Radiology Vs AI

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It’s the age-old story of human labor vs. machine. The assembly line worker replaced by robotic machines. Cashiers traded out for self-service technology. Taxi drivers usurped by apps like Uber and Lyft.

Even the field of medicine has a history of battling between embracing advances in technology and reserving tasks and job descriptions for human staff. Radiologists are among those who are contending with technological advancement.

One the one hand, technology can allow for faster reads and alleviate an already heavy workload. On the other hand, some things cannot be programmed. Such as a complex diagnosis or face-to-face explanation of a condition.

In this article we will look at the rising tide of AI and what it means for radiology and telemedicine in the future.

Benefit of AI: Increasing the Speed of Play and Improving Efficiency

The doctors, CEOs and administrators of radiology groups that we have talked to all say the same thing: AI is definitely going to change and create efficiencies for the physicians. But they don’t see it ever replacing a physician.

There’re too many factors with diagnostics and the human body that are fluid and that need to be considered before by a physician before an interpretation is made.

But your bread and butter studies might work really well with an algorithm. Is there a fracture on this femur? But will it be able to say everything about the fracture? Maybe not, depending on the severity.

There’s certainly no doubt that it will improve the speed of play.

In a 2017 NPR article on the subject, Dr. Bob Wachter, author of The Digital Doctor says, "Radiology, at its core, is now a human being, based on learning and his or her own experience, looking at a collection of digital dots and a digital pattern and saying 'That pattern looks like cancer or looks like tuberculosis or looks like pneumonia. Computers are awfully good at seeing patterns."

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For example, AI has already been able to identify a brain bleed or not. The computer actually knows enough about the anatomy of the brain and, using a CT scan, it can create a 3d image and determine if there is a bleed. This takes about a minute to complete. Once this algorithm has run and determined there is no brain bleed at 99.99%, then it can rule out that the scan needs to be read as a critical. So, on our end as a teleradiology company, we know based on this algorithm whether a scan needs to be read in 15 minutes or less (critical) or 30 minutes or less (STAT).

This makes sure that injuries with brain bleed, or similar critical issues, are automatically pushed to the top of the list.

Some radiologists are excited about the future of AI as it relates to prioritizing scans and creating better efficiencies. They foresee their jobs as less time spent analyzing images and more time interpreting results based on selected algorithms.

What AI Can’t Do (or Replace)

Depends on the style of modality and the type of x-ray. Take a knee or ankle, for instance. It may be necessary to do a 3-view x-ray of the area. An algorithm would need to understand so many aspects for that read. An x-ray won’t show flesh very well and it won’t get into tendons or ligaments, an MRI is needed for that.

An MRI aligns your ions and then takes an image off of the RF (radio frequency). For a knee or ankle or shoulder, an MRI scan could contain a multitude of detailed images. A computer, no matter how advanced, will not be able to determine which image to focus on to deliver the best, most thorough, read.

Then when you get into digital mammography or tomosynthesis, they will have ten times the amount of studies or images. A radiologist will be able to look through these images and determine which scans to focus on. The dataset is too large for a computer algorithm to make that kind of educated decision (we’re talking more than intelligence here – professional history, experience, understanding of intricacies and human error all go into this intelligent read).

There is also interpretation and analysis when it comes to the patient worksheet that accompanies the scan. When a radiologist is presented with an x-ray or MRI scan, they also get a worksheet that explains, for example, this patient has pain lifting this shoulder or there’s a tightness when he bends a certain way. Then, the radiologist is already putting the pieces together and knows to focus on a certain ligament or tendon when reviewing the scans.

AI is great for determining the presence or absence of, as we said above, a brain bleed. But when it comes to also taking into consideration patient history, size of data set, and diagnostic interpretation – a computer is simply not going to be able to provide that depth of analysis.

What Does the Future Look Like for Radiology and AI?

It should be clear from the above section that radiologists are not at risk of being replaced by machines. The stakes are too high, and their jobs are too intricate to be boiled down to an algorithm. But, that doesn’t mean there isn’t a place for AI in the future of radiology. By increasing speed, creating automations, and bettering efficiency in the journey from scan to interpretation, AI is a useful tool that radiologists can use to help maintain quality patient care while managing large workloads.

3 Common Causes of TAT Delays

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Over the past several years, the utilization of teleradiology has become more prevalent within the medical community. The need for 24/7/365 coverage with timely turn-around-times and accurate interpretations have become the standard.

However, while teleradiology services are growing, some in the healthcare industry fear quality and customer service may suffer under the present growth levels. Chief among these concerns: Missing turnaround times (TAT).

Turnaround times refer to the time it takes for a scan to be received, read (aka interpreted), and the physician’s report returned to the facility. With teleradiology, emergent turnaround times are measured in minutes as opposed to hours and days with traditional, non-emergent radiology studies.

Effective turnaround times dramatically improves patient care, especially in critical areas such as emergency departments, urgent care, and stand-alone ER facilities. Ideally, there is a healthy balance between timely TAT and accurate reads in providing quality patient care. However, there are times when TAT delays may occur and disrupt this balance and the flow of your facility.

What causes these delays? Moreover, perhaps and more importantly, how can they be avoided in the future? In this blog post, we’re going to tackle the first question and, in a future article, we’re going to break down how to make sure your reports are delivered on time.

Cause #1: The Human Factor

The #1 cause for TAT delays occurs when a tech has several studies to send and, rather than addressing individually to completion, all studies are transmitted at once (in a batch). Waiting on prior reports for comparison and waiting on the tech worksheet (which provides essential patient data) are examples of what may hold up the technician from sending the exam to the Radiologist. This portion of the delay doesn't affect the TAT, although it does cause a delay in the receipt of the study for the radiologist to read.

  • Comparisons/Priors - Receiving comparison/prior reports is essential to provide accurate interpretations (especially for a CT Chest or Chest X-Ray) if sent "critical.” If a prior becomes available and they want it compared, the site will request an addendum. Delays can arise if the technician provides a late prior report. A plethora of details accurately noted help provide timely reports; e.g., identify if the findings are old or new, of any increase/decrease in size, whether the study is a CT or MRI, if the patient received contrast and if so, noting if there was a reaction of the tissues or anatomy to the contrast medium.

  • Tech Worksheet - The Radiologists require the worksheet to review their measurements, which also describes how the patient tolerated the exam. If there are images taken outside of protocol, the Radiologist needs to know the reason(s) why and take into consideration the technologist's notes or summations.

    • For CT - Documentation of the patient’s understanding of the contrast media, advised of the complications associated with contrast (with signature), any listed allergies, and a brief medical history.

    • For MR - Documentation of brief surgical history, implanted devices, understanding of the complications associated with the magnetic field, and any prior reactions to MRI contrast media.

  • Upgrading Exams to STAT or Critical - When an exam is transmitted as a routine or a STAT, then the site decides to upgrade the exam’s status to either STAT or Critical and this may cause the exam to become overtime (OT), or over the contracted turnaround time set for the status. Example: A non-emergent or “routine” CT Chest is sent over with a 24 hrs. TAT, an hour passes and the site decides they want it reported STAT (commonly read within 30 minutes). The exam is OT by 30 minutes by the time it is assigned to a Radiologist. There are many reasons this scenario is best to avoid. The stronger understanding the ED care providers have of the patient's potential severity, the less likely this occurs.

  • Incomplete Images - Not all images are sent to complete the exam.

    • X-Ray - Tech sends an order for a 3-view Knee and only sends 2-views. Within the X-Ray modality, there are a vast number of examples where situations like this occur.

    • CT - Tech sends the axial source images but forgets to transmit all the recons or part of the recons, 3D, any post-processing or manipulation of the data.

    • MR – Tech forgets to send the contrast images, a series that is part of the protocol, the recons (if applicable), 3D, post-processing, or manipulations of the data.

As with any profession, the more seasoned and professional the technologist the less likely instances noted above will occur. Our clients' and REAL Radiology's associates have a shared mission, and patient care excellence is the focus. Together, we work hard to eliminate these "unforced errors."

Cause #2: Multiple Injury or Post-Op Issue

For a multiple injury or trauma exams, you are dealing with large data sets that can take longer to read accurately.

  • Trauma patients sent over with 5 - 6 CT's at once - CT Head/ CT Cervical spine/ CT Thoracic spine/ CT Lumbar Spine/ CT Chest/ CT Abdomen/Pelvis - all the images and recons are sent over at one time. It is more time efficient and effective in receiving the reports promptly if the exams are transmitted as individual orders.

  • CT Head/ CT Angio Head/ CT Angio Neck - These are large data sets with reconstructions to review and interpret. The same goes for these exams, send separately to receive the reports back more efficiently.

  • CT Neck/ CT Chest/ CT Abdomen/Pelvis – Another example of large data sets with reconstructions to review and interpret. If it is possible to send these exams as the CT Neck and Chest separately, and then the Abd/Pelvis sent together, the Radiologists can be reporting one set of images while the next exam is downloading to be reported.

  • Most Trauma X-Ray sets are sent over at once – Same logic applies, if they can be separated into groupings that make sense, that is the preferable process and more efficient workflow for the Radiologists.

Cause #3: The Broken Model: Quick Growth, Slowed TAT

The final potential cause of TAT delays comes from teleradiology groups that are unable to keep up with increased demands from their facilities.

Causes may stem from the following:

  • High-physician turnover

  • The pursuit of business over the practice of medicine. Can refer to many dichotomies, including the absence of a patient-care-focus in the organization's mission and planning.

  • Investor-owned vs. physician-owned

    • The idea is that these groups must focus on profit as much as, or more, than patient care to appease capital partners and to provide a return on investment for shareholders.

    • Build to sell mentality - As with most industries, this can often be the worst situation. Add business on price (without having a system in place to sustain) to increase perceived value (to sell again to other investors). This model may work for the sellers, but it rarely works out well for the clients, their ED care providers or patients.

    • Quality medical reporting takes second place to business

    • Concerns such as contractual obligations, fast service, and profit

Essentially, medicine becomes a commodity under the broken models listed above. As practices grow larger, their ability to provide outstanding relationship-based service to their clients becomes more and more difficult.

The robust, strategically-built organizations in teleradiology do not have the symptoms of the broken models. These organizations have thoughtful growth plans in place that are girded with high-integrity, physician leadership, and physician accessibility.

A teleradiology redefined group has the highest retention rate of their physicians and clients. They also provide 24/7/365 customer and IT support and can provide dozens of client references. Rarely, a teleradiology group has 100% retention of its clients (emergent radiology groups and hospital clients). REAL Radiology is one of the few. Consistency is systemic of any business that delivers on its commitments (TATs and quality), and our clients share a mutual respect and focus on patient care excellence.

FAQs

At REAL Radiology, we pride ourselves in making trust a priority.

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Having a trustworthy and transparent relationship with clients is often an overlooked, but a vital part, of any working partnership.

We frequently receive questions from prospective clients, radiology groups and/or hospitals, who are considering beginning to use for the first time or selecting a new teleradiology service partner. The following are popular questions we receive from potential clients who have a general grasp of 1) What and how teleradiology services work, and 2) What services REAL Radiology provides. Looking for this information? Check out our general FAQ page.

Acting on our promise of trust and transparency, we have provided the answers to the most common questions we receive about working with us; perhaps you have the same questions?

Five Commonly Asked Questions About REAL Radiology

  1. Reaching a REAL Radiology Doctor
    Q: If a tech or physician at our facility has a question for the radiologist, how do we reach them and how long does it take for that conversation to take place? Do we have to go through a call center operator?

A: There’s a single phone number for reaching our doctors (303) 590-9795, and it is also listed on REAL Radiology's PACS, viewable after clicking the “Help” button. Your call is not outsourced to a call center; you will be answered by a trained REAL Radiology associate who will connect the call to the Radiologist. The important thing is that you have quick and direct access to our radiologists to answer your questions.

  1. Implementing REAL Radiology Teleradiology Services

Q: Is there a person from REAL Radiology who will come on-site to aid in the initial setup or is it handled remotely?

A: Short answer: All integrations have been successfully performed remotely.  

Utilizing web-conference, conference calls, email communication, coupled with a proven project management/accountability process.  The feedback from clients has been extremely positive. Whether the appropriate connection/Integration Is a gateway application or more complex bi-directional HL7 with auto-prior fetching, a seamless implementation process is the final result with REAL Radiology's team.

  1. REAL Radiology Connection and Bandwidth

Q: What is the REAL Radiology connection type and bandwidth? What if we are in a rural location? Will REAL Radiology still be able to maintain high connectivity with us?

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A: Connectivity is most often achieved through a Gateway Application, which provides secure, HIPAA compliant encryption and compression of the images prior to transmission. Regardless of the facility's Integration type (whether utilizing REAL's Gateway Application and portal alone, an HL7 (or bi-directional HL7), if the facility has bandwidth limitations, then the built-in file compression in REAL Radiology's Gateway will improve patient/Image transfer speeds. This, in turn, will help improve services to care providers and, ultimately, the patient.

  1. REAL Radiology Turnaround Time

Q: What’s the average turnaround time for STAT cases?

A: REAL Radiology’s average TAT for emergent studies has consistently remained under 20 minutes (<20 minutes STAT) and under 10 minutes for Critical/CT-Stroke Protocol (<10 minutes Critical/CT-Stroke Protocol).

  1. REAL Radiology Track Record

Q: In the past year, have there been any issues with meeting turnaround times?

A: None whatsoever, and that has been a true statement since our beginning 6+ year ago. REAL's average TAT for emergent studies has consistently been under 20 mins for STAT and under 10 mins for Critical/CT-Stroke Protocol. We built this business correctly from the beginning to be patient-care focused and highly respectful of our physicians. With processes in place to ensure authenticity, there are stop-loss measures in place to ensure our promises are kept.

Have further questions or interested in learning more about our teleradiology services? Give us a call at (303) 590-9795 or send us a message at info@REALrads.com.

But What About Our Bylaws?

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Why Aren’t More Hospitals and Facilities Using the Credentialing by Proxy Process?

Credentialing by Proxy, or the Delegated Credentialing Agreement, is a simplified means for getting hospitals the physicians and practitioners they need to support their patient care. It eliminates the burdensome, and time-consuming, primary source verification process and replaces it with a streamlined process that can get new doctors through your doors in as little as two weeks. For a full report on the benefits of Credentialing by Proxy, check out our article.

Often, there’s an urgent need to credential additional physicians to help improve patient care. However, even with the Credentialing by Proxy process being offered to expedite getting telemedicine-based physicians and practitioners through your doors, some facilities have been hesitant to utilize this agreement. In a 2017 Telemedicine & Digital Health Survey Report conducted by Foley & Lardner, only a third of respondent hospitals or provider groups used telemedicine credentialing by proxy (Foley & Lardner 2017).

Regardless of whether a hospital utilizes CMS or Joint Commission standards for their credentialing (both of which accept credentialing by proxy) a hospital may choose not to take this quicker route.

This may be due to several factors.

Afraid of the “Risks”

“How can we just not have primary source verification be our process anymore?” is a question we often hear, followed by:

“What about our state-specific or hospital-specific credentialing criteria?”

Or:

“We’ve been burnt in the past by [insert other radiology company]. What about the risks that come with a speedier credentialing process?”

And, of course:

“But, our bylaws won’t allow for it.”

We’ll get to this last one in a moment.

But, to address this fear of the unknown, facilities can be assured that standards will meet or exceed those of the Joint Commission. Meaning, they no longer need to go through their own checklist for verification, they simply receive a file (how much documentation needed varies by hospital – this is a flexible process) that they can present to their credentialing committee.

Since we are accredited by the Joint Commission, we are being audited and have to be in good standing with the commission and uphold their standards for every doctor that we hire. Each year we are evaluated and receive a positive review, so you can be assured that every doctor that goes through the credentialing by proxy process will provide the best care for your patients.

Big Bad Bylaws

We can list the benefits of credentialing by proxy all day long, but if a hospital’s internal bylaws won’t allow for this kind of agreement then they feel their hands are tied and they cannot utilize this process.

However, this doesn’t have to be the end of the road.

We offer a proven, note-efficient, process for amending your bylaws to allow Credentialing by Proxy. This is just another way our clients and REAL Radiology help deliver patient care excellence.

We provide suggested wording that can be added to the bylaws so that your hospital is free to do delegated credentialing. This wording is entirely based on the specific hospital or facility, but it’s a great starting point.

Edit it, change it, mold it to fit the language of your organization and how your laws are written. Then, take these proposed changes to your credentialing committee and your board to have your bylaws changed to adopt a delegated credentialing agreement. Bylaws can be malleable and updating them to allow for credentialing by proxy will, in the end, be worth it.

Radiology Capacity Ripple

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Can your teleradiology company keep up with demand?
 
 Supply versus Demand
 
The demand for teleradiology is reaching an all-time high. Some companies are struggling to keep up with their current customers, let alone bring on new clients. These companies are finding it hard to continue to produce the same quality, timely results they promise. When companies reach their breaking points, patients are the ones that suffer.
 
Jumping Ship
 
A decline in quality has caused many firms to jump ship and search for other firms to help provide the high-quality results they need. Many firms have limited capacity to take on new clients because they only have so many radiologists, and their current radiologists are hitting their capacity for reads.
 
Save Yourself
 
If you are going to change, change early – don’t wait around for bad service. Do your research now to make sure the company you choose will be able to handle your demand in one year, three years, and five years. Find a  provider that has the capacity to take care of your needs before someone else takes that spot.  If you find a company that you like, take advantage of it now because the opportunity might not be there in six months
 
What to Look For

  • Specialization and expertise
  • Radiologist accessibility and capacity
  • Dedicated radiologist
  • Universal access to reports
  • Reputation of the group
  • Shared goals – mission and vision

Does your Teleradiology Company Have Alternative Goals?

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It might be all butterflies and rainbows at the first meeting. They say all the right things and have all the right answers. They can meet all the metrics and promise to deliver the results you need, when you need them. You agree to the terms, sign the contract, and settle in. But is it what it seems, or is there an ulterior motive?

Some teleradiology company are going hosting contracts that give them access and information to your clients. They are starting to target radiology groups that use teleradiology companies that would want to supplement them for the work.

Ask yourself

  • Does your teleradiology company really share your mission and vision?
  • Are they going to help provide the solutions and support your need to reach your goals or are they just trying to reach their goals?
  • Is your teleradiology provider going after on-site contracts like the ones you have with your hospitals?

What to look for

  • Look for a well-established and trusted radiology services partner
  • Do your research – do they have any negative reviews?
  • Consider their existing clients – are there any red flags?
  • Speak to more than one existing client

Just because they say that they are patient-focused and have quality and integrity doesn’t mean they always do. Pay attention to the details and make sure you are truly getting a partner that will be working with you, not against you.