We’re pleased to open this issue with a conversation between Laura Carabello, Publisher of Medical Travel Today, and Robert M. Kolodner M.D., National Coordinator for Health Information Technology (HIT) with the Department of Health and Human Services.
In the few short years since Dr. Kolodner joined the Department, he has been instrumental in advancing the President’s Health IT initiative and has much insight to offer medical professionals in our industry about record sharing both domestically and abroad.
For those involved in facilitating travel for medical tourists, we’re please to offer the legal perspectives of Purvi B. Maniar, Partner, Epstein, Becker Green P.C. Specifically, she addresses the legal questions related to Health Insurance Portability and Accountability Act (HIPAA) that should be considered by those in the United States who facilitate international travel by U.S. patients.
As always, we welcome your thoughts and feedback. Please send comments to firstname.lastname@example.org.
Laura Carabello, Publisher of Medical Travel Today recently had the privilege to speak with Robert M. Kolodner M.D., National Coordinator for Health Information Technology (HIT) with the Department of Health and Human Services.
Since joining the Department in 2006, Dr. Kolodner has made steady progress in advancing the President’s Health IT initiative. Prior to joining HHS, Dr. Kolodner served as the Chief Health Informatics Officer at the Veterans Health Administration in the Department of Veterans Affairs (VA). He was involved in the development and oversight of VistA—the VA’s electronic health records system—and My HealthVet—the VA’s Personal Health Records for veterans.
Medical Travel Today spoke to Dr. Kolodner regarding his thoughts on the growth of medical travel and how players in the health information technology industry, both here in the U.S. and abroad, will need to begin to address the critical issue of medical records sharing and the impact upon patient safety.
Following are excerpts of the conversation:
Laura Carabello of Medical Travel Today (MTT): What kind of, if any, international records sharing systems currently exist?
Robert Kolodner (RK): At the current time, there is none in widespread use. The problem is in the lack of standards in any one country. There are really three issues impacting internal record sharing: policies, understanding and trust.
You’ve got the policies that exist in each country. Often, you’ve got a lack of understanding of the complexity and scope of records management. And then there’s the question of trust. You need to be certain that the information is going to the right entities.
MTT:What nations outside the United States, if any, do you feel are doing the best job in terms of creating reliable systems for sharing and transferring records?
RK: In my opinion, this progress is limited to a few countries including the Netherlands, Denmark, New Zealand and the United Kingdom – and there may be others. Since adoption of electronic health records (EHR) in the United States is still at a low level, with current estimates holding that only 14 percent of providers currently have an EHR, it may be premature to advance discussions of interoperability with even those nations that are generating traction.
MTT: What obstacles currently stand in the way of creating a secure and seamless means for sharing records both domestically and across borders?
RK: Foreign countries certainly face more challenges because of the language issues. In some European countries, stakeholders have to contend with 27 or more language variations, making interoperability a significant challenge.
Some of the information translates easily. For example, with drugs, ingredients are comparable throughout the world and readily understood. Also, there are data elements and identifiers in the EHR that are fairly straightforward and not complicated by translation.
The challenge comes with progress notes. While there are incremental advances and some physicians overseas can provide care and record information in English, there’s simply no reliable translator to handle this type of information. It becomes quite difficult to address the complexities and in the short term, these challenges persist.
MTT: What kind of consideration are you giving to international records sharing as you develop the Nationwide Health Information Network?
RK: We are wrestling with standards ourselves. We are not unique—others are having challenges to automate their systems. Before we can delve into international record sharing, we have to better develop what we’re doing domestically.
MTT: One aspect of medical tourism that seems to be of greatest concern to doctors in the US is the after-care that returning patients may require. What are your thoughts on applying a CCR approach to this patient group?
RK: The solution should be a continuity of care (CCR) standard set by American Society for Testing and Materials (ASTM). This would be a great first step.
We need to harmonize a way of moving as much information as CCR offers but doesn’t inherently make available. Groups are beginning to collaborate to bring together the best of CCR and other standards, with movement toward the common criteria document (CCD). This is where the standard is moving—incorporating the data of the CCR but enhancing it with versioning and combining it with recommendations from HL7 Groups. If an entity can transport information in a CCD format, then interim solutions such as a USB port or CD will be possible long before interoperability is achieved.
Another opportunity is for sharing-entities to introduce a portal to their systems so information can be shared. The challenge with this approach is that it may not meet the physician needs, since they can’t log on to different sites.
Another solution for today’s volume of patients traveling outside the country for medical care is to download their own data, print it out and carry along to the destination. This is a short-term solution and while it’s not ideal, it will promote continuity of care.
We’re also seeing “in-patient IT vendors” now playing in an international marketplace. They are building features into their products that may become available to promote record sharing.
We’ve got the beginnings of a solution in place but there are steps to go before we get there. What we need are patient-centered solutions as the industry undergoes a great deal of change and all stakeholders are focused upon patient outcomes.
MTT: Do you feel that the Department’s Certification Commission might be used as a model for developing a unified set of international standards related to care provided through medical tourism?
RK: Discussion and exploration is underway with the European Union to determine areas for collaboration. But I want to stress that it’s really the model of certification that we’re looking at, not the certification itself.
MTT: Do you have any forecasts for the industry?
RK: Some observers think that personal health records—PHRs—may be a driving force for consumers to get their electronic health records underway. It is an interesting time for this aspect of data collection.
Everyone recognizes that the healthcare sector is dependent upon implementing sound healthcare information technology as a necessity for better care and improved outcomes. But HIT and EHRs unto themselves will not get us there.
We need to encourage every individual to understand that the quality of healthcare they receive—especially when there are multiple providers involved—is largely dependent upon physician use of EHRs to aid in the delivery and exchange of information. It is in everybody’s interest to see widespread adoption of EHRs, particularly providers who want to take care of people and streamline practice workflow.
Among the legal questions often raised by organizations in the United States which are involved in facilitating travel abroad by U.S. patients for medical care are to what extent are they governed by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and what are their obligations under HIPAA with respect to patient privacy. This article is intended to examine the implications of HIPAA for “intermediaries” or “matchmakers,” in medical tourism, i.e. companies (in the United States) which facilitate overseas medical tourism in certain typical medical tourism arrangements these days.
By way of brief overview, HIPAA is a United States federal statute that includes various provisions intended to protect the privacy and security of personal health information of individuals. HIPAA privacy standards govern the use and disclosure of “protected health information” by “covered entities”.
“Protected health information” (commonly referred to by its acronym “PHI”) generally refers to information created or received by a health care provider, health plan, employer, or health care clearinghouse which relates to the past, present or future physical or mental health or condition of or provision of health care to an individual or the past, present or future payment for the provision of healthcare to an individual, and that identifies (or provides the means to identify) the individual.
“Covered Entities” are healthcare providers (e.g. physicians, hospitals), health plans (e.g., health insurance and managed care companies and employer sponsored benefit plans), and healthcare clearinghouses (e.g. WebMD, intermediaries between providers and payors to translate data into required formats). HIPAA security rules are applicable to covered entities which transmit, create or receive PHI in electronic form and these rules require reasonable physical, technical and administrative safeguards to protect the security of PHI. This article is intended to focus on the patient privacy implications of HIPAA, and therefore a full discussion of the application of the HIPAA security rules is beyond the scope of this article.
As a general matter, HIPAA does not directly require compliance by intermediaries which facilitate overseas medical tourism because these companies do not generally fall within the definition of “covered entities”. (However, as discussed below, these companies may be indirectly required to comply with the HIPAA privacy standards if they become “business associates” of covered entities.)
Thus, in the not uncommon medical tourism scenario, where an individual patient in the United States elects to travel abroad to receive medical care by arranging for such care either directly with an overseas hospital or through an intermediary that facilitates such travel, the intermediary arranging for the treatment would not be liable under HIPAA with respect to use or disclosure of medical information of the patient.
Of course, the overseas hospital providing the care or the intermediary may still be held liable if violation of any applicable privacy laws of the local country where the treatment was provided were to occur. (It is also unclear whether the overseas hospital would have liability under HIPAA and the answer may depend on the level and type of involvement it has in seeking patients in the United States.) The intermediary or the overseas provider may also be held liable if they violate any agreement which they entered into with the patient, or any policy to which they are subject that the patient relied upon, governing the use and disclosure of the medical information of the patient.
As medical tourism is becoming more widely accepted in the United States, an increasing number of health plans, e.g. managed care companies and employer sponsored benefit plans are becoming interested in offering medical tourism as an option to their enrollees in an effort to manage costs while providing quality medical care.
For a medical tourism intermediary, contracting with such health plans to provide medical care to or facilitate medical tourism by their enrollees represents a significant opportunity to attract patients in volumes rather than on an individual basis. However, because a health plan in the United States is a covered entity, it is not, in many instances, allowed to disclose protected health information to third parties unless the third party enters into an agreement to become a “business associate” of the health plan.
As a “business associate”, the intermediary is required to use appropriate safeguards to prevent use or disclosure of the PHI other than as provided for by its contract with the health plan, report to the health plan any use or disclosure of the information not provided for by its contract of which it becomes aware, and ensure that any subcontractor to whom it provides PHI agrees to the same restrictions and conditions that apply to the business associate with respect to such information.
As a business associate, the intermediary will also be required to satisfy individual rights requirements as to access, amendment and accounting on behalf of the health plan, make internal practices, books, and records relating to the use and disclosure of PHI available to the Secretary of the U.S. Department of Health and Human Services and return or destroy all PHI at the termination of the agreement.
While HIPAA does not provide for direct liability of business associates to the government or to individual patients, the business associate agreement with the covered entity will often require the business associate to indemnify the covered entity for damage incurred by the covered entity arising out of violations by the business associate. Thus, the intermediary may be contractually liable to reimburse the health plan for civil penalties that the health plan may incur arising out of privacy violations by the intermediary, including fines of up to $50,000 for multiple violations of the same standard in a calendar year and fines up to $250,000 for knowing misuse of individually identifiable health information.
For intermediaries in medical tourism, a successful, scaleable business model usually presumes contracts with managed care plans or self-insured employers who can refer a steady stream of patients who can take advantage of medical tourism. Such a relationship will inevitably require the intermediary to become a business associate of the health plan.
To the extent that the intermediary can demonstrate that it is already compliant with applicable industry privacy and security standards by having effective policies, procedures and monitoring mechanisms in place, this will go a long way in reassuring the health plan that it is entering into a relationship with the right partner. Such measures could include retaining a designated HIPAA officer for implementation and oversight, which is not specifically required by HIPAA, but is one of the industry best practices.
As a final caveat, the intermediary should bear in mind that while HIPAA preempted all state privacy laws which were less stringent than HIPAA, to the extent a state’s privacy laws are more stringent, they remain in effect and are applicable in addition to the requirements of HIPAA. Therefore, whether or not the intermediary is a business associate of a covered entity under HIPAA, it should always examine and comply with applicable laws of the states in which it is located and in which the patients that it facilitates reside.
If you have any questions or comments about this article or on this topic, please feel free to contact Purvi B. Maniar by email at email@example.com. This publication is provided for general information purposes; it is not and should not be used as a substitute for legal advice.
Three Hospitals in Singapore Join Companion Global Healthcare Network
COLUMBIA , S.C. , March 6 /PRNewswire/ — Companion Global Healthcare, Inc. today announced the addition of three hospitals located in Singapore to its network of overseas medical facilities, bringing its total network membership to seven hospitals. Mount Elizabeth Hospital, Gleneagles Hospital and East Shore Hospital, all operated by Parkway Health (www.ParkwayHealth.com), have agreed to treat Companion Global Healthcare's U.S. clients at pre-negotiated, in-network rates. The hospitals offer a wide range of medical and surgical services at rates lower than those typically charged by hospitals in the United States.
"Patients in increasing numbers are crossing international borders seeking top-quality care at affordable prices," said Dan Snyder, Parkway Health's CEO. "Our three world-class hospitals in Singapore have fully English-speaking, reputable specialists and nurses who offer some of the best treatment available anywhere in the world.
"We are delighted to be working with Companion Global Healthcare to help their beneficiaries who seek healthcare services overseas, specifically here in Singapore where many U.S. companies and the military have established operations."
Mount Elizabeth, Gleneagles and East Shore each hold the prestigious Joint Commission International (JCI) accreditation.
"The addition of Parkway Health means our individual clients and employer groups have more outstanding options for obtaining fully credentialed medical care at affordable, all-inclusive prices," said David Boucher, Companion Global Healthcare's assistant vice president of healthcare services.
Based in Columbia, S.C., Companion Global Healthcare (www.CompanionGlobalHealthcare.com) provides streamlined access to JCI- accredited hospitals for those who elect to travel abroad for healthcare. The company provides a single launch point for appointments, travel services, case management and follow-up care in the United States.
All BlueCross BlueShield of South Carolina and BlueChoice(R) HealthPlan of South Carolina members have access to Companion Global Healthcare's network hospitals at discounted rates. Companion Global Healthcare also serves the uninsured, and is available to contract with insurance companies and employer groups that wish to include an overseas option in their benefit plans.
In addition to the Parkway facilities, Companion Global Healthcare's network includes Anadolu Medical Center in Istanbul, Turkey; umrungrad International Hospital in Bangkok, Thailand; Clinica Biblica Hospital in San Jose , Costa Rica; and Blackrock Clinic in Dublin, Ireland.
For more information about Companion Global Healthcare, call 1-800-906- 7065.
Excerpts from : Medical Tourism: Saying Goodbye to El Salvador
When I told people we were going to El Salvador their response was almost always “Why in the world would you go there?” People have the impression it’s unsafe and the last place in Central America you’d want to visit. Then, tell them you’re going for dental work and they are really baffled. Being a journalist, I’m not someone who would randomly hop on a plane and let someone pull my husband’s teeth out. I did my homework. Planet Hospital facilitated everything and thankfully got us in contact with Dr. Lorenzana. Knowing he was trained in the U.S., speaks perfect English and is an American Board Certified Prosthodontist helped us feel confident about the quality care. The Americans we’d spoken to ahead of our own decision raved about the experience and they were right.
In all my husband had three teeth pulled, seven implants, a bone graft and a sinus lift. He also has a mouth full of beautiful temporaries. The procedure took about 4 hours. He didn’t feel a thing and never had any pain. The entire process far exceeded our expectations. Dr. Lorenzana loves what he does and he loves his country. He has a real desire to let the world know what a great place it is to visit and that the quality of care really is first class.
Hard not to fall in love with the people here. They are so kind and eager to accommodate. It makes them sad and frustrated that the country still has a reputation for being unsafe, despite the war being over for more than a decade. Ricky —our host -- picked us up at the hotel and took us to Dr. Lorenzana’s office for our final visit before heading home. The doctor took all the stitches out of Doug’s mouth and gave him the final instructions for keeping his new teeth clean. He’ll need to floss and rinse with Listerine, keep his mouth healthy while the implants integrate to his bones. We’ll then come back in about five months for Doug’s permanent crowns.
It’s bittersweet to leave. In the short time we were there we made friends for life, some now are like family. I’m sold on medical tourism as a way to save a whole lot of money and get a vacation in the process. Our original estimate here in the states: 60 thousand dollars. The cost in El Salvador 19 thousand. Add a few thousand for travel expenses and we’re still saving over 30 thousand dollars. Doug’s temporary teeth look like a million bucks. We can’t wait to go back in July.
Lori Lundin is a News Anchor/Reporter with Fox News Radio
Leading Israeli Hospital, RAMBAM Healthcare Campus, Partners with IMS Global
Clarence, NY – March 10, 2008 – International Medical Services Global, Ltd. (IMS), a global healthcare firm specializing in medical tourism in Israel, has announced its partnership with the Rambam Healthcare Campus (RHCC), northern Israel’s largest medical center, pairing two of Israel’s medical tourism greats.
“IMS is dedicated to helping patients optimize their medical visit to Israel,” says Ira Nissel, founder and CEO of IMS. “This partnership with one of Israel’s top medical centers further demonstrates that this country is a prime resource for the most sophisticated and advanced medical care.”
In recent months, Israel has emerged as a quality, cost-efficient medical destination for those seeking medical care overseas. Israel’s internationally recognized medical centers have attracted thousands of visitors worldwide.
Named after Rabbi Moshe Ben-Maimon, the greatest Jewish physician of ancient times, RHCC delivers the full spectrum of healthcare services and is the exclusive provider in northern Israel for trauma treatment, oncology, neurosurgery and molecular imaging. The campus also houses the Children’s Hospital, the leading pediatric medical services provider in the northern Israel. Physicians at RHCC are leaders in their fields on an international scale, with expertise in, and access to, the most advanced medical systems.
“Rambam Healthcare Campus offers medical services for children and adults in virtually every area of healthcare,” states Yafa Perez, assistant to the director General of Rambam. "Our portfolio of services spans consultations and second opinions to a wide range of medical treatments, all delivered promptly, efficiently and with compassion for individual needs. Rambam physicians and staff ensure that all patients receive the best medical care while under our supervision.”
About IMS (www.medicaltourismforyou.com)
International Medical Services Global, Ltd. (IMS) specializes in uniquely customized medical travel to Israel. Founded in 2007 by Ira Nissel, CEO, IMS offers a full range of medical services to children and adults and provides a completely personalized treatment and travel experience.
The company also aims to advance the image of Israel as a global leader in medical treatment, research, and technological development.
El Salvador is one of the most densely populated countries in Central America. A wide mix of ethnic groups dominated largely by the Spanish and expatriate refugees, give this country its unique and rich cultural heritage. The population is friendly and welcomes tourists with open arms.
The capital city of San Salvador is the second largest city in Central America and home to approximately one-third of the country’s population and half of its wealth. The official language is Castilian Spanish but English is also widely spoken make communication quite easy. Also adding to the ease of travel there is the fact that the currency is the US dollar.
With a favorable tropical climate, temperatures do not vary too much with the seasons. The landscape is as diverse as it is spectacular; one side of the country is characterized by breathtaking jagged mountains and pristine lakes, while the other is home to beautiful beaches on the Pacific Ocean. The ancient ruins of the Mayan culture are a major tourist attraction.
Medical care at El Salvador
El Salvador is becoming one of the medical tourism hubs in Latin America. Its proximity to America is one of the prime factors fueling this industry. It can be reached within a couple of hours from any city in the US.
Countrywide modernization has also led to the establishment of state-of-the-art medical facilities and clinics across El Salvador. This country is a popular medical tourism destination for pre and post-operative medical care for cosmetic surgeries and other rehabilitative treatments.
Medical Tourism Expos Announces New Schedule
Seattle , Washington . Philip Slaton director of Medical Tourism Expos has announced the 2008 – 2009 Medical Tourism Expos schedule. Medical Tourism Expos are the only direct marketing business-to-consumer informational expos in the World today. In 2008 Medical Tourism Expos will be staged in Los Angeles ( Burbank), CA on August 22 - 24, 2008; and, in San Diego, CA on October 17 – 19, 2008. In 2009 Medical Tourism Expos will be staged in Tampa, FL; Dallas, TX; Kansas City, MO; and Atlanta, GA. Visit the website for more information on dates and locations.
The first Medical Tourism Expos event was staged in Seattle, Washington in September 2007. It drew 25 exhibitors and an astonishing 8,000 American consumers over the 2-day show. The Website was visited by some 320,000 visitors in 3-months. Visitors replied through the auto-responder on the Website and requested and received 64,000 copies of the Expos’ free Step-by-Step Medical Tourism Guide. This example of response to the only direct marketing consumer expo reinforced the point that the American consumer is very interested in medical tourism and wants to meet Medical Tourism Providers face-to-face.
The upcoming Medical Tourism Expos events in Los Angeles ( Burbank), CA and San Diego, CA, due to venue capacities, are restricted to the number of exhibit booths available. Reservations are confirmed on a first come and first paid basis. Payment is accepted by bank wire transfer and credit card. There will be a stand-by exhibitor list in the event of registration cancellations. Medical Tourism Expos boasts excellent sponsorship and advertising opportunities available. A medical Tourism provider does not have to present and exhibit at an Expo to sponsor or advertise in the Medical Tourism Expo magazine or Step-by-Step Medical Tourism Guide.
EC to Hold e-health Management Workshop
The European Commission is to hold a workshop on e-health management, organized by the ePractice.eu portal – the EC’s web service for the professional community of eGovernment, eInclusion and e-health practitioners.
The workshop will be facilitated by e-health experts and will be introduced by a high-level keynote speaker, still to be confirmed.
Three different e-health cases will be introduced briefly, before the workshop divides into three breakout sessions in which each case is explored in further detail. A number of core issues and questions will be discussed throughout the day.
Making up the three cases will be the Macro government level, centered on Britain’s NHS service, Hospital Catalonia in Spain will look at the institutional hospital level, and a separate presentation will look at the clinical to patient level, focusing on electronic patient records.
The aim of the workshop is to review IT management issues with a core focus on e-health.
It is geared to two sets of people - those with a particular interest in e-health and those with a general interest in public services and their use of information and communication technologies.
Especially welcome are health service managers and executives, public sector officials, civil servants, ICT managers, designers and implementers.
Key questions relating to e-health and IT implementation will be discussed. These are:
The event will be held in July and is free of charge. For further information and registration, please visit: http://www.epractice.eu/workshop/e-healthmanagement.
Medical Tourism Asia 2008
The agenda has been set for Medical Tourism Asia 2008. Scheduled to take place March 25-28, 2008 at the Rasa Sentosa Resort in Singapore, this year’s event will feature more than 20 respected speakers addressing a variety of topics related to the rapidly growing market. Topics addressed will include issues related to both the public and private sectors, healthcare organizations and the travel sector, potential partnerships between players such as hotel chains, property developers, airlines, insurance companies, financial institutions, and more. Medical Tourism Asia 2008 will feature leaders from Asian and International Healthcare Providers:
Seats are also on limited availability for the following exclusive site tours:
Site Tour A: Khoo Teck Puat Neuro-Navigation Integrated Operating BrainSUITE: The World's First Digitally Integrated Neuroscience Centre
Site Tour B: Visit to The National Liver Transplant Programme Facilities at National University Hospital
Take advantage of our early-bird savings today and reap the benefits of attending the ONLY medical travel event you need to attend this year. To register, please call +65 65143180 or email firstname.lastname@example.org
SIIA Schedules International Conference in Barcelona on June 10-12, 2008
The Self-Insurance Institute of America, Inc. (SIIA) has scheduled a new international conference in Barcelona, Spain on June 10-12, 2008.
SIIA's Global Self-Insurance & Alternative Risk Transfer Executive Forum will highlight self-insurance and alternative risk transfer (ART) opportunities that are emerging on multiple continents. An internationally stellar cast of business leaders will lead seminars at the Hilton Barcelona Hotel.
This new stand-alone conference comes on the heels of a successful international track of educational sessions incorporated as part of the organization's most recent National Educational Conference & Expo, held last year in Chicago.
"Alternative risk transfer including self-insurance now comprise the majority of all property-casualty and employee benefits coverage plans in the U.S. and we expect that to expand to the rest of the world," said SIIA President Dick Goff in announcing the Barcelona conference. "In addition to a splendid educational and business development opportunity, attendees will have the opportunity to explore one of the world's richest cultural and historic centers," Goff added.
SIIA's International Committee has worked to develop a seminar program that will appeal to risk managers and professional service providers throughout the world. The committee members represent seven nations in North and South America, Europe, the Middle East and Asia.
"The emergence of seamless global communications technologies have enabled us to work together as easily as if we were present in the same room," said Committee Chair Brij Sharma, CEO of Tela-Sourcing, Inc. of Baltimore, and owner of a TPA in India.
"Our objective for the Barcelona conference program was to introduce self-insurance/ART strategies and coverage concepts to people throughout the world and to provide SIIA members access to markets and service resources that are available in other countries," Sharma said. "The conference represents a true global collaboration."
Global risk management leaders that will appear at SIIA-Barcelona include the following:
For more information, visit: http://www.siia.org/files/public/ScheduleOfEvents.pdf
Attention Prospective Patients, Maryland Area
My name is David Kohn. I am a medical reporter at The Baltimore Sun. I am interested in talking with people who live in Maryland area, who are thinking about or planning to go abroad for cutting edge treatment not available in the U.S. I am especially interested in talking with people who are planning to get stem cell treatments, or other cutting edge treatments, for life-threatening diseases.
I am happy to talk to anyone, and am happy to talk "off the record" too.
Editor's Note: This newsletter is for informational purposes only and should not be construed as medical advice.