Early every morning, Dr. David Jacobs wakes up, goes down to his basement, turns on all five of his computers and gets to work looking at X-rays and examining CT scans and MRIs. "This one's from Madison, Tennessee. Came into the emergency room complaining of excruciating abdominal pain," he says as he zooms in on a CT scan of an abdomen. "Ah, there's the problem: Kidney stones." Jacobs is a radiologist living in the city of Efrat in Gush Etzion, but all of his patients live 10,000 kilometers away in America. Jacobs is one of more than a dozen American radiologists - or teleradiologists, as they are more appropriately called - who moved to Israel and took their jobs with them, thanks to the Internet. "Basically, the hospital e-faxes me the scans and I get them in my e-mail," Jacobs explains. "Then I check the scans, write my report diagnosis and send it back." Radiology is a field of medicine in which medical diagnoses are made based on imaging the body, including CT scans, MRIs, X-rays and ultrasounds. Aside from interventional radiology, radiologists require no physical contact with the actual patient. Before he made aliya with his family in 2003, Jacobs worked for Hillcrest Radiology Associates, a radiology group in Cleveland, Ohio. But the work of a radiologist was rapidly becoming more and more demanding. "People coming into hospitals started getting more X-rays and CT scans instead of just physical exams, because doctors thought if we could see inside the body, maybe we're obligated to," Jacobs explains. "So the on-call started to get worse for radiologists, because people come into the hospital at all hours of the night and radiologists had to be available 24/7." Radiologists often must work all night and still be alert the next morning, leaving them prone to making mistakes while studying the intricacies of an MRI or CT scan. Jacobs's group found a solution. "We hired an Australian group to read our stuff at night, which was during the day for them," he says. " And that kind of paved the way for me." When his family began to consider aliya seriously, Jacobs presented to his group the idea that he could work for them at night from Israel. "At first they were hesitant," he recalls, "but then they thought it was a good business idea as well, and they started selling their services to other hospitals." Now, Jacobs's group services nine emergency rooms and is working on another contract with a hospital system in Boston. He works from 6:30 a.m. Israel time till three in the afternoon, which corresponds to 11:30 p.m. until 8 a.m. Eastern standard time - allowing the radiologists in his group residing in America time to get some much-needed rest. "The whole point is that everybody gets to sleep [even though] it's a 24-hour department," says Jacobs. "There's lots of subtle things to see on scans, and who do you want looking at it, someone who's wide awake or half-asleep?" ALONG WITH two other Americans working for his group, Jacobs estimates there are more than a dozen other American teleradiologists in the country, working with hospitals all over the United States and even Australia. One of them is Dr. Iddo Netanyahu - younger brother of former prime minister Binyamin Netanyahu - who heads his own radiology group that operates out of Jerusalem, Italy and the US. Called TDI, Netanyahu's group once spent a lot of time constantly commuting back and forth between America and Israel. But now these radiologists have the option of staying here. "When the idea of night hawk service - working with people who live in a different time zone - got off the ground, we decided to use our group, enlarge it and start giving services from Israel and Europe," says Netanyahu, whose group employs five Americans in Israel and one radiologist in Italy doing night-time reads and four in America doing evening reads. Netanyahu's group teamed up with WorldWideRad, a night hawk company belonging to the university hospitals of Cleveland, which at the time had very few radiologists living outside the US. TDI has now been working with WorldWideRad for more than two years, providing preliminary diagnoses to emergency rooms for various hospitals in Ohio, Illinois and Pennsylvania. "We do what's called preliminary reports," Netanyahu explains. "Someone comes into the emergency room with a problem, they get a CT scan, we read it and give a preliminary diagnosis - he has pancreatitis, or he doesn't, he has appendicitis or he doesn't - and the next morning the local radiologist comes in, looks at our report and dictates his own full report." Echoing Jacobs, Netanyahu says teleradiology is a great solution to the problem of radiologists working at night. "We're not tired, we do very good reads and we make very, very few mistakes," he points out. Furthermore, teleradiology presents radiologists who want to make aliya with a perfect arrangement, in contrast to the dire difficulty others encounter in trying to find a job upon moving to Israel. "We have a radiologist who's planning on making aliya shortly," says Netanyahu, "so it's a great situation. He has a ready-made job here." And, Netanyahu adds, teleradiologists working for American hospitals earn according to American standards - several times the salary of most Israeli doctors. In fact, physicians in Netanyahu's group don't even work full-time, and are thus able to work or volunteer their time in Israeli hospitals a day or two a week. DESPITE THE small number of teleradiologists living in Israel, Netanyahu says the phenomenon is nothing new. For years, hospitals have been waking radiologists at night to read cases, and would often send the scans to the doctor's home through video capture across phone lines, he explains. "What's new is the capability and ease of transferring cases on the Internet," attests Netanyahu. "It takes just a few minutes for me to download a CT of 400 slices, loss of information is virtually nonexistent and the ability to play with different windows is identical no matter where I am, America or Israel." The use of night hawk service is also relatively new, having been conceived only a few years ago by a US radiology group operating out of Australia. But due to the small numbers of board certified radiologists actually living in Australia, according to Netanyahu, radiologists are often sent from America to provide services. "Israel is really the only country in the world that has a fairly sizable group of American board certified radiologists living permanently in it," he remarks. "That's what's so unique about Israel - you might find a few in France, in England, in Australia, but we have the largest amount of board certified radiologists outside of the US," he claims, adding, however, that it's possible India is catching up. All the radiologists in both Jacobs's and Netanyahu's group are American licensed and board certified. But despite this assurance, not everyone is thrilled with the idea of doctors operating over the Internet. "There are some radiologists who don't want to forgo part of their salaries to teleradiologists living in another part of the world," says one radiologist who asked to remain anonymous. "And furthermore, there are huge ethical and control issues involved here." These issues refer to the concern that a hospital can contract with an American board certified and licensed radiologist living in India and receiving an American salary, who can then pay local Indian radiologists - who are not board certified - to do his work for him for a highly reduced price. All he has to do is sign his name, and no one would know the difference. "A lot of it is based on the honor system," Jacobs admits. "But when I wanted to read for a hospital in Tennessee, they investigated me for four months to check out my credentials and who I really was before they hired me." "I also think radiologists are too scared of a lawsuit to have someone else read their cases," he continues. "And in regard to the money aspect, radiology groups will only hire [teleradiologists] if they all agree to it - each group makes their own decisions and has their own business," he says. "Some people don't like it because they don't like outsourcing. But we're all American; we pay American taxes. We just live off-shore." Dr. Mark Kwalburn, a radiologist who made aliya this year and does night hawk service for a radiology group in Miami, Florida, agrees that legally, teleradiology is still a work in progress, but says he can't imagine why a board certified radiologist would risk signing his name on cases that were read by someone else. "If something has my name on it, I'm legally bound, I'm at fault. That person would be taking the huge risk of losing his medical license, " explains Kwalbrun. Regardless of the relative novelty of the service, Netanyahu says it's "working like a dream," and many doctors are excited about the wide range of options made possible by teleradiology, especially aliya-minded Jews. "On the doctor's side, you can make an American salary and live in Israel, and on the hospital's side, it's great too, because it's very difficult nowadays to get someone to read scans overnight. It's the graveyard shift and most doctors aren't willing to do that," says Kwalbrun. "Basically, it's a win-win for everybody." Staying connected Last year, while Dr. David Jacobs was in the middle of reading cases in his home office, his Internet connection suddenly went down. "It was horrible, it slowed down to a snail's pace," recalls Jacobs. "If your 300 image CT scan takes 10 seconds an image to download, that's nearly an hour per case - and that's unacceptable." That's where Eric Guth and Efrat Networks came in. "To receive his scans from the emergency rooms, [Jacobs] had been using one Internet service provider (ISP) and they couldn't fix the problem," says Guth, the head of Efrat Networks, a computer network installation company based in Jerusalem. "We found the problem and got him two ISPs delivered on two different infrastructures so if one went down, he had the second as a back-up." Furthermore, someone from Efrat Networks constantly manages Jacobs's bandwidth, ensuring the links are fast and operating properly. Jacobs says he hasn't had a problem since. Guth's group also set up Dr. Mark Kwalbrun's office at Shaare Zedek Hospital in Jerusalem, which they equipped with two ISPs, phone lines and a video conference system and also constantly manage to check for problems. Now, Guth says he'd like to create an environment where the community of teleradiologists in Israel can work together - but independently - under one roof. "We'd like to have two facilities, one in Jerusalem and one in Petah Tikva, where the radiologists can work for their separate hospitals and consult with each other," explains Guth, who says this group setting may be more productive for the doctors involved, many of whom work from their own homes. "There are huge advantages to working at home," admits Guth, "but after speaking to teleradiologists here, we realized there are also advantages to working in an office - having a separation between home and work and being able to fraternize with other doctors." Guth says he expects the project to get underway by the summer, and that his company is still in the process of putting a plan together. "The idea of remotely working is one of the great benefits of the Internet," he says, "and we've created ways to make this work highly reliable." And that doesn't apply solely to radiology. "Remote workstations are a popular phenomenon now," Guth explains. "Lots of people are making aliya and keeping their day jobs in the US if the infrastructure supports it. That's the promise of the Internet, and that's what we provide."