When patients needed urgent CAT scans, MRIs and ultrasounds late at night at St. Mary's Hospital in Waterbury, Conn., emergency room workers used to rouse a bleary-eyed staff radiologist from his bed to read the images. Not anymore.
The work now goes to Arjun Kalyanpur — 8,000 miles away in Bangalore, India. When it is the middle of the night in Connecticut, Kalyanpur is in the middle of his day, handling calls from St. Mary's and dozens of other American hospitals that transmit pictures to him electronically so he can quickly assess them and advise their doctors.
Kalyanpur runs one of an increasing number of "nighthawk" companies operating in the United States and overseas to take advantage of time-zone differences and the latest technology by having radiologists read images from such far-flung places as Hawaii, India, Australia, Switzerland, Israel and Brazil.
Trend raises questions
The companies, and the doctors and hospitals using them, say the trend is improving care by guaranteeing that well-rested radiologists are always available, even in the middle of the night, even for the smallest hospitals and in the most rural areas.
Skeptics, however, say the practice raises a host of concerns. Are the radiologists qualified? Is communication as good when the radiologists are so far away? Can an overseas doctor be held accountable when something goes wrong? Is anyone ensuring that properly trained and licensed radiologists are actually doing the work? Is patient privacy being protected?
Both sides see the trend as the leading edge of a movement toward greater use of telemedicine, which is widening the spectrum of care doctors can provide from afar and enabling more outsourcing of medical services overseas.
"What we're seeing with teleradiology is really just the beginning," said Jonathan D. Linkous, executive director of the American Telemedicine Association. "Similar things are already starting to happen in other areas, such as pathology."
The trend has sparked a flurry of regulatory initiatives, including proposed state and federal legislation designed to ensure that doctors performing the work are properly trained and licensed, and that patients are notified whenever information about them is transmitted elsewhere, especially overseas.
"Patients have the right to know, and the right to say no, before their X-rays or other private health information is offshored to countries that lack strong privacy safeguards," said Rep. Edward J. Markey (D-Mass.), who with Sen. Hillary Rodham Clinton (D-N.Y.) recently introduced legislation that would require patient consent in advance.
More tests, fewer technicians
The advent of remote radiology services was prompted by various factors, including a shortage of radiologists and rapid advances in imaging technology, which has caused a sharp increase in the number of tests. As a result, many hospital radiologists have a hard time keeping up with the demand, especially at night.
"We don't have the staff to have some guy up all night and then come back in the next day," said Robert Lehman, who heads the St. Mary's radiology department. "It's just too dangerous."
In response, St. Mary's and hundreds of other hospitals and radiology practices have begun outsourcing, allowing their staff radiologists to come to work fresh each morning.
"I'm convinced patient care is improved," said Paul Berger of NightHawk Radiology Services. The company, based in Coeur d'Alene, Idaho, has about 40 radiologists in Zurich and Sydney serving about 600 U.S. hospitals and other facilities, including 16 in Virginia.
Some worry about ‘ghosts’
But skeptics worry that remote radiology operations may be staffed with one or two U.S.-certified radiologists who approve reports prepared by less-qualified technicians, a practice known as "ghosting."
"The nightmare scenario is you have one or two people with licenses and a room with 25 or 30 computer terminals staffed by people who may or may not be radiologists," said John Haaga, chairman of the radiology department at Case Western Reserve University in Cleveland.
Wipro Infotech, a large company in India that provides a variety of services to U.S. companies, began using non-U.S. licensed radiologists to provide "preliminary" interpretations of images for U.S. hospitals in 2003. Wipro halted the service because of intense criticism but remains interested because the market has only increased, officials said.
"The demand is huge. We get a couple of calls every week," Wipro's T.K. Kurien said. "We'd like to see some kind of process where our guys could provide this kind of service to hospitals in the United States."
Hiring standards defended
NightHawk and several other companies providing the offshore radiology services say they hire only U.S.-trained doctors who are licensed in every state where they have clients and credentialed at the hospitals they serve. But policing the services remains a concern.
"Because of the ease of moving this stuff around, the problem of being able to authenticate who is doing the work is an issue," said Robert Wise of the Joint Commission on Accreditation of Health Care Organizations, which is upgrading its standards for accrediting hospitals in response to the trend.
The companies providing the service, and the hospitals using it, argue that the reports are double-checked each morning by staff radiologists, so questionable interpretations would quickly be spotted.
"We'll find little things here and there, the same way we find little discrepancies amongst our own radiologists," said Russell McWey, chief radiologist at the Virginia Hospital Center in Arlington, which uses NightHawk. "But there's been no major discrepancies."
But some say there are other potential pitfalls, such as possible communication problems when doctors are so far apart and are strangers.
"It's difficult to point out something on an image if you're not actually standing there in the room with the other doctor looking at the same image," said Arl Van Moore, who chaired an American College of Radiology task force that issued guidelines on the practice in February.
Face-time overrated?
Proponents say most conversations between radiologists and emergency-room doctors take place over the phone, even when the doctor is down the hall or at home, making it just as easy to communicate from thousands of miles away.
"You can't reach over and slap them on the back, but every other aspect of the interaction is preserved," Kalyanpur said.
Nevertheless, Kalyanpur is embroiled in a malpractice case where communication has become an issue. The Grand View Hospital in Sellersville, Pa., and one of its emergency-room doctors is being sued in the case of a man sent home with a diagnosis of diverticulitis. He died hours later when an artery in his heart burst. The hospital and doctor allege Kalyanpur failed to make it clear that more testing was urgently needed to follow up on a CAT scan he read. Kalyanpur denies any wrongdoing.
"Over the past few years, we have worked very hard against the 'anti-India' factor to build up a U.S.-standard company," Kalyanpur wrote in an e-mail. "Our quality reports are saving lives every night in the U.S."
Who’s in charge?
Some also worry about what will happen when mistakes occur. Will a radiologist on another continent be as easily held liable? Could a physician in Bangalore or Beirut be compelled to come to the United States for court proceedings?
"If your radiologist is in Australia or India, I'm not so sure how easy it would be hold them accountable," said Dennis F. O'Brien of the Maryland Trial Lawyers Association.
Companies offering the services say they have the same malpractice insurance as any U.S.-based radiologist, and such cases would be handled no differently.
"It would be very much in their interest to return to the United States to participate in any proceedings," said Sean Casey, chief executive of Virtual Radiologic Consultants of Eden Prairie, Minn. "This is where their livelihood is. They're not going to risk losing their licenses."
