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Today, both of these patients and hundreds of others like them would receive middle-of-the-night CT scans, taxing the hospital's radiologists. But midnight in Bangor, Maine, is 10:30 a.m. in Bangalore, India. There — and in Switzerland, Australia, and Israel — sit teams of radiologists ready to read the scans and fax their findings back to the United States (urgent findings are phoned back). "You can't reach over and slap [the radiologist] on the back, but every other aspect of the interaction is preserved," says Dr. Arjun Kalyanpur, a Yale-trained radiologist who runs Teleradiology Solutions, a "nighthawk" company based in Bangalore. In published studies of teleradiology, reports of technical problems have been rare, and the readings have been rapid (average turnaround, one hour) and accurate.1,2
The American College of Radiology (ACR) has, unsurprisingly, stated that it is "very concerned" about overseas teleradiology, though its concern is tempered by a recognition that the practice fills a vacuum left by its own members, who would like to sleep at night. The ACR recommends that radiologists who are performing distant readings be board-certified and carry licenses and malpractice coverage in the state where the image was obtained and appropriate credentials at the source facility.
Several hundred U.S. hospitals use overseas teleradiology services. Industry leaders, such as Teleradiology Solutions, NightHawk Radiology Services, and Virtual Radiologic, state that they adhere to the ACR guidelines with respect to licensure, insurance, and hospital privileges. As for compensation, regulations of the Centers for Medicare and Medicaid Services (CMS) prohibit payments to providers outside the United States — an obstacle that many of the companies finesse by providing a "preliminary report," which is later followed by a U.S. radiologist's "final primary report." The overseas radiologists are paid directly (by the hospital or the local radiologists) at a rate of $50 to $75 per radiograph, whereas the local radiologists bill the payer. The ACR has voiced concern about this practice, because of the worry that some domestic radiologists are signing off on the "ghost-read" radiographs without carefully scrutinizing the films themselves.
Although most international teleradiology companies have followed the ACR licensure and credentialing guidelines, in 2003, the Indian technology giant Wipro "tested the waters" (in the words of one Wipro executive) by using Indian radiologists who were neither licensed nor board-certified in the United States. The controversial experiment was subsequently suspended, but the potential for such practices remains. Although the ACR presents its teleradiology guidelines as quality-assurance measures (and quality is doubtless the organization's greatest concern), the possibility that low-wage foreign radiologists will take work from its members has surely entered its calculus. As one U.S. radiologist wrote on a popular professional Web log, "Who needs to pay us $350,000 a year if they can get a cheap Indian radiologist for $25,000 a year?"
The technical and logistic hurdles of remote teleradiology have been overcome, and the practice of having radiologists who were trained and credentialed in the United States read films overseas is now largely accepted. If the ACR guidelines hold, the growth of overseas teleradiology will be markedly constrained by the limited supply of U.S.-trained radiologists who are willing to work abroad. It seems likely that battles over licensure, credentialing, and reimbursement will determine whether providers who were trained and credentialed overseas will be allowed to compete openly with U.S. radiologists. The outcome of these battles will strongly influence the diffusion of international outsourcing to other areas of U.S. medicine.
Source Information
Dr. Wachter is associate chairman of the Department of Medicine, University of California, San Francisco.
An interview with Dr. Wachter can be heard at www.nejm.org.
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