cons of teleradiology.”
To access the study, “Quality Assessment of Out Sourced After-Hours Computed Tomography Teleradiology Reports in a Central London University Hospital,” go to Sciencedirect.com/science/article/pii/S0720048X12001866.
The American College of Radiology (ACR) Whitepaper on Teleradiology Practice, published online May 20 in the Journal of the American College of Radiology (JACR), proposes comprehensive best-practice guidelines for the practice of teleradiology, with recommendations offered regarding future ACR actions to ensure quality patient care. Access at: http://www.jacr.org/article/S1546-1440%2813%2900185-3/fulltext.
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