When a medical transcriptionist contracted to work for the University of California-San Francisco Medical Center threatened last October to post patients' medical records online if she wasn't paid money that she claimed the hospital owed her, the hospital's administrators and information managers scrambled to resolve the potential security breach. Complicating matters was the angry contractor's location: Pakistan.
The academic medical center had signed an outsourcing agreement with an area company called Transcription Stat, which had worked for the hospital without difficulty for nearly two decades, says Clifton Louie, associate director of clinical services at UCSF Medical Center. But that company's subcontracting within the U.S., and eventually offshore, led to the Pakistani woman's access to patient information.
"To the best of our knowledge, the incident did not result in the release of any patient information in violation of the Health Information Portability and Accountability Act of 1996 or state law," Louie testified before California state representatives.
Outsourcing is not new to healthcare, but the globalization of medical documentation and other services such as billing and the reading of radiology images is growing for U.S. healthcare organizations that want to cut costs by sending business and clinical processes to countries such as China, India, Pakistan and the Philippines.
Consulting firm Gartner reports that one in 10 U.S. computer services and software jobs will go overseas by year-end, and analysts are expecting healthcare to reach similar ratios in a few years. While healthcare was initially slow to follow U.S. business trends in offshore outsourcing, that is changing as providers turn toward that solution when faced with a dwindling pool of qualified U.S. workers in various specialties and time constraints for processing both billing and patient data. But connecting with less expensive laborers overseas isn't always as smooth or efficient, as managers at UCSF Medical Center discovered.
Louie says the hospital was aware that its vendor used subcontractors but not any overseas. He says the facility has since reviewed all of its transcription service contracts to determine the specific nature and status of each, including provisions for confidentiality and security.
"It's incumbent upon providers to do their due diligence initially and on an ongoing basis to make sure the vendors are conducting themselves in the way they are expected to," says Sean Carroll, president of the Medical Transcription Industry Alliance, or MTIA, a not-for-profit membership association serving medical transcription companies and workers.
Peter Preziosi, executive director of the American Association for Medical Transcription, the largest association for medical transcription, says 8% to 10% of all contracted transcription in U.S. healthcare is done overseas according to the most recent estimates. The industry is working to establish standards for medical transcription, which, as a field, has no real licensure requirements. Ensuring that workers have proper training, especially those overseas, can be difficult, he says.
"Right now, anyone can open up an educational program for medical transcriptionists," Preziosi says. "We've even got Sally Struthers on television claiming, `Even you can become a medical transcriptionist and earn money from your home!' The programs aren't good enough to qualify people to get jobs and it has been frustrating not only for students going into programs but also for hospitals because they will hire these people and sometimes they're not good enough."
The MTIA's Carroll is working with Preziosi and his group and the American Health Information Management Association to try to prevent California state legislators and Congress from passing legislation that could encumber outsourcing overseas and further exacerbate the shortage of medical transcriptionists and other health information workers. He says the answer is better workforce standards and technology development incentives, not restrictive legislation.
Altering the picture
Recently, Sen. Hillary Rodham Clinton (D-N.Y.) and Rep. Edward Markey (D-Mass.) introduced two bills in Congress that would limit radiology outsourcing overseas by regulating the export of U.S. personal information. Both bills would require patients to give consent for the use of overseas radiology readings. The legislation stands to affect companies like Nighthawk Radiology Services, which uses radiologists based in Sydney, Australia, to provide overnight teleradiology coverage for upwards of 400 U.S. healthcare facilities in 46 states.
Rising volumes, under-staffing and the need for round-the-clock coverage has led to a rise in off-site image-reading. While the trend raises questions on quality-assurance standards, offshore outsourcing is likely to become more accepted because of labor shortages and high costs.
"Whenever you get into a new or growing area of the healthcare industry, people are going to run it differently," says Mark Bakken, president of the Radlinx Group, which specializes in off-site, remote radiology. "But quality control measures have to be the same."
Radlinx doesn't send imaging work overseas, and uses only U.S.-based and U.S.-licensed radiologists, Bakken says. He says he has been approached by businesspeople in India who want to partner with the company, but he opposes the idea on quality and malpractice grounds.
"Is the liability going to fall on the hospital that is doing the outsourcing, the referral physician, the patient or the physician reading the image overseas?" he says. "No one knows, and if that physician isn't U.S.-trained or U.S.-licensed then providers really have a problem."
Last year, the American College of Radiology board convened a task force to examine the legal, regulatory, reimbursement, insurance, quality assurance and other issues associated with the growing practice of offshore radiology reading. The college says that physicians who interpret images by teleradiology should, among other things, meet or exceed the same standards met by physicians practicing in the U.S., including being licensed to practice medicine in the state where the imaging examination is done. The physician should further have the necessary medical or other license required within the jurisdiction of the interpretation site and also be credentialed as a provider and maintain appropriate privileges in the U.S. health facility or hospital that conducted the examination, according to the college.