Telehealth PDF

Telehealth 18 Justin B. Starren, Thomas S. Nesbitt, and Michael F. Chiang After reading this chapter you should know the molecular...

Telehealth 18 Justin B. Starren, Thomas S. Nesbitt, and Michael F. Chiang After reading this chapter you should know the molecular processes and physical environments. answers to these questions: Collaboration reflects not only inter-professional What are the key informatics requirements for collaboration, but also a realization that success- successful implementation of telehealth systems? ful attainment of optimal well-being and effec- What are some key benefits from and barriers tive management of disease processes necessitate to implementation of telehealth systems? active engagement of clinicians, lay persons, con- What are the most promising application cerned family members, and society as a whole. domains for telehealth? This chapter introduces the concepts of telemedi- cine and telehealth, and illustrates how maturing computer networks like the Internet make possible 18.1 Introduction the collaborations necessary to achieve the full benefits of our growing understanding of health Complexity and collaboration characterize health promotion, disease management and disability care in the early twenty-first century. Complexity prevention. Consider the following situation: arises from increasing sophistication in the understanding of health and disease, wherein etiological models must take into account both Samuel is a 76 year-old man with coronary artery disease, poorly-controlled Type II diabetes, and high blood pressure. In the J.B. Starren, MD, PhD (*) past, he has been unable to keep medical Division of Health and Biomedical Informatics, appointments consistently because of diffi- Department of Preventive Medicine and Medical Social Sciences, Northwestern University Feinberg culty arranging transportation. He had a School of Medicine, 750 N. Lake Shore Dr., recent acute hyperglycemic episode that Chicago, IL 60611, USA required hospitalization. After 4 days he is e-mail: [email protected] medically stable and ready for discharge. T.S. Nesbitt, MD, MPH He is able to measure his blood glucose and Department of Family and Community Medicine, can safely administer the appropriate dose School of Medicine, UC Davis Health System, 4610 X Street, Suite 3101m, Sacramento, CA 95817, USA of insulin. The nurse notes that Samuel e-mail: [email protected] sometimes has trouble calibrating his insu- M.F. Chiang, MD, MA lin dose to the blood glucose reading. Department of Ophthalmology & Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, 3375 SW Terwilliger This chapter is adapted from an earlier version in the third Boulevard, Portland, OR 97239, USA edition authored by Patricia Flatley Brennan and Justin e-mail: [email protected] B. Starren. E.H. Shortliffe, J.J. Cimino (eds.), Biomedical Informatics, 541 DOI 10.1007/978-1-4471-4474-8_18, © Springer-Verlag London 2014 542 J.B. Starren et al. 18.1.1 Telemedicine and Telehealth and, telehealth (see Sect. 18.3.5.3). Some sub- to Reduce the Distance domains do not fit neatly into this naming para- Between the Consumer digm. Correctional Telehealth (see Sect. 18.3.5.2) and the Health care System refers to the location of the patient in a correctional institution. It is discussed separately because of the Historically, health care has usually involved different business model, and the fact that it rep- travel. Either the health care provider traveled resents an early and sustained success. Remote to visit the patient, or more recently, the patient Intensive Care (see Sect. 18.3.5.5) is the term traveled to visit the provider. Patients with diabe- used to describe the use of telehealth technologies tes, like Samuel, typically meet with their physi- in an ICU setting. Teleconsultation is a general cian every 2–6 months to review data and plan term describing the use of telehealth technologies therapy changes. Travel has costs, both directly, to support discussions between clinicians, or in terms of gasoline or transportation tickets, and between a clinician and a patient. The archetypal indirectly, in terms of travel time, delayed treat- teleconsultation occurs when the patient and the ment, and lost productivity. In fact, travel has generalist clinician are in a rural or remote location accounted for a significant proportion of the total and a specialist is at a distant tertiary referral facil- cost of health care (Starr 1982). Because of this, ity. Telepresence (see Sect. 18.3.6) refers to high- both patients and providers have been quick to speed, multi-modality telehealth interactions, such recognize that rapid electronic communications as Telesurgery, that gives the feeling of “being have the potential to improve care by reducing the there”. costs and delays associated with travel. This has It is clear from the definition above that there involved both access to information resources, is considerable overlap between telehealth and as well as direct communication among various Biomedical informatics. In fact, one will fre- participants, including patients, family members, quently find papers on telehealth systems pre- primary care providers and specialists. sented at Biomedical Informatics conferences As is the case with informatics, the formal and presentations on informatics at telehealth definitions of telemedicine and telehealth tend and telemedicine meetings. Some groups, espe- to be very broad. Telemedicine involves the use cially in Europe, have adopted the rubric health of modern information technology, especially information and communication technology two-way interactive audio/video communica- (HICT). The major distinction is one of emphasis. tions, computers and telemetry to deliver health Telehealth and telemedicine emphasize the dis- services to remote patients and to facilitate infor- tance, especially the provision of care to remote mation exchange between primary care physi- or isolated patients and communities. In contrast, cians and specialists at some distance from each Biomedical Informatics emphasizes methods for other (Bashshur 1997). Telehealth is a somewhat handling the information, irrespective of the dis- newer and broader term referring to remote health tance between patient and provider. care that includes clinical services provided using Consumer health informatics (CHI) is telemedicine, as well as interactions with auto- a related domain that bridges the distance mated systems or information resources. Because between patients and health care resources, of its broader scope, we are using the term tele- and that typically emphasizes interactions with health in this chapter. computer-based information such as websites As is the case with Biomedical informatics, or information resources. Collectively, CHI and there are many different sub-domains within tele- telehealth deliver health care knowledge and health. For nearly every clinical domain, there is expertise to where they are needed, and are ways a “tele-X” or “X telehealth”, where X is the clini- to involve the patient as an active partner in care. cal domain. Examples include: Teleradiology Despite their similarities, CHI and telehealth (see Sect. 18.3.4.1); Teleophthalmology (see come from very different historical foundations. Sect. 18.3.4.2); Telepsychiatry (see Sect. 18.3.5.1); Telehealth derived from traditional patient care, 18 Telehealth 543 while CHI derived from the self-help movements prescribe care, such as “take one number five and of the 1970’s. Largely owing to this historical two number fours.” separation, practitioners and researchers in the Modern telehealth can be traced to 1948 when two fields tend to come from different back- the first transmission of a radiograph over a phone grounds. For these reasons, we are presenting line was reported. Video-based telehealth can be CHI and telehealth as two distinct, but closely traced to 1955 when the Nebraska Psychiatric related domains (see Chap. 17 for more on CHI). Institute began experimenting with a closed- curcuit video network on its campus. In 1964 this was extended to a remote state mental health 18.2 Historical Perspectives facility to support education and teleconsulta- tion. In 1967, Massachusetts General Hospital The use of communication technology to convey (MGH) was linked to Logan International health-related information at a distance is noth- Airport via a microwave audio-video link (Bird ing new. The earliest known example may be the 1972; Murphy et al. 1973). In 1971 the National use of so-called “leper bells” carried by individu- Library of Medicine began the Alaska Satellite als during Roman times. Sailing ships would fly Biomedical Demonstration project linking 26 a yellow flag to indicate a ship was under quaran- remote Alaskan villages utilizing NASA satel- tine and awaiting clearance by a doctor, or a lites (Hudson and Parker 1973) yellow and black “plague flag” to indicate that The period from the mid 1970’s to the late infected individuals were on board. By some 1980’s was a time of much experimentation, but accounts, when Alexander Graham Bell said few fundamental changes in telehealth. A vari- “Mr. Watson. Come here. I need you” in 1876, it ety of pilot projects demonstrated the feasibility was because he had spilled acid on his hand and and utility of video-based telehealth. The military needed medical assistance. In 1879, only 3 years funded a number of research projects aimed at later, the first description of telephone use for developing tools for providing telehealth care clinical diagnosis appeared in a medical journal on the battlefield. The early 1990’s saw sev- (Practice by Telephone 1879). eral important advances. Military applications developed during the previous decades began to be deployed. Military teleradiology was 18.2.1 Early Experiences first deployed in 1991 during Operation Desert Storm. Telehealth in military field hospitals was One of the earliest and most long-lived telehealth first deployed in 1993 in Bosnia. Several states, projects is the Australian Royal Flying Doctor including Georgia, Kansas, North Carolina and Service (RFDS), founded in 1928. In addition to Iowa implemented statewide telehealth networks. providing air ambulance services, the RFDS pro- Some of these were pure video networks, based vides telehealth consultations. These consulta- on broadcast television technology. Others were tions first used Morse Code, and later voice, radio built using evolving Internet technology. During communications to the remote sheep stations in this same period, correctional telehealth (see the Australian outback. Lay people played a sig- Sect. 18.3.5.2) became much more common. nificant role here, clearly communicating their For example, in 1992 East Carolina University concerns and clinical findings to the RFDS and contracted with the largest maximum-security carefully carrying out instructions while await- prison in North Carolina to provide telehealth ing, if necessary, the arrival of the physician. The consultation. RFDS is most famous for its standardized medi- Telehealth projects in the early 1990s con- cal chest, introduced in 1942. The chest contains tinued to be plagued by two problems that had diagnostic charts and medications, identified hampered telehealth since its inception: high only by number. This allowed the consulting cli- cost and poor image quality. Both hardware and nician to localize symptoms by number and then high-bandwidth connections were prohibitively 544 J.B. Starren et al. expensive. A single telehealth station typically Newer network routing technologies such as cost over $50,000 and connectivity could cost multiprotocol label switching (MPLS) can, in thousands of dollars per month. Most programs addition to providing superior network throughput were dependent on external grant funding for sur- performance, permit explicit prioritization of clini- vival. Even with this, image resolution was fre- cal traffic while simultaneously providing access quently poor and motion artifacts were severe. to lower priority administrative and other non- The Internet revolution that began in the late clinical traffic. The individual data packets of high 1990s drove fundamental change in telehealth. priority traffic (e.g., telehealth or patient monitor- Advances in computing power both improved ing sessions) are “tagged” with a numerical prior- image quality and reduced hardware costs to the ity flag. As the QOS-tagged packets traverse the point that, by 2000, comparable systems cost less network, each routing/switching device recognizes than a tenth of what they had a decade earlier. the priority tag and preferentially processes and Improvements in image compression made it pos- forwards the packets. This explicit QOS combined sible to transmit low-resolution, full-motion video with advanced security and privacy features within over standard telephone lines, enabling the growth a broadband network has been characterized as of telehome care. With the increasing popularity “Medical Grade” broadband. of the World Wide Web, high-bandwidth connec- tions became both more available and less expen- sive. Many telehealth applications that had relied 18.3 Bridging Distance with on expensive, dedicated, point-to-point connec- Informatics: Real-world tions were converted to utilize commodity Internet Systems connections. The availability of affordable hard- ware and connectivity also made access to health- There are many ways to categorize telehealth related electronic resources from the home, school resources, including classifications based on or work place possible and fueled the growth of participants, bandwidth, information transmit- consumer health information (see Chap. 17). ted, medical specialty, immediacy, health care condition, and financial reimbursement. The categorization in Table 18.1 is based loosely on 18.2.2 Recent Advances bandwidth and overall complexity. This categori- in Medical-Grade zation was chosen because each category presents Broadband Technology different challenges for informatics researchers and practitioners. As telemedicine applications are being increas- A second categorization of telehealth systems ingly used in critical medical situations such as that overlaps the previous one is the separation emergency care and remote surgery applications, into synchronous (or real-time) and asynchro- quality of service (QOS) becomes extremely nous (or store-and-forward systems). Video important. It is important to note that optimally conferencing is the archetypal synchronous provisioning a network for medical-grade QOS telehealth application. Synchronous telehealth does not simply imply that the network will pro- encounters are analogous to conventional office vide “quality” in the sense of reliability, consis- visits. Telephony, chat-groups, and telepres- tency and bandwidth performance, although these ence (see Sect. 18.3.6) are also examples of characteristic are certainly important require- synchronous telehealth. A major challenge in all ments. Any network, no matter the bandwidth synchronous telehealth is scheduling. All par- available, can become congested – overwhelmed ticipants must be at the necessary equipment at with the volume of traffic to the extent that ses- the same time. sions are interrupted and data lost. Bandwidth Store-and-forward, as the name implies, availability limitations are particularly prevalent involves the preparation of a dataset at one site in rural locations where high-capacity circuits that is sent asynchronously to a remote recipient. may be unavailable or prohibitively expensive. Remote interpretation, especially teleradiology, is 18 Telehealth 545 Table 18.1 Categories of telehealth and consumer health informatics Telehealth category Bandwidth Applications Information resources Low to moderate Web-based information resources, patient access to electronic medical records Messaging Low E-mail, chat groups, consumer health networks, personal clinical electronic communications (PCEC) Telephone Low Scheduling, triage Remote monitoring Low to moderate Remote monitoring of pacemakers, diabetes, asthma, hypertension, Congestive Health Failure (CHF). Remote interpretation Moderate PACS, remote interpretation of radiographic studies and other images, such as dermatologic and retinal photographs. Videoconferencing Low to high Wide range of applications, from low-bandwidth telehome care over telephone lines, to high-bandwidth telementoring and telepsychiatry Telepresence High Remote surgery, telerobotics the archetypal example of store-and-forward tele- investing £123 million per year in NHS Direct, a health. Images are obtained at one site and then nation wide telephone information and triage sent, sometimes over very low bandwidth connec- system that handles 27,000 calls per day. With tions, to another site where the domain expert some insurance providers reimbursing for e-mails interprets them. Other examples of store-and- and text messaging, providers are asking why not forward include access to Web sites, e-mail and reimburse for telephone calls also. text messaging. Some store-and-forward systems support the creation of multimedia “cases” that contain multiple clinical data types, including 18.3.2 Electronic Messaging text, scanned images, wave forms and videos. Electronic text-based messaging has emerged as a popular mode of communication between patients 18.3.1 The Forgotten Telephone and providers. It began with patients sending con- ventional e-mails to physicians. The popularity of Until recently, the telephone was a forgotten this grew so rapidly that national guidelines were component in teleheath. The field of telemedicine developed (Kane and Sands 1998). However, and telehealth focused on video and largely e-mail has a number of disadvantages for health ignored the audio-only telehealth. Few studies related messaging: delivery is not guaranteed; were done and few articles written. This is para- security is problematic; e-mail is transient (there doxical given that up to 25 % of all primary care was no automatic logging or audit trail); and the encounters occur via the telephone. These include messages are completely unstructured. triage, case management, results review, consul- To address these limitations, a variety of Web- tation, medication adjustment and logistical based messaging solutions, called personal clin- issues, like scheduling. In part, this can be traced ical electronic communications, have been to the fact that telephone consultations are not developed (Sarkar and Starren 2002). Because reimbursed by most insurance carriers. the messages never leave the Web site, many of More recently, increased interest in cost con- the problems associated with conventional e-mail trol through case management has driven renewed are avoided. Web-based messaging is a standard interest in use of audio-only communication feature of patient portals see Chap. 17) associ- between patients and providers. Multiple articles ated with many EHRs. The inclusion of messag- have appeared on the value of telephone follow- ing as a Meaningful Use requirement for Certified up for chronic conditions. Several managed care EHRs is expected to significantly increase the use companies have set up large telephone triage of web-based messaging to provide telehealth centers. The National Health Service in the UK is (Fig. 18.1). 546 J.B. Starren et al. Family, Friends, Patient Remote Specialist Other Images Interpretation Patients Electronic Peer Health support Imaging Eletronic Referrals Records Networks Video conferencing Health Consumer Primary Related Health Patient Telephone Care Websites Resources Provider Messaging General TeleHome Telepresence, Information Care Remote Surgery Websites Nurse Surgeon Fig. 18.1 Connections. The figure shows different ways such as Web sites or telehome care, can be accessed from that electronic communications can be used to link the patient’s home. Other resources, such as remote sur- patients with various health resources. Only connections gery or imaging, would require the patient to go to a tele- directly involving the patient are shown (e.g., use of the health-equipped clinical facility EHR by the clinician is not shown). Some of the resources, 18.3.3 Remote Monitoring Remote monitoring is used to track parameters that guide management. Any measurable param- Remote monitoring is a subset of telehealth eter is a candidate for remote monitoring. The col- focusing on the capture of clinically relevant data lected data may include continuous data streams in the patients’ homes or other locations outside or, more commonly, discrete measurements. of conventional hospitals, clinics or health care Another important feature of most remote mon- provider offices, and the subsequent transmission itoring is that the measurement of the parameter of the data to central locations for review. The and the transmission of the data are typically sepa- conceptual model underlying nearly all remote rate events. The measurement devices have a mem- monitoring is that clinically significant changes ory that can store multiple measurements. The in patient condition occur between regularly patient will send the data to the caregiver in one of scheduled visits and that these changes can be several ways. For many studies, the patient will log detected by measuring physiologic parameters. onto a server at the central site (either over the Web The care model presumes that, if these changes or by direct dial-up) and then type in the data. are detected and treated sooner, the overall condi- Alternately, the patient may connect the measure- tion of the patient will be improved. An impor- ment device to a personal computer or specialized tant distinction between remote monitoring and modem and transfer the readings electronically. many conventional forms of telemedicine is that More recently, a variety of monitoring devices remote monitoring focuses on management, have been developed that either connect directly rather than on diagnosis. Typically, remote moni- to mobile telephones or transmit the data to the toring involves patients who have already been mobile phone using Bluetooth wireless. The diagnosed with a chronic disease or condition. mobile phone then transmits the data to a provider 18 Telehealth 547 for review. A major advantage of direct electronic transfer is that it eliminates problems stemming complication, he has only rarely received from manual entry, including falsification, num- dilated eye exams for retinopathy screen- ber preference and transcription errors. The role ing. There is no eye doctor conveniently of mobile telephones in providing health services located near his home, and he feels that the has grown so rapidly that a new term mobile appointments are always too long and that health (or “mHealth”) has been coined. The term he has no problems such as blurred vision. appeared first, one time, in 2004 in PubMed. All However, his primary care doctor has of the other mentions have been since 2009. recently implemented a new retinal screen- Any condition that is evaluated by measuring ing machine in the office. During a routine a physiologic parameter is a candidate for remote medical examination, Samuel receives a monitoring. The parameter most measured in the retinal photograph from an office techni- remote setting is blood glucose for monitoring cian that is then interpreted by a remote diabetes. A wide variety of research projects and ophthalmologist. Samuel is told that he has commercial systems have been developed to high-risk diabetic retinopathy that requires monitor patients with diabetes. Patients with treatment to prevent visual loss. He is asthma can be monitored with peak-flow or full- emergently referred to an ophthalmologist, loop spirometers. Patients with hypertension can who performs a successful laser procedure be monitored with automated blood pressure to treat the diabetic retinopathy. cuffs. Patients with congestive heart failure (CHF) are monitored by measuring daily weights to detect fluid gain. Remote monitoring of pace- Remote interpretation is a category of store- maker function has been available for a number and-forward telehealth that involves the capture of of years and has recently been approved for reim- images, or other data, at one site and their trans- bursement. Home coagulation meters have been mission to another site for interpretation. This developed that allows the monitoring of patients may include radiographs (teleradiology), pho- on chronic anticoagulation therapy. See Chap. 19 tographs (teledermatology, teleophthalmology, for more on patient monitoring systems. telepathology), wave forms such as ECGs (e.g. Several factors limit the widespread use of telecardiology), and text-based medical data. remote monitoring. First is the question of effi- The store-and-forward telehealth modalities cacy. While these systems have proven accept- have benefited most from the development of the able to patients and beneficial in small studies, commodity Internet and the increasing avail- few large-scale controlled trials have been done. ability of affordable high bandwidth connections Second is the basic question of who will review that is provides. The shared commodity Internet the data. Research studies have utilized specially provides relatively high bandwidth, but the avail- trained nurses at centralized offices but it is not able bandwidth is continuously varying. This clear that this will scale up. Third is money—for makes it much better suited for the transfer of most conditions, remote monitoring is still not a text-based data and image files, rather than for reimbursed activity. streaming data or video connections. Although image files are often tens or hundreds of mega- bytes in size, the files are typically transferred to 18.3.4 Remote Interpretation the interpretation site and cached there for later interpretation. From a logistical perspective, multiple remote interpretations may be batched Although Samuel was diagnosed with and performed together, thereby providing Type II diabetes over 20 years ago and important workflow and convenience advantages realizes that visual loss can be a serious over traditional medical examinations or real- time video telehealth paradigms. 548 J.B. Starren et al. 18.3.4.1 Teleradiology cause of blindness that can be treated if detected By far, teleradiology is the largest category of early. However, it has been found that nearly remote interpretation, and probably the larg- 50 % of diabetics are non-compliant with guide- est category of telehealth. Teleradiololgy (along lines recommending annual screening eye exam- with telepathology) represents the most mature inations (Brechner et al. 1993). Systems have clinical domain in telehealth. With the deploy- been developed that allow nurses or technicians ment of picture archiving and communications in primary care offices to obtain high quality dig- systems (PACS) that capture, store, transmit ital retinal photographs. These images are sent and displays digital radiology images, the line to regional centers for interpretation. If diabetic between teleradiology and conventional radiol- retinopathy is identified or suspected, the patient ogy is blurring. In fact, routine medical care in is referred for full ophthalmologic examination. radiology and pathology is increasingly being Large-scale operational systems have been delivered primarily through “telehealth” strate- implemented by the Veterans Health Admini- gies (Radiology image management is discussed stration and by other institutions, particularly in in more detail in Chap. 20). areas with limited accessibility to eye care spe- Many factors have contributed to the more cialists (Cavalleranno et al. 2005; Cuadros and rapid adoption of telehealth in domains such as Bresnick 2009). In fact, remote interpretation of radiology and pathology. One important fac- retinal images by certified reading centers, when tor is the relationship between these specialists taken after dilation of the eyes using standard and their patients. In both domains, the profes- photographic protocols originally developed for sional role is often limited to the interpretation of clinical research trials, has been demonstrated images, and the specialist rarely interacts directly to classify diabetic retinopathy more accurately with the patient. To patients, there is therefore than traditional dilated eye examination. This little perceived difference between a radiologist is likely because retinal abnormalities found on in the next building and one in the next state. photographs may be reviewed in more detail than An important factor driving the growth of tele- what is generally feasible during traditional eye radiology is that it is reimbursable by insurance examinations. payers. Because image interpretation does not As another example of teleophthalmology, involve direct patient contact, few payers make retinopathy of prematurity (ROP) is a leading any distinction about where the interpretation cause of blindness in premature infants, and hos- occurred. Rapid dissemination of teleradiology pitalized infants are examined regularly to iden- systems has also been supported by widespread tify treatment-requiring disease. However, these adoption of vendor-neutral image storage and examinations are logistically difficult and time transmission standards such as Digital Imaging consuming, and the number of ophthalmologists and Communication in Medicine (DICOM; willing to perform them has decreased. As a discussed in more detail in Chaps. 7 and 20). result, systems have been developed in which Finally, numerous evaluation studies have trained nurses capture retinal photographs and demonstrated that digital image interpretation transmit them to experts for remote interpretation by through teleradiology has comparable, or (Fig. 18.2) (Richter et al. 2009). potentially even better, accuracy and efficiency compared to traditional film-based radiologi- cal examination (Franken et al. 1992; Reiner 18.3.5 Video-based Telehealth et al. 2002; Mackinnon et al. 2008). To many people telehealth is videoconferenc- 18.3.4.2 Teleophthalmology ing. Whenever the words “telehealth” or “tele- Another area of remote interpretation that is grow- medicine” are mentioned, most people have a ing rapidly is teleophthalmology, particularly mental image of a patient talking to a doctor for retinal disease screening. As one example, over some type of synchronous video connec- diabetic retinopathy (retinal disease) is a leading tion. Indeed, most early telehealth research did 18 Telehealth 549 Fig. 18.2 Store-and-forward telemedicine system for displayed. Diagnosis and recommendations are then sent ophthalmic disease, in which a remote grader inter- back to the local site (Source: Chiang.2007. Archives prets retinal images, along with relevant clinical data, of Ophthalmology, 125(11), 1531. Copyright © (2007) captured by a nurse. Three images from different areas American Medical Association. All rights reserved) of the patient’s right eye (OD) and left eye (OS) are a b c Fig. 18.3 Plain old telephone service (POTS)–based also equipped with close-up lenses to allow providers to home telehealth. Panel (a) shows the IDEATel Home monitor medications or wounds. Panel (c) shows a close- Telemedicine Unit. Panel (b) shows a typical full-motion up video image of a syringe indicating that the patient has video image transmitted over POTS. Because of frame-to- drawn up 44 units of insulin. The small markings are frame compression, images of nonmoving objects can be roughly 0.6 mm apart (Source: Starren 2003, reproduced of even higher quality. Many home telehealth systems are with permission) 550 J.B. Starren et al. focus on synchronous video connections. For Digital Network (ISDN) connections or leased many of the early studies, the goal was to pro- lines. Within single organizations, or in consul- vide access to specialists in remote or rural tative or educational settings, Internet Protocol areas. Nearly all of the early systems utilized a (IP) based video conferencing has become the hub-and-spoke topology where one hub, usually dominant modality. an academic medical center, was connected to Synchronous video telehealth has been used in many spokes, usually rural clinics. almost every conceivable situation. In addition to Many of the early telehealth consults involved traditional consultations, the systems have been the patient and the primary care provider at one used to transmit grand rounds and other educa- site conferring with a specialist at another site. tional presentations. Video cameras have been Most of the state-wide telehealth networks oper- placed in operating rooms at hub sites to trans- ated on this model. This was so engrained in the mit images of surgeries for educational purposes. telehealth culture, that the first legislation allow- Video cameras have been placed in emergency ing Medicare reimbursement of telehealth con- departments and operating rooms at spoke sites sults required a “presenter” at the remote site. to allow experts to “telementor” less experienced This requirement for a “presenter” exacer- physicians in the remote location. Video cameras bated the scheduling problem. Because syn- have also been placed in ambulances to provide chronous video telehealth often uses specialized remote triage. videoconferencing rooms, the televisits need to More recently, the growing popular- be scheduled at a specific time. Getting the ity of mobile devices is creating potential patient and both clinicians (expert and presenter) for new strategies involving real-time video at the right places at the right time has forced communication between patients and health care many telehealth programs to hire a full-time providers. This is especially promising because scheduler. The scheduling problem, combined mobile networks are low-cost and widely-avail- with the advent of more user-friendly equipment, able for consumers, and because they are increas- ultimately led Medicare to drop the presenter ingly accessible even in developing countries. requirement. Even so, scheduling is often the However, health information exchange using single biggest obstacle to greater use of synchro- mobile networks raises concerns about privacy, nous video consultations. security, and compliance with Health Insurance A second obstacle has been the availability of Portability and Accountability Act (HIPAA). relevant clinical information. Because of the With appropriate encryption settings, wire- inability to interface between various EHRs, it less video communication using mobile device was not unusual for staff to print out results applications may be HIPAA-compliant (e.g. from the EHR at one site and then to fax those to FaceTime; Apple Computer, Cupertino, CA). In the other site prior to a synchronous video the future, these mobile technologies may pro- consultation. vide opportunities for greater communication Unlike store-and-forward telehealth, syn- between patients and providers. chronous video requires a stable data stream. Prior to the adoption of IP-based videocon- Although video connection can use conven- ferencing, programs begun with grant fund- tional phone lines (commonly referred to as ing ended soon after the grant funding ended. plain old telephone service, or POTS) that Even after the advent of IP-based conferenc- provide 64 bits-per-second (64 kbs) transmis- ing, many programs have struggled. This is in sion speed, diagnostic quality video typically spite of the fact that Medicare has begun reim- requires at least 128 Kbs and more commonly bursing for synchronous video under limited 384 Kbs (see Chap. 5). In order to guarantee circumstances. stable data rates, synchronous video in clini- Some rural health care providers, such as the cally critical situations still relies heavily on Marshfield Clinic in Wisconsin, have integrated dedicated circuits, either Integrated Service synchronous telehealth into their standard care 18 Telehealth 551 model to provide routine specialist services to outly- centers is an expensive proposition, typically ing location. Some categories of synchronous video requiring two officers and a vehicle. Depending telehealth have developed sustainable models: tele- on the prisoner and the distance, costs for a single psychiatry, correctional telehealth; home telehealth, transfer range from hundreds to thousands of dol- emergency telehealth, and remote intensive care. lars. Because of the high cost of transportation, correctional telehealth was economically viable 18.3.5.1 Telepsychiatry even before the advent of newer low cost systems. In many ways, psychiatry is the ideal clini- Correctional telehealth also improves patient cal domain for synchronous video consultation. satisfaction. A fact surprising to many is that Diagnosis is based primarily on observing and inmates typically do not want to leave a correc- talking to the patient. The interactive nature of tional institution to seek medical care. Many dis- the dialog means that store-and-forward video is like the stigma of being paraded through a rarely adequate. Physical examination is relatively medical facility in prison garb. In addition, the unimportant, so that the lack of physical contact is social structure of prisons is such that any pris- not limiting. There are very few diagnostic studies oner who leaves for more than a day risks losing or procedures, so that interfacing to other clinical privileges and social standing. Correctional tele- systems is less important. In addition, state offices health follows the conventional model of provid- of mental health deliver a significant fraction of ing specialist consultation to supplement to psychiatric services, minimizing reimbursement on-site primary care physicians. This has become issues. This is illustrated by two projects. In 1995, increasingly important with the rising prevalence the South Carolina Department of Mental Health of AIDS in the prison population. established a telepsychiatry network to allow a sin- gle clinician to provide psychiatric services to deaf 18.3.5.3 Home Telehealth patients throughout the state (Afrin and Critchfield 1997). The system allowed clinicians, who had After Samuel misses two scheduled visits, the previously driven all over the state, to spend more Diabetes Educator calls see what is the mat- time in patient care and less time traveling. ter. Samuel explains that it is a 1-h drive from The system was so successful that it was his home to the diabetes center, that his expanded to multiple providers and roughly daughter had trouble taking time off from 20 sites. The second example comes from the work to drive him, and that he would have New York State Psychiatric Institute (NYSPI), difficulty leaving his wife home alone because which is responsible for providing expert con- she has been ill recently. The Diabetes sultation to mental health facilities and prisons Educator notes that Samuel lives in a rural throughout the state. As in South Carolina, area and is eligible to receive educational ser- travel time was a significant factor in providing vices via teleheath. She signs Samuel up to this service. To address the problem, the NYSPI receive a Home Telehealth Unit and sched- created a videoconference network among the ules delivery. The unit is initially difficult for various state mental health centers. The system him to use because he is not familiar with allows specialists at NYSPI in New York City computer systems. However, after this initial to provide consultations in a timelier manner, learning process, Samuel rarely misses a improving care and increasing satisfaction at video education session. At one visit, Samuel the remote sites. complains that his children and wife are always “on his case” about his injections. The 18.3.5.2 Correctional Telehealth nurse schedules the next video visit during an Prisons tend to be located far from major met- evening when Samuel’s daughter can attend. ropolitan centers. Consequently, they are also She also schedules Samuel to have a video located far from the specialists in major medi- visit with the dietician. cal centers. Transporting prisoners to medical 552 J.B. Starren et al. Somewhat paradoxically, one of the most active areas of telehealth growth is at the low- est end of the bandwidth spectrum—telehealth activities into patients’ homes. In the late 1990s, many believed that home broadband access would soon become ubiquitous and a number of vendors abandoned POTS-based systems in favor of IP-based video solutions. The broad- band revolution was slower than expected, espe- cially in rural and economically depressed areas most in need of home telehealth services. A few research projects paid to have broadband or ISDN Fig. 18.4 Emergency telemedicine care system, in which installed in patients’ homes. In response to this, a remote expert performs videoconsultation with a local physician or nurse (University of California, Davis Health the American Telemedicine Association released System, 2010, reproduced with permission) new guidelines for Home Telehealth in 2002 in which synchronous video is provided over POTS connections. telehealth frequently involves a longer duration Most vendors have returned to POTS-based of care and less frequent interactions. Video solutions and a number of new products have interactions tend to focus on patient education, appeared in the past 3 years. In addition to video, more than on evaluation of acute conditions. the devices typically have data ports for connec- The largest such project to date is the tion of various peripheral devices, such as a digi- Informatics for Diabetes Education and Tele- tal stethoscope, glucose meter, blood pressure medicine (IDEATel) project (Starren et al. 2002). meter, or spirometer. Although the video quality Started in 2000, the IDEATel project was an would not be adequate for many diagnostic pur- 8-year, $60 million demonstration project funded poses, it is adequate for the management of exist- by the Center for Medicare and Medicaid Services ing conditions. Figure. 18.3 shows actual POTS (CMS, formerly the Health Care Financing video quality. Administration, or HCFA) involving 1665 dia- Home telehealth can be divided into two major betic Medicare patients in urban and rural New categories. The first category, often called tele- York State. In this randomized clinical trial, half home care, is the telehealth equivalent of home of the patients received Home Telemedicine nursing care. It involves frequent video visits Units (HTU) (Fig. 18.3), and half continued to between nurses and, often homebound, patients. receive standard care. With the advent of prospective payment for home At peak, 636 patients were actively using the nursing care, telehome care is viewed as a way HTU’s. In addition to providing 2-way POTS- for home care agencies to provide care at reduced based video, the HTU allowed patients to interact costs. As with home nursing care, telehome care in multiple ways with their online charts. When tends to have a finite duration, often focused on patients measure blood pressure or fingerstick glu- recovery from a specific disease or incident. cose with devices connected directly to the HTU, Several studies have shown that telehome care the results were automatically encrypted and can be especially valuable in the management of transmitted over the Internet into the Columbia patients recently discharged from the hospital University Web-based Clinical Information and can significantly reduce readmission rates. System (WebCIS; Hripcsak et al. 1999) at New The second category of home telehealth York Presbyterian Hospital (NYPH) and to dia- centers on the management of chronic diseases. betes-specific case management software. Nurse Compared with telehome care, this type of home case managers monitored patients by viewing the 18 Telehealth 553 uploaded results, participating in bulletin board discussions, videoconferencing, and answer- neurologist who confirms the diagnosis of ing e-mailed questions daily. The case manager ischemic stroke and institutes thrombolytic received an alert when a patient’s transmitted val- therapy via pre-arranged protocol. Samuel ues exceed set thresholds. is transferred to the intensive care unit for An important distinction between telehome close monitoring of his diabetes, hyperten- care and disease management telehealth is that sion, and evolving stroke. interactions in the former are initiated and man- aged by the nurse. Measurements, such as blood pressure, are typically collected during the video “Just in time” consultation in the emergency visit and uploaded as part of the video connection. setting potentially represents one of the most For disease management, the HTU also needs to beneficial uses of telehealth (Fig. 18.4). support remote monitoring, patient-initiated data Emergency telemedicine has been used in a vari- uploads and, possibly, Web-based access to edu- ety of ways and has demonstrated significant cational or disease management resources. benefits, including in such area as tele-trauma A project that reversed the conventional notion care, burn care, and critical care pediatric special- of home telehealth was the Baby CareLink proj- ists consulting on critically ill or injured children ect (Gray et al. 2000). This project focused on (Ricci et al. 2003; Saffle et al. 2009; Heath et al very low birth weight infants who typically spend 2009). Telehealth in the emergency setting is months in neonatal intensive care units (NICU). likely to have the greatest benefit when time- The project used high-speed (ISDN) video con- limited critical decision making by a specialist nections to connect from the NICU into the par- physician regarding a specific intervention is ents’ home. This allowed parents who could not necessary. visit the NICU regularly to maintain daily contact An important and increasingly frequently with their infants. The video connection was sup- used application demonstrating this is in the eval- plemented by communication and educational uation and treatment of the stroke patient. Best material on a project Web site. practice management of ischemic stroke in appropriate patients now includes the use of 18.3.5.4 Emergency Telemedicine thrombolytic therapy such as tissue plasminogen activator (tPA), which has been shown to have Samuel develops slurred speech and weak- statistically significant clinical and financial ben- ness on the right side of his body. His efits. Recommendations and drug labeling limit daughter, who is with him at the time, the use of intravenous tPA to within 3 h of when calls 911. The ambulance crew notifies the the patient was last seen as well or had witnessed emergency room that they are in route with onset of symptoms. a possible stroke victim. On arrival, the This therapy, however, has significant compli- rural emergency department (ED) physi- cations, particularly in patients with hemorrhagic cian does a quick evaluation and connects rather than ischemic events – requiring urgent via telemedicine with a stroke neurologist specialty consultation, along with rapid expert at an academic health center. The neurolo- interpretation of imaging and laboratory work. gist talks with the Samuel and his daughter, Many settings lack the specialty expertise to have and participates in the examination with on-site “stroke teams” to accomplish best prac- the ED physician. Following laboratory tice. Telemedicine can bring specialty expertise work and a CT negative for hemorrhage, to a remote location for emergency evaluation of the ED physician again consults with the the patient directly, while transmit images and laboratory work for immediate interpretation. 554 J.B. Starren et al. This model of care, first called “telestroke” Consultation models in the in-patient set- care by Levine and Gorman, has been increas- ting using telemedicine in a variety of special- ingly used throughout the country (Levine 1999). ties have been reported. including intensive The efficacy of this model, compared to tradi- care where timely consults are often essential tional telephone consultation, was evaluated by (Assimacopoulos et al. 2008; Marcin et al. Meyer et al. (2008). These investigators found 2004). Although, these consultation models in that telestroke care resulted in more accurate deci- critical care have shown benefit, a comprehensive sion making than did telephone consultation. multi-modality model has becomeh more com- Based on a comprehensive review of evidence, mon. This is often referred to as tele-ICU, and is the American Heart Association and American defined as care provided to critically ill patients Stroke Association have recommended that with at least some of the managing physicians “whenever local or on-site acute expertise or and nurses in a remote location. resources are insufficient to provide around-the- Some of the initial work in this area, done by clock coverage for a health care facility, telestroke Rosenfield and Bresslow in the Sentara Health systems should be deployed to supplement System, demonstrated improved mortality, resources at participating sites” (Schwamm et al. reduced lengths of stay and decreased costs 2009). This comprehensive and detailed report (Rosenfeld et al. 2000). Remote intensive care makes other recommendations in support of tele- has grown significantly over time with an esti- medicine in the area of stroke care. mated 10 % of all ICU beds in the U.S. covered under this model of care, in large part due to a 18.3.5.5 Remote Intensive Care shortage of critical care physicians Typically, a single “Command Center” can cover multiple intensive care units over a large geographic Samuel was admitted to the intensive care region creating significant efficiencies and econ- unit (ICU) in his local hospital with the omies of scale. diagnosis of stroke, diabetes and hyperten- This model of care integrates several of the sion. He is being treated with thrombolytic technologies discussed in this book and is pri- therapy. During the night, Samuel’s blood marily enabled using electronic health records, pressure begins to rise significantly above evidenced based decision support tools, connec- the recommended level for patients under tions to bedside monitoring systems and audio/ treatment with thrombolytic therapy. This video based telemedicine into patient rooms. is quickly recognized by a remote tele-ICU Most commonly, critical care health profession- team that provides coverage for all of the als co-manage care from a Command Center ICU beds in Samuel’s rural hospital. This led by board-certified critical care physicians. remote intensive care team has complete Protocols and treatments reviews for patient access to Samuel’s electronic health record management are incorporated into the care pro- and bedside monitors and they also have cess using data from the monitoring and alert video and audio connectivity into the room. systems that indicate when changes in care The remote critical care team is able to should take place. The goal is to assure adher- quickly connect to Samuel’s room and do a ence to best practice, achieve shorter response neurological exam with the assistance of times to alarms, abnormal laboratory values and the on-site nursing team. They determine more rapid initiation of life saving interventions that the exam is unchanged from the emer- (Lilly et al. 2011). gency room. They are able to order appro- Recent studies have shown mixed results in priate medications, recommend more terms of the benefits of tele-ICU. Morrison and frequent neurological checks, and directly colleagues studied mortality, length of stay, and follow his blood pressure response. total cost in 4,088 patients admissions at two met- ropolitan hospitals. Age, gender, race/ethnicity, 18 Telehealth 555 trauma status, APACHE III score, and physician Accurate millisecond force feedback has been utilization of the eICU were included as covari- historically limited to distances under 100 miles. ates. In this study, the investigators did not find a The endoscopic gall bladder surgery mentioned reduction in mortality, length of stay, or hospital above is an exception to this general principle cost attributable to the introduction of the eICU because that specific procedure relied almost (Morrison 2009). In a study by Thomas in 2009, exclusively on visual information. It used a dedi- the investigators found that although remote mon- cated and custom configured 10 Mb/s fiberoptic itoring of ICU patients was not associated with an network with a 155 ms latency. overall improvement in mortality or LOS, there Providing tactile feedback over large distances was a significant interaction between the tele-ICU actually requires providing the surgeon with sim- intervention and severity of illness (P <.001), in ulated feedback while awaiting transmission of which tele-ICU was associated with improved the actual feedback data. Such simulation survival in sicker patients but with no improve- requires massive computing power and is an area ment or worse outcomes in less sick patients of active research. Telesurgery also require (Thomas et al. 2009). extremely high-reliability connections. Loss of a In a more recent study, Lilly et al. reported connection is an annoyance during a consulta- that in a single academic medical center, imple- tion; it can be fatal during a surgical procedure. mentation of tele-ICU was associated with Robotic surgery systems have been commer- reduced mortality and LOS, as well as lower rates cially available since the early 2000s. In these of preventable complications (Lilly et al. 2011). systems, surgical instruments and a camera are Further research is needed in this area to deter- introduced into the patient through small inci- mine the benefits of tele-ICU and the specific sions. The surgeon controls these instruments components that account for these benefits. remotely, while he or she is viewing a magnified three-dimensional camera image of the patient’s anatomical structures. These systems are cur- 18.3.6 Telepresence rently being used in some medical centers for small-incision surgery, typically performed by Telepresence involves systems that allow clini- surgeons seated adjacent to their patients. The cians to not only view remote situations, but also increasing availability and use of these robotic to act on them. The archetypal telepresence appli- surgery systems creates possibilities for an cation is telesurgery. The most basic surgical increasing number of telesurgery applications. telepresence systems simply permit two-way To date, robotically-assisted surgery has been audio-video communications, by which remote most common in fields such as cardiothoracic surgeons can observe, teach, and collaborate with surgery, gynecology, and urology. Potential local surgeons while they operate on patients. advantages of remote robotically-assisted sur- More advanced surgical telepresence sys- gery may include smaller incisions, improved tems allow procedures to actually be performed anatomic visualization, and finer control of sur- remotely. Although largely still experimental, a gical instrumentation. Several clinical studies trans-Atlantic gall bladder operation was dem- comparing robotically-assisted surgery with tra- onstrated in 2001 (Kent 2001). The military ditional surgery have suggested that the outcomes has funded considerable research in this area are similar (Allemann et al. 2010; Ficarra et al. in the hope that surgical capabilities could be 2009). However, additional research is required extended to the battlefield. Telepresence requires to determine the optimal role of robot-assisted high bandwidth, low latency connections. surgery and its applications to telesurgery. Optimal telesurgery requires not only teleop- A novel form of telepresence gives clinicians eration of robotic surgical instruments, but also the ability to not only to see, but also to walk accurate force feedback (or haptic feedback) around. Since the early 2000s, a commercially- that requires extremely low network latencies. available system has combined conventional 556 J.B. Starren et al. questions of identity and trust become para- mount. At the same time, the shifting focus from treating illness to managing health and wellness requires that clinicians know not only the history of the individuals they treat but also information about the social and environmental context within which those individuals reside. In the diabetes example, knowledge of the family history of risk factors, diseases, and the appropriate diagnostic and interventional protocols, aid the clinical staff in providing timely and appropriate treatment. Fig. 18.5 Telehealth robot. This is controlled by a remote clinician, and includes videoconferencing and remote 18.4.1 Challenges to Using the monitoring capabilities. In this example, physician is Internet for Telehealth speaking with a nurse while conducting remote patient Applications rounds (Source: InTouch Health, reproduced with permission) Because of the public, shared nature of the Internet, its resources are widely accessible by video telehealth with a remote controlled robot citizens and health care organizations. This pub- (Fig. 18.5). It allows clinicians to literally make lic nature also presents challenges to the secu- remote video rounds. A frequent problem with rity of data transmitted along the Internet. The telehealth systems is having the equipment openness of the Internet leaves the transmitted where it is needed. With this system, the tele- data vulnerable to interception and inappropri- health equipment is literally able take itself to ate access. In spite of significant improvements wherever it is needed. Remote monitoring may in the security of Web browsing several areas, be also performed by interfacing digital devices including protection against viruses, authenti- such as stethoscopes or imaging systems to the cation of individuals and the security of email, remote-controlled robot. These remote-con- remain problematic. trolled systems are most often used by physi- Ensuring every citizen access to the Internet cians and nurses to examine patients in nursing represents a second important challenge to the homes or other long-term facilities, improve ability to use it for public health purposes. Access health care access in rural areas, and perform to the Internet presently requires computer equip- post-operative examinations. It is too early to ment that may be out of reach for persons with tell whether this model of telepresence will marginal income levels. Majority-language liter- become widely adopted, but, like many earlier acy and the physical capability to type and read innovative systems, it raises many interesting present additional requirements for effective use questions. of the Internet. Preventing inequalities in access to health care resources delivered via the Internet will require that health care agencies work with 18.4 Challenges and Future other social service and educational groups to Directions make available the technology necessary to capi- talize on this electronic environment for health As telehealth evolves from research novelty to care. being a standard way that health care is deliv- As health care becomes increasingly reliant ered, many challenges must be overcome. Some on Internet-based telecommunications technol- of these challenges arise because the one patient, ogy, the industry faces challenges in insuring the one doctor model no longer applies. Basic quality and integrity of many devices and network 18 Telehealth 557 pathways. These challenges differ from previous At the same time, national organizations rep- medical device concerns, because the diversity resenting a variety of health care professions and reliability of household equipment is under (including nurses, physicians and physical thera- the control of the household, not the health care pists) have proposed a variety of approaches to providers. There is an increased interdependency these issues. While the existing system is built between the providers of health services, those around individual state licensure, groups that who manage telecommunication infrastructure favor telemedicine have proposed various inter- and the manufacturers of commercial electronics. state or national licensure schemes. The Federated Insuring effective use of telehealth for home and State Board of Medical Examiners has proposed community based care requires that clinical ser- that physicians holding a full, unrestricted license vices be supported by appropriate technical in any state should be able to obtain a limited resources. telemedicine consultation license using a stream- lined application process. The American Medical Association is fighting to maintain the current 18.4.2 Licensure and Economics state-based licensure model while encouraging in Telehealth some reciprocity. The American Telemedicine Association supports the position that—since Licensure is frequently cited as the single biggest patients are “transported” via telemedicine to the problem facing telemedicine involving direct clinician—the practitioner need only be licensed patient-provider interactions. This is because in his or her home state. The National Council of medical licensure in the United States is state- State Boards of Nursing has promoted an based, while telemedicine frequently crosses state Interstate Nurse Licensure Compact whereby or national boundaries. The debate revolves licensed nurses in a given state are granted multi- around the questions of whether the patient “trav- state licensure privileges and are authorized to els” through the wire to the clinician, or the clini- practice in any other state that has adopted the cian “travels” through the wire to the patient. compact. As of 2002, 19 states had enacted the Several states have passed legislation regulating compact. the manner in which clinicians may deliver care The second factor limiting the growth of remotely or across state lines. Some states have telehealth is reimbursement. Prior to the mid- enacted “full licensure models” that require prac- 1990s there was virtually no reimbursement for titioners to hold a full, unrestricted license in each telehealth outside of teleradiology. At present state where a patient resides. Many of these laws Medicare routinely reimburses for synchronous have been enacted specifically to restrict the out- video only for rural patients. Nineteen states of-state practice of telemedicine. To limit Web- provide coverage for synchronous video for based prescribing and other types of asynchronous Medicaid recipients. Five states also mandate interactions, several states have enacted or are payments by private insurers. A few insurers considering regulations that would require a face- have begun experimenting with reimbursement to-face encounter before any electronically deliv- for electronic messaging and online consulta- ered care would be allowed. In contrast, some tion, although this has been limited to specific states are adopting regulations to facilitate tele- pilot projects. Although teleradiology is often health by exempting out-of-state physicians from reimbursed, payments for other types of store- in-state licensure requirements provided that elec- and-forward telehealth or remote monitoring tronic care is provided on an irregular or episodic remain rare. Few groups have even considered basis. Still other models would include states reimbursement for telehealth services that do not agreeing to either a mutual exchange of privi- involve patient-provider interaction. An expert leges, or some type of “registration” system system could provide triage services; tailored whereby clinicians from out of state would regis- on-line educational material, or customized dos- ter their intent to practice via electronic medium. age calculations. Such systems are expensive to 558 J.B. Starren et al. build and maintain, but only services provided liability must be established. Software that dis- directly by humans are currently reimbursed by plays clinical information required for remote insurance. management, and that integrates into exist- Historically, patients have been perceived as ing workflow patterns and maximizes effi- reluctant to pay directly for telehealth services, ciency through good usability principles will especially when face-to-face visits were cov- be required. Methods for providing added value ered by insurance. This may be changing. The from technology toward telehealth diagnos- Marshfield Clinic in Wisconsin has reported that tic systems through strategies such as links to many patients are willing to pay a small technol- consumer health resources or computer-based ogy fee ($10–20) to avoid a several hour drive diagnosis may be explored (Koreen et al. 2007). to see the specialist face-to-face. Private com- Finally, studies have suggested that patient satis- panies have begun providing direct-to-patient faction with telehealth systems is high (Lee et al. video consults utilizing normal Web browsers 2010). However, the practitioner-patient relation- and Flash™ video at a charge of $45 for 10 min ship is fundamental to health care delivery, and and have placed video stations in workplaces and mechanisms must be developed that this bond is pharmacies. Some insurers have begun reimburs- not lost from telehealth. ing for such visits when a patient’s primary clini- cian is not available. Finally, home telehealth monitoring may 18.4.4 Telehealth in Low Resource reduce the health care costs associated with unre- Environments imbursed hospital readmissions. For example, some insurance payers do not reimburse for hos- In many parts of the developing world, the den- pital readmissions that occur within 30 days of sity of both health care providers and of tech- discharge, and there are anecdotal reports of nology is quite low. Thus, the demand for health systems paying for 32 days of home moni- telehealth is high, but the ability to deliver it is toring post-discharge. Determining whether, and challenged. Many of these regions have largely how much, to pay for telehealth services will skipped traditional land-line telephony and likely be a topic of debate for years to come. moved directly to cellular infrastructure (Foster 2010). This, combined with advances in low- cost laptop computers that do not depend on 18.4.3 Logistical Requirements stable power-grids, has allowed the develop- for Implementation of ment of a wide variety of telehealth and tele- Telehealth Systems education applications. The majority of these are based on an asynchronous model. Transport Telehealth systems must be carefully evaluated media range from standard broadband in the before implementation for routine use in indi- urban areas, to satellite connections, to cellular vidual disease situations, to ensure that they have data, to SMS messaging. The largest group of sufficient diagnostic accuracy and reproducibility applications focuses on the provision of remote for clinical application. Appropriate training and consultations for difficult cases using computer- credentialing standards must be developed for based systems, while general health education personnel who capture clinical data and images and remote data collection have been the pri- from patients locally, as well as for physicians mary applications using cellular telephony and nurses who perform remote interpretation applications. However, the development of and consultation. Clear rules and responsibilities smart mobile telephones with high-resolution must be developed for remote patient manage- cameras is rapidly blurring this distinction. The ment, including the appropriate response for situ- e-book by Wootton provides an overview of this ations in which data are felt to be of insufficient domain (Wootton 2009) and Foster focuses on quality for telehealth. Guidelines for medicolegal the role of mobile telephones (Foster 2010). 18 Telehealth 559 18.5 Future Directions Suggested Readings Telehealth validation studies across a range of Bashshur, R.L., Shannon, G.W., Krupinski, E.A., Grigsby, J., Kvedar, J.C., Weinstein, R.S., et al. (2009). National clinical domains have demonstrated good diag- telemedicine initiatives: Essential to healthcare nostic accuracy, reliability, and patient satisfac- reform. Telemedicine and e-Health, 15, 600–610. This tion. Based on these results, numerous real-world paper discusses cost-benefit tradeoffs associated with telehealth programs have been implemented telemedicine within the context of large-scale efforts promoting health care reform in the United States. throughout the world. In the long term, success- Gray, J.E., Safran, C., Davis, R.B., Pompilio-Weitzner, ful large-scale expansion of these programs will G., Stewart, J.E., Zaccagnini, L., et al. (2000). Baby require addressing the above challenges. CareLink: Using the internet and telemedicine to Beyond these practical factors, traditional improve care for high-risk infants. Pediatrics, 106, 1318–1324. Families of very-low-birthweight babies medical care uses a workflow model based on use interactive television and the world-wide-web to synchronous interactions between clinicians and monitor the babies’ progess while in hospital and to individual patients. The workflow model is also a receive professional coaching and support once the sequential one in that the clinician may deal with babies return home. Richter, G.M., Williams, S.L., Starren, J., Flynn, J.T., & multiple clinical problems or data trends but only Chiang, M.F. (2009). Telemedicine for retinopathy within the context of treating a single patient at a of prematurity diagnosis: Evaluation and challenges. time. Medical records, both paper and electronic, Survey of Ophthalmology, 54, 671–685. This article as well as billing and administrative systems all reviews the potential benefits and implementation challenges associated with the use of store-and- rely on this sequential paradigm, in which the fun- forward telemedicine for an ocular disease affecting damental unit is the “visit.” Advances in telehealth infants hospitalized in neonatal intensive care units. are disrupting this paradigm. Devices have been Schwamm, L.H., Holloway, R.G., Amarenco, P., Aude- developed that allow remote electronic monitor- bert, H.J., Bakas, T., Chumbler, N.R., et al. (2009). A review of the evidence for the use of telemedicine ing of diabetes, hypertension, asthma, congestive within stroke systems of care: A scientific statement heart failure (CHF), and chronic anticoagulation. from the American Heart Association/American As a result, clinicians may become inundated Stroke Association. Stroke, 40, 2616–2634. This by large volumes of electronic results. This may is a systematic evidence-based review of scientific data examining the use of telemedicine for stroke mean that clinicians will no longer function in an care delivery by two major medical organizations. assembly-line fashion, but will become more like Published studies are categorized according to their dispatchers or air-traffic controllers, electroni- level of certainty and class of evidence. cally monitoring many processes simultaneously. Shea, S., Weinstock, R.S., Teresi, J.A., Palmas, W., Starren, J., Cimino, J.J., et al. (2009). A randomized Clinicians will no longer ask simply, “How is trial comparing telemedicine case management with Mrs. X today?” They will also ask the computer usual care in older, ethnically diverse, medically “Among my 2,000 patients, which ones need my underserved patients with diabetes mellitus: 5 year attention today?” Neither clinicians, nor EHRs, results of the IDEATel study. Journal of the American Medical Informatics Association: JAMIA, 16, 446– are prepared for this change. 456. This paper describes an evaluation study examin- Perhaps the greatest long-term effect of the ing the effectiveness of home telemedicine for clinical information and communication revolution will case management in a group of over 1,600 medically- be the breaking down of role, geographic, and underserved patients with diabetes mellitus. social barriers. Medicine is already benefiting from this effect. Traditional “doctors and nurses” are collaborating with public health profession- Questions for Discussion als, and anyone with computer access can poten- 1. Telehealth has evolved from systems tially communicate with patients or experts designed primarily to support consul- around the world. The challenge will be to facili- tations between clinicians to systems tate productive collaborations among patients, that provide direct patient care. This their caregivers, biomedical scientists, and infor- has required changes in hardware, user mation technology experts. 560 J.B. Starren et al. interfaces, software, and processes. Therefore we should only reimburse a Discuss some of the changes that must very small amount for these screening be made when a system designed for use services.” In your opinion, is this a legit- by health care professionals is modified imate argument? Explain. to be used directly by patients. 3. Using telehealth systems, patients can 2. There are many controversies regarding now have interaction with a large num- reimbursement for telemedicine ser- ber of health care providers, organiza- vices. Imagine that you are negotiating tions and resources. As a result, with an insurance carrier to obtain reim- coordination of care becomes increas- bursement for a store-and-forward tele- ingly difficult. Two solutions have been medicine service that you have proposed. One is to develop better ways developed. The medical director of the to transfer patient-related information second insurance payer states: among existing EHRs. The other is to “Telemedicine seems like ‘screening’ give the give the patient control of the rather than a mechanism for delivering health record, either by giving them a health care. This is because you are sim- smart card or placing the records on a ply using technology to identify patients central web site controlled by the who need to be referred to a real doctor, patient. Assume and defend one of these rather than providing true medical care. perspectives.