Pediatr Radiol (2010) 40:1349–1352

DOI 10.1007/s00247-010-1666-y

POINT/COUNTERPOINT

Pediatric teleradiology outsourcing: downside considerations

William E. Shiels II

Received: 17 March 2010 / Accepted: 23 March 2010 / Published online: 5 June 2010
# Springer-Verlag 2010

Introduction The focus of this discussion lies in the consequences of

This discussion is about teleradiology as a means of
outsourcing evening and night radiological interpretations
and is offered from the perspectives of both radiology
departmental and hospital administrative leadership. To be
objective and realistic, outsourcing of radiological patient
care to third-party radiologists might be a critical strategic
decision for small hospitals that lack sufficient specialty
and subspecialty expertise to accomplish the enterprise
radiology mission, either at night, weekends, or during
daylight hours. Other authors have undertaken excellent
discussions of the value of teleradiology and professional
issues involved with teleradiology [1–8]. In this discussion,
I will focus on risk considerations of teleradiology
outsourcing in moderate- to large-size radiology depart-
ments. As such, the assumptions of this discussion include
first the fact that teleradiology outsourcing for night and
weekend coverage is an increasingly common practice in
radiology departments, as an important lifestyle element for
radiology practice groups. Second, given the option without
consequence, most physicians would rather only work
weekday hours. Last, the reality exists that group practice
decisions affect others and are scrutinized by others, and
that this scrutiny can have a long-term impact on a group.
An alternative view of pediatric teleradiology can be found at doi
10.1007/s00247-010-1667-x.
W. E. Shiels II (*)
Department of Radiology and The Children’s Radiological Institute,
Nationwide Children’s Hospital,
700 Children’s Drive,
Columbus, OH 43205, USA
e-mail: william.shiels@nationwidechildrens.org
such decisions, with the potential for long-term negative
outcomes, both for the individual and for a practice. The
decision for teleradiology outsourcing involves numerous
stakeholders: the radiologists, hospital administrators, hos-
pital boards of trustees, and clinical physician specialists.
There are five main issues:
(1) Radiology value attribute
(2) Professional reputation and respect
(3) Administrative credibility and partnership
(4) Economic liability
(5) Radiology as a fungible asset
Radiology value attribute
Chieftains who believe they can’t influence events
have, in fact, surrendered before the battle begins.
Attila the Hun [9]
Simply stated, we as radiologists create the value added
perception or “value attribute” of our groups within the
organizations in which we practice. Our value attribute is
something that we actively create and define by individual
and collective actions, both as radiologists and as leaders.
In our groups we, hopefully, actively define, discuss, and
implement a plan for creating, nurturing, and protecting our
group value attributes. Additionally, the value attributes of
a radiology practice are defined by others. We, more than
anyone, have the ability to assess the organization’s needs,
values, and opportunities for our practice groups to meet
these needs and to be perceived as valuable assets that meet
organizational needs, add desired “enabling” value, and
help propel our organizations, better with us than without
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us. In short, if we fail to create and define perceptions of
our practices, we become victims of others’ perceptions.
In any healthcare enterprise, the impact of a fully
engaged pediatric radiology department is broad and
potentially profound (Table 1). As we and others evaluate
radiology’s organizational impact, full engagement in
clinical care needs includes day, night, and weekend care.
Simply stated, night and weekend teleradiology outsourc-
ing involves the decision to disengage, partially or
completely (preliminary vs. definitive teleradiology inter-
pretations), from organizational care needs during nights
and weekends. In the practice model with night and
weekend teleradiology outsourcing, radiologists hope to
re-engage in enterprise healthcare partnerships during
daytime hours, and hope that all clinical relationships will
resume unaffected. As drivers of perception and definition
of appropriate behavior, our buy-in of teleradiology
outsourcing defines “disengagement” as an acceptable and
appropriate professional relationship behavior. This implies
that disengagement is appropriate both for us and other
enterprise stakeholders (administration and clinical col-
leagues). The longer we disengage from the needs of our
organizations, the more we sense decreasing levels of
Table 1 Radiology organizational impact
Clinical mission
• Daytime care
• Night care
• Weekend care
Research mission
Education mission
Corporate readiness
Policy development and implementation
Quality assurance
Quality improvement
Accreditation
Safety culture development, implementation, and improvement
Strategic plan implementation
Business model/business case development
Capital budget process
Technology assessment
Capital management
Innovation
Utilization management
Technologist management and career development
Marketing
Public relations/media relations
Forensic consultation
Legal consultation support
Billing and reimbursement
Crisis management
Pediatr Radiol (2010) 40:1349–1352
administrative and collegial commitment and partnership
toward our groups and departments.
Professional reputation and respect
Chieftains should never intentionally place Huns in a
situation where the price of losing outweighs the
rewards of winning.
Attila the Hun
When we disengage from night and weekend care with
teleradiology outsourcing, we create the perception of
ourselves as valuable to our administrative and clinical
colleagues only when it is convenient or comfortable for
us, and not at other times. In this paradigm, we settle
for professional reputations and respect that are based on
our clinical partnership, when present. In this partial or
fractionated partnership, we should be comfortable with
ongoing limited professional relationships. We should not
be naïve in thinking that as valued and expert professionals
our absence is not noted in critical night and weekend care
encounters.
With specific regard to outsourced teleradiology groups
providing care for our colleagues, one study demonstrated
that 93% of teleradiology studies were interpreted within
30 min [6]. Let us assume that when we are providing on-
site care, our critical radiological care is delivered with
turnaround times (to include critical result reporting) in 5–
15 min. By providing teleradiology with a 30-min response,
we might be forcing our colleagues to accept performance
well below the standards that we set when we are present
in the hospital. With teleradiology outsourcing, we teach
our colleagues that contingency support is the greatest
commitment that we are willing to provide in our clinical
partnerships. This message speaks loudly, is heard loudly,
and is readily translated into the foundation of our profes-
sional reputations.
Administrative credibility and partnership
Reduced clinical presence translates into reduced partner-
ship, both on clinical and administrative levels. With
teleradiology outsourcing, we teach our administrative
stakeholders that clinical and administrative disengagement
is acceptable. During weekday daytime administrative
leadership meetings, committee meetings, resource nego-
tiations, capital budget decision deliberations, hospital
Board of Trustees meetings, and the like, we are regarded
as part-time stakeholders with reduced administrative
credibility and partnership. If we ask our administrators
for disengagement, we may get more disengagement than
Pediatr Radiol (2010) 40:1349–1352
initially intended. Consider that the request or demand for
teleradiology outsourcing is a statement to the hospital, “we
need you to do without us for 33% of the week,” and when
they say yes, we should not be surprised when they
presume they can do without us the remaining 67% of the
week. “We will do without you” implies that administra-
tive, resource, and policy decisions might be increasingly
made without the input of Radiology.
Economic liability
One of the most insidious ways to abuse power and
position is to spend tribal monies irresponsibly.
Attila the Hun
The cost of teleradiology outsourcing can be provided in
two ways: (1) The cost is a line-item expense in the
radiologists’ professional operations, or (2) The radiology
group negotiates that this expense should be borne by the
hospital and not impact the radiologists’ revenue and income.
If the radiologists personally absorb the expense, then
the only liabilities lie in reputation, respect, and partner-
ships as discussed above. The direct cost to group
economics might be seen as worth the lifestyle tradeoff
until the group sees the manpower cost of performing daily
final interpretations as a liability. If the teleradiology
company provides final interpretations and quality issues
arise, the radiologists might be required by the hospital to
perform routine quality audits with double-reading of work
performed by the teleradiology outsourcing company. This
QA double-work might become a financial drain on the
radiology group, worth reconsideration.
On the other hand, if the hospital assumes the financial
liability of teleradiology outsourcing service (for discussion
purposes, assume $250,000 annually), then radiologists’
disengagement and teleradiology outsourcing represent a
new corporate financial liability. As hospital operations
budgets are analyzed for cost-saving opportunities, tele-
radiology outsourcing cost is weighed against organiza-
tional value. If the organization finds that teleradiology
outsourcing helps the enterprise provide better, more
competitive care, with greater safety margin, better provider
and customer satisfaction, and full administrative support,
then this financial investment is a true corporate asset. If, on
the other hand, teleradiology outsourcing represents a
corporate financial and professional liability, then each
financial review reinforces corporate dissatisfaction with
the radiologists, their leaders, and the practice model. As
healthcare evolves with greater financial pressures and
limitations, hospital corporate reviews become more criti-
cal, with hospital leaders looking for liabilities to reduce or
eliminate in order to fund mission-critical programs.
1351
Radiology as a fungible asset
Chieftains who complain of too many bad days are
reminded that ‘tough’ is when you have no place left
to turn.
Attila the Hun
In corporate terms, a fungible asset is one that is easily
replaced. When we choose teleradiology outsourcing as a
priority commitment, we make the simple statement to our
professional colleagues, administrators, and hospital board
members that our professional radiology services are
easily replaced. If a hospital contracts with a teleradiology
company that is looking to expand (especially if publicly
traded, or owned by an academic medical center that
desires greater radiology market share), the company will
likely also offer the hospital daytime services as an
opportunity to further cut costs and improve hospital
budgets. In the simplest case of a hospital contracted with
a private practice group for radiology services, downsizing
the FTE requirements for radiologists may save the
hospital costs of secretarial support, office space, or other
administrative costs included in the radiology professional
services contract. An aggressive teleradiology company
might offer the hospital administrative support in the form of
utilization review, capital equipment technology assessment,
quality assurance support, technologist continuing education,
legal professional opinion support, and corporate strategic
planning consultation, to name a few. In the culture of
disengagement on the part of the radiologists and adminis-
tration, professional loyalties become fragile hopes that are
readily dismissed during corporate financial deliberations.
If the radiologists are hospital employees (with annual
operational costs of salaries, benefits, pensions, secretarial
support, research support, office space and furniture, etc.),
then expansion of teleradiology outsourcing care during
daytime hours to a firm (that is able to hire radiologists
cheaper than the hospital) might prove to be financially
advantageous for the hospital enterprise. In this model,
pediatric radiologists would only be needed for fluoroscopy,
US studies requiring on-site presence, contrast agent and
sedation supervision, and interventional radiology care. For
financial modeling, assume a radiology group of 15
radiologists and a cost savings of only 10% for each
radiologist replaced with teleradiology outsourcing, reducing
the group size to five radiologists could provide net hospital
savings of one FTE (assume conservative total cost estimate
of $350,000/radiologist) while maintaining clinical interpre-
tation services at current or better levels. If teleradiology
outsourcing were offered by an aggressive academic center
with low expenses, a hospital savings of $350,000–
$700,000 per year could be quite tempting for hospital
1352
leaders to consider. Once the previously employed radiol-
ogists were dismissed, an aggressive teleradiology firm
would work diligently to maintain its contract and assure
that the value it adds to the healthcare system is perceived as
greater than any pleas from the disengaged radiologists for
re-employment. Having seen this exact scenario play out in
our state, in a teaching community hospital, this is no longer
a naïve hypothetical consideration. Furthermore, once on-
site radiologists are discharged, ACGME requirements
become difficult to meet (such as one radiologist FTE for
each of the nine radiology subspecialties, a residency
director, and a minimum of 7,000 radiology studies per year
per resident) and residency programs close. Now, the so-
called academic medical center that provides out-of-state
teleradiology services (with the potential of closing radiol-
ogy residencies and fellowships) becomes quite the business
pirate, with less than lofty academic ethical goals for the
common good of the radiology community.
Additionally, if hospital administrations look for ways to
reduce the need for radiologists, other physician specialty
groups might be happy to provide professional services for
care traditionally considered in the realm of diagnostic and
interventional radiology (e.g., emergency US, cardiac MR
and CT, interventional procedures provided by surgeons
and intensivists, neuroimaging provided by neurologists).
In closing, I quote a concise statement from an American
College of Radiology White Paper on radiology value
added: “In the end, the success or failure of the specialty
will be the aggregate outcome of how individual responsi-
bility is exercised” [8]. If teleradiology outsourcing pro-
vides critical support for a hospital with few radiologist
Pediatr Radiol (2010) 40:1349–1352
assets, and is critical to the mission success of the hospital,
then teleradiology plays a valuable role in professional
partnerships for a healthcare enterprise. If teleradiology
does not provide critical survival support for healthcare
enterprises, the potential downside considerations of tele-
radiology outsourcing should be seriously reviewed prior to
disengaging from our clinical care opportunities, from
which we hope to garner a livelihood.
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