March 31, 2008

The Power of Telemedicine
By Selena Chavis
For The Record
Vol. 20 No.7 P. 14

Whether it’s providing invaluable assistance to the lone doctor on a faraway island or connecting undermanned rural hospitals with their big-city brethren, telemedicine is doing its part to boost the quality of healthcare.

A child is taken to an emergency department (ED) in a rural community where there are currently no pediatricians available for consult. The ED physician completes a patient assessment and then turns to his videoconferencing equipment to speak with a leading pediatrician in a large city two hours away.

A lone physician on a remote island located more than 1,600 miles from the mainland faces the challenges of administering quality healthcare with limited equipment and no subspecialists. Technological advances allow the physician to consult in real time with leading physicians and access the resources of a major university healthcare system.

A young girl and her brother are involved in a serious car accident. Videoconferencing technology allows the girl to attend her brother’s funeral and speak to others while she is still admitted to the intensive care unit (ICU).

These real-world examples are all part of the evolving realm of telemedicine, which many industry professionals believe is a promising field for improving accessibility, efficiency, and quality of care. Thanks to recent IT advances, there are new opportunities for patients and doctors to interact in ways that were impractical only a few years ago, according to several industry professionals. Known as telemedicine, this methodology is essentially the ability to diagnose, treat, and monitor patients’ medical conditions from remote locations.

“The potential is pretty large. … There’s so many different directions that this could go,” says Scott Harrington, MD, the medical director of the University of Pittsburgh Medical Center’s (UPMC) communications center who points to the growth of the Internet, improvements in computer software, and the advent of high-speed telecommunications networks as the factors leading to rapid growth in telemedicine. “As digital technology becomes better and better, you could see a significant increase in value.”

James P. Marcin, MD, MPH, the director of pediatric telemedicine at UC Davis Children’s Hospital Center for Health and Technology in California, agrees, noting that “the technology could transform the way we do medicine in that it will allow specialists to be available at any hospital.”

Healthcare systems are creatively implementing telemedicine to address numerous needs and realizing that these programs go a long way toward delivering better access and efficiency. “Technology should be able to address the disparities in healthcare by improving access,” Marcin says.

Extending Pediatric Expertise
An outgrowth of the Center for Health and Technology, the pediatric telemedicine program at UC Davis Children’s Hospital took a different path than the typical outpatient consulting services found in many telemedicine ventures. “It would be safe to say that it’s the first pediatric ICU telemedicine program in the country,” Marcin says.

Among other programs, the Center for Health and Technology offers one of the largest telemedicine programs in the country, covering a diverse range of specialties, including home health, acute care, teleradiology, remote monitoring, and its FamilyLink program.

In the case of the pediatric ICU program, Marcin says the need was first identified at Mercy Medical Center in Redding, approximately 160 miles north of UC Davis. He points out that the Redding facility wanted to have a pediatric ICU program but was not large enough to support one. “We started the program out of that need. They are level 2 trauma, so the need was certainly there,” he says.

After the Redding initiative, the program spread to other hospitals, making it a win-win situation for all, according to Marcin, in that it improves the quality of care and financial efficiencies for the healthcare entities involved. “The hospitals pay us to be available 24/7 and provide consults,” he says, adding that the cost is less than what the facilities would pay for a single staff person devoted to this type of program. “Financially, they benefit because they can keep [pediatric patients] in the ICU.”

Marcin says the project relies on a well-established scoring system to distinguish between children who are at a lower risk and can be safely cared for with a telemedicine critical care consult from those at a higher risk who require immediate transport to the children’s hospital.

The program has also been extended to support EDs in rural communities and inpatient programs at community hospitals where a pediatric subspecialty may be needed. “Usually, with the [EDs] we support, there are not even local pediatricians,” Marcin notes. “They may not get a lot of kids, but when they do, they need to [consult with experts].”

Facing a Remote Challenge
Before November 2007, the sole physician on the world’s most remote inhabited island had to rely on minimal technology and virtually nonexistent medical support to serve approximately 270 British citizens that call the island home. Located nearly 1,700 miles west of Cape Town, South Africa, Tristan da Cunha is only accessible by a week-long boat trip.

“The access is very restricted to the island,” Harrington says, pointing out that, fortunately, it is served by a capable physician—Carel Van der Merwe, MD. “My hat’s really off to Dr. Van der Merwe for being willing to practice in such a challenging market.”

Working from a hospital without even its own telephone to provide care for patients, Van der Merwe at one time performed life-saving diagnoses and procedures without proper equipment or specialized expertise. He also lacked a communications system that could accept e-mail attachments and had to scan and fax digital images to specialists thousands of miles away, often causing significant delays in diagnosing patients.

Last November, IBM and Beacon Equity Partners joined Medweb and UPMC to implement Project Tristan to deliver a pro-bono remote medical solution combining medical equipment, satellite communications, and remotely supported electronic health record technology. Harrington notes that UPMC was a natural choice for the program because its communications center was already fully functioning and contracted to provide similar consultations to airlines when passengers have heart attacks or other medical emergencies in flight.

“Dr. Van der Merwe has the ability to contact us by phone for consult,” Harrington says, adding that the center accepts x-rays, electrocardiograms, pulmonary function tests, and other digital images from the island. “In the communications center, we have an emergency services physician available at all times. We can facilitate getting him in touch with a subspecialist if need be.”

Harrington points to technology breakthroughs as a catalyst for improved global healthcare. “From a technology standpoint, he [Van der Merwe] can get information on an x-ray in the same manner as the patient down the hall,” he says.

Harrington also suggests that telemedicine could improve care during emergencies where physicians are able to access patient information immediately from an ambulance as opposed to talking with emergency medical technicians by radio.

Serving the Underserved
Following the success achieved through a grant-funded telemedicine program for dementia screenings in the late ‘90s, Saint Luke’s Health System in Kansas City, Mo., sought ways to improve access within its own system, which encompasses 11 hospitals and several primary care clinics. Steve Kropp, Saint Luke’s director of outreach services in telehealth, recalls that a number of its rural facilities were facing issues when it came to recruiting needed subspecialties to their various regions. “Once we realized that we had specialists no longer willing to drive to outlying areas, we knew we had to figure out a way to provide those services,” he says.

The answer was the establishment of four regional telemedicine centers serving cardiology, pulmonary, psychiatric, and neurology needs. “Each one of those programs is extremely busy,” Kropp says. “Two years later, we are looking at adding dermatology and [ear, nose, and throat].”

Looking at statistics from 2006 and part of 2007, Kropp suggests that the telemedicine venture has saved individuals in just two of the outlying regions $40,000 in transport costs alone.

Based on the venture’s success, Kropp says Saint Luke’s is gearing up to extend the program outside of its own network. “The biggest opportunity is to [implement the program] through the state networks that are beginning to form,” he says, adding that these programs will allow the organization to provide telemedicine on the existing state networks.

Kropp says the healthcare field is also becoming more at ease with telemedicine’s growth. “Reimbursement has been an issue,” he says, noting that until recently, only Medicare and Medicaid would reimburse for telemedicine. “Some states are now mandating [telemedicine use], and some private insurance groups are stepping up.”

As reimbursement issues become less of a barrier, Kropp believes the healthcare industry will see an explosion of telemedicine programs for specialty services and home health. “It would keep [home health] patients from going to a doctor’s office and home health from having to go to them for every visit,” he says. “It will allow them to age in place.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.

Connecting Patients With Peers
Telemedicine experts are quick to point to the technology’s broad potential and applications as it relates to many facets of medicine. Consider the story of 15-year-old Crystal Rippetoe, who benefited from the Center for Health and Technology’s FamilyLink program at UC Davis Children’s Hospital.

Following a serious injury due to a 2005 car accident, Rippetoe was hospitalized for several months, according to James P. Marcin, MD, MPH, the center’s director of pediatric medicine. “One of the things she voiced was that she missed her classmates,” he recalls.

During her stay, the FamilyLink program enabled Rippetoe to talk with her classmates at Trinity High School during their lunch hour. FamilyLink uses a camera, phone, and television connection to let families and friends at home see and talk with loved ones in a hospital room. The center’s staff send a video unit to a home—or in this case a classroom—and set up a similar device at the patient’s bedside.

As a nice amenity, the telemedicine program manager also enlisted the services of a volunteer makeup artist who helped Rippetoe look her best on camera when she appeared before her peers.

According to Marcin, FamilyLink was the brainchild of UC Davis Medical Center staff who noticed that previously used video and telephone equipment could offer an easy and inexpensive way to connect patients with their families anywhere in California.

— SC

Looking Deeper
“Convenient Care and Telemedicine,” a new report from the National Center for Policy Analysis, says the technology can remedy a number of problems facing the healthcare industry. The report details how telemedicine “brings a new dimension to 21st century healthcare” by addressing the following inherent issues:

It can be difficult to meet with a doctor. As many as one in three people has trouble seeing his or her primary care physician, and nearly one in four has problems taking time from work to see a doctor.

Patients have trouble contacting physicians by telephone or e-mail. Although lawyers and other professionals routinely consult with their clients by telephone and e-mail, few doctors will consult by telephone, and less than one in four communicates with patients electronically.

There are not enough doctors in rural areas. Compared with metropolitan areas, there are fewer physicians serving rural patients, who also face the burden of having to travel farther for office visits.

Patients overuse emergency departments (EDs). Because their primary care physicians are inaccessible by telephone or after hours, many patients turn to hospital EDs. More than one half of all ED visits are for nonemergency health problems.

Patients have difficulty getting information during office visits. More than one third of physicians do not have the time to deliver enough information to their patients during office visits, and 60% of patients later say they forgot to ask questions during their visits.

Care is often fragmented. Because most patients see a number of physicians over time, physicians must frequently treat patients with inadequate information.

The chronically ill are not well served. More than 125 million Americans have chronic medical conditions, but most are not receiving appropriate care, in part because monitoring is complex and expensive.

— SC