Medical outsourcing is a growing trend in American hospitals, driven by shortages of on-call radiologists and intensivists, economic pressures, and advances in telemedicine. Hospitalists will likely encounter—if they haven’t already—outsourced services that range from off-site medical transcription and language interpreters to long-distance radiology and, increasingly, electronic intensivist services.1 What are the implications for quality patient care and collegial interface when hospitals contract with outsourced providers? What are the advantages, possible disadvantages, and opportunities for hospitalists as teleradiology and eICUs become facts of life?
A Variety of Configurations
According to Rick Wade, senior vice president for strategic communications for the American Hospital Association (Chicago), it’s difficult to quantify the extent to which outsourcing is currently being used in U.S. hospitals. VISICU, Inc., a leader in the provision of eICU services, currently has 150 client hospitals. Eight hospitalists contacted at community and university hospitals in Colo., Fla., Maine, Minn., Ga. and N.M. reported that they were not directly involved with outsourcing other than with transcription services.
Robert M. Wachter, MD, professor and associate chairman, Department of Medicine, and chief of the Medical Service at the University of California at San Francisco (UCSF), whose “Perspective” piece on medical outsourcing appeared in the February 16 New England Journal of Medicine, is intrigued by the implications of outsourcing trends for medicine: “I think medicine has been peculiarly insulated from [the globalization of services], and it’s just very interesting and exciting—and troubling as well.”1
Off-Site X-Ray Reads Common
According to the American College of Radiology, teleradiology has become a fixture in most practices and hospitals.2,3 Some institutions have retained their own radiologists, who take advantage of teleradiology by reading digitized radiographs and CT scans from home instead of within the hospital building. A shortage of radiologists has led others to contract with off-site providers of teleradiology services. Those who provide services at night are sometimes called “nighthawk” companies.1 Outsourcing of radiology, Dr. Wachter believes, is a logical step due to technological advances, though he admits that visiting the radiology department in his hospital often yields educational and collegial opportunities that online X-ray reading does not.
At Saint Clare’s Hospital in Weston/Wasau, Wis., a new, 107-bed state-of-the-art facility built by Ministry Health Care, Richard Bailey, MD, is medical director of Inpatient Care and Hospitalist Services. Radiology and other ancillary specialist services are provided by the Diagnostic and Treatment Center (DTC), jointly owned by Ministry Health Care and the Marshfield Clinic. The DTC, through a relationship with a radiology group in Hawaii, provides night coverage for full reads of radiographs and scans from 5 p.m. to 5 a.m. The interactions are virtually seamless, according to Dr. Bailey. “We don’t even notice they’re in Hawaii” when conferring with radiologists on the phone, he reports.
Off-site radiology also created an opportunity for his hospitalist group, Dr. Bailey says. Saint Clare’s hospitalist group provides supervision of contrast administration when needed during night and weekend coverage times. “This is one more way our hospitalist program supports the hospital and provides value beyond just seeing patients,” he says.
Overseas Outsourcing a ‘Hot Button’
Using an overseas teleradiology company provides many advantages, says Sunita Maheshwari, MD, a consulting pediatric cardiologist and director of Teleradiology Solutions, a four-year-old teleradiology company located in Bangalore, India. The company’s radiologists do mostly preliminary night-reads but also do final-reads on approximately 20% of their cases. If contrast must be administered for an imaging study at the client hospital, a local tech, emergency department physician, or resident usually handles the procedure, with the Teleradiology Solutions radiologist in constant voice contact.
“The time zone advantage is huge,” says Dr. Maheshwari. With the 12.5-hour time difference between the United States and India, Teleradiology Solutions’ radiologists work regular day shifts and are able to cover 10-20 hospitals simultaneously, depending on how busy their client hospitals are.
“You don’t have to have one radiologist who stays up all night to be able to read two CT scans and one X-ray, who will [then] be groggy the next morning for his [or her] regular day shift,” she says. It makes a lot of sense from the standpoint of human resource efficiency to not waste several nights of several doctors covering multiple hospitals.” Dr. Maheshwari reports that American hospital staff are often pleasantly surprised to find a “cheerful, awake” radiologist on the other end of the phone line.
Despite these benefits, however, Dr. Maheshwari and her colleagues have noticed a political backlash stemming from the outsourcing of U.S. jobs to Asia that colors Americans’ reactions to overseas teleradiology. In her company’s first two years, some physicians questioned the company’s level of quality and lashed out because it is located in India, reports Dr. Maheshwari.
“Our work speaks for itself,” she says. “We have not lost a client, and, in fact, our hospitals have managed to grow because they have been able to take their radiologists off the night shift, and they take on more day work.”
Like several overseas teleradiology companies, Teleradiology Solutions retains a staff of U.S.-trained radiologists and goes through the same licensing and credentialing (they are JCAHO-accredited) as American companies.
The company now has 40 U.S. hospitals as clients and includes in its client mix some remote hospitals in India and Singapore, where the Ministry of Health is experiencing a similar shortage of radiologists.
Filling an ICU Gap
Shortages of specialists—and federal mandates to improve access to care—have spurred the growth of telemedicine in remote rural areas. Wade notes that multi-hospital systems are now installing remote electronic ICU care programs, where intensivists simultaneously monitor ICU patients in several hospitals from a central location. Preliminary studies have demonstrated both improved clinical outcomes and heightened hospital performance with programs such as VISICU Inc.’s eCare Manager software, which features built-in online decision support, adverse events alerts, and outcomes tracking. One 2004 study documented a 27% reduction in severity-adjusted hospital mortality for ICU patients, a 17% reduction in ICU length of stay, and a savings of $2,150 per patient, even after accounting for initial capital outlays to install the eICU system.4
SHM President Mary Jo Gorman, MD, MBA, is now chief executive officer for Advanced ICU Care, headquartered in St. Louis, Mo. Using VISICU’s patented software platform, the new company currently contracts with two community-based Midwestern hospitals to deliver real-time intensivist rounding and decision-making support.
Saint Clare’s Hospital, located in north central Wisconsin, was opened by Ministry Health Care in October 2005 with the intention of creating a tertiary referral center, says Dr. Bailey. To be competitive in the market, the hospital needed to provide a full-service intensive care unit. He explains, “[Unfortunately,] we are in an area that is suffering from the same kind of recruitment drought in pulmonary and critical care medicine as everyone else—and ours is accentuated because we are not in a large city, and we are not a teaching hospital.”
Advanced ICU proved a good fit for addressing the hospital’s ICU needs. The hospital “went live” with eICU in January and no longer has to send patients to sister hospitals with on-site intensivist coverage, says Dr. Bailey. Saint Clare’s staff intensivist works regular day shifts, and the hospitalist group co-manages the ICU with Advanced ICU’s staff the rest of the time, providing 24/7 coverage. ICU mortality, after adjusting for Acute Physiology and Chronic Health Evaluation (APACHE) scores and other severity indices, is also below predicted numbers.
Patient and Staff Acceptance
Does the notion of real-time video surveillance coupled with real-time data feeds on vital signs, lab work, and medications present problems for patients or staff? Patients are “very accepting and feel it’s an extra sort of security” knowing that Advanced ICU intensivists are on the job, says Dr. Gorman: “One patient referred to us as a ‘guardian angel’ looking over them.
“The nursing staff has been extremely accepting because it reduces their stress about making a determination of whether to interrupt the attending doctor during his office hours or at night,” she continues. “We’re really a partner to the local medical staff. We all know that to reduce medical errors, the bedside caregiver needs to recognize the problem, be able to contact somebody, address the problem, and then see if that intervention is the right one for the problem described. With eICU, you just move past all of those points of failure to get the patient right to the doctor in a very timely manner.”
Janet Pestle, RN, MSN, director of the Cardiovascular Program at SSM Health Care’s St. Mary’s Hospital and Medical Center in Jefferson City, Mo., echoes Dr. Gorman’s assessment. Encountering the same intensivist drought as other hospitals outside of metropolitan areas, St. Mary’s also contracted with Advanced ICU.
“I’d have a fist fight if I ever wanted to take [the eICU] away from the nurses and staff on the night shift,” declares Pestle. “I think there is definitely some guilt associated with healthcare workers having to wake up a doctor who may have been working all day. They love being able to push a button and have a physician there.”
Dr. Bailey believes the eICU offers many advantages for Saint Clare’s six-member hospitalist group. Although hospitalists have a large presence in the ICU, “ … we shouldn’t expect them to be intensivists,” he insists. “Given that the typical hospitalist is very young, I was concerned about setting up hospitalists for failure by not giving them the resources to help them provide high quality care and to be successful.”
Partnering with Advanced ICU has also helped recruitment of younger hospitalists, he says, noting that hospitalists have chosen Saint Clare’s over other hospitals because of the eICU presence. “Our hospitalists get very concerned about being pulled in too many directions,” says Dr. Bailey. “Advanced ICU frees up our hospitalists, giving them a high degree of comfort and confidence that they can handle multiple cases at once.”
To ensure continuity between the ICU and the medical floor, all admissions are still handled by the hospitalists. The eCare Manager software used by Advanced ICU also provides another layer of attention to quality indicators, with built-in decision support and alerts.
Outsourcing Opens the Box
Dr. Bailey visited Advanced ICU’s command center and was impressed with the frequency with which the company’s intensivists were virtually “rounding” on Saint Clare’s patients. “It’s very exciting if you think about it,” he says. “Intensivists in Missouri can talk with a radiologist in Hawaii about a patient in Wisconsin. This is certainly improving our quality of care.”
“The eICU is really mind-blowing,” agrees Dr. Wachter. Once services are no longer located in the building, “there’s not much difference between 30 miles and 10,000 miles away, and this just opens up the box in some very interesting ways.” Service providers operating from different countries under different sets of laws and value systems, he notes in his New England Journal of Medicine article, can, however, “create opportunities for new kinds of mischief.”
Asked for an example of this, he explains that his institution’s initial foray into medical outsourcing was a bit of a cautionary tale. Unbeknownst to UCSF, their domestic medical transcription company sub-contracted with a transcription company in Pakistan. Administrators discovered this fact when a Pakistani transcriptionist contacted the university, threatening to put all the medical records she had transcribed on the Web if she did not get a raise. This would have constituted a breach of HIPAA and would have created multiple liability issues for UCSF. Contractors dealing with the medical center now have to guarantee, in writing, that they will use only domestic subcontractors, says Dr. Wachter.
Because of the “high-touch” nature of hospital medicine, Dr. Wachter does not think that hospitalists’ services are feasible candidates for outsourcing.
“I guess one could conceive of a robotic hospitalist running around the building being controlled by a joystick in Singapore, but that’s science fiction and not a real risk,” he quips.
Still, relationships with specialists such as radiologists and intensivists may more likely be formed over the telephone, through video conferencing, and in online interactions—phenomena with which younger physicians may be much more comfortable.
Dr. Maheshwari, who, like the company’s founder Arjun Kalyanpur, MD, trained at Yale University in New Haven, Conn., expects that Teleradiology Solution’s business will continue to grow and that, over time, “the world will truly be flat—hopefully!”
Wade admits that the need for outsourced services is not going to diminish. “Our need to be able to harness technology to provide [a high] level of intensive care to patients, no matter where they are, is going to be very strong,” he says. “So I think we will see more of this [outsourcing]. But I also think we’ll see a much greater emphasis on trying to train new physicians. Outsourcing is part of the same phenomenon as medical tourism. Hospitals that go this route are going to have a responsibility to demand high-quality physicians, demand Joint Commission certification, and demand to know the background and training of these [outsourced] physicians, because the patients and families are going to have questions. That’s part of the doctor-patient relationship that the hospital is going to create.” TH
Gretchen Henkel is a frequent contributor to The Hospitalist.
- Wachter RM. The “dis-location” of U.S. medicine – the implications of medical outsourcing. N Engl J Med. 2006; 354(7):661-665.
- Larson DB, Cypel YS, Forman HP, et al. A comprehensive portrait of teleradiology in radiology practices: results from the American College of Radiology’s 1999 Survey. AJR Am J Roentgenol. 2005 Jul;185(1):24-35.
- Dimmick SL, Ignatova KD. The diffusion of a medical innovation: where teleradiology is and where it is going. J Telemed Telecare. 2006;12 Suppl 2:S51-58.
- Breslow MJ, Rosenfeld BA, Doerfler M, et al. Effect of a multiple-site intensive care unit telemedicine program on clinical and economic outcomes: an alternative paradigm for intensivist staffing. Crit Care Med. 2004 Jan;32(1):31-38.