Telemedicine
Whitley Anders, Krystina Beattie, Joshua Gaby, Dustin Jonas, & Sarah Sullivan
University of Texas at Arlington: ISNY 5350-050
August 7, 2016
Introduction
Telemedicine, in some form or other, has been in practice since the early 20th century since the creation of telecommunication technology, and the potential of utilizing these technologies in health care has only grown. As early as 1925, when a conceptual invention by the name of teledactyl surfaced that “would use spindly robot fingers and radio technology to examine a patient from afar, and show the doctor a video feed of the patient,” scientists and doctors were already imagining what the future could hold once telemedicine became more than just a concept.
Today, telemedicine is growing and changing at a rapid pace in order to keep up with the current technological climate. Because of its exponential ubiquity, some form of telemedicine or telehealth is currently used in most health care settings, sometimes without the patient even realizing the technology behind their experience. For clarification sake, telehealth typically refers to telecommunications used in health services on a broad scale and telemedicine is usually a more specific service involving some sort of treatment; these terms are often used interchangeably. There is potential for both telemedicine and telehealth to not only improve the quality of care and cost of delivery but also to increase the number of lives reached. We are moving towards a time where physical location will no longer determine the quality of healthcare available. This will change healthcare in so many different ways and, as both consumers and leaders of this industry, it is necessary we remain as informed as possible in order to gain the most from these changes.
Positive Effects on Patient Care
Telemedicine has great potential to positively affect patient care by allowing patients to communicate with their doctors through email, video-conferencing, or through their smartphones to relay their blood pressure, heart rate and other vitals, all while being in the comfort of their home. Telemedicine allows for 24/7 access to health professionals, remote monitoring, medication adherence, and online wellness applications.
One application that comes to mind that is progressively growing is iHealth. One of our research group members uses this wellness application to manage her blood sugar levels and to communicate with her endocrinologist about her blood sugar readings. Instead of keeping a physical log and jotting down her readings in a journal, she can use the application to record her readings electronically. Her iHealth Smart Glucometer syncs up with her iPhone and the application automatically logs her blood sugar readings. She can then send her results instantly over to her endocrinologist who will then review her results and send her an email to let her know if she is on track or if she needs to come in for a visit. The application has been both convenient and cost effective for her as a consumer because it has allowed her to conduct all her testing without needing to miss work to make an appointment with her doctor. She has greater access to her physician but this technology has also encouraged greater personal accountability to make improvements on her health and well-being.
Telemedicine seems to be making a huge impact on those with limited mobility by providing low cost, accessible, quality care. According to a post on Nursing@Georgetown, “telemedicine has been identified as a successful means of administering mental health services to deaf patients, a difficult health challenge to address given the shortage of professionals who specialize in it. For patients whose conditions or location limit their mobility, telemedicine can also connect the dots in care.” A study performed by Royal Children’s Hospital in Queensland Australia in 2015 also found that telemedicine was a preferred treatment option for children with disabilities like cerebral palsy. This has allowed for children with this disability, who have been stricken by limited mobility, to obtain the same quality of care as a child in a large healthcare facility, seeing a physician face-to-face. Royal Children’s employed iMedicalApps to summarize who all were utilizing telemedicine and how they were effected by this use. They found an improvement in not only frequency and quality of care received but also the costs related to transporting the children studied.
Telemedicine was convenient and had a positive effect on a patient in a remote town in central Idaho. Mimi Rosenkrance, 58, was working her cattle ranch when 1,000 cows stampeded her as she was trying to vaccinate a baby calf. Transported by an ambulance, driven by volunteers to a small 14-bed hospital, Lost Rivers, with one full-time doctor, and an emergency room with just three beds, the hospital staff gave Mrs. Rosenkrance the same quality care she would have received in a larger hospital. The small remote hospital has no pharmacist on staff so she was given a prescription for all of her pain medicines through a remote pharmacy service. She states, “It was the kind of full-service medical treatment that might be expected of a hospital in a much larger town.”
The article goes on to state that rural hospitals are one of the great slow-moving crises in American health care and that about 14% of the U.S population lives in rural communities. The CEO, Brad Huerta of Lost Rivers Hospital, employed an effective strategy using technology and innovation to provide high-quality medical care to increase patient retention. "Necessity is the mother of invention," Huerta said. "Small hospitals like mine are always going to be under the gun. You have to get creative." Experimenting with telemedicine keeps patients coming back, especially in cases where small hospitals serving rural communities may lack the technology of larger hospitals serving urban communities. It provides the same high quality of care and increases accesibility; these smaller hospitals have to be able to stay abreast of the innovating technology and be able to provide the same quality of care to patients who are not able to get to larger hospitals. Huerta’s strategy to deliver services to his patients to ensure they do not have to travel, includes telemedicine and this strategy was life-changing for Mrs. Rosenkrance.
Positive Effect on Providers
Case Studies
As telemedicine and telehealth continue to grow and develop, hospitals across the country are learning from and referring to case studies that have been published over the years. One of the largest non-profit health care organizations in the United States, Banner Health, expanded outside of the hospital to reach patients suffering from chronic conditions. When this program was introduced, 5% of the patients on Banner’s health plan accounted for 50% of the healthcare spending due to multiple chronic conditions. The plan was to create a telehealth pilot program titled Banner’s Intensive Ambulatory Care, or IAC.
“The goal for the pilot was to improve the quality of life for participants while reducing costs by looking for adverse trends and intervening before those trends became adverse outcomes,” says Deborah Dahl, Banner’s Vice President of Patient Care Innovation. The focus was providing patients, that were a financial risk for the system, with the standard tools they needed to combat their chronic illnesses, “such as scales, glucometers, and heart monitors that were Bluetooth enabled, along with a tablet for video visits.”
Going beyond just providing the tools necessary, Banner created a full team to work, as they described it, “behind the camera”, to help develop a more personal relationship with each patient. These teams consisted of physicians, RNs, pharmacists, and other healthcare professionals that were trained in motivational interviewing. “Many telehealth solutions are focused on episodic events, so there isn’t the time or need to build a relationship, but in the IAC program, we wanted to motivate our patients to make behavior changes where appropriate and help them be generally happier. Achieving that requires a personal connection and trust,” said Dahl.
The results were released in 2015, providing data on 1,283 patients who were monitored at least one year prior to the IAC and one year post IAC. According to the study, the results showed an overall cost of care reduction of 34.5%, a reduction in hospitalizations by 49.5%, a reduction in the number of days in the hospital by 50% and a reduction in the 30-day readmission rate by 75%. While these numbers are overwhelmingly good, the program was not viewed as a complete success. “We had patients we would visit at home two weeks after an inpatient stay who believed that because they were out of the hospital, they were no longer ‘sick’ and didn’t need to monitor their health,” said Dahl.
There were also issues in regards to interoperability, as not a single patient’s electronic medical record matched the medications the patients were taking at home. This was discovered as pharmacists would conduct video visits with each patient to discuss medications prescribed by specialists. “There’s a huge opportunity in the United States to address this, and we hope that sometime soon we’ll see it in our organization,” said Dahl.
The value in this program is easily reflected in the numbers stated, but as usual there is recognized room for improvement. Banner is working to expand this current program to include Medicaid or dual-eligible patients as well as developing what Dahl refers to as a “virtual” hospital that will allow for patients to be monitored for adverse events in their homes, rather than a hospital observation unit. “Telehealth provides an amazing opportunity to change the way health care is delivered in the United States,” says Dahl. “Consumers are ready for this change and health care organizations are starting to catch up to those expectations.”
While the previous study showcased the positive and negative effects telemedicine can have on a large system, the main focus of telemedicine is centered on its effects in rural areas of the United States. Grundy County Memorial Hospital in Iowa received a grant in 2010 to provide the 25 bed, critical access hospital with funds to build a telemedicine program to provide patients access to specialists, including oncologists, neurologists, cardiologists, etc. via video equipment set up for the providers. While the funds, totaling over $2.3 million helped to provide the technology, the bigger issue that faced the hospital was physician buy-in. In order to achieve greater access to the patients, the physicians needed to be sold on the idea of telemedicine.
According to Grundy County CEO Jennifer Havens, “The big challenge is encouraging providers to test the waters. We still have a ways to go until we can more effectively convince providers of the benefits.” This is despite the fact that visits can typically be scheduled in smaller windows of time allowing the providers to see more patients. Additionally, the physicians had concerns over the lack of an IT person readily available in the office should a “glitch” arise. Havens remarked on the typical behavior of the providers stating that after one or two instances of the technology not working, “physicians are not going to want to do it again.”
Grundy County Memorial was able to work through their issues and in 2014 was named a “Most Wired” hospital by Hospitals & Health Networks. One example cited by the study involved orthopedic surgeons who, through the use of this technology, were able to “round on their joint replacement patients, rather than having to drive 40 minutes to the hospital.” Other examples of success that were discussed in this article include the hospitals ability to provide hospitalist coverage during slower hours as well as linking the hospital to “nine EMS services and 10 schools on its telehealth platform, which allows it to provide training and education in the community.”
The case of Grundy County Memorial shows that for all of the benefits of telemedicine and telehealth that are touted, the implementation is not always easy. When met with provider resistance, a program will likely have issues during the beginning implementation phases. Luckily for this hospital, they were able to work through their perceived barriers and become highly involved in the practice of telemedicine. “This is important for us in rural America, where a lot of physicians are still practicing independently,” says Haven. The next step for Grundy County Memorial is to continue to use mobile technologies and expand their telehealth strategies to target gaps in rural primary care.
Potential Barriers for Patients and Providers
Literature suggests there are significant barriers to the implementation and use of telemedicine in the United States. Barriers exist not only for providers, but also for the patients they treat and the organizations they work for.
The American Heart Association, AHA, looked at some of the different barriers that can be encountered in telemedicine. At the top of the list is cost. The costs associated with telemedicine programs including “the lack of capital for the purchase and maintenance of telehealth equipment and infrastructure continues to be a barrier for more widespread implementation of telehealth” (Schwamm et al., 2017, p. 7).
One study looked at the adoption of telemedicine in the intensive care units of over two hundred hospitals located within the United States from 2003 to 2010. This study noted that a significant barrier to implementation in the adoption of telemedicine in the hospital setting is cost. “…the cost of a telemedicine program exceeds $3 million annually and are not easily borne by hospitals that are already observing declines in revenue” (Kahn, Cicero, Wallace, & Iwashyna, 2014, para. 18). Depending on the type of hospital, the location of the hospital, and the patient population of the hospital, this annual cost can be crippling to an organization’s telemedicine efforts.
One might argue that the cost for implementation of a telemedicine program in an intensive care unit within a healthcare organization could be recovered by services provided and reimbursement for those services. Unfortunately, reimbursement in telemedicine does not always happen. In fact, “although physician reimbursement for telemedicine is increasingly common few payers currently reimburse for critical care services provided via telemedicine” (Kahn et al., 2014, para. 18).
Reimbursement issues are not uncommon and unique to intensive care units. Over all, coverage for specialty services under the telemedicine umbrella have significant gaps and “no two states are alike” (Thomas & Capistrant, 2016, p. 4). A 2014 telemedicine survey, indicated that reimbursement is the number one barrier to implementation of telemedicine programs. This survey explains that some telemedicine services are not reimbursed at all and if reimbursement occurs it is typically at a lower rate than an in person visit (Foley & Lardner LLP, 2014). As telemedicine expands in scope and potential, states are looking at this reimbursement issue. One way to address this issue at the state level is through the enactment of parity laws. “Full parity is classified as comparable coverage for telemedicine-provided services to that of in person services” (Thomas & Capistrant, 2016, p. 8). Unfortunately, twenty-two states do not have these laws in place. For healthcare providers and organizations, reimbursement remains a significant barrier for implementing, operating, and maintaining telemedicine programs.
In a 2017 benchmark survey by Reach Health, four other challenges identified for providers and hospitals were related to the electronic medical record or EMR. This survey pointed out that often times EMRs lack certain telemedicine service capabilities as they were not originally designed to carry out these functions. With lack of telemedicine capabilities within the EMR, changes or adaptation of the EMR have to be made which can be labor intensive and costly.
Other barriers include the providers’ and organizations’ resistance to change, interstate licensure for providers, and regulations imposed by regulatory agencies. There are also challenges for those in rural communities whose access to broadband connectivity is limited (The Role of Telehealth, n.d).
Patients often face many of the same barriers in using telemedicine services as providers and healthcare organizations. The differences in insurance requirements and payment models for telemedicine services can add a layer of complexity for the patient in an already complex healthcare system (Thomas & Capistrant, 2016). Patients in rural communities are also affected if broadband connectivity is limited in their geographic region (The Role of Telehealth, n.d).
The good news is that as telemedicine finds it place in the current medical landscape these barriers will continue to be addressed and removed. The future holds significant promise for telemedicine.
Future of Telemedicine
Telemedicine is moving at a fast pace, but where is it headed? According to one article, drones will play a big part in the advancement of telemedicine by digitizing and expediting medication delivery. Geoff Baird, a plane enthusiast, is working alongside Timothy Amukele, an assistant professor of pathology at Johns Hopkins Medical School, and Jeff Street, a systems engineer, to create a safe and effective way of bringing blood samples and other test specimen to and from different testing facilities via drone delivery. As Baird discusses in the article, drones also have the potential to be used in emergency settings such as a child swallowing some unknown drug and being rushed to the emergency room. Baird proposes, instead of waiting on samples to be sent to a lab via courier service, a drone could be used to transport the samples to the testing facility to expedite the process of figuring out which drug the child consumed.
These ideas would be a great advancement considering that it is not particularly cheap or quick to transport lab specimen via courier service. TriCore Reference Laboratories, based in Albuquerque, New Mexico, handles almost 75% of New Mexico’s testing and spends roughly $3.5 million per year just for transportation. A technology like drone delivery service for lab specimen would completely change the way TriCore does business and would drastically cut the costs of their services. Although drone delivery shows great promise, like most healthcare advances, there are concerns. According to Amukele, safety could be an issue. Because some drones use dropping mechanisms, potential dangers associated with the delivery could arise and those issues would need to be addressed and corrected immediately, leaving no chance for error. Although drone safety is still somewhat unknown, the Federal Aviation Administration has begun collecting data on how many incidents have occurred and what percentage of those incidents were caused by human error versus drone malfunction.
One of the bigger issues facing new advancements of drone technology is regulatory. Flying drones whenever and wherever you want is not currently permitted and although legislation on this topic has improved to allow greater use of commercial drones, ambiguity still remains as far as where the limit to this technology lies.
Another feature of telemedicine we will most likely see in the coming years will be the advancement of wearable technology. We already have technology with the ability to track steps, distance, heart rate, sleep cycles, etc. Wearable technology of the future will be able to monitor more complex data sets at a greater level of sophistication while becoming smaller and smaller in size. According to Victoria Garshnek, because the military is looking to make devices that are undetectable to the naked eye these wearable devices will start to disappear into everyday wear, such as eye glasses or clothing. Eventually these technologies, in different shapes, sizes, and forms, will spread into the healthcare industry.
The future of telemedicine is materializing at a rapid pace. Most of these changes go unnoticed because they are subtle and being integrated into our lives piece by piece. With the increasing expectations of greater convenience and access at a lower cost, telemedicine is the future of health care.
Conclusion
We are living in an exciting time where innovation is happening quicker than we can plan for the effects of these inventions. Telemedicine has great potential due to the continuous innovating that occurs in our technological landscape but before implementing these exciting new technologies, extensive research and planning must be done. With great risk and cost of implementing a new technology comes great responsibility to understand the full and complete impact these technologies will have on our healthcare organizations, our providers, and most importantly our patients. One thing we can say definitively is that telemedicine is not going away anytime soon and these technologies will continue to change what is possible in a healthcare setting.
References
Introduction:
The Ultimate Telemedicine Guide | What Is Telemedicine? (2017). Retrieved August 01, 2017, from https://evisit.com/what-is-telemedicine/
Positive Effects on Patient Care:
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Positive Effect on Providers:
Case Studies:
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Potential Barriers for Patients and Providers:
2017 U.S. Telemedicine Industry Benchmark Survey(Rep.). (2017, April). Retrieved August 3, 2017, from REACH Health website: http://reachhealth.com/wp-content/uploads/2017-US-Telemedicine-Industry-Benchmark-Survey-REACH-Health.pdf
Kahn, J. M., Cicero, B. D., Wallace, D. J., & Iwashyna, T. J. (2014). Adoption of intensive care unit telemedicine in the United States. Crit Care Med, 42(2), 362-368. DOI: 10.1097/CCM.0b013e3182a6419f
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Thomas, L., & Capistrant, G. (2016, January). State Telemedicine Gaps Analysis: Coverage & Reimbursement(Rep.). Retrieved August, 2017, from American Telemedicine Association website: https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/3c09839a-fffd-46f7-916c-692c11d78933/UploadedImages/Policy/State%20Policy%20Resource%20Center/Coverage%20-%202016_50-state-telehealth-gaps-analysis–coverage-and-reimbursement.pdf
Future of Telemedicine:
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Landhuis, E. (2016, September 13). Doctors Test Drones To Speed Up Delivery Of Lab Tests. Retrieved August 02, 2017, from http://www.npr.org/sections/health-shots/2016/09/13/493289511/doctors-test-drones-to-speed-up-delivery-of-lab-tests