The Critical Role of Radiology in Patient Care

Radiology is the branch of medicine that utilizes imaging technology to diagnose and treat diseases with X-ray (XR), computed tomography (CT), magnetic resonance (MR) imaging, nuclear medicine (NM), positron emission tomography (PET), ultrasound (US), and interventional radiology (IR). Physicians who have specialized training in radiology are known as radiologists. The radiologist reviews the medical images, interprets the findings, and submits a final report. The final report may identify abnormalities, provide information that leads to guidance or confirmation of the patient’s treatment plan, interpret imaging test results, perform interventional procedures, and perform therapeutic procedures for radiotherapy. Patients entering the hospital will have some form of medical imaging performed to assist with determining the diagnosis and/or treatment plan, which deems medical imaging very crucial for diagnosing a wide range of medical conditions.  Increased volumes of medical imaging requests, rising staffing demands, declining reimbursement rates, and mounting pressures to meet turnaround time metrics have led healthcare institutions to seek assistance for this highly valued profession.

Radiology Staffing Approaches for Overnight Coverage

Large academic healthcare institutions have started employing overnight onsite radiologists, while other healthcare institutions continue to use radiology residents when the radiologist is unavailable. However, many healthcare institutions are utilizing teleradiology services.

Benefits of Overnight Onsite Radiologists

Employing an overnight onsite radiologist can be more costly; however, the healthcare institution will benefit from improved turnaround times, reduced delays in care, improved ED throughput workflow, improved final reporting timelines, established direct communication with overnight technologists, and increased knowledge of scan protocols, leading to decreased callbacks and discrepancies.

Understanding Teleradiology and Its Role

Meanwhile, teleradiology is the interpretation of medical images that occur from a remote location different from the institution where the imaging exam took place. There is a societal need to provide radiological care to the less populated and rural areas in the United States.

Final vs. Preliminary Reports: A Key Distinction

It is important to emphasize that radiology residents and teleradiologists can only complete a preliminary report, while the overnight onsite radiologist submits a final report. Although costs may appear to be higher as they relate to the salary for an attending radiologist, the final report will be completed sooner, which meets the shorter turnaround time demands. The throughput in the ED is positively impacted by having an overnight radiologist available, making this option desirable for radiology departments.

Cost and Benefit Considerations

Radiology residents and teleradiologists can only complete a preliminary report, while the overnight onsite radiologist submits a final report. Although costs may appear to be higher as they relate to the salary for an attending radiologist, the final report will be completed sooner, which meets the shorter turnaround time demands. The throughput in the ED is positively impacted by having an overnight radiologist available, making this option desirable for radiology departments.

• Is it beneficial and cost-effective to employ an overnight on-site radiologist in radiology departments?
• Are there situations in which teleradiology or the use of radiology residents is more cost-effective for radiology departments?

Interdisciplinary Coordination and Workflow Considerations

 As healthcare institutions are becoming more patient-centered, the need for service lines to communicate and function as an interdisciplinary team is important. When images are transmitted from the health care institution to the teleradiology service, prior images and reports must be sent for comparison along with the current images for the preliminary report. The teleradiology service can be responsible for reading for multiple health care institutions for large regions, which could be quite cumbersome to remember the nuances for each health care institution.

ED Throughput and Patient Safety Metrics

ED throughput is measured by a patient’s length of stay. A patient’s admission length of stay was not included in the metric. Decreasing the ED length of stay is a patient safety and quality care performance metric. Patient overcrowding in the ED can be problematic as well.  Having a dedicated overnight team of radiologists to contact is desirable. The overnight radiologist position could be beneficial to the ED. Liberman and McCarthy reported that the traditional standard is for the ED physician to work with the radiology resident after hours to review the medical images and complete the preliminary reports, and the report is finalized by the attending radiologist the next morning. The ED physicians could make medical decisions or diagnose health conditions much more quickly if there were a final report from the requested image, thereby resulting in a higher level of care.

Technology, Training, and Communication Challenges with Teleradiology

When using overnight teleradiology services, technologists will need additional training on how to send medical images electronically to the teleradiologist. The process of communicating with the teleradiologist should be included in the training. Additional support staff should be notified when there are network connectivity problems. Unlike the overnight radiologist, the teleradiologist will not be able to come onsite to view medical images from the modality workstation when network issues or information technology downtimes occur, resulting in longer reporting delays. The teleradiologist may not know the modality’s distinct protocols and may not be able to provide specific imaging guidance. It should be understood that there are health care institutions with financial budgets or stakeholders that may dictate how decisions are made, and money is spent. Those decisions may not be in favor of paying for an on-site overnight radiologist. However, the teleradiology service does cost less, has a wide geographic capability, and helps with turnaround times. Furthermore, the health care institution must vet the teleradiology services to ensure they are partnering with the best service to meet their needs.

Improving Technologist Communication and Protocol Adherence

One critical component will be to increase effective communication among technologists.  The technologist must be knowledgeable and aware of the scan protocols and communicate image quality issues, such as motion, pain, and contractures, that would prohibit ideal positioning and quality images. To improve communication, it would involve training technologists to increase the use of notes in PACS for the radiologist. The notes should contain pertinent patient information, as it pertains to safety, quality, patient limitations, contrast concerns, allergies, IV infusions, and prior radiologist protocol instructions.

Scan Protocols and Their Impact on Report Accuracy

Scan protocols serve as a valuable resource for radiologists and technologists. The findings demonstrated the impact of not having access to the health care institution’s scan protocols on preliminary report outcomes. Glazer performed a retrospective study at a 793-bed academic health care institution, which focused on better communication among the radiologist-to-radiologist and radiologist-to-technologist through a closed-loop notification system, to discourage deviations from scan protocols and encourage learning opportunities and improved image quality. “Deviations from the prescribed protocol” can result in discrepancies followed by patient callbacks and rescans.

Additional Training and Support for Teleradiology Workflows

When using overnight teleradiology services, technologists will need additional training on how to send medical images electronically to the teleradiologist. The process of communicating with the teleradiologist should be included in the training. Additional support staff should be available when there are network connectivity problems. Unlike the overnight radiologist, the teleradiologist will not be able to come onsite to view medical images from the modality workstation when network issues or information technology downtimes occur, resulting in longer reporting delays.

Finding the Right Balance

In conclusion, the increasing demand for medical imaging is causing many health care institutions to consider options for handling these demands and determining which is the most cost-effective for the radiology department. Although having an overnight attending radiologist onsite may cost more as it relates to the salary requirement, it is the best option when looking at the ED throughput, improved quality, and patient safety. It is not meant to suggest that all health care institutions should eliminate the use of radiology residents or teleradiology services. It is understood that despite the results found in the review, there are health care institutions with financial budgets or stakeholders that may dictate how decisions are made. Those decisions may not be in favor of paying for overnight radiology attending. However, the teleradiology service costs less, has a wide geographic capability, and helps with turnaround times. In addition, the health care institution must vet the teleradiology services to ensure they are partnering with the best service to meet their needs. Based on the findings, the most common reason for patient callbacks due to discrepancies is incorrect scan protocol. Proper training and improved communication for all involved will decrease scan protocol errors.