Look Again?
By Beth W. Orenstein
Radiology Today
Vol. 25 No. 6 P. 10

Radiology second opinion services are growing in popularity, but questions about their role in patient care remain.

In the old days, “It was hard to move images around,” says Elliot Fishman, MD, a diagnostic radiologist, the director of diagnostic imaging and body CT, and a professor of radiology and radiological science at Johns Hopkins University School of Medicine in Baltimore. Patients had to ask for their imaging to be put on a CD, which was sent by courier or hand delivered to a radiologist who could provide a second opinion.

Thanks to PACS and EMRs, that’s no longer the case. Images requiring a second read can easily be shared electronically. Now, entrepreneurs in radiology are taking advantage of the changing landscape and offering patients the ability to get a second opinion from a radiologist on their own—if they are willing to pay, Fishman says.

Direct-to-patient second opinion radiology services aren’t all that new, but the number of them has been growing of late, and they seem to be thriving. One of the earliest was DocPanel.com, which was started in 2016 by Philip A. Templeton, MD, FACR, and Nirish Mathias. It was started to, among other things, offer patients second opinions from radiologists who specialize in specific types of imaging.

MDView, a virtual care and medical second opinion platform, launched in June 2023. Started in Florida, MDView recently expanded to serve patients in 22 US states, and they are adding more each month. Also last year, radiologist Ali Rahman, MD, founded RadiologyCheck.com, based in Bern, Switzerland, enabling patients to upload files and receive a “comprehensive” analysis from fellowship-trained radiologists in 24 hours or less.

Another online medical consultation service, Second Opinions, recently launched an AI functionality for its platform. Second Opinions is offered by USARAD, a subsidiary of Nanox, a medical imaging company based in Petach Tikva, Israel. The service now incorporates three FDA 510k-cleared AI solutions offered by Nanox.AI, another Nanox subsidiary. This enables patients to get second opinions from experts in various medical and surgical subspecialties, including radiology. (It also offers second opinions in neurology, oncology, and orthopedic surgery.)

“The integration of Nanox.AI’s tools is intended to promote the early detection of chronic conditions on chest and abdominal CT scans,” says Orit Wimpfheimer, MD, CMO of Nanox.

Digging Deeper
While patients may be able to use their health savings accounts to pay for second opinions, they are not likely to be covered by health insurance. “Our platform is self pay,” says Tracy Amato, CEO of MDView. Sunil Kini, MD, medical director of MDView, believes that insurance may be willing to pay for these consumer-sought second opinions in the future, as they add value to decision-making care.

MDView’s prices start at around $200 and go up to $400. An extra $150 is charged if patients want a guaranteed turnaround of 24 hours or less. “Our turnaround is pretty quick,” Amato says. “But a lot of patients don’t mind paying the extra $150 because the response is so important to them.” Second Opinions charges $249 for a CT scan. The price includes a written report, but adding a single comparative analysis is $29 per study.

Those who offer these services believe they are in demand because patients want confirmation that the initial radiologist’s interpretation was accurate. They also want answers to questions the initial study raised that they or their provider may have. Second opinions from DocPanel.com help guide patients facing major medical decisions based on their imaging, such as determining the necessity of surgery, exploring new treatment options, or understanding the nature of a concerning lesion, cofounder and chief innovation officer Templeton says.

“Our platform allows patients to submit questions and interact directly with the reading radiologist,” Templeton says. “This helps them better understand their imaging results and become stronger advocates for their own health. By seeking a second opinion, patients and their providers can make more informed decisions about their health, which ultimately leads to better outcomes.” Wimpfheimer agrees that second opinions are “an additional source of assurance, assisting and strengthening decision making.”

Wimpfheimer says second opinions can confirm a diagnosis or help patients and providers explore alternative treatment options for their medical journey from diagnosis through treatment. “This is helpful,” she says, “as follow-up is rife with complexities that one expert alone may not fully unravel.”

Enhanced Follow-Up
Kini says his second opinion radiology service helps fill in gaps and increase interaction among patients and providers. In most health systems, radiologists who read the imaging studies rarely interact directly with the patients whose studies they read, he says. Typically, radiologists report to the referring physician, and the referring physician relays the findings to the patient.

Kini believes second opinion services like his change that dynamic for the better. It’s not unusual, he says, for radiologists to have to interpret imaging studies without all the background information they need. Often, the radiologist is “shooting in the dark.” They do the best they can, and sometimes it doesn’t make a difference, “But there are times where knowing the context of the situation and all the history of the patient’s illness can be huge.”

MDView allows patients to work directly with the radiologist providing their second opinion and reading their study. “If a patient is not sure about a symptom they’re having or has a question that wasn’t addressed in the initial radiologist’s report, we give them the opportunity to say to our radiologist, ‘Look at this specific area’ or ‘this specific symptom,’” Kini says. “It lets the patient know their study is being looked at again with the questions they have in mind. It’s kind of a failsafe but also an opportunity to interact with the radiologist directly.”

“We also offer an add-on to order a video consultation with the doctor, which is interesting as most patients never have a chance to meet/speak with a radiologist,” Amato adds. Patients love learning more about what is seen in their imaging and the areas of interest, she says.

MDView has received encouraging feedback, Kini says. It’s not only patients but also referring physicians “who have been happy with our service,” he says. As much as 88% of their second opinions in radiology provide new or refined diagnoses, Amato says. “With a second opinion, patients can be confident they have the right diagnosis before embarking on invasive surgeries or procedures.”

At DocPanel, patients and their reading radiologists can communicate directly with one another via a message board in their account dashboard. “Our radiologists use this feature to ask patients questions, such as clarification on symptoms or prior imaging,” Templeton says. “Patients also have the opportunity to ask their radiologist follow-up questions after they’ve received their second opinion report.”

Reasons for Review
Users of the MDView platform report a wide variety of reasons for wanting second opinions, Amato says. “In some instances, the hospital or doctor is recommending they get repeat imaging due to the quality of the original report,” she says. “Some report their doctors have recommended they have someone take another look at the imaging. Some report long turnaround time for the report and are looking to learn what is found in their imaging faster.”

Others request a second opinion from MDView because they are unsure of the original findings due to ongoing symptoms. Still, others have more complex conditions and want each exam read by the same radiologist for multiple exams in an effort to have consistent expert reporting, Amato says. “Overall, patients are looking to verify that their radiology reports are accurate and complete, and they appreciate the ability to share details with the radiologist about their condition and symptoms, which helps the radiologist provide a better report.”

Wimpfheimer says Second Opinions incorporates AI technology to facilitate the early detection of findings correlated with chronic diseases. “By analyzing existing CT scans, even before symptoms appear, our AI algorithms can help identify patients who may be at risk of chronic conditions,” she says. “One of the key advantages of using AI in this context is that it can eliminate the need for additional, separate imaging procedures, which streamlines the diagnostic process.”

Wimpfheimer offers some examples of AI’s utility: The Nanox.AI Cardiac solution detects coronary artery calcification in chest CTs, a significant risk factor for coronary artery disease. The Nanox.AI Bone solution helps identify vertebral compression fractures and low bone mineral density in chest and abdominal CT scans.

“These can be indicators of osteoporosis and hip fractures, so detecting them early can prompt treatment and prevent physical deterioration,” Wimpfheimer says.

In addition, the Nanox.AI Liver Solution uses chest and abdominal CTs to highlight liver density measurements. Low liver density can indicate fatty liver disease, which has a 25% global prevalence and is considered a “silent” global pandemic. The AI component of Nanox.AI Second Opinions is currently being used the most by patients who have undergone chest or abdominal CT scans, Wimpfheimer says.

Comprehensive Evaluation
Users are of all ages and come from across the globe, Amato says. Patients have requested second opinions for everything from routine screenings to complex conditions. “We also have doctors submitting on behalf of their patients because they want a radiologist who specializes in their imaging to review for a second opinion,” she adds. MDView receives the most requests for MRI, especially neuro, abdominal/pelvic, and musculoskeletal MRI.

Patients are encouraged to share their imaging and second opinions with their physicians. MDView has a place on its request form for the patient to provide their physician’s email address. If submitted, the physician will receive an invite to a free MDView account to view the shared study, DICOM images within a diagnostic viewer, patient provided medical records, and the second opinion report. Patients also have the option to download their second opinion report to share with their physician or any future physicians they visit.

“We’ve had many patients report that their MDView report helped support a change in treatment plan, and we’ve had patients share that their physicians appreciated the quality of the second opinion report and the level of detail it included,” Amato says.

Templeton reports that patients use DocPanel.com for similar reasons. “Patients seek our expertise to ensure their scans are read by the best-suited subspecialty radiologist, as well as to obtain a more detailed and comprehensive report,” Templeton says. “They also use our service as an opportunity to have multiple scans that were taken over the years reviewed by a single specialist they have come to trust.”

Sometimes, Templeton adds, patients reach out when their initial interpretation did not yield a definitive diagnosis or clear findings. “They seek a second opinion to explore all possible explanations and ensure that no crucial details have been overlooked.” Patients also are looking for confirmation that a particular treatment or operation that was recommended is the best course of action.

Second opinions aren’t always in agreement with initial reads. What then? When MDView surveyed users, Amato says, 100% reported that their MDView second opinion included new or additional information about their condition. Additionally, 100% of respondent surveys stated their MDView second opinion contained different information from their original radiology report.

Templeton doesn’t consider conflicting opinions to be setbacks. Rather, he sees them as a critical step in the diagnostic process that ensures a thorough and comprehensive evaluation. “If the second opinion conflicts with the first, it presents a valuable opportunity for the patient and their primary health care provider to have an open discussion about the differing interpretations,” he says. “In cases where the second opinion identifies something initially missed, this can be life changing or even lifesaving. Additionally, a differing opinion may provide insights that lead to further investigations, additional imaging, or consultations with other specialists, ultimately supporting a more accurate diagnosis and treatment.”

Questions Remain
Not everyone is enthusiastic about patient-direct second opinion services. The issue with these second read companies is that they are businesses, Fishman says. He has no issue with the business per se, but he questions where the data is to support the claims about second reads. Fishman says he has not seen any data that indicates second read businesses do better than radiologists, nor is it clear “who their experts are.”

He agrees “that in some cases, such as pancreatic cancer, second reads are critical if the first reader is not experienced in the field, as an example.” However, he notes, “This is why many academic and private practice groups do subspecialization whenever possible.” To just say a second read is better is “hot air” and seems “like an election year claim,” Fishman says. “Patients need a proper read the first time so they get the best care,” he adds. He believes second reads can be valuable, “But it all depends on who the first and second reader is.”

Fishman suspects that the original radiologist and the second opinion radiologist are in agreement about what the imaging shows in the majority of cases. A second read is not necessarily more accurate or more detailed just because it’s a second read, and there’s no data to support this claim, he says. Fishman wonders whether some of the second read companies’ claims are “marketing” rather than solid science.

Fishman also believes second opinion services, because they are self-pay, are for patients who are “financially able” and not for those who are of limited means. He has no doubt these services have many anecdotal stories describing when a second opinion was lifesaving, but in general, he doesn’t believe that they are truly necessary.

At Johns Hopkins, Fishman says radiologists do many second reads, especially in oncology patients, but they are included in the care the patients’ physicians routinely provide. “At the end of the day,” Fishman says, “Every patient deserves the best read possible and radiology working with the referring clinician of the patient needs to make it happen.” In the future, Fishman says, it’s possible that AI could make a major impact on lesion detection and characterization and replace the need for some additional reads.

— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and regular contributor to Radiology Today.