In 1837, Oliver Wendell Holmes, MD, returned from medical studies in Paris and urged his fellow American physicians to increase their use of stethoscopes. In just three short years, without benefit of the Internet, personal digital assistants, e-mail, or telephones, American physicians accepted the first protocol for distance medicine by adopting stethoscopes as a standard diagnostic procedure.

Nearly 175 years later, telehealth has become another catalyst for change.

“Orthodox medicine does not recognize the next stage of distance medicine, and it’s an issue whose time has come,” says David J. Brailer, MD, PhD, National Coordinator for Health Information Technology. “For some time, radiologists have not been in the same room with the patient or physician to provide conclusive and effective test results. I reject the notion that a doctor and patient have to be in the same place to deliver safe and effective care. Patients shouldn’t have to suffer because they are in an underserved or rural area. We’re saving lives through remote ICUs.”

In 1994, the FDA approved the first robotic surgical device for experimental use, and in doing so created a new field that has, until recently, defined the look and feel of telemedicine.

Distance Medicine Now Showing
“There is a lot of water and farmland between us and the people we serve,” says Scott Simmons, assistant director, The Telemedicine Center at the Center for Health Sciences Communication at East Carolina University (ECU) in Greenville, N.C. Simmons has a degree in biomedical engineering and came from NASA to accept a leadership position at ECU. With 13 years of experience in telemedicine, the staff at ECU’s Telemedicine Center is appreciative of the nation’s reinvigorated move toward distance medicine.

The ECU telemedicine (TM) center consists of four practice suites that rotate specializations. Connected to patients via sophisticated teleconferencing and medical equipment, physicians provide real-time services to treat patients with asthma, diabetes, hypertension, congestive heart failure, ear infections, allergies, and skin problems.

The TM center reaches out to residents living in the eastern agricultural regions, coastal plains, and Outer Banks areas of eastern North Carolina. The area encompasses 41 counties, some with fewer than five physicians. Irrespective of socioeconomic level, a trip to the hospital to see a specialist means up to a 100-mile drive to Greenville or across the state line to Virginia.

Using cameras to connect patient with physician, a patient comes to a local health facility and is examined by a remote telemedicine coordinator (RTC), usually an RN, who is also trained in operating special video instruments. Sitting in a video suite at the TM center, a physician manages the patient exam through a monitor.

“It doesn’t take the physicians more than one or two visits to get used to seeing their patients through the telemedicine system,” Simmons says. Patients readily adapt to telemedicine, supported by ECU’s patient satisfaction studies that demonstrate patients are highly satisfied with their telemedicine experiences.

“Following the exam, we report the findings to a referring physician, if applicable, and keep an electronic record of the encounter,” Simmons says. “We’re still faxing the reports to the primary care physician, but we see a time when we’ll be electronically exchanging those records.

“We’re a cost center for the ECU Brody School of Medicine’s clinical practice and Pitt County Memorial Hospital, the school’s teaching hospital, but it’s an investment the university stands behind because of the outreach we bring to the community. When patients are satisfied with our service, they are more likely to come into the hospital when in-patient care is required.”

When the TM center is not scheduled for distance medicine, it doubles as a center for distance learning. “The technical principles are basically the same,” Simmons explains.

In West Virginia, Mountaineer Doctor Television (MDTV), provided by the Robert C. Byrd Health Sciences Center of West Virginia University (WVU) in Morgantown and the Charleston Area Medical Center/WVU campus, is similar to a long-distance call for medical care. Telecommunication technologies support community health education, continuing education for health professionals, and clinical applications.

“We move data, not patients, until it is the right time,” says Julian Bailes, MD, chairman department of neurosurgery, WVU in Morgantown. “Our telemedicine program has resulted in a $500,000 annual savings with the largest portion due to avoiding unnecessary patient transfers.”

When MDTV is not in use for clinical consultations, it can be used for continuing education and community health education for health professionals and clinical applications. However, clinical consultations take priority over all educational offerings and administrative teleconferences. The consultations are available 24/7 through Morgantown and during business hours at the Charleston location and include almost every specialty. (Dermatology, rheumatology, neurology, and ear, nose, and throat are the most requested.)

Is Telehealth in Your Future?
Jonathan Linkous, executive director of the American Telemedicine Association in Washington, D.C., says the number of telemedicine centers hasn’t grown much beyond 200 regional networks. “But the number of local clinics connecting to the host hospital is where we’re seeing the most growth, up from 2,000 four years ago to about 3,500 sites today,” he says. “It’s become an excellent resource for patient retention, especially for rural hospitals that don’t want to lose their patients to major institutions.”

Linkous adds that the host hospital’s return on investment is evident in patient and physician loyalty when patients need the more specialized care once only available in larger institutions.

“The best news is for consumers wanting to manage their health and for employers managing health costs,” he adds. An RTC at an employer’s location is an effective way to provide on-site care for employees, if appropriate privacy and security measures are in place and utilized.

“We’re also seeing a decrease in mitigation than once anticipated,” Linkous says. “The encounter is better documented and saved.” This could be a real plus for employers requiring documentation for worker’s compensation claims.

Costs to start a telemedicine center are a fraction of what they used to be, Simmons reports. Videoconferencing hardware that used to cost $50,000 to $75,000 is now available for less than $8,000. “Bandwidth is becoming less an issue even in most of the rural areas we service due to broadband Internet,” he says.

Medical peripherals to consider include the following:

• Otoscope system: $10,000;

• Stethoscope (send site): $4,000; and

• Stethoscope (receive site): $6,500.

Other expenses from the hub site include the following:

• teleconference center;

• videoconferencing bridging system;

• scheduling system;

• network equipment and management tools; and

• security equipment and tools.

Human resources costs usually include the following:

Local site

• site coordinator;

• scheduling coordinator (may be the same as site coordinator); and

• trained technician.

Hub site

• administration;

• clinical coordinator;

• training staff; and

• technician.

An excellent guide to funding telehealth is available from the Office for the Advancement of Telehealth at http://telehealth.hrsa.gov/grants/funds.htm. The site provides additional links to organizations that describe funding availability. With costs dropping and broadband expanding, telemedicine has caught the attention of investors, especially since telehealth services are reimbursable.

Growth Market
According to Simmons and Linkous, telemedicine and telehealth services rank in the top three emerging market areas, and it’s no longer limited to large companies such as GE Healthcare, Siemens, and Hewlett Packard. Telemedicine, when combined with the distance-learning infrastructure already in place at most academic medical centers, is showing up in some unexpected places.

Outsourced Telehealth Consultations
Offshore private contractors—quick adopters of telehealth—are starting to secure contracts with large businesses to provide after-hours healthcare services as part of an employee benefit package. Offshore services are not well accepted by providers who are likely to turn over a piece of their business to overseas contracting of information technology services. The potential savings from urgent care visits, coupled with late-night consultation, may ease the shortage of healthcare workers. Privacy and security concerns remain significant with offshore healthcare contractors.

Home Health Video Treatment
Home video monitoring continues to grow, particularly among the Internet-savvy aging population that aggressively defends its independence. Privacy and security concerns can be addressed as hospitals extend the quality of safety and care.
The single largest user of telemedicine in the government is the Department of Veterans Affairs. “Its ambitious home healthcare project and the use of telemedicine for the population receiving direct services from the government is increasing,” Linkous says.

— Carolyn P. Hartley is president and CEO of Physicians EHR, LLC, located in Cary, N.C., and can be reached at Carolyn@physiciansehr.com.

American Telemedicine Association
http://www.atmeda.org

Link to Medicare Telehealth Services
http://www.cms.hhs.gov/manuals/pm_trans/R31BP.pdf

Office for the Advancement of Telehealth
http://telehealth.hrsa.gov/grants/funds.htm