Telepathology--threat or hope

[Nilf]

Recently I have heard about the following business plan from the dermpath director at my place, which (according to him) is already up and running somewhere on the West Coast.

The system works a little bit like cytology setup. Dermpath cases get shipped to India via telepathology, where they are triaged. Anything simple (BCCs, most of squamous lesions) get diagnosed, anything complex gets flagged and is shipped back for review. Dermpath attending in the US then cosigns the simple cases, and diagnoses the complex ones.

I do not want to raise the specter of the telepathology-outsourcing boogeyman, because this topic has been beaten to death. However, I would like to discuss the viability and legality of this practice, and the effect that tele-technologies will have on the practice of pathology. I think that if this becomes more prevalent model, some sort of quality control should be imposed, similar to what cytology has. Does it mean that the pathologists in the US will compete with their offshore brethrens for work? In the era of healthcare cost-savings measures, it would be every healthcare administrator's dream.

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[Matte Kudesai]

It seems to me that economic forces will eventually force this kind of model. For one, it is less expensive. Also, I think telepath has the potential to increase quality because you will be able to set up centers with a fairly narrow scope of work (e.g. the Worldwide center for diagnosis of Dermal Spindle Cell Lesions) where screeners would gain a vast amount of experience by looking at a high volume of a relatively limited spectrum of cases (much like cytology). Also, quality would be much easier to monitor and control in such specialized centers. In principle, ordering recuts, immunos, etc. could be done online and with the same turnaround time.

Telepath also has the potential to change to role of the pathologist. Currently, pathologists need broad training because their case load is generated by location. Telepath will break that linkage and, in theory, one could have sufficient volume to focus on a very narrow spectrum of cases. One could question whether a person needs a medical degree and 4 to 5 yrs of graduate medical training to perform such a narrow task.

While this model will make pathology less attractive for pathologists, cost and quality considerations will lead companies in this direction. Certainly, pathologists will try to create barriers to prevent this. For example, they will claim that quality will suffer unless slides are read reads by US-trained board-certified pathologists. While inputs such as training certainly influence quality, the bottom line is that outcomes are what matter most. Thus, it really doesn't matter who reads the slides as long as the output meets quality specification. I suspect that highly focused facilities would be able to reach or exceed the current levels of quality using less broadly trained labor. In particular, one could ask whether you really need an MD with 5 yrs of postgraduate training to read slides in a highly focused facility. Further, a highly focused facility will be better able to provide evidence for their performance. Thus, quality assurance will rely more heavily on evidence based on output measures than reliance upon proxies for quality such as training of personnel.

Information technology often transforms work processes and work roles. A technology like telepath has the potential to reshape the field and, in doing so, will change the role of the pathologist.

The only factor preventing these models (including scanning) from moving ahead full bore are the legal issues.

Very soon the cost/benefit ratio of having insurance pay for F-ups at some mill in India will favor outsourcing.

This is already happening with high throughput biopsy mills....

It will be easy to pay a "big name" to watch your arse as the pseudo final signout person...

Also tons of IMG's with US credentials may prefer living in their home countries making salaries that will be HUGE compared to US...

Who will fight for us man???????

 

[pathstudent]

Recently I have heard about the following business plan from the dermpath director at my place, which (according to him) is already up and running somewhere on the West Coast.

The system works a little bit like cytology setup. Dermpath cases get shipped to India via telepathology, where they are triaged. Anything simple (BCCs, most of squamous lesions) get diagnosed, anything complex gets flagged and is shipped back for review. Dermpath attending in the US then cosigns the simple cases, and diagnoses the complex ones.

It takes all of 30 seconds to diagnose the easy cases so how is shipping them to India doing anything at all? Surely the dermpather in the US takes a quick look at the case to make sure that he doesn't think it is something else before signing it out. Any dermpather that takes that job is a chump.

In any case it doesn't matter. Medicine is going to collapse in the US. In the minds of Congress and the public it is always acceptable to take money from physicians, so in ten years we will all basically be like firefighters, cops and school teachers, that is, honorable people who do their jobs for much less than they deserve.

 

[Alteran]

It takes all of 30 seconds to diagnose the easy cases so how is shipping them to India doing anything at all? Surely the dermpather in the US takes a quick look at the case to make sure that he doesn't think it is something else before signing it out. Any dermpather that takes that job is a chump.

In any case it doesn't matter. Medicine is going to collapse in the US. In the minds of Congress and the public it is always acceptable to take money from physicians, so in ten years we will all basically be like firefighters, cops and school teachers, that is, honorable people who do their jobs for much less than they deserve.

And collapse it will. Honor really doesn't mean much anymore in this culture other than lip service. If you want people to be motivated and do a consistently good job, you pay them well. Salary has always been the indicator of value in US society, not worth. I do not think that the suits making these decisions are worth the carbon they're made of, but they're certainly being valued more than we are.

I'm just waiting for the day when some guy gets told: "You know that funky growth we plopped out of your neck....yeah...we don't have any pathologists in this country that can see it in the next 6 months...hope its not malignant. But if you're up for it, here's a Wheater's Functional Histo book and and atlas of path...good luck."

 

[yaah]

In any case it doesn't matter. Medicine is going to collapse in the US. In the minds of Congress and the public it is always acceptable to take money from physicians, so in ten years we will all basically be like firefighters, cops and school teachers, that is, honorable people who do their jobs for much less than they deserve.

At least then maybe we'll get overtime pay.

 

[docbiohazard]

In any case it doesn't matter. Medicine is going to collapse in the US. In the minds of Congress and the public it is always acceptable to take money from physicians, so in ten years we will all basically be like firefighters, cops and school teachers, that is, honorable people who do their jobs for much less than they deserve.

Here's a serious problem - the costs and time investment associated with becoming a physician far outweigh those of any of the other fields you mentioned. So who's going to want to train to be a physician, saddled with huge debt, in a world where you're not going to make the cash to pay off your loans in any reasonable time frame? Not very many people.

If they're going to keep killing reimbursement, they need to pony up and start paying for our education...

DBH

 

[malchik]

At least then maybe we'll get overtime pay.

. . . and summers off.

 

[yaah]

Here's a serious problem - the costs and time investment associated with becoming a physician far outweigh those of any of the other fields you mentioned. So who's going to want to train to be a physician, saddled with huge debt, in a world where you're not going to make the cash to pay off your loans in any reasonable time frame? Not very many people.

If they're going to keep killing reimbursement, they need to pony up and start paying for our education...

DBH

That is the key problem, isn't it. The problem with our society is that it is an instant gratification, what have you done for me lately society. If you can do something now and do it well, great. But looking five years down the road is too far. And in the past, well, we can learn some lessons from the past but we can't focus on it too much. Therefore, the american public is never going to really have the patience for the type of forward-thinking behavior that would recommend that medical education be funded, at least partially, to reduce the debt of graduates and remove that burden from future equations. No one will ever vote, for example, for a temporary increase in taxes to pay for something that will lower taxes in the future.

However, the american public also does not have the patience or the stomach for considering current debt burdens and future troubles when deciding what the priorities are - hence, priorities for the majority will always focus on the present - how much money can this save me? How much will this cost me? I don't care if I'm mortgaging everyone's future, just give me my $1200 economic stimulus check! Politicians, as representatives of the present, have similar concerns. The future to a politician is 2 years down the road. Thus, the solution that inevitably presents itself (to the problem that health care is too expensive) is to cut salaries. Why? Because cutting payments to entities with deep pockets and lobbying skills (like drug companies, medical device manufacturers, health insurance companies, and anything to do with malpractice attorneys) is too difficult and politically inflammatory. Cutting payments to rich doctors, well, we all have to make sacrifices (Except for politicians who will add on an amendment to the bill to increase their salaries, and private lawyers of course) and thus, doctors will have to accept less in this time of war. Investing now to increase efficiency and innovation in preparation for the future is bad, because that costs money now.

It's times like this that politicians have to make decisions to cut funding to those who are least likely to complain or have a big media or lobbyist backer. Hence, physicians. Physicians are too busy (or blind) to complain. Can't cut funding to anybody else in healthcare! Are you going to cut nursing salaries? Hospital administration? Children's programs? Construction of new hospitals for children? Funding of special insurance programs and drug benefits for sick children? No. You cut physician salaries. Preferably young physician salaries, because they won't stop donating money to the hospital (or politicians!) when you cut their salary, whereas Dr Ancient, a 70 year old who is still practicing, would stop donating. So keep Dr Ancient's salary high.

 

[LADoc00]

yeah..no. Telepathology will never really flourish aside from some niche applications.

Pathology is too managerial to allow for outsourcing of anything other than select outpatient Ameripath type business models.

I am worried about ALOT of issues in modern pathology, telepath is FAR FAR down on my list.

Nothing is going to "India" which is just a catch all buzz phrase that invokes xenophobic fears of Indiana Jones and the Temple of Doom heart ripping shenanigans mixed with your typical Western vision of soccer ball making sweat shop where slides are read at maximal speed and the topless pathologist is viciously whipped by a cat o nine tails by the pit bosses.

This firey version of pathology hell, although may be occurring right now, is not our destiny, trust me.

 

[Matte Kudesai]

Nothing is going to "India" which is just a catch all buzz phrase that invokes xenophobic fears of Indiana Jones and the Temple of Doom heart ripping shenanigans mixed with your typical Western vision of soccer ball making sweat shop where slides are read at maximal speed and the topless pathologist is viciously whipped by a cat o nine tails by the pit bosses.

This firey version of pathology hell, although may be occurring right now, is not our destiny, trust me.

Awesome description man..... AWESOME...

I do agree that the Ameripath model does lend itself to outsourcing though...

Do you think this model will dominate the majority of future pathology business?

 

[Nilf]

Nothing is going to "India" which is just a catch all buzz phrase that invokes xenophobic fears of Indiana Jones and the Temple of Doom heart ripping shenanigans mixed with your typical Western vision of soccer ball making sweat shop where slides are read at maximal speed and the topless pathologist is viciously whipped by a cat o nine tails by the pit bosses.

This firey version of pathology hell, although may be occurring right now, is not our destiny, trust me.

hehehe, good one Ladoc. BTW, did you guys like the new Indy movie?

 

[Gut Shot]

However, I would like to discuss the viability and legality of this practice, and the effect that tele-technologies will have on the practice of pathology.

If they haven't consumed diagnostic radiology already, I doubt they're much of a threat. The setup you describe sounds insanely convoluted, perhaps the brainchild of some bean monkey in a suit. Having now known quite a few people who have been outsourced, the phenomenon of outsource remorse is steadily becoming more apparent. On paper a company can save some dollars by shipping labor overseas, but the world isn't so flat as to not generate significant problems in doing so. Technical glitches, communication issues and time delays create drag on stateside activities and negate much, if not all, of the presumed monetary savings. For now I view telepath as a potentially useful tool for consults, but not much else is clear (or threatening). At the end of the day, LADoc00 is right - our jobs are too managerial to go anywhere. And there is too much demand from clinicians to speak directly with the diagnosing pathologist for general pathology to suddenly go the way of the Dodo.

 

[Cloaca]

I agree with LADoc and Gut Shot - easy cases are easy for US pathologists as well and if your turnaround time is forked up because of transcontinental communication issues, patients and referring clinicians will be very unhappy. The consequences are generally more dire than not being able to reach your Verizon tech support.

The reason why the cytology pre-screening model works is because there are so many negatives (i.e., a lot of cytology specimens are screening samples or part of a larger work-up). However, the rate of positives in surg path and biopsy specimens is higher (well, except maybe GI). Ok, so what? Well, there is subtlety and nuance in a lot of pathology diagnoses -it is very very often not a cut and dry kind of thing. Many entities have a differential diagnosis (something you learn during medical and pathology training). A lot of times, you need to take the clinical setting into consideration, imaging infomation, need more info from clinician, take into account the clinical consequences of a given diagnosis (i.e. therapeutic interventions), etc etc. So at the end of the day, outsourcing in this kind of setting may save you very little, if any, time and money.

 

[MOHS_01]

We actually were a pilot site for a version of this during our last year of residency (2005). There are sizable technological hurdles that need to be overcome, although I have to say that, for dermpath, it was acceptable.

The comparison to radiology is tenuous -- from a technology perspective radiology imaging is much easier to accomplish adequate resolution, etc, as this is truly two dimensional (and in large part grayscale / black & white). Radiology is at risk of globalization for a multitude of factors; pathology is much less so.

A more likely scenario (for both rads and path) is that reimbursement will continue to be driven down to the point where the cost-effectiveness of outsourcing is reduced to a level where it is no longer deemed worthwhile.

 

[Matte Kudesai]

I agree with LADoc and Gut Shot - easy cases are easy for US pathologists as well and if your turnaround time is forked up because of transcontinental communication issues, patients and referring clinicians will be very unhappy. The consequences are generally more dire than not being able to reach your Verizon tech support.

It is not that hard to get a relaying center in a place like Dubai...

It is not rocket science to imagine the internet and scanning being used to at least globalize consults .
LADOCs visions of sweat shops aside...

There are incredibly bright engineers and entrepreneurs on the hardware/software end of these technologies...

TRUST ME it will be a reality. Not sure about the outsourcing part yet.
But at least at the consultation level remote access will be a reality soon.

You will not have to FEDEX slides through your consult service etc.

The way outsourcing will become a possibility is based solely on who will want to invest in these techonologies.

There are gazillionaires that are already branding out US medical centers outside of the US.

The infrastructure can be set up to either scan or real time slides (telepath) (through the internet) in a second site type system...
This is already being set up in places like Dubai.
Whether it becomes successful.. who knows.
It can be only as cheap as memory and dedicated bandwidth coupled to someone with the cash and vision to push it through..

I mean crap... google is already getting into the medical history BIZ...

 

[Matte Kudesai]

http://www.clevelandclinicabudhabi.com/

http://www.hmsdc.hms.harvard.edu/

http://www.budubai.ae/

http://www.mayoclinic.org/english/dubai-cardiology.html

http://en.wikipedia.org/wiki/Dubai_Healthcare_City

http://www.bi-me.com/main.php?id=295&t=1




UAE, Japan discuss boosting ICT collaboration
posted on 05/05/2008

UAE Minister of Economy Eng. Sultan Bin Saeed Al Mansouri and Japanese Government and private sector representatives on Sunday discussed mutual collaboration in information and communications technology (ICT). Both sides affirmed the UAE?s status as Japan's primary trade partner in the Middle East. The meeting also explored ways to further boost UAE-Japan cooperation in the field of ICT and related services.
The Japanese delegates discussed their country's leadership in traffic information; personal authentication; telepathology; and e-government technologies, and also offered their services in establishing efficient digital terrestrial broadcasting; mobile WiMAX; and advanced cellular phone systems.
"IT services spending in the UAE rose 23 per cent to Dh 1.86 billion in 2007 and is expected to grow by 15 per cent this year; we thus welcome our Japanese partners' offer of further expanding this growth industry. Japanese ICT technologies will also perfectly complement federal efforts to enhance inter-agency communications and develop the country's ICT infrastructure to meet burgeoning consumer demand," said Al Mansouri.
Bilateral trade between the UAE and Japan reached Dh69 billion in the first half of 2007, with Japan importing more than 30 per cent of its mineral fuels from the UAE during the same period. The group agreed that this productive relationship should be further expanded into growth areas such as ICT; they also exchanged views on the ICT-related policies of their respective countries and the important role of ICT technologies and services in societal development. – Emirates News Agency, WAM

 

[Cloaca]

It is not that hard to get a relaying center in a place like Dubai...

It is not rocket science to imagine the internet and scanning being used to at least globalize consults .

TRUST ME it will be a reality. Not sure about the outsourcing part yet.
But at least at the consultation level remote access will be a reality soon.

You will not have to FEDEX slides through your consult service etc.

The way outsourcing will become a possibility is based solely on who will want to invest in these techonologies.

Right, I'm not saying that telepathology will not be important for consultations (everyone agrees that this will happen and that it will be good for patient care) but we're talking about telepathology outsourcing, i.e. replacing on-site pathologists with technicians in Dubai or wherever to screen all of your surgical/biopsy specimens as a cost-saving measure. I am dubious that this will happen for the above-stated reasons.

 

[Zuwie]

I wouldn't worry about it too much. First of all, what about frozens? How are they going to be outsourced?
Second, pathologists often need to closely interact with clinicians, histotechs and clinical labs. What if you need to request additional tissue? What if there is a processing problem? What if you need to look at previous slides or cytology? What if the surgeon wants to look at the slides with you and discuss the diagnosis? A pathologist is not just someone who looks at the microscope but someone who participates in patient care as a whole. You might as well outsource all medicine.

 

[Matte Kudesai]

Right, I'm not saying that telepathology will not be important for consultations (everyone agrees that this will happen and that it will be good for patient care) but we're talking about telepathology outsourcing, i.e. replacing on-site pathologists with technicians in Dubai or wherever to screen all of your surgical/biopsy specimens as a cost-saving measure. I am dubious that this will happen for the above-stated reasons.

True Tue...

I think the slide scanning thing coupled to some of these high volume biopsy mills might be the only model that may be outsourced....


Telepathology is less likely... for the reasons you have stated.