Teleradiology, the electronic transmission of radiological images from one location to another for consultation purposes, has successfully entered routine health services and by many accounts, now ranks as telemedicine's largest field. This technology is predicted to play a significant role in improving service to rural areas, and has the potential to alleviate the current shortage of radiologists. However, teleradiology services are currently characterized by a compromise between expense and quality of digital images, as well as billing and reimbursement obstacles, quality of care concerns and state licensure requirements.

Advantages of Teleradiology.
Teleradiology can be an effective means of distributing radiological services. In many cases, teleradiology has become a necessity for healthcare facilities to outsource some of their imaging interpretation needs. Small hospitals with no staff radiologist can send images to teleradiology providers throughout the world, making it possible to have images read within minutes rather than days.

Hospitals that are focused on general radiological services can use teleradiology to send images of complex problems to major medical centers for evaluation. In addition, via teleradiology a clinical radiologist may seek a second opinion from a specialist without transferring the patient, thus minimizing patient discomfort and improving efficiency of service delivery.

There is immense pressure on radiologists, given the huge volume of images being produced worldwide combined with the shortage of radiologists. Teleradiology has become a financially advantageous approach to solving these issues. The technology has led to reduced workload on radiologists, faster turn-around time for patients, and cost savings for hospitals who find that teleradiology presents an attractive alternative to having radiologists available twenty-four hours a day.

Teleradiology can also be used as an educational device with case presentations provided by educational centers for groups of clinical radiologists or individuals in their own hospitals. This is especially significant for continuing education for rural health practitioners, who may not be able to leave a practice to take part in professional educational meetings.

Challenges
The Center for Medicare & Medicaid Services (CMS) considers the site of service to be the location where the professional service was provided, and Medicare does not allow payment for services that are outsourced to places outside the United States. For international teleradiology services, Medicare permits payment only if the services are a preliminary interpretation.

Medicare reimbursement and other billing issues can arise with teleradiology. Hospitals are probably the easiest settings in which to utilize teleradiology without running into these kinds of regulatory concerns because Medicare does not require interpretations to be performed on the hospital campus, and hospitals are allowed to bill for the interpretations under the Medicare Modernization Act (MMA) Section 952 exception. MMA Section 952 advises that the CMS will pay a person, group or facility enrolled in Medicare for services provided by a physician under contract, regardless of where in the United States the service is furnished. However, because of the 2005 Medicare Physician Fee Schedule Rules, group practices are not as fortunate and must provide services to its patients onsite. Because of this Stark onsite requirement, separate billing of Medicare services is the best way to proceed for group practices.

Additionally, for Independent Diagnostic Test Facilities (IDTF), since the technical and professional components of the service are not performed at the same location when utilizing teleradiology interpretations, the two components must be billed separately, specifying the two separate locations and dates of service. IDTFs also have a more rigorous supervision requirement, creating a situation where, if an IDTF contracts with an out-of-state group to interpret its images, local radiologists must take on a supervision-only role.

Problems regarding quality of care also can arise because emergency room referrers often do not know off-site image readers, and generally the more the referrer knows and trusts the radiologist, the more they trust their medical opinion. A 2003 survey found that in up to 10 percent of teleradiology cases, the scans were unreadable due to poor image quality, raising other quality of care concerns. Additionally, there are sometimes incompatibilities between Picture Archival and Communication Systems (PACS) of different vendors or a lack of integration with PACS and Radiology Information Systems. Generally, in order to combat some quality of care concerns, many companies use only U.S. board-certified radiologists to read their images, even if a radiologist is located in another country.

The American College of Radiology (ACR) has outlined standards for teleradiology that require the radiologist to be licensed in the state in which they read the image and the state in which the transmitting facility is located. Most medical boards view the radiologist who interprets images from outside the state as having traveled electronically into the state and thus to be subject to the patient's state licensing laws. Additionally, radiologists are required to be credentialed at the transmitting facility, and for certain modalities the radiologist must be certified by the American Board of Radiology. The standards set by the ACR make it easier to select reliable and reputable teleradiology companies, but have also caused many hospitals to streamline the teleradiology services they offer because of logistical and legal considerations.


June 2007