Kyle Green | The Roanoke Times

Dr. Daniel Maxwell, a radiologist, is working temporarily for Carilion Clinic after a physicians group moved to another hospital.

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• Talk about this story and Carilion's move to a clinic-based approach

Radiology terms

• Regular X-ray: to examine organs and bones
• Contrast X-ray: injects dye agent for detailed look at blood vessels and organs
• Mammography: to detect and treat breast cancer
• Fluoroscopy: a video device; used to guide a catheter during an artery examination, for one example
• MRI (Magnetic Resonance Imaging): produces two- and three-dimensional images of tissue, often to diagnose tumors and strokes or view torn ligaments
• CT (also called a CAT scan): often used to view trauma injuries and diagnose cancer and strokes
• Ultrasound: uses sound waves to produce images of organs, to view the fetus or detect pelvic problems and gall bladder trouble

Many X-rays at Carilion Clinic hospitals are being interpreted over the Internet by physicians outside of Roanoke because the valley's largest group of radiology doctors moved most of their practice to Lewis-Gale Medical Center in March.

Carilion has hired some temporary radiologists to read X-ray images and has increased the use of an outsource radiology service for both daylight and nighttime readings.

For doctors changing hospitals, the goal is to keep their businesses independent. For patients, the issues are medical care and where they receive it.

For most of March, after Radiology Associates severed most of its ties that had existed with Carilion Roanoke Memorial Hospital for nearly six decades, the medical community buzzed about slow turnaround times and questionable readings on many types of radiology scans.

Emergency X-rays, as well as inpatient and outpatient images, weren't functioning the same as before, several doctors said.

Mammogram screenings, which continue to be done in Roanoke, also experienced a slowdown, Carilion acknowledged.

These developments were set in motion last June when Carilion, then calling itself a health system, announced plans to reorganize as a clinic. Carilion officials held a series of public meetings to explain what the restructuring meant, vowing one result would be higher-quality medical care.

Yet some doctors cautioned that the clinic model would turn some medical providers against the Roanoke Valley's largest hospital system, which employs more than 400 physicians. Those critics said the level of health care would suffer.

There's a simmering debate over whether care quality is threatened. Two medical-practice groups -- veteran radiologists and ophthalmologists -- have left Carilion and moved to Lewis-Gale's Salem location.

In the past year, Carilion Clinic has hired 75 new doctors, including a leadership team for its drive to directly employ most of the physicians who provide care in its buildings. It plans to erect a clinic building on Jefferson Street to make doctor appointments easier on patients.

Doctors who operate their own medical practices, on the other hand, are starting to make new plans. Two that have left Carilion, or plan to, and are going to Lewis-Gale are Radiology Associates of Roanoke and Vistar Eye Center, with about 30 doctors between them.

Because of the ophthalmologists' move, a few complex eye procedures probably won't be available locally to patients for a few months until Vistar ramps up its equipment and training in the new Lewis-Gale location, Dr. Frank Cotter of Vistar said.

Since Radiology Associates left Carilion on March 1, in a move announced three months earlier, the clinic has been forced to rely heavily on doctors who read X-rays over the Internet from other cities, including some in Australia.

Radiology Associates continues to supply four doctors at Roanoke Memorial, two who do some of the clinic system's mammography work. Two others perform radiology-guided procedures, such as threading catheters into arteries for heart-related treatments.

Nearly all other X-rays are interpreted by a few Carilion-employed doctors or by an off-site radiology service.

Carilion chief executive Edward Murphy said concerns about radiology errors and delayed readings have been overblown by doctors who criticize Carilion's switch to the clinic model of providing health care.

It's normal to have a low percentage of errors on X-ray reads, Murphy said.

"In radiology we do 1,000 images a day. If that's done 99.9 percent perfectly, it's a mistake a day," Murphy said.

Also, he said, statistics show turnaround times on X-rays improved after the off-site readings began.

Dr. James Blackwell of Radiology Associates said the statistics Carilion cited probably used a timing method that yielded an incomplete, apples-to-oranges comparison of his group's turnarounds to those of off-site radiologists.

Carilion, when asked about Blackwell's response, said it believes the statistics show it has met its targets for X-ray turnaround times. Carilion spokesman Eric Earnhart stopped short of saying that Blackwell was wrong in his assertion about how the statistics were compiled.

Carilion says the changes haven't harmed patient care and the hospital system will continue to meet all X-ray and eye-surgery needs -- without interruption.

The problems several doctors cited with Carilion's X-ray readings in March, after the radiology group moved to Lewis-Gale, have been resolved and statistics prove it, Murphy said.

Turnaround times on the X-rays improved after the off-site readings began, Carilion said.

Criticism of Carilion's plans, Earnhart said, comes mostly from independent physicians who actively oppose the clinic model.

To be sure, some independent doctors are supportive of Carilion. Dr. Joe Austin, an independent cardiologist, said he hasn't seen any drawbacks with Carilion's X-ray work. "The service, if anything has been better," Austin said, citing timely reports on critical daytime reads directly from Carilion's X-ray department, which he uses five to 10 times a week.

Dr. Geoff Harter, an ear, nose and throat doctor, served as spokesman for a group of physicians who voted 198-88 to adopt a "no confidence" resolution toward the clinic model in October.

"I'm still significantly displeased with the readings I'm getting from Carilion," Harter said Friday.

"Where previously radiology reports would go into detail, these reports are shorter with general comments which don't focus a lot," Harter said.

In addition, Harter said, he received a CT image reading from a Nighthawk radiologist that reversed the patient's right and left sides.

"Even the patient noticed that," Harter said. "He said, 'But all my problems are on my right side.' "

Another physician, Dr. Larry Monahan, who has an internal medicine practice independent of Carilion, told The Roanoke Times about two incorrect reads of X-rays that he observed.

In one, a reading done at night of an X-ray for a 96-year-old female patient failed to note a fractured thigh bone that had broken when she fell at home. Further study, a day later by a Roanoke-area consulting radiologist, detected the break and led to a cast being placed on her leg.

Monahan cited another X-ray report concerning a female patient from an off-site radiologist who failed to note evidence in an image of her brain that indicated she had suffered a stroke.

That report "did not mention at all 'an area of lucency in the right vertex area consistent with a right anterior cerebral artery territory infarct,' (i.e., an ischemic stroke)," Monahan said.

A consulting radiologist in Roanoke detected the stroke the next day, Monahan said, and he began a new treatment procedure for the woman.

"The treatment has been successful, and she right then began a remarkable and progressing recovery of function in her paralyzed left side," Monahan said.

Harter said most of the readings done for him through Carilion now apparently come from Nighthawk, an outsource provider of radiology reads that is used by more than 1,300 hospitals and radiology groups.

Nighthawk, a U.S. company, was formed in Australia in 1994, and for several years, doctors working in daylight hours there have read nighttime X-rays for Carilion's emergency department.

Since Radiology Associates left Carilion in March, the hospital has increased its use of off-site radiology services, relying on daytime as well as nighttime service from Nighthawk.

All of the Nighthawk radiologists who read Carilion X-rays are "American trained, American board certified radiologists, they are all members our medical staff, credentialed individually by the radiology department," Murphy said.

That means the peer-review process for off-site doctors is just as rigorous as the review Carilion requires of its own staff and independent local doctors, Murphy said.

Nonetheless, critics say, many of those off-site radiologists don't communicate clearly, and often are not readily available to talk with physicians who requested the X-rays.

"Radiologists with special training in interventional procedures will be hard to recruit because they are scarce," Blackwell said.

He acknowledged a division among doctors in the Roanoke Valley about Murphy's plan to restructure Carilion.

"You either think the administration has got a great plan that's the wave of the future, or you don't," Blackwell said.