Fill-in radiologist stood down after errors

Recruitment processes at Southland Hospital are under review after a locum radiologist was stood down because of his error rate three weeks after he began work on December 1.

The hospital was under contract to continue paying the locum until March 1, the chief medical officer for Southland said yesterday.

The American radiologist was recruited by the Southern District Health Board through Whanganui recruitment centre Medlink but was interviewed by chief medical officer David Tulloch on December 19 after complaints were made about the quality of the radiologist's reports. Mr Tulloch said the locum was experienced and had excellent references.

But an audit found 37 of the 218 CT, MRI and ultrasound scan reports made by the locum had errors. Mr Tulloch said the doctor was stood down on full pay which Mr Tulloch could not disclose.

A district health board spokesman said the average salary for a locum radiologist at Southland Hospital was $275,000-$325,000 per annum.

The locum has returned to the United States pending the outcome of a review of processes, Mr Tulloch said, while Medlink and medical councils both here and in the US had been informed of the audit and the review.

Patients had not been adversely affected, Mr Tulloch said.

While the hospital was confident no-one had been harmed because of the errors, they were not acceptable and the hospital would be looking at its processes closely, he said.

An 0800 number had been set up for anyone concerned about their reports at Southland Hospital from December 1 to19.

Medlink executive director Kathleen Haskell said this was the first time an incident like this had happened for the recruitment company and it put Medlink in an uncomfortable position.

"We have absolutely no idea what happened. He came with good references, which were backed up verbally both in the US and in New Zealand, and had worked under supervision as all new doctors to New Zealand do."

Efforts had been made to find the radiologist since his return to the US, to look into the incident, with no success so far, she said.

The radiologist was a senior doctor, she said. "All we can do is speculate at this time."

The Southern District Health Board had reacted "perfectly" to the situation, she said.

"They did what needed to be done and acted quickly to look after their patients."

Implementation of three clinical protocols dramatically improves stroke patient outcomes (National Stroke Foundation)

Acute stroke patients who receive three clinical protocols to manage fever, sugar and swallowing are 16 percent more likely to be alive and independent three months later - a collaborative research study led by Professor Sandy Middleton, National Stroke Foundation Clinical Council member and Director of the Nursing Research Institute at the Australian Catholic University and St Vincents & Mater Health Sydney has found. This research has provided critical data demonstrating significant improvements for the management of patients following stroke.

Stroke is caused by a clot or a bleed in the brain and is Australia’s second biggest cause of death and leading cause of disability. While a patient suffers irreversible brain damage as a result of the stroke, there is potential to salvage surrounding brain tissue and limit the damage by effectively managing fever, sugar and swallowing.

The NHMRC-funded trial is the first nurse-led trial in acute stroke of its kind carried out in Australia and involved 19 acute stroke units across New South Wales and more than 1,600 patients.

The trial developed, implemented and evaluated the effectiveness of team-building workshops and education to introduce three clinical protocols to manage fever, sugar and swallowing (the FeSS protocols) following an acute stroke.

“Patients admitted with an acute stroke to hospitals that were randomised to receive our support to implement these FeSS protocols, were 16 percent more likely to be alive and independent at 90 days.” Professor Middleton said.
“These results are better than any current drug or treatment for stroke including clot busting therapy, and can be universally applied in acute stroke units.”

Published online today in The Lancet, the study showed that patients who received care in stroke units using these protocols were also more likely to have fewer episodes of fever, lower average temperatures and sugar levels, and better screening for swallowing difficulties.

“We found better outcomes for patients and consistently better processes of care in these hospitals because we created opportunities for teams to come together and agree on what they could do as an integrated service to improve quality of care. These results provide some of the best evidence to date in Australia on how to change clinicians’ behaviour and also evidence for effectiveteam work and good nursing care.”Professor Middleton said.

“Good management of fever, high blood sugar levels and swallowing can salvage brain tissue - poor management however can result in extension of the stroke and have devastating consequences for the patient.”

The study was a collaboration between the Australian Catholic University, the University of Newcastle, the University of Ottawa, the University of Western Sydney, the University of Sydney and the University of Melbourne, as well as a team of clinicians from NSW Health and support from the Agency for Clinical Innovation’s Stroke Services NSW.

The National Stroke Foundation is encouraging the delivery of such programs in Australian stroke units to support the use of the FeSS protocols based on the success of Professor Middleton’s trial.

“Recovery after a stroke can be significantly improved when health professionals are supported to implement protocols that ensure consistent and prompt clinical management of these three factors – fever, blood sugar levels and swallowing. Stroke is Australia’s second leading cause of death and a major cause of disability. The delivery of programs resulting in improved care for stroke care is critical in ensuring more Australians survive stroke, and that costs associated with stroke care are minimised.” says CEO Dr Erin Lalor.

Professor Middleton said she had been delighted to find so many stroke units eager to step up and adopt best practice. “This is great news for evidence-based health care.”

Distance a killer in the bush (SMH)

A cancer diagnosis is just the latest in a series of crushing misfortunes for Garry Lyons. Following a redundancy this year - the third for the 60-year-old boiler worker - he invested the money in paying down his mortgage, only to find this left him ineligible for Centrelink payments. But a lack of any income has not protected the Wagga Wagga man from a $600 out-of-pocket payment for a follow-up scan on his prostate to assess the effects of treatment, which had to be carried out privately ... Read More

Radiology gap deprives bush patients (SMH)

RURAL and regional Australians are missing out on vital radiation services that can increase survival and recovery rates for cancer sufferers, according to radiology experts.

A survey of Australia's radiology workforce found that while the total number of radiologists across Australia has increased since 2000, less than 25 per cent of radiologists serviced a third of the population in rural and regional areas.

Professor Chris Milross, from the Royal Australian and New Zealand College of Radiologists (RANZCR), said there was a national shortfall of about 40 radiology machines.

There are also worries about the ageing population and an increasing number of future cancer cases.

Professor Milross said while it cost about $5 million to set up a machine, the benefits were enormous.

He said part of the problem was training and enticing radiologists to country areas, but the RANZCR was working to address that shortfall.

The survey was released at the RANZCR annual scientific meeting in Melbourne this weekend.

More than 1000 global experts are discussing new technologies that promise to deliver higher standards of care for Australians with cancer.

Professor Milross said half of all cancer patients could benefit from radiotherapy, but in NSW just 35 per cent received it.

DI and commoditisation: an industry in transition

Recent articles in this series have focused on funding issues, including the government funding review. It is now perhaps time to explore the growth of commoditisation in DI, with particular reference to the Australian context. While a systemic issue for DI, encompassing all segments of supply and demand, a private sector bias is implied when discussing a service with an attached market price. But broad extrapolation of the debate is appropriate.

Although technology and other “market” factors have underpinned the emergence of commoditization, radiologists supposedly reacting to market pressure have facilitated the process. Now from within the profession we have calls for increased awareness of the perceived dangers, even for strategies to save radiology as a clinical specialty. But is there really a fundamental threat to radiology? As always, change brings both risk and opportunity. Let’s examine the dynamics at play, and look for a way forward.

Commoditisation involves portraying the DI service as an undifferentiated tradable commodity, resulting in market behaviour driven solely by price. Many argue this “de-professionalises” the service – reducing it to a dataset of images and report – thus ignoring other elements of radiology practice like consultation activities and monitoring quality and appropriateness. Fair point, but times have changed, and the profession must look forwards objectively, not to the past, as it transitions radiology for the future.

So here is the challenge – to embrace the reality of globalization and other drives of commoditisation, yet maintain professional practice models that promote the role of radiologists in the clinical team. The challenge should not be underestimated. Current debate indicates that radiologists hold divergent views on commoditisation, and while turf protection is ultimately a unifying force, optimal strategic outcomes may require trading short-term commercial gain for future sustainability, surely an added complexity.

But just how has a professional service morphed into a perceived undifferentiated commodity in the real market? While inconceivable a decade ago, the seeds were already there. In a sense, DI as an industry, with radiology its core clinical specialty has fallen victim to its own evolution and success. Okay, so what are the commoditisation drivers?

Governance activities from within the profession and industry have delivered DI practice standards; appropriateness criteria & decision support systems to guide referrers; and funding-linked accreditation criteria for providers. Add the increasing threat of litigation, and we have constant upward pressure on the standard of care. To the DI consumer, usually the referring clinician as patient agent, supply within a “market” (or geographic area of supply & demand) seems undifferentiated. Quality, access, and timely results – products of a competitive market – are a given, so price then drives referrals. Lower prices result. Loyalty, special expertise, and other “value-adds” now exert only minor influence in most segments of the overall market.

We continue to see the above scenario unfold. At the coalface, busy DI practices run on slick work-flow management protocols that embrace scheduling, reception, examination, and report generation. With highly-trained technologists operating the various modalities, radiologist input revolves around reading progressively larger and more complex digital image data-sets. And years of real funding cuts have demanded a massive hike in radiologist productivity, together with overall enterprise efficiency. In the workplace, radiologists are time-poor and under pressure, and can rarely be involved in all elements of the patient episode. In essence, the service has been segmented by necessity, and this resonates with the trend towards commoditisation.

The digital age in DI, together with advances in information and communication technology, has been another key player in commoditisation. While a godsend in facilitating better productivity, PACS and Teleradiology now pose some fundamental questions for the profession. Ability to read digital images anywhere on the globe breaks the historical nexus between patient and radiologist. This unsettles many in the profession, who merely see further erosion of the “integrated service” concept. However, the ability to exploit time-zones and give 24/7 coverage with “wide-awake” radiologists, to provide sub-specialty reporting, and to service remote communities must be positive, trumping the perceived downside. Then as newer generations of radiologists actively seek more flexible working arrangements, teleradiology will be an integral tool in service provision. This technology is here to stay. It is up to radiologists to manage it effectively and limit its power to commoditise.

Returning now to the basic premise of a commoditised service and price-driven market behaviour. As already noted, radiology has been trending in this direction for a number of years, and for a variety of reasons. But one of the most powerful drivers has been our Medicare funding system – specifically the underlying politics. Here, the combination of two levers, 1) a managed fee-for-service environment, and 2) a floor price, lit the commoditisation fuse many years ago. Add to this the initially attractive rebate settings plus pressure on providers to accept this floor price, and commoditisation was inevitable, especially given the evolutionary forces at work within the industry. For once DI was seen as an amorphous offering in the market, lacking qualitative differentiation between providers, the percentage of bulk-billed services began to rise. Now by simply operating the “floor price” lever, government could lower the price, forcing productivity gains and ensuring lower margins. Despite this, providers have increasingly become eager price-takers in search of market share; yet in reality, participants in a potential race to the bottom.

Finally, a short note on corporatization, cited by some as a commoditisation driver in the American market. Possibly so, but Australian health-care has a different set of funding and delivery structures, making any such linkage tenuous at best. Experience here, though to date a mixed bag and generally sub-optimal, suggests that with a well-managed and appropriate business model for DI services corporatization, both professional and shareholder interests can be successfully aligned. Such an outcome should be neutral on commoditisation.

To recap on all the above, commoditisation is occurring in DI, driven by multiple factors. This is not a mortal blow to radiology. But it calls for an objective understanding of the forces at play, acceptance of irreversible change, and a resolve to cement and enhance the relevance of the radiologist in patient management. These goals should not be seen as mutually exclusive. The next article will focus on the profession’s response to commoditisation.

Overnight leadership doesn’t happen overnight

Imaging Partners Online was established in response to a national and international shortage of radiologists and increasing demands for after-hours radiology. Almost 5 years later, IPO reports over 4,000 urgent CT scans every month and leads the way in measuring quality and service levels.

In the first month of operations in 2007, with only one afterhours client, Imaging Partners Online
reported 19 urgent, after hours CT scans.

IPO now reports over 4,000 urgent CT scans and 40,000 routine examinations every month for some 80 hospitals and clinics across Australia and the UK.

While a lot has changed at Imaging Partners Online after almost 5 years, there are some things that haven’t changed. True to its founding principles,radiology reporting at IPO is always performed in dedicated reporting centres and always in the radiologist’s normal waking hours.

Now with fully equipped and staffed reporting centres in Sydney, Melbourne, Perth, London and Leicester, IPO ensures that reporting is performed in an environment and a time-zone that gives
the best chance of a quality radiology report.

Regardless of location, all IPO radiologists are FRANZCR and registered in all Australian states. Multiple sites in multiple countries also provide important system redundancy.

At any given hour of the day or night, up to 6 IPO radiologists and a team of Quality Assurance and IT staff is dedicated to reporting every urgent case in the shortest possible time. Quality is measured and maintained through an extensive peer review process, an initiative that has been embraced by IPO’s 50+ radiologists.

‘We’re proud of what we have achieved’ says Founder and CEO of Imaging Partners Online, Bob Sheraton, ‘but I think we’re entering a new phase. The ability to provide a quality 24x7
reporting service is no longer in question. The ongoing challenge for us is to find new or better ways to integrate with our client hospitals and in doing so, lead the way in adding value to our clients.’

It’s all in the timing…

Imaging Partners Online provides urgent, off-site reporting for over 70 hospitals and clinics and has been running its ‘around the clock’ service for over four years. Its unique workflow and in-house developed IT has been honed to ensure that every study is reported to a high standard and in the shortest possible time. A rigorous peer review and quality assurance program reinforces that quality and timeliness are equally important at Imaging Partners Online. 

Opening up a world of opportunity - Imaging Partners Online’s ongoing investment in innovative information technology

 Imaging Partners Online’s ongoing investment in innovative information technology has opened up a world of opportunity for radiology.

24 hours in the life… A typical day in an Imaging Partners Online reporting centre never ends.... ever!

 That’s because cases are reported by radiologists in London, Sydney, Melbourne and Perth using international time zones to ensure that radiologists are always reporting during their ‘awake’ hours from a fully equipped and supported reporting centre. 

Imaging Partners Online technology, supporting best practice

 Peer review is a cornerstone of modern day radiology, giving definition to the concept of ‘quality’ and ensuring that radiologists are constantly learning about their strengths and weaknesses. Imaging Partners Online has recognised the need to support peer review and to provide feedback to both its radiologists and its clients. To assist with this, Imaging Partners Online has developed its own software, IPO QA.