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ACR White Paper on Teleradiology Practice: a Report from the Task Force on Teleradiology Practice Ezequiel Silva III, MD (Chair)A,B, Jonathan Breslau, Mdc, Robert M

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ACR White Paper on Teleradiology Practice: a Report from the Task Force on Teleradiology Practice Ezequiel Silva III, MD (Chair)A,B, Jonathan Breslau, Mdc, Robert M ACR White Paper on Teleradiology Practice: A Report From the Task Force on Teleradiology Practice Ezequiel Silva III, MD (Chair)a,b, Jonathan Breslau, MDc, Robert M. Barr, MDd, Lawrence A. Liebscher, MDe, Michael Bohl, RT, MHAf, Thomas Hoffman, JD, CAEg, Giles W. L. Boland, MDh, Cynthia Sherry, MDi, Woojin Kim, MDj, Samir S. Shah, MD, MMMk, Mike Tilking Teleradiology services are now embedded into the workflow of many radiology practices in the United States, driven largely by an expanding corporate model of services. This has brought opportunities and challenges to both providers and recipients of teleradiology services and has heightened the need to create best-practice guidelines for teleradiology to ensure patient primacy. To this end, the ACR Task Force on Teleradiology Practice has created this white paper to update the prior ACR communication on teleradiology and discuss the current and possible future state of teleradiology in the United States. This white paper proposes comprehensive best-practice guidelines for the practice of teleradiology, with recommendations offered regarding future actions. Key Words: Quality of care, technology, teleradiology, teleradiologist, teleradiology company, regulatory issues, end-user standards, patient primacy, business standards of practice, disintermediation J Am Coll Radiol 2013;10:575-585. Copyright © 2013 American College of Radiology BACKGROUND commend nor to condemn the practice of teleradiology Introduction and Definitions but to comment on the current status of domestic telera- diology, propose guidelines for best practice, and recom- The rapid evolution of the corporate business model and mend possible actions to the ACR. the absence of a public ACR statement on acceptable In taking on this responsibility, the task force consid- practices and quality standards for teleradiology compa- ered any instance in which diagnostic images are trans- nies impelled John A. Patti, MD, chairman of the ACR mitted for purposes of interpretation to a location in the Board of Chancellors, to establish the ACR Task Force United States, beyond the immediate vicinity of where on Teleradiology Practice in January 2012. The outcome the images were acquired, to represent domestic teleradi- of our work is this white paper. Its goals are neither to ology.Ateleradiologist is the physician providing these interpretive services, and a teleradiology company is an aSouth Texas Radiology Group, San Antonio, Texas. entity that employs multiple teleradiologists and engages bDepartment of Radiology, University of Texas Health Science Center at San in the management of workflow and image distribution. Antonio, San Antonio, Texas. We refer to the site at which the images are actually cRadiological Associates of Sacramento Medical Group, Inc, Sacramento, acquired as the transmitting site. The site at which either California. a preliminary or a final interpretation is provided is the dMecklenburg Radiology Associates, PA, Charlotte, North Carolina. receiving site. eCedar Valley Medical Specialists, PC, Waterloo, Iowa. fRadiology Group, PC, SC, Davenport, Iowa. Prior ACR Comments on Teleradiology gAmerican College of Radiology, Reston, Virginia. Several extant ACR documents address the topic of tel- hMassachusetts General Hospital, Boston, Massachusetts. eradiology. In 1994, the ACR Council adopted a resolu- iTexas Health Presbyterian Hospital, Dallas, Texas. tion concluding that state licensing boards should require jDepartment of Radiology, Perelman School of Medicine at the University of licensure of Pennsylvania, Philadelphia, Pennsylvania, USA. kVirtual Radiologic, Eden Prairie, Minnesota. out-of-state physicians who provide official, authenticated written Corresponding author and reprints: Ezequiel Silva III, MD, South Texas radiological interpretations of examinations that are performed on Radiology Group, 8401 Datapoint, Suite 600, San Antonio, TX 78229; patients in the licensing state but interpreted in another jurisdiction, e-mail: [email protected]. provided that such law or regulation does not restrict the ability of © 2013 American College of Radiology 575 0091-2182/13/$36.00 ● http://dx.doi.org/10.1016/j.jacr.2013.03.018 576 Journal of the American College of Radiology/Vol. 10 No. 8 August 2013 radiologists to provide second opinion radiological consultations re- Despite the aggressive behavior of some companies, quested by physicians in states in which the consulting radiologist is their success is not assured. Virtual Radiologic (vRad), a not licensed. [1] major national teleradiology firm, recently announced In 2005, the ACR Task Force on International Tel- that it would cut the pay of its contracted radiologists [8]. eradiology studied legal, regulatory, reimbursement, in- Uncertain market forces have compelled other teleradi- surance, quality assurance, and other issues associated ology companies to rebrand or retrench [9,10]. One ex- with the practice of international teleradiology, whereby ample is the 2010 acquisition of NightHawk Radiology interpretations were generally outsourced and prelimi- Inc by vRad, which merged the two biggest publicly nary in nature [2]. The ACR, along with the American traded teleradiology companies into one large private Association of Physicists in Medicine and the Society for equity–controlled group [11]. Imaging Informatics in Medicine, recently adopted and Positives and Negatives of Teleradiology. Teleradiol- issued an updated 2012 ACR technical standard for the ogy has the potential to bring both positives and nega- electronic practice of medical imaging [3] that defines the tives to patient care. Radiologists have used teleradiology goals and qualifications for the use of digital image data, to simplify geographic and overnight coverage challenges including the electronic transmission of patient examina- as well as to strengthen subspecialty expertise. An impor- tions from one location to another for the purposes of tant virtue of teleradiology is that many smaller hospitals interpretation. The forthcoming ACR IT Reference Guide that struggle to maintain adequate off-hour and subspe- for the Practicing Radiologist provides IT and informatics cialty coverage can rapidly provide high-quality interpre- guidance on a wide range of topics across the practice of tations around the clock. Centralized image distribution radiology, many of which are particularly relevant to hubs allow efficient access to qualified teleradiologists by teleradiologists practicing in a remote setting. hospitals and emergency departments needing quality reports for their imaging services. These hubs can also Current State of Teleradiology assist small groups to match manpower capacity with After the 2005 ACR publication on international telera- volume fluctuations or vacation coverage, obviating the diology, the teleradiology model of outsourced, prelimi- need for more expensive on-site solutions. nary after-hours interpretations experienced continued Unfortunately, some teleradiology companies focus growth, but evidence suggests that market penetration exclusively on report delivery. Besides devaluing our spe- peaked in 2010 at 50% (ie, half of radiology practices in cialty and undermining the role of the radiologist as an the United States outsourced their call). Recent reports independent expert in diagnostic imaging and a fully indicate that the preliminary interpretation market is engaged member of the consulting team, this practice decreasing as a sizable percentage of practices are “taking further commoditizes the product of our efforts [12]. back the call” they previously outsourced [4]. In contrast to international teleradiology, in which the The End Users. The principal end users of teleradiology interpretations are preliminary, domestic teleradiology services include hospitals, radiology groups, referring often provides final interpretations and represents a shift physicians, and patients. Among the largest of these are in the business model. Some domestic teleradiology pro- hospitals that directly contract with teleradiology service viders offer a full complement of on-site and off-site providers, typically providing a combination of on-site imaging services, including procedures requiring the and teleradiology coverage. There is also a significant physical presence of a radiologist, subspecialty interpre- number of contractual relationships between radiology tations of images, and general management of the radi- groups and teleradiology service providers whereby the ology department. This rapid evolution has led to the teleradiology companies provide supplemental after- emergence of large public and private companies that hours coverage or bolster subspecialty coverage that often compete with established community and academic would otherwise be inadequate, intermittent, or nonex- radiology group practices [5]. Some of these teleradiology istent. Additionally, radiology groups frequently partici- companies are financially integrated subcontractors of larger pate in teleradiology off-site coverage arrangements with health care systems [6]. These companies are under substan- remote regional hospitals or local imaging centers. Refer- tial pressure to demonstrate growth and profitability [4]. ring physicians, including emergency room physicians, Given the saturated nature of the outsourced, prelim- can be considered end users because they base clinical inary teleradiology market and the need for large telera- management decisions on teleradiology reports and con- diology companies
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