American diagnostic radiology moves offshore: surfing the "Internet wave" to worldwide access and quality.

• Author: Nyberg, Eric M.

1. INTRODUCTION II. MEDICAL CARE VIA THE INTERNET III. REGULATION FOR QUALITY IV. HEALTH CARE COST CONTAINMENT V. IMPORTANCE OF ON-SITE RADIOLOGY VI. OFFSHORING AND OPTIMIZATION VII. CONCLUSION I. INTRODUCTION

   International reading of medical imaging studies, or offshore teleradiology, has been a successful, though limited, practice benefiting patients and physicians for over a decade. Domestic and international market forces will continue to expand the demand for teleradiology as an important complement to United States based diagnostic radiology, though a full exodus of diagnostic reading to offshore sites is unlikely and inappropriate. Considerable obstacles remain to taking the teleradiology market to scale; however, barriers related to licensure, liability, quality assurance, and reimbursement will likely yield to market forces to be resolved in recognition of the significant benefits teleradiology offers to consumers and providers.

2. MEDICAL CARE VIA THE INTERNET

   As in other aspects of the economy, the world of medicine is becoming flat as the necessity of physical proximity is becoming less essential in the doctor-patient relationship. Telemedieine, which is the use of electronic information and communication technologies to diagnose and manage medical care from a distance, is realistic, successful, and even preferred in several instances. (1) Telemedicine has existed for decades with telephone and fax, but with the Internet and the ability to view large amounts of audio and visual data at increasingly faster and cheaper rates, the practice of telemedicine is rapidly expanding.

   Radiology is not the only specialty affected by telemedicine and, by extension, the possibility of being offshored. Intensive care unit telemedicine is growing, and studies have shown it to achieve profoundly improved clinical and economic outcomes for both pediatric and adult populations. (2) Telepathology, which is the remote interpretation of cytological specimens, has been active for two decades and continues to grow more sophisticated as virtual laboratories are being created. (3) And tele-home care, which is the use of telemedicine in home-based settings, has shown to be successful in enabling community living older adults to maintain independence by providing monitoring of such vitals as blood sugar, blood pressure, heart rate, and mental status. (4) Even the practice of telemedicine in psychiatry has grown with one major study finding that there was no significant difference on patient satisfaction between telepsychiatric care and other specialty care via telemedicine. (5) Some patients, particularly those who were abused or suffered trauma, even show a strong preference for it. (6)

   Teleradiology specifically has considerable advantages for both providers and patients. One such benefit is using differences in time zones to alleviate the local burden of overnight calls and the loss of quality that comes with sleep deprivation. This service is generically known as "nighthawking" after the pioneering company NightHawk Radiology Services whose founder coined the term after nighthawk helicopter pilots on night flights in Vietnam. (7) When it is midnight on the east coast, a well-rested radiologist can be reading studies at 2 p.m. in Sydney, Australia. Teleradiology provides economic benefit to many smaller private radiology practices who would need to allocate one of their partners to staff an overnight shift which may only generate a few studies per hour while losing that staff member during the subsequent "post-call," more productive day time shift. In this case, the teleradiology service can keep its partners productive by servicing enough domestic radiology practices to keep them operating at capacity. Teleradiology also provides critical access to imaging services and timely interpretations for rural areas that cannot attract or afford on-site radiology interpretation, or alternatively in cities where the workload is too great. Similarly, teleradiology offers access to sub-specialists when experts consult or second opinions are needed.

   Several companies already successfully provide on-shore (where all radiologists are located domestically) and offshore teleradiology services. This sector has grown remarkably since its inception currently providing on call services to roughly 1000 or almost twenty percent of American hospitals; this number is growing rapidly. (8) One company that has arisen to meet this particular need is NightHawk Radiology Services, as mentioned above, based in Coeur d'Alene, Idaho; it sends locally generated images to American board certified radiologists living overseas, typically in Australia or Switzerland. (9) NightHawk, which currently services over 900 hospitals in the United States, has enjoyed significant growth after going public in early 2006, acquired several smaller teleradiology practices in the last year, and enjoyed a forty-four percent increase in revenues during 2005. (10) Other on call service providers, such as Virtual Radiologic Consultants (VRC), give their radiologists the freedom to live where they choose. (11) While a few of VRC's radiologists are scattered across the globe, the majority are local and simply adjust their lifestyles to accommodate overnight shifts. (12) At least two Indian based teleradiology organizations, Teleradiology Solutions and TeleDiagnosys, have successfully lured American trained and board certified radiologists and entered the American market. (13)

3. REGULATION FOR QUALITY

   Extensive regulation is justified and necessary in medical care, and teleradiology is no exception. In response to increased demand for teleradiology and in an effort to ensure quality, the American College of Radiology (ACR), which is the principal organization of radiologists, radiation oncologists, and clinical medical physicians in the United States, created Technical Standards for Teleradiology. (14) The ACR's standards define goals, qualifications of personnel, equipment guidelines, licensing, credentialing, liability, communication, quality control, and quality improvement for teleradiology. (15) Accountability and privacy in patient care are likewise essential to a high quality health care system, and the ACR's technical standards further define expectations around these issues. The enforcement of the Health Insurance Portability and Accountability Act (HIPAA), the law that protects patient privacy, as well as governs jurisdiction, poses significant problems in holding individuals responsible outside of the reach of American courts. (16) Issues of liability are of substantial concern for teleradiology providers based outside of the United States that do not use American licensed physicians because jurisdictional loopholes might allow these providers to avoid medical malpractice liability which would likely shift the burden of medical malpractice liability from providers to hospitals. (17)

   The ACR also provides guidance regarding requirements for personnel qualifications. While any radiologist with access to an approved workstation and sufficient bandwidth can provide their services from anywhere in the world, ACR standards state that a radiologist performing teleradiology should be American board certified, carry licenses required by the states in which they practice (or from where their patients are located), carry malpractice insurance in those states, and be credentialed by the hospitals they service. (18) Current teleradiology service providers state that they comply with ACR's recommendations. (19) One offshore company, the Indian outsourcing giant Wipro which provides dozens of business and technical services to a broad range of companies, attempted to enter the United States market in 2003. (20) Although its radiologists are not American board certified, Wipro argued that it should have been allowed to enter the American market because their radiologists were essentially acting as 'virtual residents' offering preliminary reads only. (21) Because Wipro could not obtain malpractice insurance, it could not establish a foothold in the market. (22) Wipro is currently providing imaging post-processing services, such as 3D reconstructions, and "collaborative interpretations" for four hospitals in the United States; however, the company has not disclosed these organizations, nor have they added additional clients over the past several years. (23)

   Given the United States' position as the international gold standard of medical training and the current lack of an acceptable alternative international standard, completion of an American Council of Graduate Medical Education approved residency in diagnostic...