Tuesday, May 10, 2005

Reading X-rays Overseas

MedGadgets linked an article in the Washington Post that I found disturbing. It describes the increasingly common practice of beaming digitized radiologic images overseas by high-speed internet connections. Foreign-based radiologists then read them and the results are transmitted back either by phone or internet.

The benefits of such an arrangement are two-fold. On the one hand hospitals and emergency departments will have access to a radiologist at night who is as well-rested as someone working banker's hours. At the same time, the entities utilizing these services don't have to pay the additional expense of a night pay differential (or at least the radiology groups employing the practitioners who can presumably pass these savings on).

At the same time, this system allows American radiologists to go on "working" vacation trips where they can live overseas for a period and still work, getting their usual American wages. This has been quite popular for some radiologists.

I've known about this trend for some time. I've never had a problem with the idea that the radiologists, though located overseas, are all board certified in the U.S. and licensed to practice in the states where their services are used.

A number of important questions were raised by this article however.

First of all, the question was raised about whether all the radiologists involved are in fact licensed in the appropriate states and board certified. People have wondered what would stop an company from having local radiologists (for example in India) read the studies and have certified American doctors simply sign off on them.

This concern has been addressed with the argument that such a scenario would be no more likely to occur overseas than here in the U.S. To me this is somewhat disengenuous. The likelihood that an American-based radiology group could put unlicensed, uncertified radiologists on its payroll seems very remote. It is, however, quite conceivable that this could happen in another country. In fact, according to this article, one company did just that until the practice was halted in 2003.

One might also ask how an accreditation organization such as JCAHO (Joint Committee for Accreditation of Healthcare Organizations) could police such a foreign-based system. In fact, they may very well choose not to.

Another important problem of great importance is that of privacy safeguards. The privacy of anything related to individual medical records is strongly regulated under the aegis of a set of laws referred to as HIPAA (Health Insurance Portability and Accountability Act). Sending digital renditions of imaging and other health data overseas which has no such regulation would not appear to be HIPAA compliant. Many or most patients would probably object to such an unanticipated release of one's medical data if they knew about it.

For this reason, congress is debating a bill requiring patients to sign an informed consent explaining this possibility to them. I wonder if this bill, in its final form, will have any provisions requiring such consent to be very apparent rather then be buried in complicated legal jargon.

The article also raises the issue of whether this kind of "medicine-from-a-distance" fosters miscommunication between doctors. To me, this is a bit of a red herring because current "nighthawk" systems have existed for years where a radiologist at one facility (or at home) is servicing multiple (local) hospitals. I've participated in phone discussions with radiologists in many settings my entire professional career and have never found this a significant impediment to the practice of medicine.

This entire process of digitizing radiological data and beaming it overseas is yet another example where the advances of technology move much faster than our ability to absorb their legal, ethical and practical implications.


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