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Telemedicine connects remote areas with care

From the April ACP Internist, copyright © 2008 by the American College of Physicians.

By Stacey Butterfield

A young mother living on a remote island off the coast of Maine has postpartum depression.

A prison inmate in Texas requires follow up for recent knee surgery.

A very sick adolescent arrives at a hospital on Christmas Day when no pediatric specialists are on duty.

In the past, these patients might have had to travel long distances to access the care they required, delaying and potentially threatening their recovery. But thanks to modern technology all of these patients received telemedical care, a rapidly growing area of medicine that is dramatically changing health care delivery, especially in remote locations.

Telemedicine connects remote areas with careTelemedicine encompasses medical technology ranging from electronic health records to e-mails between patients and doctors. But some of the most interesting advances in the field today use two-way live video connections.

In one such case, a small clinic in Northern California used its telemedicine connection to connect a severely burned child with a major burn hospital. Before the technology, the parents would have had to drive two hours to a hospital in Sacramento. Instead the local physicians dialed up the video connection for an expert consult.

“We brought in our burn surgeon, she guided the ER staff through the whole procedure, and it went so well that they didn’t even need to bring the child in until the next day,” said Daniel A. Kurywchak, a consultant who has set up telemedicine systems for consultations ranging from children injured by cluster bombs in Lebanon to a Brazilian clinic that treats everything from leprosy to trauma 18 hours away from the nearest hospital.

With video technology, physicians now can see patients, as well as listen to their hearts and lungs or look in their ears, noses and mouths from anywhere in the world. The technology’s potential applications are almost endless, and research is ongoing about its effects on quality of care and satisfaction.

Technology’s long reach

The most common uses of telemedicine so far include care for rural patients and prison inmates, and subspecialty consultations, particularly in dermatology and psychiatry, experts say. In some cases, such as those involving psychotherapy, patients prefer being treated via video connection, said Mr. Kurywchak, who has set up telemedicine units in small-town primary care clinics that allow patients to receive therapy remotely.

“I felt embarrassed going to these towns and talking people into divulging their deepest, darkest secrets over video,” he said. But it turned out that the patients actually preferred the video visits, because they knew there was no risk of a neighbor seeing their car parked outside a psychiatrist’s office or running into the therapist at the grocery store.

The rural doctors also liked the arrangement, he said. When telemedicine is used for psychiatry, the on-site provider just sets up the equipment and collects a facility fee, but in many specialty consultations, the primary care physician participates in the consultation.

Using a handheld camera or a scope connected to the computer, the generalist presents the patient’s problem to the distant specialist and then participates in a three-way discussion of the diagnosis and treatment.

“While they’re doing the procedure, the specialist is treating the patient but also providing distance education to the rural doctors at the same time,” said Mr. Kurywchak. “Most physicians in rural areas that I’ve met with say, ‘Thank God, because I don’t have anybody to bounce ideas off of.’”

There are also benefits for the specialist on the other end, said James Marcin, MD, an associate professor of pediatric critical care and director of pediatric telemedicine at the University of California, Davis Children’s Hospital.

He and his colleagues provide their expertise to a number of smaller hospitals, even dialing in sometimes from their homes (as in the case of the sick child on Christmas). “We build partnerships with remote hospitals and clinics. We provide a service that improves quality of care and we can benefit at the same time by getting their referrals that might be profitable to the hospital,” he said.

He has, of course, also provided consultations over the phone, and he believes that the visual aspect of telemedicine does add value. “We’ve done some video studies and you get to realize that seeing a patient is worth 1,000 words,” he said. In the case on Christmas Day, for example, he was able to advise on-site physicians about ventilator adjustments based on the movement of the patient’s chest.

Locations and applications

Christy Calderon, MD, a family physician with Kaiser Permanente in Whittier, Calif., has found telemedicine to be less of an improvement over telephone medicine, but that may be due in part to the technology to which she and her patients have access.

Inspired by a patient who got an Internet connection to chat with her distant granddaughter, her practice is using standard computer webcams to conduct virtual house calls. Dr. Calderon’s pilot project is atypical in that the patient is alone on the opposite end of the connection. (Most telemedicine programs have a nurse or other allied health professional with the patient, if not a referring physician.)

The technique works best for patients with chronic conditions who need quick and simple follow-up visits to discuss lab results or medication management. “You can do a lot of visits over the phone, and the webcam adds a more personal touch,” said Dr. Calderon. However, the poor picture quality of the webcam connection means that the image doesn’t provide much extra clinical value, she added.

Most telemedicine programs use direct high-speed connections rather than the Internet and benefit from the clearer, more reliable video, explained Mr. Kurywchak. Extra tools can also make the telemedicine units more useful. In addition to a universal coupler that can attach to almost any kind of endoscope, some set-ups give physicians the capability to remotely control the camera on the patient’s end.

“If you’ve got a patient coding, you can’t stop and tell the clinicians, ‘Please move the video camera. I can’t see that monitor,’” he explained.

Obviously, Dr. Calderon’s homebound patients aren’t going to spend thousands of dollars on elaborate telemedicine units, but treatment of elderly patients with mobility issues may be a promising avenue for telemedicine.

Debbie Voyles is the director of telemedicine at Texas Tech University Health Sciences Center, which provides telemedicine care for thousands of prison inmates and residents of rural areas of Texas. Rural nursing homes and assisted living facilities—many located in counties without a single doctor—seemed like an obvious application of the technology, she said.

“The nursing home residents have to be stuck in an ambulance and driven to Lubbock just to be seen for a primary care visit. The entire county may only have one ambulance, so if that ambulance is bringing a patient and somebody happens to have a wreck, there’s no EMS there to take care of them.”

The nursing home patients were definitely on-board with the idea. (“I have little old ladies getting dressed up because they’re going to be on TV,” said Ms. Voyles.)

Who will pay?

The problem which prevented Ms. Voyle’s program from getting off the ground was reimbursement.

With some stipulations, Medicare reimburses telemedicine consultations, particularly in rural areas, but payments vary widely from state to state. “Texas Medicaid right now says that you have to have a physician or a nurse practitioner presenting the patient back to the specialist. If these communities had a medical doctor, they wouldn’t need telemedicine,” Ms. Voyles said.

All of the interviewed experts listed reimbursement as the biggest hurdle to implementation. “The No. 1 thing to get providers enthused and energized about the technology is to improve the current reimbursement. … Movement has been glacial but it seems to be accelerating here in the last several months,” said Oscar Boultinghouse, MD, associate director and chief medical officer of the University of Texas Medical Branch’s (UTMB) electronic health network.

Progress on reimbursement also seems to be moving from west to east across the country, with California leading the way, noted Mr. Kurywchak.

Medical licensure is another issue. Connecting via telemedicine with another facility in the same state is no problem, but to consult across state lines, you have to be licensed in both. “That’s a minor irritant. State medical boards are working on it,” said Jonathan D. Linkous, executive director of the American Telemedicine Association.

Liability coverage had been a concern, but is becoming less so, according to Dr. Boultinghouse. “Increasing numbers of medical malpractice insurers are willing to cover telemedicine activities,” he said.

Decreasing costs and increasing portability in the required technology should also drive greater adoption, the experts said. “In years past, it had to be bulky carts and over $100,000. Now you’re talking about $10,000 to $15,000 and as portable as you want,” said Mr. Kurywchak.

Stronger evidence for both the clinical results and the cost-effectiveness should also help the technology come into the mainstream. Dr. Marcin is currently conducting research on telemedicine’s effect on patient satisfaction, provider satisfaction and quality of care. “All of us that do telemedicine have anecdotal stories of incredible cases where the ability to see the patient has made a huge difference, but it’s very difficult to quantify that scientifically,” he said.

Researchers at the University of Texas are looking at the potential cost-effectiveness of a national rollout. “The cost to equip all emergency rooms with telehealth technology could easily be covered by the savings in a reduction in transfers between emergency departments,” said Alexander Vo, PhD, executive director of UTMB’s AT&T Center for Telehealth Research and Policy. Cost savings from securely transporting prison inmates and nursing home residents would also make implementation in those locations worthwhile, he added.

For a practice, the efficiencies of telemedicine compared to an office visit seem obvious, said John E. Mattison, MD, chief medical information officer for Kaiser Permanente. “They don’t have to check in. They don’t have to be roomed. They don’t have to go through the checkout encounter. That should not only save the patient time and effort but it would probably impact cost as well.”

For now, Kaiser is exploring those possibilities with a one-practice pilot, but Dr. Calderon has bigger dreams for someday providing remote care to large employers, like school districts. “Eventually down the line maybe what we can do is put a webcam in the school. And patients that are Kaiser members will be able to access their physician via the webcam without having to leave work,” she said.

Dr. Boultinghouse is imagining even wider prevalence for the technologies of telemedicine. “We would like people to have ready access to care, whether that be at home, at their workplace, on their handheld, wherever they have the bandwidth to support video,” he said.

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Remote island communities rely on floating telemedicine units to access care
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The Atlantic Ocean may seem like a strange place to find the future of medicine, but that’s where Sharon Daley, RN, is using cutting-edge technology to bring care to some very underserved patients. Ms. Daley’s office is on a 75-foot boat that cruises among four small islands off the Maine coast (Frenchboro, Matinicus, Swans and Isle au Haut) which are otherwise accessible only by a weekly, or in one case, monthly ferry. The islands, on which the main industry is lobstering, are home to about 65 to 70 people each and have no resident physicians.

Through Ms. Daley and her on-board telemedicine unit, island residents are able to connect with health care providers on the mainland, including family physicians, specialists and counselors. The boat, called the Sunbeam, visits each island twice a month, and islanders who want medical care make appointments ahead of time directly with their practitioners.

At the appointment, Ms. Daley goes through the usual check-in routine (she has intake forms for each of the providers that she works with), faxes any necessary information to the office, and dials up the doctor on-screen. In addition to video conferencing which allows the physician and patient to see and hear each other, the Sunbeam’s telemedicine unit has a stethoscope and an otoscope which transmit sounds and images to the remote doctor.

“Obviously, the limitation is the provider not being able to touch the patient, so I end up being the hands,” said Ms. Daley. She can also give blood tests, do strep screening, check oxygen levels, and conduct other basic labs.

“Actually in the very beginning, patients are more comfortable with it than providers,” she said. “In the beginning, physicians feel uncomfortable. It just feels odd that they’re not in the same room with the patient.”

A large part of her work is follow-up for chronic conditions like diabetes or hypertension, but she also does general primary care. “I always say if you’re lucky enough to have an earache on the day I’m out there, we do that, too,” she said.

Of course, in some cases, it turns out that patients need to see a doctor in person, but for those whose problems can be treated remotely, the program is a major time and money saver. “In order to see the physician they have to take the ferry off and spend the night off. There’s the expense of the medical care, the ferry boat, the hotel room and food. Being able to come down to the boat and not have to miss a day of lobstering or being the teacher at the school is a big advantage,” said Ms. Daley.

The cost of a telemedicine visit is the same for the patients as it would be on land. The providers’ offices take the patients’ insurance information and bill insurers for telemedicine consultations.

Ms. Daley’s salary and the boat’s operating expenses are covered by the Maine Seacoast Mission, a charitable organization that has been providing services to islanders for more than 100 years. In the 1930s and 1940s, the mission placed Red Cross nurses on the islands, said executive director Gary A. DeLong. They decided to update the program after learning about federal grants for telehealth initiatives in rural areas.

One challenge was finding providers willing to work in such an unusual way. “They were physicians who were intrigued by it and saw it as a kind of adventure. The ones that were most successful were the physicians who already had a number of islanders as patients and wanted to serve them better,” said Mr. DeLong.

The biggest challenge for Ms. Daley is scheduling, which requires her to take into account the calendars of multiple physicians’ offices, the Sunbeam (which has other projects) and the tides. “I can have it all set up and then the wind blows, and I have to cancel it,” she said.

So far, the wind seems to be blowing all good for Sunbeam Island Health Services. The Veterans Administration is looking into offering care for the islands’ veterans through telemedicine and the mission is working on expanding the program to have a 24/7 presence on some of the islands.

A telemedicine unit would be permanently set up in a clinic, and an emergency medical technician trained to use it. The unit could then be used for emergency care, as well as patient education and even Alcoholics Anonymous meetings.

“Two guys on an island have been having an [AA] meeting for 20 years and saying, ‘Hey Jim, I’m an alcoholic.’ Whereupon his longtime friend replies, ‘Yeah, I know that,’” joked Mr. DeLong. “We try to link them to people who are working on their sobriety on other islands.”

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