Q: What is the difference between teleradiology and outsourcing?
A: Teleradiology refers to the process by which an image is sent – i.e. electronically. The images may be seen by:
(A) The same doctor who would normally have seen it anyway (examples 1 and 4 above).
(B) Another doctor in the same organisation who would not normally have seen it (examples 2 and 3).
(C) Another doctor in a different organization (example 5).
Only (C) qualifies as outsourcing.
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Teleradiology and outsourcing in Singapore
Q: Is teleradiology being performed in Singapore?
A: Yes! Teleradiology has long been a part of everyday practice here in Singapore, on both a formal basis (example 1), and an informal basis (example 2). In fact, as far back as 1996, a teleradiology link was established between Singapore General Hospital and Stanford University in California, USA. [Reference: Png MA, et al. Remote consultation for computerized tomography and magnetic resonance studies by means of teleradiology--experience at the Singapore General Hospital. J Telemed Telecare. 1997;3 Suppl 1:54-5]
Q: Is outsourcing being performed in Singapore?
A: Also yes! Starting in December 2005, Ang Mo Kio polyclinic has been sending 700 x-rays a month to India for reporting. This was extended to other NHG polyclinics (which comprise Ang Mo Kio, Bt Batok, Choa Chu Kang, Clementi, Hougang, Jurong, Toa Payoh, Woodlands and Yishun) in April 2006, with the aim that the Indian doctors will take over the reading of X-rays from eventually from all of them.
Experts say the more sophisticated CT scan, ultrasound and MRI images may also find their way to India. This has been confirmed by the Health Minister, who has stated he will expand this "to study other applications of telemedicine" (Presumably telepathology, tele-robotic-surgery, tele-icu-monitoring, tele-whatever). [References: NHG Polyclinics Annual Review 2005-2006, Pg 10. Indiatimes Health, X-rays outsourced to India, 1435209.cms. MOH Budget Speech, Mr Khaw Boon Wan, 06 Mar 2007] ]
Q: Tell me more about this outsourcing.
A: The x-rays are taken in the polyclinics and outsourced to Teleradiology Solutions in Bangalore. Teleradiology Solutions was started in 2002 by Dr Arjun Kalyanpur who returned to India from Yale-New Haven Hospital for family reasons. Yale later stopped the program, apparently because of internal complaints and the high costs of communications. Undaunted, he moved on to other hospitals, and their website now lists 9 radiologists as of 17 March 07 (Aditya R.Daftary, Anjali Agrawal, Arjun Kalyanpur, Mini Pandit, Mythri Shankar, Sanjay V. Kamath, Steve R. Klepac, Magie Michail Malaro and Kenneth Koster) who cover nearly 50 hospitals in the United States. [Reference: New York Times, Nov 16, 2003. rediff.com, India to be teleradiology hub!, April 26, 2005. Seattle Times, 6 Dec 2004, Indiatimes.com]
Q: What is the rationale behind outsourcing?
A: According to the Ministry of Health, there are three aims:
Q: How much money is saved with outsourcing?
A: This is unknown. Indeed, there is no evidence that there are indeed cost savings as:
(1) MOH has not published any financial information, unlike their initiatives to compare prices in other areas (e.g. Lasik, Hospital Inpatient charges, etc.)
(2) No open tender was conducted, so the details and prices of the contract are not transparent to the public.
(3) Both NHGD and Teleradiology Solutions decline to reveal the pricing structure citing commercial confidentiality.
The only figure publicly reported so far is that $2.3 million has been spent on a system to send digital images to India for reporting.
Perhaps the only conclusion that may be drawn is an indirect one: If you compare the NHG polyclinics that have outsourced their X-rays to India, against those that have not, both charge the same prices for X-rays – ipso facto, the patient is not saving money by having their X- rays reported in India.
Q: How much does it cost to report an x-ray anyway?
A: Some private locum radiologists charge roughly S$2 to $4 per plain x-ray (i.e. chest xray, knee xray). This means that out of the S$28 you pay for the X-ray, about 5-6% of the cost goes into generating the professional report.
(Side note: I feel using a locum radiologist pricing is the cleanest way to estimate the plain film reporting cost, compared to a full-time radiologist who has other duties e.g. reporting CT/MRI, administrative tasks.)
Q: Come on, I'm sure you have some clue on how much the Indians charge?
A: Openly published data from Teleradiology Providers quote "X-Ray - 10 US Dollars / Rs.300" (as of 20 March 07). The price for bulk reads will naturally be cheaper, possibly (don't ask where I got this from) about S$24000 per month(25 days, excluding Sundays) at the base(minimum) rate of 10 films/hour, with additional films charged on a sliding scale.
10 films/hour x 12 hours/day x 25 days = 3000 films per month. $24000 divided by 3000 films = S$8 per film.
So prices ranges from S$8 to S$18 (US$10) per film, compared to S$2. Okay, maybe my figures are wrong or my math sucks. Anyway, you go get your own quotes and do your own math if you so desperate to know.
Q: According to NHG, outsourcing has decreased the turnaround time for X-ray reporting from two to three days to 1 hour.
A: This is due to the implementation of teleradiology, not of outsourcing. Teleradiology has enabled images to be sent electronically, instead of the previous system of sending hard-copy xray films. (Refer back to example 1 in the section “What is teleradiology").
The same time savings could have been achieved with by enabling teleradiology with a local institution (e.g. TTSH).
In fact, outsourcing (by itself without teleradiology) would increase turnaround time. Can you imaging flying the films from Ang Mo Kio Polyclinic to India for reporting and having the report flown back in 1 hour?!
Q: So how long does it take to send the images to India anyway?
A: This answer is probably going to be outdated in no time at the rate the Internet is progressing, but a study by Arjun Kalyanpur (the chief radiologist of Teleradiology Solutions himself) published in Radiology (a leading radiology journal) reported the following:
[Reference : Kalyanpur A, Neklesa VP, Pham DT, Forman HP, Stein ST, Brink JA. Implementation of an international teleradiology staffing model. Radiology 2004;232:415-9.]
Q: How about the third point – better quality reports?
A: The largest study to date (124,870 cases, in California in 2003) reported a discordant rate of 1.09%. In other words, the report by the teleradiologist differed from the first radiologist in about 1 out of every 100 cases. Note that 'different' may not necessarily mean 'wrong'.
However, the above study is not 100% relevant to the Singapore context. Unfortunately, no audit data or papers been published regarding the Singapore-Indian experience, and to the best of my knowledge, a similar paper is unlikely to appear anytime soon, for the simple reason that 'double-reading' (i.e. reading of the same x-ray by two radiologists) is not being practiced for the outsourced films.
Lastly, anecdotal stories abound (I'm sure most medical professionals have heard some, one way or another), but these are of little, if any, scientific value.
Q: Okay, so we don’t have data on quality. How do I know my radiologist is qualified?
A: That’s where accreditation, standards and training comes in - see the next section.
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Accreditation, Standards and Legal issues
Q: What training is need to become a radiologist?
A: A typical route here in Singapore would be to first complete 5 years of undergraduate training in the National University of Singapore (NUS) and obtain a basic medical degree (M.B,B.S). This gives someone the right to be called “Doctor".
This doctor would then do at least more 2 years of clinical training (e.g. Surgical houseman or Orthopaedic medical officer) before starting basic specialty training (BST) in a Radiology department.
After a minumum 3 years of training in Radiology, the trainee would then sit for (and hopefully pass!) the UK FRCR (Fellow of the Royal College of Radiologists) and/or local MMed(Diagnostic Radiology) examination.
This is followed by 2 more years as a Registrar in the Advanced Speciality Training(AST) program, before taking one last examination known as the “Exit Examination".
In summary, it takes 12 years and 3 major examinations to become a Radiologist under the Singapore training program.
Q: Do the radiologists from Teleradiology Solutions have MMed or FRCR?
A: No. Looking through the curriculum vitae of the 9 radiologists (available online), none of them possess the MMed or FRCR. Their qualifications have been obtained from India and/or the United States.
Q: What’s so different about foreign training in India or the USA?
A: These foreign medical training programmes are quite different from our UK-based curriculum. For example, many radiologists in India enter the radiology training program without first spending the 2 years in clinical (ward) practice treating patients.
Therefore, the Singapore Medical Council stipulates that non-Singaporean doctors trained overseas need to meet the following conditions to qualify for full registration:
Q: I see. Are the radiologists in Teleradiology Solutions registered with the Singapore Medical Council?
A: No. The 9 doctors listed on their website cannot be found on a search of the SMC register. (12 Feb 07) [Note: The direct link above to the search page often changes, but should be accessible from www.smc.gov.sg - Register of Medical Practitioners]
Q: Are the radiologists in Teleradiology solutions accredited by the Specialist Accreditation Board?
A: No. There are 143 registered radiologists in Singapore listed on the SAB website (as of 12 Feb 07) [Once again, the direct link may change, but may be found on the smc.gov.sg website - Register of Medical Practitioners -> View List of Specialists]. The 9 Teleradiology Solution doctors are not found on the list.
Q: How about the “2 years of good perfomance" and “5 years of clinical experience"?
A: To the best of my knowledge, none of the 9 doctors have worked in Singapore for 2 years, much less been assessed for that period. Referring to their online c.v., approximately half of the 9 have less than 5 years of post-speciality experience.
Q: So if the exact same doctor from Teleradiology Solutions was in Singapore right now, is he allowed to report my x-ray?
A: No.
Q: But right now they are in India reporting my x-ray?
A: Yes.
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Q: What does the law have to say about unregistered doctors practicing medicine?
A: Under the Medical Registration Act, Chapter 174, Part V, Sections 13-17, “Any unauthorised person who is not registered under [the] Act and has a valid practising certificate… shall be guilty of an offence and shall be liable on conviction to a fine not exceeding $100,000 or to imprisonment for a term not exceeding 12 months or to both and, in the case of a second or subsequent conviction, to a fine not exceeding $200,000 or to imprisonment for a term not exceeding 2 years or to both."
Q: So they are breaking the law? Surely they won't throw a doctor in jail!
A: Whether they are breaking the law is for the courts to decide, not you or me. Having said that, An Indian ayurvedic practitioner operating an illegal medical practice was sentenced to eight months' jail, so there is already a precedent. [Reference : Straits Times, Indian doctor jailed for illegally treating workers, 9 Nov 05]
Q: Big deal. Who cares what happens to these un-registered radiologists? After all, I now get my x-rays faster and cheaper.
A: Let’s go back to the example of your knee x-ray. Suppose your radiologist missed a fracture (which in itself is not negligent). But let’s say (hypothetically, of course) he missed it because he had 700 films from 50 hospitals to report within 1 hour, so he decided “I’m too busy, let’s just report all of the x-rays as ‘Normal’ without even looking at them."
Or perhaps he gave half his pile of films to the medical trainee on attachment with him (who can generate a basic report, but has no clue what an avulsion injury of the tibial spine (which you have) looks like), and said “Report this pile, and sign it out under my name."
So there you are, stuck with a undiagnosed knee fracture because the radiologist didn’t even see the film (despite having his name on the report). In fact, you’re mad as hell. It’s one thing to make an honest mistake in the course of your job (which we all do), but another to not even do your job. So being a typical Singaporean, you complain. Which is where your problems begin.
Your first stop will be your GP, where you should bang the table and say, “How did heck did you miss this fracture!" Unfortunately for you, he may shrug and point to the “Normal – no fracture seen" report. Which is quite fair, since it’s the radiologist getting paid to report the x-ray,
So your next stop will be the radiologist. Now if he’s registered with the SMC, that’s not a problem. Simply key his name into the SMC search engine, and viola! His qualifications and address of practice will pop up in seconds and you can hunt him down. (Don't believe, key "Gerald" into the form!)
Of course, if he’s not registered with the SMC, your search is going to turn up a big fat nothing, nada, zilch. How are you going to scold/complain about/sue someone you can't even find?
Q: Can I apply to SMC to remove them from the register and stop them from practicing?
A: Sure you can, but they aren’t registered in the first place. You can’t strike a person off something they’re not on.
Q: Won’t SMC forward my complaint to its overseas counterpart?
A: That is for SMC to decide. Even if they do to pursue the matter, the other medical council is not obliged to even investigate the case, much less punish the doctor in question.
Recall the case of Prof Shorvon, who SMC convicted of performing illegal experiments on patients in NNI. SMC chased him back to the UK, complained to the General Medical Council (GMC) of UK, and even hired a Queen's Counsel (the most elite lawyer available) to argue the case in the British High Court. Of course, we all know how that turned out. (For those of you who don’t, the GMC declined to even formally investigate the case, much less convict or punish him.) [References : Asia Sentinel, London Calling, 22 January 2007. channelnewsasia.com, One case, two verdicts, 08 January 2007]
Q: Okay, how about I sue them myself instead?
A: Sure you can, but once again, it is pointless to sue someone who isn’t in Singapore and doesn’t have any assets here. Even if you win, all you’ll have is the taste of hollow victory in your mouth and a large legal bill.
Q: Don’t they have medical malpractice insurance like all the other doctors in Singapore? Can’t I collect from that?
A: I don’t have access to the subscription lists of the Singapore medical insurance companies, but I do know that they will not provide malpractice cover if you aren’t a registered doctor.
Q: Fine, fine, how about I go to their home country and sue them?
A: Be my guest, and good luck.
Q: The Ministry of Health stated in a letter to the Straits Times Forum (6 Mar 2006) that “(the referring hospital/doctor) remains legally accountable to its patients for the quality of its radiological services, including X-ray reports that are outsourced". I’m going to sue them instead!
A: This is partly true, because:
1) “Doctors have an obligation to ensure that the report they depend on came from a reliable source, and that the radiologists are qualified". [Reference : Dr Ming Keng Teoh, International Medico-Legal Adviser, SMA News December 2005 Vol 37 (12)]
2) Dr Ming Keng Teoh goes on to say “Case law and legislation have yet to catch up with this rapidly developing area of healthcare. It is not yet clear how the legal process is going to be tested, and how liability is going to be apportioned between the hospital, the remote radiologist and the clinician in charge of the patient."
3) However, as far as most medical lawsuits go, the doctor-in-charge(primary physician) would have been included as a defendant anyway.
My (non-legal(!)) opinion therefore, is that assuming the patient wins the case, one of two things will happen:
a) The court will divide blame between the primary physician (e.g. 40%) and the overseas radiologist (e.g. 60%), and the patient will only get 40% unless he is willing to pursue the matter overseas (i.e. go to an foreign court to enforce the judgement).
b) The court will decide that the primary physician was both directly responsible (same 40%), but should have known better than to depend on the report of the un-accredited, un-registered radiologist, and therefore also has to pay the radiologist’s 60% share.
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Comparison with other teleradiology setups overseas
Q: What are the main differences between how outsourcing is practiced in Singapore and in the United States?
| Exploits time zone differences to report films done at night(USA) while it is daytime in India or Australia | No significant time difference with India |
| Be licensed to practice medicine in the state where the imaging examination is originally obtained | Not necessary to be a registered Singapore doctor |
| Radiologist must hold American Board of Radiology Certification | No requirement to hold FRCR or MMed(Diag Radio) |
| Must be licensed to work as a radiologist in USA | Not necessary to be a licensed Singapore radiologist |
| Must be credentialed with the individual hospital | No requirement |
| Have appropriate medical liability coverage for the US state. | No requirement |
| Be responsible for the quality of the images being interpreted | Not stated |
| Security protocols in place to maintain patient confidentiality | Not stated |
| May be “double-read"(checked for accuracy) by a US-based(local) radiologist before final report is issued. | Not practiced |
- ACR Standard for Teleradiology, Revision 2002 (Res 11)
- ACR Statement on the Interpretation of Radiology Images Outside the United States (5/8/04)]
Q: Can radiologists in Singapore practise "in-sourcing" from the USA, i.e. read outsourced films from there?
A: Yes, by meeting the requirements in the table above.
Q: So why is it easier for the Indian radiologists to "insource" Singapore's films, than for Singaporean radiologists to "insource" USA films?
A: Because there is no requirement for them to meet the local(Singapore) registration/licensing requirements, unlike the requirements to report US films.
Q: Why would Teleradiology Solutions report Singaporean films rather than concentrate on the American market?
A: The exact reasons are known only to them.
However, it appears to have difficulty in securing contracts with the larger American hospitals, and may be trying to use Singapore as a temporary stepping stone in opening doors into the USA. This could be by using the Singapore-USA free-trade-agreement as a backdoor, or by leveraging on the Singapore brandname and credibility. (See inset).
Other (hypothetical) reasons may be that they have radiologists who are not qualified to report American films (see above requirements), and thus need to find work for them to do.
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Advantages
Advantages of teleradiology
Advantages of outsourcing
Disadvantages / Limitations
Disadvantages / Limitations of teleradiology
* - The time, effort and cost of the items by a (*) are currently being absorbed (i.e. done for free, without explicit costing) by the radiologists in Singapore. It is possibly, that as reporting workload (and reimbursement) leaves the hospital, these "hidden costs" will surface and begin to be charged separately.
Disadvantages of outsourcing overseas
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My Opinion
Teleradiology and outsourcing is a double-edged sword, for the patient, the hospital and the radiologist. On the one hand, it has the potential to improve patient care. On the other hand, it introduces new complexities and legal issues, and has the potential for many problems and pitfalls.
In my opinion, the following criteria should be met for teleradiology/outsourcing to be a success:
1. Patients should benefit in one (or more) of the following ways:
- Time savings that affect clincial management.
(Faster is not always better, if it costs more and does nothing to improve patient care, or results in shoddier reports)
- Costs to the patient are reduced (taking into account startup equipment, training, and data transmission costs).
- Contracts should ideally be awarded in an open, competitive tender for transparency.
- Care should be taken against anti-competitive/predatory behaviour
(e.g. quoting below cost for first 3 years in order to drive out the competition and secure a monopoly, in order to raise prices subsequently)
- Xrays can now be reported by a subspeciality radiologist, where none was previously available
- Xray reports are statistically shown to be more accurate, resulting in significant improvements in patient management.
(Anecdotal reports of "missed" diagnoses or "better" reports that "saved lives" do not count)
2. Quality standards and legal requirements must be fulfilled
- Educational and professional accreditation requirements of the patient's (host) country.
- Host(local) medical council registration
- Accountability to the host country medical council and law courts
- Medical malpractice insurance cover, valid in the host state/country
3. Work should be recognised and rewarded
Not all work is equal, and not all work is paid. Let me elaborate.
- We all know that a CT or MRI is more difficult to report than a chest X-ray, and accordingly, the reporting fee for a CT is understandably higher.
- However, even within chest X-rays, there are different levels of difficulty.
- A outpatient screening chest x-ray (e.g. taxi driver employment) is more likely to be "normal" than a chest-xray of an ICU patient, and therefore faster to report.
- A outpatient chest x-ray is also much easier to perform than an ICU x-ray - the patient simply takes off his shirt and walks up to the machine by himself.
An ICU x-ray involves pushing the machine up to the ward, undressing the patient, positioning him, etc. etc.
- Assume it costs the hospital $10 to perform a "screening" chest xray, and $20 for an ICU x-ray.
- To avoid administrative hassle, the hospital may choose to charge everyone $15 for a chest xray, and reports its costs as so ("$15 for a chest-xray").
- In effect, the "screening" xray cross-subsidizes the "ICU" xray. (Whether this is right or wrong is a debate for another day).
- Now another organisation comes along, and says, we'll do (or report) your outpatient x-rays at $12. On paper, this looks good - hospital saves $3 ($15-$12).
- Problem arises: The hospital may have saved money on the outpatient x-ray, but is now losing money on the ICU xrays ($15-$20) = $5 per film.
- In fact, the hospital is probably losing even more money, since it has fixed costs that do not decrease despite outsourcing the outpatient X-ray.
(e.g. X-ray machines cost $2 million regardless of whether it runs at 50% or 100% capacity, lights must still be turned on, administrators must still be paid, etc.)
- The only solution is now to raise the ICU price to $20, or even $22.
- So now instead of saving money by outsourcing their x-rays, the hospital (and patients) are now paying more!
$12 for outpatient films, and $22 for ICU films (vs $10 and $20 originally).
- Recognise that 'cross-subsidies' exist, not just on a small scale (example above), but between modalities (e.g. CT subsidises angiography), and between hospital departments (e.g. Radiology profits subsidises the A&E loss).
- Recognise that 'cherry-picking' and 'creaming-off' (yes, that's what the above is known as colloquially) of 'healthy x-rays' and 'healthy patients' will (and is) happening.
- Either 'cross-subsidies' have to be abolised, and prices changed to reflect true costs (e.g. polyclinic xrays should be priced cheaper than hospital xrays) (e.g. A&E attendence fee goes up and xray fees go down), or;
- 'Cherry-picking' has to be banned by the powers that be (ala Medishield cherry-picking ban).
- Let's say Dr A is paid $100 per day to report 100 films, while Dr B is paid $200 per day but also reports 100 films. Who is more productive?
- (Obviously that was a trick question). Sure, Dr A may seem more productive, but what you don't know is that Dr B spends only 25% of his time reporting films.
- In other words, Dr B can report 400 films a day, twice as fast as Dr A.
- Ah ha, you say! Productive maybe, but a slacker. Wrong again.
- You see, Dr B spends the other 75% on department administration, supervising the radiographers, training the sonographers, conducting tumor boards for the clinical departments, conducting research, resusucitating patients that fell off the CT table, answering complaint letters, etc. etc.
- None of which is documented or explictedly costed or rewarded.
- No one really grumbles either, since it's assumed to be part of the job, and most departments spread the work out fairly evenly.
- Until recently, with the advent of large-scale outsourcing.
- You see, between Dr A ($100 for $100 films) and Dr B ($200 for 100 films), any administrator worth his salt will choose Dr A (incidentally based in India).
- Of course, that means 100 less films to report for the department, so they fire Dr B, and save $100. Woo hoo!
... but now who's going to do all the extra crap that Dr B was doing?
- Definitely not Dr A. He's in India, and you can't resusuciate a patient by teleradiology.
- How about Dr C (the only remaining radiologist in the department after Dr B got fired)?
No can do. He's already got his own pile of shit. Any more, his reporting rate will go down, and we know where his job will go.
- So that means hiring Mr Adminstrator, Ms Superivising Radiographer, Prof Sonographer, Researcher K and of course, Dr X.
(Dr X is a junior doctor who sits around all day in case patients fall off tables).
- Now if you're sharp, you'll notice 2 things that Dr B did, that all the extra hirees don't cover.
That's right - tumour boards (which got cancelled), and complaint letters (which Dr C answers - some things you can't outsource, no matter how much you want to).
- Ok, ok, some real suggestions from me:
- There is a need to recognise that radiologists do more than just report xrays.
- Radiologists (in fact, ALL doctors) need to stand up and claim credit for what they do. Learn from the lawyers.
- These activities need to be broken down, costed and itemised.
- Costs need to be charged. No more helping clinicians "take a quick look at this x-ray (for free)".
The competition is brutal, and you think it's going to take a free "quick look at your x-ray" when you tele it over? Hell no, they probably even charge you extra.
Once again, learn from the lawyers - have you ever tried to get (free) advice from the lawyer over the phone?
- If itemised charging is unpalatable and politically unacceptable, then protected time (and resources) has to be set aside for such activities.
"You benchmarked my pay to my colleague in Bangalore and we both worked from 8 to 5. If tumor board runs from 5 to 7 pm, either I get overtime pay, or I get time off."
To summarise this section (Point 3):
4. Anticipation of contingencies
- Environmental : Earthquakes, Tsunami, bird flu.
- Technical : Internet downtime, server crash, need to report hard copy films.
- Political : War, riots, strikes.
- Economic : Termination of contract, closure of company, price increases
- Legal : Third-party suits for negligence.
- It is no use hiring Wipro as a backup to Telerad Solutions (both in India), if an earthquake breaks the only Internet cable joining Singapore to India.
- Recognise that apparently diversified risks may be unknowningly correlated.
(e.g. you contracted Nighthawks Teleradiology, Australia, as a backup, but so did everyone else, and they're now swamped!)
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Further reading and references used in multiple instances
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Legal Stuff |
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