The long reach of medicine

At Shanghai East International Medical Center in China, a robot glides along the hospital corridors, rounding with attending physicians.

On this particular day, the robot is checking on a cardiology patient, who has been hospitalized with symptoms related to a previously undiagnosed congenital heart defect.

But the patient's team isn't limited to just the physicians and residents at Shanghai East. The chief of cardiology at the University of California at Davis—6,100 miles away—is also on hand to consult on the case.

From a video screen on the robot, and using an attached ophthalmoscope and stethoscope, the UC-Davis cardiologist can examine the telltale nail clubbing and ocular symptoms as well as listen to the patient's heart in real time.

New technology has created an explosion in demand for international telemedicine, especially in fields such as radiology and pathology that lend themselves to virtual care. It's an area that has humanitarian interest and is also a growing business for the hospitals participating in it.

Not only can physicians treat patients in remote or underserved regions, but they can also tap into a market of international patients who want access to specialty care in the U.S. without getting on an airplane.

Children's Mercy Hospitals and Clinics, Kansas City, Mo., made the foray into international medicine nearly a decade ago when it forged a partnership with Guangzhou Women's and Children's Hospital in Guangdong province, China. Its first international collaboration was a way to provide educational and training opportunities for clinicians and administrators.

But during the past two years, Children's Mercy has sought to build on that relationship. In May, it signed two deals with Zhujiang (Pearl River) Hospital, also in Guangdong province—one that establishes a sister relationship with the medical center as well as another agreement to provide imaging consultation services.

Karen Cox, executive vice president and co-chief operating officer at Children's Mercy, notes that the partnership is not only a way for the organizations to share expertise, but also establish a formal business agreement in the country. “We feel like we need to be able to do both,” Cox says. “We want to be able to monetize the relationship in some way.”

Compared with 263-bed Children's Mercy, Pearl River is a mammoth 2,000-bed hospital, with 500 pediatric beds.

“They've got a lot of patients; they've got a lot of complex cases,” says Dr. James Brown, chairman of the radiology department at Children's Mercy. “It opens up discussion on interesting cases they send us.”

Children's Mercy has about 20 pediatric radiologists who read imaging scans from Pearl River. Brown acknowledges that there are financial drivers behind the partnership, but says, “My primary motivation for doing this is offering my expertise to other hospitals.”

Children's Mercy was already using SeeMyRadiology, a cloud-based program for medical image sharing. The technology allowed the medical center to quickly download scans from U.S. patients who were referred or transferred from other facilities, such as in cases of severe trauma, sometimes before the patient even arrived.

Expanding its use internationally, Cox says, was “such a win-win for everyone because you can share the fixed costs over many organizations.”

The increasing purchasing power of the middle class in countries such as China means that more patients have the means and opportunity to pursue treatment from Western medical centers. “They're paying readily to get the best healthcare in the world,” says David Jahns, managing partner at venture capital firm Galen Partners, which invests in telemedicine technology companies.

And that means U.S. medical centers, particularly large academic institutions, are making a concerted effort to build their brands abroad. “It's 100% financially motivated,” Jahns says. “This is a great way for the U.S. to export what we have an advantage in.”

Payment can be better than reimbursement in the U.S., as patients are either self-pay or have government health plans. Physicians can also bypass the additional licensing and paperwork they would need if they were going to expand their practices in another state.

“It's actually easier to do telemedicine internationally than across state lines,” Jahns says. In the U.S., “getting reimbursed for telemedicine—even if it is lower-cost—is very difficult to do.”

Among Galen Partners' investments is InTouch Health, Santa Barbara, Calif., which makes the robots used in the cardiology program at Shanghai East. The company launched in the international market about two years ago and has seen a “tremendous appetite” for Western expertise in fields including plastic surgery and trauma care, says Michael Chan, general manager, international, at InTouch.

While videoconferencing technology has been available for some time, the next frontier is clinical validation—the ability for physicians to take a full physical or even perform robotic surgery from thousands of miles away. The availability of technology also means that academic medical centers no longer have a first-mover advantage in emerging markets. “Healthcare today is unbounded,” Chan says.

Chan adds that “healthcare reform is a global phenomenon,” pointing to China's pledge to build 20,000 hospitals to meet its growing demand. The healthcare sector in China is undergoing “massive restructuring and growth,” Chan says. “I think that's creating opportunities.”

The UCLA Health System conceived the idea for its telepathology program in late 2010, and has performed nearly 900 cases since its launch in early 2011. UCLA partners with Zhejiang University, which operates a tertiary-care center in China with a network of smaller campuses, to read biopsies including prostate and gastrointestinal tract. It also has agreements in place with private laboratories in China.

“Financially they are very well set because they are government-paid and also have a large patient base,” says Dr. Jianyu Rao, professor of pathology and epidemiology at UCLA's David Geffen School of Medicine, about the labs it works with. But China is facing a dire shortage of pathologists—leading to longer wait times for patients there.

Most of the biopsies UCLA receives are from patients who can afford to send them, and Rao estimates that 80% of the time, UCLA can deliver faster results than in-country facilities. The medical center uses an e-pathology system made by Aperio that allows biopsy slides to be converted to digital files, which can then be shared anywhere in the world.

The exact size of the market for international telemedicine is difficult to quantify. “Most of the data is anecdotal,” says Jon Linkous, CEO of the American Telemedicine Association. “But I can tell you, it's growing.”

In the U.S., the group estimates that close to 10 million patients receive telehealth services annually, with teleradiology representing the largest service. The market has been estimated from $1 billion to $14 billion, depending on how “telemedicine” is defined.

But business arrangements can also vary considerably, from providing healthcare services for expatriates to partnerships with other medical centers abroad. And while international telemedicine has its financial drivers, hospitals around the world are also sharing their expertise for charitable or even diplomatic purposes, Linkous says, pointing to telemedicine services that Indian hospitals are providing in Africa.

Children's National Medical Center, Washington, D.C., has participated in telemedicine since the early 1990s. But in 2005, as part of a collaboration with the Mosaic Foundation, a charitable group founded by the wives of Arab ambassadors to the U.S., representatives from the hospital visited Morocco for the first time to provide education and patient care.

“Over the past three years, it's really accelerated,” says Molly Reyna, executive director of telehealth and videoconferencing services at Children's National. “The main reason for that is because of the commercialization of technology.”

The medical center now has projects in Africa, the Middle East and Germany covering a number of specialties, including cardiac surgery, neurology and genetics. It performs mission-driven work in countries such as Uganda and Morocco and also has business arrangements in Qatar, Kuwait and the United Arab Emirates, where it focuses primarily on treating neuro-developmental disorders.

Yet unlike some other telemedicine programs, “most of what we do is not direct-to-patient,” and most patients do not self-pay, Reyna says. Rather, patients with national healthcare coverage can negotiate a deal to come to the U.S. for complex surgeries. Children's National also consults with local physicians pre- and postoperatively.

Despite challenges such as language and cultural barriers, and time differences, hospitals involved in cross-border telemedicine are forging ahead with plans to grow their programs. UCLA, for instance, is also exploring offering similar telepathology services in Russia.

“We are really doing very well and now we want to expand this to other countries,” Rao says.

Children's Mercy is also in talks with other hospitals in India, the Middle East and Africa.

“We're doing it very methodically,” Cox says. “You have to be sensitive to the culture you're working with. We really have to take the time to make it worthwhile.”

Children's National is looking at branching out into other subspecialties, such as diabetes management. Reyna also notes that while time differences have made live services more challenging, the hospital is working to find ways to improve synchronicity.

“It's never a one-way street,” she says. “We're always learning from them. In many ways, the international community has led efforts in telemedicine.”