It's more than just a business model.
In this column, we will examine an issue that has energized — and divided — radiology and the ACR: teleradiology.
Many spirited debates at recent ACR Council meetings have focused on the merits and drawbacks of teleradiology. Proponents maintain that teleradiology benefits patients and the profession. They regard teleradiologists as pioneers who have brought sophisticated, high-quality care to hospital systems and academic medical centers requiring 24/7 coverage they cannot obtain from incumbent radiology departments. Supporters emphasize that teleradiology delivers imaging to remote areas that lack the proper technology and workforce. They also praise teleradiology’s productivity and lifestyle advantages.
Conversely, many radiologists believe that teleradiology commoditizes the profession and has deteriorated radiologists’ vital relationships with clinicians as well as patients. In the opposition’s view, teleradiology’s relentless focus on productivity increases the risk that a teleradiologist will miss a finding and thus jeopardize patient care. Skeptics also criticize teleradiology because those who practice it cannot communicate in person with those who depend on it, such as emergency department physicians. Teleradiology providers tout their quality assurance programs. However, some question the bona fides of a program that depends on verifying the credentials of practitioners whom a hospital cannot assess directly.
ACR members do agree that, as a clinical and economic paradigm, teleradiology carries legal obligations — and some unforeseen consequences. For instance, interpreting studies in another location implicates equal, if not higher, medical liability risk than if a radiologist reads a study down the hall from a patient. One teleradiology company had to settle a malpractice lawsuit alleging that its contracted out-of-state teleradiologist misdiagnosed a study.1 The patient’s estate claimed that the teleradiologist failed to detect changes in a patient’s aneurysm, which led to his death. Although the company denied any negligence, it paid $500,000 to avoid going to trial and placing its teleradiology platform at the mercy of a judge or jury.2
State Boards Have a Say
Courts represent one forum for adjudicating a claim of negligent care that involves teleradiology. Where else could a teleradiology-related claim land? Would you guess a state board of medical examiners? State medical boards might investigate and resolve teleradiology-related disputes. The ACR Legal Department has communicated with members who have indicated that certain state boards have targeted teleradiologists. Our members describe a “snowball” environment in which one board imposes a settlement that leads other boards to take disciplinary action against a teleradiologist across the United States.
State regulators reportedly have taken this type of approach:
First, a state medical board and a teleradiologist reach a single malpractice settlement. Next, the board issues a formal public admonition or reprimand. The board then reports its public reprimand to the federal National Practitioner Data Bank (NPDB). Under the NPDB regulations, a reprimand of a physician qualifies as an action “based on reasons relating to a physician’s professional competence or conduct.” An insurer or other health-care entity that makes a payment to settle a medical malpractice claim or judgment against a physician must also report that action to the NPDB.
Besides reporting to the NPDB, the state medical boards in question have also reported teleradiologist-based settlements to all boards of states in which the physician is licensed. Subsequently, those other states begin formal inquiries into their licensee’s conduct. Many states’ licensure requirements impose a reciprocal form of automatic discipline of the physician’s license. Consequently, one state board settlement may launch numerous state board investigations and sanctions. For a teleradiologist who holds many state licenses, this domino effect is troubling. A single settlement can result in multiple, automatic state board disciplinary actions, each of which is a separate reportable event. Members note that this process can last up to two years with teleradologists incurring sizable legal costs.
What is ACR doing to address this situation? Although it cannot intervene in individual state medical board cases, ACR has established a new Task Force on Teleradiology Practice to shape best practices for quality care. The task force will develop standards to attain ethical, open competition for safe, high-quality teleradiology practice for radiologists, their groups, their patients, and companies that primarily serve as contractors to hospitals. A prior ACR Task Force on teleradiology focused on international teleradiology practice. It issued a white paper that recommended members resolve key legal considerations such as medical liability, licensure, and hospital credentialing.3 Similarly, this new task force will delve into current forces affecting teleradiology, including regulatory issues of credentialing, licensure, and physician supervision. ACR will give members who engage in teleradiology — and those who do not — guiding principles for a topic that will remain at the crux of imaging debate.
1. Shields B and Hoffman T. “Little Images Can SpellBig Trouble.” ACR Bulletin 2009;64(7):26.
3. Moore, AV, et al, “Report of ACR Task Force onInternational Teleradiology.” JACR 2005;2:121–125.
By Bill Shields, JD, LLM, CAE, and Tom Hoffman, JD, CAE