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Hospital Services Performed Overseas

Training, Licensing Questions Raised

By Rob Stein
Washington Post Staff Writer
Sunday, April 24, 2005; Page A01

When patients needed urgent CT 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.

Arjun Kalyanpur of Teleradiology Solutions in Bangalore, India, is among an increasing number of "nighthawks" employed by U.S. hospitals. (G.K. Vale -- Teleradiology Solutions)

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."

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