The prime reason for a university radiology department to establish a teleradiology practice is to increase its income. The more studies read the greater the net revenue. As discussed previously, the billing costs and other university practice costs tend to be significantly less for teleradiology than for the in-house side of the practice. Depending on the teleradiology clients, there may be a significant advantage for teaching and research missions as the teleradiology case mix may be completely different than everyday practice. Our teleradiology practice reflects the large incidence of diabetes and its complications found in Native American communities. There are many studies showing instances of osteomyelitis, Charcot arthropathy, pneumonitis, and atherosclerotic disease. The congenital and developmental diseases and degenerative diseases tend to be more complex and different in Native American and rural communities than in the typical academic practice.
While our in-house university practice is in a medical center with a Level 1 trauma center, we have seen many unusual traumatic injuries as part of our teleradiology practice. The Native American communities and rural community hospitals we serve do not have a high level of everyday trauma, but they do have unusual traumatic injuries related to horse, cattle, and sheep ranching, rodeo events, and the occasional severe automobile accident on a remote stretch of the interstate highway system.
Since many of our teleradiology studies are initially interpreted by a senior resident, they broaden the residents’ learning experiences, and during the day, the teleradiology cases are incorporated into the academic practice in each section of the department. This is an excellent learning experience for our residents and fellows. They learn how to read studies from remote locations with all the associated challenges of connectivity, report generation, and obtaining proper history as well as making sure a critical finding is directly communicated to the patient’s providers in a timely fashion.
Teleradiology reports have to be brief and to the point [36
]. Most of our client locations have CT imaging and standard radiography, but many do not have ultrasound or MRI imaging. Some do not even have CT imaging, and most do not have nuclear medicine imaging. Long rambling reports with no firm conclusions and ill thought out recommendations for further imaging are of no use. Thus, diagnosing pneumonitis in an infant, appendicitis in an adolescent or acute cholecystitis in an elderly adult, for example, without clear radiographic findings burdens the patient and his or her physician with an unnecessary, possibly harmful treatment plan of action. A patient may be transported over 100 miles in the middle of the night to a larger medical center for more advanced treatment based on our readings.
Residents and inexperienced faculty in particular may succumb to the temptation to overcall marginal radiologic findings to cover themselves from missing a diagnosis. Some cases are quite difficult, and it is incumbent on the interpreting radiologist on the spot to contact the treating physician to discuss the patient’s findings [28
]. It may necessitate consultation with a colleague or attending radiologist, and sometimes one has to admit the findings are equivocal and difficult to interpret. Recommending further imaging is frequently the case in daily radiologic practice. It should be based on sound radiologic and clinical findings. In a teleradiology practice recommending an MRI study or a nuclear medicine exam for a somewhat frivolous reason may have major costs and inconveniences for the patient and medical facility far greater than in an urban area.
Residents and faculty have to be cautious when interpreting ultrasound examinations for which they are not physically present and not able to view or participate in the real-time portion of the examination. However, one cannot simply refuse to interpret freeze frame images from remotely obtained ultrasound examinations as a matter of principle, because this will endanger the contract for that facility as the facility will quickly look for another provider. More importantly, it will deprive patients of imaging expertise. The majority of ultrasound examinations transmitted is interpretable and provides helpful information for patient treatment. Gallstones, abscess formation, aneurysms, large hematomas, pleural effusions, ascites, liver masses, and so forth are readily apparent. One becomes adept at being cautious when the images are not of high quality and when one is uncertain as to the actual scanning technique.
Our teleradiology practice contributes significantly to the teaching mission of the department in addition to its economic benefit. It also contributes to the academic mission of the department as well. Residents, fellows, and faculty see a case mix quite different from the usual academic practice. They learn how to interpret studies from remote locations with its challenges and its satisfaction of helping underserved populations. Departmental faculty are major investigators examining telemedicine and teleradiology both from a technical point of view and from a patient service point of view ([30
]). Moreover, it is likely most of our residents and fellows will join a practice in which they will interpret studies from remote locations.
4.2. Disadvantages and Challenges
Teleradiology practice has considerable challenges for a university-based radiology department. The monies generated may not be worth the inconvenience engendered by the increased workload which is often significant after-hours. This may distort the departmental work schedule and put additional stress on residents, fellows, and faculty who typically handle the after-hours cases. Academic practices pride themselves on their subspecialty expertise, but it is difficult to provide subspecialty expertise around the clock. Our increased teleradiology workload was initially put on the backs of the on-call residents, the nighttime faculty, and the faculty covering the morning work slots. The morning faculty received a large number of preliminary readings from the prior evening not only having to provide final reports but also having to correct any erroneous readings from on-call residents and having to contact remote physicians to give them amended reports for their patients.
Our early teleradiology contracts were signed by the departmental leadership with little or no consultation from the affected faculty. As is typical with many academic practices, the infrastructure was somewhat lacking. Initially, there were no additional resources given to the residents and faculty reading studies from the teleradiology sites. In fact, the teleradiology workstations were in inconvenient locations, the software was clumsy, and faculty had to print out their reports and individually fax them to the teleradiology sites!
Any teleradiology practice typically covers multiple institutions concurrently on a given work shift. Cases can sometimes backup, and our overworked residents and faculty often vented their frustrations on a physician inquiring why it was taking so long to receive a patient report. It does not engender good will to tell a hard working physician in a remote location with a very sick patient that his patient’s study will be read in the next hour or so after cases from other locations are cleared first. All of these challenges were gradually overcome by hiring more faculty, by separating the on-call in-house workload from the after-hours teleradiology work, and by constructing a voluntary paid teleradiology moonlighting practice for our senior residents as noted above. A daytime teleradiology coordinator was hired to facilitate the teleradiology practice both for the in-house teleradiologists and for the teleradiology sites.
As our teleradiology practice evolved, more user friendly software was installed, and several workstations were added making it considerably more convenient to report teleradiology cases. The faculty participated fully in the addition of new departmental contracts, teleradiology and otherwise, and some sites were dropped from our teleradiology practice due to financial or coverage considerations. The finances and work schedule for the department were openly discussed at faculty meetings, and the faculty had considerable say in departmental operations creating more of a buy-in and vested interest in expanding our teleradiology practice.
In our practice most of the after-hours coverage is from different radiologists from night to night. This is generally not a problem, but it can lead to an inconsistency in readings [41
]. This has been overcome in part by having the same faculty on during the regular work day and by having each section covering its portion of the teleradiology practice. This daytime consistency has proved very useful as physicians from the teleradiology locations are used to calling during the day to consult with our faculty. We also found that our moonlighting teleradiology residents became quite familiar with our teleradiology sites and became adept at conveying important patient information to the patients’ physicians. The residents and teleradiology faculty take the time to review previous patient studies and reports.
4.4. Putting It Together for a Successful University Based Teleradiology Practice
In the United States and elsewhere it is a tough competitive world, and a university-based teleradiology practice is by no means guaranteed to be successful. If it is imposed on the faculty and if there are insufficient resources both technical and personnel, it will fail. It cannot be imposed on the faculty from above, and faculty cannot be forced to travel to remote sites unwillingly. The faculty should not perceive the teleradiology as added extra duty with no reward. A teleradiology practice is not for every academic radiology department. However, under the proper circumstances, it can be financially rewarding and contribute significantly to the department’s service, teaching, and research missions. Table 4
lists general recommendations for a successful university based teleradiology practice.
Recommendations for a Successful University-Based Teleradiology Practice.
Recommendations for a Successful University-Based Teleradiology Practice.
|Subspecialty based practice with consistent faculty and resident participation on a daily basis|
|Concise, well written reports with definitive conclusions and recommendations where appropriate|
|Round the clock support services-teleradiology technical help line; physician’s teleradiology resource line|
|Consistent delivery of patient reports to the originating site with formal process for the prompt communication of critical findings|
|Proper faculty licensing, credentialing, and peer review|
|Peer review results available to contracting sites obeying confidentiality and peer review protection|
|Easy, formal process for resolving complaints concerning erroneous reports or other problems|
|Regular communication and periodic on-site visits|
Teleradiology should be an intimate part of a university based radiology practice rather than being an added on side business. One has to provide good readings with short reports to the point, ideally with the impression first in the report. There must be rapid turnaround of cases, and there has to be excellent urgent and emergency coverage. Good daily interactions with originating site providers is a requisite as is a technical help line for the originating sites when there are problems with the transmission of images or the receipt of reports. There should also be a physician’s resource line or a call center for physicians wishing to speak with a teleradiologist or inquire about patient studies. It is also beneficial for at least one representative from the department to visit the referring sites on a regular basis to discuss potential issues and challenges or simply to reaffirm commitments and “put a face” on the teleradiology practice.
It goes without saying that any university-based teleradiology practice has to have its faculty credentialed at each facility for which studies are interpreted. The faculty should have proper medical licensure and be covered by adequate malpractice insurance. There should be a formal peer review process for the continued evaluation of the faculty, residents, and fellows. The results of this peer review process should be available to the facilities contracting teleradiology services in a manner consistent with legal peer review protection and confidentiality according to applicable state laws. There should also be a formal mechanism to resolve complaints or queries concerning a specific radiologic report or possible error by an interpreting radiologist.