Telemedicine Q & A: Are you still in the dark?
Telemedicine Q & A: Are you still in the dark?
Experts shed light on this field
Whether you’ve heard of telemedicine or you’re still in the dark about it, chances are you’ll hear much more about this burgeoning telecommunications technology soon. Despite its 30-plus-year history, most people are unaware of its existence let alone its myriad applications. Today, that is rapidly changing. Telemedicine is poised on the brink of joining the mainstream.
Hospital Home Health talked to several experts and got their insights into the future of this new field:
Question: What is telemedicine?
Answer: Telemedicine is the transfer of electronic medical data, such as patient records or high-resolution images, from one location to another. This transfer technology may involve something as simple as a standard telephone line, the Internet, or more complex methods such as a T-1 line (a high-speed digital line) or satellite.
"Simply put, it is a way to achieve a more efficient use of resources, where a resource such as a health care provider is in one place and someone who wants to use that resource is in another," explains Douglas Perednia, MD, president of the Association of Telemedicine Service Providers (ATSP) and director of the Telemedicine Research Center, both in Portland, OR.
Home telemedicine is an extension of that transfer and uses telecommunications technology to provide services that normally would be carried out in the patient’s home by a home health aide or nurse. When used in a home care setting, Perednia stresses that home telemedicine should be viewed as "a health care extender and not a replacer."
Question: Is there a difference between telemedicine and telehealth?
Answer: Yes and no. The words have come to be used interchangeably. However, a subtle distinction does exist, says Barbara Johnston, MSN, California children’s services coordinator for Sacramento-based Kaiser Permanente.
"Telemedicine is physician-driven and is associated with institutional medicine. It started with doctors who were using the technology to consult with each other remotely," she explains. "Telehealth is more general and opens the field to other health care providers such as home care. It encompasses things like preventative programs and health education."
Question: How is telemedicine being used?
Answer: You name it and telemedicine has probably played a role — oncology, radiology, surgery, cardiology, and psychiatry are just a few of the specialties in which telemedicine is being used.
Teledermatology, says Johnston, is one of the fastest growing areas. A typical scenario, she says, may center on a patient who goes to see a pediatrician for treatment of acne. "While most pediatricians are familiar with acne’s causes and treatments, the doctor may want the patient to see a dermatologist for a backup consultation," she says. "Instead of sending the patient and parent down to the dermatology clinic to make an appointment to come back in several weeks — something that will require another missed day of class and work — they can go down to the teledermatology department, where an RN will take a high-resolution picture.
"This, in turn, is electronically transmitted to a dermatologist who will examine the picture and make a diagnosis. If a prescription is needed, it can be called in directly to the patient’s pharmacy or the patient can be called back in for a physical examination if the doctor sees something suspicious," she says.
In hospital settings, telemedicine has a variety of applications and has proven especially beneficial in rural settings, where hospitals and staff may not have ready access to certain medical specialists or trauma centers. Specialists hundreds of miles away can be consulted in an instant via ISDN lines and the like.
Depending on the format, telemedicine can take on a variety of uses. "With a store-and- forward format, a radiology exam can be conducted in Ohio and the information and image then be transmitted to Boston where a specialist can see it," Johnston explains. "Live video was used to assist with performing surgery in the Gulf War."
Question: How can the technology be used in a home care setting?
Answer: "Generally, most telemedicine systems aren’t used for the regulation of life-support machines," says Perednia. "They relay information which is then used as a basis for using or adjusting certain settings." It is not surprising that home care agencies have found them ideal for monitoring vital signs and assisting patients in complying with their care protocols.
For this reason, telemedicine is ideal for patients living with chronic diseases such as asthma or diabetes. Telecommunications-ready glucometers can assist patients with monitoring their insulin more effectively, for example. Glucose levels can be sent in to the home health agency nurse who can in turn advise patients within a matter of minutes if there is a problem.
Telemedicine is not all passive, notes Jay Sanders, MD, president of Global Telemedicine Group in McLean, VA; immediate past-president of the American Telemedicine Association in Washington, DC; adjunct professor of medicine at Johns Hopkins University in Baltimore; and visiting professor at Yale in New Haven, CT. "With it I can listen to your heart and lungs and check your vital signs. I can look into your eyes, measure your pulse, and perform a pulmonary function test," he says. "And while I can’t physically touch you, depending on the situation, it’s not always so important that a doctor be able to see you in real time as it is getting other data like an EKG or listening to what’s going on in your lungs."
Another interesting use in the home, he says, could spell substantial savings for the U.S. health care system. "We have a $100-billion-a-year problem in the health care industry," Sanders explains. "People just aren’t compliant about taking their medication. Either they don’t take it, or they take it at the wrong time or with other medications that it shouldn’t be mixed with. When we can get to the patients more frequently and ask to actually see the medication bottle, patients pay a lot more attention and their overall compliance improves dramatically . . . particularly with chronically ill patients who have a revolving-door history of hospital admissions, their re-admission rate goes down significantly."
Question: Do the systems require extensive training?
Answer: Johnston had set aside several weeks for training her staff on the operation of their telemedicine system. But, she says, the training took only an hour.
Not everyone may have it so easy, and it may take some time for home health agency staffs to become familiar — and comfortable — with the systems. Patients, for the most part, have it much easier as many systems use touch-screens and the like.
It has to be simple, Sanders points out. "You have to remember that one of the people who will be using it is a patient and by definition not in perfect health. It really has to be user-friendly and can’t be something that will be difficult for the patient. You could really teach yourself. In fact, most systems are easier to operate than putting together my son’s toys."
Question: Is a telemedicine system expensive?
Answer: As with many electronic products, pricing is dependent on a variety of factors, not the least of which are the sophistication of the system and the manufacturer. Then too, a good source of information is another user of the technology.
In Johnston’s case, she found the cost of the equipment more than paid for itself in 12 months. Still, she has a large health care network behind her. Smaller health care providers, like most home health agencies, are not in an ideal financial position to make large capital investments these days as the prospective payment system and the interim payment system cut into already tight budgets. Luckily, some systems are fairly affordable — glucometers may only cost about $100, for example, and automated calls to patients (as a reminder to take their medication) run about 33 cents a minute. A video phone system that could be used to manage wound care would cost around $300 to buy and install.
Of course, higher level systems come with larger price tags. A telehealth workstation that is able to do just about everything you would find on a fully equipped hospital floor can cost upward of $25,000.
Vendors, now that they’re selling more units, are offering agencies and other providers who don’t want to commit to purchasing a system the option to lease. Even though purchasing outright will save money in the long run, "with technology today, you really have to see it as disposable. You must see a return on your investment within a year. After that it will obsolete anyway," Perednia points out. "You really need to have a short horizon when looking to recover your costs. On the other hand, the equipment might be outmoded, but things like blood pressure [gauges] won’t go out of fashion any time soon. So for basic equipment, leasing might not be the best bet."
If an agency is considering using telemedicine, he suggests it classify its cases according to their complexity level and purchase systems accordingly. If you have 30% low-level patients and another 30 classified as in need of high monitoring, you want to be sure your purchase reflects your usage, he says.
Perednia cautions potential buyers to spend some time and energy studying manufacturers and their equipment before investing any capital. "If possible, you want to arrange for a testing period, otherwise let the buyer beware," he says. "There are so many configurations and manufacturers, it’s not necessarily the case that one system will communicate easily with that of another manufacturer."
Question: Why should my agency consider home telemedicine?
Answer: Cost savings. With fewer miles logged by nurses, considerable savings in mileage reimbursement can be seen. "If time is money, then you save a substantial amount in traffic time," says Perednia. And, by cutting down on travel time — often 45 minutes to an hour between visits — nurses are able to see more patients in a day. Some estimates place that number as high as five to eight times as many as were previously seen. Not only does this assist the nurse in caring for her patients, but increased contact benefits the patient as well.
"It gives back to the patients some level of control," Johnston says. "Now, instead of being fit into a visitation schedule based on where other patients live, they’re better able to decide when they want to be seen."
Any fears of impersonal provider-patient relationships have gone unfounded, she continues. Johnston says Kaiser did a controlled survey of patients and asked if they were intimidated by the devices and if they felt the system was too impersonal. "More than 90% were in favor of it — an overwhelmingly positive response. They still have actual visits from the nurses, but this way they have that extra measure of contact."
Sanders has found that the home telehealth visit becomes an event for patients, especially the elderly. "They see themselves on the screen, and it’s like being on TV. It’s captivating for them. And it gives them that extra sense of security that they can get in touch with the doctor or nurse any time they want. It gives them a sense of empowerment."
Question: Why, if there are so many applications, aren’t more agencies using telemedicine?
Answer: Cost is clearly one reason, but it’s not as large a concern as reimbursement. At this time, the Health Care Financing Administration reimburses for home telemedicine in very few instances, says Johnston, and then only in particular rural settings. While a lack of reimbursement is certainly the largest determining factor in why agencies are holding off on the use of telemedicine, it’s not the only factor. (See box, p. 51.)
In the 1998 Report on U.S. Telemedicine Activity, the ATSP reported that the use of telemedicine is up. Teleconsultations increased by 90% from the previous year to 41,740, 18 new programs went on-line during 1998, and overall, 157 active programs were operating, up from 10 in 1993. Even as it grows in popularity, telemedicine must overcome several serious hurdles if it is to mature. Survey respondents, says ATSP, cited payment and technology costs, ambiguity over interstate licensure, and liability as major points of concern.
Nurses, too, have proven to be a substantial barrier in implementing telemedicine, adds Johnston. "For them it’s a big change and coming at a time when they are being asked to go through a lot. They don’t know whether their agencies will be in business next month so it’s hard for them to think about investing time and energy and money into a start-up program when their reimbursements have already been cut in half."
Susan Nelson, BSN, staff nurse for home care/hospice at Redwood Falls (MN) Hospital has first-hand experience with barriers to the technology. "We have the telemedicine units and tried to use them, but the nurses didn’t buy into it," she says.
"They didn’t work as well as they thought they should so they were put on the back burner. Last year, we tried to encourage them to use them again but it hasn’t worked," Nelson adds. While telemedicine hasn’t worked — yet — for Nelson’s agency, she says she still believes in the concept.
"You have to have people in the home who can accept the technology and understand how it works. It’s not difficult to use, but people need to be willing to use it. I think there is definitely a lot of value to telemedicine. It’s just a matter of getting the right mix of people, diagnoses, and nurses."
Johnston says that about one-third of her nursing staff was initially anti-telemedicine. To overcome that barrier, Johnston used their questions and input as fodder for team conferences and focus groups. "You really need to survey people about what they like and don’t like about a system and share the information. Complaints can make a system improve. Some of them were even incorporated by the vendor to improve the equipment," she notes.
As for coping with patients who are leery of telemedicine, the last thing one should do is foist it upon them, explains Johnston. "We’ll let patients know they are eligible for telemedicine and have their nurses do a demonstration. If they’re interested, great; if not, we won’t push it. We won’t dictate to our patients, and we’re certainly not in the business of forcing technology on sick people."
Sources
• Barbara Johnston, MSN, CCS Coordinator, Kaiser Permanente, 1650 Response Road, Sacramento, CA 95815. Telephone: (916) 614-4963.
• Susan Nelson, BSN, Staff Nurse in Home Care/Hospice, Redwood Falls Hospital, 100 Fallwood Road, Redwood Falls, MN 56283. Telephone: (507) 637-2907.
• Douglas Perednia, MD, President, Association of Telemedicine Service Providers, 7276 S.W. Beaverton-Hillsdale Highway, Suite 400, Portland, OR 97225. Telephone: (503) 222-2406.
• Jay Sanders, MD, President, Global Telemedicine Group, 1317 Vincent Place, McLean, VA 22101. Telephone: (703) 448-9640.
Who’s Paying and Who’s Not?
Currently, the reimbursement prospects for telemedicine are rather grim and confusing, too. With luck, the Health Care Financing Administration (HCFA) will decide to cover home telemedicine expenses and include them under the umbrella of a visit, says Jay Sanders, MD, president of Global Telemedicine Group in McLean, VA. Until then, reimbursement stands as follows:
Ten states (Arkansas, California, Georgia, Iowa, Kansas, Montana, North Dakota, South Dakota, Virginia, West Virginia) reimburse telemedicine expenses under Medicaid, provided the health care agency or institution can document that the use of telemedicine saved the agency money. However, as there is no standard reimbursement fee, it is up to each state to determine how much it will pay. Medicare operates four demonstration sites in West Virginia, Iowa, North Carolina, and Georgia. Experts contend these findings will alter HCFA’s current stance against home telemedicine reimbursement. Commercial insurers have been, in some instances, reimbursed for home telemedicine when those services are bundled with conventional services. A few states have passed legislation relating to telemedicine. However, as of mid-1998, none has specifically targeted coverage for home telemedicine. Certain HMOs have started telemedicine programs for selected members, typically those with chronic diseases. To date, no long-term initiatives have been taken.Source: Kinsella A. Cost and reimbursement for home telemedicine services. Information for Tomorrow 1998. Web site: tie.telemed.org/.
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