_{Published March 23, 2020}

With technological innovation teeming and networks more globalized than ever before, teleradiology—an imaging practice heavily reliant upon both—would seem uniquely moored to rise with these two tides. As advancement often begets acquisition, and especially as radiology practices continue to amalgamate, some teleradiology experts are floating a seemingly counterintuitive notion: the teleradiology wave could be starting to crest.

To be sure, long-distance diagnosis has been dialed into imaging for some 30 years.

In late 1991, University of Kansas researcher Arch W. Templeton boasted in AJR that more than 1,000 cases had been “digitized, transmitted, and printed on our teleradiology system.” Four years later for the journal, Douglas R. DeCorato detailed his after-dark developments, writing “all radiologic studies performed at Roosevelt Hospital between the hours of midnight and 8 A.M. were digitized and then transmitted over a T1 fiberoptic link to the radiology department of St. Luke’s Hospital, 4.8 kilometers away.”

Transmissions from individual institutions coming in loud and clear, by the summer of 2005, David B. Larson and colleagues had painted the first “comprehensive portrait of teleradiology in radiology practices.” Based upon a 66% response rate from the 970 practices that the American College of Radiology (ACR) surveyed in 1999, as Larson confirmed in AJR, “Seventy-one percent of multiradiologist practices had teleradiology systems in place, using them to interpret 5% of their studies. For solo practices, corresponding statistics were 30% and 14%.”

Flash forward a scant two years, when Todd L. Ebbert sought to capture and communicate just how big teleradiology had become. His 2007 AJR web exclusive had two distinct objectives: “to describe in detail the use of teleradiology in 2003 and to report on changes since 1999 in this rapidly evolving field.” Armed with the ACR’s Survey of Radiologists from 2003 (sent by mail, ironically), as well as its 1999 Survey of Practices, Ebbert et al. verified that 67% of radiology practices in the United States, “which included 78% of all U.S. radiologists,” had performed teleradiology.

Almost a decade’s worth of telemedicine would be performed until the first nationally representative approximation of telehealth practices across all medical specialties was published.

According to the 2016 American Medical Association’s Physician Practice Benchmark Survey, “15.4% of physicians worked in practices that used telemedicine for a wide spectrum of patient interactions.” Said interactions included e-visits, “as well as diagnoses made by radiologists who used telemedicine to store and forward data.”

Now, nearly three decades removed from AJR’s initial frontline reporting, is the teleradiology revolution running out of steam? Well, the business answer at least is rather hazy.

Citing a trend analysis from Research and Markets, in 2018, Diagnostic Imaging reported that the global teleradiology marketplace was forecasted to reach $8.2 billion by 2024. Despite that healthy compound annual growth rate, president and chief executive officer of Imaging Consultants, Inc., Lawrence Muroff, cautioned that teleradiology’s market share was likely to shrink over the next three to five years.

Echoing Muroff’s sentiments, Elizabeth Krupinski, professor and vice chair for research in the department of radiology and imaging sciences at Emory University School of Medicine, indicated a swing allied with artificial intelligence, saying “I can see teleradiology changing as a byproduct of the overall industry shift.”

And already, less than a year later, as Muroff told Diagnostic Imaging this past September: “Teleradiology is a saturated, mature market that is no longer growing.” “If anything,” he compounded, “it’s shrinking somewhat because, as practices get larger, they have a greater capability of providing comprehensive call themselves.”

Corporate takeovers of independent radiology practices—what AuntMinnie flagged as one of 2019’s “biggest threats to radiology”—has taken on teleradiology, too. As reporters Brian Casey and Erik Ridley explained: “The rise of corporate radiology companies— which have oftentimes grown by acquiring smaller groups— is turning many radiologists from entrepreneurs into employees. Meanwhile, hospitals continue to expand by swallowing up outpatient centers that once operated independently.”

The bigger they are, the louder their call, indeed.

In his inquiry into the October white paper from the ACR’s Corporatization Task Force, Jake Fishman of The Imaging Wire concluded that continuing consolidation within the industry should be expected through 2030, “depending on capital liquidity, legislative/regulatory changes, and market volatility.”

A newer survey from KPMG tapped 330 corporate, private equity, and investment banking executives in the life science industries for their two cents. And what did this “Big Four” accounting organization find? This year, the health care sector will endure even more absorption than it did in 2019.

Of course, suffering the slings and arrows of more and more mergers and acquisitions (M&A) doesn’t have to necessarily stymie teleradiology’s forward march.

In this past November’s issue of AJR, Michael A. Bruno and team pointed out that “in a fully integrated practice model a single group of subspecialist radiologists would provide care seamlessly at all practice sites, either on a rotational basis or by sharing cases through teleradiology or shared PACS systems, across the full spectrum of care.”

Ultimately, the truest test of tele-harmony writ large depends on who, how, and expressly where you ask.

The law firm Foley & Lardner’s third end-of-year, state-by-state canvass of telehealth coverage recounted a “sea change” in legislation requiring commercial payers to reimburse providers for virtually rendered services. Yet, two months prior, the assessment from analytics juggernaut J.D. Power noted coast-to-coast consumer adoption of telehealth services as “stubbornly low.”

Alas, crunching the latest numbers on the international ledger fuzzies things further.

Worldwide venture funding for digital health, including private equity and corporate venture capital, declined 6% over the last fiscal year. Nevertheless, a Global Market Insights report from March 2019 had predicted that telemedicine’s global share would more than triple by 2025—ballooning from its current $38.3 billion valuation to $130.5 billion.

In light of all the headline legislation, relentless coups, and exaggerated projections implying the demise of enterprise teleradiology, according to its most thorough clinical evaluation to date, the actual practice of teleradiology is very much alive and well.

In the December 2019 issue of Journal of the American College of Radiology, incoming AJR editor in chief Andrew B. Rosenkrantz got granular regarding radiologists’ overall “habits, attitudes, and perceptions on teleradiology practice.”

Defining teleradiology as “the interpretation of medical imaging examinations at a separate facility from where said examination was performed,” Rosenkrantz and his colleagues solicited responses (appropriately enough, via email) from a random sample of 936 ACR members. While a clear majority, 731 respondents, designated their main work setting as non-teleradiology, 85.6% of that cohort indicated they had practiced teleradiology within the past 10 years. Furthermore, 25.4% stated teleradiology comprised a majority of their annual imaging volumes.

No longer the realm of nighthawks, a staggering 91.3% of respondents said that they had implemented teleradiology during normal business hours, while 44.5% to 79.6% said they had implemented teleradiology over evening, overnight, and weekend shifts.

In rural areas, 46.2% of American radiologists surveyed by Rosenkrantz reported performing teleradiology, and 37.2% reported performing teleradiology in critical access hospitals.

Helping working radiologists realize after-hours success and expand coverage for underserved patients, “despite historic concerns,” Rosenkrantz reassured, “teleradiology is widespread throughout modern radiology practice.”

Like most cutting-edge revolutions, efficacious telemedicine continues to spread.

From the TeleWOW program in northern Maine connecting more than 50 obese children and young adults with certified health and wellness specialists to the Michigan Department of Health and Human Services’ four-year, $1.6 million federal grant to expand a statewide telehealth platform for epilepsy care management, right now, individual states are the freer laboratories for this digital democracy.

At the same time, Amazon is paying for workers diagnosed with cancer to physically see specialists down in Los Angeles’ Silicon Beach, while piloting its own virtual health service for employees and their dependents, Amazon Care, led by pulmonary specialist, public health wonk, and defector from Apple, Vin Gupta.

There’s good news from abroad, too.

A pilot study just published ahead-of-print in AJR by a team from Germany’s second-largest city and Europe’s third-largest port, Hamburg, christened the concept of maritime telemedicine with the inauguration of a PACS-centered service staffed 24/7 by specialized radiologists at a tertiary hospital on shore.

So, what do the trade machinations of tomorrow or the next administration’s regulations portend for teleradiology’s next wave, the clinical and the commercial?

Perhaps a startup like Nines in Palo Alto, California might know those breakers best.

Fresh out of stealth mode and buttressed by $16.5 million in Series A cash, the mission of this teleradiology company is decidedly asynchronous—assist radiologists in triaging head CT scans through machine learning.

In other words, M&A, meet AI.