Tele-radiology and outsourcing of X-rays in Singapore
Frequently Asked Questions and Answers


Contents

  • Introduction to teleradiology  
  • Teleradiology in Singapore  
        - Who, when, where, how and why are we doing it?   
        - Quality and accreditation – how does it affect me?  
        - Legal issues  
        - Comparison with other teleradiology programs  
  • Advantages of teleradiology and outsourcing   
  • Disadvantages of teleradiology and outsourcing   
  • My opinion  


    Updated: 15 Apr 07 Return to Main Medical Index


  • Introduction
    Q: What happens when you have an X-ray done?
    A: Let’s pretend you have knee or low back pain, and you consult an orthopaedic surgeon, who sends you for an x-ray. What happens after that?
  • You make your way to the x-ray department, usually in the same hospital or building.
  • There, a clerk takes your x-ray request form and bills you. Details such as your name, IC/ID/SSN, examination requested, etc. are captured in the RIS (Radiology Information System) database.
  • Next, a radiographer (someone who specialises in taking x-ray pictures) takes x-rays of your knee using an x-ray machine.
  • The x-ray images are instantly digitised and stored in the PACS (Picture archiving and communication system) computer system.
  • The next few steps happen behind the scenes as you walk back (slowly, because your knee hurts), to your surgeon. Teleradiology and outsourcing refer to these steps.
  • Your x-ray is assigned to a radiologist (someone who specialises in interpreting x-ray pictures), and your knee x-ray appears on his specialised computer monitor. Based on the images, he diagnoses you with osteoarthritis (or a fracture, or gout, or a smurf hiding in your kneecap, or whatever).
  • He then dictates or types his findings into the RIS, and the report is sent electronically to the Hospital Information System, where it is merged with the rest of your records.
  • When you finally make your way back to the surgeon, he already has both the x-ray image and the report waiting on his computer. And you thought it was magic!!
      So the question is, why should I care about this radiologist dude whose name appears at the bottom of my knee-xray report, who I never even met? Isn’t my surgeon the important guy? And what does this have to do with teleradiology and outsourcing anyway! Let’s find out more.

    Q: What is teleradiology?
    A: The American College of Radiology defines teleradiology as the electronic transmission of radiological images (e.g. x-rays, CTs, and MRIs) from one location to another for the purposes of interpretation and/or consultation. Examples include:
       (1) You see a doctor at Toa Payoh polyclinic for knee pain, who orders an x-ray of your knee. Previously, the physical(hard copy) x-ray film would have been sent to Singapore General Hospital (SGH) by courier at the end of the day. Instead, with teleradiology, the images are now sent electronically (via the Internet) immediately. At SGH, the radiologist (a doctor who specialises in interpreting x-rays) ‘reads’ it, and sends an electronic report back to the doctor at Toa Payoh.
       (2) A MRI scan of the brain is performed in Alexandra Hospital (AH), which shows a rare or complicated condition. The radiologist-in-charge sends the images to National University Hospital (NUH) or National Neuroscience Institute (NNI) to get a second opinion from his subspeciality colleague there. No money changes hands.
       (3) A pedestrian hit by a car in a rural town in the USA is brought to the nearest hospital with suspected head injury. This small hospital has a CT scan machine and a radiographer (the technologist who operates the machine), but the hospital does not employ a radiologist. The emergency department doctor orders a CT brain, and does his best to interpret the images based on his basic training and experience. Now, with the advent of teleradiology, the images are sent immediately to the radiology department of the nearby city hospital for specialist interpretation.
       (4) Another small town hospital employs a full-time radiologist, but he works only during office hours (Radiologists may be Supermen, but they still have a wife and kids and dinner to go home to). After office hours, the hospital sends the pictures to his home computer for him to read.
       (5) A third small town hospital also employs an office-hour-only radiologist. Any emergency x- rays at night are sent to Australia for interpretation.

    Q: What is outsourcing?
    A: Many definitions exist. These are some of them:
  • The concept of taking internal company functions and paying an outside firm to handle them.
  • The transfer of a function previously performed in-house to an outside provider.
  • The delegation of non-core operations or jobs from internal production to an external entity (such as a subcontractor) that specializes in that operation.

    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:
  • cost savings
  • faster turn-around time
  • better quality reports.

    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:
  • Rate of data-transfer to local US server: 15 images per minute (8.8 minutes total for an 'average' CT)
  • Rate of data-transfer to Bangalore server: 3 images per minute (52.8 minutes total)
  • Downtime in two instances (during the 4 month study period): "The first downtime resulted from the expiration of the satellite Web server license, and the second resulted from a temporary routing loop on the Internet, which prevented normal transmission and subsequently caused overloading of the queue." The remote radiologist accessed the images via a backup Internet site (?presumably at home - not stated), and uploaded his reports the next morning.
    [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 are the guidelines regarding teleradiology?
    A: The Academy of Medicine Singapore has published a set of
    Teleradiology Guidelines.

    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:
  • Such qualifications as may be recognised by the Medical Council, and satisfies the Medical Council that he has special knowledge and skills and sufficient experience in any particular branch of medicine.
  • Registered with the Singapore Medical Council
  • Accredited by the Specialists Accreditation Board
  • 2 years of “good performance" under the supervisor, employing institution and the SMC
  • 5 years of clinical experience after obtaining specialty qualification.

    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 accredited by the Specialists Accreditation Board (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]
    2010 Update: A doctor who sent samples to overseas labs has been charged in court (see below).

    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 rope in my teenage son who's on vacation to help out.
       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.

    Q: No way that could happen!!
    A: I didn't think so too. But it has. (2010 Update)
    Teleradiology firm RSI hit with ghosting-related charges

       The president of teleradiology services provider Reddy Solutions (RSI) of Atlanta was arraigned last week on charges filed by the U.S. government related to alleged "ghosting" activities. Dr. Rajashakher Reddy could face a maximum penalty of up to 20 years in prison and a fine of up to $250,000 if convicted.

       The November 3 federal grand jury indictment alleges that Dr. Rajashakher Reddy, 39, signed and submitted thousands of reports from May 2007 through January 2008 in his name without reviewing the films that were the subject of the reports -- a practice known in radiology as "ghosting."

       The indictment alleges that nonphysician technicians (radiology practice assistants) reviewed many films and prepared reports at RSI. Under current standard of care, RPAs are permitted to assist radiologists -- for example, by performing a preliminary review of radiology films and data -- but are not themselves physicians and cannot render clinical findings or diagnoses.

       However, the complaint alleges that Reddy directed the RSI staff to simply sign for him, and transmit the report as if he had prepared it; other times, Reddy accessed the system only for the purpose of signing and submitting the reports, according to the indictment.

       According to the complaint filed in the case, Reddy had certain RPAs review films first and file a draft report. Under current standard of care, Reddy should have then confirmed the accuracy of the report by independently reviewing the images and data, editing the draft report as necessary, and submitting the final report under his electronic signature.

       However, on more than 40,000 occasions during the time period in question, Reddy signed and submitted reports under his name in cases where neither he nor any other RSI physician reviewed the underlying films and data, the complaint states. The indictment alleges that RSI received over $1.5 million from its clients for these reports.

       "The indictment alleges that the majority of the time he never looked at and analyzed the underlying films, and that the reports signed by him therefore did not bear his medical conclusions or those of any other doctor," according to a release from the U.S. Attorney's Office for the Northern District of Georgia.

       The indictment does not allege fraud in connection reports signed by any other RSI doctor.

       The complaint also charges that in February 2008, Reddy allegedly altered access logs maintained by RSI in a response to a subpoena dated January 29, 2008, by the U.S. Department of Justice and the U.S. Department of Health and Human Services.

       Reddy was arraigned on November 5 and charged with wire fraud, mail fraud, healthcare fraud and obstruction of justice. He faces a maximum sentence of up to 20 years in prison, and a fine of up to $250,000 for each count.

       Reddy and RSI did not immediately respond to requests for comment by AuntMinnie.com.

    Source: Erik L. Ridley auntMinnie.com, November 12, 2009
      I didn't even know there was already a term for it - "Ghosting". And 40 THOUSAND cases. Wow.


    Q: Ok, so maybe something like this could happen. Big deal, I'll complain to the Health Minister and sue the pants off them.
    A: Yes, very typical Singaporean. Unfortunately, the big difference between the case above, and yours, is that the radiologist above is licensed and based locally (in the USA). Whereas yours is neither Singapore licensed nor based.
      That's where your problems begin. Let's pretend you are at your GP, banging the table and saying, “How did heck did you miss this fracture!" Unfortunately for you, he just points 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 Doctor Register 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't the Ministry of Health remove them from the register and stop them from practicing?
    A: Which register are you talking about? The Singapore one? They aren’t even on it in the first place - how do you can’t strike a person off something they’re not on? Or if you're talking about their overseas home town register, well, Minister Khaw's arm is certainly long, but at the end of the day, he's still only the Singapore Health Minister...

    Q: Won’t the MOH forward my complaint to its overseas counterpart?
    A: That is for them 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 if I were running an insurance company, I'm not sure I'd insure an un-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.

    2010 Update : Doctor fined for sending samples to overseas non-accredited lab
    Charged with sending samples to non-endorsed laboratories

       A DOCTOR was summoned to court on Wednesday to face four charges of breaching the Private Hospitals and Medical Clinics Act.

       <Name omitted>, 62, who runs Clinique Suisse at Paragon, allegedly sent specimens and samples taken from patients to foreign clinical laboratories not accredited by the Director of Medical Services between 2008 and 2009.

       He is thus said to have operated a medical clinic in breach of a licensing condition issued by the Ministry of Health.

       Doctors are required to send their patients' specimens to either local laboratories licensed under the Public Hospitals and Medical Clinics Act or to overseas laboratories that are accredited by accreditation agencies approved by the MOH.

       This is to provide greater assurance that test results yielded are reasonably accurate and reliable for clinical management purposes.

       If convicted, he faces a fine of up to $20,000 and/or a jail term of up to two years on each charge.

    Source: Straits Times, 10 Feb 2010

    Doc fined over non-accredited foreign labs

       A DOCTOR was fined a total of $24,000 yesterday for failing to comply with a condition of his clinic licence by sending specimens and samples taken from patients to unaccredited medical laboratories overseas.

       <Name omitted>62, the licensee of Clinique Suisse at Paragon Medical Centre, admitted to three Ministry of Health summons charges under the Private Hospitals and Medical Clinics Act. A fourth charge was taken into consideration. Wong specialises in detoxification and preventive medicine against ageing.

       The court heard that between 2007 and 2009, he collected and sent patients’ specimens or samples to foreign clinical laboratories for various tests or examinations. He charged his patients between $250 and $3,000 for each test.

       These overseas laboratories, however, are not accredited by the Director of Medical Services here.

       Doctors are required to send their patients’ specimens to either local laboratories licensed under the Act or to laboratories located overseas which are accredited by agencies approved by the Ministry of Health.

       This is to provide greater assurance that test results yielded are reasonably accurate and reliable for clinical management purposes.

       Wong could have been fined up to $20,000 and/or jailed for up to two years on each charge. Judgment has been reserved after a four-day hearing.

    Source: The Straits Times, 08 May 2010
    The case is ongoing at the time of writing, and therefore one has to be careful in commenting on it. Nonetheless, without prejudice to the outcome, I would draw the following parallels/conclusions:
      1) Just because the labs are licensed in their home country, or the overseas doctor holds a radiology certificate, does not mean they are MOH accredited.
      2) MOH will charge doctors who send specimens to un-accredited labs.
      3) The rationale being to ensure patient safety i.e. that the test results are reasonable accurate and reliable.
      4) Sending xrays images is not much different from sending lab specimens.
    Conclusion: If your xrays are being sent overseas for reporting, check with your doctor that the overseas reporting centre is MOH accredited. It could save you from a wrong diagnosis (and your doctor from a fine and jail term!).

    Q:How about if my doctors send me overseas (e.g. Johor Bahru(JB), Malaysia) to get the scan done, instead of sending the images?
    A: From the medical viewpoint, I feel that this is even more dangerous than sending just the images. In addition to the risk of substandard reporting of the images, you could now be exposed to the risk of substandard/improperly maintained equipment (which could lead to radiation overdose), poorly trained/unaccredited radiographers and uncertain quality of contrast medium/PET isotope. (For example, 18-FDG used in PET-CT scans has a half-life of 110 minutes, meaning that it is only half as effective after less than 2 hours).
      And while I am not the legal expert, my personal opinion is that if MOH is willing to charge a doctor for sending lab samples overseas, they will be even more likely to frown one who sends the entire patient overseas.

    2010 Update : Medical Practioner struck off for misconduct oveseas
    High Court judge closes a possible "loophole" in misconduct of TCM treatment

    Traditional Chinese Medicine (TCM) practitioners registered with the profession's governing body here could face sanctions even when they are guilty of professional misconduct or negligence overseas, a High Court Judge ruled yesterday.

       If not, a TCM practitioner could exploit "a loophole" simply by performing unsafe treatments on his patients in a nearby overseas country, Justice Tay Yong Kwang said.

       Justice Tay was ruling on an appeal by TCM practitioner Huang Danmin, who had his registration cancelled for professional misconduct, after he gave unapproved treatment to a terminally-ill patient in his Johor Bahru clinic.

       Mr Tan Nan Kee, 72, had approached Mr Huang at his clinic in Rochor Road for an alternative treatment in January 2004. But Mr Tan was told to visit Mr Huang's second clinic in Johor Bahru. There, Mr Huang gave Mr Tan an injection, which caused the latter to experience an adverse allergic reaction.

       At the centre of Mr Huang's appeal was whether a sub-section of the TCM Act allowed the TCM Practitioners Board to take into account Mr Huang's treatment of his patient at the Johor Clinic.

       Due to the significance of this determination for future cases and for disciplinary tribunals constituted under other Acts where similar wording appears, the court invited a lawyer, Ms Koh Swee Yen, as amicus curiae - or friend of the court - to make submissions on this specific issue.

       Mr Huang argued that the TCM Act's sub-section had "no express provision" that provides for an "extra-territorial effect". But Justice Tay felt otherwise in his grounds of judgement released last Tuesday (May 18). He agreed with the TCM Board's arguments that the primary purpose of the TCM Act - which is to regulate the standards of practice in order to ensure the safety and well being of patients in Singapore - would be undermined if the Board's disciplinary powers are curtailed for misconduct beyond Singapore.

       "Registered TCM practitioners who wish to perform unauthorised and possibly unsafe treatments on their patients will have a ready mechanism: they can simply cross the Causeway and perform those treatments there with seeming impunity. This is a loophole that cannot be accepted," Justice Tay said.

       The High Court Judge ruled that Mr Huang's conduct during Mr Tan's treatment "reflected a disregard of the patient's safety, as well as a deliberate intent to flout the Ethical Code".

    Source: Today Online, May 21, 2010
    Again, while not 100% identical, I think enough similarities exist to draw the following parallels/conclusions:
      1. The primary purpose of both the TCM Act and those covering doctors are to ensure the safety and well being of patients
      2. Sending patients overseas does not absolve a local doctor of his responsbility to the patient
      3. Practitioners will face sanctions even when they are guilty of professional misconduct or negligence overseas
    Conclusion: If your doctor suggests that you have your xrays done overeas, check that the overseas centre is MOH accredited. It could save you from a wrong diagnosis (and your doctor from a fine and jail term!).

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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?
    USA
    Singapore
    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
    References (USA requirements) :
      - 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.
    Tie-up for 24-hr global radiology service

      THE National Healthcare Group (NHG) has gone into business with an Indian company to supply a worldwide, 24-hour scan-reading service.
    .
    .

      While TS(Teleradiology Solutions) already provides night services to several smaller hospitals in the United States, it has had difficulty breaking into the market for bigger hospitals.

      In a telephone interview from India, NHG chief Dr Lim Suet Wun told The Straits Times that Singapore's free trade agreement with the US means it can bid for certain big contracts from US government agencies that are blocked to Indian firms. 'They are hoping that our name and credibility will open doors,' he said.

      The Indian partners were open in expressing hope that NHG will not suffer from the 'brown ceiling' - rejection on the basis of colour - it has encountered when dealing with some hospitals in Europe and the US. They said these big hospitals still think of India as poorly developed and question the quality of work
    .
    .

       While some Singaporean doctors will be involved in the actual work, Dr Lim said NHG's main contribution will be 'our brandname and credibility'.

    salma@sph.com.sg
    8 Mar 2007
    Straits Times


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    Advantages
    Advantages of teleradiology
  • Films can be read and a diagnosis provided 24 hours a day, anywhere where Internet is available.
  • Sub-speciality opinions can be delivered to locations where the expertise is otherwise unavailable.
  • Radiologists will be able to work in large group practices and concentrate in their area of subspecialisation, beyond that possible if they had to run a general radiology service.

    Advantages of outsourcing
  • Quality of care delivered by a wide awake radiologist working a day shift will be superior to one working extended hours on an overnight shift.
  • It may be cost-effective to the hospital, as the need to recruit night shift personnel is minimised.

    Disadvantages / Limitations
    Disadvantages / Limitations of teleradiology
  • Cost involved in setting up the network.
  • Geopolitical, environmental (e.g. earthquakes disrupting internet cables) risks.
  • Real-time diagnostic procedures (e.g. ultrasound, fluoroscopy) are best performed with the reporting radiologist on-site so that additional views/images can be obtained before the patient leaves the department.
  • Interventional procedures still require an on-site radiologist.
  • On-site doctor is still required to "protocol" scans, explain procedures and take consent, and deal with medical problems (e.g. emergency resuscitation, set i/v plugs, giving sedation and medication, post-procedure pain and complications e.g. contrast extravasation) (*)
  • Clincians will no longer be able to obtain informal consults by simply "dropping by" the department. (*)
  • Training of undergraduate medical students, doctors from other departments, and junior radiologists may decrease due to lack of on-site radiologists. (*)
    * - 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
  • Continual medical education, skills upgrading and certification of overseas doctors will run into administrative and legal problems.
  • Different legal, patient privacy requirements.
  • Clinicans will no longer be able to have face-to-face meetings to clarify findings or discuss management issues with the reporting radiologist.
  • Long-distance IDD phone calls or videoconferencing may be necessary instead.
  • Local radiologists would also be more cognisant of the social and situational issues of patients and the disease pattern in the local context.
  • Clinico-patho and x-ray rounds will no longer be attended by the reporting radiologist.
  • Participation of radiologists at local conferences would also decrease.

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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:
  • Faster
       - 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)
  • Cheaper
       - 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)
  • Better
       - 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)
  • Decisions to trade "better" for "faster" or "cheaper" (or vice versa) should be made following a thorough cost-benefit analysis.

    2. Quality standards and legal requirements must be fulfilled
  • All reporting radiologists should meet the same professional and legal requirements, regardless of their organisation/country. These include:
       - 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
  • There should be a level playing field for all. Teleradiologists should not have to meet fewer or extra requirements compared to local radiologists.

    3. Work should be recognised and rewarded
    Not all work is equal, and not all work is paid. Let me elaborate.
  • Not all work is equal
       - 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).
  • Solutions to "Not all work is equal":
       - 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).

  • Not all work is paid
       - 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?
  • Solutions to "Not all work is paid":
       - 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).
  • REAL Solutions to "Not all work is paid":
       - 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):
  • Work must be priced appropriately, otherwise there will be cherry picking of the more lucrative sectors (e.g. polyclinic plain films, outpatient screening CT scans.)
  • Cherry picking results in short-term cost savings but long-term cost increases.
  • Shortages in 'unrewarding' subspecialities (e.g. interventional radiology) will develop in the long run, similar to the shortage of renal and geriatric physicians.

    4. Anticipation of contingencies
  • The outsourcing organisation must prepare for 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.
  • Risks should be diversified.
       - 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
  • Sanjay K, India to be teleradiology hub!, rediff.com, April 26, 2005
  • Lindsey Tanner, U.S. doctors turn to outsourcing to help diagnose ills, The Seattle Times, December 06, 2004
  • Goh J, Teleradiology Outsourcing, SMA News May 2006 Vol 38 (5)
  • Straits Times, Hospital in US, doctor in India, Dec 6, 2004
  • Cheng LT, Ng SE. Teleradiology in Singapore – Taking Stock and Looking Ahead. Ann Acad Med Singapore. 2006 Aug;35(8):552-6
  • The Royal College of Radiologists, London. Teleradiology – a guidance document for clinical radiologists. BFCR(04)4. UK: The Royal College of Radiologists, 2004.




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