An Eye on Teleradiology

Practicing remotely carries legal implications that ACR members should evaluate.

ACR members are undoubtedly aware of growth in teleradiology. Whether group members read from home, groups provide coverage for one another, academic practices provide subspecialty coverage for small practices, or national companies provide nighthawk or full backup for practices, virtually all of imaging uses teleradiology in one form or another. In this column, we will review the fundamentals of teleradiology and assess the legal impact of recent market developments.
 
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Teleradiology refers to the process of medical images being generated at one location and then sent to a radiologist for interpretation at a different physical location. Some benefits of incorporating teleradiology into your practice are listed below:
 
• It may enable practices to provide patients with subspecialty expertise within the practice or have it provided from an outside entity.
• It can allow small practices to provide 24/7 coverage that they cannot provide with their own radiologists.
• It can provide the capacity to distribute the case workload across the available radiologists in a multi-site practice.
• It can provide significant savings when a practice does not need to support as many radiologists onsite or when the practice only pays or is paid for interpretations on a per-case basis.
 
In all these cases, teleradiology can be used to provide faster turnaround time and significant benefit to patients. Yet, ACR members who interact with teleradiology have experienced an unintended consequence of this technology: commoditization. Imaging services in certain areas have become indistinguishable from those in other locales. Consumers are buying on price alone. This commoditization is happening across the radiology community. To ensure the quality and value of their services, many teleradiology organizations have devised algorithms to establish worklist study distributions. This approach facilitates more subspecialty interpretations and better allocation based on criteria such as subspecialty training and state and facility credentials.1
 
More globally, ACR members have observed that the teleradiology market has become stable and mature.2 Approximately 50 percent of private practice groups outsource teleradiology for call coverage. In fact, the teleradiology market may be decreasing somewhat, because large groups are bringing (or have already brought) call coverage back into their practices. They have done this either to decommoditize themselves or to use their call coverage capability as a means of generating outside revenue.
 
Larger national radiology companies have acquired most of the smaller teleradiology entities. Some standalone teleradiology entities remain but struggle to compete with the major players. If these market trends continue, some ACR members maintain that “private practice radiology will change from independent owner groups to a specialty of shift workers.”2
 
A key legal issue that both in-practice and corporate teleradiology raise for members and their practices is restrictive covenants, or “non-compete” clauses in their contracts. Under state law, courts will scrutinize whether those provisions are reasonable in duration and scope. Can a radiologist leave the group and join a national teleradiology company? Can radiologists read purely by teleradiology for other groups in the same area as their old practice? Almost all private practice groups have a non-compete clause in their employment agreement with their radiologists, but most do not address teleradiology.2 Therefore, members and their groups must review their employment contracts regularly and consider teleradiology in any non-compete clauses that they have.
 
Another significant legal issue involves licensure and credentials. Teleradiologists generally must obtain and keep medical licenses in multiple states. Additionally, they must apply for and obtain credentials at dozens, if not hundreds, of healthcare entities. Medical staff credentialing committees or private credentialing offices may take months to review and grant one’s “ticket” to offer imaging care through teleradiology.3
 
So, what does teleradiology look like in 2019? For most, it is an empowering technology enabling practices to improve patient care. Regarding working for a corporate teleradiology entity, the answer likely depends on an individual radiologist’s professional and personal preference. Some members have formed or joined a corporate teleradiology practice in pursuit of a balance between a productive position and perceived enhanced quality of life. Others have reported difficulties with a larger teleradiology company’s demanding focus on productivity and challenging employment conditions. As the ACR Task Force on Teleradiology Practice noted in its 2013 white paper, teleradiology also poses important quality and safety issues, such as communication errors and particularly the prospect of increased radiation or treatment gaps.3 Regardless of practitioner or practice setting, teleradiology still involves medical-legal considerations that members should continue to evaluate.
ENDNOTES
1. Friedberg E, et al. Unifying the silos of subspecialized radiology: the essential role of the general radiologist. J Am Coll Radiol. 2018;15(8):1158–1163. Available at bit.ly/JACR_GeneralRadiologist.
2. Personal conversation with L. Muroff, MD, FACR, on Nov. 1, 2018.
3. Silva E III., et al. ACR white paper on teleradiology practice: a report from the Task Force on Teleradiology Practice. J Am Coll Radiol. 2013;10(8):575–585. Available at bit.ly/ACRWhitePaper_Teleradiology.

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