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Despite barriers, telemedicine services poised to change care delivery

Telemedicine services, from video conferences to monitoring devices, can keep patients out of the emergency room, provided regulatory and technological hurdles are cleared.

Dr. Jay Sanders began his foray into telemedicine services more than four decades ago, when he and Dr. Ken Bird ran a microwave line from Massachusetts General Hospital to Logan International Airport. This let Sanders examine patients at the airport clinic without making the hour-long, three-and-a-half-mile trek through notorious Boston traffic and the crowded Callahan Tunnel.

Now, a patient can wear a wristwatch to monitor his blood glucose or blood pressure and port that data to a smartphone or clinical data analytics system -- either of which can compare incoming readings to normative figures, and alert the patient when something is amiss, Sanders notes. Then there's telepresence, which lets doctors examine patients remotely, sometimes from the comfort of the patient's home.

The definition of telemedicine nonetheless remains unchanged, according to Sanders. "It's the transfer of information from one location, where it is, to another location, where it is needed," he said. "Connected health care, mobile health, telehealth -- we ought to get rid of all the terms. It's just medicine."

Telemedicine services stand at a crossroads, however, with the potential that Sanders describes often thwarted by spotty Internet connections, inadequate IT infrastructure, state and federal red tape, or a combination of the three. Some health care providers have made a successful transition to telemedicine, but many remain on the sidelines.

Using telemedicine technology to expand, enhance services

For the Marshfield Clinic, which serves northern and central Wisconsin, it is just medicine. The clinic uses telemedicine so extensively -- in 45 clinical services including all medical and surgical specialties -- that it is considered a business development priority, not just an IT initiative.

Telehealth is a tool for access. It's part of the way we deliver health care. It's not about technology -- it's about meeting unmet needs.
Dr. Nina Antoniottiprogram director, Marshfield Clinic's TeleHealth Network

"At this point, it's about patient health needs and focusing on the business needs of the clinic," said Dr. Nina Antoniotti, program director for the organization's TeleHealth Network. "Telehealth is a tool for access. It's part of the way we deliver health care. It's not about technology -- it's about meeting unmet needs."

In 1997, the Marshfield Clinic used a Department of Health & Human Services (HHS) telemedicine grant to get five regional centers and 15 clinical services online. At that time, the organization had a proprietary telecommunications network. It simply used that network to launch its telemedicine program, giving rural regional centers access to clinical services, such as dermatology and radiology trauma, that hitherto had been lacking, Antoniotti said.

PeaceHealth likewise saw telemedicine services as a means of addressing a shortage -- in this case, the lack of geriatric physicians in the rural Pacific Northwest and Alaska. Geriatrics worked particularly well, said Dan Reece, formerly the executive director of Peace Health's Gerontology Institute, because geriatricians do not lay hands on a patient, and therefore can conduct an interactive analysis remotely.

Given its success with geriatrics, PeaceHealth has expanded its telemedicine services to specialty consultations, such as stroke services and pediatric intensive care, and is exploring its use in areas that could include psychiatry, home monitoring and interpretive services, Reece said. (To that end, he has since has assumed responsibility for advancing Peace Health's telemedicine use.)

Overcoming barriers to telemedicine use, adoption

Organizations such as PeaceHealth and the Marshfield Clinic represent the exception, not the rule.

A recent IDC Health Insights report, Monetizing telemedicine: Vendors, service providers and payers opportunities, indicated that fewer than 5% of consumers have encountered health care over video.

Plus, those wristwatches and other remote patient monitoring devices are hardly a panacea, either, the report said:

  • They must be highly customized yet easy to use, especially for those with physical or mental impairments.
  • They require hefty investments in product support and performance -- downtime, after all, is unacceptable when a customer's life is at stake.
  • They require an OK from the Food and Drug Administration, which does not dole out approvals at will.
  • They confound retail stores, who struggle to craft the correct sales pitch.

Lack of high-speed Internet access  also hinders telemedicine use by hospitals, physicians and patients. That may change. Broadband expansion played prominently in the American Recovery and Reinvestment Act of 2009, as did health care in the Federal Communication Commission's National Broadband Plan.

At the institutional level, meanwhile, organizations must get their IT infrastructure in order. For PeaceHealth, this meant using high-speed broadband, video conferencing and common medical records across its three-state network -- and tying into the Oregon Health & Science University will only necessitate further network expansion, Reece said.

In addition, existing resources must be fully utilized. "Most organizations already have some kind of video communication" or telecommunications system, the Marshfield Clinic's Antoniotti said, "but they don't know how to use it for clinical applications."

That said, telemedicine and telepresence vendors see value in lessening the technology's impact on hospital infrastructure.

While Polycom Inc. does offer products that range from immersive telepresence operating rooms to carts equipped with a wireless video system, and exam tools connected to a video unit, Chief Compliance Officer Bob Preston said. "In many cases, it's no more than video endpoint with high-definition plasma," he said. In that scenario, provided that the hospital has a firewalled high-speed network, everything can be done over IP, he added.

Meanwhile, Vidyo Inc. develops teleconferencing software that can run on a PC without dedicated hardware -- users only need a webcam, said Michal Raz, Vidyo's vice president of vertical applications. The software also is designed to maintain a video connection at speeds as low as 128 KB, by reducing the frame rate or resolution, he said: "[Providers and patients] will get fluctuations in bandwidth, and we accommodate for that."

Red tape, telemedicine laws present additional challenges

Once technological hurdles are overcome, however, there are regulatory and policy obstacles as well. Chief among them is reimbursement, said Jon Linkous, CEO of the American Telemedicine Association (ATA). "If you can't get paid for providing services, there's little incentive to do the rest," he said.

Payment for health care services remains "complex and diversified," Linkous said. Physicians receive reimbursements from numerous sources -- private insurers, employment plans, Medicare, Medicaid and patients' pockets. Private payers do the best job of reimbursing for telemedicine services, he said. On the other hand, only about half of states reimburse under Medicaid; and, though Medicare has improved, telemedicine reimbursement remains limited to certain facilities, to services already written into telemedicine laws, and to non-urban areas.

"Tackling it and correcting it," Linkous said, "requires a multimodal approach." Not surprisingly, telemedicine reimbursement ranks highest among the ATA's telemedicine public priorities for 2010.

Licensing, too, remains problematic. To use telemedicine to see a patient, a physician must be licensed in the patient's home state. The ATA is working with the Federation of State Medical Boards to establish a national licensure model, but it is still several years off, Linkous said.

Finally, there's telemedicine credentialing -- the burdensome process through which Medicare hospitals must complete and verify the credentials of those who provide telemedicine services. At the moment, the Centers for Medicare & Medicaid Services within HHS is considering changes to telemedicine credentialing that would let hospitals use a third party for this process, but a final rule is not expected until the end of the year.

Future of telemedicine: Improved care for all?

Even with technological and regulatory challenges, telemedicine services are regarded as a key way to improve health care and lower the costs of care.

As Polycom's Preston pointed out, several factors are driving the health care industry to consider new ways to provide care: the growing shortage of primary care physicians; the 32 million Americans entering the system through health care reform; and the nation's 72 million baby boomers, each with unique health needs. This will require "innovative integration with complementary solutions," ranging from clinical workflow, to picture archiving and communication systems, or PACS, technology, to network infrastructure, he said.

Vidyo's Raz agreed. The Vidyo telepresence system integrates with medical devices, including cameras and videoscopes, as well as with bedside applications for tracking patient vital signs. Integration remains a work in progress, though. "We have a lot of software and devices that [Vidyo] will integrate with, but every time we walk into a provider's office, there is a new software or device to connect to," he said.

It is those devices, and their vast potential for remote patient monitoring, that many believe will keep patients with chronic conditions out of the emergency room. Home health providers, for example, can keep a virtual eye on patients and, based on information imported from devices, send skilled nurses as needed, not on a set schedule that may miss critical medical events.

More importantly, according to Sanders, the future of telemedicine services and remote patient monitoring points to an "incredible sea change" in the way patients and physicians view their health.

Hypertension does not happen overnight, and Type 2 diabetes can set in a decade before it is diagnosed. A patient whose blood pressure and glucose levels steadily increase, yet remain below statistical norms, will never throw up a red flag, Sanders said. With a monitoring device and a clinical data analytics system capable of setting individualized norms for a patient, physicians can "catch small issues before they become big issues," he said.

Car owners treat their vehicles well, filling tires when air pressure gets too low and visiting a service station when the check-engine light comes on. "We would never buy a car that has to go in for a yearly physical to tell us what's wrong," Sanders said. "But we . . . treat ourselves that way."

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