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ALHEChapter17_Telemedicine.pptxChapter 17: Telemedicine
Robert Hoyt MD
Thomas Martin PhD
Learning Objectives
After reviewing the presentation, viewers should be able to:
State the difference between telehealth and telemedicine
List the various types of telemedicine consultations, such as teleradiology and teleneurology
List the potential benefits of telemedicine to patients and clinicians
Identify the different means of transferring information with telemedicine, such as store and forward
Discuss the most significant ongoing telemedicine projects
Definitions
Telehealth: The use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration
Telemedicine: “the use of medical information exchanged from one site to another via electronic communications to improve patients' health status” or simply the remote delivery of healthcare
Popularity of Telemedicine
Rising cost of healthcare worldwide
new strategies (telemedicine) to prevent readmissions
Shortage of specialists in rural areas
Rise in chronic diseases and aging of population
Improved collaboration among physicians and disparate healthcare organizations
Raises patient satisfaction when it results in better access to specialty care
Electronic Telemedicine Modes
Radio Doctor—predicted in 1924
TV
Telephone
Internet
Telemedicine Communication Modes
| Communication Mode | Pros | Cons |
| Patient-Portal Secure messaging | Asynchronous. Able to attach photos. Response can be formatted with template. Could use VoIP. Audit trail is available | Not as personal as live visit. Usually not connected to EHR or other enterprise information but may be in the future |
| Telephone | Widely available, simple and inexpensive. Real-time | Not asynchronous. Unstructured. No audit trail. Only real-time |
| Audio-Video | Maximal input to clinician. Can include review of x-rays, etc. Perhaps more personal than just messaging | Currently, most expensive in terms of networks and hardware, but that is changing |
Telemedicine Transmission Modes
Store-and-forward
Images or videos are saved and sent later
Asynchronous communication
Real time
A specialist views video images transmitted from a remote site and discusses the case with another physician
Requires more sophisticated equipment: two way interactive telemonitors permit the specialist to see and talk to the patient
Remote monitoring
Monitor patients at home or in a nursing home; usually part of disease management
Telemedicine Categories (Author’s classification)
Televisits:
Teleconsultations:
Teleradiology, teledermatology, teleneurology, telepharmacy
Telemonitoring
Telerounding: hospital inpatients
Telerobots
eICUs
Telehomecare: monitoring physiological parameters, activity, diet, etc. at home
Teleconsultation is a worldwide phenomenon because specialists tend to practice in large metropolitan areas, and not in rural areas
Most programs consist of a central medical hub and several rural spokes
Programs attempt to improve access to services in rural and underserved areas, to include prisons. This reduces travel time and lowers the cost for specialists and patients alike
The most commonly delivered services are mental health, dermatology, cardiology, radiology and orthopedics
Teleconsultations
Teleradiology: with new digital imaging, EHRs and other technologies, this teleconsultation makes sense
Radiologists can be home at night, read an image, dictate a report via voice recognition and host it all in the cloud for others to view and link to the local EHR
vRad is a service that reads images, usually during the night, when there may be a shortage of radiologists in some areas
In 2013 The American College of Radiologists published Teleradiology Practice Guidelines. The Task Force outlined benefits as well as challenges to the practice
Teleconsultations
Teleneurology: there is a shortage of neurologists in rural areas and a shortage covering ERs due to liability issues
This is very significant given the fact that many stroke patients may benefit from receiving “clot busters” in the first 3 hours of a stroke
Teleradiology permits a remote neurologist to read the CAT scan of the brain and see the neurological exam being conducted on the patient
There are now several commercial teleneurology groups that contract to cover emergency rooms remotely
Concussions are another medical problem that potentially could benefit from teleneurology
Teleconsultations
Telemental Health (Telepsychiatry): There is a national shortage of mental health workers in the US
There is evidence that a remote session with a therapist has the same outcome as a face to face visit
This approach is particularly valuable for ERs, prisons and post-deployed active duty military personnel
Some use Skype to accomplish a visit, while others use more elaborate audio-visual technology
This is an international effort
Teleconsultations
Teledermatology: Very logical specialty because there are very few emergencies in this specialty and an image of a skin lesion is frequently diagnostic
Store and forward most common mode
Digital cameras/camera phones have only made the process that much easier
There are several international initiatives that support teledermatology, mentioned in the textbook
Artificial intelligence can interpret the images
Teleconsultations
Retinal images can now be obtained, even without dilating the pupil.
A primary care doc can image a diabetic while in the office and forward it to an ophthalmologist for a reading (store and forward)
There is go evidence that this increases screening in patients with diabetes
Teleophthalmology
Telerounding
Robot rounds: expensive robots can be placed at the bedside to collect and store information and then communicate to the responsible physician, preventing a second set of rounds
Virtual ICU or eICU: Due to a nationwide shortage of ICU experts (intensivists) eICUs have appeared that have a central hub at a larger medical center covering small remote ICUs
It includes not just an ICU nurse and physician covering remote patients but care is based on the best possible evidence
Particularly valuable at night or weekends when coverage may be light
Families can converse with remote staff
eICUs have great potential to improve morbidity/mortality and length of stay but articles have tended to show conflicting results
Telemonitoring
Telehomecare: the concept is that monitoring patients at home may prevent unnecessary ER visits and hospital admissions
Multiple sensor now exist to measure a myriad of physiological markers (see next slide)
This approach is embraced by the medical home model and accountable care organizations
Unfortunately, thus far most telehomecare studies have not shown a significant impact on medical quality, cost, etc.
Telemonitoring
Available Sensors and Devices
Measure:
Weight
Blood Pressure
Glucose: blood sugar
Oximeter: oxygen level
Spirometry : breathing capacity
Temperature
Medication tracker
PT/INR: how thin the blood is on blood thinners
Motion detectors/chair and bed sensors: can detect falls
Fitness
Health Buddy Telemonitoring Example
Telemedicine Initiatives
Informatics for Diabetes Education and Telemedicine (IDEATel)
Georgia Partnership for Telehealth (GPT)
Middle East Society of Telemedicine (MESOTEL)
University of Texas Medical Branch at Galveston
Teleburn at the Ottawa Telemedicine Network
California Central Valley Teleretinal Program
Northwest Telehealth
More examples in the textbook
Barriers to Telemedicine
Limited reimbursement
Limited research showing reasonable benefit and return on investment
High initial cost
Limited availability of high speed telecommunications
Bandwidth issues
Need for high resolution images or video for some specialties
Licensure laws
Lack of standards
Lack of evaluation by a certifying organization
Fear of malpractice as a result of telemedicine
Ethical and legal challenges
Sustainability due to inadequate long term business
Lack of sophistication on the part of the patient
Barriers to Telemedicine
21
Telehealth is a broad term that means remote delivery of medical care, administration and education
Telemedicine is the remote delivery of medical care using technology
Almost all specialties are testing telemedicine
In spite of no reimbursement eICUs are expanding
Telehomecare is popular but too new to know its actual impact
Multiple barriers to telemedicine exist
Conclusions
