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
