Hospitals have begun to call on doctors in India, for example, for preliminary readings of computed tomography (CT), x-ray, ultrasound and other scans. Proponents argue that this allows reading of emergency scans in the middle of the night without having to wake in-house physicians. Others fear it will lead to wholesale outsourcing of these and other tasks. Here, we explore the evolution of, and the some of the issues associated with, the offshore radiology trend. The rise of offshore radiology can be traced to the tremendous growth in emergency imaging that began in the late 1990s, as CT scanners were installed in increasing numbers of hospitals, quickly becoming an integral component in emergency care. Emergency room physicians were not trained to read CT scans, and as a result, radiologists often found themselves on call 24 hours a day. Also, the cost of bandwidth dropped considerably in the wake of the dot-com boom, allowing transmission of radiological images at the speed necessary for emergency readings at remote locations. Seeing an opportunity, teleradiology companies such as NightHawk Radiology Services LLC of Scottsdale, Ariz., The Radlinx Group of Irving, Texas (which was acquired by NightHawk Radiology Holdings Inc. in 2007) and Virtual Radiologic Consultants of Minneapolis formed to meet the growing demand for off-hour readings of scans. Within a few years, a majority of hospitals in the US were relying on these and other companies – which came to be known as “nighthawks” – for off-hour, emergency readings. These ventures proved successful, and the companies began to offer daytime services as well. The growth of teleradiology – and offshore radiology, in particular – has many radiologists concerned for their jobs. It should be noted that, unfortunately, one of the originally touted benefits of teleradiology – facilitating readings for remote and otherwise underserved communities – remains largely unrealized. In a Clinical Radiology editorial published last year, Giles W.L. Boland noted that only a fraction of all teleradiology services provided were in these areas, in part because few health care providers have been able or willing to pay for them. With teleradiology companies demonstrating the cost benefits of having scans read off-site, it was only a matter of time before offshore companies began to offer further savings. In India, Teleradiology Solutions was established in 2002, with its base in Bangalore. This firm offers readings by a staff consisting of all US board-certified radiologists. More recently, a handful of Indian companies such as Wipro Technologies Ltd. and the Manipal Group of Hospitals have begun to perform 3-D reconstructions for radiologists and technologists in the US. Here, board certification is not required because the reconstructions do not involve actual interpretation. In “Teleradiology: The Indian perspective,” a paper published last year in the Indian Journal of Radiology and Imaging, Nishigandha Burute and Bhavin Jankharia list several advantages to outsourcing readings of radiological scans to India. Besides the time difference – off-hours in the US are business hours in India – they note the skilled IT and business process outsourcing support staff available in the country and, of course, the cost. More and more hospitals are outsourcing readings of computed tomography, x-ray and other scans to teleradiology companies based abroad, especially emergency readings needed during off-hours. An MRI performed with a state-of-the-art scanner in India costs the equivalent of about $150, they said, with the professional fee component typically amounting to 10 to 15 percent of the cost, or $15 to $25. Thus, outsourcing to Indian radiologists can offer “a significant monetary advantage.” An MRI in the US can cost anywhere from several hundred to several thousand dollars. Another advantage, particularly for hospitals looking to outsource daytime radiological services, is the “cheap labor” to be found in India. An Indian radiologist working in the area of CT and MRI, five years after receiving Indian board certification, earns the equivalent of about $60,000 per year, Burute and Jankharia said. In contrast, in the US, a radiologist with similar qualifications makes approximately $350,000 per year. This, of course, translates to considerable savings for the hospitals. But Indian teleradiology companies face hurdles as well. These include a dearth of US board-certified radiologists in the country – because of the significant differences in salary and compensation, many of the radiologists that train in the US may choose not to return home – and to “ ‘Third World’ status and credibility.” Even given the relatively high quality of medical facilities available in India, many in the US have difficulty moving beyond preconceived notions of the country (although, as Boland points out in a 2008 American Journal of Roentgenology commentary, patients themselves are largely unaware of the fact that reading of their scans could be outsourced to remote radiologists). Despite these challenges, the rise of offshore radiology has many radiologists concerned. As hospitals continue to cut costs, more and more might look to outsource readings of scans, eliminating jobs or even entire departments as they do so. Even if this comes to pass, however, some areas of the field will remain largely untouched. Demand for radiological subspecialists will continue to be strong, while the field of interventional radiology – the practice of which cannot be outsourced – could even grow. Other challenges Outsourcing CT and other scans involves a number of additional challenges. Included among these are legal and privacy issues associated with sending patients’ protected health information to third-party services, especially when transmitting the information across borders. At the same time, the quality of the service provided can be hampered by the technology available, especially with respect to the picture archiving and communications systems (PACS) widely used by hospitals. Introduced in the 1980s, PACS originally was intended for digital archiving of medical data. Developers later added various work flow features, including display of protocols and integration with radiology information and reporting systems. The systems still were used only at the single-site level, but, with increased availability of communications technology, hospitals began to allow remote access to authorized personnel. It was only a matter of time, then, before health care providers operating multiple facilities began to implement PACS that enabled sharing of data across sites. Here, sharing of work flow is possible only if all sites have installed the same PACS. Various means of sidestepping this issue have been put forth, but to date, third-party services do not have the same access to relevant clinical information as on-site radiologists. This could affect the accuracy and quality of the reports they provide.