Teleradiology: images of an improved standard of medical care?

• Author: Nayar, Vivek

INTRODUCTION

Teleradiology, a subset of telemedicine, is "a means of electronically transmitting radiographic patient images [X-rays, CT scans, etc.] and consultative text from one location to another." (1) In theory, teleradiology allows a radiologist to remotely diagnose images anywhere in the world from a phone or Internet connection. As a result, a nascent international outsourcing industry has formed, providing inexpensive and efficient diagnoses of images (2) sent by American medical groups. (3) Despite this growth, regulatory entities have not embraced offshore teleradiology because of the sensitive and private nature of the transmission data, the potentially life-threatening consequences of a mistaken diagnosis, and jurisdictional issues affecting a patient's legal recourse. This note argues that despite these legitimate concerns, the benefits of offshore teleradiology and other forms of telemedicine may increase the overall standard of medical care available to underserved and rural communities. Telemedicine may improve this standard by providing critical access to medical specialists in areas where no specialists practice, at a cost significantly lower than U.S.-based physicians. Impeding the growth of teleradiology, however, is a collection of professional organizations, federal and state statutes, and medical negligence laws that have decreased the incentive for domestic medical groups to implement telemedical protocols. While the general purpose of this regulatory collection is to protect healthcare consumers by upholding and enforcing the highest standard of medical care possible, this note argues that the regulations are too broad and unfocused. A more flexible approach by regulators may allow for and promote the use of telemedicine as a means of providing underserved and rural communities with a similar level of access to medical care as that found in urban medical centers throughout the U.S., while still protecting patients against sub-standard medical practices. The increased implementation of teleradiology and other forms of telemedicine may also create a type of "disruptive innovation that can transform traditional processes" to create benefits not currently anticipated or foreseeable. (4)

Part I of this note defines teleradiology, discusses the differences between the onshore and offshore teleradiology models, and describes some of the potential benefits of teleradiology. Part II describes the current condition of rural medicine, arguing that the paucity of medical specialists in underserved and rural communities is due to a combination of government policies within the past fifty years and personal choices by physicians graduating from medical school. Part II also provides examples of current teleradiology practices in a rural medical context. Part III discusses impediments to the growth of offshore teleradiology, including the recommendations of professional medical organizations, state and federal statutes, and medical negligence law. Part IV argues that government policy should endorse teleradiology and recommends changes to current state licensure and medical negligence law.

1. WHAT IS TELERADIOLOGY?

   "Telemedicine" is the use by medical practitioners of "telecommunication to diagnose and treat a patient." (5) Teleradiology, a subset of telemedicine, "is a means of electronically transmitting radiographic patient images [X-rays, CT scans, etc.] and consultative text from one location to another." (6) Teleradiology is a natural subset of telemedicine because radiologists have increasingly replaced traditional analogue film with digital imaging technology. (7) Advancements in data storage, data transmission and increased bandwidth have allowed radiologists to sit at a given workstation anywhere in the world and "send, receive and manipulate any digital information from imaging studies at the click of a button or turn of a dial." (8) This technical sophistication has enabled the growth of medical outsourcing, (9) where medical groups send delegable components of health care treatment to other countries. Although the U.S. healthcare industry was initially slow to adopt outsourcing, (10) certain sectors have embraced it. For example, "[t]he $20 billion medical transcription industry subcontracts as much as half its work overseas." (11)

   1. Different Models of Teleradiology

      There are two teleradiology models: (1) "onshore" readers located within the United States, and (2) "offshore" readers that are trained and reside in foreign countries. (12) The first model employs only U.S.-trained, board certified radiologists residing in the U.S. (13) or other parts of the world to take advantage of time zone differences. (14) In contrast, the offshore model employs foreign trained radiologists who reside on foreign soil, usually in China or India. (15) The first model is currently more popular; 80% of American private radiology practices use entirely domestically trained radiologists, while less than 15% use foreign-based radiologists. (16) Although the offshore model can take advantage of both lower labor costs (17) and time-zone arbitrage, Part III will argue that significant regulatory and legal barriers have prevented the growth of the offshore teleradiology outsourcing model.

   2. Teleradiology: Reasons to Offshore Radiological Diagnosis

      Benefits to using the offshore teleradiology model include lower costs, increased efficiency, and accessibility to medical specialists by underserved and rural communities. Offshored teleradiology will decrease the costs of radiological diagnostic services for a couple of reasons. The cost of domestic radiology diagnosis has increased as the demand for image readers has outstripped the supply of radiologists graduating from medical school. (18) This demand for diagnostic services has increased due to the aging baby-boomer generation and an increasingly sophisticated arrangement of imaging equipment that requires expert interpretations. (19) As a result of this shortage, there are roughly 300 U.S. hospitals using some type of international outsourcing model to read images. (20) In addition, at least 1000 hospitals employ some form of teleradiology service to read x-rays during off-peak hours. (21)

      Another reason why teleradiology will decrease the cost of diagnostic services is because foreign doctors cost less than domestic doctors. According to the Radiological Society of North America (RSNA), non-interventionist diagnostic radiologists are the fifth highest paid medical specialty group, averaging a 2004 salary of $364,899, up 5.58% from 2003. (22) In 2005, this salary jumped to an average of $400,000. (23) In contrast, current Indian radiologists who provide diagnostic services to U.S. clients earn between $20,000 and $30,000 per year. (24) Lower salaries and lower service costs benefit patients in light of the current state of the health care industry, (25) where in the aggregate, the U.S. spends more money on healthcare than any other country but is below the median on service utilization because of the amount spent. (26) Given these two factors--a shortage of radiologists relative to demand and high salaries--offshore teleradiology may provide a better value proposition than current options.

      A second benefit to using an offshore teleradiology model is an overall increase in efficiency and productivity. Broadband technology provides Internet users with fast data transmission, enabling the quick transfer of large image files. As a result, teleradiologists "may now give rapid diagnostic readings." (27) This turnaround speed between time of file transfer and diagnosis enables medical groups employing offshore teleradiology to take advantage of time zone differences between the U.S. and foreign countries. Hospitals can outsource any critical work that comes in after hours, relieving doctors from working evening shifts that would require them to take time off during the following day, (28) and preventing fatigued doctors from potentially misdiagnosing an image. This around-the-clock ability to read and diagnose medical images, in some cases within thirty minutes after receiving the image, (29) creates a level of efficiency and productivity that is a noted benefit of outsourcing in general. (30)

      A third benefit to using the offshore teleradiology model is access to medical care in areas that do not normally have specialist services. Offshore teleradiology provides the ability to read and diagnose images anytime of the day or night, for a cost that is significantly lower than domestic alternatives. As discussed in Part II, these benefits may serve patients located in rural and underserved areas who may not have affordable access to radiologists or other specialists during times of need. Teleradiology and other forms of telemedicine may help bridge this gap by providing access to critical and preventive care at a relatively low cost.

2. THE ISSUE OF RURAL MEDICINE: A PREVENTABLE CRISIS?

   In a national survey, rural health leaders identified access to health services as a top priority. (31) Access as a top priority is unlikely to change in the near future because of an aging national population over sixty-five, 22% of which reside in rural areas. (32) In addition, roughly 20% of the U.S. population lives in an area designated by the U.S. Department of Health and Human Services as a "Health Professional Shortage Area or a Medically Underserved Area of the Population." (33) However, "major barriers to long-term care for the rural elderly are lack of providers, limited knowledge of available resources, isolation, socio-economic factors, [and] lack of availability and coordination of services ..." (34)

   Several exogenous factors contributed to this dearth of rural healthcare practitioners. These factors facilitated the growth of large-scale and centralized hub hospitals rather than the growth of a geographically diverse network of healthcare providers. (35) The...