Cross-border consultations have become commonplace, but developing best practices for international telemedicine is as much a question of regulation and technology as one of healthcare protocols.
A robot helps a cardiologist in California consult with a heart attack patient in China. A pediatric neurologist on sabbatical in Europe examines a patient in Washington, D.C. An orthopedic surgeon in Texas lectures medical residents in Kuala Lumpur, Malaysia. A transcriptionist in India creates a medical note based on dictation from a physician in the United States. These instances reflect international telemedicine’s diversity of services and technologies. Participant motivations are equally varied.
International telemedicine as practiced in the United States incorporates for-profit and nonprofit models, says Jonathan Linkous, CEO of the American Telemedicine Association. U.S. hospitals may partner with organizations in the developing world to expand healthcare services in disadvantaged regions. Alternately, hospitals may pursue international telemedicine commercially, offering for-profit medical care to customers in nations that may have areas of concentrated wealth but still lack the capabilities of the American medical market. Often, different departments within a single healthcare organization use both models.
“You have a lot of work between U.S. hospitals and the developing world, while the marketing arms of hospitals work to offer for-profit services to other places,” Linkous says.
He also mentions a reverse model, in which American hospitals stand on the receiving end of telemedicine, purchasing services found more readily or inexpensively overseas. Examples include medical transcription, which has long been performed abroad, and interpretation of pathology and radiology images. International “nighthawk” radiology services — which provide second- and third-shift diagnostic examinations of images and caused some controversy when they became widespread 10 years ago — are now routine.
One Hospital, Many Paths
Children’s Mercy Hospital in Kansas City, Missouri, participates in charitable and profit-based international medical consulting while maintaining a robust domestic telemedicine program.
“Internationally, our providers who have to leave Kansas City and live abroad for extended periods of time use InTouch Health to continue caring for their patients,” says Lisa Large, MSBE, Telemedicine Research and Training Coordinator at Children’s Mercy. “They continue to participate in clinics and examine patients as they normally would. The experience is smooth for providers, patients and families.”
Children’s Mercy also participates in larger-scale telemedicine initiatives, such as partnerships with two hospitals in Guangdong Province, China. Outreach to partner hospitals includes radiology interpretation and medical education.
“A few years ago, our medical director was investigating international telemedicine opportunities,” Large says. “At the same time, our medical director of radiology was working with a hospital in China. We realized this was a service we could use to help them. We have a great staff of coordinators who facilitate daily needs and look for new contracts and opportunities so we can continue offering services such as pediatric radiology to them.”
Collaborating electronically in real time with physicians abroad has its challenges, Large says, including technical and regulatory barriers.
“Even with high-bandwidth fiber networks, your connection is only as good as the one you are connecting to,” she says. “We have to evaluate how we can connect on both ends.”
Large notes that using a Web-based cloud system has eliminated many of the difficulties.
Regulations, credentialing and contracts also pose challenges for domestic and international telemedicine. Not all states have reciprocity laws for medical credentialing, making it difficult for U.S. physicians to practice medicine across state borders. When working with international partners, Large says, it is prudent to outline the terms of the partnership in advance.
“We formulate a contract with those sites and make sure expectations are clearly defined,” she says. “We discuss reimbursement, too. We rely on a contract to help navigate these boundaries and create a plan that will work well both for the near and the distant sites.”