A shortened version of this article appeared in Applied Radiology 2009;38,12:22-23.
The worst-case scenario in personal computing technical support is having your call routed to some far-off call center in Calcutta, or maybe Bombay, and having all of your queries met with scripted responses and guarantees that “power cycling” your device (a fancy term for shutting it off and turning it on) will solve your problem. Situations like this leave the caller wishing she could just get someone on the phone who she could communicate with instantly. Fact is, many radiology groups are letting this type of activity transpire with their referring physicians while they are off counting sheep.
Estimates today place the number of radiology groups using some form of third-party teleradiology service at about 70%. Clearly, U.S. radiologists place a high value on lifestyle and the quality of that lifestyle. These days, a nighttime-reading solution is close to a business necessity in order to recruit radiologists. With more than 100 companies offering such services, how do you ensure that your referrings don’t come to expect a lower-quality read just because a scan was sent at 11:13 p.m.?
A teleradiology service must be considered carefully and not just evaluated on a cost-per-procedure scale. The service should be viewed as a seamless extension of the practice. Referring physicians should be able to pick up the phone and contact the radiologist who read the study at 2 a.m. the same way they can at 2 p.m.
This article will review 6 main criteria that should be evaluated when negotiating a service level agreement (SLA) for new or replacement teleradiology services. The primary selection criteria for any teleradiology provider should be:
By carefully evaluating the services that other teleradiology providers bring to the table, you may realize it’s time to power cycle your old provider.
Part of the challenge to selecting a teleradiology vendor is looking past the concept of these services as mere commodities. It is true that in many cases a practice can come to the negotiating table with price as the foremost concern but simply choosing the lowest-cost provider could be sacrificing numerous value-added features.
With increasing competition, there has been downward pressure on pricing exhibited in the past several years. The competition has directly affected quality and the reduced cost is attributable to more efficient technology. Given this climate, a radiology group seeking to contract with a teleradiology provider would be able to secure high-quality reads from board-certified or fellowship-trained radiologists at extremely competitive prices. Commoditization becomes an issue, however, when the price competition forces these services to be moved off shore. On a level playing field, such that teleradiology salaries are commensurate with regular, on-site radiology salaries across the United States, the cost structure for teleradiology providers will be the same for economies of scale and efficiency. When the clinical process is moved to off-shore radiology, for preliminary reads and nongovernment payor final reports, the playing field gets less level. Further, the consumer trades the accountability of having a domestic teleradiology provider as well as having the ability to regulate and check up on that provider.
“With so many players in this space, there is significant pricing pressure,” said Rob Kill, Chairman and CEO of Virtual Radiologic Corp., Eden Prairie, MN. “While many providers can compete on price, not all of them have established reputations when it comes to quality of care and service excellence. Undoubtedly we are living in a cost-focused environment, but ultimately we are talking about patient care and you can’t make decisions on patient care based only on price.”
As the pricing structures and technology have matured, so have the services and the perceived value of a teleradiology provider.
“The initial push in teleradiology was to improve the quality of life, but now our customers are looking at us as partners in their practice,” said Timothy Myers, MD, Chief Medical Officer, Nighthawk Radiology Services, Scottsdale, AZ. “For instance, perhaps there is a small radiology group reading for a hospital and a new orthopedic surgeon moves into town and starts sending more hands, knees and toes. Suddenly the MRI volume doubles. We are moving aggressively into being able to cover subspecialty musculoskeletal and neuroradiology, and there are some areas of the country where we have had customers tell us that it is simply harder to hire good subspecialists.”
In such situations, the current imaging volume may not justify an entire FTE but in order to keep the business, the practice would still need a radiologist to cover those studies. A teleradiology provider with subspecialty services could take that workload and the practice could hire an FTE radiologist when the workload justifies it. Many radiology groups are looking to teleradiology providers, especially those that can offer subspecialty reads, as a way to alleviate workforce shortages from retirements or staffing changes.
“Instead of looking to replace 1 FTE radiologist, a group may come to us to add .75 FTE of subspecialty, fellowship-trained musculoskeletal or neuroradiology reading so they can maintain a similar level of service without incurring the full cost of hiring a new employee,” said Mark Stevens, Chief Operating Officer, U.S. Teleradiology, Atlanta, GA.
Quality assurance (QA) and final reads
Another point to consider is how the teleradiology provider handles discrepancies. In this regard, it helps to understand the provider’s quality assurance (QA) processes. Some vendors have dedicated QA committees while others will provide more ad hoc QA reviews. Additionally, some vendors will overread a certain percentage of studies in an effort to continually control quality.
“A lot of companies simply do not have the manpower to put a QA program into effect,” said Dr. Myers. “We perform random reviews of cases. In many other cases radiologists are sequestered from the issue of quality. Our radiologists are not shielded from the need to provide high-quality reads. We look at it from a group perspective. If an on-site radiologist has a consistently bad quality, his or her income will reflect that. Our radiologists similarly have their income linked to the quality of their interpretation. We read more than 9000 cases per night and our discrepancy rate is 0.3%.”
Generally, the model in teleradiology had been to provide preliminary reads overnight and then to perform final reads with on-site radiologists in the morning. As technology has increasingly improved, it is now possible to perform final reads at night and eliminate the case backlog the following morning. This shift has been echoed by government payors as the Centers for Medicare & Medicaid Services (CMS) are beginning to consider preliminary reading as an inherently inefficient process. CMS is also evaluating how it reimburses for radiology and the agency will not reimburse for studies that are read in foreign countries; the rationale is that billing is done for the radiologist’s location and not the patient’s location. So it is also important to ensure that if the teleradiology provider is making claims about final billing that it has a CMS-compliant billing processes in place.
Finally, it is important that the provider can deliver on the technical integration of teleradiology. Specifically, the provider must have a way to get the report back into the hospital’s radiology information system (RIS) or hospital information system (HIS).
Joint Commission accreditation
The same way that hospitals and departments maintain Joint Commission accreditation by demonstrating commitments to operational efficiency and safety, so too must teleradiology companies maintain a high-level of efficiency and now they can also obtain Joint Commission recognition for their efforts. A number of vendors now carry Joint Commission accreditation and this step ensures a consistently high-level of operational efficiency.
“I think the pursuit and maintenance of this accreditation holds us to a higher standard,” said Stevens, of U.S. Teleradiology. “We have an FTE who is solely tasked with ensuring we are Joint Commission compliant and up to date in all of our processes, whether it be a single event or an environment-of-care issue, this employee is on top of our policy and processes on a daily basis.”
Workflow and turnaround time
An additional factor to consider is how quickly the provider turns around images and how they route images to their radiologists. Some providers can guarantee a consistent turnaround time <30 minutes. However, longer turnaround times for nonemergent cases could help a facility better tailor an SLA to its particular budgetary needs.
“When competing for business it almost always comes down to a combination of price, turnaround time, availability and a certain QA level,” said Howard Reis, Director of Business Development at Imaging on Call, Poughkeepsie, NY. “We see that a 30-minute turnaround time has been fairly standard but the turnaround number can change as you go from preliminary reads to finals. However, nonemergent cases can be read at a slower turnaround time, perhaps 2 hours, and these specifics could be built into the SLA.”
It is also important discern how images are routed to radiologists. Some providers have elaborate routing schemes and employ radiologists who read in centralized locations vs. radiologists who read from home offices. The benefits here are that workflow coordinators can route calls so that the radiologist who interpreted the study, or another qualified radiologist, is always available to discuss results with referring physicians. In some business models these workflow coordinators also do initial review of the studies to ensure that they are complete and that the study finds its way to the proper physician.
“At U.S. Teleradiology, our radiologists read out of teleradiology centers that are supported by radiologist assistants,” said Stevens. “We can redeploy images to one of several such off-site centers that are on separate electrical circuits or fiber rings. So if there is a widespread event, we are not relying on a home-based reading model. We see more productivity this way and attribute this to their work ethic and the infrastructure that we put in place in our reading centers. We also have a live person to answer the phone and we have a radiologist available to take calls 24/7. So the referring physicians get the same level of service regardless of what time they choose to contact radiology.”
Contract terms and coverage
Several smaller teleradiology service providers require minimum weekly reading volumes. Typically the reasons for these minimums stem from the high cost to initialize service, especially when a radiology group has low night time reading volumes, said Bill Franz, Director of Business Development at NightShift Radiology, Montara, CA, radiology groups should be aware that some vendors will also charge for credentialing in order to offset the startup and administrative costs.
Most large teleradiology groups have done away with a contractual clause for a guaranteed minimum amount of cases per week or month, or with the practice of charging exorbitant credentialing fees. Some companies also provide a termination-without-cause period and these can fluctuate from 60 to 90 days or longer. The maturation of Web technology has conferred the ability to offer these flexible contract terms. In the early 2000s there was significantly more infrastructure investment to bring new groups online in a teleradiology model. Now the bandwidth has improved, and better PACS/Web integration has made it easier to retrieve images and information making it more cost-effective to add redundant systems and components (see sidebar below).
In general, radiology groups should continually evaluate the level of service they receive from their teleradiology provider. In such a competitive market, a significant portion of new business comes from competitive conversions. “We see more of our clients coming to us from previous teleradiology providers where they have been dissatisfied with the service level,” said Joe Moock, Chief Operations Officer of StatRad, San Diego, CA.
In some cases, the turbulent economy has also forced groups to reduce their number of covered hours. “We haven’t seen any groups bring services in house completely but we have seen a lot of large groups read until later in the evening,” said Moock. “We have seen some groups go from starting services at 5 or 6 p.m. to now 10 or 11 p.m. Some of the reasons for the switch are either to provide more income opportunities for group radiologists who are interested in ‘moonlighting’ or to cut costs for the group as whole.”
If looking to change the covered hours, it is important to ensure that the teleradiology provider has an appropriate level of coverage for the busier evening hours.
The teleradiology market is becoming a practice necessity across the country. With radiologists, in general, at a premium, the old contention that teleradiology services help foster a better quality of life, and thus happier and more productive radiologists, cannot be overlooked.
Selecting the right teleradiology services provider can ensure that referring physicians, and ultimately patients, receive a similarly high quality of care no matter what time they present to a hospital.
Historically, teleradiology companies have stood at the forefront of digital image delivery. These groups were some of the first to devise solutions to distribute medical images outside of the traditional healthcare chain and today many lessons can be learned from these companies as they continually develop and innovate tomorrow’s software solutions.
As PACS increasingly moved into a Web-based delivery of images, the times for teleradiology looked bleak. There was a real need to be able to manipulate and move images and get them to the radiologist, especially in environments where bandwidth is a challenge. It is not a simple matter of download speed either. Many PACS do not maintain connections below a certain bandwidth. As a solution, Voyager Imaging (Victoria, Australia) has implemented a pre-emptive download methodology, whereby the full-resolution diagnostic studies are downloaded in the background while the radiologist is reading. The technology has been optimized for low-bandwidth settings.
“Preemptive downloading fills the gap that occurs when images cannot be delivered via high-speed lines,” said Lance P. Thomas, Business Manager, Voyager Imaging Victoria, Australia. “Downloading multiple studies or high-resolution, multislice CT data sets creates an inherent latency that adds up to lost time in the radiologist’s workday. Finding solutions to this workflow challenge is of paramount importance.”
Besides delivering images, the other significant cost to teleradiology providers had been integrating new practices. With many disparate PACS solutions, the cost to integrate new practices had driven up the overall cost of teleradiology services in the past. Companies like Orion Health, Santa Monica, CA, now offer solutions to ease the integration and thus bring down the cost of teleradiology services.
Particularly, the Rhapsody Engine from Orion Health drives the technology behind such teleradiology players as Nighthawk and Virtual Radiologic Corp.
“The integration engine has been used in the radiology market for about 12 years,” said Art Ramos, Rhapsody Service Manager. “Rhapsody is a vertical interface engine that allows multiple disparate PACS or other hospital information systems to interoperate in a teleradiology workflow so that images and reports are properly routed among physicians. So when companies like Nighthawk or VRC acquire new business the hospital is integrated to their services via the Rhapsody tools. Some of the types of integrated data include HL7communications, DICOM images or any other structured data format.”
According to Ramos, the Rhapsody Engine is applicable to 15-bed hospitals or larger integrated delivery networks with 1,500 beds or more. Essentially, the solution manages, routes, translates and transports all of your data. As care networks expand across the country radiologists will see workflow benefits that are driven by tools like pre-emptive downloading and integration engines. The end result will be simplified workflow and a seamless delivery of images and information across a healthcare enterprise.Back To Top