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"n ight hawk " rad iolog y ser v ices — which provide second- and third-shift diagnostic examinations of images and caused some controversy when they became widespread 10 years ago — are now routine. One Hospital, Many Paths Children's Mercy Hospital in Kansas City, Missouri, participates in charitable and profi t-based international medical consulting while maintaining a robust domestic telemedicine program. "Internationally, our providers who have to leave K a nsa s Cit y a nd live abroad for extended periods of time use InTouch Health to continue caring for their patients," says Lisa Large, MSBE, Telemedicine Research and Training Coordinator at Children's Mercy. "They continue to participate in clinics and exa mine patients a s t hey norma lly would. The experience is smooth for providers, patients and families." Children's Mercy also participates in la rger-sca le telemedicine initia- tives, such as partnerships with two hospit a ls i n Gu a ngdong P rov i nce, China. Outreach to partner hospitals includes radiology interpretation and medical education. "A few years ago, our medical direc- tor wa s investigating internationa l telemedicine opportunities," Large says. "At the same time, our medical director of radiology was working with a hospital in China. We realized this was a service we could use to help them. We have a great staff of coordinators who facilitate daily needs and look for new contracts and opportunities so we can continue of fering ser v ices such a s pediat ric radiology to them." Collaborating electronically in real time with physicians abroad has its chal- lenges, Large says, including technical and regulatory barriers. "Even w ith high-ba ndw idth fiber networks, your connection is only as good as the one you are connecting to," she says. "We have to evaluate how we can connect on both ends." Large notes that using a Web-based cloud system has eliminated many of the difficulties. Regulations, credentialing and con- tracts also pose challenges for domestic and international telemedicine. Not all states have reciprocity laws for medical credentialing, making it difficult for U.S. physicians to practice medicine across state borders. When working w it h inter nationa l pa r t ners, La rge says, it is prudent to outline the terms of the partnership in advance. "We formulate a contract with those sit e s a nd m a ke s u re e x p e c t at ion s a re clea rly defined," she says. " We discuss reimbursement, too. We rely on a contract to help navigate these boundaries and create a plan that will work well both for the near and the distant sites." ■ TELEMEDICINE BY THE NUMBERS SINCE IT WAS fi rst recognized by the U.S. Department of Health and Human Services in 2000 as a viable practice, telemedicine has grown rapidly, both domestically and abroad. The Centers for Medicare & Medicaid Services maintains telemedicine billing codes and reviews them annually; however, coverage extends only to a limited range of modes, healthcare settings and patient geographic locations. This makes a precise count of telemedicine services diffi cult. International telemedicine services are even more challenging to gauge, as many nations do not have a governing body tracking telemedicine offerings, according to the World Health Organization (WHO). TELEMEDICINE IN THE UNITED STATES + Approximately 200 telemedicine networks + 3,500 telemedicine service sites + Approximately half of hospitals engage in telemedicine. TELEMEDICINE ABROAD WHO surveys member states about telemedicine policy and use by modality, fi eld and other factors. Some nations have formal telemedicine policies, while others may practice informal telemedicine. Approximately half of surveyed nations expressed some form of telemedicine engagement, as of a 2010 report. The most common services were pathology and radiology, both of which require sharing slides or images rather than face-to-face consultation. + Pathology: 17 percent of WHO member states report an established policy; 41 percent report implementation of some form, ranging from established policy to informal practice. + Radiology: The same formulas produced reports of 33 and 62 percent, respectively. By specialty and modality, cardiology was the most common form of international telemedicine, with 17 nations reporting established services and 28 reporting at least an informal level of service. Ultrasonography, mammography, surgery, consultation, ophthalmology, nephrology and obstetrics/gynecology were also somewhat common, with at least fi ve nations reporting some form of telemedicine use for each fi eld. M D N E W S . CO M ■ MD NEWS Greater Boston | 1 1