- Email: [email protected]
Nighthawks Across a Flat World: Emergency Radiology in the Era of Globalization
NEWS AND PERSPECTIVE
Introduction
Annals News and Perspective explores topics relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their
management will be rare. By design, it will not be a ‘‘breaking news’’ section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. If you have any feedback about this section, please forward it to us at [email protected].
0196-0644/$-see front matter Copyright © 2007 by the American College of Emergency Physicians.
NIGHTHAWKS ACROSS A FLAT WORLD: EMERGENCY RADIOLOGY IN THE ERA OF GLOBALIZATION By William B. Millard, PhD Special Contributor to Annals News and Perspective Ordering a computed tomography (CT) reading at 3 AM used to mean waking up a groggy colleague from the radiology department, assuming one was available locally at all. In about a quarter of the hospitals in the United States, it now means transmitting an image partway around the world in return for a rapid reading, a confirming report the next day, and a preview of medicine’s conceivable future. Along with contributing timely information to clinical decisions, global teleradiology suggests that the house of medicine is becoming less a single structure than a network of functions. Like many other diagnostic procedures, radiologic studies combine a high-touch component, involving direct contact with the patient, and a high-thought interpretive component; teleradiology mediates the 2 through high technology. Now that the hands-on and cognitive aspects of image studies are discrete and separable, observers say, the relevant specialties can engage in further subspecialization, freeing some practitioners from performance-dulling working conditions while giving others access to more accurate specialist consultations. It should follow logically, but does not automatically, that these changes will also produce benefits for patients. Teleradiology overcame the technical barriers to rapid remote interpretation about a decade ago, recalls R. Nick Bryan, MD, PhD, professor and chairman of the department of radiology at the University of Pennsylvania School of Medicine, Philadelphia, PA, and a past president of the Radiological Society of North America. Related technical developments—the digitalization of most clinical images in picture archiving and communication systems (PACS) using the Digital Imaging and Communications in Medicine (DICOM) image format standard, the wide availability of broadband Internet connections, and the proliferation of affordable workstations—
Volume , . : November
mean that an emergency department (ED) no longer needs to lean on its local radiologic colleagues for a grueling night call. This is a particular boon in areas where the caseload outweighs the local professional workforce. Considering the chronic national shortage of radiologists, such areas are not limited to the hinterlands.
AROUND THE CORNER OR AROUND THE WORLD Once a radiologist did not have to be in the same building as the physician requesting a read, it was only a matter of time before these colleagues no longer had to be on the same continent. According to the field’s foundational legend, former Long Beach Memorial Medical Center neuroradiologist William G. Bradley, Jr., MD, PhD, was lecturing in China when his office sought his help with a difficult early morning case, which he handled through his center’s new PACS system and a local Internet café. Struck by his fresh daytime perspective, he speculated to a colleague that the time-zone differential could help reduce sleep loss and burnout. Bradley and the colleague, Paul E. Berger, MD, ended up launching a firm replacing bleary-eyed radiologists with fully alert ones situated 8 to 12 time zones away. The name of the field’s pioneer group has acquired the status of a generic term, describing both overseas and domestic “nighthawks.” Coeur d’Alene, Idaho-based NightHawk Radiology Services stations about a quarter of its radiologists in Sydney, Australia, a quarter in Zurich, Switzerland, and half within the US. Its success has attracted multiple competitors.1 The scale of all these operations is not yet large: NightHawk has grown from 2 physicians to 120, and some practices comprise ten or fewer.
Annals of Emergency Medicine 545
News and Perspective Economies of scale and energetic, patient credentialing support for its physicians (all board certified) allow NightHawk to serve nearly 1,400 U.S. hospitals. The average NightHawk radiologist, says co-founder/president/CEO Berger, has 38 state licenses and is on staff at over 500 hospitals. Ninety percent of the firm’s workload is CT scans; ultrasound makes up 4%-5%, and nuclear medicine, magnetic resonance imaging, and plain films 1%-2% each. “It has created a new practice model that a number of people, particularly young people, are interested in,” comments Dr. Bryan, noting that the flexible work hours and practice locations have contributed to concentration of talent, both geographically and institutionally, within the specialty. “It’s just an alternative way of delivering the service. It doesn’t eliminate jobs, but it could redistribute the jobs from traditional practices to these larger, at least partially remote companies.” Robert M. Wachter, MD, of the University of California at San Francisco Department of Hospital Medicine, views international teleradiology as a fortuitous entrepreneurial response to perceived needs. “Nobody wired radiology or got rid of films [and] replaced them with pixels, thinking that this would facilitate readings coming from Bangalore or Sydney,” he says. “They did it so that you could read your film on the 14th floor of the building without going down to the third floor, or so that the radiologist could read the film at 3 AM without schlepping in.” Like other unplanned phenomena, this field has grown quickly enough to catch related institutions unprepared. Along with its obvious benefits come a host of questions about accountability, clinical context, economics, professional culture, and the quality of patient care.
GHOSTS, WET READS, AND SILOS What strikes many emergency physicians as a common sense service—and, under certain clinical circumstances, a godsend— raises concerns in other quarters. The relevant professional organizations in the US, the American College of Emergency Physicians (ACEP)2 and the American College of Radiology (ACR),3 both recognize the value of global teleradiology, provided the legal entities involved observe standards for licensing, institutional credentialing, liability coverage, and strict quality assurance measures. In May 2006, the ACR also revised its official statement43 to incorporate a new paragraph cautioning about sweatshop-style arrangements overseas, particularly discrepancies between the responsible signature on a report and the identity of the person actually examining the images (“ghost reporting” or “ghost reads”). Arl Van Moore, Jr., MD, chairman of the ACR’s Board of Chancellors and head of the group’s task force on international teleradiology, distinguishes acceptable and unacceptable nighthawk practices, noting that the marketplace’s answer to the strains of nocturnal shiftwork makes sense but requires safeguards. “The biggest concern was the qualifications,” he says, “because when you’re half a world away, you have absolutely no idea who the individual is.” 546 Annals of Emergency Medicine
Ghost reporting, as Bryan emphatically points out, is “unethical, unprofessional, and illegal.” Despite rumors, documented evidence of ghost reads is scarce, the sweatshop metaphor is far from literal, and several commentators regard the ACR’s caveat more as a preventive measure aimed at a hypothetical scenario than a response to known abuses. NightHawk’s Berger –who presumably would have as much to gain as anyone from confirmed reports that competitors were violating the law—states categorically, “I am absolutely unaware of any specific people doing that anywhere. . .. In this day and age I cannot imagine a hospital or radiology group contracting with [unlicensed readers]. The legal liability would be enormous.” Centers for Medicare and Medicaid Services regulations impose an additional condition on international teleradiology by limiting payment to providers within the US. Since insurers generally follow Medicare’s lead, overseas nighthawks are currently limited to preliminary (“wet”) reads, comparable in some respects to initial reads by residents; a secondary or “dry” read by a domestic radiologist is necessary for a final report and for reimbursement. The cost of the initial wet read is a physician-to-physician transaction, excluded from bills to the payer or patient. As the terminology derived from film-based radiography implies, duplicate reads are nothing new. They are common in mammography, in resident training, and in the ACR’s RadPeer program providing anonymous peer review for quality assurance. However, they are not the norm in emergency practice. Discrepancies between initial and secondary reads are not widespread, but they require some orderly process of resolution. The NightHawk firm, according to Berger, uses routine discrepancy reports and a tiebreaking third reader if interpretations still differ after repeat reads and consultation between the original 2 readers.
NO QUALITY CONTENTION To date, informed commentators have been satisfied with the quality of nighthawk readings. One large peer-reviewed study of discordancy rates in after-hours general teleradiology5 found that primary and confirming reads differed in an overall average of 1.09% of cases (95% confidence interval, 0.70% to 1.41%). The specific topic of nocturnal international teleradiology is only beginning to receive study, but an early report indicates a small difference in reinterpretation rates between overnight resident readings (2.3% of which were changed in morning overreads by an attending radiologist) and overseas nighthawk readings (2.5%).6 These disagreement rates are consistent with the rates of 2%-3% found between general radiologists (working either as nighthawks or on call in addition to daytime duties) and neuroradiologic specialists in evaluating emergency head CT scans.7 James Killeen, MD, assistant clinical professor at the University of California at San Diego Medical Center’s Division of Emergency Medicine and a co-author of the recent study of overseas nighthawks’ reinterpretation rates, observes that the Volume , . : November
News and Perspective overseas service solved several problems his department was facing. “Our main concern was the number of rereads being done,” he recounts, noting the need for callbacks to patients for admission or other studies after official daytime reads revealed further information. Changes in Residency Review Committee policies restricting residents’ hours also forced faculty to make up the time that residents could not practice, exacerbating workforce shortages and cutting into sleep. Killeen’s department has engaged international nighthawks for initial confirmation or correction of residents’ results, finding the results timely and accurate. Another recurrent concern with teleradiology involves the isolation of image reading from other aspects of the clinical context. No telecommunications arrangement is as informationrich as the human contact with patients or the informal consultations that colleagues share in the halls of a single institution, but a well-designed diagnostic protocol connects radiologic images to the patient record and includes real-time telephone consultations instead of isolating the radiologist and other physicians in separate silos. At the University of California San Diego, the nighthawks’ reports are integrated into a homegrown electronic medical records system designed by Killeen, a medical informatics aficionado who has also contributed to the department’s Wireless Internet Information System for Medical Response in Disasters (WIISARD). “One of things we like to pride ourselves on is the redundancy, not only for our electronic medical records program but for the way we set up our radiology system,” Killeen says. “We don’t like to keep our radiologists— either the ones here or the ones abroad—in a vacuum.”
encryption as strong as the systems used in online banking is standard: at least 128-bit, ranging as high as 1024-bit. “So far so good,” notes Wachter, with a touch of skepticism about promises of confidentiality and actual practices, online or off. “I mean, so does Visa tell me that’s true with my [financial] records, and then every few days I read about another spillage of 5 million records.” In any event, he adds, the digital realm is not the sole threat to confidentiality. “I don’t think it takes an international transmission to make these sorts of movements of data risky. It may very well be that they’re more careful than when they get shipped across town for a payment review.” Barry B. Cepelewicz, MD, JD, physician-attorney and partner at Meiselman, Denlea, Packman, Carton, & Eberz, a law firm in White Plains, NY, that represents both teleradiology practices and health care providers using their services, advises clients to consult with their malpractice carriers about ways to reduce exposure. Contracts should include explicit indemnification and “hold harmless” clauses with respect to the parties’ obligations regarding HIPAA compliance, identity and credentialing of readers, verification that image transmission has succeeded, disclosure to patients, and other variables that could conceivably come up at trial.8 Most patients, he has found, assume that diagnostic images and other records are interpreted and maintained at the same hospital they have visited. Patients are often surprised or confused when they learn about international outsourcing. Disclosure policies that might be appropriate to establish informed consent for elective procedures are often not applicable in the ED setting. Case law and legislation in this new area have not established clear guidelines.
CHASING GHOSTS? HOW HIP TO HIPAA? When either detailed records or individual images travel across national boundaries, privacy is a paramount consideration. Health Insurance Portability and Accountability Act (HIPAA) compliance is a common selling point for teleradiology practices here and abroad. NightHawk’s Berger, while describing himself as a “card-carrying techno-peasant” who relies on his information technology personnel for assurance in this area, reports, “We’ve been HIPAA-compliant since day 1. That has not been an issue.” However, to Moore of the ACR, HIPAA compliance is not a cut-and-dried question. “Even if you’re an American citizen practicing in another country, you’re really subject to the laws and jurisdiction of that country,” he notes. “I’m not aware of any country that has as strong a privacy law as does the US.” Moore emphasizes that teleradiology firms need to adhere to the rigorous US jurisdiction. Maintaining the security required by HIPAA requires both technical and procedural measures. Killeen’s department uses a server-to-server virtual private network with firewalls at both ends. In his view, secured passwords rotated every 90 days are a good safeguard against fraudulent access, and many hospitals’ legacy systems already use that precaution. Across the industry, Volume , . : November
In the event of malpractice allegations, Cepelewicz says, local physicians or hospitals could conceivably be held negligent not only for their own conduct, but also for the choice of a nighthawk group or for its actions. He cautions that contract enforceability overseas may be harder in practice than in theory, leaving domestic physicians as the target of choice. “These contractual provisions, as much as we hope they will help, you never know how much they’re going to help until you’re sucked into litigation,” he advises. “The big problem is that many of these entities are out of reach. You can have all these great provisions that seem to offer protection, but at the end of the day, if these guys are in Australia and they can’t be reached, then you have problems. . .. What you should try to do is show a jury that you acted reasonably in selecting the teleradiology entity, and that by including all these contractual provisions relating to quality assurance, you thought of the issues. . . and [if] they were breached by the other side -- ‘Well, we should not be blamed for that.’ ” Representative Edward Markey (D-Mass.), founder of the bipartisan Congressional Privacy Caucus, has sponsored several efforts to require patients’ consent before medical records can leave the country. His Stop Taking Our Health Privacy Act of 2003 (HR 1709) expired in the Subcommittee on EmployerAnnals of Emergency Medicine 547
News and Perspective Employee Relations; the Health Information Technology Promotion Act of 2006 (HR 4157), with his privacy-related amendment, passed the House in the 109th Congress but never became law. Whether HIPAA as currently worded remains the chief privacy safeguard or future regulations become more rigorous, clear communication about data security with both patients and hospital administrators appears prudent.
THE DREADED O-WORD AND THE FRAGMENTED FUTURE The very term “outsourcing” is controversial in this field. Berger and his colleagues at NightHawk explicitly steer clear of the word, noting that it always connotes cheapness and often implies corner-cutting. In contrast, he says, NightHawk’s radiologists are among the most highly paid in the US. Applications for positions are soaring, and the company has carefully selected urban practice locations for a quality of life that will appeal to American talent: Sydney and Zurich abroad, San Francisco for its first centralized US reading center. Others have frankly leveraged geographical differences in labor costs. In 2003, Bangalore-based Wipro, Ltd., which provides communications services to a wide range of industries, controversially “tested the waters” (in one executive’s words) by outsourcing some scans from Massachusetts General Hospital and several other institutions to Indian radiologists who lacked US licensing and board certification and earned 5-figure incomes. The experiment attracted attention mixed with alarm in the medical,9 trade,10 and lay11 press, and it was shortlived.12 However, Wipro is still engaged in what it calls “clinical process outsourcing,” an outgrowth of the 2003 experiment, including image interpretation and 3D image processing. Susheel Ladwa, an executive in Wipro’s North American health care practice, comments, “We have not received any quality complaints or issues in our clinical process outsourcing business. It’s been a growing business for us.” Wachter notes the implicit nationalism in the concerns that global teleradiology has evoked: “The bias in the industry was, ‘How can they be any good? These are docs trained in another country, out of our system. . .They’re going to undercut our people on price by a factor of 10, but at a cost in terms of quality and safety that is unacceptable.’ And that is a predictable argument that happens in every industry where outsourcing begins. . .You have no idea, in the absence of measurable data, whether it is absolutely true or predictable guildlike behavior by provider groups that are protecting turf and income.” As those measurable data accumulate in scholarly publications, it may become possible to determine whether the ACR’s caution is warranted. For the moment, the question appears unanswerable. Image interpretation practices have been found to vary widely in community hospital EDs,13 and optimal patient care calls for the broadest and most efficient access to high-level expertise, wherever it is found. The general assumption in the US is that American licensing and board certification are the default standard, but as technology drives 548 Annals of Emergency Medicine
medicine toward a more borderless world, Wachter wonders whether apprehensions about outsourcing include some degree of xenophobia and misplaced nostalgia along with legitimate concern over quality. “All of us old guys can lament the ending of the days of the giants,” he says, reflecting on William Osler’s legendary olfactory diagnostic skills and on contemporary meditations by Abraham Verghese, MD, about onscreen icons replacing living patients as the object of diagnostic attention. “Lament all we want, these skills of listening and touching and smelling are rapidly being replaced—whether we think about doing it from a thousand miles away or doing it in the same room with the patient— by technological adjuncts.” The geographic separation between different specialists, he finds, may be less troubling than the schism between embodied patients and disembodied data, a pervasive trend whether practice sites are unitary or dispersed. Wachter adds that a medical system adjusting to the economic processes described in Thomas Friedman’s The World Is Flat14 should strive not to provide top-quality services to everyone – an effort that has incurred tangible downsides, from major corporate bankruptcies to the exclusion of much of the population from coverage— but to give patients the best value, defined as “essentially quality or safety divided by cost.” The winners in the future medical environment “may increasingly be the highest-value providers. . . the Toyota Camrys rather than the Lamborghinis.”
THE GLOBAL VILLAGE The global organizational model for radiology may ultimately join other outsourcing phenomena, plus remote laboratory work, medical tourism, electronic intensive care units, and remote surgery, in making national borders irrelevant to the widespread provision of Camry-level care.15 Wachter speculates about an international equivalent of TJC helping patients worldwide make informed decisions about value for differential cost—answers to the persistent question, “How do you measure the quality of care, not just from the provider in Bangalore, but from the provider in Boca Raton?” Arl Van Moore and Paul Berger have different levels of enthusiasm for teleradiology, but they agree about its effects on the practice environment, particularly as it raises standards for small and remote settings. Berger is enthusiastic about the tendency toward greater specialization. “These doctors are in essence specialists in emergency radiology,” he says, “because that’s all they do. And like anything else, when you do a lot of something and focus your attention on one particular area, you get very, very, very good at it.” “A 3-man radiology practice,” Moore notes, “can’t have an interventional radiologist, a neuroradiologist, a pediatric radiologist, a chest radiologist, an abdomen radiologist, a practicing mammographer, and have those in enough depth to be able to provide 7-day, 24-hour coverage as needed. So those individuals tend to be jack-of-all-trades and master of none, just by the nature of the practice locale. I think (teleradiology) Volume , . : November
News and Perspective provides an opportunity for those groups to affiliate with larger groups at a level of subspecialty expertise that heretofore has not been available for them.” Moore, too, views the development of international teleradiology in Friedmanian terms: the economy now extends beyond national borders, the medical profession is following economic incentives as any other industry does, and radiology is merely the first specialty to adapt to globalization, with its emergency subspecialty leading the way. Friedman, he notes, is “talking about migrating to a global economy. It’s occurring; it’s just that different planes are migrating at different rates. . .. Radiology’s not the only one there; we just happen to be first.”
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doi:10.1016/j.annemergmed.2007.09.012
REFERENCES
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1. Radiology PACS Administrator Site. Twelve major teleradiology firms are compared. Available at: http://www.pacsadminforum.com/ Nightwark-Teleradiology-Services/PACS-teleradiolgy-services. html. Accessed August 28, 2007. 2. ACEP Emergency Medicine Practice Subcommittee on Contemporaneous Interpretation of CT Scans. Radiologic imaging and teleradiology in the emergency department. Available at: http://www.acep.org/webportal/PracticeResources/issues/admin/ radioimagingteleradiology.htm. Accessed August 28, 2007. 3. Moore AV, Allen B Jr, Campbell SC, et al. Report of the ACR Task Force on International Radiology. American College of Radiology, 2004-2007. Available at: http://www.acr.org/Secondary MainMenuCategories/BusinessPracticeIssues/Teleradiology/ ReportoftheACRTaskForceonInternationalTeleradiologyDoc3.aspx. Accessed August 29, 2007. 4. American College of Radiology. Revised statement on the interpretation of radiology images outside the United States. May
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2006. Available at: http://www.acr.org/SecondaryMainMenu Categories/quality_safety/guidelines/GeneralDiagnosticRadiology/ RevisedStatementontheInterpretationofRadiologyImagesOutside theUnitedStatesDoc11.aspx. Accessed August 28, 2007. Wong WS, Roubal I, Jackson DB, et al. Outsourced teleradiology imaging services: an analysis of discordant interpretation in 124,870 cases. J Am Coll Radiol. 2005;2(6):478-84. Venieris PY, Chan TC, Killeen J. Multicenter trial assessing the impact of an overnight international “nighthawk” teleradiology system on CT radiology re-interpretation rates. Ann Emerg Med. 2006;48(Suppl):S16. Erly WK, Ashdown BC, Lucio RW 2nd, et al. Evaluation of emergency CT scans of the head: is there a community standard? Am J Roentgenol. 2003;180:1727-1730. Cepelewicz BB. Telelegalities. Imaging Economics, June 2003. Available at: http://www.imagingeconomics.com/issues/articles/ 2003-06_13.asp. Accessed August 31, 2007. Wachter RM. International teleradiology. N Engl J Med. 2006;354: 662-663. Brice J. Globalization comes to radiology. Diagnostic Imaging. Nov. 2003. Available at: http://web.mit.edu/outsourcing/class1/ DI-radiology-1.htm. Accessed August 29, 2007. Pollack A. Who’s reading your X-ray? New York Times 2003 (Nov. 16), p. BU01; Available at: http://ibs.colorado.edu/⬃kuhnr/socy2091/handouts/xray.htm. Accessed August 29, 2007. Stein R. Hospital services performed overseas. Washington Post, April 24, 2005, p. A01. Saketkhoo DD, Bhargavan M, Sunshine JH, et al. Emergency department image interpretation services at private community hospitals. Radiology. 2004;231:190-197. Friedman TL. The World Is Flat: A Brief History of the Twenty-first Century. NY: Farrar, Straus and Giroux, 2005. Wachter RM. The ”dis-location” of U.S. medicine: the implications of medical outsourcing N Engl J Med. 2006;354:661-665.
THE TRIALS AND TRIBULATIONS OF HEALTH INFORMATION SHARING: THE TURBULENT RISE OF THE RHIO By Jan Greene Special Contributor to Annals News & Perspective Any given emergency department (ED) patient can have dozens of medical record scattered across a city or a region, leading to inefficient health care resource use and general poor care, but efforts to fix the problem have failed time and again. Information sharing, creating one medical record that follows the patient wherever he or she presents, is the technological holy grail sought by dozens of health information exchange projects around the country. Called Regional Health Information Organizations (RHIOs), they have different organizational structures, goals, funding sources and membership. But what they have in common, despite the enthusiasm for the potential good they could do, is a financial uphill battle. They are the second generation of a trend that failed utterly in the 1990s, then referred to as Community Health Information Networks (CHINs). Over the past few years, improvements in health information technology, increasing Volume , . : November
costs of care and the quality movement have nourished resurgence in the trend, with the hope that growing conditions are better this time around. There are a few exchanges that have found a business model to sustain them and an unusual level of cooperation among the parties in their markets, notably in Indianapolis, Spokane and Colorado. But the headlines have been more focused on some highly public failures. An exchange in Santa Barbara, CA, was touted as a national model and had high-powered support from the California HealthCare Foundation and David Brailer, the former head of health information technology for the federal government. But the effort lost momentum and the exchange died. More recently, a health data exchange in Portland, OR, stalled, reportedly because participants balked at the price tag. Meanwhile, at least 165 health information exchange projects exist in 49 states and the District of Columbia, Annals of Emergency Medicine 549
Introduction
Annals News and Perspective explores topics relevant to emergency medicine, in particular those in which our specialty interacts with the political, ethical, sociologic, legal and business spheres of our society. Discussion of specific clinical problems and their
management will be rare. By design, it will not be a ‘‘breaking news’’ section with the latest (and undigested) developments, but instead a reflective investigation of recent and emerging trends. If you have any feedback about this section, please forward it to us at [email protected].
0196-0644/$-see front matter Copyright © 2007 by the American College of Emergency Physicians.
NIGHTHAWKS ACROSS A FLAT WORLD: EMERGENCY RADIOLOGY IN THE ERA OF GLOBALIZATION By William B. Millard, PhD Special Contributor to Annals News and Perspective Ordering a computed tomography (CT) reading at 3 AM used to mean waking up a groggy colleague from the radiology department, assuming one was available locally at all. In about a quarter of the hospitals in the United States, it now means transmitting an image partway around the world in return for a rapid reading, a confirming report the next day, and a preview of medicine’s conceivable future. Along with contributing timely information to clinical decisions, global teleradiology suggests that the house of medicine is becoming less a single structure than a network of functions. Like many other diagnostic procedures, radiologic studies combine a high-touch component, involving direct contact with the patient, and a high-thought interpretive component; teleradiology mediates the 2 through high technology. Now that the hands-on and cognitive aspects of image studies are discrete and separable, observers say, the relevant specialties can engage in further subspecialization, freeing some practitioners from performance-dulling working conditions while giving others access to more accurate specialist consultations. It should follow logically, but does not automatically, that these changes will also produce benefits for patients. Teleradiology overcame the technical barriers to rapid remote interpretation about a decade ago, recalls R. Nick Bryan, MD, PhD, professor and chairman of the department of radiology at the University of Pennsylvania School of Medicine, Philadelphia, PA, and a past president of the Radiological Society of North America. Related technical developments—the digitalization of most clinical images in picture archiving and communication systems (PACS) using the Digital Imaging and Communications in Medicine (DICOM) image format standard, the wide availability of broadband Internet connections, and the proliferation of affordable workstations—
Volume , . : November
mean that an emergency department (ED) no longer needs to lean on its local radiologic colleagues for a grueling night call. This is a particular boon in areas where the caseload outweighs the local professional workforce. Considering the chronic national shortage of radiologists, such areas are not limited to the hinterlands.
AROUND THE CORNER OR AROUND THE WORLD Once a radiologist did not have to be in the same building as the physician requesting a read, it was only a matter of time before these colleagues no longer had to be on the same continent. According to the field’s foundational legend, former Long Beach Memorial Medical Center neuroradiologist William G. Bradley, Jr., MD, PhD, was lecturing in China when his office sought his help with a difficult early morning case, which he handled through his center’s new PACS system and a local Internet café. Struck by his fresh daytime perspective, he speculated to a colleague that the time-zone differential could help reduce sleep loss and burnout. Bradley and the colleague, Paul E. Berger, MD, ended up launching a firm replacing bleary-eyed radiologists with fully alert ones situated 8 to 12 time zones away. The name of the field’s pioneer group has acquired the status of a generic term, describing both overseas and domestic “nighthawks.” Coeur d’Alene, Idaho-based NightHawk Radiology Services stations about a quarter of its radiologists in Sydney, Australia, a quarter in Zurich, Switzerland, and half within the US. Its success has attracted multiple competitors.1 The scale of all these operations is not yet large: NightHawk has grown from 2 physicians to 120, and some practices comprise ten or fewer.
Annals of Emergency Medicine 545
News and Perspective Economies of scale and energetic, patient credentialing support for its physicians (all board certified) allow NightHawk to serve nearly 1,400 U.S. hospitals. The average NightHawk radiologist, says co-founder/president/CEO Berger, has 38 state licenses and is on staff at over 500 hospitals. Ninety percent of the firm’s workload is CT scans; ultrasound makes up 4%-5%, and nuclear medicine, magnetic resonance imaging, and plain films 1%-2% each. “It has created a new practice model that a number of people, particularly young people, are interested in,” comments Dr. Bryan, noting that the flexible work hours and practice locations have contributed to concentration of talent, both geographically and institutionally, within the specialty. “It’s just an alternative way of delivering the service. It doesn’t eliminate jobs, but it could redistribute the jobs from traditional practices to these larger, at least partially remote companies.” Robert M. Wachter, MD, of the University of California at San Francisco Department of Hospital Medicine, views international teleradiology as a fortuitous entrepreneurial response to perceived needs. “Nobody wired radiology or got rid of films [and] replaced them with pixels, thinking that this would facilitate readings coming from Bangalore or Sydney,” he says. “They did it so that you could read your film on the 14th floor of the building without going down to the third floor, or so that the radiologist could read the film at 3 AM without schlepping in.” Like other unplanned phenomena, this field has grown quickly enough to catch related institutions unprepared. Along with its obvious benefits come a host of questions about accountability, clinical context, economics, professional culture, and the quality of patient care.
GHOSTS, WET READS, AND SILOS What strikes many emergency physicians as a common sense service—and, under certain clinical circumstances, a godsend— raises concerns in other quarters. The relevant professional organizations in the US, the American College of Emergency Physicians (ACEP)2 and the American College of Radiology (ACR),3 both recognize the value of global teleradiology, provided the legal entities involved observe standards for licensing, institutional credentialing, liability coverage, and strict quality assurance measures. In May 2006, the ACR also revised its official statement43 to incorporate a new paragraph cautioning about sweatshop-style arrangements overseas, particularly discrepancies between the responsible signature on a report and the identity of the person actually examining the images (“ghost reporting” or “ghost reads”). Arl Van Moore, Jr., MD, chairman of the ACR’s Board of Chancellors and head of the group’s task force on international teleradiology, distinguishes acceptable and unacceptable nighthawk practices, noting that the marketplace’s answer to the strains of nocturnal shiftwork makes sense but requires safeguards. “The biggest concern was the qualifications,” he says, “because when you’re half a world away, you have absolutely no idea who the individual is.” 546 Annals of Emergency Medicine
Ghost reporting, as Bryan emphatically points out, is “unethical, unprofessional, and illegal.” Despite rumors, documented evidence of ghost reads is scarce, the sweatshop metaphor is far from literal, and several commentators regard the ACR’s caveat more as a preventive measure aimed at a hypothetical scenario than a response to known abuses. NightHawk’s Berger –who presumably would have as much to gain as anyone from confirmed reports that competitors were violating the law—states categorically, “I am absolutely unaware of any specific people doing that anywhere. . .. In this day and age I cannot imagine a hospital or radiology group contracting with [unlicensed readers]. The legal liability would be enormous.” Centers for Medicare and Medicaid Services regulations impose an additional condition on international teleradiology by limiting payment to providers within the US. Since insurers generally follow Medicare’s lead, overseas nighthawks are currently limited to preliminary (“wet”) reads, comparable in some respects to initial reads by residents; a secondary or “dry” read by a domestic radiologist is necessary for a final report and for reimbursement. The cost of the initial wet read is a physician-to-physician transaction, excluded from bills to the payer or patient. As the terminology derived from film-based radiography implies, duplicate reads are nothing new. They are common in mammography, in resident training, and in the ACR’s RadPeer program providing anonymous peer review for quality assurance. However, they are not the norm in emergency practice. Discrepancies between initial and secondary reads are not widespread, but they require some orderly process of resolution. The NightHawk firm, according to Berger, uses routine discrepancy reports and a tiebreaking third reader if interpretations still differ after repeat reads and consultation between the original 2 readers.
NO QUALITY CONTENTION To date, informed commentators have been satisfied with the quality of nighthawk readings. One large peer-reviewed study of discordancy rates in after-hours general teleradiology5 found that primary and confirming reads differed in an overall average of 1.09% of cases (95% confidence interval, 0.70% to 1.41%). The specific topic of nocturnal international teleradiology is only beginning to receive study, but an early report indicates a small difference in reinterpretation rates between overnight resident readings (2.3% of which were changed in morning overreads by an attending radiologist) and overseas nighthawk readings (2.5%).6 These disagreement rates are consistent with the rates of 2%-3% found between general radiologists (working either as nighthawks or on call in addition to daytime duties) and neuroradiologic specialists in evaluating emergency head CT scans.7 James Killeen, MD, assistant clinical professor at the University of California at San Diego Medical Center’s Division of Emergency Medicine and a co-author of the recent study of overseas nighthawks’ reinterpretation rates, observes that the Volume , . : November
News and Perspective overseas service solved several problems his department was facing. “Our main concern was the number of rereads being done,” he recounts, noting the need for callbacks to patients for admission or other studies after official daytime reads revealed further information. Changes in Residency Review Committee policies restricting residents’ hours also forced faculty to make up the time that residents could not practice, exacerbating workforce shortages and cutting into sleep. Killeen’s department has engaged international nighthawks for initial confirmation or correction of residents’ results, finding the results timely and accurate. Another recurrent concern with teleradiology involves the isolation of image reading from other aspects of the clinical context. No telecommunications arrangement is as informationrich as the human contact with patients or the informal consultations that colleagues share in the halls of a single institution, but a well-designed diagnostic protocol connects radiologic images to the patient record and includes real-time telephone consultations instead of isolating the radiologist and other physicians in separate silos. At the University of California San Diego, the nighthawks’ reports are integrated into a homegrown electronic medical records system designed by Killeen, a medical informatics aficionado who has also contributed to the department’s Wireless Internet Information System for Medical Response in Disasters (WIISARD). “One of things we like to pride ourselves on is the redundancy, not only for our electronic medical records program but for the way we set up our radiology system,” Killeen says. “We don’t like to keep our radiologists— either the ones here or the ones abroad—in a vacuum.”
encryption as strong as the systems used in online banking is standard: at least 128-bit, ranging as high as 1024-bit. “So far so good,” notes Wachter, with a touch of skepticism about promises of confidentiality and actual practices, online or off. “I mean, so does Visa tell me that’s true with my [financial] records, and then every few days I read about another spillage of 5 million records.” In any event, he adds, the digital realm is not the sole threat to confidentiality. “I don’t think it takes an international transmission to make these sorts of movements of data risky. It may very well be that they’re more careful than when they get shipped across town for a payment review.” Barry B. Cepelewicz, MD, JD, physician-attorney and partner at Meiselman, Denlea, Packman, Carton, & Eberz, a law firm in White Plains, NY, that represents both teleradiology practices and health care providers using their services, advises clients to consult with their malpractice carriers about ways to reduce exposure. Contracts should include explicit indemnification and “hold harmless” clauses with respect to the parties’ obligations regarding HIPAA compliance, identity and credentialing of readers, verification that image transmission has succeeded, disclosure to patients, and other variables that could conceivably come up at trial.8 Most patients, he has found, assume that diagnostic images and other records are interpreted and maintained at the same hospital they have visited. Patients are often surprised or confused when they learn about international outsourcing. Disclosure policies that might be appropriate to establish informed consent for elective procedures are often not applicable in the ED setting. Case law and legislation in this new area have not established clear guidelines.
CHASING GHOSTS? HOW HIP TO HIPAA? When either detailed records or individual images travel across national boundaries, privacy is a paramount consideration. Health Insurance Portability and Accountability Act (HIPAA) compliance is a common selling point for teleradiology practices here and abroad. NightHawk’s Berger, while describing himself as a “card-carrying techno-peasant” who relies on his information technology personnel for assurance in this area, reports, “We’ve been HIPAA-compliant since day 1. That has not been an issue.” However, to Moore of the ACR, HIPAA compliance is not a cut-and-dried question. “Even if you’re an American citizen practicing in another country, you’re really subject to the laws and jurisdiction of that country,” he notes. “I’m not aware of any country that has as strong a privacy law as does the US.” Moore emphasizes that teleradiology firms need to adhere to the rigorous US jurisdiction. Maintaining the security required by HIPAA requires both technical and procedural measures. Killeen’s department uses a server-to-server virtual private network with firewalls at both ends. In his view, secured passwords rotated every 90 days are a good safeguard against fraudulent access, and many hospitals’ legacy systems already use that precaution. Across the industry, Volume , . : November
In the event of malpractice allegations, Cepelewicz says, local physicians or hospitals could conceivably be held negligent not only for their own conduct, but also for the choice of a nighthawk group or for its actions. He cautions that contract enforceability overseas may be harder in practice than in theory, leaving domestic physicians as the target of choice. “These contractual provisions, as much as we hope they will help, you never know how much they’re going to help until you’re sucked into litigation,” he advises. “The big problem is that many of these entities are out of reach. You can have all these great provisions that seem to offer protection, but at the end of the day, if these guys are in Australia and they can’t be reached, then you have problems. . .. What you should try to do is show a jury that you acted reasonably in selecting the teleradiology entity, and that by including all these contractual provisions relating to quality assurance, you thought of the issues. . . and [if] they were breached by the other side -- ‘Well, we should not be blamed for that.’ ” Representative Edward Markey (D-Mass.), founder of the bipartisan Congressional Privacy Caucus, has sponsored several efforts to require patients’ consent before medical records can leave the country. His Stop Taking Our Health Privacy Act of 2003 (HR 1709) expired in the Subcommittee on EmployerAnnals of Emergency Medicine 547
News and Perspective Employee Relations; the Health Information Technology Promotion Act of 2006 (HR 4157), with his privacy-related amendment, passed the House in the 109th Congress but never became law. Whether HIPAA as currently worded remains the chief privacy safeguard or future regulations become more rigorous, clear communication about data security with both patients and hospital administrators appears prudent.
THE DREADED O-WORD AND THE FRAGMENTED FUTURE The very term “outsourcing” is controversial in this field. Berger and his colleagues at NightHawk explicitly steer clear of the word, noting that it always connotes cheapness and often implies corner-cutting. In contrast, he says, NightHawk’s radiologists are among the most highly paid in the US. Applications for positions are soaring, and the company has carefully selected urban practice locations for a quality of life that will appeal to American talent: Sydney and Zurich abroad, San Francisco for its first centralized US reading center. Others have frankly leveraged geographical differences in labor costs. In 2003, Bangalore-based Wipro, Ltd., which provides communications services to a wide range of industries, controversially “tested the waters” (in one executive’s words) by outsourcing some scans from Massachusetts General Hospital and several other institutions to Indian radiologists who lacked US licensing and board certification and earned 5-figure incomes. The experiment attracted attention mixed with alarm in the medical,9 trade,10 and lay11 press, and it was shortlived.12 However, Wipro is still engaged in what it calls “clinical process outsourcing,” an outgrowth of the 2003 experiment, including image interpretation and 3D image processing. Susheel Ladwa, an executive in Wipro’s North American health care practice, comments, “We have not received any quality complaints or issues in our clinical process outsourcing business. It’s been a growing business for us.” Wachter notes the implicit nationalism in the concerns that global teleradiology has evoked: “The bias in the industry was, ‘How can they be any good? These are docs trained in another country, out of our system. . .They’re going to undercut our people on price by a factor of 10, but at a cost in terms of quality and safety that is unacceptable.’ And that is a predictable argument that happens in every industry where outsourcing begins. . .You have no idea, in the absence of measurable data, whether it is absolutely true or predictable guildlike behavior by provider groups that are protecting turf and income.” As those measurable data accumulate in scholarly publications, it may become possible to determine whether the ACR’s caution is warranted. For the moment, the question appears unanswerable. Image interpretation practices have been found to vary widely in community hospital EDs,13 and optimal patient care calls for the broadest and most efficient access to high-level expertise, wherever it is found. The general assumption in the US is that American licensing and board certification are the default standard, but as technology drives 548 Annals of Emergency Medicine
medicine toward a more borderless world, Wachter wonders whether apprehensions about outsourcing include some degree of xenophobia and misplaced nostalgia along with legitimate concern over quality. “All of us old guys can lament the ending of the days of the giants,” he says, reflecting on William Osler’s legendary olfactory diagnostic skills and on contemporary meditations by Abraham Verghese, MD, about onscreen icons replacing living patients as the object of diagnostic attention. “Lament all we want, these skills of listening and touching and smelling are rapidly being replaced—whether we think about doing it from a thousand miles away or doing it in the same room with the patient— by technological adjuncts.” The geographic separation between different specialists, he finds, may be less troubling than the schism between embodied patients and disembodied data, a pervasive trend whether practice sites are unitary or dispersed. Wachter adds that a medical system adjusting to the economic processes described in Thomas Friedman’s The World Is Flat14 should strive not to provide top-quality services to everyone – an effort that has incurred tangible downsides, from major corporate bankruptcies to the exclusion of much of the population from coverage— but to give patients the best value, defined as “essentially quality or safety divided by cost.” The winners in the future medical environment “may increasingly be the highest-value providers. . . the Toyota Camrys rather than the Lamborghinis.”
THE GLOBAL VILLAGE The global organizational model for radiology may ultimately join other outsourcing phenomena, plus remote laboratory work, medical tourism, electronic intensive care units, and remote surgery, in making national borders irrelevant to the widespread provision of Camry-level care.15 Wachter speculates about an international equivalent of TJC helping patients worldwide make informed decisions about value for differential cost—answers to the persistent question, “How do you measure the quality of care, not just from the provider in Bangalore, but from the provider in Boca Raton?” Arl Van Moore and Paul Berger have different levels of enthusiasm for teleradiology, but they agree about its effects on the practice environment, particularly as it raises standards for small and remote settings. Berger is enthusiastic about the tendency toward greater specialization. “These doctors are in essence specialists in emergency radiology,” he says, “because that’s all they do. And like anything else, when you do a lot of something and focus your attention on one particular area, you get very, very, very good at it.” “A 3-man radiology practice,” Moore notes, “can’t have an interventional radiologist, a neuroradiologist, a pediatric radiologist, a chest radiologist, an abdomen radiologist, a practicing mammographer, and have those in enough depth to be able to provide 7-day, 24-hour coverage as needed. So those individuals tend to be jack-of-all-trades and master of none, just by the nature of the practice locale. I think (teleradiology) Volume , . : November
News and Perspective provides an opportunity for those groups to affiliate with larger groups at a level of subspecialty expertise that heretofore has not been available for them.” Moore, too, views the development of international teleradiology in Friedmanian terms: the economy now extends beyond national borders, the medical profession is following economic incentives as any other industry does, and radiology is merely the first specialty to adapt to globalization, with its emergency subspecialty leading the way. Friedman, he notes, is “talking about migrating to a global economy. It’s occurring; it’s just that different planes are migrating at different rates. . .. Radiology’s not the only one there; we just happen to be first.”
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1. Radiology PACS Administrator Site. Twelve major teleradiology firms are compared. Available at: http://www.pacsadminforum.com/ Nightwark-Teleradiology-Services/PACS-teleradiolgy-services. html. Accessed August 28, 2007. 2. ACEP Emergency Medicine Practice Subcommittee on Contemporaneous Interpretation of CT Scans. Radiologic imaging and teleradiology in the emergency department. Available at: http://www.acep.org/webportal/PracticeResources/issues/admin/ radioimagingteleradiology.htm. Accessed August 28, 2007. 3. Moore AV, Allen B Jr, Campbell SC, et al. Report of the ACR Task Force on International Radiology. American College of Radiology, 2004-2007. Available at: http://www.acr.org/Secondary MainMenuCategories/BusinessPracticeIssues/Teleradiology/ ReportoftheACRTaskForceonInternationalTeleradiologyDoc3.aspx. Accessed August 29, 2007. 4. American College of Radiology. Revised statement on the interpretation of radiology images outside the United States. May
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2006. Available at: http://www.acr.org/SecondaryMainMenu Categories/quality_safety/guidelines/GeneralDiagnosticRadiology/ RevisedStatementontheInterpretationofRadiologyImagesOutside theUnitedStatesDoc11.aspx. Accessed August 28, 2007. Wong WS, Roubal I, Jackson DB, et al. Outsourced teleradiology imaging services: an analysis of discordant interpretation in 124,870 cases. J Am Coll Radiol. 2005;2(6):478-84. Venieris PY, Chan TC, Killeen J. Multicenter trial assessing the impact of an overnight international “nighthawk” teleradiology system on CT radiology re-interpretation rates. Ann Emerg Med. 2006;48(Suppl):S16. Erly WK, Ashdown BC, Lucio RW 2nd, et al. Evaluation of emergency CT scans of the head: is there a community standard? Am J Roentgenol. 2003;180:1727-1730. Cepelewicz BB. Telelegalities. Imaging Economics, June 2003. Available at: http://www.imagingeconomics.com/issues/articles/ 2003-06_13.asp. Accessed August 31, 2007. Wachter RM. International teleradiology. N Engl J Med. 2006;354: 662-663. Brice J. Globalization comes to radiology. Diagnostic Imaging. Nov. 2003. Available at: http://web.mit.edu/outsourcing/class1/ DI-radiology-1.htm. Accessed August 29, 2007. Pollack A. Who’s reading your X-ray? New York Times 2003 (Nov. 16), p. BU01; Available at: http://ibs.colorado.edu/⬃kuhnr/socy2091/handouts/xray.htm. Accessed August 29, 2007. Stein R. Hospital services performed overseas. Washington Post, April 24, 2005, p. A01. Saketkhoo DD, Bhargavan M, Sunshine JH, et al. Emergency department image interpretation services at private community hospitals. Radiology. 2004;231:190-197. Friedman TL. The World Is Flat: A Brief History of the Twenty-first Century. NY: Farrar, Straus and Giroux, 2005. Wachter RM. The ”dis-location” of U.S. medicine: the implications of medical outsourcing N Engl J Med. 2006;354:661-665.
THE TRIALS AND TRIBULATIONS OF HEALTH INFORMATION SHARING: THE TURBULENT RISE OF THE RHIO By Jan Greene Special Contributor to Annals News & Perspective Any given emergency department (ED) patient can have dozens of medical record scattered across a city or a region, leading to inefficient health care resource use and general poor care, but efforts to fix the problem have failed time and again. Information sharing, creating one medical record that follows the patient wherever he or she presents, is the technological holy grail sought by dozens of health information exchange projects around the country. Called Regional Health Information Organizations (RHIOs), they have different organizational structures, goals, funding sources and membership. But what they have in common, despite the enthusiasm for the potential good they could do, is a financial uphill battle. They are the second generation of a trend that failed utterly in the 1990s, then referred to as Community Health Information Networks (CHINs). Over the past few years, improvements in health information technology, increasing Volume , . : November
costs of care and the quality movement have nourished resurgence in the trend, with the hope that growing conditions are better this time around. There are a few exchanges that have found a business model to sustain them and an unusual level of cooperation among the parties in their markets, notably in Indianapolis, Spokane and Colorado. But the headlines have been more focused on some highly public failures. An exchange in Santa Barbara, CA, was touted as a national model and had high-powered support from the California HealthCare Foundation and David Brailer, the former head of health information technology for the federal government. But the effort lost momentum and the exchange died. More recently, a health data exchange in Portland, OR, stalled, reportedly because participants balked at the price tag. Meanwhile, at least 165 health information exchange projects exist in 49 states and the District of Columbia, Annals of Emergency Medicine 549