Images on Demand: Why is Teleradiology so Underused?

Licensing, HIPPA Concerns are Biggest Barriers

By Julie Crawshaw

There may come a time when radiology will be practiced in a manner that allows any image to be available to any location at any time to any authorized user. At least that’s the vision of Tom Johnson, MD, Chief Medical Officer for the Dallas-based radiology practice management firm of U.S. Radiology Partners.

So why isn’t this the case now, when the required technology is already here? Johnson says the biggest thing holding teleradiology back is the licensing barrier. He points out that radiologists in one state don’t want their colleagues in another state interpreting images without a license to practice medicine where those images are taken. Johnson, who spent two years acquiring medical licenses in 12 states, tells of a California radiologist who spent four years and $60,000 to obtain licenses in 49 states. The only state he didn’t get a license for is New Hampshire, which requires that the practice be physically located there. Johnson points out that this "circle the wagons" approach isn’t unique to radiology. "Telemedicine includes psychiatry, dermatology, pathology—all of those things are threatening to medical societies everywhere."

The medical-legal issues are complex. "I’m a Texas radiologist," says Johnson. "Say I’m reading an image taken in Virginia, where I also have a license, and I miss something that leads to a lawsuit. Am I sued under Texas law or Virginia law? And is my professional liability insurance company going to cover me at the Texas rate or the Virginia rate? Somebody would have to decide where the venue would be."

Even with all these attendant problems, teleradiology can be the radiologists’ best friend. The whole idea behind it is putting the image in front of the expertise, which benefits radiologists practicing in small or rural communities who lack nearby colleagues for backup.

"You have 400 hospitals nationwide that don’t have radiologists on site, and a large number of radiologists congregated in the nice metropolitan areas," Johnson says. "Receiving the expertise at the site of care requires teleradiology."

A lot of practices are looking for backup in whatever form they can get it, and they are turning toward teleradiology as a solution. Johnson’s brother-in-law practices at a 60-bed hospital in a town with a population of 9000 people in western Nebraska. "He’s there by himself," Johnson says, "and his closest backup is 60 miles away. When he wants to leave town, he switches to telerad and gets coverage from Denver or Cheyenne, Wyoming."

In fact, the original driver for teleradiology was the physician’s convenience. Some practices now use a "nighthawk" system, in which one radiologist at a central location reads images sent from several facilities.

Johnson points to four additional factors that also fuel the drive for teleradiology.

A nationwide shortage of radiologists that began in the early-to-mid 1990s is creating even more pressure. Johnson says the radiology community actually closed down some residencies in response to the government’s attitude that U.S. medicine needed more generalists than specialists. The number of radiology residencies decreased by about 9% as medical imaging increased by 8-12% per year. "The number of radiographs and medical images has skyrocketed," Johnson says. "The technology has improved, and you get a lot more information. Everybody who comes into a hospital today gets at least one radiographic study."

An aging population full of baby boomers who now require more medical care. The demand for medical imaging is actually growing faster than the general medical demands. Ten years ago, only 30-40% of women got mammograms. Now 60-70% do, and somebody’s got to read those x-rays.

The days of an 8-10 hour work day for radiologists have ended. Technological sophistication and demands being placed on the entire medical care system today mean radiology practices now require coverage 24 hours a day, seven days a week. "Instead of covering our hospitals in Dallas with 10 radiologists, we now need 12 or 15 to cover those same facilities," Johnson says.

More radiologists are retiring early because they don’t want to work more to have less money. Many radiologists who began practicing during the fat and happy days of the 1970s, 1980s, and early 1990s when fee-for-service indemnification plans were in place, have decided they don’t need to continue practice under today’s more restrictive, time-consuming reimbursement climate. A radiologist accustomed to earning $300,000 a year, doing an 8-to-5 job and now 55 years old, is being called back to the hospital at 9 p.m., again at 11 p.m., and maybe at 2 a.m., all for less money than before. "It used to be that physicians practiced until they were 65 or 70 years old," Johnson says. "Many of those who were the recipients of a very good previous 20 years during which they were able to build up their assets are bailing out at 50 to 55."

Right now, reimbursement is not an issue because Medicare reimburses for teleradiology as do most insurances. But successfully wooing new radiologists is another story. "This is the tightest radiology market I’ve ever seen," Johnson comments. "It’s hard even to get a radiologist to go to a nice place for a good salary, let alone to somewhere in the snowbelt for less money."