Telemedicine

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Telemedicine is the use of information technologies to provide health care when distance separates the medical professional from the patient. (IOM 2001)

Introduction

Most of developed countries have robust telemedicine programs however, the most wide stepping countries in this field are USA, UK, Sweden, India and Philippines.

Telemedicine is nearly used in all medical fields. The most prominent uses for telemedicine are:

  • Telemedicine and teledermatology (actual physical examination of the patient)
  • Endocrinology (review for the lab results).
  • Teleradiology (reading still and full motion radiographic images)
  • Tele-ophthalmology (Screening for diabetic retinopathy and retinopathy of prematurity)
  • Telepathology ( analysis of tissue histology samples)
  • Geriatric care and monitoring at home
  • In-patient ICU and infectious disease consultation
  • Real-time emergency care
  • Telepsychology
  • Telepharmacy and teleinterpreting
  • Surgeries and surgery fields [general surgery, GIT surgery and special surgeries as vascular, orthopedics, pediatrics, plastic …] are still at early stage of dependency on telemedicine.
  • Robotic Telepresence
  • Depression
    • Depression is a relatively new area of telemedicine with promising results that all informaticists need to be aware of, as do mental health professionals. It is an area to keep an eye on for the hopefully promising successes to be seen.
  • Telestroke
  • Health coaching
  • Traumatic Brain Injury (SMS)
    • Diagnoses of TBI are increasing among US soldiers returning from recent conflicts. (SMS)
  • Telemedicine for patients with cardiovascular diseases

How telemedicine is used

1. Synchronous - Live video conferencing

This is the most common type of telehealth, and involves two-way interactive audio and video technology to facilitate a live, face-to-face interaction between a patient and their healthcare provider.

Applications include:

- Medical specialists can examine patients in remote locations – such as Telestroke Programs

- Behavioral Health professionals can evaluate patients who are unable or unwilling to come to the office

- Reaching patients who are incarcerated, institutionalized or have limited mobility

- Enabling language translators to provide video interpretation services to multiple locations


2. Asynchronous - Store and Forward

Store and Forward Technologies allows secure electronic transmission of medical information, such as recorded video or images, to be reviewed by a provider at a later time.

Applications include:

- Radiology – Imaging studies taken at one location can be interpreted by a radiologist at another location.

- Pathology – image rich pathology data can be transmitted between distant locations for the purposes of diagnosis, education and research.

- Dermatology – Primary care physicians can take digital photos of their patient’s skin lesions and forward the images to a dermatologist for review.

- Ophthalmology – eye screenings for diabetic retinopathy can be captured digitally by retinal cameras and transmitted to a specialist for review.


3. Remote Patient Monitoring (RPM)

Remote Patient Monitoring utilizes medical devices to collect patient’s health data from the patient in one location and is then sent electronically to a healthcare professional for monitoring and review.

The standard build of RPM devices consists of 4 core components

1. Wireless sensors that transmit patient information (ie. Heart rate)

2. Localized data storage at the patient site that receives information from the device.

3. Centralized repository that receives information from the patient site.

4. Diagnostic software built to provide solutions and recommendations as a result of the collected data.


Applications Include:

- Monitoring programs for chronic disease management (such as diabetes)

- Cardiac monitoring

- Devices that monitor gait and balance to detect if patients have fallen

Technologies employed in telemedicine

  1. Facsimile
  2. Medical data transmission
  3. Audio –telephone and radio
  4. Still images
  5. Full motion videos
  6. Recently Robotics and virtual reality interfaces have also been introduced

Peripherals used in telemedicine

  1. Non-medical : VCR, video cameras…
  2. Medical: auscultation, imaging, biometric data collections, otoscope, ophthalmoscope, dermoscope, thermometers , blood pressure cuffs, ECGs , spirometers, pulse oximeters for continuous data collection and maintaining records of patients.
  3. Special devices and larger bandwidths are required to transfer a video image ( with frame rate of 30/sec or more ) so that examining physician can perceive it as a smooth image.

Causes for the increased demand of telemedicine

  1. Increased healthcare expenditure globally [in USA it’s up to 16% of GDP] and the need for a way to reduce this % without affecting the quality of medical services.
  2. Limited healthcare resources in the form of physicians, nurses, technicians and workers.
  3. Increased number of population relatively to the number of available doctors and increased area of housing that will take much time for the provider to move to.
  4. Increased number of people with chronic illness who need continuous care that might be sometimes defective.
  5. Some countries whose nature is full of mountains and/or rural areas.
  6. Revolution in IT [e.g. internet, GPS…] and communication infrastructure.
  7. lower cost of bandwidth and improvements in video and data compression standards
  8. Further advancement is by using satellite technology to broadcast a medical or other consultations in two countries by videoconfercing facilities-mostly in military settings.

Advantages of telemedicine

A systematic review was conducted by Flodgren et al to assess the effectiveness of interactive telemedicine as an alternative to usual care. They found evidence that telemedicine can improve the control of blood glucose in those with diabetes and helped reduce LDL cholesterol and blood pressure.

  1. For the patient:
  • Reduced physician’s fees and cost of medicine
  • Reduced travel expenses
  • Treatment by qualified physician, iinterpretation of imaging & histopathology, when professionals are distantly placed
  • Early detection of diseases
  • Reduced burden of morbidity
  • Saves work-loss time and increase productivity
  • Home health care by using telemedical home monitoring device for chronic cases. In a study condtucted by Margolis et al, the authors used home BP telemonitoring device with pharmacist case management for patients with high BP. the patients had controlled BP and improved lifestyle in the 6th, 12 and 18 month primary care visit follow up.
  1. For the doctor:
  • Telemedicine is an excellent opportunity to share the knowledge between physicians all over the world.
  • Joint consultation with expert physicians and surgeons for better management of complicated disease.
  • Local doctors can be updated at any time with the most recent advancement in medicine.
  • Medical education in the form of teleconferencing.
  • Ability to provide care while reducing travel, allowing them more time with their families/at their practice. (SMS)
  1. For the government:
  • Reduced rush to the medical facilities in the cities
  • Improve monitoring facilities at the rural based centres
  • Increased reliance on the government health care system
  • Increases stuff productivity
  • Economizes resources (optimal use of instruments and surgical facilities).
  • Reduces expenditures on healthcare - the Veterans Administration pays for veterans' travel to VA hospitals. Reduced travel = conserved funds. (SMS)

Disadvantages of Telemedicine

  1. The laws and regulations have not caught up with the technology.
  2. Reimbursement issues (Many advocates argue telemedicine will not reach its potential without reimbursement so now there is growing advocacy for increased reimbursement in the political arena).
  3. Insurance issues (Most health insurance payers do not cover telemedicine services).

Constraints of Telemedicine

  1. Different technological standards, infrastructure and regulatory mechanisms.
  2. Different medical cultures, approaches, standards and different medical care resources.
  3. Socio-Economic factors such as political and bureaucratic barriers, different languages and literacy levels.

Telehealth or telemedicine is a fairly new field which combines technology and expertise to evaluate and treat patients in underserved areas. Rural areas do not have the needed specialists, yet there is technology available to allow these patients to be treated in their own communities by experts in the field. In rural settings, a telemedicine based collaborative care intervention for depression is effective but can be expensive (Pyne, MD et al., 2010). Patients in rural settings suffering from depression or other mental health conditions do not have options for care, and often do not have the funds or means to travel to cities where they may be able to access the care they need. Telemedicine allows for collaboration among healthcare professions through educating patients, monitoring adherence to therapies, and evaluating and adjusting treatment (Kroenke, MD et al., 2010).

Telemedicine is a field used for many disciplines where specialists are not readily available, and is showing particular value for patients suffering from depressions who can meet with their therapist or counselors over the Internet in much the same way they would in a regular office visit. Because of the high risk nature of the depressed patient it is important that there is a local team involved to help manage the care of the depressed patient and to monitor their progress and compliance. The Veterans Administration (VA) is involved in evaluation of therapy for their depression patients and for those working with a diagnosis of post traumatic stress disorder (PTSD). According the Veteran’s Affairs Department it is the belief that treatment options should be widely available and uniquely tailored to the individual needs of each Veteran (veterans.senate.gov).Many soldiers returning home from service are finding value in the telemedicine programs that allow them to remain close to their families and whole support system rather than having to go to a large VA institution.

Examples of telehealth

By far the most prominent example of telehealth in the US comes from the Department of Veterans Affairs (VA) Veterans Health Administration. One of the growing areas of telehealth care is the identification of Traumatic Brain Injury (TBI) in soldiers and veterans, including their recovery care and support services. TBI has been diagnosed more frequently in soldiers returning from recent conflicts. (SMS)

To meet this growing need, the Department of Defense created the National Center for Telehealth and Technology (T2) within the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. A focus of T2 is to develop new ways to provide care and information to service members in the field and at home through interactive video-teleconferencing (VTC), cell phones and computers. Teletherapy has been found to improve the physical and cognitive functional outcomes in patients with TBI. These technologies allow providers to ‘check-in’ on their patients more regularly without the expense of travel, sometimes to very distant rural areas. (SMS)

Several studies have shown the benefit of remote patient monitoring in patients with congestive heart failure (CHF) with a reduction in both hospital readmissions and mortality. For instance, in a program at Partners Healthcare, more than 3000 patients received care using in-home monitoring of weight, blood pressure, heart rate, and pulse oximetry. The data was securely uploaded and clinical decision support software assisted in identifying those who needed attention. This resulted in a decrease of hospital readmissions and generated cost savings of more than $10 million during a 6-year period. [3]

Telemedicine is being used as a tool to practice medicine and this is especially true with dermatology, a specialty that has become comfortable making diagnoses using two-dimensional images at a distance. People found the interactive video conferencing call “real time services” more effective and efficient especially when they live far away from their specialists or care providers. Another strategy that’s been noted useful is “store and forward services,” an asynchronous communication where the patient uploads images of skin findings to a secure site, which is later accessed by the consulting dermatologist who responds accordingly. [3]

Patient medication adherence is another problem that appears to improve with the help of telehealth. Center for Connected Health performed a randomized controlled clinical trial where a wireless electronic pill bottle was provided to remind the patients to take their blood pressure medication timely. The study findings demonstrated an increased adherence (68% higher than in controls). Although there are multiple technologies to help patients adhere to the treatment plan, such as blister medication packages, internet-connected pill caps, these technologies are at a nascent stage and quite expensive. [3]

Physician behavior in the era of telemedicine - bedside manners

Despite the scientific and technological advances in clinical medicine, some things remain constant. This includes how the doctors make patients feel during the visit, which is well known as bedside manners. It has been observed that good bedside manners foster patients’ trust, has a placebo effect on them and lead to increased treatment adherence. An article from Modern Healthcare mentions of a 2014 study that revealed statistically significant impact of bedside manners on the incidence of hypertension, diabetes, asthma, osteoarthritis, and obesity. Therefore, it becomes imperative to translate these bedside manners while interacting with patients on desktop since telemedicine will most likely become mainstreamed in the future, and this has been coined as “webside” manners. [6]

Certain guidelines to practice webside or desktop manners compiled from Medscape and Orbit Health include the following: [1,4,5,7]

  1. Introduce yourself and the role: It allows care delivery to follow naturally and easily. If not done, a distance would be created at the beginning of the appointment itself, which later impacts patient care.
  2. Virtual eye contact: It is essential to see the camera on the computer while interacting with the patient and not at the patient’s image that is visible on the screen. Otherwise, the patient may feel the doctor is disengaged.
  3. Show empathy and calm patient’s fear and anxiety as and when needed.
  4. Awareness of the surroundings: The room should not be cluttered, should be silent, have good lighting quality to be clearly seen and have good audio and video connection to ensure a smooth encounter.
  5. Appropriate use of body language such as head nodding, friendly hand wave, facial expressions of smile and concern must be used generously to reassure the patient is being heard. Also important is to maintain a straight posture since sagging in the chair indicates disinterest in patient’s conversation, while leaning too close intimidates the patient and leaning back too far can show disinterest.
  6. Do not interrupt the patient’s flow: Studies have shown that patients require an average of 32 seconds to state their concerns, but are interrupted within 20 seconds into the visit, which is against William Osler’s teachings: “Just listen to your patient, he is telling you the diagnosis.” Practice active listening.
  7. Communicate clearly and avoid side conversations or taking any phone calls to limit distraction.
  8. Do not hesitate to ask for help as patients appreciate such honesty and will feel more confident about physicians’ thought process and decision-making abilities.
  9. Ending the session well and not abruptly is crucial. Ample time must be given to respond to patient’s unanswered queries and concerns.

All these simple doable acts have a tremendous impact on patient care, patient’s adherence to the physician’s recommended treatment plan.

Regardless of the time, distance and advancements, Atul Gawande’s comment below will continue to remind healthcare professionals of the importance of human element in any kind of patient interaction, be it bedside or webside:

It is unsettling how little it takes to defeat success in medicine. You come as a professional equipped with expertise and technology. You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific matter of how casual you should be, how formal, how reticent, how forthright. Also how apologetic, how self confident, how money minded. In this work against sickness, we begin not with genetic or cellular interactions but with human ones. [2]


Telemedicine Policies

1. Reimbursement

Telehealth reimbursement varies greatly at the federal and state levels. Reimbursement of telehealth services through Medicare is determined at the federal level, whereas policies regarding Medicaid and private payers are set at the state level. Under Medicare, reimbursement is restricted by type of service, type of provider, and where telehealth services take place (both geographically and facility-wise). For example, only synchronous, live video conferencing services are currently eligible for Medicare reimbursement. Similar restrictions are also in place at the state level for both Medicaid and private payers, and vary greatly from state to state. In particular, there are difference in parity laws and although a state may require an insurer to cover a telehealth visit as if it were a face-to-face visit, the insurer does not need to pay the same amount for both services. For a report of laws from all 50 states, please see: https://www.cchpca.org/sites/default/files/2018-10/CCHP_50_State_Report_Fall_2018.pdf

2. Licensing

Licensing has traditionally been a major hurdle for adoption of telehealth, however, recently some state medical boards have tried to accommodate for the practice of telehealth. There are currently fourteen state medical boards that issue special licenses related to telehealth. These special licenses allow out of state providers to deliver care in states where they are not located. A few states, namely New York, Maryland and Virginia, also offer reciprocity to providers in bordering states. The Federation of State Medical Boards (FSMB) has also implemented an Interstate Medical Licensure Compact which provides an expedited licensure process for licensed physicians to apply for licenses in other states. As with many of the policies regarding telehealth, policies are set at the state level and vary from state to state.

For a report of state medical board regulations, please see: http://www.fsmb.org/globalassets/advocacy/key-issues/telemedicine_policies_by_state.pdf

3. Credentialing

CMS has approved regulations to allow hospitals to credential by proxy. This allows a critical access hospital (originating site) to contract with another hospital or telemedicine entity (distant site) and provide services via telehealth and credential those providers by relying on credentialing done by the distant site, if certain conditions are met.

4. Prescribing

One of the concerns regarding telehealth is whether or not prescriptions should be written if a patient-provider relationship is based solely on virtual interactions. This is especially scrutinized for prescribing controlled substances. Some states have rules in place that require the patient to have a face-to-face visit prior to allowing prescriptions to be written for telehealth visits.

At the federal level, e-prescribing of controlled substances is dictated by the Ryan Haight Online Pharmacy Consumer Protection Act, which was originally enacted to target ‘rogue internet pharmacies’. According to the Ryan Haight Act, a provider must have conducted at least 1 in-person medical evaluation prior to issuing a prescription for a controlled substance or meet one of the ‘telemedicine exceptions’. The exceptions include treatment in a hospital or clinic, treatment in physical presence of a practitioner, Indian Health Service or Tribal organization, public health emergency declared by Secretary of Health and Human Services, Special Registrant, Department of Veteran Affairs Medical Emergency or Other Circumstances by Regulation.

5. Security and Privacy

Many telehealth applications are based on potentially sensitive health information being collected, stored and transmitted between two different sites. Currently, there is not a comprehensive federal regulatory framework that covers privacy and security rules for telehealth applications. Presently, there are federal and state guidelines in place, but no one federal agency has authority to enact privacy rules for the telehealth ecosystem.

When telehealth applications involve provider-to-provider communications, both ends are required by HIPAA to implement appropriate security safeguards. However, many telehealth applications are now patient facing. The patient’s side is outside of a HIPAA regulated care setting and depending on the application, may fall under the jurisdiction of either the Federal Trade Commission or the Food and Drug Administration. The Federal Trade Commission (FTC) has authority to penalize consumer-facing companies for failing to abide to commitments regarding fair data use and privacy policies. However, this relies on the company’s policies regarding data usage. Many of these privacy policies are written unilaterally or unread by patients. The Food and Drug Administration (FDA) regulates telehealth technology if it is considered a medical device. However, the FDA’s concern is focused is on security protections to ensure safety, rather than privacy. Specifically, the FDA safeguards do not include collection, use or disclosure of potentially sensitive health information.

6. Malpractice

Not all malpractice carriers will provide coverage involving telehealth and not all coverage will extend across state lines. Healthcare provider may need to ensure their malpractice insurance covers specific states if they intend to see patients across state lines using telehealth.

References (rev1)

  1. Kroenke, K., MD, Theobald, D., MD, Wu, J., MS, Norton, K., BA, Morrison, G., PhD, Carpenter, J., PhD, RN, & Tu, W., PhD (2010, July 14). Effect of telecare management on pain and depression in patients with cancer. Journal of the American Medical Association, 304, 163-171.
  2. Pyne, J., MD, Fortney, J., PhD, Tripathi, S., MS, Maciejewski, M., PhD, Edlund, M., MD, & Williams, K., PhD (2010, August). Cost-effectiveness analysis of a rural telemedicine collaborative care intervention for depression. Archives of General Psychiatry, 67, 812-819. Retrieved from http://www.archgenpsychiatry.com/veterans.senate.gov/hearings.cfm?action=release.display&release_id=0608c8d9-d3ca-437c-912c-743b8ad9d2bd

Submitted by Marie Lowery


References (rev2)

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  2. Whitten, P., Mair, F., et al. (2002). Systematic review of cost effectiveness studies of telemedicine interventions. British Medical Journal, 324: 1434‐1437.
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  10. Hersh, W., Helfand, M., et al. (2001). Clinical outcomes resulting from telemedicine interventions: a systematic review. BMC Medical Informatics and Decision Making, 1: 5. http://www.biomedcentral.com/1472‐6947/1/5.
  11. Grigsby, J. and Bennett, R. (2006). Alternatives to randomized controlled trials in telemedicine. Journal of Telemedicine & Telecare, 12(Supp 2): 77‐84.
  12. Defining Obtrusiveness in Home Telehealth Technologies: A Conceptual Framework Journal of the American Medical Informatics Association Volume 13, Issue 4, July-August 2006, Pages 428-431
  13. Web-based telemedicine systems for home-care: technical issues and experiences Computer Methods and Programs in Biomedicine, Volume 64, Issue 3, Pages 175-187 R.Bellazzi
  14. JAMIA 1997;4:69-70 doi:10.1136/jamia.1997.0040069 ;Telehealth; The Need for Evaluation: Daniel R Masys.
  15. JAMIA 2002;9:89-91 doi:10.1136/jamia.2002.0090089 ,Telehealth;The Need for Evaluation Redux:William R Hersh,Patricia K Patterson,Dale F Kraemer.
  16. JAMIA 1996 3: 245-246 William W Stead Informatics of Medical Imaging for Papers on Telehealth and the Focus on the Frontiers of Informatics.
  17. http://www.citris-uc.org/system/files/James_Marcin-Telemedicine.pdf
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  19. http://www.telemedindia.org/eseminar/Telemedicine,%20EMR%20&%20Remote%20Connectivity.pdf


Submitted by: Tariq Mohasseb

References (rev3)

  1. Bush N, PhD, Fullerton N, MSW, Crumpton R, MBA, LPN, Metzger-Abamukong M, BS, & Fantelli E, BS. Soldiers’ Personal Technologies on Deployment and at Home. Telemedicine and e-Health, 2012 May;18(4):253-63.
  2. Girard P, MS. Military and VA telemedicine systems for patients with traumatic brain injury. Journal of Rehabilitation Research & Development, 2007;44(7):1017–1026

Submitted by: Sara Marinucci-Seevers

References (rev4)

  1. Edelson, C. (2017, February 6). Virtual Bedside Manner: Connecting with Telemedicine | | Physician's Computer Company. Retrieved from http://www.pcc.com/virtual-bedside-manner-connecting-with-telemedicine/
  2. Gawande A. Better: A Surgeon's Notes on Performance. New York: Metropolitan Books; 2007. pp. 81–82.
  3. Kvedar, J., Coye, M. J., & Everett, W. (2014). Connected Health: A Review Of Technologies And Strategies To Improve Patient Care With Telemedicine And Telehealth. Health Affairs, 33(2), 194-199. doi:10.1377/hlthaff.2013.0992
  4. Orbit Health. (2015). The Web-side Manner. Retrieved from http://www.orbithealth.com/the-webside-manner/
  5. Re: William Osler: A Life in Medicine | The BMJ. (2000, October 28). Retrieved from http://www.bmj.com/content/321/7268/1087.2/rr/760724
  6. Teichert, E. (2016, August 27). There's a growing need to train physicians on how to handle virtual visits with patients - Modern Healthcare. Retrieved April 20, 2017, from http://www.modernhealthcare.com/article/20160827/MAGAZINE/308279981
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Submitted by: Swetha Yenduru


References (rev5)

1. Center for Connected Health Policy. (2018). What is Telehealth?. Retrieved from http://www.cchpca.org/what-is-telehealth

2. Center for Connected Health Policy. (2018). State Telehealth Laws and Reimbursement Policies: A Comprehensive Scan of the 50 State and District of Columbia. Retrieved from http://www.cchpca.org/state-laws-and-reimbursement-policies

3. Federation of State Medical Boards. (2018). Telemedicine Key Issues and Policy. Retrieved from https://www.fsmb.org/advocacy/telemedicine/

4. Hall, J (2014). For Telehealth to Succeed, Privacy and Security Risks Must be Identified and Addressed. Health Affairs, 33, No. 2(2014): 216-221. Doi: 0.1377/hlthaff.2013.0997

5. Kruse, C. S. (2016). Evaluating barriers to adopting telemedicine worldwide: A systematic review. Journal of Telemedicine and Telecare, 24(1), 4-12. doi:10.1177/1357633x16674087

6. Lacktman, N. (2018) Prescribing Controlled Substances Without an In-Person Exam: The Practice of Telemedicine Under the Ryan Haight Act. Retrieved from https://www.healthcarelawtoday.com/2017/04/17/prescribing-controlled-substances-without-an-in-person-exam-the-practice-of-telemedicine-under-the-ryan-haight-act/

7. National Consortium of Telehealth Resources Centers. (2018) Telehealth Policy Issues. Retrieved from https://www.telehealthresourcecenter.org/wp-content/uploads/2018/05/Policy-FS-FEBRUARY-2018.pdf

8. Northeast Telehealth Resource Center. (2018) Types of Telehealth. Retrieved from http://netrc.org/types-of-telehealth/

9. Yang, T. (2016). Health Policy Brief: Telehealth Parity Laws. HealthAffairs. doi: 10.1377/hblog20160815.056155


Submitted by: Brian Tran