The current moment represents a time of rapid change in many medical specialties, including radiology. Changes in regulations, payment, business arrangements, clinical practice, and information and medical technology are all contributing to this being a particularly unsettled period for practicing radiologists in the United States.
With the volume of diagnostic imaging procedures increasing at the same time as shortages of radiologist availability afflict many hospitals and multispecialty medical groups, a confluence of policy, business, and technological forces is continuing to build the teleradiology market. Just a decade-and-a-half ago, teleradiology was still viewed in many quarters in U.S. healthcare as a somewhat marginal phenomenon, one involving gaps in radiologist coverage during late-night and weekend periods, and initially filled by small groups of radiologists working mostly in India—where the time difference, and a surfeit of U.S.-trained radiologists who had returned to India to live, helped boost the initial teleradiology phenomenon.
Much has happened since then. Among other things, younger radiologists working in hospitals and medical groups are, like their counterparts in other medical specialties, demanding a better work-life balance. Meanwhile, technology has made teleradiology far easier to implement and optimize, and the engagement of teleradiology firms, staffed by radiologists from all over the world, has boomed.
One of the organizations that has made use of external teleradiology services is William W. Backus Hospital, a 213-bed community hospital in Norwich, Connecticut. Phillip Kohanski, M.D., chief of radiology at the hospital, has been practicing there for 17 years, the past five of them as head of radiology. The use of teleradiology at Backus has evolved over time. Three years ago, Kohanski led his colleagues to select the New Haven, Conn.-based Teleradiology Solutions, as their teleradiology services partner.
Recently, Dr. Kohanski spoke with Healthcare Informatics Editor-in-Chief Mark Hagland about the organization’s journey around the use of teleradiology services. Below are excerpts from that interview.
Can you share with us the background story leading up to your hospital’s use of teleradiology services?
When I first started here 17 years ago, we did our own overnight call. We did what was in effect teleradiology, ourselves; we simply read cases at home. Over time, the ER sort of exploded, and there were just more and more cases. About ten years ago or so, it just became too much, and we made the shift to using external services. Once, the volume of radiological cases [that we manage through external teleradiology] was five or six cases a night, but now it’s all night. It supports us [as attending radiologists]. We use the reads overnight and then do an over-read in the morning.
Phillip Kohanski, M.D.
We started with a small company that was OK, though their interpretations were somewhat spotty. Then, over time, we moved to a bigger company that was physician-owned, and the quality and turnaround time were somewhat better. But after that company was sold to non-physicians, our experience of their work was that the level of service had gone down, while the price had gone up. So we came across Teleradiology Solutions about three years ago now, and have been pleased with them.
In selecting a teleradiology firm, you were looking for good service, accurate reads, and reasonable pricing, correct?
Yes, that’s right. The first two things go hand in hand. Any external company really does have to provide both a quick turnaround time and accurate reads. The teleradiology service represents us during night hours when we’re not taking call. And if they take too long, the ER doctors are eager to tell me about it. And there have been some hiccups along the way. But the Teleradiology Solutions people are very responsive, and take care of everything right away. When I meet someone who represents the company, I deal with that person; he’s the point person, and he takes cares of things.
There used to be some hesitation among referring physicians, and among radiologists, about using external services, correct? But that hesitation has dissipated now?
Not entirely, actually. As soon as ordering physicians see a new name on a report, they’re skeptical, and it takes a while, maybe four or five or six months, for people to get comfortable [with the use of teleradiology-based colleagues’ services]. We’ve had three external services now, and yes, that happens. Also, we were slow to go onto teleradiology external services, for fear of losing our work; but over time, we’ve learned to rely on it.
Do you ever get to try anybody out, in the sense of a trial run, with teleradiology companies?
Well, vetting a company is not easy. The first time, the physician who connected with that first external company, met them at RSNA. And they started out OK. It was a small company, and there were only four or five guys, and over time, their turnaround time got worse; and they hired a new guy, and his interpretations weren’t so good. So then we switched to a new physician-owned company, and that worked out well until they were sold to investors. And now we’re on our third; and most of the Teleradiology Solutions guys trained at Yale, and that helped a lot. And of course, we have our own informal network, and we ask them.
What would your advice be, around vetting teleradiology firms?
Talk to their other customers. It’s better if you can find people on your own, so you get a less biased view; but if you have to resort to people recommended by the company, that can be OK, too. And the first year with Teleradiology Solutions, it was a month-by-month contract, and so yes, don’t sign a long-term contract.
Do you have any thoughts about the information technology or imaging informatics involved in making these processes run well?
I’m not a technological guy. But if you go with a company that’s providing teleradiology, you need redundancy. If their system were to go down, you’d need an alternate path to get there. We do have offsite redundancies with our hospital. And our lines are pretty fast. I know when they try to send stuff to my house over cable lines, it’s slower and choppier. So you should definitely investigate the IT capabilities of any firm you’re thinking of working with.
How do you see some of the business, clinical, and technological shifts involved in the current landscape, in the context of what may happen in the next couple of years, especially around ongoing consolidation among teleradiology firms on the one hand, and the availability of radiological specialists, on the other?
I can’t say that I’ve worked it all out for myself, but I have two answers for you. It’s good to have greater specialization available, but there should also be competition. And partnering with smaller teleradiology groups works well for us; we’ve consistently found that they provide better service.
It’s a little bit like the cable companies, right? When they get too big, service quality deteriorates?
Yes, that’s right! It is like that.
How are practicing radiologists’ attitudes changing? Practicing radiologists, more and more, are accepting the need to partner with external firms, correct?
Yes, exactly. We got involved in it the way everybody else did. The workload is just too much. And if you’re a small group, as we are, you can’t afford to have someone up all night and then resting the next day. And I’m not a proponent of anyone working more than 12 hours. You lose your sharpness.
How big is your hospital’s cadre of radiologists?
We have 10 radiologists here.
And is there some level of specialization on your team at the hospital?
Yes, everyone has a fellowship in some specialized area. At the same time, everyone still has to practice general radiology as well. We have teleradiology coverage only from 10 at night to 7 in the morning. So after 5 PM, you have to be able to do everything.
Is that good or bad, overall…?
Well, it’s good; it’s the reality of the situation; it helps keep us, the radiologists, sharp. A read I do on a spine MRI may not be as good as one by a neuroradiologist’s, but it’s important to have that flexibility.
What should CIOs and CMIOs be thinking about, in all of this?
What I would be careful of is that there’s a place for teleradiology; but there’s also a place for boots on the ground, and you can’t just eliminate that. And in the last 17 years since I’ve been here—it’s a very tight-knit group of people. Everybody knows what everybody’s strengths and weaknesses are. The orthopedic guy isn’t going to ask me to read a hand MRI, or ask a musculoskeletal guy to read a study of breast tissue. And there’s the possibility of final reads overnight, but we don’t do that, we want to do the final reads. So that’s our value, is that accountability.
How do you see radiology practice evolving in the next few years?
In the short term, I don’t think much is going to change; I think what we’re doing is going to be the norm for a while. Here in the Northeast, as more and more hospitals join together to become systems, and you have more and more hospitals in a system, you’ll find that teleradiology may actually become less global and more local, that there will be more local teleradiology; I think that’s probably going to happen.