Outsourcing Health IT: Should Doctors Cut the Cord?

Health care organizations are turning to distant practitioners to interpret radiographs and monitor intensive care units, a trend with both advantages and drawbacks.

In an era of rising costs and dwindling access to experts, IT is untethering doctors from patients physical presence. Already, health care organizations are turning to distant practitioners to interpret radiographs and even to monitor intensive care units.

Such practices are not unique opportunities in niche markets, said Robert Wachter, a medical-safety expert at UCSF Medical Center, but the "first salvos" in an escalating trend.

Many tasks no longer need to be performed by a highly trained expert in the same room, or even in the same country, as a patient.

"IT was built to facilitate the ability of existing providers to do their work better and faster," Wachter said. But once the technology to record, store, and send digital images became commonplace, it revealed unanticipated applications.

"As soon as radiologists can read films sitting in office across street," Wachter asked, "then why not across town or in another state or another country?"

Outsourcing can result in cost savings that can help hospitals invest in IT. "For some community hospitals, this is driving the adoption of clinical systems," said Blackford Middleton, chairman of the Center for IT Leadership at Partners Healthcare Systems, known for its cutting-edge use of health-related IT.

Currently in the United States, several hundred hospitals employ radiologists outside of the country, often in India. These radiologists work during night-time hours in the United States and are paid far less than U.S. radiologists.

For the most part, Wachter said, Indian radiologists have had to be licensed and insured according to guidelines established by the American College of Radiologists.

However, WiPro has started using radiologists that are not licensed or board-certified in the United States. Another concern regarding health care outsourcing is that patient privacy may not be taken as seriously and that violations will be harder to identify and prosecute.

Radiology is just the tip of the iceberg. Increasingly, technology allows tasks to be split into subtasks that are divvied up and sent "over the wire" to where they can be performed most efficiently. For example, physical procedures, like moving a camera through a colon, may not need to be performed by a trained physician so long as an expert can monitor proceedings or interpret readings remotely.

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With experts earning over a quarter million dollars a year, assigning tasks to less expensive technicians can cut costs dramatically. It could also provide better care, since images could be sent to distant specialists rather than interpreted by local generalists. Such practices are increasing as digital images from microscope slides are rapidly becoming just as informative as the view of the actual slide under a microscope.

But technology alone does not remove the barriers for shipping services to distant experts, Wachter said. "We have a hundred questions to work out in how these people get licensed, get overseen."

Furthermore, local specialists worried about their jobs and high salaries will likely exaggerate safety concerns, making legitimate issues hard to sort out.

Relocating services will also affect the relationship between doctors and patients. The doctor-patient relationship can be fostered by health IT, Middleton said, but, "It can also be broken by IT when patients are receiving opinions from remote docs that they dont even know. I believe you should have a doc-patient relationship established in person before you can render an opinion."

Even the relationships between doctors should be considered. "For subspecialists that dont care for patients directly, their most important relationship is with the referring doc, and nuances of care might be lost," Middleton said. That doesnt mean that IT should not be used to disaggregate tasks, he said, but it means health care providers need to consider and accommodate such ramifications.

In fact, IT might help ease the very worries it has helped to create, Wachter said. "To the degree that services are being delivered by IT systems, it creates a pipeline to tap into to measure the quality of their real practice."

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