An MRI or CAT  scan in India costs $20 and there is no waiting
time , in Britain its $1000 with a six month delay , which is the
richer country?

April 24, 2005
Hospital Services Performed Overseas
Training, Licensing Questions Raised
By Rob Stein
Washington Post Staff Writer

When patients needed urgent CAT scans, MRIs and ultrasounds late at
night at St. Mary's Hospital in Waterbury, Conn., emergency room
workers used to rouse a bleary-eyed staff radiologist from his bed to
read the images. Not anymore.

The work now goes to Arjun Kalyanpur -- 8,000 miles away in Bangalore,
India. When it is the middle of the night in Connecticut, Kalyanpur is
in the middle of his day, handling calls from St. Mary's and dozens of
other American hospitals that transmit pictures to him electronically
so he can quickly assess them and advise their doctors.

Kalyanpur runs one of an increasing number of "nighthawk" companies
operating in the United States and overseas to take advantage of
time-zone differences and the latest technology by having radiologists
read images from such far-flung places as Hawaii, India, Australia,
Switzerland, Israel and Brazil.

The companies, and the doctors and hospitals using them, say the trend
is improving care by guaranteeing that well-rested radiologists are
always available, even in the middle of the night, even for the
smallest hospitals and in the most rural areas.

Skeptics, however, say the practice raises a host of concerns. Are the
radiologists qualified? Is communication as good when the radiologists
are so far away? Can an overseas doctor be held accountable when
something goes wrong? Is anyone ensuring that properly trained and
licensed radiologists are actually doing the work? Is patient privacy
being protected?

Both sides see the trend as the leading edge of a movement toward
greater use of telemedicine, which is widening the spectrum of care
doctors can provide from afar and enabling more outsourcing of medical
services overseas.

"What we're seeing with teleradiology is really just the beginning,"
said Jonathan D. Linkous, executive director of the American
Telemedicine Association. "Similar things are already starting to
happen in other areas, such as pathology."

The trend has sparked a flurry of regulatory initiatives, including
proposed state and federal legislation designed to ensure that doctors
performing the work are properly trained and licensed, and that
patients are notified whenever information about them is transmitted
elsewhere, especially overseas.

"Patients have the right to know, and the right to say no, before
their
X-rays or other private health information is offshored to countries
that lack strong privacy safeguards," said Rep. Edward J. Markey
(D-Mass.), who with Sen. Hillary Rodham Clinton (D-N.Y.) recently
introduced legislation that would require patient consent in advance.

The advent of remote radiology services was prompted by various
factors, including a shortage of radiologists and rapid advances in
imaging technology, which has caused a sharp increase in the number of
tests. As a result, many hospital radiologists have a hard time
keeping
up with the demand, especially at night.

"We don't have the staff to have some guy up all night and then come
back in the next day," said Robert Lehman, who heads the St. Mary's
radiology department. "It's just too dangerous."

In response, St. Mary's and hundreds of other hospitals and radiology
practices have begun outsourcing, allowing their staff radiologists to
come to work fresh each morning.

"I'm convinced patient care is improved," said Paul Berger of
NightHawk
Radiology Services. The company, based in Coeur d'Alene, Idaho, has
about 40 radiologists in Zurich and Sydney serving about 600 U.S.
hospitals and other facilities, including 16 in Virginia.

But skeptics worry that remote radiology operations may be staffed
with
one or two U.S.-certified radiologists who approve reports prepared by
less-qualified technicians, a practice known as "ghosting."

"The nightmare scenario is you have one or two people with licenses
and
a room with 25 or 30 computer terminals staffed by people who may or
may not be radiologists," said John Haaga, chairman of the radiology
department at Case Western Reserve University in Cleveland.

Wipro Infotech, a large company in India that provides a variety of
services to U.S. companies, began using non-U.S. licensed radiologists
to provide "preliminary" interpretations of images for U.S. hospitals
in 2003. Wipro halted the service because of intense criticism but
remains interested because the market has only increased, officials
said.

"The demand is huge. We get a couple of calls every week," Wipro's
T.K.
Kurien said. "We'd like to see some kind of process where our guys
could provide this kind of service to hospitals in the United States."

NightHawk and several other companies providing the offshore radiology
services say they hire only U.S.-trained doctors who are licensed in
every state where they have clients and credentialed at the hospitals
they serve. But policing the services remains a concern.

"Because of the ease of moving this stuff around, the problem of being
able to authenticate who is doing the work is an issue," said Robert
Wise of the Joint Commission on Accreditation of Health Care
Organizations, which is upgrading its standards for accrediting
hospitals in response to the trend.

The companies providing the service, and the hospitals using it, argue
that the reports are double-checked each morning by staff
radiologists,
so questionable interpretations would quickly be spotted.

"We'll find little things here and there, the same way we find little
discrepancies amongst our own radiologists," said Russell McWey, chief
radiologist at the Virginia Hospital Center in Arlington, which uses
NightHawk. "But there's been no major discrepancies."

But some say there are other potential pitfalls, such as possible
communication problems when doctors are so far apart and are
strangers.

"It's difficult to point out something on an image if you're not
actually standing there in the room with the other doctor looking at
the same image," said Arl Van Moore, who chaired an American College
of
Radiology task force that issued guidelines on the practice in
February.

Proponents say most conversations between radiologists and
emergency-room doctors take place over the phone, even when the doctor
is down the hall or at home, making it just as easy to communicate
from
thousands of miles away.

"You can't reach over and slap them on the back, but every other
aspect
of the interaction is preserved," Kalyanpur said.

Nevertheless, Kalyanpur is embroiled in a malpractice case where
communication has become an issue. The Grand View Hospital in
Sellersville, Pa., and one of its emergency-room doctors is being sued
in the case of a man sent home with a diagnosis of diverticulitis. He
died hours later when an artery in his heart burst. The hospital and
doctor allege Kalyanpur failed to make it clear that more testing was
urgently needed to follow up on a CAT scan he read. Kalyanpur denies
any wrongdoing.

"Over the past few years, we have worked very hard against the
'anti-India' factor to build up a U.S.-standard company," Kalyanpur
wrote in an e-mail. "Our quality reports are saving lives every night
in the U.S."

Some also worry about what will happen when mistakes occur. Will a
radiologist on another continent be as easily held liable? Could a
physician in Bangalore or Beirut be compelled to come to the United
States for court proceedings?

"If your radiologist is in Australia or India, I'm not so sure how
easy
it would be hold them accountable," said Dennis F. O'Brien of the
Maryland Trial Lawyers Association.

Companies offering the services say they have the same malpractice
insurance as any U.S.-based radiologist, and such cases would be
handled no differently.

"It would be very much in their interest to return to the United
States
to participate in any proceedings," said Sean Casey, chief executive
of
Virtual Radiologic Consultants of Eden Prairie, Minn. "This is where
their livelihood is. They're not going to risk losing their licenses."

Hospital Services Performed Overseas
Training, Licensing Questions Raised
By Rob Stein
Washington Post Staff Writer

When patients needed urgent CAT scans, MRIs and ultrasounds late at
night at St. Mary's Hospital in Waterbury, Conn., emergency room
workers used to rouse a bleary-eyed staff radiologist from his bed to
read the images. Not anymore.

The work now goes to Arjun Kalyanpur -- 8,000 miles away in Bangalore,
India. When it is the middle of the night in Connecticut, Kalyanpur is
in the middle of his day, handling calls from St. Mary's and dozens of
other American hospitals that transmit pictures to him electronically
so he can quickly assess them and advise their doctors. <<

=====================================

Future Emergency Department Scene

Doctor: "Okay, who's up on the board? Bed 3?"

Nurse: "Mrs. Jones, 85 year-old female, brought in from Golden Sunsets
Manor complaining of low back pain with radiation to right leg."

Doctor: Could be a radiculopathy. I'll fill out the form for the MRI.
We can bill Medicare for that. At least the hospital will be happy, and
the hospital pays my salary, you know. Call me when the report comes in
from Bombay or Bangalore or wherever. Boy, the local group of
radiologists were sure pissed when the hospital didn't renew their
contract!  But they all made 3 times the salary I do, so I'm not crying
much for them. Poor guys. Ha. They might have to go interventional, and
actually have to *touch* patients somewhere.

[Later] Nurse: Here's the MRI report on Bed 3, Doctor.

Doctor: Hmmm. Look how they spell nerve "fibre". And "Radiological
Speciality." Wonderful. Well, anyway, nothing here except a couple of
partly collapsed vertebrae, and they're cervical so that's not the
source of our pain. Okay, I'll write her for some physical therapy, 3
times a week. You know anybody who can't use a little physical therapy?
Certainly not any 85 year-olds who can't.

Nurse: You ARE going to see her??

Doctor: Sure. I'm going to poke my head in and say "hi." Maybe prod her
back a little and see if she moves her feet. Look, Medicare pays about
$36 for one of these, and that's about enough time to say "hi." Unless
I dictate a complete exam, which I'm not about to do for an elderly
lady with low back pain, since whether she's demented or not, that will
take so long Medicare will never pay enough to wins at that. So we're
not going there.

Nurse:  What does Medicare get billed for the MRI?

Doctor: $1300 or so. I should have added contrast. And they pay way
more for an emergency room visit than any doctor would get for an
office exam, I'll tell you. But look what they saved in reading fees.
Boy, did I mention how pissed off our rad guys were when they all got
fired?

Nurse: Did she need the MRI?

Doctor: How should I know!  They don't pay me enough to find out. And
no neurologist is going to come in at this hour, because they SURE
wouldn't pay one of them enough. Medicare clearly wants to pay for lots
of MRI machines, and lots of MRI machines is what they get. I'm OUT of
that game. Who's our next patient?

Nurse: Mr. Smith, 69 year-old man with upper abdominal pain.

Doctor. Ah.  Okay, CBC, chem panel, 12-lead, and enzymes. If this guy
hasn't had a heart cath, it's even money he's getting one before he
leaves. Can't really rule out coronary syndrome without it, you know.
Big bills there. I should have gone into cardio, you know. I wonder how
long it will be before Bombay reads those angiograms, too? But at least
they can't DO 'em....

SBH