It is well documented nationally the use and cost of outsourcing (teleradiology) as well as the imbalance with regards to insourcing.
There is no denying outsourcing in radiology (teleradiology) exploded over the past decade+ and looks set to continue with the advance of digital pathology (telepathology). There was original resistance, focused mainly on quality e.g. no access to the full imaging history however, that quickly dissipated with the rapid realisation of its absolute necessity (due to relentless annual growth in volumes). To the point of practically every NHS Trust now outsourcing to a teleradiology provider.
Recently we’ve seen the emergence of successful insourcing models like CAMRIN, EMRAD, and the Scottish National Radiology Reporting Service (SNRRS). This is a really interesting development and here we discuss what’s changing to enable this to happen—how does the business case stack up!
Traditionally the biggest barrier to insourcing hubs (or models) was technology. But COVID-19 changed that. Pre-COVID-19, radiology remote reporting bandwidth was ‘the poor relation’ and largely had to compete with general hospital bandwidth (Microsoft Teams calls and general internet usage), using constrictive Virtual Private Networks (VPNs), and whilst also trying to sync a Picture Archiving and Communication Systems (PACS), a Radiology Information System (RIS), and Voice Recognition (VR) at the other end. COVID-19 brought relevance to remote reporting for in-house staff (at home/off-site), and the technology got a serious focus for once.
In parallel, a lot of PACS and RIS reporting is becoming a single system (e.g. PACS-based reporting) and more importantly, the PACS systems are evolving to being web-based and cloud-based (which enables HTTPS direct access). Both these are really significant.
The net effect is now bypassing competitive and restrictive hospital networks while also improving clunky technologies (like firewalls and VPNs) with dedicated Imaging Virtual Desktop Infrastructure (VDIs) taking it to the next level to offer remote performance equal to, or better than in-trust/on-site. Hence technology is one major barrier to an insourcing model largely overcome! It remains to be seen where this will go, but the significant jump in technology has definitely changed things. Interesting to see the emergence of new teleradiology providers (eg Axon Diagnostics) that are specifically focused on these new aspects of the technology (to offer both insourced and outsourced models) and appear to be doing really well.
There is actually a commonly held belief held by lots of knowledgeable and experienced Imaging and PACS managers that outsourcing is actually more cost-effective than setting up an insourcing model/hub! That’s mainly because the outsourcers are just better able to manage it, particularly the reporters. Perhaps this is the key concept/consideration in this debate.
Pay-per-report, i.e. performance-based working, again, is something that has proved difficult in the NHS (but not so with private teleradiology providers). Reporters could set up their own companies and charge the NHS (and offset their costs too). There was also the well-documented issues over payments to reporters (IR35) and the significant tax and pension implications.
I’m open to contradiction, but I honestly believe the pay-per-report insourcing wasn’t appealing to Trusts as they didn’t want tabloid headlines along the lines of X radiologist earned a Y (vast) sum in overtime (despite them working their butt off to do so!).
Whereas now I think they are more open to that as a business model as they can make a direct comparison to what it would cost if outsourced (e.g. ‘if we outsourced it would cost £25 per report whereas we negotiated a rate of £18 with our in-house team’).
Hence why getting the management right is the key part to the overall success of insourcing models and key to that management is the emergence of Imaging Networks (INs).
INs have led to a power shift in terms of buying power. It’s no longer Trusts negotiating teleradiology rates independently, it’s now done at an Imaging Network level on a bigger scale, -bigger prizes, tighter margins!
A key insourcing management objective (at Imaging Network level) is the pooling of resources and establishing an insourced reporting hub. These are ‘intense reporting farms’, dedicated high through-put reporting productivity in a non-clinical setting. There are also health inequality benefits too.
There could be several hubs across a region, (linked virtually) combined with home reporting and designed and located around reporter convenience (i.e. in a facility close to major access routes). Access to the latest high-speed network technology, highest specification (shared/pooled) reporting workstations, and availability of cloud-deployed tools.
In the past different hospitals (independently) negotiated different rates with the same companies. There are only four main teleradiology companies with perhaps 2-3 peripheral/upcoming providers. Each Trust’s rate depended on the strength of the negotiator with resultant rate disparity across regions with the absence of shared learning or sharing of best rates.
Imaging Networks are changing that by standardising rates across regions. While in parallel, having enough and significant buying power to negotiate the best rate (using the best negotiators) and saving money in the process—the savings here could be substantial.
The most expensive aspect of outsourcing is Out of Hours (OoH) reporting. This is where the big teleradiology providers actually make most of their profit. The model is favoured by Trusts too as it reduces the need for reporters ‘on-call’ at night (which can result in 2 days compensation). Given current daily clinical workforce shortages, outsourcing is seen as a solution to having more staff on-site and available during daily hours, hence happy to pay for expensive OoH work.
Models used by outsourcing companies include ‘follow the sun’ where reports for OoHs in the UK are performed in locations with daytime hours (e.g. all of Wales OoH service was/is provided from Australia). In parallel, traditional problems revolved around IG whereby data could not leave England. Modern systems (eg Cimar) provide ways around this with cloud and streaming services available locally. There is potential for the INs to look at similar models.
It appears that when managed/’oversighted’ at Imaging Network level, there are promising signs. Who knows in years to come, Imaging Networks with their own efficient teleradiology entity, could work for other areas (INs), almost like a stand-alone teleradiology (outsourced) company themselves. But any insourcing model requires creative management to cover all bases.
So, I’ve covered two aspects here, technology improvement and the impact of imaging networks. I’d be delighted to hear your thoughts on the insourcing versus outsourcing debate in the comment section below!
Insourcing
Insourcing refers to renumeration of current employee reporters to perform extra reporting on a cost-per-unit basis (similar to the teleradiology companies model). The potential benefit is reduction in cost by eliminating the teleradiology company margin.
Outsourcing (teleradiology)
Teleradiology is essentially a buyer’s marketplace for unit reporting services.
About The Author
Pauric Greenan is an experienced PACS consultant that has been PACS lead on several high-profile PACS projects in both the UK and Ireland. Pauric is internationally available for PACS consulting. Contact him here for more details.
Did you know that we are able to fulfil a variety of your imaging diagnostic needs?
Choice Health is highly experienced in clinical trial and research imaging, PACS consultancy, telehealth, imaging AI and medical physics.
Would you like a free consultation to see if we’re a match? If so, do not hesitate to reach out via our contact page.
