Telehealth: A tool for the 21 st century Karen S. Rheuban MD Professor of Pediatrics Medical Director, Telemedicine University of Virginia
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Telehealth: A tool for the 21st century
Karen S. Rheuban MDProfessor of PediatricsMedical Director, TelemedicineUniversity of Virginia
DisclosureDisclosure
I have no financial relationships to report that would create any conflict of interest in relationship to this presentation
Objectives
Understand the applications of telemedicine in the delivery of healthcare, especially as they relate to children
Understand statutory and regulatory issues impacting the development of telemedicine networks
Definitions
“Telemedicine” is the use of medical information exchanged from one site to another via electronic communications to support
• Medical diagnosis Ongoing patient care Remote patient monitoring
“Telehealth” encompasses a broader definition of remote healthcare that does not always involve clinical services
Health-related distance learning
Telemedicine: History
Alexander Graham Bell Hugo Gernsback (vision) Massachusetts General U of Nebraska NASA Dept of Defense University of Virginia
Mission
Facilitate the Health System’s missions of
• Clinical Care• Teaching• Research• Public Service
Services Videoconferencing for patient care
Store and forward applications Distance learning
health professionals patients students
UVA Specialty/Subspecialty Participants
CardiologyDermatologyDiabetesEmergency MedicineEndocrineENTGastroenterologyGeneticsGeriatricsGynecologyHematologyInfectious DiseaseNephrologyNeurologyNeurosurgeryOphthalmologyOrthopedics
Obesity Oncology/Tumor boards Pain management Pediatric cardiology Pediatric nephrologyPediatric oncology Plastic surgery Psychiatry Pulmonary medicine Radiology Rheumatology Surgery TCV Toxicology/Poison control Urology Wound care
Partnerships
Academic-community hospital linkages Academic-academic hospital linkages Rural clinics (FQHCs, Veteran’s clinics) Virginia Department of Health Virginia Department of Corrections School health Nursing home Home telehealth
Barriers to Access Geographic– >20% of US population reside in rural areas– Burden of transportation to care generally borne by patients– Medicaid programs bear the burden of transportation costs
1999: >$50 million/year in Virginia alone– Multiple definitions of rural
Financial– The uninsured, underinsured (> 40 million uninsured)– Delayed access to services for uninsured– High cost of travel for locally unavailable specialty care
Barriers to Access
Societal– Societal stigmatization– Cultural barriers– Language barriers
Maldistribution/shortage of providers– Predicted shortage of physicians 85,000-200,000 by 2020– Urban predominance of specialty providers– Isolation of rural health providers– Need for continuing health professional education
Benefits of telehealth
Patients:• Timely access to locally unavailable services• Spared burden and cost of transportation• Improvement in quality of care
Health professionals• Access to consultative services• Access to CME• Primary care oversight of patient care
Rural communities• Enhanced healthcare/economic empowerment
Patients served: UVA program
>15,000 patient encounters >30,000 teleradiology readings Services in >30 different specialties• Emergency• Urgent• Single consults• Block scheduled clinics• Screenings with store forward technologies• New mobile digital mammography van• Retinopathy
More than technology and numbers: Saving lives: Infant with Interrupted aortic arch
More than technology and numbers:Facilitating expert care
Enhancing access
Educational programs
Broadcast continuing health professional education
UME, GME Patient education School Health Projects
International humanitarian outreach Swinfen Charitable Trust
In conjunction with the Center for Online Health in Brisbane Automated email consultation system Physician to physician consults with attached digital images Volunteer consultants in 59 subspecialties, 1479 cases Consults from:
Pre/perinatal care ANGELS program - Arkansas
Antenatal Neonatal Guidelines, Education and Learning System• University of Arkansas/Medicaid partnership• Increase prenatal screening and referrals• Genetic counseling, targeted ultrasounds, MFM
consultations, pediatric consultations• Outcomes
– 2 year period – 467 congenital malformations– 50% referred for delivery– No-show rate for TM clinics 12%, UAMS 20%
Shannon Barringer, UAMS – Presentation Pediatric Telehealth Colloquium, 9/07
Tele-ophthalmology
Tele-ophthalmology technologies: live or store forwardMost data in patients with diabetesRetinopathy of prematurity
ATA: Tele-ophthalmology standards
Pediatric cardiology
Incidence of CHD is 8/1000 live births Traditional models of care:
Schedule appointment Emergency transfer Wait for field clinic Obtain echo and mail, courier
Models for tele-echocardiography Live interactive support of remotely located technologists Store forward images sent in digital format
•
Acute stroke intervention
Challenge of lack of access to stroke neurologist in rural areas
Time is of the essence (3 hour window for thrombolytic agents
Increase use of TPA in rural hospitals from 4% to 23%
HIV/AIDS
Outcomes: UVA Telehealth HIV Program1
213 correctional patients treated with 1812 visits over 5 year period Of patients naïve to therapy:
– 77% attained undetectable viral load (<50 copies/ml)– 50-60% in HIV clinic – 40% receiving community based care by non-HIV specialists
1 Rheuban,KS, Wispelwey B et al HIV/AIDS, HRSA Telemedicine Technical Assistance Documents 2004
Cancer outreach: Mobile digital mammography
Tele-pathology
Primary interpretation Second opinion Collaborative tumor boards Remote access to clinical trials
Tele-mental health
Shortage of mental health providers in rural areas
Consultations, medication management Sign language for hearing impaired Interpreter services
Tele-mental health
Comprehensive review of the medical literature in telepsychiatry1
• Technology predominantly interactive videoconferencing• Improve access, shorter wait times• High rates of patient satisfaction in all age groups• Diagnosis change from PC provider diagnosis in 91% • Medication changes in 57%• Reduced geriatric hospital admissions from long-term care facility
by 59%
1Hilty, D, et al, Can J Psych 2004; 49:12-23
e-ICU
Models for support of intensive care units1
• Two adult ICUs in large tertiary care hospital system• 2140 patients receiving ICU care • E-ICU services from 12 noon – 7am• Program utilized off-site intensivists, physician
extenders, electronic data display, decision support tools
• Results:Hospital mortality decreased from 12.9-9.4% ICU length of stay shorter 4.35-3.63 days
1 Breslow, MJ, Crit Care Med 2004 32(1): 31-38
Remote monitoring and Home telehealth
Remote monitoring– CHF– Diabetes– COPD/ Asthma
Challenges
Funding of telehealth (Stark, Anti-kickback Laws) Reimbursement Outcomes Confidentiality JCAHO Licensure Malpractice Telecommunications venue/costs Integration with EMRS/RHIOS Interagency alignment related to policies
Federal (definition of rural, rural vs urban)State (eligible plans, coverage of store and forward)
Outcomes:2006Agency for Healthcare Research and Quality (AHRQ)
Still significant gaps in the evidence base between where telemedicine is used and where its use is supported by high-quality evidence.
Further well-designed and targeted research that provides high-quality data will provide a strong contribution to understanding how best to deploy technological resources in health care.
Hersh, W, Supplement. Telemedicine for the Medicare Population: AHRQ Evidence Report/Technology AssessmentNumber 24, Supplement, 2006
Virginia Telehealth Network
Multi-institution/organization collaboration initiated by Virginia Department of Health
Inventory current activities Increase awareness of telehealth Increase collaboration Secure funding – competitive grants, appropriations Advocate in support of critical policy issues
The future of telehealth
Outcomes Standards Demonstration projects (ARRA) Integration into mainstream medicine Collaboration amongst providers,
policymakers, regulators Champions at all levels Engage your legislators!!!
Champions
Congressman Rick Boucher, Mrs. Lisa Hubbard, Alexandra Bartley
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