April 2, 2007

Telemedicine: Healthcare Goes Anywhere
By Mary Anne Gates
For The Record
Vol. 19 No. 7 P. 18

From Alaska to Texas, telemedicine programs reach out to patients who have limited access to vital services.

Determining the best way to provide prompt medical attention coupled with saving time and money is critical to deliver quality patient care. It is the essence of this attitude that helps define where telemedicine fits in today’s healthcare system.

“Medical need and vision for where the organization wants to go drives the need for telemedicine. It is not about the technology,” says Joe Kvedar, MD, director of the Center for Connected Health in Boston.

For example, there are well-documented cases of chronic and acute ear diseases among approximately 150,000 native Alaskans served by the Alaska Native Medical Center (ANMC) in Anchorage, says John Kokesh, MD, of ANMC’s ear nose and throat (ENT)/otolaryngology department. Several factors, including genetics, an increased proximity to wood smoke, and other living conditions, may contribute to the prevalence of ear diseases in native Alaskans, he says.

More than 50% of ANMC patients live in small towns or remote villages with little access to medical services. Because there are no roads in or out of many areas, costly air travel is often the only way to see a doctor who is usually hours and sometimes hundreds of miles away. Native Alaskans who couldn’t afford air travel or couldn’t travel for other reasons often delayed seeking treatment.

Conversely, doctors traveling to remote areas were faced with the same dangers and high travel costs plus a time-consuming commute that could have been spent seeing patients. “We could never travel enough to see patients in all the remote areas they live in,” says Kokesh.

Realizing the need for more accessible healthcare, Kokesh partnered with the Alaska Federal Healthcare Access Network (AFHCAN). Together, they started with the technology at hand—satellite transmission capability and video otoscopes, Kokesh says. “We’ve really kind of found our own way matching our patients’ needs with what was available from a technology standpoint,” he says.

Alaska Isn’t Alone…
At the other end of the country, Texas also has residents who were cut off from adequate medical care before telemedicine’s arrival. For example, West Texas covers approximately 131,000 square miles over 108 counties. Additionally, some counties classified as “frontier” may have only one person for every seven square miles, according to Don McBeath, managing director of telemedicine and rural health at Texas Tech University in Lubbock.

“We have counties in this area that have more cows than people. It’s not unusual for people to travel 30 or 40 miles for primary healthcare,” McBeath says. “For specialty care, a patient may have to travel more than 130 or 140 miles for treatment. Our interest in telemedicine is how to best use it where it is most effective. We do that by using telemedicine as part of our outreach program, which includes serving an indigent population that cannot afford healthcare and West Texas residents who live in an area where healthcare is not readily available.”

Telemedicine Technology
There is no agreement on an exact definition of telemedicine covering the full range of technological capabilities. However, in the simplest terms, telemedicine (also called telehealth and sometimes e-health) is defined as the delivery of data, images, and sound-enabling medical practitioners to provide diagnosis and options for medical care at a distance. Transmission of medical data can be accomplished via telephone, computer, fax, or interactive video.

Two types of telemedicine systems are real-time, or synchronous, applications and a store-and-forward, or asynchronous, method of delivery.

A real-time system links participants at the same time for the purpose of delivering healthcare. This could be something as common as two doctors discussing treatment options via telephone to something more interactive between a doctor and patient that includes video or other imaging transfer. Specialized software, exam cameras, peripheral devices, such as otoscopes, and other standard medical devices designed for use in the transmission of patient data yoke doctor and patient as if they were in the same room.

A store-and-forward system does not require participants to be linked at the same time. Using such a system allows medically trained professionals to gather patient information, including medical history, images, and other pertinent data, before sending it to a doctor or specialist for diagnosis and recommendations about treatment at a later time.

A combination of both delivery systems can be used to obtain the most efficient use of equipment and personnel. “Physicians need to be sure the systems provide for a true-to-life experience, both from video and audio, so whether they are conducting patient consultations, holding research meetings with peers, diagnosing ailments, or performing surgeries, the participants should feel like they are actually in the same room even if they are miles apart,” says Karoline McLaughlin, director of corporate marketing at LifeSize Communications, a high-definition video communications company in Austin, Tex.

Treating Native Alaskans
Since the program’s launch in 1999, Kokesh says the number of patients seen via telemedicine has grown steadily each year. He estimates the otolaryngology department will treat at least 2,000 patients this year.

“It started really small with a lot of otoscopes and saying [to each other], ‘Do you think we can use this?’ We took hundreds of pictures of each other’s ears to determine if treatment via telemedicine was possible. We wanted to see if the video otoscopes would work for the problems we were seeing,” he explains.

That cautious start changed the way otolaryngology is practiced in Alaska. Today, a patient can go directly to the audiologist, who compiles patient history, uses a video-otoscope to take pictures of the ear, then sends the information to the ENT, who diagnoses the problem and prescribes treatment.

In remote areas where an audiologist is not available, community health aide/practitioners are trained to collect all patient data and images necessary to submit cases for review using a mobile workstation called an AFHCAN cart.

“Before telemedicine, we would fly out to very remote villages once or twice a year, maybe three times a year,” says Phil Hofstetter, an audiologist at Norton Sound Regional Health Corporation in Nome, Alaska. “Access to healthcare was very low. A patient could wait nine months to a year for evaluation and treatment. I couldn’t believe how long patients had to wait. It was disturbing to me.

“It’s amazing; with telemedicine we get a response within 24 hours. Overnight, we are able to get access to consults and prescribed treatments. It’s sort of cutting-edge and a new frontier in audiology. We are constantly learning something every day,” he adds.

He acknowledges that surgeries, MRIs, and CT scans still require patients to travel to Anchorage.

Hofstetter says a typical ENT treatment cycle begins with a visit to a primary care physician, who may refer the patient to an audiologist, who will also examine the patient, then make the referral to an ENT specialist.

“Here, [in telemedicine] the roles are almost reversed. We are acting more like a primary care provider,” he says. “We are the first person to see the patient. We set up the case and send it to the ENT. We are learning a lot more in that process. We are changing the audiology description of what we do.”

Texas Telemedicine
A demonstration grant in 1989 from Health and Human Services’ Office of Rural Health Policy launched the telemedicine program at Texas Tech Health Sciences Center. The system, called HealthNet, links the four Texas Tech campuses and reaches out to the medically underserved throughout West Texas.

For example, burn victims in the El Paso area no longer have to endure the nearly six-hour drive to Lubbock for a 30-minute consultation. A telemedicine exam camera allows the doctor to get a close-up of the burn and make treatment recommendations. The physician can order special compression garments to help the burn heal or suggest range-of-motion exercises during recovery.

“It’s basically allowing the patient to stay in the community and receive all the healthcare they can,” says Debbie Voyles, assistant director of telemedicine at Texas Tech.

McBeath seems prepared for any limitations or deficiencies healthcare users of the telemedicine system believe they encounter. “We charge physicians not to change the way they practice medicine to accommodate telemedicine technology. If they are not certain and need to see a patient in the office, it is not a condemnation of telemedicine,” he says.

“If telemedicine wasn’t available, [patients] would have to travel anyway,” McBeath adds.

Advantages
Spending less time and money traveling for both patient and physician are benefits of a telemedicine program, says Kokesh. Seeing more patients who receive treatment sooner is also an obvious improvement. Whether it is an initial consultation with an ENT or a follow-up for tympanostomy tube placement, telemedicine makes life simpler for everyone involved.

Besides reducing costs and wait times for treatment, telemedicine brings order to triage, a basic component of finding and treating more severe problems first.

“It allows us to kind of triage to deal with everyone’s problems in a timely manner. With telemedicine, we can see who has the most severe problems and needs treatment right away and who has less serious problems that can be seen at a regular appointment,” says Kokesh.

Patient education has also improved. When before-and-after pictures are taken of the tympanic membrane or middle ear, patients have a better understanding of the problem and why certain treatments are prescribed and others are not. Additionally, a patient who has a better understanding of his or her condition seems to have an increased compliance with postoperative care instructions.

Finally, if a patient cancels an office visit at the last minute, the physician can spend that unexpected down time reviewing telemedicine cases, says Kokesh.

Disadvantages
Kokesh sees only one disadvantage to telemedicine—perhaps it might best be called too much of a good thing.

“It’s really hard to match your capacity to do telemedicine with what can be an unpredictable growth rate,” he notes. “When we started, we had two to three cases a week. Now, we have 80 to 90 cases a week.”

McBeath cites the difficulty of reimbursement as a major obstacle to the growth and development of the Texas Tech program.

Reimbursement
Several questions surrounding reimbursement for telemedicine services have hindered their growth, according to Kvedar. Questions include what needs are being met and who is going to pay the bill.

If it’s private pay, Kvedar says, then it’s going to be like any other entrepreneurial effort: “What do the customers want?”

If it’s Medicaid, then it becomes a matter of going to a government agency and convincing it that telemedicine will save money. Pointing out the savings on ambulance rides when telemedicine is in place can be a convincing argument, says Kvedar.

With any new program or technology such as telemedicine, economical models are not always apparent on the surface. You need to find value. Patients can get medical attention by merely turning on a screen and talking to their doctor face to face. As costs are addressed and savings are recognized, reimbursement issues associated with new ways of practicing medicine begin to disappear, Kvedar says.

Kokesh estimates Medicaid reimbursement in Alaska saves approximately $7 in travel costs for every dollar spent on telemedicine. For example, a telemedicine consult for an ANMC patient may have a Medicaid reimbursement range between $40 and $200. On the other hand, a child with an adult escort could cost Medicaid between $200 and $800 for travel, not counting the face-to-face office visit.

Texas has had a different experience with reimbursement. While acknowledging there has been progress in researching viable pilot telemedicine projects, McBeath says the Texas Tech program has not been successful in maintaining active sites due to reimbursement issues.

Validating Telemedicine
As with any new technology in medicine, a comparison of the new and old ways of performing a procedure will occur. A study comparing an in-person examination and video-otoscope imaging for tympanostomy tube follow-up found a high concordance between in-person exams and video-otoscope still images. “Concordance between our own exams and telemedicine was good,” says Kokesh.

Despite apparent confidence in the quality and reliability of telemedicine images for tympanostomy, only a slight majority of physicians regard telemedicine consultations as good or better than seeing the patient in person. This finding appears to indicate that while the technology is available to produce quality images, some physicians are unenthusiastic about incorporating the technology into their practice.

Making Telemedicine Work
Proper training in the use of telemedicine is critical to its success, says Kvedar. Often, healthcare workers are not fond of workflow changes. They may believe their job is in jeopardy or they may not know how to do their new job, he says.

Hofstetter is adamant that, when done correctly, telemedicine works. But, he cautions that everyone must embrace and learn how to use it correctly. “If you don’t believe in it, [telemedicine] doesn’t work. If they aren’t using it properly, it isn’t going to work either. It’s our collaboration and the technology that make this work,” he says.

He also stresses the importance of incorporating it into the daily routine of healthcare like any other medical procedure. “It’s the provider being open to the technology and using it that makes it effective,” says Hofstetter.

Kokesh agrees and has incorporated telemedicine into ANMC’s routine. Even what may have been considered free time or down time between appointments for the on-call physician is now spent at a computer reviewing patient cases that were prepared remotely by an on-site audiologist or another healthcare worker. The otolaryngology department’s goal is to respond to all telemedicine cases within 24 hours.

“Everyone wants to take care of their patients, and they soon realize this approach increases the quality of care,” says Kvedar.

“Telemedicine is a tool in the tool kit that can be used to increase healthcare services,” McBeath adds.

— Mary Anne Gates is a medical writer based in the Chicago area.

Resources
Kokesh J, Ferguson AS, Patricoski C. Telehealth in Alaska: Delivery of health care services from a specialist’s perspective. Int J Circumpolar Health. 2004;63(4):387-400.
Patricoski C, Kokesh J, Ferguson AS, et al. A comparison of in-person examination and video-otoscope imaging for tympanostomy tube follow-up. Telemed J E Health. 2003;9(4):331-344.

www.afhcan.org/news/default.aspx
www.amdtelemedicine.com/faqs.cfm
www.cpa.state.tx.us/tpr/tpr4/c2.hhs/c214.html