Teleradiology: Hype Vs Reality

Dr Saji Salam

When EHM carried my article defining Clinical Process Outsourcing, way back in Jan 2003, I never did imagine that CPO would become an industry term or that so many businesses would want to jump into the CPO bandwagon. One of the more hyped about areas in CPO is Teleradiology. Today every presentation on healthcare is peppered with Teleradiology for flavor.

The fact remains that the demand for radiology services in the US market is growing while the supply of radiologists is not growing enough to match the requirements. However, we need to take a step back and examine this from a different perspective which some times is missing when every other person wants to be running a healthcare BPO business these days. My intent is not to discourage the gold seekers, but to play the devil's advocate. This article is meant to be a reality check. I would appreciate critical feedback on this piece.

Can India be a teleradiology hotspot?

Some of the teleradiology centres in Australia and Lebanon have several US board certified radiologists working from those locations. I guess we have a handful of US certified radiologists of Indian origin working from India, which is perfectly within the confines of US regulations. However when a large Indian IT organisation wanted to relocate more radiologists of Indian origin to Bangalore, there were no takers. Is there the right incentive for a radiologist in US to relocate to India today, for professional reasons?

US radiologist vs Indian radiologist debate

Healthcare in US is built on stringent regulations, because healthcare is a politically sensitive issue in the country. The fact is that, though there is a shortage of healthcare professionals in the US, the country would not accept lesser qualified professionals providing healthcare services. The reality is that though you and I are aware of the excellent clinical knowledge of Indian radiologists, the perception in US is different. The point is that US is not so much concerned about Indian radiologists whose credentials are suspected by many of the folks here. To the common man, despite all the hype we have created about outsourcing, India is still a developing country. My tax consultant is worried that US supermarkets are importing prescription drugs from India, which he feels may not be meeting FDA standards. Credibility being a key issue, the answer to successful teleradiology operation is to have one/several US board certified radiologists who can sign off on the radiology reports. The US board certified radiologist should be willing to take the risk of litigation arising from the transaction, as he signs off on a report generated by the offshore radiologist.

Medical Transcription vs Teleradiology

The layered review approach used in medical transcription may not work very well in teleradiology. The teleradiology equivalent of this (having some medical students run through the initial report and then reviewed by a senior radiologist and then finally by the US radiologist) kind of model may not work very well. Analysing an image coming up with a report is a highly individualistic clinical centric affair and cannot be broken down into phases. At the bottom of the heart no US Board Certified radiologist (at least the ones I have talked to including one of the veteran US radiologists) is really confident of signing off on a report with his name, without actually having infinite confidence in the offshore radiologist, who comes up with the report.

Training & Scalability

My understanding is that just about 50-100 radiologists graduate every year from the medical colleges in India. Many of them are very quickly absorbed into the labor pool. How many would want to moonlight after their regular work at hospitals/radiology centers? As the teleradiology facilities scale up one could expect shortage of radiologists in India accompanied by and attrition and wage inflation. So scaling up the operation to large numbers may be a concern. To create a reasonable supply of radiologists there needs to be collaborative policy decisions from the Indian Medical Council and the Government such as more medical seats and training facilities in the country.

Legal and regulatory aspects

Apart from HIPAA there are other regulatory and political challenges as well. The American College of Radiology has come up with a stance that only US Board certified radiologist with malpractice insurance should be involved in teleradiology. A recent discussion in the radiology circles in the US centered around a limit on the number of radiology reports a radiologist could sign per day. So if a radiologist signs too many reports per day than humanly possible it might be considered that the radiologist did not actually review the records. Though tracking reports of each radiologist on a daily basis and building a legal case may be not practical, it also reflects the extreme reactions in the healthcare community to clinical process outsourcing.

The path ahead

I would think that more than the operational and business side of teleradiology, the real issue that slows adoption of offshore teleradiology services is to do with the regulatory framework surrounding the same in the US. We are seeing political initiatives being taken to reign in healthcare costs that may limit medical malpractice lawsuits, which are so rampant in the country today. Would there be a tipping point when the cost of radiology services becomes so expensive that the healthcare payer community would lobby to rationalise the cost of radiology services in the US?

Would offshore teleradiology then be the norm for US hospitals? Would other countries follow suit?

The writer is chairman, Health Level Seven India. Email:saji@chn.cognizant.com