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NightHawk Teleradiology Services: A Template for Pathology?

2008; American Medical Association; Volume: 132; Issue: 5 Linguagem: Inglês

10.5858/2008-132-745-ntsatf

1543-2165

Douglas E. Johnson,

Radiology practices and education

Obviously, when you have the term sales in your title, that gives a little bit of idea about what your motivation is but not today. My motivation today is to provide an overview of NightHawk, teleradiology in general, and an idea about where things might be in a few years.William G. Bradley, Jr, MD, PhD, FACR, who is the chief of radiology at University of California, San Diego, is a kind of a guru in the magnetic resonance imaging field. In the early 1990s, he was taking calls at the central reading facility for a group of hospitals, covered by a group of radiologists in Southern California. They had very little ability to aggregate very many studies at the same time, and so the radiologists did a little bit of this when they were on call.Here is just a brief overview of this presentation: How has radiology changed with technology? What are the barriers? What are the limitations? And what value has telemedicine added to radiology?The first marketing piece that we sent out in 2001 focused on the main crux of why we started NightHawk. The radiology department manager or the business manager for a radiology group can look haggard because covering night calls is tough. The impetus for NightHawk was just to take this very small segment of very unproductive work for radiologists and be able to allocate that time better from nighttime to daytime.The interesting part about what we decided to do was to locate the radiologists in a place that was very attractive for them to take night calls from, and that happened to be Sydney, Australia.There was the redeployment of radiologist hours; the unproductive time was really the motivating factor for radiology groups all around the country that wanted to outsource their night calls. It just did not make very much sense for a radiologist to be up in the middle of the night taking 6 cases and then not being able to be productive the next day. It just made a whole lot more sense for that doctor to be very productive the next day and to better allocate that time.There were lifestyle issues as well, because nobody wants to be up in the middle of the night taking a call. So that was really the main thing that prompted a lot of our initial customers to give us a call.That was then when we had our first 2 radiologists. We are now currently in the Grovernor Building on the 11th floor where one of our reading facilities is located. We also have an office in Zurich, Switzerland, that radiologists read from, and then we have several offices here in the United States where we do daytime interpretations as well.We cover almost 1400 sites across the United States in one way or another, and we now have 400 employees worldwide. We are a publicly held company. A little more than a year ago, we went public and we provide more than just nighttime services now. We do final interpretations during the daytime. We still have our core business, which is the nighttime interpretations.Something that we are very excited about is 3-dimensional imaging for cardiac interpretations, which is really new technology. I think that there are some good correlations that you can see about that, with some challenges that we are having in that area. One thing that was touched on before was our ability to help radiology groups with distributing their workflow and making sure that they have a good workflow solution internally for their facilities.We have heard the term digital imaging and communications in medicine (DICOM) used today. I do not know whether you know how prevalent DICOM is within the world of pathology, but it is the standard within radiology. Early on, in my radiology experience, back in 2000 to 2001, DICOM was the standard, but the hospitals, their technology, and all the pieces of equipment that were in place in the hospitals had not really caught up yet. And there were non-DICOM compliant machines in the hospitals; those machines were really a stumbling block to hospitals being able to use digital systems to make the hospitals and the radiologists more efficient. However, they were also not allowing the hospitals to be able to distribute the images from underserved areas to groups like ours, or they were not allowing the PACS (picture archival and communications system) capability and the storage of those images to make them more efficient and able to retrieve those studies.Obviously, DICOM has been a big boon for radiology. It allowed for multivendor platforms early on and we saw that the vendors really thought that the way to go was to have everything be proprietary. In a short time, just a period of 5 years, that has gone out of style, and the fact that the vendors are seeing that being able to cross platforms and have the human element as a piece that we will always have to consider. When you are making decisions about what platform you go on from a technology standpoint, those hospitals and radiology groups have a huge investment in those platforms, and for them ultimately to be able to not talk to each other has become a problem. DICOM and the interoperability of the different platforms has become something that the people have come to rely on.Ease of technical support is important. For organizations such as ours, these systems are really useless if they are not up and running. To have people able to support these multivendor platforms is very important.They must be easy to scale. One of the things that is happening is that the radiologists who are the most efficient are the people who are the most productive. They are the ones growing, and to grow quickly, you have to be able to scale; DICOM allows everybody to do that very well.Although the timeframe for using this technology in radiology was 10 years, that cycle may be much faster for pathology. The Internet is one thing that will really help develop this quickly in pathology. We had struggles early on in the teleradiology world, but the Internet has very quickly become more reliable, more affordable, and more available.Early on, we had some serious problems with radiologists thinking that we can live and read from wherever we want, but they found out that being located several miles outside an urban community might mean the Internet was not available to them or that there was no high-speed Internet. That has quickly gone away with wireless technology, and so it has become less of a problem.In terms of ensuring affordability, more and more government programs are becoming available. The Federal Communications Commission has some pretty large grants to allow for rural hospitals and rural applications to be subsidized by the government. Some of those expenses from a hospital's perspective and from the physician's perspective have gone away. Early on, there were reliability issues and some security standards that were just in their infancy, but now everybody has caught on. There are some things that you would have to address had not radiology already tackled this issue.In terms of modalities, probably 75% of most hospitals now are digital from their plain films standpoint. We are moving closer to having 100% digitized images, and they continue to improve the techniques of these different modalities. The computerized tomography scanner is probably the biggest example of that. Just about the time that you make your million dollar–plus investment in a computerized tomography scanner, it is out of date.In the last 2 years, it was the 64-slice multidetector scanner, and as people got funding and bought those, the 128-slice scanners started to come onto the market. Already better things with less radiation exposure are coming out for better patient care and better accuracy.The interesting thing is that the techniques continue to evolve, even though the radiologists are not available. This is one of the things that has been really a big boon to our industry, that you will get a 3-, 4-, or 5-person practice in rural upstate New York that has a 64-slice scanner installed, and the hospital wants to do 3-dimensional cardiac imaging. This takes quite a bit of training from a radiologist's perspective because it is something that they have not been trained to do. So the technical capabilities are there, but the radiology group might not be able to do that. The technology is outpacing the availability of the radiologists or their training in a lot of cases.In reviewing the barriers, it might interest people to know that of those 400 employees that we have, more than 150 are dedicated to getting state licensure and credentialing our radiologists at hospitals across the United States.This process through the Joint Commission has become easier at some sites, but it is just a huge regulatory burden from our standpoint. It is, however, all done in the best interest of patient care, and so, we are letting the hospitals drive that. Credentialing is still done at hospitals on an individual basis, at an individual site, and they determine how they want to do that. We have a full range of credentialing processes from using a Joint Commission standard to being able to use reciprocity between Joint Commission facilities and all the way to full process credentialing that can take up to 6 to 8 months to get a physician privilege. We see the full spectrum of that and it often becomes a real burden to the radiologists who are there because the hospitals are a barrier to entry to providing telemedicine at the site.Many times that creates a situation in which the radiologist cannot stay at a hospital anymore because he or she is overtaxed or overburdened, and so the radiologist leaves and then the hospital suddenly becomes very creative about credentialing when it no longer has a radiologist.Malpractice insurance is not so much of an issue anymore. I think the malpractice insurance industry has warmed up a little bit to teleradiology because it finally has come to the realization that just about every study now is done via teleradiology. Almost every case is sent over some sort of digital mechanism, and it does not matter whether it is sent to the radiologist who is reading on a PACS system over at the imaging center across the street or whether it is being sent to Australia. They are still the same images, and the radiologist is still credentialed. It is still quality, and the malpractice insurance industry is finally warming up to that concept and understanding teleradiology a little bit more.From our perspective, international law has been tough because it is very sensitive about American radiologists practicing within international borders. A question that we get asked a lot is how many Australian studies do you read every year? The answer to that is none. One of the visa requirements for our radiologists is that they do not practice medicine within the country of Australia and the same thing is true in Zurich.So there is a lot of “hand holding” in international law. The countries of Switzerland and Australia have been good in allowing us to operate there, and there have been good recruiting advantages, as well as time zone advantages for us.One of the things that teleradiology or radiology opened itself up to is the perception of quality and where these images are going. It is very refreshing to hear that these are American, board-certified radiologists and whether something is being read in India, Switzerland, or Australia, these people have gone through the same standards that people who are sitting right in your local hospital have gone through. It just so happens that they live where they want to live, and it is made possible through technology. There has been some speculation about the perception of quality and where these images are going, but more and more people understand the concept, especially when the hospitals are the gatekeeper from a credentialing standpoint. They are the ones that are holding the standards for the people who are performing medicine within these facilities. We have been very much a supporter of the hospitals being the standard bearer and the keeper of the quality of the physicians who are reading.Finally, there are some workflow technologies that we developed, but these are all pieces of technology that NightHawk managed to adopt and bring together along with the human element so that we could manage workflow. The workflow is a tremendous thing and one thing that we have done very well is managed the “herding of cats.” There are all kinds of “cats” out there running around: the technology cat, and the hospitals with their rules and regulations, the state, the insurance companies, and the radiologists. All of these need to be gathered together so that they can be coalesced into one efficient workflow mechanism so that we can do the thousands of cases that we do every day for hospitals across the United States. Workflow is a very important part of that, which needs to be addressed when looking at a telemedicine program.Image size is becoming less and less of a limitation with large amounts of bandwidth available. NightHawk Radiology Services is the largest user of bandwidth in Australia. We are concerned about image size and how that affects our cost for buying bandwidth and also our turnaround time. The larger the image sets, the longer the turnaround times take, because when sending these huge image sets that are coming out of 64-slice scanners, it takes a long time to get there. When the situation involves emergency medicine, time becomes even more critical.The average turnaround time for us to return a study back on an emergent patient is 17 minutes, and a good portion of that time is taken up with just the transmission of images. Equipment and image quality are becoming less and less of an issue as more people get onboard with DICOM.With new advances, radiologists' training becomes one of the things we struggle with. We made a big investment in cardiac imaging, and we put all of our radiologists through the courses so that if there is emergency cardiac imaging in the middle of the night, should that become an emerging specialty, we will be able to serve our radiology group clients with that.Interaction with the attending physician is something that you are just going to have to build into your workflow models. That can be handled through technology, whether it be through IP telephone systems or some sort of central dialing location, which is how we have solved it. But that is an important part along with interaction with the patient and the fact that this technology is very technology dependent to get good images, especially when you start talking about cardiac imaging. To get good images is very important. It is not only the radiologists who need training on this new technology but also the technicians. That is one thing that we are struggling with in the hospitals, the technicians who can take these quality images.In terms of value added, when we look at this situation from a radiologist's perspective, obviously it is important to the quality of life, the individual hospitals or clinics, and subspecialty expertise. It is amazing how these small rural hospitals are now able to have Harvard-trained radiologists at their disposal any time of the day—highly trained radiologists available to very small rural facilities.Added efficiencies, from a profitability standpoint, are one issue, but then so is improved turnaround time. Collaboration is a huge issue. People need to be able to share ideas, be able to cache those together and ask, “Can you take a look at this study?” This is important from a patient quality standpoint and from a training standpoint. When you get built-in efficiencies, then those revenues start increasing as well.We talked about ability to reach underserved areas and decreased overhead. When we entered this market 5 or 6 years ago, the overhead at some of these hospitals was absolutely tremendous. They had what we called the “sneaker network,” where people were driving around in cars delivering films to radiologists, and those kinds of expenses were tremendous.The radiologists being able to expand their practice is just a huge part of the growth of using this technology in new markets. NightHawk is truly an international company servicing hospitals and other markets. We are in Canada now, and we are exploring other opportunities in other countries. There are people who are, especially from an expatriate standpoint, working in other countries such as China and Dubai, which have a lot of expatriates who would like to see American physicians be able to service them. These new markets are a tremendous opportunity for us.