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4 Tips When Opening Foreign Telemedicine Operations

Analysis  |  By Mandy Roth  
   August 16, 2018

Lessons from Emory Healthcare's launch of an eICU facility in Australia.

As more U.S. healthcare systems open telehealth and other facilities on foreign soil, they find legal, data security, staffing and other challenges to overcome.

Emory Healthcare addressed these issues when the Atlanta-based health system opened an eICU control room in Perth, Australia. Lessons from that experience may help other systems embarking on this quest.

Dynamics Behind the Trend

As telemedicine, patient experience, and population health initiatives expand, along with the need to provide 24-7 access to clinical experts, more U.S. healthcare systems are exploring the advantages of opening facilities in foreign countries.

One of the motivating factors behind this trend is a diminishing supply of critical care clinicians, combined with a shortage of seasoned personnel willing to work the night shift. Moving operations to a different time zone enables workers located there to work daytime hours that correspond with the night shift back home.

Emory's motivation was tied to these dynamics, as well as a need to improve the lives of its critical care workforce. The eICU directors also wanted to eliminate the adverse effects of working the night shift, which created an increasing challenge as its experienced professionals aged.

Emory's Australian Outpost

Emory's foreign outpost is located in a room at Royal Perth Hospital, Perth, Australia, on the western coast of the country. The city is exactly 12 hours ahead of Atlanta, where Emory is based. After polling current providers about a variety of potential locations, including sites in Asia, they indicated they preferred to say g'day as night fell in Georgia.

Nurses and intensivists sign up for two- to three-month rotations in the land down under. A second control room is located in Atlanta.

Using remote eICU technology by Philips, the providers in the control room monitor ICU patients at four Emory hospitals, plus a rural Georgia hospital that has contracted with Emory for this service. Clinicians can speak directly to care providers at the patient’s bedside in Georgia, while also talking with the patient or family members. Specialized cameras, video monitors, microphones, and speakers enable two-way communications.

1.  Protect Patient Data

With technology come concerns about data protection – and data security is paramount these days. Setting up operations in a foreign country raised red flags for Emory's legal team.

"You have to make sure patient data is protected and you are not violating any HIPPA laws," says Cheryl Hiddleson MSN, RN, CENP, CCRN-E, director of Emory's eICU Center.

The solution? Emory's IT team worked with AT&T to build an end-to-end fiber-optic circuit between Atlanta and Perth.

"All of our machines over there—our computers and telephones—actually sit on the Emory network, so there's no transmission of any patient information at all," explains Hiddleson. "This includes the camera sessions. Everything is done privately on the Emory network. No one in Australia has access to those machines, so we managed to overcome that obstacle."

2. Tackle Legal Hurdles with Credentialing

Personnel who work in Emory's eICU control center include physicians and critical care nurses. Hiring providers who were Australian residents was not only problematic due to the need to obtain U.S. credentials for foreign professionals; it would eliminate the opportunities the system wanted to create for the people it already employed.   

Yet the reverse situation also raised questions. "Credentialing and licensing a physician or a nurse in another country is a very arduous, expensive, and time-consuming process," says Hiddleson. The team spent a significant amount of time exploring this issue. If foreign licensing and credentialing was required, "That probably would've been a no-starter for us," Hiddleson says.

Exploring these issues was a long journey that began with hiring a legal team. There also were consultations with Australian medical and nursing associations, as well as state government officials for healthcare.

"The decision was made that as long as we were only providing care to our own patients, and we were not going to deliver care or advice to Australian patients, it was fine," says Hiddleson.

3. Address the Fourth Pillar: Increasing Satisfaction

The goal in healthcare "is no longer just about producing better outcomes, better patient and family experiences, and lower costs," says Timothy Buchman, MD, PhD, FACS, FCCP, MCCM, who also serves as director of the Emory Critical Care Center, professor of surgery and anesthesiology at the Emory University School of Medicine, and chief of critical care services at Emory Healthcare. "That was the triple aim. We now talk about the quadruple aim [which also addresses] professional satisfaction and professional joy."

When healthcare professionals don't feel fulfilled and cared for, says Dr. Buchman, "they don't do their best work" and may leave and seek employment elsewhere."

Emory's decision to open the eICU control room in Australia "not only improves the quality, effectiveness, and timeliness of patient care… but it also ensures the satisfaction of our professionals," says the medical director. "When I say satisfaction, it's not just a matter of feeling good; it actually results in the ability to retain people in service."

4. Assess the Investment

Setting up operations in a foreign country can be expensive. And, if the arrangement is similar to Emory's, travel and housing costs must be factored into the investment.

Is it worth it? For Emory, it is, says Dr. Buchman. He points out that losing experienced, respected critical care providers creates a knowledge vacuum in the system; it's almost impossible to find personnel with the depth of experience required to work in an ICU, he says.  But there's a financial cost as well.

"Let's talk about the following scenario," Dr. Buchman says. "An experienced doctor decides to leave and says, 'I'm quitting and going somewhere else.' You have to absorb all the costs of getting a replacement. That cost will include premium shifts for the people who are still on staff. You also have the cost of interviewing, recruiting, onboarding, and the rest of it. It costs a lot to replace a physician."

Hiddleson says the same dynamic applies to critical care nurses.

Emory measures its ROI in terms of retention: the program pays for itself if the unit retains one physician and one nurse annually.

Mandy Roth is the innovations editor at HealthLeaders.

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