American College of Physicians: Internal Medicine — Doctors for Adults ®


Beaming images overseas sparks controversy at home

Outsourcing trend promises savings and access but some worry that remote contracts take a toll on quality

From the May ACP Observer, copyright 2006 by the American College of Physicians.

By Sarah Lovinger, ACP Member

As health care becomes increasingly digitized, those keeping close tabs on the bottom line see outsourcing as an attractive option.

Already as many as 300 hospitals nationwide are using teleradiology, sending images to be read by radiologists as far away as India and Australia, while more than 100 hospitals use remotely monitored intensive care units (ICUs). Such arrangements make the most of lower-cost, around-the-clock providers—and make it possible for rural and other populations to access specialized care not locally available.

Robert M. Wachter, FACP

But outsourcing has also sparked its share of controversy. In the absence of hard data—little outcomes research has been done on outsourcing's problems or benefits—how can physicians ensure the quality of care being delivered by doctors located several time zones away? And what does this trend mean for the traditional physician-patient relationship?

Robert M. Wachter, FACP, professor and associate chair of medicine at the University of California, San Francisco Medical Center, addressed these issues in a Feb. 16, 2006, article in New England Journal of Medicine entitled "The 'Dis-location' of U.S. Medicine—The Implications of Medical Outsourcing." Dr. Wachter recently spoke with ACP Observer about what outsourcing might mean for internal medicine:

Q: How does outsourcing affect internists?

A: For non-procedural internists, the implications are relatively small—they may be speaking to a radiologist in another country. But for internists who do procedures, the implications may be much greater.

Q: What are some examples?

A: We have traditionally thought of a colonoscopy as one task. In the early days, one physician was responsible for completing the entire procedure—inserting the colonoscope, observing the appearance of the mucosa and biopsying a lesion.

Now the procedure can be divided into smaller components, and a lower-cost technician can be taught to do the insertion. The pictures can be reviewed by a physician who no longer needs to be at the bedside or even in the same country. Increasingly biopsies are done via a joystick, no longer requiring physical presence, and there are people doing laparoscopic surgeries on patients in other countries.

Q: So is this good or bad for internists?

A: It could go either way. Creative and appropriate use of outsourcing might help lower health care costs while preserving quality. That probably helps patients and payers, and may free up resources for undercompensated specialties like primary care. However, the domestic physician whose job is lost might not see this so positively. It may also become a bit tougher to communicate with some consultants if they are no longer in the building.

Q: If more hospitals look to outsourcing, could there be a backlash?

A: I don't think it is a matter of the number of hospitals using outsourcing that will create the backlash, but rather when alternative providers—particularly lower-wage providers—begin competing for tasks that domestic providers don't want to give up. If e-ICUs compete successfully against onsite intensivists, or foreign radiologists compete for daytime business with domestic radiologists, then we'll be in for the great battle. Right now, much of the outsourcing fills niches—like nighttime radiologists or ICU coverage—that domestic folks don't want to fill.

Q: Might outsourcing actually be good for rural hospitals, perhaps providing a good balance of skills?

A: Absolutely. Particularly for rural hospitals, having a competent physician fill a niche through outsourcing that they can't fill locally could be very positive.

Q: Will patients see any other benefits of outsourcing?

A: The same phenomenon that is driving outsourcing—namely the wiring of American medicine—will also allow some patients to manage some of their own care at home, facilitated by the Internet.

IT [information technology]-facilitated disease management has the capacity to change the way we look at medical care, from our present view of care being delivered through single episodic encounters to a new view of much more continuous monitoring and management. Patients will self-manage a considerable amount of their care using computer-based algorithms that guide them to deal with common scenarios and tell them when they're complex or sick enough to need to speak to or see the doctor.

Q: Should we tell patients that a radiologist in India might be reading their CT scan?

A: I don't know. At one level I say yes because it's never wrong to be transparent. But do we tell patients that their X-ray is being read by a resident? Or that their path specimen was FedExed to the lab a few hundred miles away. I don't think that full patient disclosure is the most robust way to ensure quality.

Q: So how can we ensure quality?

A: Because health care is becoming more digitized, there will be all sorts of new ways to measure and monitor care.

To take the example of radiology, we could re-review a random sample of a physician's X-rays to make sure that the readings are confirmed. To me, the fact that the films are being read abroad does not change the importance of quality or the challenges of measuring it. Five to 10 years from now, virtually all of our care will be recorded or delivered via computer. The same technology that allows the radiologist in India to read films can potentially facilitate examining the quality of his or her care.

Q: How far does board certification go in guaranteeing quality?

A: We have to think about board certification in a broader way. Ensuring quality has to go well beyond passing a board exam—we need to tap into what you do, not just what you know. I think the "dis-location" trend will force us to ask these questions irrespective of whether the doctor delivering the care is in California or even the United States.

When I buy a computer or a car, I don't really care about where it was made, I care about the quality and value of the product. In that way, medicine is going to look more and more like the rest of the economy.

Sarah Lovinger, ACP Member, is a freelance medical reporter based in Evanston, Ill., and a general internist who practices part-time in Chicago.


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