RSNA News - September 2004

Maximize Productivity Before Outsourcing, Expert Says

First leverage your existing radiologist full-time equivalents by fully exploiting the electronic management of images. Before you think of outsourcing, let's talk about maximizing productivity with existing personnel.
— Paul J. Chang, M.D.

Outsourcing radiologic services can be a successful and productive experience, if productivity is first maximized and then local and off-site radiologists function as members of the same team.

The University of Pittsburgh Medical Center (UPMC) and Air Force Medical Services (AFMS) have joined forces in a teleradiology initiative now under way at Wright-Patterson Air Force Base in Dayton, Ohio. It is based on a workflow model designed to increase productivity and enhance patient care across AFMS sites.

The model, created by Paul J. Chang, M.D., UPMC director of radiology informatics, is also in use throughout the UPMC health system, which includes 19 hospitals. "We don't have nearly enough radiologists at each of these sites, and yet, we've not had to significantly increase radiologist staffing and we don't outsource," says Dr. Chang, a member of the RSNA Electronic Communications Committee.

UPMC performs 1.3 million studies a year. Each radiologist is electronically linked to a system that provides access to all cases across radiology departments throughout the system. "It doesn't matter where we are, because we have a global view of all the studies that need to be interpreted throughout our 19 hospitals," Dr. Chang explains. "So, after you've finished the few cases at your satellite clinic, this shared context model allows you to cooperate and look at studies throughout our system, no matter where you're located."

Dr. Chang says UPMC recommended the same approach to the Air Force. "The Air Force has a severe problem with a shortage of radiologists," he says. "What we've been telling them is, 'First leverage your existing radiologist full-time equivalents by fully exploiting the electronic management of images. Before you think of outsourcing, let's talk about maximizing productivity with existing personnel.'"

Dr. Chang has the same advice for hospitals. "First do everything possible to avoid outsourcing by maximizing efficiency within your own shops, fully leveraging PACS and getting rid of film and paper. Then and only then do you outsource," he says. "And do it in a way that the outsource group feels more integral by having the workflow model be cooperative, rather than sending piecemeal work out to another country."

Dr. Chang says the Air Force teleradiology initiative is a symmetrical outsourcing model. "For instance, when Wright-Patterson Air Force Base uses our system to outsource to the private sector, instead of just sending a bunch of image studies, the private sector radiologist gets a real-time continuously updated worklist that is identical to Wright-Patterson's worklist," he explains.

This shared workflow allows radiologists at Wright-Patterson and those in the private sector to work cooperatively, as part of the same team. "So even though they may be outsourcing to a different economic entity, from a patient care workflow perspective, it's as if they're colleagues just across the hall," Dr. Chang says.

"The vision I have is that you outsource, not because you can't handle the workload, but because you want to optimize the quality and value of the interpretation to your patients," he concludes.

Quality is the Key

The American College of Radiology (ACR) issued a statement last May on the interpretation of radiology images outside the United States. The statement is available at www.acr.org/media/statement_teleradiology.html.

ACR believes that physicians who interpret images by teleradiology should meet or exceed the same standards met by physicians practicing within the United States. That includes being appropriately trained, licensed, credentialed and accountable for the service they provide.

"Outsourcing to non-credentialed radiologists overseas is not good medicine," says E. Stephen Amis Jr., M.D., ACR president and chairman of the Department of Radiology of Montefiore Medical Center, Bronx, N.Y.

Some small community hospitals in rural areas that do not have a radiologist on board during evening and weekend hours send satellite transmission of images to sites overseas, where non-board-certified, non-U.S.-trained radiologists read or give preliminary interpretation of a study.

ACR also warns that these "offshore" radiologists are not licensed in the state in which they are practicing. "If an image is being sent from Iowa to India, the interpreting physicians don't have a license in Iowa—and they should," says Dr. Amis. "If it's a hospital practice sending the image, the interpreting physician should be credentialed by that hospital to provide the service."

"We feel they should be subject to litigation," he says. "They should be held accountable if they miss something."

Dr. Amis says the ACR statement is not directed at practices that have sent a member of their group to another country, such as Israel or Australia, so they can read during off-hours. Nor is the statement directed at "nighthawks" who provide service within the United States. Nighthawks are radiologists who are licensed in the states for which they are reading images, who have malpractice insurance and who provide a real service to hospitals that are without a radiologist 24/7.

"That type of service is to be commended," Dr. Amis says.

Nighthawk service is available for small hospitals, but some still choose to have images read overseas. "I think it's wrong to buy from the lowest bidder when more appropriate services are available," Dr. Amis says. "We strongly discourage these discount, no-name radiology services from overseas."

He says the best possible scenario is to have the radiologists in practices or in hospital groups providing the coverage necessary for that facility. "The second alternative would be appropriately trained and board-certified, credentialed nighthawk services available in this country," he says.