Outsourcing Health Care

A post by guest blogger Robert Wachter....

I wrote a couple of pieces in last month's (2/16) issue of the NEJM on the future of medical outsourcing. I had an epiphany after reading Friedman's "The World is Flat" this summer - namely, medicine has been uniquely insulated from globalization because of the physicality of the enterprise (we need to be in the room to examine the patient, read a paper chart, and, in the old days, look at a "film" (remember films). Now with digitalization, all that will rapidly change, as the computers de-tether us and make all kinds of things possible without physical presence.

The two camel's nose examples are international teleradiology (tonite, about 200 hospitals will have their ER CT scans read by radiologists sitting in another country) and e-ICUs (in which intensivists sit in front of monitors, watch patients on closed circuit televisions, follow streams of physiologic data, and sometimes even enter orders into the hospital's CPOE system). Today, the e-ICUs use domestic providers, but you can bet there will ultimately be international entrants to this market as well.

These are just the start - think robotic and laparoscopic surgery. I tried to depict the possible advantages and disadvantages of this model - it'l be your call how well I did. Like all kinds of globalization, the concerns center around ensuring quality (in addition to the domestic job loss); some of these concerns will be quite legitimate, and some will be protectionism in the garb of QA. In the accompanying podcast, the interviewer asked me several times, "how can we ensure quality when the docs are 5000 miles away?" My answer: "how can I ensure quality when my mom sees her doc in Boca Raton?"

Increasingly, quality assessment will be web enabled and involve real-time assessment of practice. Once this happens (and I don' minimize the challenges here), ensuring the quality of the provider in Bangalore may not be fundamentally more complex than doing the same for the one in Bangor.

One thing for sure: fasten your seat belts.

The Journal has made the articles freely available, even for non-subscribers: http://content.nejm.org/cgi/content/full/354/7/661
http://content.nejm.org/cgi/content/full/354/7/662
And the podcast: http://content.nejm.org/cgi/content/full/354/7/662/DC1