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Health Care USA: The “Dis-location” of U.S. Medicine — The Implications of Medical Outsourcing — by Robert 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.

Until recently, the need to take a patient's history and perform a physical examination, apply complex techniques or procedures, and share information quickly has made medicine a local affair.

Competition, too, has played out between crosstown medical practices 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 exceptions.

This localization was largely a product of medicine's physicality. To examine the heart, the cardiologist could be no farther from the patient than his or her stethoscope allowed, and data gathering required face-to-face discussions with patients and sifting through paper files.But as health care becomes digitized, many activities, ranging from diagnostic imaging to the manipulation of laparoscopic instruments, are rendered borderless. The offshore interpretation of radiologic studies is proof that technology and the political climate will now permit the outsourcing of medical care, a trend with profound implications for health care policy and practice.

Skyrocketing health care costs are increasingly seen as unsustainable drains on public coffers, corporate profits, and household savings. Concern about these costs has led to wide-ranging cost-cutting efforts, often accompanied by attempts to improve quality and safety.

In other areas of the economy, a similar search for cost savings and value has created a powerful impetus for outsourcing. Although corporate globalization has been controversial, when the forces of protectionism have butted up against the demand of consumers for decent products atlow prices and the desire of shareholders to maximize 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 interpretation services from outside companies, whose interpreters often speak a range of languages that individual hospitals cannot match. Outsourcing could also provide patients with access to specialized care that would otherwise be unavailable. A group of mammography experts, for example, could read remotely transmitted mammograms obtained at community 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 presence of patients. 

In a “dis-located” world, patients may benefit from some of the quality advantages of focused factories without 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 saving money, getting a late-night dictation into the chart by morning, or allowing a radiologist a full night's sleep), its scope is bound to grow, as administrators consider other candidates for outsourcing — analysis of pathology specimens or reading of echocardiograms and even colonoscopies. By severing the connection between the “assay” and its interpretation, digitization allows 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 longermneeds to be in the building — or the country.

For the completereport go to : The “Dis-location” of U.S. Medicine — The Implications of Medical Outsourcing — NEJM

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