One dictionary meaning of the prefix tele- is "at or to a distance." In the last 2 years, these distances for teleradiology have gone from image transmissions across town to transmissions halfway around the planet. In both cases the radiologists reading the film are American trained and licensed. They might even be the same people, grabbing a plane to read abroad for a couple of months on a sort of working vacation.

The reason radiologists are going halfway around the globe to read film is a simple one. It is more efficient, and possibly healthier, for radiologists to read film during the daytime. So today, it is not uncommon for American radiologists to be sitting in Australia or Spain or England reading night emergency department images from American hospitals while their colleagues back in the States are happily, gratefully, sleeping.

The reason for this "sun chasing," as one respondent calls it, is attributable to more than just wanting to work in the daytime. It is also attributable to the shortage of radiologists, which has increased workloads, and to the sheer demand for more reading because the new modalities have become superior diagnostic tools. Referring physicians, including those in emergency departments at night, are ordering images at an unprecedented rate.

"We have become victims of our own success," says Brian Fellmeth, MD, a radiologist with Sacramento Radiology Medical Group (SRMG). "In the last 5 years, there has been a tenfold increase in the amount of overnight work. I'm talking about working all night reading 60 to 70 cases."

For night work, Fellmeth's group of 17 radiologists must cover five hospitals. They cover them also in the daytime, and additionally cover five outpatient centers. But it was the night work that was driving the radiologists to look for a solution to constant on-calls. "We had this crisis," says Fellmeth. "We were all exhausted. The quality of our daytime reads was going down. We had people working all night at home reading cases. When we started doing this 15 years ago, the average was between zero and one scan per night per hospital."

Shortly after giving this interview, Fellmeth was scheduled to fly from Sacramento, Calif, to Barcelona, Spain, to begin his maiden stint reading abroad. He was to read the same night work SRMG had been covering in Sacramento. The Spanish night reading has been under way since March, and has been a resounding relief, according to Fellmeth.

"We decided that, if we had somebody in Spain, then this onerous nighttime work here would become a very pleasant day shift over there. After a little jet lag, your pineal gland resets, your circadian rhythm resets, and you have Europe to enjoy in your off time."

SRMG chose Barcelona for a site because it was in the proper time zone to read for the West Coast of the United States. At 7 AM in Barcelona, it is 9 PM in Sacramento, says Fellmeth. Barcelona was also chosen because it is on the seacoast and because of its high-tech communication infrastructure. The infrastructure dated back to the 1992 Olympic Games.

Fellmeth says SRMG originally thought about using a reading service to outsource its night work, but outsourcing was discarded as an option because unknown radiologists would be doing the reads. "We did not want our brand name associated with radiologists we could not control," Fellmeth says. "We did not want to risk patients with doctors we didn't know and couldn't vouch for."

So the practice rented a three-bedroom apartment in Barcelona and set it up for reading. It was big enough that a radiologist could bring his family with him for the 3-to-8-week stint that would be required of each doctor.

There were, of course, hurdles. One of them was malpractice insurance. Initially, Fellmeth says, SRMG's carrier balked. But after it was convinced that the physicians would be reading the same patients with the very same images the doctors would be getting at home, the carrier agreed to coverage. "The physical location of the radiologist is completely irrelevant to the risk," adds Fellmeth.

Mike Kelso is information systems analyst and network administrator for SRMG. He says each of the practice's hospitals has a dedicated server connected to all of that hospital's modalities. The server uploads all images to the Internet, after encryption and coding for patient privacy. The images are called over the Web to Barcelona, where they connect to the reading station through "high-end DSL lines," says Kelso. Phone consults also go over the Web, for the price of a local phone call. This does require what Kelso calls a "voice over internet protocol (IP)" phone, which costs around $1,000. The connection to the workstation computer, which can be either a high-end PC or a similar laptop, must be broadband, Kelso adds. He says in the beginning there were a few glitches from some of the hospitals' interfacing equipment. "We had to put T1 lines into the hospitals," he explains. In Spain there are two transmission lines for redundancy and for faxing over the Web.

"It's a slick system," Kelso says. "I would guess it has been an investment of about $200,000." Images arrive in compressed fashion in about 15 seconds, Kelso says. Then it takes another minute or minute and a half for the uncompressed full image to arrive. "It's like when the pictures fill in when you get something over the Internet," he says.

Fellmeth says the radiologist in Spain dictates a brief report to a technician who transcribes it to hard copy in Sacramento, or the reports may be faxed. Turnaround time is minutes. "The result is probably in the hands of the referring physician faster than it is in the daytime," says Fellmeth.

SRMG has talked about marketing its nighthawk service to others, but it wants to proceed for a year or so before taking that step. "We want months of reliable service first," says Fellmeth. He says that when everybody who wants to do Spanish duty has been to Barcelona, SRMG may move its overseas reading to Thailand or some other nice spot in the time zone just to give the radiologists a new locale for cultural variety. "We could do this from a sailboat in the middle of the South China Sea if we had the satellite connection," says Fellmeth, "and I'm not joking."

If, for some reason, the system goes down, then SRMG can revert to its on-call rotation until the problem is fixed. "I'm ecstatic," says Fellmeth. "This call obligation was starting to destroy our practice because people were just so unhappy working all night."

DOWN UNDER

Where ideas begin is hard to pinpoint, but the original vision for the overseas nighthawk service may have come from William Bradley, MD, a world-famous MR expert who is now chairman of the radiology department at the University of California at San Diego. Bradley says about 3 years ago he had made a visit to China to give a lecture to radiologists there; when he later returned to California, he found himself on the phone to one of the Chinese doctors. "I realized I was talking to him in mid day for me, but it was night for him there," Bradley says. "I realized that we all read in the day because that's when we're sharp."

Bradley shared his idea for overseas American night reading with a colleague, Paul Berger, MD, while both were still working in Long Beach, Calif. Today, the idea has taken hold as a company in northern Idaho that markets a nighthawk service with American radiologists working out of Sydney, Australia. One of those doctors is Monte Zarlingo, MD, a former fellow of Bradley's and an MR specialist. He has been reading from Sydney for about a year and a half and he is committed by contract to remain in Australia for another 2 years. That is not to say he will not stay longer; the contract indicates that the company must have a commitment from its doctors signing on for overseas duty.

Zarlingo was one of two radiologists to begin reading from Sydney, but since he started, the company has grown rapidly. It now has five other radiologists it calls "superusers" who are licensed and credentialed to read in any state and at any hospital where the company does business. The company now handles night coverage for about 50 American hospitals in several states, mostly along the East Coast since the East Coast fits best for the time zone in Sydney. The Sydney doctors are reading close to 300 scans nightly, working 12-hour (8 PM to 8 AM Eastern Standard Time) shifts every day of the year. Zarlingo says numerous studies have shown that night workers tend to have shorter lives and more health problems than people who work during the day.

Zarlingo says the biggest hurdle, by far, has been getting credentialed and licensed to read at all stateside locations. A whole team of about 15 support people in Idaho handles the credentialing and licensing. While some states have no legal requirements regarding outsource reading, most states require all readers to be licensed. Likewise, hospitals require readers to be credentialed. This means a huge amount of paperwork, especially for hospitals or schools where the doctors must have letters attesting to their residencies. Zarlingo says that sometimes a radiologist will have to make the 11-hour flight back to America from Sydney just for a 15-minute licensing interview. But the company has persevered through all of this paperwork hassle, sometimes even sending little gifts to the college clerks and hospital administrators who have to handle huge amounts of forms gratis to help the radiologists get licensed and credentialed. Zarlingo has a spreadsheet in Sydney showing him where and for whom he can read, and he says he has never made a mistake and read for the wrong institution.

Zarlingo says the service has much more demand than it can meet. It reads almost exclusively for emergency department doctors, with the majority of its reads being CT, MRI, and ultrasound. "They are mostly for people with stroke, and a million people with belly pain, so the majority is abdomen/pelvis CT, more abdomen than head CT," he says.

Because the service does only preliminary or "wet" reads, quality control is built in when the primary reads are done by stateside radiologists the next day. Zarlingo says it has been professionally gratifying that his reads have rarely been reversed. Doing only preliminary reads keeps local radiologists from seeing the service as a threat to their own volumes, he adds.

The scans reach Australia via a 45-megabit Internet pipeline from the United States to Sydney, an enhanced web portal connection that supplies 30 times the Internet capacity of a T1. The client sites are hooked to the Internet through VPNs (virtual private networks) for security and confidentiality purposes. The images arrive in about 2 minutes, Zarlingo says, and then voice recognition software is used by the Sydney doctors to dictate immediate reports that are faxed back to the hospitals in under 30 minutes. Phone consults are frequent. Each Sydney doctor has a technician (an Australian) to window level images, send confirmations of receipt, fax reports, and perform other duties.

Zarlingo says the two-country setting has created numerous glitches from equipment interface problems to visa concerns, but with effort these difficulties have been surmounted, he adds. Visas have turned into a nonissue since the American doctors are doing a job reading for American patients that Australian radiologists cannot perform.

On the personal side, Zarlingo says he is well paid in US dollars. He says the exchange rate is essentially a breakeven, except for a few things, like airline travel, which is much cheaper from Australia than to it. Food costs less, and the moorage slip for his modest sailboat is way less than it would be back home in California, he adds.

He says the American radiology practices using his company for nighthawk reading save lots of money. "If you read 10 examinations a night as a radiologist and have interrupted sleep because you're up every 2 hours and have to be awake a half hour to read those exams, then the next day you can't read and your company has to hire somebody else. Radiologists' salaries are up to $300,000 per year now. If we read those 10 exams per night, we're going to save you $250,000."

KING COUNTY TO CAMBRIDGE

James Borgstede, MD, chairs the patient safety task force and the commission on small and/or rural practices for the American College of Radiology (ACR). As such, he has been monitoring teleradiology, including the recent trend to follow the sun. Borgstede says one drawback to reading from a foreign country is that Medicare does not allow it for its patients. "The problem," Borgstede says, "is that there is an obscure section in the Medicare rules that says you can't render Medicare treatment outside the United States. Thus, these doctors working overseas can do only preliminary reads, but that can still be beneficial because they can provide consultation in the middle of the night."

Both SRMG and Zarlingo's group do only preliminary night reads. But that means those cases have to be given a primary read the next day. In setting up its overseas in-house night service, Valley Radiologists in Renton, Wash, sought to avoid this duplication of effort. At Valley, Medicare cases are flagged for preliminary reading, but all other cases, which amount to 90% of the volume, are given primary reads overseas. Doctors in Washington the next day do not have to reread.

Valley has 23 radiologists who read for three hospitals with a combined capacity of about 550 beds, for which they also do night coverage. They also cover four outpatient centers during the day. The coverage area is extensive, a big piece of King County southeast of Seattle.

Philip Lund, MD, is a member of Valley and one of the boosters of its overseas reading venture. He is a diagnostic radiologist with a pediatrics specialization. Lund says Valley worked on its overseas venture for more than a year before going live with coverage 14 months ago. For a site, it eventually chose Cambridge, England, where it rented a three-bedroom house and set up the imaging equipment. The incentives were the time zone, the language, and the "tax consequences," Lund says.

To connect its Washington sites with Cambridge, Valley is using what Lund calls "a mini-PACS (picture archiving and communications system) without an archive" and a dedicated T1 line to England. "Everyplace I have a radiologist, there's a computer set up so they can send images, and one of the limbs of that is to Cambridge."

Lund says the England site reads between 35 and 45 cases per night, and sometimes picks up slack by reading backlogged day cases from Washington. Because the radiologist who has rotated to England is a Valley staff physician, there are no licensing or accreditation problems, the doctor knows the ED physicians he consults with, andthat big incentivehe can do final reads. "To read a case over the next morning is probably reading for free," says Lund. Quality control is achieved by double-reading the small percentage of Medicare cases, which must be finalized by doctors in the United States.

Lund says setting up the system probably cost $160,000. "And about $70,000 of that was for a PACS software system and the workstation in Cambridge," he says. "The rest was consultants and paying fees."

He says ongoing costs are still under study. "But most of our group don't care what they have been, because our lives have been so much better. The ED guys love it, because when they have an appendicitis [case] at 3 AM they know and trust the radiologist they're talking to in England," he notes.

One of the most difficult parts has been "getting the right people to rotate" to Cambridge, he says. Sending interventional radiologists (IR) turned out to be a mistake, because that put too much pressure on IR on-call while they were gone. "The optimal," he says, "is to go with a body imager, somebody who does CT, MRI, and ultrasound. The downside is if those guys have a family that makes it difficult." One doctor has bid for a 2-year assignment to England because he loved it so much, and Valley is assessing that solution, Lund says.

STAYING HOME

Of course, the bulk of night reading with teleradiology is still being done by local doctors reading images on-call from home or from a centralized location. In some cases, practices have set up night reading centers using specialists in emergency department imaging. That was the solution for Radia, a Seattle-area radiology group with about 50 radiologists.

William Shuman, MD, is Radia's vice president. He also is director of radiology at Evergreen Hospital and a clinical professor of radiology at the University of Washington. Shuman says Radia provides complete coverage for five major hospitals and night coverage only for two smaller ones. Radia also owns and operates three imaging centers.

Radia installed a fiber-optic network to connect its hospitals through its own PACS. During the daytime, images can be transferred over the PACS so that doctors overloaded in one location can route studies to less busy colleagues for reading. This equalizes the workload and processes studies more quickly. During the late afternoon, Radia begins what Shuman calls "an E-Hawk service" that routes images to its headquarters where they can be read quickly. The E-Hawk shift is a bridge between the day shift and the nighthawk shift that takes over at 10 PM.

The night shift doctorsthere are four on staff, two permanently on nights and two who rotate shiftsread from the same headquarters reading rooms as the afternooners. "All four are subspecialized in emergency department radiology," says Shuman. He says the nighthawk radiologists work out their own schedules. They are required to provide night coverage 365 days a year. Shuman says they read a total of about 120 examinations per night, and do 10 phone consults per night. They do final reads, and try to report back with a preliminary report within 20 minutes. Shuman says the nighthawk service is not a profit center for Radia, but it does break even.

To get its night specialists, Radia pays them 1.4 times what daytime doctors make. The afternoon readers get daytime pay, but they work on average 7.75 hours per day, compared to 10 hours for regular daytime doctors. For fast track emergency patients, Radia can go to real-time reading. They are not usually the really sick patients but those with minor injuries who can be moved in and out quickly, Shuman says.

He says one of the benefits of the nighthawk service is better medical care. "If you accept the thesis that what radiologists do is provide good health care, then it's as true at 2 AM as it is at 2 PM" But Shuman says there is another big upside to night serviceturf protection. If radiologists do not read the ED studies on a timely basis, he says, then the ED doctors will read them and bill for the interpretations. The radiologists will lose the billings and gradually lose turf to ED doctors, who can legally read images. "We were very worried about that, and it was one of the things that got us going in this direction," says Shuman.

CONCLUSION

If American radiologists who read for overseas services have to be licensed and credentialed wherever they read in the United States, what about going the other direction? What about American doctors in the United States who read for overseas clients? At the University of California at San Diego (UCSD), specialists are under contract to read studies from Belgium, Portugal, and other countries using teleradiology to send and receive the images. Donald Resnick, MD, a professor of radiology who supervises much of that work, says it is legally unclear whether the US doctors have to be licensed in the foreign nations to read for patients in those countries. For now, the doctors at UCSD are ducking the issue.

"Currently, what we do with Belgium is that we provide the reports to the physicians and we do the preliminary or the overread, but then the foreign doctor reads it and puts his name on it," Resnick explains. "But," he adds, "international licensing is going to become an issue. Right now, most of the traffic is coming into the United States, but with the shortage of radiologists here, there may come a time when US cases will be sent elsewhere."

Arriving at a solution for licensing and credentialing on the national level is one issue international nighthawks are putting high on their wish list. But nobody knows when, or if, this legal streamlining will take place.

George Wiley is a contributing writer for Decisions in Imaging Economics.