perspective - armenian association of...

Perspective

The NEW ENGLAND JOURNAL of MEDICINE

february 16, 2006

n engl j med 354;7 www.nejm.org february 16, 2006 661

Until recently, the need to take a patient’s history and perform a physical examination, apply com-plex techniques or procedures, and share information quickly has made medicine a local affair. Competition, too, has played out between crosstown medical prac-tices and hospitals. Although there have always been patients who chose to travel for care —

making pilgrimages to academic meccas for sophisticated surgery, for example — they were excep-tions.

This localization was largely a product of medicine’s physicality. To examine the heart, the cardi-ologist could be no farther from the patient than his or her stetho-scope allowed, and data gather-ing required face-to-face discus-

sions with patients and sifting through paper files. But as health care becomes digitized, many ac-tivities, ranging from diagnostic imaging to the manipulation of laparoscopic instruments, are ren-dered borderless. The offshore in-terpretation of radiologic studies (see p. 662) is proof that tech-nology and the political climate will now permit the outsourcing of medical care, a trend with pro-found implications for health care policy and practice.

Skyrocketing health care costs are increasingly seen as unsus-tainable drains on public coffers, corporate profits, and household savings. Concern about these costs has led to wide-ranging cost-cutting efforts, often accom-panied by attempts to improve quality and safety. In other areas of the economy, a similar search for cost savings and value has

The “Dis-location” of U.S. Medicine — The Implications of Medical OutsourcingRobert M. Wachter, M.D.

When a patient in Altoona, Pa., needs an emergency brain scan in the middle of the night, a doctor in

Bangalore, India, is asked to interpret the results. Spurred by a shortage of U.S. radiologists and an exploding demand for more sophisticated scans to diagnose scores of ailments, doctors at Altoona Hospital and dozens of other American hospitals are finding that offshore outsourcing works even in medicine. . . . Most of the doctors are U.S.-trained and licensed — although there is at least one experiment using radiologists without U.S. training.

—Associated Press, December 6, 2004

Downloaded from www.nejm.org on November 29, 2008 . Copyright © 2006 Massachusetts Medical Society. All rights reserved.

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n engl j med 354;7 www.nejm.org february 16, 2006662

created a powerful impetus for outsourcing. Although corporate globalization has been contro-versial, when the forces of pro-tectionism have butted up against the demand of consumers for de-cent products at low prices and the desire of shareholders to max-imize returns, outsourcing has usually triumphed.

Although outsourcing is often motivated by the desire for cost reduction, health care’s version may offer substantial advantages for patients. For example, many hospitals now purchase interpre-tation services from outside com-panies, whose interpreters often speak a range of languages that individual hospitals cannot match. Outsourcing could also provide patients with access to special-ized care that would otherwise be unavailable. A group of mam-mography experts, for example, could read remotely transmitted mammograms obtained at com-munity hospitals, replacing less specialized radiologists. Herzlinger praised the “focused factory” in the predigital era, using examples (such as the “hernia hospital”) that required the physical pres-ence of patients.1 In a “dis-locat-ed” world, patients may benefit from some of the quality advan-tages of focused factories with-out the burdensome travel.

Outsourcing is often initially endorsed by local providers, since the off-site professionals begin by doing work the locals are happy to forgo, such as nighttime reading of radiographs. (Most of today’s overseas teleradiology is designed to capitalize on time differences — Indian radiologists read films while U.S. radiologists are sleeping.) If the arrangement meets its goals (whether these are

the “dis-location” of u.s. medicine — the implications of medical outsourcing

International Teleradiology

Imagine two patients arriving in the emergency department of a Maine hospital at midnight. The first has a presentation consis-tent with pulmonary embolism; the second, appendicitis. A dec-ade ago, the first patient might have been started on heparin therapy and scheduled for an early-morning ventilation–perfu-sion scan. The second patient would have been seen by a sur-geon, who would have made a judgment call regarding the diag-nosis of appendicitis and the need for surgery.

Today, both of these patients and hundreds of others like them would receive middle-of-the-night CT scans, taxing the hospital’s radiologists. But midnight in Ban-gor, Maine, is 10:30 a.m. in Ban-galore, India. There — and in Switzerland, Australia, and Israel — sit teams of radiologists ready to read the scans and fax their findings back to the United States (urgent findings are phoned back). “You can’t reach over and slap [the radiologist] on the back, but every other aspect of the interac-tion is preserved,” says Dr. Arjun Kalyanpur, a Yale-trained radiolo-gist who runs Teleradiology Solu-tions, a “nighthawk” company based in Bangalore. In published studies of teleradiology, reports of technical problems have been rare, and the readings have been rapid (average turnaround, one hour) and accurate.1,2

The American College of Radi-ology (ACR) has, unsurprisingly, stated that it is “very concerned” about overseas teleradiology, though its concern is tempered by a recognition that the practice

fills a vacuum left by its own members, who would like to sleep at night. The ACR recommends that radiologists who are perform-ing distant readings be board-cer-tified and carry licenses and mal-practice coverage in the state where the image was obtained and ap-propriate credentials at the source facility.

Several hundred U.S. hospitals use overseas teleradiology services. Industry leaders, such as Telera-diology Solutions, NightHawk Radiology Services, and Virtual Radiologic, state that they adhere to the ACR guidelines with re-spect to licensure, insurance, and hospital privileges. As for compensation, regulations of the Centers for Medicare and Medic-aid Services (CMS) prohibit pay-ments to providers outside the United States — an obstacle that many of the companies finesse by providing a “preliminary report,” which is later followed by a U.S. radiologist’s “final primary report.” The overseas radiologists are paid directly (by the hospital or the lo-cal radiologists) at a rate of $50 to $75 per radiograph, whereas the local radiologists bill the payer. The ACR has voiced concern about this practice, because of the worry that some domestic radiologists are signing off on the “ghost-read” radiographs without carefully scru-tinizing the films themselves.

Although most international teleradiology companies have fol-lowed the ACR licensure and cre-dentialing guidelines, in 2003, the Indian technology giant Wipro “tested the waters” (in the words of one Wipro executive) by using Indian radiologists who were nei-



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ther licensed nor board-certified in the United States. The contro-versial experiment was subse-quently suspended, but the po-tential for such practices remains. Although the ACR presents its teleradiology guidelines as quality-assurance measures (and quality is doubtless the organization’s greatest concern), the possibility that low-wage foreign radiologists will take work from its members has surely entered its calculus. As one U.S. radiologist wrote on a popular professional Web log, “Who needs to pay us $350,000 a year if they can get a cheap Indian radiologist for $25,000 a year?”

The technical and logistic hur-dles of remote teleradiology have been overcome, and the practice of having radiologists who were trained and credentialed in the United States read films overseas is now largely accepted. If the ACR guidelines hold, the growth of overseas teleradiology will be markedly constrained by the lim-ited supply of U.S.-trained radiol-ogists who are willing to work abroad. It seems likely that battles over licensure, credentialing, and reimbursement will determine whether providers who were trained and credentialed overseas will be allowed to compete openly with U.S. radiologists. The out-come of these battles will strongly influence the diffusion of interna-tional outsourcing to other areas of U.S. medicine.

Kalyanpur A, Weinberg J, Neklesa V, Brink JA, Forman HP. Emergency radiology cover-age: technical and clinical feasibility of an international teleradiology model. Emerg Radiol 2003;10:115-8.

Kalyanpur A, Neklesa VP, Pham DT, For-man HP, Stein ST, Brink JA. Implementation of an international teleradiology staffing model. Radiology 2004;232:415-9.

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saving money, getting a late-night dictation into the chart by morning, or allowing a radiolo-gist a full night’s sleep), its scope is bound to grow, as administra-tors consider other candidates for outsourcing — analysis of pa-thology specimens or reading of echocardiograms and even colon-oscopies. By severing the con-nection between the “assay” and its interpretation, digitization al-lows the assay to be performed by a lower-wage technician at the patient’s bedside and the more cognitively complex interpretation to be performed by a physician who no longer needs to be in the building — or the country.

Another illustration of “dis-location” is the electronic inten-sive care unit (ICU), in which off-site intensivists monitor pa-tients by closed-circuit television. Streams of physiological data ap-pear in real time on a remote screen, allowing the off-site physician to advise local provid-ers, sometimes even entering orders remotely into the hospi-tal’s computer system. Although electronic ICUs are currently marketed as a response to the national shortage of critical care physicians,2,3 they may ultimately compete with on-site intensivists. And if lower-wage foreign inten-sivists develop the knowledge and skills of their U.S. counter-parts, they may enter this market as well, following the path of the “nighthawk” radiologists.

Some observers will see the outsourcing of medical care as a positive development. To the ex-tent that outsourcing focuses on improved quality or access to spe-cialized care — allowing patients to obtain services from the best

provider, not just the best in town — it will be hard to criticize it without seeming unduly paro-chial. In fact, when applied to-ward these goals, outsourcing represents an extension of tele-medicine programs that have long granted some rural providers ac-cess to big-city expertise for com-plex problems.

Provided that quality is not compromised, outsourcing that is focused on the bottom line may also have virtue, particularly for patients who must pay a portion of their bill, for payers, and for fiscally challenged hospitals. Even domestic providers may celebrate outsourcing that frees them from off-hours duties or permits round-the-clock services. Finally, health care outsourcing is the sort of “disruptive innovation” that can transform traditional processes and relationships, ultimately lead-ing to benefits that are hard to anticipate today.4

But harm may also result — particularly if, as seems likely, the main driving force proves to be saving money, rather than im-proving quality. First, to the ex-tent that some care will be pro-vided by anonymous people in cyberspace rather than by local doctors, distinguishing compe-tent providers from hucksters will become even more difficult. In addition, having service pro-viders operating under different laws and, potentially, value sys-tems can create opportunities for new kinds of mischief.

Second, if outsourcing erodes the economic underpinnings of local health care, there will be irremediable consequences — and not only for displaced providers. If the United States loses its do-


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mestic textile or automobile in-dustry because of foreign com-petition, Americans mourn the loss of jobs, but no locale actually needs a car company or a sock manufacturer. Patients, however, will always need local doctors and hospitals.

In light of these potential problems, it is easy to rail against this trend or to pray that it all happens after we retire. And ob-serving the snail’s pace of the quality, safety, and information-technology movements in health care one might predict that full-blown medical outsourcing is decades away. But judging by the speed with which high-tech call centers have migrated to Banga-lore, the pace of change might actually be shockingly rapid.5

People and institutions that are harmed by outsourcing will not take it sitting down, and I expect to see a f lurry of initiatives to protect the status quo. Physicians

and specialty societies will un-doubtedly use the tools of legis-lation, licensure, certification, and reimbursement to thwart per-ceived threats to their livelihoods. Such efforts will nearly always be framed as protections of quality or patient safety, though some will be difficult to defend against charges of hypocrisy. (After all, it is tricky to argue that an off-shore radiologist is sufficiently competent to read U.S. films at 2 a.m. but not at 2 p.m.) Never-theless, many of these worries will be valid, and it will be left for patients and policymakers to differentiate legitimate fears from protectionism.

Though defensiveness and re-sistance are inevitable, I believe that a more productive strategy is for local caregivers, advocacy groups, and institutions to wel-come — or at least accept — outsourcing that serves their pa-tients’ interests and to focus their

attention on improving the qual-ity and efficiency of the care they themselves deliver. In the digital-ly globalized world, the painful truth is that the only durable protection against the outsourc-ing of services is to provide the highest quality of care at the low-est cost.

As they struggle to improve their technical skills and delivery systems to meet this new chal-lenge, local doctors and hospitals should not miss the opportunity to preserve and enhance the low-tech practices that are best deliv-ered in person. Patients will not willingly part with doctors who have shown them true empathy in times of need. The radiologist who not only reads his colleagues’ radiographs but also discusses important findings with them may be less likely to be replaced by a practitioner living a dozen time zones away. Competition may make us more responsive to


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The Words Count — Radiology and Medical LinguisticsJohn F. Bruzzi, F.F.R.R.C.S.I.

T hanks to European Union (EU) regulations, I, an Irish-

man, was recently permitted to pursue a radiology fellowship in France. Though free movement of labor within the EU is legal, it is not necessarily easy — not least because of language barri-ers. I soon came to appreciate that language is the lifeblood of radiologists. I also discovered that much of what we think is determined by what we can say.

When I arrived, I was profi-cient enough in French to formu-late a radiology report, though it

involved a long, painful process of interpreting the images and mentally translating my thoughts into French. My reports were short and full of curt, declarative sen-tences that read like barked mil-itary orders. (“The right lung is normal. In the left upper lobe there is a mass. A big mass. 5×6 cm. Probably lung cancer.”) Subordi-nate clauses, subjunctives, and commas went out the window. When asked my opinion about something, I could only point to the relevant images and describe abnormalities as “cancer” or “in-

fection,” “big” or “small.” There were no gray areas, no doubts, no conjectures. Sitting on the fence — a radiologist’s stock in trade — necessitates using words for balance, weighing diagnostic probabilities, and leaning toward the heavier side. But because I couldn’t use the subjunctive mood, I was forced into the realm of ap-parent diagnostic certainty.

Outside the interpreting room, things were even more difficult. Routine tasks such as triaging pa-tients, choosing scan protocols, and having coffee involved multi-

the needs of our patients and col-leagues, even as it extracts waste from the system.

Whatever the outcomes, four things seem certain: the outsourc-ing of health care will grow; it will challenge traditional arrange-ments between patients and both physicians and institutions; it will require rapid and thoughtful de-velopment of new ethical, legal, and quality standards; and it will be controversial.

An interview with Dr. Wachter can be heard at www.nejm.org.

Dr. Wachter is associate chairman of the De-partment of Medicine, University of Califor-nia, San Francisco.

Herzlinger RE. Market-driven health care: who wins, who loses in the transformation of America’s largest service industry. New York: Perseus Books, 1997.

Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr, Committee on Manpower for Pulmonary and Critical Care Societies (COMPACCS). Caring for the critically ill pa-tient: current and projected workforce re-quirements for care of the critically ill and

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patients with pulmonary disease: can we meet the requirements of an aging population? JAMA 2000;284:2762-70.

Breslow MJ, Rosenfeld BA, Doerfler M, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and eco-nomic outcomes: an alternate paradigm for intensivist staffing. Crit Care Med 2004;32:31-8. [Erratum, Crit Care Med 2004;32:1632.]

Christensen CM, Bohmer R, Kenagy J. Will disruptive innovations cure health care? Harv Bus Rev 2000;78(5):102-17.

Friedman TL. The world is flat: a brief his-tory of the twenty-first century. New York: Farrar, Straus and Giroux, 2005.

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Tree-in-Bud Nodules — Arbre en Bourgeons. Ground-Glass Opacities — Verre Dépolis.


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