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  • portable work station?

    Posted by kilian.rothenbuhler on March 12, 2023 at 1:27 pm

    It will be ideal for telerad to carry a portable station to travel. Sth like a laptop with multiple monitors. Plug in cable in hotel and start to work. Such thing available in the market?

    buckeyeguy replied 1 year, 3 months ago 13 Members · 55 Replies
  • 55 Replies
  • JohnnyFever

    Member
    March 12, 2023 at 1:46 pm

    A diagnostic monitor of adequate size is going to be the issue here. A newer intel performance NUC would be small and adequate for the computer, could screw it on the back of a barco. With a custom carrying case and wireless keyboard/mouse, it could be “portable”

    I think you could read CT and MRI on a powerful laptop with a large high quality screen. Add on an auxiliary USB monitor for better productivity

    • Unknown Member

      Deleted User
      March 12, 2023 at 4:01 pm

      I have worked from home for years reading from 4K TV.   No mammo of course.   Have used 17 in laptop on call at ballgames but screen real estate inadequate, IMO.  Any strong gaming laptop has enough oomph.
       
      I use a 40 in and 65 in 4K tv at home

      • buckeyeguy

        Member
        March 12, 2023 at 5:04 pm

        What do you all think is truly the speed/cnxn minimum to reasonably read from a portable or remote workstation?

        • Unknown Member

          Deleted User
          March 12, 2023 at 5:43 pm

          Have done quite well as low as 30 mb,  currently at 300mb.   no issues

          • buckeyeguy

            Member
            March 12, 2023 at 5:52 pm

            I’m guessing in the 20s is easily doable, and is most even high DSL type lines, to be honest. The real question is how does one get “back up”?

            • Unknown Member

              Deleted User
              March 12, 2023 at 6:24 pm

              Have also used a backup 6 mb wireless hotspot,  was adequate for a backup but slow.    

              • buckeyeguy

                Member
                March 13, 2023 at 7:42 am

                Quote from kcrad

                Have also used a backup 6 mb wireless hotspot,  was adequate for a backup but slow.    

                 
                Boss. How easy was 20-30? Reasonable?

                • Unknown Member

                  Deleted User
                  March 13, 2023 at 3:03 pm

                  took a minute to download a CTA runoff.    most exams loaded as fast as I scroll thru the first series

                • Unknown Member

                  Deleted User
                  March 13, 2023 at 3:07 pm

                  took a minute to download a CTA runoff.    most exams loaded as fast as I scroll thru the first series

                  • buckeyeguy

                    Member
                    March 13, 2023 at 3:40 pm

                    Sweet, thanks

                    • ruszja

                      Member
                      March 13, 2023 at 4:02 pm

                      – If you want to be ‘flying to Hawaii’ level portable, get a Pelican case big enough to hold a 32in monitor. A LG31HL512DB is the cheapest medical display (that will hold a dicom calibration etc.) I just kept the box, it has a handle, works well enough to take a monitor to the beach rental etc.
                       
                      – A laptop with a good graphics card will drive that size display without problems. Diagnostic images on the medical display, worklist and dictation software on the laptop screen.
                       
                      – If you are in a situation where you only need he PACS client to receive images, a very ‘thin’ internet connection will do. It gets problematic once you have an integration with a hospital EMR or you need to run Powerscribe off a in-hospital server. The latency between hotel wifi, VPN tunnel and hospital gateways may make it glitchy and cause things like uncommanded closures of the EMR client.

                    • beatsluver152_896

                      Member
                      March 13, 2023 at 9:06 pm

                      I take my system all over. happy to discuss off-line.. PM me if interested

                    • Patrick

                      Member
                      March 13, 2023 at 11:06 pm

                      You need a local license. Medicare wants to know where you practice. Huge compliance issues are a risk if you read from anywhere willy nilly.

                    • ruszja

                      Member
                      March 14, 2023 at 5:22 am

                      Quote from NYC

                      You need a local license. Medicare wants to know where you practice. Huge compliance issues are a risk if you read from anywhere willy nilly.

                       
                      This sounds interesting. Tell me more about it. References to CMS regulations and relevant OIG enforcement cases appreciated.

                    • dzerangel_635

                      Member
                      March 14, 2023 at 5:32 am

                      ACR policy is to require physicians interpreting images in other states to be licensed in both the state where the image was generated as well as the state where the interpretation takes place.

                    • ruszja

                      Member
                      March 14, 2023 at 6:12 am

                      Quote from rads4meplease

                      ACR policy is to require physicians interpreting images in other states to be licensed in both the state where the image was generated as well as the state where the interpretation takes place.

                       
                      ACR can issue recommendations and ‘practice standards’. The practice of medicine is governed by the respective states who can issue actual policies regarding this.
                       
                       
                       

                    • beatsluver152_896

                      Member
                      March 14, 2023 at 6:42 am

                      FW – correct. 
                      I cant find anything about ACR recommendations on this. if anyone can – please attach

                    • ruszja

                      Member
                      March 14, 2023 at 8:01 am

                      Quote from La Dolce Vita

                      FW – correct. 
                      I cant find anything about ACR recommendations on this. if anyone can – please attach

                      I believe it’s in the ‘practice standards’ for teleradiology.

                      There may be a state or two that requires it, I have not encountered it in that setting.

                    • dzerangel_635

                      Member
                      March 14, 2023 at 12:12 pm

                      From what Ive seen, most state boards require you to have a license if you are reading from that state. Here is a list I found.

                      [link]https://www.medicallicensedirect.com/telemed.html[/link]

                    • ruszja

                      Member
                      March 15, 2023 at 11:24 am

                      Quote from rads4meplease

                      From what Ive seen, most state boards require you to have a license if you are reading from that state. Here is a list I found.
                      [link=https://www.medicallicensedirect.com/telemed.html]https://www.medicallicensedirect.com/telemed.html[/link]

                       
                      Mh, so that’s a list of the state requirements by an outfit that makes its money from assisting with the licensing footwork. Which of these rules spell out that one needs to have a license in both states ? They all deal with practicing telemedicine ‘in that state’ iow, on patients located in that state.
                       
                      I am not saying that there isn’t a state that requires this, I just haven’t seen it.

                    • gmail.com

                      Member
                      March 15, 2023 at 12:27 pm

                      The state medical boards are going to regulate the physicians that are taking care of patients in their state.  They don’t have a say about a physician providing care in another state especially if it is all the way across the country.   I think in the ACR white paper on teleradiology from several years ago, they recommend or suggest you have a medical license in the state you are sitting in and reading cases as well as the state where the patient is being scanned when rendering final reports.   But they never gave any reasoning for this position.   I can’t think of a reason except that Medicare patients claims will be made w/ the MAC in the location where the service was provided and the appropriate GPCI will be applied for the work, PE and MP expense RVUs.
                       

                      Quote from fw

                      Quote from rads4meplease

                      From what Ive seen, most state boards require you to have a license if you are reading from that state. Here is a list I found.
                      [link=https://www.medicallicensedirect.com/telemed.html]https://www.medicallicensedirect.com/telemed.html[/link]

                      Mh, so that’s a list of the state requirements by an outfit that makes its money from assisting with the licensing footwork. Which of these rules spell out that one needs to have a license in both states ? They all deal with practicing telemedicine ‘in that state’ iow, on patients located in that state.

                      I am not saying that there isn’t a state that requires this, I just haven’t seen it.

                    • ruszja

                      Member
                      March 15, 2023 at 12:57 pm

                      Quote from PPRad

                      The state medical boards are going to regulate the physicians that are taking care of patients in their state.  They don’t have a say about a physician providing care in another state especially if it is all the way across the country.   I think in the ACR white paper on teleradiology from several years ago, they recommend or suggest you have a medical license in the state you are sitting in and reading cases as well as the state where the patient is being scanned when rendering final reports.   But they never gave any reasoning for this position.   I can’t think of a reason except that Medicare patients claims will be made w/ the MAC in the location where the service was provided and the appropriate GPCI will be applied for the work, PE and MP expense RVUs.

                       
                      That matches my understanding.
                       
                      The service is provided to the patient where the patient is located. If the patient is located at community memorial hospital in Ants Elbow, KB when they get their CT scan, it is the Kanbraska board of medicine that has jurisdiction over this medical care.
                       
                      Medicare, I am not sure about. I have heard expensive lawyers and experts tell me both ways. 

                    • buckeyeguy

                      Member
                      March 16, 2023 at 8:41 am

                      Quote from fw

                      Quote from PPRad

                      The state medical boards are going to regulate the physicians that are taking care of patients in their state.  They don’t have a say about a physician providing care in another state especially if it is all the way across the country.   I think in the ACR white paper on teleradiology from several years ago, they recommend or suggest you have a medical license in the state you are sitting in and reading cases as well as the state where the patient is being scanned when rendering final reports.   But they never gave any reasoning for this position.   I can’t think of a reason except that Medicare patients claims will be made w/ the MAC in the location where the service was provided and the appropriate GPCI will be applied for the work, PE and MP expense RVUs.

                      That matches my understanding.

                      The service is provided to the patient where the patient is located. If the patient is located at community memorial hospital in Ants Elbow, KB when they get their CT scan, it is the Kanbraska board of medicine that has jurisdiction over this medical care.

                      Medicare, I am not sure about. I have heard expensive lawyers and experts tell me both ways. 

                       
                      It’s like tax advice, almost, so stupid and bureaucratic. If you just do “all of the above” to “be safe”, it defeats the point of getting advice or paying for an “expert.” Everyone else could have just resorted to wasting more time and money for “safety” or fear – they didn’t need someone to be conservative for no reason. That’s not advice or expertise, that’s waste and stupidity. Unless it’s clearly in a law.

                    • Patrick

                      Member
                      March 16, 2023 at 2:04 pm

                      Maybe I worry a bit about the extremes…
                      What happens if I read a head CT from Alaska in Ohio and I am only licensed in AL?  Likely nothing…  However, what if I get pulled into a med mal suit or there is a patient complaint in AK and it was determined on investigation (calendar and IP addresses) that I was in OH and had no license to practice medicine there?  How will AK and OH medical boards respond?  
                       
                      How about if Medicare or another payor audit the specific procedural bill under the same circumstances?  (I do think the US gov would construe the use of a VPN to appear in a specific location while in another, particularly if out-of-Country as fraud).
                       
                      Seems best to me to just maintain the relevant licenses AND be transparent and limited in sites from which one provides teleradiology services.   At least, until the necessary legal and regulatory frameworks are worked out to allow for nomad radiologists…

                    • Unknown Member

                      Deleted User
                      March 16, 2023 at 2:13 pm

                      Who is to say what happens away from the hospital and imaging center. I could train my teenage son to read ultrasounds while I do other household chores. Bone densities? Bone films? mammograms? No one will know the difference. As long as the government can’t confirm I am somewhere else I’m good.
                       
                      Offsite reading is really a pandora’s box.

                    • buckeyeguy

                      Member
                      March 16, 2023 at 2:33 pm

                      Ok, then no teleradiology should exist, even in the already “you must be in the commonwealth even though you are a natural born citizen and licensed in the state where the studies take place”?
                       
                      I could already be not looking at the studies, and just signing normal every time – but I don’t. So the whole “someone else could be doing something” is an irrelevant point.
                       
                      Offsite reading was made necessary by all the absurd demands of the CYA culture and medicine in general. Let’s get back to the obvious realities here, people.

                    • Patrick

                      Member
                      March 16, 2023 at 3:48 pm

                      drad123, that is called fraud…  Technology may enable it, but it doesn’t mean that it isn’t unethical and illegal.  Does it happen, likely…  Will I do it? NO.  Will I blow a whistle if I discover it?  Yes, I’m not going to let sketchy practices threaten the viability of my or my partners’ practice.
                       
                      I’m not going to search the rules and regulations…  It’s on the person doing it to prove to me that it is all above board…

                    • Unknown Member

                      Deleted User
                      March 16, 2023 at 3:57 pm

                      No hospital is going to credential you to read exams if you are not licensed IN THAT STATE.   

                    • Patrick

                      Member
                      March 16, 2023 at 4:08 pm

                      That’s a given.  The question is with a mobile workstation, what are the requirements to read from another state?  I believe one really needs a license in both the state being covered and the state where the radiologist is physically located.  

                    • buckeyeguy

                      Member
                      March 16, 2023 at 7:23 pm

                      Quote from NYC

                      That’s a given.  The question is with a mobile workstation, what are the requirements to read from another state?  I believe one really needs a license in both the state being covered and the state where the radiologist is physically located.  

                       
                      Based on what? Your feelings? I cannot think of one good reason why that should be the case. It’s the definition of (more) hoop jumping/redundancy, and God knows we have careers of that kind of stuff. Please, tell me why you are of this belief? I’m curious how convincing this will or will not be …

                    • Unknown Member

                      Deleted User
                      March 18, 2023 at 7:17 pm

                      what about if you are enroute to a “radiology conference” or similar, cross-country at 35,000 ft reading films from above?  I know some busy rads that do that, especially ones that read for imaging centers.

                    • ruszja

                      Member
                      March 18, 2023 at 9:19 pm

                      Quote from Wilhelm Roentgen-the original

                      what about if you are enroute to a “radiology conference” or similar, cross-country at 35,000 ft reading films from above?  I know some busy rads that do that, especially ones that read for imaging centers.

                      The feds have already sent a rad to prison for signing time-stamped reports while he was on board of a plane. That was before the days of routine internet access on board of international flights. The main thrust of the case was a ghosting scheme, but part of the evidence was that they matched his IBIS record and flight schedules to show that it wasn’t him who was issuing and signing reports.
                      So for all the smartypants with their ‘but I can use a VPN’ workaround. Sure, you can make the computer appear to be somewhere else, but as long as your name was on a passenger manifest when you left the country and you scanned your passport when you returned, the feds know that you were gone.

                    • dzerangel_635

                      Member
                      March 19, 2023 at 12:30 am

                      They can simply track you by your cell phone now.

                    • gustavobarraza_207

                      Member
                      March 19, 2023 at 6:08 am

                      I am curious.
                      Does anyone on the forum have definite personal knowledge of either of the following:
                       
                      1. Investigation of a radiologist reading remotely out of their home state while on a short vacation (one week).
                       
                      2. Investigation of a practice (or radiologist) for billing the professional reading component in a county thats different from the county that the exam was performed in (within the same state). I.e., if a large group practice in New Jersey has centers in different counties, for which a rad reads from only one place…. and the practice bills the fee from ONLY the scan location. I know some academic places try to correlate the reading station location with the billing, but I think this is rare for a private practice.

                    • ruszja

                      Member
                      March 19, 2023 at 10:06 am

                      Quote from drgl

                      1. Investigation of a radiologist reading remotely out of their home state while on a short vacation (one week).

                       
                      No.
                       

                      2. Investigation of a practice (or radiologist) for billing the professional reading component in a county thats different from the county that the exam was performed in (within the same state).

                       
                      Yes. It wasn’t radiology. We have different MACs for different regions of our state. Local surgeon thought he struck gold when he bought a small practice from a retiring colleague and started to bill all his E&Ms and pre-op testing from that new ‘metro’ location taking advantage of a 20% higher geographic adjustment factor. About two years in, this tripped a breaker at one of the MACs involved and they started to pull charts. Yada yada consent decree, a big check with triple damages, suspension from the medicare program etc. All the fun stuff.
                       
                       
                       
                      A qui-tam suit is only a concern if you:
                      – do something easily provable to be illegal
                      – do a lot of it (a few million in volume)
                      – screw an insider of your operation out of his fair share.
                       
                       

                    • buckeyeguy

                      Member
                      March 20, 2023 at 4:34 pm

                      Quote from fw

                      A qui-tam suit is only a concern if you:
                      – do something easily provable to be illegal
                      – do a lot of it (a few million in volume)
                      – screw an insider of your operation out of his fair share.

                       
                      Good summary by fw, and accurate. That alone means that unless you’re a greedy shyster, it’s a silly idea that anything will happen to you. The people that get and got busted were doing really stupid, greedy, crazy stuff. Like the Indian dude robo-reading mammo in Georgia about 10 years back. Mammo of all things. I think the tech called something in on him. Dude read like 10,000 studies in a month, maybe a week.

                    • Patrick

                      Member
                      March 20, 2023 at 5:20 pm

                      Just because you can do something undetected without consequence, does not make it legal or appropriate or ethical.  Plato’s Gyges would be a great point of discussion.  I always felt Tolkein’s ring was actually a derivative.

                    • Unknown Member

                      Deleted User
                      March 21, 2023 at 7:37 am

                      Quote from NYC

                      Just because you can do something undetected without consequence, does not make it legal or appropriate or ethical.  Plato’s Gyges would be a great point of discussion.  I always felt Tolkein’s ring was actually a derivative.

                      Lack of transparency is power. Immense power. Teleradiologists will not have this power.

                    • buckeyeguy

                      Member
                      March 21, 2023 at 12:58 pm

                      Quote from NYC

                      Just because you can do something undetected without consequence, does not make it legal or appropriate or ethical.  Plato’s Gyges would be a great point of discussion.  I always felt Tolkein’s ring was actually a derivative.

                       
                      While of course that’s true, why is that generic statement relevant to this discussion? Do you honestly think ethics is involved with a guy reading Florida studies from Washington state, when he has a Fla license? Why are you guys creating problems that aren’t at all questionable?

                    • amado.rodriguezbenitez_967

                      Member
                      March 19, 2023 at 8:30 am

                      [link=https://law.justia.com/codes/hawaii/2022/title-25/chapter-453/section-453-2/]https://law.justia.com/co…ter-453/section-453-2/[/link]
                       
                      This pertains to Hawaii but as I far as I can tell it seems to specifically allow for a  teleradiologist to read for other states (that they are currently licensed to read in) while physically being in Hawaii without the need for HI license as well.  Section (7)
                       
                      Anyone have a different reading? The legalese is somewhat confusing. 
                       
                       

                    • Unknown Member

                      Deleted User
                      March 19, 2023 at 9:39 am

                      never heard of any investigation for that.  I’ve been doing telerad for >30 yrs. 
                      Too time consuming and what is there to really gain?
                      Unless it happens to be Medicare – there is no potential “whistle blower” reward available for uncovering this or snitching on somebody.
                      Remember, they’d have to prove beyond any reasonable doubt and until that time – you’d be innocent unless proven guilty.
                      Any because this is really a state (not federal issue – unless Medicare) claim that you are practicing medicine in a state without their license to consult or read a couple of xrays, it would probably not amount to any very serious consequences.

                    • Patrick

                      Member
                      March 20, 2023 at 5:18 pm

                      Not a lawyer, but HI sounds like they carved it out…  Did this preexist this 2022 law?  Have other states followed?  A lot has changed in recent years.
                       
                      Also, what do the payers say?  Not just Medicare?  
                       
                      I am happy to be convinced that we are free to practice anywhere within the US for states in which we are licensed without having a local state license.  But, I am not yet convinced that the laws are clear in all 50 states and US Territories.  Payor issues also remain open.  If it can be proven, great.  Until then, I’m not gonna be very happy to find people that work with me jet setting around with portable workstations, not clearly declaring where and how they are being deployed.  Still too grey for me.  Still too much of a compliance risk for my current practice.

                    • amado.rodriguezbenitez_967

                      Member
                      March 20, 2023 at 5:43 pm

                      To me the biggest potential issue is that Medicare/CMS wants to know the actual address where you are reading from.  From what I understand this cant be easily changed/updated on a whim, making it difficult to impossible for the people who want to travel around (the U.S. of course) with some sort of suitcase reading station.  

                    • dzerangel_635

                      Member
                      March 20, 2023 at 5:48 pm

                      Quote from MD20/20

                      To me the biggest potential issue is that Medicare/CMS wants to know the actual address where you are reading from.  From what I understand this cant be easily changed/updated on a whim, making it difficult to impossible for the people who want to travel around (the U.S. of course) with some sort of suitcase reading station.  

                       
                      Yes this is exactly the issue.  Our hospital informed us we cannot even read from a different location within the state for this reason.

                    • JohnnyFever

                      Member
                      March 20, 2023 at 5:58 pm

                      Dream run sounds like a real ass.

                      Imagine this:. You’re reading remotely from California but billing medicare for rural Montana rates. You piss your tech off, and they report you for CMS fraud, getting a 30% finders fee of whatever you owe

                    • ruszja

                      Member
                      March 21, 2023 at 8:16 am

                      Quote from RoleCall

                      Dream run sounds like a real ass.

                      Imagine this:. You’re reading remotely from California but billing medicare for rural Montana rates. You piss your tech off, and they report you for CMS fraud, getting a 30% finders fee of whatever you owe

                      It’s not as easy as making a phonecall and collecting a fee. You have to file a lawsuit as a private person. The feds will move to have your suit sealed. They spend some time investigating. If they decide that the juice is worth the squeeze, they take over your suit, unseal it and proceed against the malfeasor. If they settle, you get a cut.

                      They will do that if there is at least a million to recover. If there isn’t , they hand the suit back to you and wish you good luck in your effort to save the taxpayer some money.

                    • buckeyeguy

                      Member
                      March 21, 2023 at 1:00 pm

                      Quote from RoleCall

                      Dream run sounds like a real ass.

                      Imagine this:. You’re reading remotely from California but billing medicare for rural Montana rates. You piss your tech off, and they report you for CMS fraud, getting a 30% finders fee of whatever you owe

                       
                      Why am I an arse? Lemme guess, you’re indian, lol
                       
                      I never said you should bill from different locations. That’s not what other people are talking about either. Different topic, and fw even said that the guy that did that got busted. So, precedent I don’t disagree with. He’s been accurate so far on everything, facts are facts.

                    • ruszja

                      Member
                      March 20, 2023 at 6:13 pm

                      Quote from MD20/20

                      From what I understand this cant be easily changed/updated on a whim, making it difficult to impossible for the people who want to travel around (the U.S. of course) with some sort of suitcase reading station.  

                      Log into PECOS
                      Add practice location.
                      Hold claims
                      Wait for retroactive date
                      Bill from new practice location

                      Worth doing if you are at the beach for a week and read a few leftover spines ? Prob no. Worth doing if you buy a winter home in AZ. Probably.

                    • buckeyeguy

                      Member
                      March 16, 2023 at 8:37 am

                      Quote from fw

                      Quote from rads4meplease

                      From what Ive seen, most state boards require you to have a license if you are reading from that state. Here is a list I found.
                      [link=https://www.medicallicensedirect.com/telemed.html]https://www.medicallicensedirect.com/telemed.html[/link]

                      Mh, so that’s a list of the state requirements by an outfit that makes its money from assisting with the licensing footwork. Which of these rules spell out that one needs to have a license in both states ? They all deal with practicing telemedicine ‘in that state’ iow, on patients located in that state.

                      I am not saying that there isn’t a state that requires this, I just haven’t seen it.

                       
                      Yes, and what’s more, how would they know and why would it matter?

      • JohnnyFever

        Member
        March 12, 2023 at 6:28 pm

        Quote from kcrad

        I have worked from home for years reading from 4K TV.   No mammo of course.   Have used 17 in laptop on call at ballgames but screen real estate inadequate, IMO.  Any strong gaming laptop has enough oomph.

        I use a 40 in and 65 in 4K tv at home

        Can you technically bill for x-ray on a 4k tv? I’d imagine the contrast wouldn’t be adequate

        • Unknown Member

          Deleted User
          March 12, 2023 at 8:21 pm

          There is no requirement.   ACR suggests 3 mp monitors for radiographs.    CT,  MR,  US need less.   4K tv is 8 mp.
          The only legal requirement is 5 mp for mammo.   I have compared my 4K monitors side by side with Barco 3 MP,  preferred the 4K as image is much larger.  Looking at a pneumothorax on a COPD patient on both types should convince you. 
           
          Important to look for specs with capability for high brightness and contrast.   Play with video settings to optimize grey scale.      
          Medical grade monitors maintain brightness and contrast till failure.  Commercial monitors do not and may gradually fade.

          • Unknown Member

            Deleted User
            March 12, 2023 at 8:22 pm

            The 5 mp monitors for mammo have to be certified for mammo,  

            • andy.lippman_422

              Member
              March 12, 2023 at 10:57 pm

              I read on an OLED 42″. X-rays look amazing. At least as good as a Barco 6230 which I use occasionally and way better than the diagnostic Eizo I had before.

              • andy.lippman_422

                Member
                March 12, 2023 at 10:58 pm

                For my portable setup, I have a Gator carrying case that I take a 32″ LG in. Any laptop will have more than enough power to run PACS. Use the laptop screen for PS360.