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Tim Kelley:
Welcome to Imaging and Teletech Innovations, brought to you by TeleRay. I’m your host, Tim Kelley. Join us as we explore the latest trends and developments in teleradiology and imaging solutions, from expert insights to real-world case studies. We cover everything you need to know to stay ahead in the rapidly evolving field of radiology. So sit back, relax, and let’s dive in.

Tim Kelley:
So today, we have Dr. Samir Shah with Envision. Thank you for joining us today. It says here you’re the Chief Clinical Officer, and the Master of Teleradiology, and the SVP of Radiology.

Samir Shah:
Thanks, Tim. It’s nice to be here with you.

Tim Kelley:
Yeah. Could you tell us a little bit about yourself?

Samir Shah:
Yeah, I’m originally from New Jersey, grew up there, northeast, went to Boston University for a college in medical school, and then I went to Philadelphia, did my residency at UPenn, graduated in 2003, went to Chicago for a year, I did my fellowship in interventional radiology, and in between residency and medical school, I did my internship in Pittsburgh on the western side of the state of Pennsylvania, and that’s where I met my wife. And so after my fellowship, we moved back to Pittsburgh where I took my first job, I’m speaking to you from Pittsburgh, Pennsylvania, I’ve been here for 20 years now; and that was an interventional radiology position, almost 100%. I barely read any films. How, I’m going to anticipate your next question, how did I become the master of teleradiology? My group, I had great practice for five years in a Western PA doing mostly interventional radiology, and my group basically dissolved. There were a combination of things that were hitting back in 2007-2008, there was a deficit reduction act, and UPMC had gone from like an academic medical center to the E-Myth, and there were a lot of things going on in the world at that time. And so my practice actually went under, and I built we had built the house that I’m sitting in right now, and my wife was pregnant with my second of three kids, and unfortunately, my father passed away in the ICU. And so it was a terrible time to change practices. And back then, very different from teleradiology and radiology, quite frankly, today, is that people would join a practice and be like, That’s where I’m going to be for the next 35 years. So that’s why I built the house and everything else because I was like, This is where I’m going to be. But I ended up calling my best friend from residency in Australia and basically telling him my sob story that like, this is what happened, and he’s, Join my group, join Teleradiology, and I was like, I don’t think you understand. All the teleradiologists in his group were in Australia, and that’s where teleradiology was done. If they weren’t in Australia, they were in Zurich, but if they weren’t in Zurich, they might have been in some other place in Europe or China or something like that, and I was just like, How can I join your group? And he was like, We’re hiring US Rads, there’s this thing called Final Reads, which are very different than the preliminary wet reads that we do at night, daytime for them, nighttime for the US. And lo and behold, I became one of the first final readers based in the US for night, both radiology. And NightHawk was the original teleradiology group, the progenitor of a lot of the subsequent groups that exist today. And I, a lot of sea change, in 2008, there was a financial crisis, etc., the finals were coming into play, a lot of the radiologists came back to the US. I was already here, and I was elected medical director of NightHawk in 2010, and I worked with the other medical directors who came back to the US. By 2011, we had been acquired by vRad, so that was like a first big transition, but I had spent seven years at vRad, eventually becoming senior medical director, working with the Chief Medical Officer hand-in-hand. I was doing a lot of the sales and account management and client management, and so I was traveling all over, but it was an amazing experience because I got to meet a lot of groups and understand the dynamics of teleradiology like nobody else. It was a unique position, so I’m very grateful. In 2018, I know, I do realize, Tim.

Tim Kelley:
That’s all right.

Samir Shah:
Talking a lot here, but in 2018, I went to Radiology Partners. I was recruited to help build teleradiology there, and that was very successful. It was, taught me a lot, because basically, we started as a startup Telerad Group, numbering single digits, and grew that practice to about 200 Telerads, and that put me on the radar for Envision, and I’ve been here for about nine months, and I am acting as Chief Clinical Officer for the teleradiology practice. We have a large practice. We have probably 200 Telerads, like I said, and we have about another 500 or so on-site, on-the-ground radiologists. So it’s a large practice, one of the largest there is. And so we do, we are revamping the practice, bringing it into the latest and greatest era of technology and efficiency, basically.

Tim Kelley:
Sure, yeah, it’s a big need. And then, you mentioned some of our customers between the span of the Midwest here. And so you got to experience Chicago cold as well as some Primanti sandwiches.

Samir Shah:
Certainly, yeah, I definitely am a fan of the Primanti Brothers sandwiches, but I did love my time in Chicago, no question. I could have stayed there, except it was definitely cold in the winters, let’s put it that way, not that Pittsburgh’s any better.

Tim Kelley:
Yeah, yeah, it can get pretty brutal here, but we have.

Samir Shah:
It can be, the Lake Erie effect and the Buffalo cold.

Tim Kelley:
For sure, … that too.

Samir Shah:
Yeah, it’s not that great.

Tim Kelley:
But we still play football outside, so that’s what counts.

Samir Shah:
Correct! Absolutely right.

Tim Kelley:
Can you tell me a little bit about the organization’s challenges facing solving these new technologies that are coming out and how you satisfy patients with how they’re dictating more of how they’re going to practice their own medicine?

Samir Shah:
Yeah, one of the challenges unique to teleradiology, which has existed since time immemorial, Telerad came around at the turn of the millennium, and over the years, there’s been cycles in terms of how many rads you have and how much volume you have, and that is probably the number one challenge every group faces is because you’re held to certain turnaround times. If you make the turnaround times too good, your radiologists are hungry for cases, and if you make them too bad, you’ve got ERs and hospital systems complaining about turnaround times. We’re in a severe rad crunch right now, which is no news to you, and I think that maintaining service, and in that time, is probably our number one priority to make sure turnaround times are top-notch. I think technology is a huge challenge, quite frankly. I don’t think there’s any great system out there. There’s nothing that is really groundbreaking. When I was in training 20 years ago, voice recognition came about, PACS came about, and things with the EMR were coming out, and nothing’s changed really in 20 years. Voice recognition made us less efficient as radiologists. PACS systems probably slowed down the speed at which we can look at X-rays, because we used to be able to look at a whole bunch of X-rays on an alternator and just put our foot to the metal, and that board would go as fast as you could dictate into the Dictaphone. Now, it wasn’t all rainbows and unicorns. Sometimes, it took two days for a report to be transcribed. It was easy. That was a problem with not having radiology reports for the staff; people forget about those days. So, technology has come a long way, but I think you generally see that radiologists are frustrated because the volume is so high that they need to get through it, and reimbursements have come down so much, probably on the order of 40% since I first became an attending. And I’d say those two things create a perfect storm of requiring a new technology. And, of course, we both know that’s going to be AI, and it’s just the game.

Tim Kelley:
So with that, you were talking about the voice dictation and that slowing things down and the moving away from that click macros and stuff like that. So when you go to working at things like ChatGPT and these kinds of technologies and then recognizing voice dictation, do you think that’ll fix some of those problems or create more?

Samir Shah:
Oh yeah, I try to use ChatGPT every day because I think it’s groundbreaking. It’s open-source software, and it’s generative AI, so it’s really something unique that can really change the game. I’ve been using programs to help me beyond just your simple macros since they started: pseudo-NLP programs, natural language processing programs that are not AI-based, but that will map things in your report to certain structured headings. And then, since then, you have natural language processing AI-based programs that’ll create your impression. I use both of those programs, but what I’m really excited about is having ChatGPT do those things together in one program, build a radiologist report and impression, and learn, right? Because it is AI, and that, to me, is super exciting. I did find a published article from Germany that showed 170 reports created with, 170 perfect reports created with ChatGPT4 pretty impressive stuff.

Tim Kelley:
That’s really impressive.

Samir Shah:
It excites me, Tim, because we are in that next era. When Bill Gates was like programming on a PC in high school in his early college years, he probably felt the way I do about what’s happening in the AI space now. We were talking about AI for years, but we were in that peak expectations of AI, and then we went through reality basically and hit the truss. But now we’re coming out of it and seeing that AI really can have some powerful effects in radiology as a tool.

Tim Kelley:
Without question. And then, as part of that, you mentioned the lack of radiologists, and now you start seeing more and more specialists doing reads at home, doing their own workstations in their office and so forth, and using these tools and exchange. And that may lend itself more to their capabilities to work alongside radiologists or to be independent. So what do you think about that?

Samir Shah:
I think that is an interesting observation. I think that you are absolutely right. And I told you, I’ve been doing Telerad for 15 years, right? What, why didn’t this movement to work from home specialize work during the day? Why didn’t it occur long ago? I was even late to the game. You could say Telerad started around the turn of the millennium. Why didn’t we do it then? I think that the images are all digital, and they’re all over the internet, and the technology has been there. But what we really needed to happen is like a global pandemic to really shake the entire system and say, Hey, these images do not have to be interpreted within the walls of the hospital. They can be interpreted from the daytime, during the day, from any location. I think that’s really changed the entire spectrum of what people are thinking. And I think the other part of that is, as volumes have come back from COVID, not even like back to normal, but like super normal, radiologists attitudes are like we need, we can use this tool as AI, it’s not going to replace us. It’s just a tool in our tool belt that will help us focus on the actual stuff that we need to know rather than getting us bogged down with the non-critical parts of our.

Tim Kelley:
Yeah. How about, when you look at that same type of process using some of these technologies, these virtual visits where we can put you, or a qualified physician, in the room for patient positioning, pro positioning, getting the right image at the right time to reduce scans, have better, basic consultative approaches with technologists who may not be properly trained. There are so many little nuance issues in there.

Samir Shah:
You just think about the power of what we’re going to be able to do in the AI era, right? Not only from a remote perspective, because again, it’s going to learn, right? So it’s going to make mistakes and may need a human to be in the location, but eventually, we can do a lot remote. Robotics is advancing to tell you the truth about things. And I think that the advances that are going to happen are going to revolutionize workflow, first of all, and are going to revolutionize what is a radiologist’s role in the future. Maybe we’ll be more talking about actually not just what a …, not that …, but what chemotherapy has sensed based on the AI evaluation of its morphology. So there are things that are happening in the space that we can’t even put our minds on completely. I read a paper recently where AI is going to be able to accurately predict the gender of the patient based on their retinal scan. Okay, no ophthalmologist can tell that right now. There is another paper out of Emory that shows that you can take a portion of an x-ray, you can then put a bunch of artifact in that x-ray, just imagine a rib or something, and the AI can tell what race the patient is, but no human being can do that. So it understands things that are in a black box that we don’t. That’s incredibly powerful technology.

Tim Kelley:
And then you just mentioned, what is the role of radiologists in the future? A few years ago, there was talk about because of a shortage really hit about radiologists starting to consult with patients directly, and that has definitely been put on the back burner. But I think as we go forward, there might be this integration of Bethe’s multi consultations that go on between the radiologist, the primary care, and saying, okay, we take this consultative approach towards the patient because they’re looking for better.

Samir Shah:
I agree with you. In the old days, when we had a reading room, the docs would come in to consult with us, and sometimes we would talk to patients as well. And we still do in mammography, interventional radiology, etc., but we are the doctors’ doctor in radiology. We have lost some of that due to technology, due to PACs, due to voice recognition, etc. So they, the films aren’t located in the reading room anymore, so the doctors don’t need to come in to see us because we don’t own the films anymore. When you’re talking about technology and things changing, if we have more time, right now, we consider like communication to our referring docs as an interruption. But really, if a doc wants to talk to us, that’s not an interruption, that’s our job. So, we will have a chance to redefine our roles if we don’t have this crushing workload, and AI can help us get through more cases. We’ll have more time to do things that the healthcare system actually wants, which is radiologists communicating to patients, radiologists communicating to other dogs, etc.

Tim Kelley:
Yeah, and no doubt about it. And then when you look at one of the things that holds back some of this technology is the fear of compliance. How do you manage integrity of data, and HIPAA, and so forth? And so people are afraid to embrace some new technologies. How do you think Envision, or yourself, and others are going to manage that going forward?

Samir Shah:
It’s going to be tough. We are developing a mobile app with our partner in AI, which is iDoc. We’re developing this app that is actually going to put like the whole imaging department on your phone and maybe even on your desktop as a one-stop repository. But certainly, what we find is that right now, let’s say we have a critical, life-threatening finding that occurs at 2 a.m. If that doc who’s taking care of the patient is tough to get a hold of, it might take us 20 minutes to actually convey that finding. What if it just popped up on his app like immediately as a critical finding? That’s awesome, but we have to be very secure with the data, very cognizant of patient privacy because we have somebody’s life that’s going to be on phones, and I’m sure eventually images are going to be on the phones as well. And so it’s all going to be carefully done to protect patients, but at the same time, imagine we could save people’s lives if people, even that 20 minutes, if we could shorten that 20 minutes to a couple of minutes, that’s lifesaving in many cases, as we know. Like, that’s the whole point behind all the stroke interventions that we do as every minute time is brain parenchyma that is spared because we act quickly.

Tim Kelley:
Yeah, no doubt about it. And that’s a little scary out there when you think about these things, because if you look at the CPR, anyone can perform CPR if they’re protected, but you could be in a critical or trauma situation. As radiologists move data, you could be exposed, which so those rules need to change a little bit, when it comes down to those types of cases.

Samir Shah:
Yes, true, true, 100%.

Tim Kelley:
So that’s how you guys are going to stay ahead of competition and using apps and some of these technologies.

Samir Shah:
Absolutely. We’re going to innovate. We’re going to take advantage of AI and technology.

Tim Kelley:
Being one of the guys.

Samir Shah:
That’s my number one goal at Envision.

Tim Kelley:
That’s good to hear as a technology company. We love to hear that. All right, so as you guys are moving forward with all this stuff, and you’re the guy that was one of the guys with NightHawks, that’s like these little names that goes way back for guys like us.

Samir Shah:
It’s such an iconic name because, like, it’s the name for the whole field, right? What I do is NightHawk, and what we do is NightHawk. That’s a generic name, and it comes with so much history. So many people I know in the industry are have ties back to NightHawk. So yes, it was really formative. I was lucky to be in the right place at the right time in my career.

Tim Kelley:
Yeah, it does have that legacy to it. So with that, what’s the biggest lesson you think you’ve learned in your space, and your kind of doing this?

Samir Shah:
One of the, one of my favorite lessons that I’ve been taught was by my colleague Ray Montecalvo at vRad. He always used baseball analogies, and he always said, Remember, when you get hit by a ground ball really fast, and you’re a shortstop, every shortstop always takes a second or two to compose themselves, gets the ball, and then throws to first. You have a few seconds, right? Like, you have to make sure you have control of the ball. When the shortstop acts too fast, that’s when they throw a wild ball to first. That’s when it goes through their mitt and into the outfield. The lesson was always data is coming at you fast. You’re going to be asked to act quickly on something, but make sure you have all the facts, make, nothing is so urgent to act on. In leadership, especially when you’re talking about radiologists, nothing is so urgent that you need to go immediately. That’s the one lesson I’ve learned. The second lesson I’ve learned is sometimes technology is not always amazing, right? Like I’m talking to you about AI and everything else. I don’t necessarily think things have gotten better for radiologists with time. I think then, like I said, voice recognition, you could say that it hurt us in terms of being productive. It probably cut our productivity by 25%. It, PACS says, hurt us in terms of our special relationship we had with doctors. We are concerned, as radiologists, about getting through the volume. I want us to step back and say, how do we get that special relationship we had with our referring docs? One of the things that I love about Envision is that we are multi-specialty. We actually have 12,000 ER physician colleagues in our radiology group has access to. And that is really great, because I told you we’re the doctors’ doctor. So, for me, I feel as we’re making this app for critical findings and everything else, working with them to design it is a boon that don’t have at any other practice because we’re literally on the same team. We’re Envision docs. And so I think getting back to being the doctor’s doctor is what I see for radiologists that I want, back to that special relationship, back to having time to really intellectually look at images, not being so rushed, and I think we’ll get there. That’s the key, is to notice that everything technological is not always what you need. You always need to remember your role.

Tim Kelley:
Yeah, and then that just that general sharing of the data is so critical because so many times there’s pieces missing and it’s, when patients, they usually get a report, they don’t have the images, or if they get the images, they don’t have the report.

Samir Shah:
Yes.

Tim Kelley:
There’s all the other information missing, so there’s no holistic view.

Samir Shah:
You’re right. Communication between docs and communication between patients. What you mentioned ChatGPT, one of the things that it does, it can do, and people are working on this now, is converting radiology reports into layman’s language. Think about how many friends and neighbors you have that would love that. My wife is not a physician and she just had her shoulder … I would love to be able to translate that for her in a speech, saying what everything means in language people can understand. That’s actually improving the experience that patients have. And look, at the end when we talk about our role and everything else, all that matters is the patient. That’s our role is to be the best doctor for our patients.

Tim Kelley:
Yeah, and that’s so lame that you say, looks like you hurt yourself pretty good.

Samir Shah:
Yeah, I do. That would be ChatGPT10.

Tim Kelley:
With that, looking at TeleRay, we’re actually working with you guys already on your tech side and with a few of your doctors.

Samir Shah:
Fantastic.

Tim Kelley:
And your former medical director, Dr. Aldo Ruffolo, is a user of ours and well, yeah, we moved data super fast for trauma cases for some of the largest institutions, some that you worked with before, UPMC, and so forth. And hopefully, we keep integrating with you guys and help you guys more with these virtual visits and delicate protocols and all that kind of stuff.

Samir Shah:
This is the future. Let’s do it together, and if you see Aldo, tell him I said hi.

Tim Kelley:
I will, I might see him later, actually.

Samir Shah:
Oh, fantastic.

Tim Kelley:
All right, sounds great. Thanks for joining us today.

Samir Shah:
Thank you.

Tim Kelley:
We’ll talk to you again.

Samir Shah:
It was a pleasure.

Tim Kelley:
Thanks for joining us today on Imaging and Teletech Innovations, brought to you by TeleRay. We hope you like this episode. If you have any questions or feedback, please don’t hesitate to reach out to us at info@TeleRay.com. Be sure to subscribe to the podcast so you don’t miss any future episodes, and stay tuned for more insights into Imaging Solutions and Teletech with TeleRay.

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