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NEWS AND PERSPECTIVE
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Introduction
nnals News and Perspective explores topics relevanto emergency medicine, in particular those in whichur specialty interacts with the political, ethical,ociologic, legal and business spheres of our society.
nnections, and the proliferation of affordable workstations—
lume , . : November
anagement will be rare. By design, it will not be a‘breaking news’’ section with the latest (andndigested) developments, but instead a reflectivenvestigation of recent and emerging trends. If youave any feedback about this section, please forwardt to us at [email protected].
Discussion of specific clinical problems and their
0196-0644/$-see front matterCopyright © 2007 by the American College of Emergency Physicians.
NIGHTHAWKS ACROSS A FLAT WORLD: EMERGENCY RADIOLOGY IN THE ERA OFGLOBALIZATION
By William B. Millard, PhDSpecial 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 radiologydepartment, assuming one was available locally at all. In about aquarter of the hospitals in the United States, it now meanstransmitting an image partway around the world in return for arapid reading, a confirming report the next day, and a previewof medicine’s conceivable future.
Along with contributing timely information to clinicaldecisions, global teleradiology suggests that the house ofmedicine is becoming less a single structure than a network offunctions. Like many other diagnostic procedures, radiologicstudies combine a high-touch component, involving directcontact with the patient, and a high-thought interpretivecomponent; teleradiology mediates the 2 through hightechnology. Now that the hands-on and cognitive aspects ofimage studies are discrete and separable, observers say, therelevant specialties can engage in further subspecialization,freeing some practitioners from performance-dulling workingconditions while giving others access to more accurate specialistconsultations. It should follow logically, but does notautomatically, that these changes will also produce benefits forpatients.
Teleradiology overcame the technical barriers to rapidremote interpretation about a decade ago, recalls R. Nick Bryan,MD, PhD, professor and chairman of the department ofradiology at the University of Pennsylvania School of Medicine,Philadelphia, PA, and a past president of the RadiologicalSociety of North America. Related technical developments—thedigitalization of most clinical images in picture archiving andcommunication systems (PACS) using the Digital Imaging andCommunications in Medicine (DICOM) image formatstandard, the wide availability of broadband Internet
mean that an emergency department (ED) no longer needs tolean on its local radiologic colleagues for a grueling night call.This is a particular boon in areas where the caseload outweighsthe local professional workforce. Considering the chronicnational shortage of radiologists, such areas are not limited tothe hinterlands.
AROUND THE CORNER OR AROUND THEWORLD
Once a radiologist did not have to be in the same building asthe physician requesting a read, it was only a matter of timebefore these colleagues no longer had to be on the samecontinent. According to the field’s foundational legend, formerLong Beach Memorial Medical Center neuroradiologist WilliamG. Bradley, Jr., MD, PhD, was lecturing in China when hisoffice sought his help with a difficult early morning case, whichhe handled through his center’s new PACS system and a localInternet café. Struck by his fresh daytime perspective, hespeculated to a colleague that the time-zone differential couldhelp reduce sleep loss and burnout. Bradley and the colleague,Paul E. Berger, MD, ended up launching a firm replacingbleary-eyed radiologists with fully alert ones situated 8 to 12time zones away.
The name of the field’s pioneer group has acquired the statusof a generic term, describing both overseas and domestic“nighthawks.” Coeur d’Alene, Idaho-based NightHawkRadiology Services stations about a quarter of its radiologists inSydney, Australia, a quarter in Zurich, Switzerland, and halfwithin the US. Its success has attracted multiple competitors.1
The scale of all these operations is not yet large: NightHawk hasgrown from 2 physicians to 120, and some practices comprise
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Economies of scale and energetic, patient credentialingsupport for its physicians (all board certified) allow NightHawkto serve nearly 1,400 U.S. hospitals. The average NightHawkradiologist, says co-founder/president/CEO Berger, has 38 statelicenses and is on staff at over 500 hospitals. Ninety percent ofthe firm’s workload is CT scans; ultrasound makes up 4%-5%,and nuclear medicine, magnetic resonance imaging, and plainfilms 1%-2% each.
“It has created a new practice model that a number ofpeople, particularly young people, are interested in,” commentsDr. Bryan, noting that the flexible work hours and practicelocations have contributed to concentration of talent, bothgeographically and institutionally, within the specialty. “It’s justan alternative way of delivering the service. It doesn’t eliminatejobs, but it could redistribute the jobs from traditional practicesto these larger, at least partially remote companies.”
Robert M. Wachter, MD, of the University of California atSan Francisco Department of Hospital Medicine, viewsinternational teleradiology as a fortuitous entrepreneurialresponse to perceived needs.
“Nobody wired radiology or got rid of films [and] replacedthem with pixels, thinking that this would facilitate readingscoming from Bangalore or Sydney,” he says. “They did it so thatyou could read your film on the 14th floor of the buildingwithout going down to the third floor, or so that the radiologistcould read the film at 3 AM without schlepping in.”
Like other unplanned phenomena, this field has grownquickly enough to catch related institutions unprepared. Alongwith its obvious benefits come a host of questions aboutaccountability, clinical context, economics, professional culture,and the quality of patient care.
GHOSTS, WET READS, AND SILOSWhat strikes many emergency physicians as a common sense
service—and, under certain clinical circumstances, a godsend—raises concerns in other quarters. The relevant professionalorganizations in the US, the American College of EmergencyPhysicians (ACEP)2 and the American College of Radiology(ACR),3 both recognize the value of global teleradiology,provided the legal entities involved observe standards forlicensing, institutional credentialing, liability coverage, andstrict quality assurance measures. In May 2006, the ACR alsorevised its official statement43 to incorporate a new paragraphcautioning about sweatshop-style arrangements overseas,particularly discrepancies between the responsible signature on areport and the identity of the person actually examining theimages (“ghost reporting” or “ghost reads”).
Arl Van Moore, Jr., MD, chairman of the ACR’s Board ofChancellors and head of the group’s task force on internationalteleradiology, distinguishes acceptable and unacceptablenighthawk practices, noting that the marketplace’s answer to thestrains of nocturnal shiftwork makes sense but requiressafeguards. “The biggest concern was the qualifications,” hesays, “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 sweatshopmetaphor is far from literal, and several commentators regardthe ACR’s caveat more as a preventive measure aimed at ahypothetical scenario than a response to known abuses.NightHawk’s Berger –who presumably would have as much togain as anyone from confirmed reports that competitors wereviolating the law—states categorically, “I am absolutely unawareof any specific people doing that anywhere. . .. In this day andage I cannot imagine a hospital or radiology group contractingwith [unlicensed readers]. The legal liability would beenormous.”
Centers for Medicare and Medicaid Services regulationsimpose an additional condition on international teleradiologyby limiting payment to providers within the US. Since insurersgenerally follow Medicare’s lead, overseas nighthawks arecurrently limited to preliminary (“wet”) reads, comparable insome respects to initial reads by residents; a secondary or “dry”read by a domestic radiologist is necessary for a final report andfor reimbursement. The cost of the initial wet read is aphysician-to-physician transaction, excluded from bills to thepayer or patient.
As the terminology derived from film-based radiographyimplies, duplicate reads are nothing new. They are common inmammography, in resident training, and in the ACR’s RadPeerprogram providing anonymous peer review for qualityassurance. However, they are not the norm in emergencypractice. Discrepancies between initial and secondary reads arenot widespread, but they require some orderly process ofresolution. The NightHawk firm, according to Berger, usesroutine discrepancy reports and a tiebreaking third reader ifinterpretations still differ after repeat reads and consultationbetween the original 2 readers.
NO QUALITY CONTENTIONTo date, informed commentators have been satisfied with the
quality of nighthawk readings. One large peer-reviewed study ofdiscordancy rates in after-hours general teleradiology5 foundthat primary and confirming reads differed in an overall averageof 1.09% of cases (95% confidence interval, 0.70% to 1.41%).The specific topic of nocturnal international teleradiology isonly beginning to receive study, but an early report indicates asmall difference in reinterpretation rates between overnightresident readings (2.3% of which were changed in morningoverreads by an attending radiologist) and overseas nighthawkreadings (2.5%).6 These disagreement rates are consistent withthe rates of 2%-3% found between general radiologists (workingeither as nighthawks or on call in addition to daytime duties)and neuroradiologic specialists in evaluating emergency headCT scans.7
James Killeen, MD, assistant clinical professor at theUniversity of California at San Diego Medical Center’s Divisionof Emergency Medicine and a co-author of the recent study of
overseas nighthawks’ reinterpretation rates, observes that theVolume , . : November
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overseas service solved several problems his department wasfacing. “Our main concern was the number of rereads beingdone,” he recounts, noting the need for callbacks to patients foradmission or other studies after official daytime reads revealedfurther information. Changes in Residency Review Committeepolicies restricting residents’ hours also forced faculty to makeup the time that residents could not practice, exacerbatingworkforce shortages and cutting into sleep. Killeen’s departmenthas engaged international nighthawks for initial confirmation orcorrection of residents’ results, finding the results timely andaccurate.
Another recurrent concern with teleradiology involves theisolation of image reading from other aspects of the clinicalcontext. No telecommunications arrangement is as information-rich as the human contact with patients or the informalconsultations that colleagues share in the halls of a singleinstitution, but a well-designed diagnostic protocol connectsradiologic images to the patient record and includes real-timetelephone consultations instead of isolating the radiologist andother physicians in separate silos. At the University of CaliforniaSan Diego, the nighthawks’ reports are integrated into ahomegrown electronic medical records system designed byKilleen, a medical informatics aficionado who has alsocontributed to the department’s Wireless Internet InformationSystem for Medical Response in Disasters (WIISARD). “One ofthings we like to pride ourselves on is the redundancy, not onlyfor our electronic medical records program but for the way weset up our radiology system,” Killeen says. “We don’t like tokeep our radiologists—either the ones here or the onesabroad—in a vacuum.”
HOW HIP TO HIPAA?When either detailed records or individual images travel
across national boundaries, privacy is a paramountconsideration. Health Insurance Portability and AccountabilityAct (HIPAA) compliance is a common selling point forteleradiology practices here and abroad. NightHawk’s Berger,while describing himself as a “card-carrying techno-peasant”who relies on his information technology personnel forassurance in this area, reports, “We’ve been HIPAA-compliantsince day 1. That has not been an issue.”
However, to Moore of the ACR, HIPAA compliance is not acut-and-dried question. “Even if you’re an American citizenpracticing in another country, you’re really subject to the lawsand jurisdiction of that country,” he notes. “I’m not aware ofany country that has as strong a privacy law as does the US.”Moore emphasizes that teleradiology firms need to adhere to therigorous US jurisdiction.
Maintaining the security required by HIPAA requires bothtechnical and procedural measures. Killeen’s department uses aserver-to-server virtual private network with firewalls at bothends. In his view, secured passwords rotated every 90 days are agood safeguard against fraudulent access, and many hospitals’
legacy systems already use that precaution. Across the industry,Volume , . : November
encryption as strong as the systems used in online banking isstandard: at least 128-bit, ranging as high as 1024-bit.
“So far so good,” notes Wachter, with a touch of skepticismabout promises of confidentiality and actual practices, online oroff. “I mean, so does Visa tell me that’s true with my [financial]records, and then every few days I read about another spillage of5 million records.” In any event, he adds, the digital realm is notthe sole threat to confidentiality. “I don’t think it takes aninternational transmission to make these sorts of movements ofdata risky. It may very well be that they’re more careful thanwhen they get shipped across town for a payment review.”
Barry B. Cepelewicz, MD, JD, physician-attorney andpartner at Meiselman, Denlea, Packman, Carton, & Eberz, alaw firm in White Plains, NY, that represents both teleradiologypractices and health care providers using their services, advisesclients to consult with their malpractice carriers about ways toreduce exposure. Contracts should include explicitindemnification and “hold harmless” clauses with respect to theparties’ obligations regarding HIPAA compliance, identity andcredentialing of readers, verification that image transmission hassucceeded, disclosure to patients, and other variables that couldconceivably come up at trial.8
Most patients, he has found, assume that diagnostic imagesand other records are interpreted and maintained at the samehospital they have visited. Patients are often surprised orconfused when they learn about international outsourcing.Disclosure policies that might be appropriate to establishinformed consent for elective procedures are often notapplicable in the ED setting. Case law and legislation in thisnew area have not established clear guidelines.
CHASING GHOSTS?In the event of malpractice allegations, Cepelewicz says, local
physicians or hospitals could conceivably be held negligent notonly for their own conduct, but also for the choice of anighthawk group or for its actions. He cautions that contractenforceability overseas may be harder in practice than in theory,leaving domestic physicians as the target of choice. “Thesecontractual provisions, as much as we hope they will help, younever know how much they’re going to help until you’re suckedinto litigation,” he advises. “The big problem is that many ofthese entities are out of reach. You can have all these greatprovisions that seem to offer protection, but at the end of theday, if these guys are in Australia and they can’t be reached,then you have problems. . .. What you should try to do is showa jury that you acted reasonably in selecting the teleradiologyentity, and that by including all these contractual provisionsrelating to quality assurance, you thought of the issues. . . and[if] they were breached by the other side -- ‘Well, we should notbe blamed for that.’ ”
Representative Edward Markey (D-Mass.), founder of thebipartisan Congressional Privacy Caucus, has sponsored severalefforts to require patients’ consent before medical records canleave the country. His Stop Taking Our Health Privacy Act of
2003 (HR 1709) expired in the Subcommittee on Employer-Annals of Emergency Medicine 547
News and Perspective
Employee Relations; the Health Information TechnologyPromotion Act of 2006 (HR 4157), with his privacy-relatedamendment, passed the House in the 109th Congress but neverbecame law. Whether HIPAA as currently worded remains thechief privacy safeguard or future regulations become morerigorous, clear communication about data security with bothpatients and hospital administrators appears prudent.
THE DREADED O-WORD AND THEFRAGMENTED FUTURE
The very term “outsourcing” is controversial in this field.Berger and his colleagues at NightHawk explicitly steer clear ofthe word, noting that it always connotes cheapness and oftenimplies corner-cutting. In contrast, he says, NightHawk’sradiologists are among the most highly paid in the US.Applications for positions are soaring, and the company hascarefully selected urban practice locations for a quality of lifethat will appeal to American talent: Sydney and Zurich abroad,San Francisco for its first centralized US reading center.
Others have frankly leveraged geographical differences inlabor costs. In 2003, Bangalore-based Wipro, Ltd., whichprovides communications services to a wide range of industries,controversially “tested the waters” (in one executive’s words) byoutsourcing some scans from Massachusetts General Hospitaland several other institutions to Indian radiologists who lackedUS licensing and board certification and earned 5-figureincomes. The experiment attracted attention mixed with alarmin the medical,9 trade,10 and lay11 press, and it was short-lived.12 However, Wipro is still engaged in what it calls “clinicalprocess outsourcing,” an outgrowth of the 2003 experiment,including image interpretation and 3D image processing.Susheel Ladwa, an executive in Wipro’s North American healthcare practice, comments, “We have not received any qualitycomplaints or issues in our clinical process outsourcing business.It’s been a growing business for us.”
Wachter notes the implicit nationalism in the concerns thatglobal teleradiology has evoked: “The bias in the industry was,‘How can they be any good? These are docs trained in anothercountry, out of our system. . .They’re going to undercut ourpeople on price by a factor of 10, but at a cost in terms ofquality and safety that is unacceptable.’ And that is a predictableargument that happens in every industry where outsourcingbegins. . .You have no idea, in the absence of measurable data,whether it is absolutely true or predictable guildlike behavior byprovider groups that are protecting turf and income.”
As those measurable data accumulate in scholarlypublications, it may become possible to determine whether theACR’s caution is warranted. For the moment, the questionappears unanswerable. Image interpretation practices have beenfound to vary widely in community hospital EDs,13 andoptimal patient care calls for the broadest and most efficientaccess to high-level expertise, wherever it is found. The generalassumption in the US is that American licensing and board
certification are the default standard, but as technology drives548 Annals of Emergency Medicine
medicine toward a more borderless world, Wachter wonderswhether apprehensions about outsourcing include some degreeof xenophobia and misplaced nostalgia along with legitimateconcern over quality.
“All of us old guys can lament the ending of the days of thegiants,” he says, reflecting on William Osler’s legendaryolfactory diagnostic skills and on contemporary meditations byAbraham Verghese, MD, about onscreen icons replacing livingpatients as the object of diagnostic attention. “Lament all wewant, these skills of listening and touching and smelling arerapidly being replaced—whether we think about doing it from athousand miles away or doing it in the same room with thepatient—by technological adjuncts.” The geographic separationbetween different specialists, he finds, may be less troublingthan the schism between embodied patients and disembodieddata, a pervasive trend whether practice sites are unitary ordispersed.
Wachter adds that a medical system adjusting to theeconomic processes described in Thomas Friedman’s The WorldIs Flat14 should strive not to provide top-quality services toeveryone – an effort that has incurred tangible downsides, frommajor corporate bankruptcies to the exclusion of much of thepopulation from coverage—but to give patients the best value,defined as “essentially quality or safety divided by cost.” Thewinners in the future medical environment “may increasingly bethe highest-value providers. . . the Toyota Camrys rather thanthe Lamborghinis.”
THE GLOBAL VILLAGEThe global organizational model for radiology may
ultimately join other outsourcing phenomena, plus remotelaboratory work, medical tourism, electronic intensive careunits, and remote surgery, in making national borders irrelevantto the widespread provision of Camry-level care.15 Wachterspeculates about an international equivalent of TJC helpingpatients worldwide make informed decisions about value fordifferential cost—answers to the persistent question, “How doyou measure the quality of care, not just from the provider inBangalore, but from the provider in Boca Raton?”
Arl Van Moore and Paul Berger have different levels ofenthusiasm for teleradiology, but they agree about its effects onthe practice environment, particularly as it raises standards forsmall and remote settings. Berger is enthusiastic about thetendency toward greater specialization. “These doctors are inessence specialists in emergency radiology,” he says, “becausethat’s all they do. And like anything else, when you do a lot ofsomething and focus your attention on one particular area, youget very, very, very good at it.”
“A 3-man radiology practice,” Moore notes, “can’t have aninterventional radiologist, a neuroradiologist, a pediatricradiologist, a chest radiologist, an abdomen radiologist, apracticing mammographer, and have those in enough depth tobe able to provide 7-day, 24-hour coverage as needed. So thoseindividuals 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 largergroups at a level of subspecialty expertise that heretofore has notbeen available for them.”
Moore, too, views the development of internationalteleradiology in Friedmanian terms: the economy now extendsbeyond national borders, the medical profession is followingeconomic incentives as any other industry does, and radiology ismerely the first specialty to adapt to globalization, with itsemergency subspecialty leading the way. Friedman, he notes, is“talking about migrating to a global economy. It’s occurring; it’sjust that different planes are migrating at different rates. . ..Radiology’s not the only one there; we just happen to be first.”
doi:10.1016/j.annemergmed.2007.09.012
REFERENCES1. 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 onContemporaneous Interpretation of CT Scans. Radiologic imagingand 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 TaskForce on International Radiology. American College of Radiology,2004-2007. Available at: http://www.acr.org/SecondaryMainMenuCategories/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. MaySpecial Contributor to Anna
improvements in health information technology, increasing
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2006. Available at: http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/GeneralDiagnosticRadiology/RevisedStatementontheInterpretationofRadiologyImagesOutsidetheUnitedStatesDoc11.aspx. Accessed August 28, 2007.
5. Wong WS, Roubal I, Jackson DB, et al. Outsourced teleradiologyimaging services: an analysis of discordant interpretation in124,870 cases. J Am Coll Radiol. 2005;2(6):478-84.
6. Venieris PY, Chan TC, Killeen J. Multicenter trial assessing theimpact of an overnight international “nighthawk” teleradiologysystem on CT radiology re-interpretation rates. Ann Emerg Med.2006;48(Suppl):S16.
7. Erly WK, Ashdown BC, Lucio RW 2nd, et al. Evaluation ofemergency CT scans of the head: is there a community standard?Am J Roentgenol. 2003;180:1727-1730.
8. Cepelewicz BB. Telelegalities. Imaging Economics, June 2003.Available at: http://www.imagingeconomics.com/issues/articles/2003-06_13.asp. Accessed August 31, 2007.
9. Wachter RM. International teleradiology. N Engl J Med. 2006;354:662-663.
10. 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.
11. 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.
12. Stein R. Hospital services performed overseas. Washington Post,April 24, 2005, p. A01.
13. Saketkhoo DD, Bhargavan M, Sunshine JH, et al. Emergencydepartment image interpretation services at private communityhospitals. Radiology. 2004;231:190-197.
14. Friedman TL. The World Is Flat: A Brief History of the Twenty-firstCentury. NY: Farrar, Straus and Giroux, 2005.
15. 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 TURBULENTRISE OF THE RHIO
By Jan Greene
ls News & PerspectiveAny given emergency department (ED) patient can havedozens of medical record scattered across a city or a region,leading to inefficient health care resource use and general poorcare, but efforts to fix the problem have failed time and again.
Information sharing, creating one medical record thatfollows the patient wherever he or she presents, is thetechnological holy grail sought by dozens of health informationexchange projects around the country. Called Regional HealthInformation Organizations (RHIOs), they have differentorganizational structures, goals, funding sources andmembership. But what they have in common, despite theenthusiasm for the potential good they could do, is a financialuphill battle.
They are the second generation of a trend that failed utterlyin the 1990s, then referred to as Community HealthInformation Networks (CHINs). Over the past few years,
costs of care and the quality movement have nourishedresurgence in the trend, with the hope that growing conditionsare better this time around.
There are a few exchanges that have found a business modelto sustain them and an unusual level of cooperation among theparties in their markets, notably in Indianapolis, Spokane andColorado.
But the headlines have been more focused on some highlypublic failures. An exchange in Santa Barbara, CA, was toutedas a national model and had high-powered support from theCalifornia HealthCare Foundation and David Brailer, theformer head of health information technology for the federalgovernment. But the effort lost momentum and the exchangedied. 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
