Emergency department (ED) physicians still read most plain film taken at night. They know how to spot fractures and other aberrations that show up on the grayscale. When it comes to CT scans, MRI, ultrasound, and nuclear medicine procedures that depict intricate structures, radiologists are expected to do the reading. With the proliferation of CT scans in emergency cases in particular, the demand for radiologists to read 24/7 has taken off, and even clinicians at small hospitals are demanding interpretations at night.

Nighttime reading services, whether organized in-house, regionally, or with radiologists based abroad, are riding to the rescue at just the right time to solve radiologists' quality of life complaints. But the nighthawks are doing more than that. They are reconfiguring the radiology landscape in ways that go beyond image interpretation. They may be changing radiologist recruitment patterns and shifting cost burdens in ways that the hospitals had not encountered before. To the extent that radiological images are a transportable commodity that can be interpreted via web flows, the nighthawk services are pushing the envelope there too, perhaps preparing clinicians for the day when even daytime image interpretations will be marketed transcontinentally and transnationally.

Far from complaining about these changes, most radiologistsand a lot of hospital administrators tooare thanking their lucky stars that they have the nighthawk crews to relieve what were previously brutal on-call rotations. They are doubly relieved in view of the ongoing problem of a continuing shortage of radiologists. That shortage is leaving some providers, and not just rural providers, desperate for on-call responders. About the only downside to nighthawk coverage encountered in interviews for this story was the rare times when equipment broke down and the local radiologists had to report for duty as they had done in the days before the night readers let them off the hook. Some groups talk of night technologists feeling orphaned, but by and large technologists, part of whose duty typically is making sure images arrive at the night reading sites, are reported to be dealing with the switch to night coverage without problems.

The rescued

Kent Lancaster, MD, is typical of radiologists in small town settings who say night-reading services have, as Lancaster puts it, "been a savior." Lancaster is a diagnostic radiologist with Radiology Associates of Berrien County, a Michigan group with five full-time and three part-time members that reads for a 300-bed hospital in St Joseph and a 50-bed hospital in nearby Watervliet.

"I couldn't go to bed at night without expecting an hourly call," Lancaster recalls. "Even though I was reading from home, it was still disconcerting. My on-call was every fifth or sixth night, plus weekends, 48 hours straight." After 13 years practicing radiology, the sudden demand for night reading was burning him out. "In the beginning, the night demand was nothing like it is now," he says. "Now the clinicians call us all the time because it adds so much diagnostic benefit." The on-call, he adds, "had become by far the worst aspect of the profession."

Ten months ago, Lancaster's group signed with a nighthawk service to handle the on-call hours. "I can't imagine life without the nighthawks now," he says. "It has changed my whole outlook about on-call, and about radiology in general."

In Plymouth, Mass, David Daugherty, MD, tells a similar story. "We just could not be up 36 hours straight any longer," he says. "It was becoming very burdensome and difficult. In another time, we might have hired more people, but with the radiologist shortage that was hard to do." Daugherty's radiology group contracted with a nighthawk service over a year ago. "It has worked very well for us. Their accuracy is excellent. It was a good move."

Like many radiology groups, Daugherty's group, Radiology Associates of Plymouth, is paying the nighthawks. As is the common practice, the nighthawks do the preliminary reports for the emergency department referring clinicians. Then the staff radiologists do overreads in the morning and bill for those. No bills are sent for the nighthawk reads. Daugherty's group of eight reads for the 140-bed Jordan Hospital in Plymouth. The group handles reading until 10 pm, when the nighthawks take over until 7 am. Daugherty says it is common for the nighthawks to read eight or nine studies per night. "A CT at midnight might be 200 images. The complexities of the studies have markedly increased."

The nighthawk services do not come cheap. Ann Tran, MD, is a radiologist with Regional Radiology, a four-person partnership in Cookeville, Tenn. The group reads for the 300-bed Cookeville Hospital, which is the hub facility for a seven-county area between Knoxville and Nashville. Tran's group uses the same nighthawk service as Daugherty's. Tran says her hospital averages six to eight studies per night. She estimates her group's bill for the night reads at about $100,000 per year. That is less expensive than paying the salary and benefits for an extra radiologist to do the work, she says.

Tran is familiar with the way radiologists these days are besieged by headhunters looking for staff. Tran and her partners were induced to go to Cookeville by a headhunter. "Most of the time, we threw those notices out," she says, "but this one we looked at. They were looking for a seed radiologist to form a group here." Tran and her partners had been interpreting for a 60-member group in the DC beltway, but they opted for a rural lifestyle. "It was culture shock, but it was something we wanted," she notes.

There was far less time commuting, but in the beginning the on-call burden was "pretty tough," Tran recalls. Like most hospitals now, the Cookeville facility was demanding on-call services at night. "This hospital had grown from a small to a large community facility," she says. "There was demand for 24/7, and it was more rigorous. It is for patient care. People don't get sick only during normal working hours." Like many others, Tran also says that the newer digital modalities have increased the demand for nighthawk coverage. "With a CT, you can improve mortality and morbidity," she says. "Take a head bleed. With a CT, you can tell quickly if that patient has had a stroke and needs attention right away."

Why hospitals pay

Radiology groups are not the only ones desperate for night coverage. Hospitals are sometimes so desperate to keep their daytime radiologists on staff and happyor even to attract them in the first placethat they are willing to pick up the tab for the nighthawk services. Hospital payment for night reads is a trend that appears to be increasing, and radiology groups are becoming more conscious that it is a negotiating point.

Arthur Orlick, MD, is chief medical officer for Kaleida Health Network, Buffalo, NY, which administers five hospitals in upstate New York, including its flagship, Buffalo General Hospital, licensed for 450 beds.

"We had a desperate situation," says Orlick, a cardiologist. "Buffalo is not the easiest community to recruit to. We were covering two of our sites with locum activity. We weren't happy with our radiology coverage. We had productivity issues. We needed to do something else, and we recruited a new group."

As part of that recruitment, Kaleida agreed to employ at its expense a night reading service to handle radiology on-call. "The radiologists call the shots, and most radiologists these days are requiring hospitals to provide this night coverage," Orlick says. "It's not inexpensive. It's between $300,000 and $500,000 per year. There is no way for us to recover those fees." Kaleida does get the technical fees on the examinations, but the daytime radiologists bill the professional fees when they do the overreads the next morning, Orlick says.

At North Country Regional Hospital in Bemidji, Mont, a town of about 11,000 mid-state, a difficult situation had developed, according to director of imaging James Erickson, CRA. "We had three radiologists a year ago, and two of them resigned," he recalls. The remaining radiologist was reading about 80,000 studies on an annual basis and could not handle the workload and the on-call. Erickson says the hospital has just contracted with a three-man radiology group to take over soon. The last original radiologist will retire. During the course of its realignment, the hospital contracted with a nighthawk service to read CT and ultrasound from 5 pm to 7 am using the web to transfer images. The hospital has just signed an agreement to share a PACS with a clinic in Fargo, ND, and will be able to store images on the Fargo archive, Erickson says.

Erickson says he is not certain that the hospital is shouldering the whole bill for the nighthawk coverage. He thinks that it may be shared with the remaining radiologist or that there may be a sharing arrangement with the incoming group. "I'm real satisfied with the night service," he says. "The minimum fee is $300 per night, but if I send them three CTs a night, I break even. The radiologist will quit if I don't do it. I agree with him. You wake him up five times a night, he can't work a 10-hour day the next day....He's probably reading 200 examinations a day."

Recruitment and retention are not the only reasons hospitals have an incentive to shoulder night-reading expenses. There are, of course, the patient care incentive and the need to satisfy clinicians. But beyond these there is the impact on patient flow and meeting reimbursement rules. There is also a legal liability aspect.

"The ED wants to do an x-ray on everybody because it covers them legally," says Robert Bree, MD, a partner in Radia, a 45-person group in the Puget Sound area that runs a nighthawk service as part of its practice. "Every time you do anything in medicine you have legal exposure." Not only are emergency departments getting busier as patients with no other access to health coverage seek emergency help, says Bree, radiologists too are getting busier and busier because of the radiologist shortage and the growth in demand for images. "In most practices, business is up 10% to 20% in the last several years. Very few patients get out of the emergency department without some sort of x-ray."

The hospitals also gain from quick reporting turnarounds from nighthawks because they can clear patients from ED beds based on the results of the imaging. Patients are either sent home sooner or admitted to the hospital more quickly. "Without the night coverage, it would put a big load on the clinicians," says North Country's Erickson. "They have to determine if the patient stays in the hospital until morning, or if it's a neuro case, if we ship that patient to Fargo by helicopter." And, as Tran in Tennessee points out, insurance carriers may indirectly feed the demand for nighthawks by imposing 2-day stay limits on hospital coverage, including weekend stays. If the patient is held longer because of imaging interpretation delays, "the carriers may not pay the hospitals, and that becomes a financial burden."

Recruitment

Hospitals may increasingly be paying for nighthawks, but the costs primarily still are falling on the shoulders of radiology groups whose members are desperate for relief from on-call duties. Barry Sewall, MD, is president of West Central Radiological Associates in Wilmar, Minn, a four-person group that is recruiting now and that actually has some members working only part-time. At one point, Sewall says, his original group had sunk down to only him. "It was just me for 6 months, and it was horrendous." West Central reads for Rice Memorial Hospital in Wilmar, which is licensed for about 130 beds, but it also reads 24/7 for four smaller hospitals in what Sewall calls a "75-mile clockface." All the hospitals feed into a Rice-dominated PACS system. Last March, Sewall's group turned to a nighthawk service to handle its on-call. Sewall begged his nighthawk service to begin reading at 5 pm so he would not burn out. All that time, he was recruiting. "If we hadn't had PACS when it was down to just me, it would have been a total bust," he says.

What gratified Sewall after he signed up the nighthawks was that besides making his life livable, it also made recruiting new radiologists easier. "The nighthawk was a huge draw when I was recruiting, and I was able to recruit three people. It was a tremendous advantage." David Daugherty at Jordan Hospital in Plymouth makes the same point. "I get letters all the time from headhunters," he says. "In a state like Massachusetts where reimbursements are low, it's hard to attract radiologists and to keep the ones who are coming out of residency. We were able to recruit two radiologists, but both of them told me that without the nighthawks, they wouldn't be here."\

Turf protection

While nighthawk companies that hire out the service are proliferating, many radiology groups, especially the larger ones, are adding a nighthawk component in-house. The ways of doing this vary. The reasons boil down to retention of income, quality control, and turf protection. There is a fourth reason, too, in some cases. In-house nighthawks who are on staff in the same locale and accredited in the state where they read can do final reads as the night images come in. There is no legal requirement for time-consuming overreads, as there is when state laws prohibit out-of-state doctors from doing anything but preliminaries.

One group that handles night reading in-house is Wake Radiology in Raleigh, NC. Wake is composed of 43 radiologists who cover seven hospitals and nine clinics in a six-county area. They read about 550,000 studies per year. Robert E. Schaaf, MD, is managing partner of the group. He says Wake has set up at its own expense an information technology department and has purchased all the workstations, digitizers, transmission lines, and electronic equipment to link its hospitals to its night-reading site. The modalities are owned by the hospitals. The night-reading system Wake has devised is not spelled out in its hospital contracts, Schaaf says. "We do it because otherwise we'd be driving around all night." He says the group has not done the math to see how much the night reading is costing. "Where we recoup the cost is that there is no overnight call in our practice." The group also runs its daytime email consults over the nighthawk network.

Four staff radiologists share Wake's night reading. Each works 91 nights per year. They work 4 nights, then get a week off, then work 3 nights, Schaaf says. "They are paid a very high hourly rate, and they like it. They are like emergency department doctors." The nighthawks have the option of working some added days to keep their full range of skills, he adds.

Schaaf says the newer modalities and demand for better service are factors causing smaller hospitals to demand 24/7 coverage. So are "liability issues," he adds. "The rural hospitals are struggling to compete and they want the same standard of care," Schaaf says. "We want to give them the same standard of care."

Wake uses its own nighthawks because it wants them to be familiar to referring clinicians. "So much is lost in transition by having reads done by the unknowns," Schaaf says. "In radiology, we are a vulnerable specialty. The last thing we want to do is give up our relationships with our doctors and our hospitals."

Radia in the Seattle area was organized as a merger of two previous groups just so it could gain cost-effectiveness to begin an in-house night-reading service, says Robert Bree, MD, a radiologist who is also medical director of the largest of the five hospitals the group covers. Radia uses a permanent three-person crew of night readers who split the year between them. While non-Radia ED doctors read most plain film, Radia's night crew reads everything else and, where feasible, does the final read, says Bree. "We try to limit ourselves to the digital technologies, because to digitize other modalities causes [image] degradation." Recently, Radia has marketed itself as a nighthawk-only service to a few smaller hospitals, says Bree, but he does not expect that to continue. "We're close to being maxed out."

Riverside Radiology Associates (RRA) is a 42-member group that reads primarily for the 800-bed Riverside Methodist Hospital in Columbus, Ohio. J. Geoff Wiot, MD, is a neuroradiologist and medical director of radiology at Riverside. Because it is a subspecialty group, Wiot says RRA members believe it is important to do their night reading in-house for the income, client retention, and quality.

"By turning to an outside group for night reading, we would essentially be saying, Anybody can do what we're doing,'" Wiot says. "We want to be indispensable to our doctors." RRA applies this philosophy even to night plain film reads. "The financial aspect is that ED doctors are saying, If we can read them at night, then we're good enough to read them in the daytimeand bill for them,'" says Wiot. "That was an interest we didn't want to relinquish."

RRA uses a single radiologist for ED reads from 11 am to 7 pm. Then another single radiologist takes over in the ED "box" and reads from 7 pm to 7 am, Wiot says. He estimates about 65,000 night ED studies are read annually. The ED is mostly CT and plain film, he adds.

While some Riverside radiologists opt for more than their share of the ED reading, everybody is expected to contribute at least two weeks a year to the ED night shift. "The hardest thing for us as subspecialists is shifting work. If I'm on nights, then I'm not there the next day to do neuro, so the other neuroradiologists have to pick up the load." Wiot says RRA started night reading 6 years ago because clinicians were demanding it. "We've had to hire a lot more people to do this," he says, "but we haven't seen any erosion at all in partners' income, and we're paying our incoming people a lot more than we used to pay."

The future

Randall K. Sather, MD, knows all about headhunters. He is one. Sather is head of Heritage Radiology Associates, a Chapel Hill, NC-based entity that establishes and oversees radiology practices for hospitals in the Southeast. Heritage-affiliated groups cover four hospitals and two large multispecialty groups in Florida and one hospital in Kentucky. "We have worked with hospitals that have had their groups implode. Some are imploding under the pressure of daytime and nighttime reading," Sather says. "We form new groups for these different sites. We are recruiting all the time. As we grow, we are developing training programs in the schools to get radiologists before they graduate."

Sather's view is that radiology is becoming an information business with a demand for quick turnarounds on interpretations. "Referring physicians are voracious for reports," he says. "It's more and more, sooner and sooner. Radiology is becoming a stat business. The EDs are busier and more and more things are being done with CT scans looking for hidden fractures. If you've got a busy ED, it needs rapid responses."

Like many who use them, Sather is a fan of the nighthawk services. "It's a wonderful way to get rapid responses to ED physicians on a 24/7 basis without radiologists being in-house at each site," he concurs. While he agrees that transportability has turned electronic images into something of a commodity, he thinks that is happening only to a degree. "They won't truly be commoditized because there is a minimal level of professionalism that has to be there," he says.

Maybe so. But "dayhawk" services to provide augmented coverage are already being organized. Yolanda O'Dell, business administrator for Glendora Radiology in Glendora, Calif, says her group is considering signing on for the dayhawk coverage her nighthawk service is about to offer. Sometimes doctors busy at one hospital cannot take cases quickly enough at another hospital the group covers, she says. Dayhawks might help in those situations by turning out a rapid preliminary. "We're looking at that." n

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