A vendor we met recently reported that despite all the buzz about iPad use among physicians (some reports say up to 27% already own one), they are not likely to be usable as clinical tools.
The Pros are obvious:
- Doctor's have them
- They are easy to use
- Easy to transport
- Very flexible
- With each new version they are gaining in processing power
But the CONs are not trivial:
- Patient data (protected health information) might accidentally go home with the doctor and be viewed by someone who picks it up to play Angry Birds
- Not part of the hospital's security architecture
- Not FDA approved as a "medical device" so despite the ability to USB medical instruments, it would violate standards
- Open ports and slots for germs to hide in and be transferred
- If you apply typical hospital grade cleaning products to an iPad, it melts
VeaMea has not yet melted an iPad to test this statement, but it came from a pretty reliable source.
Let us know if you have any experience that would prove this wrong.
A recent report by the state of Wisconsin on physician shortages focused on ways to increase the supply of doctors in the state to meet projected needs.
A UK Department of Health study shows that telemedicine can reduce mortality by 45%.
Both articles seem to miss the real point.
The UK study also found TeleHealth can deliver:
- a 15% reduction in emergency room visits
- a 20% reduction in emergency admissions
- a 14% reduction in elective admissions
- a 14% reduction in bed days
- an 8% reduction in tariff costs
If you never took an Economics course, go take one. If you have taken one, you should know that equilibrium in the medical system will be a function of the supply of doctors and the demand for services.
The conventional logic is that our population is aging, and that with aging comes increased use of medical services. Therefore, we need more doctors to be available. Our system is already short on certain types of doctors in certain places, so there is a crisis brewing to train more doctors.
What if doctors become more productive through application of technology ?
Electronic Medical Records are one area that has gained a lot of attention and a lot of push from the Federal Government in hopes of saving time, money and improving patient outcomes.
A quick look at the UK study, and the Wisconsin report and you can envision a world where telehealth allows the doctors we have to see and treat more patients than the doctors do today. Telemedicine is an enabling technology that makes the doctor more productive in the same way that desktop computers have made office workers more productive over the past 20 years.
If a doctor can see 20 patients per day instead of 15, you have made her 33% more productive. If the population of doctors were able to serve 33% more patients, no one would be writing reports about shortages.
Is 33% productivity improvement due to telehealth technologies realistic? For doctors who travel to outlying clinics, or who are sub-specialized, 33% may be an understatement. But 33% is just a number I made up. The real number should be constructed, as part of a business case that defines what TeleMedicine will be used for, how much it will cost to implement and maintain, and what the projected benefits are.
Doctors should be thought of like any other precision asset. You want them to have a high utilization rate (or percent of time they are doing billable work), and the more you use them, the more you spread their fixed cost and thus the lower the total cost per unit of their time.
So if telemedicine can deliver results like those shown in the UK study, an individual doctor can be more productive, AND cost less per patient they see. As if that were not good enough in a world straining its healthcare resources, patient outcomes improve as well.
Hospitals and clinics across the US are substituting RNs and NPs for MDs to combat shortages of doctors, especially in rural areas.
The picture above was taken at an Urgent Care facility. What does it show ?
A woman walked in with a hand injury and was being seen by an RN, who brought an MD into the consultation using a telemedicine system based on VeaMea, a simple Windows PC and medical peripherals from Global Med.
Why is this important ? Because it is the future of health care and a source of true health care reform for several reasons:
- The patient can go to the clinic closest to her, saving 2 hours of driving time for her 20 minute visit.
- The hospital system that operates the clinics has two MDs in its busiest Urgent Care clinic, but doesn't have enough MDs to staff every clinic, all the time. So telemedicine allows the available MDs to be in any clinic WHEN THEY ARE NEEDED, and doesn't waste their high-value time when they are not.
- Even if there were enough MDs for every clinic, the hospital couldn't afford the cost of staffing them, because the clinics don't receive enough reimbursement to cover their cost.
- In some areas of the country, there aren't enough specialists, or doctors spend half their time driving from town to town rather than seeing patients.
- Technology is connecting doctors with patients where they are needed, in real-time, at lower cost, and still providing high quality care.
THE BUSINESS CASE - ROI
What happens when the grant money runs out ? Interestingly, this system was NOT grant funded. The business case for this system was developed based on the cost savings from staffing mid-levels at the lower traffic clinics. Since this is an "In-Network" consultation, no reimbursement can be captured for the Doctor's consultation either as an "originating site" or a "professional fee."
However, this is proof of concept and a stepping stone to expanding the hospital's catchment area.
The Centers for Medicare and Medicaid Services (CMS), establish reimbursement rates for medical services that become the template for insurance providers nationwide. They are coming around to the idea that a remote consultation is acceptable when it serves underserved communities, or makes doctors more productive. When they warm up to the idea that any doctor, consulting on any patient, anywhere is reimbursable, healthcare delivery as we know it will be changed forever.
Our neighbors in Canada are smart enough to ENCOURAGE telemedicine. Perhaps someday we'll be as smart, eh ?
VeaMea, a leader in secure video conferencing, has been an advocate for implementation of telehealth technologies to reduce costs and improve patient care.
While there are many ways to help make our health care system more effecient and effective, video conferencing and collaboration software for telehealth are particularly well suited to a number of key drivers of cost and quality:
- Reaching the underserved while preserving quality of life and efficiency of practitioners
- Bringing the most qualified doctors to the patients who need them through focused application of information technology
- Giving medical students, and health care professionals pursuing continuing education, access to the best doctors and training tools
- Building best practices such as check-lists and workflow reminders into consultations
- Recording and archiving for patient information, effective discharge planning and compliance
The Department of Health and Human Services, through its HealthCare.gov portal recently launched the Partnership for Patients
Partnership for Patients' goal is to reduce costs and improve quality in healthcare. What's not to like ? We took the pledge and joined, will you ?
The program has ambitious goals to reduce cost and improve quality. On a related note, there will be a variety of demonstration projects funded through the Center for Medicare and Medicaid Innovation (CMMI) to identify processes and technologies that can help bend the healthcare cost curve down as patients transition from one care setting to another. Click here for more information about the CMMI Grant Program.
I told you so!
Almost 4 months ago, I wrote that TelePsychiatry is the Killer App for Video Conferencing. It may put a kink in Lucy's walk-in practice, but the benefits to the rest of society are clear. (And if Lucy would like to Expand Her Presence, there is a place she can go)
Who should come along to back me up, but the American College of Emergency Physicians (ACEP). Their July 2011 issue of ACEP News includes an article titled "ED Telepsychiatry Cuts Admissions, Saves Money."
The article tells the story of implementations in South Carolina and includes a commentary by the vice chair for Emergency Medicine at Lehigh Valley Hospital in Pennsylvania where a telepsychiatry program is also in place.
The following data are from the South Carolina study:
- Admission rates (33% lower)
- Length of Emergency Department stays (25% shorter)
- Outpatient follow-up rates (nearly 4x higher)
- Cost (29% lower for Medicaid patients, 38% lower for private insurance)
- Patient satisfaction: 80%
- Physician Satisfaction: 90%
- Physicians who believe they are more productive using telepsychiatry: 75%
Per the study, "the patient receives a higher quality of care, and the hospitals have reduced costs."
What's not to like ?
A friend of my wife's had his 15 minutes of fame recently when he was featured in an NPR story about TeleMedicine.
As a physician at Johns Hopkins, he sees a patient via videolink to upstate New York.
The story does a nice job of explaining both the benefits and some of the bureaucratic obstacles to adoption of telemedicine.
There is an interesting sidebar that says that in Canada the incentives are exactly the opposite: telehealth is encouraged by the Government-sponsored health plan because it is efficient for doctors and patients. Hopefully someday we'll learn form our neighbors to the North, eh?
Interestingly to VeaMea, as a provider of secure, software-based video conferencing and collaboration, the patient has to go to a remote site where the video conferencing system is located. The good news in this particular case is that the video conferencing site is just down the block; the bad news is that a block can seem like a marathon during a cold, snowy upstate New York winter--especially if the disease you are being treated for puts constraints on your movement.
A simpler alternative for patients who are computer literate, is to have the consultation in their own home, on their own PC. With an $85 Logitech C910 webcam and typical residential broadband internet, vendors like VeaMea, VSee, and Vidyo can provide a level of quality on the desktop that makes home telehealth a reality.
An study reported in Journal of the American Medical Association, and a corresponding article in the Boston Globe relating to implementation of an eICU, provide some startling numbers:
- Reduction in death rate from 10.7% to 8.6% -- beyond the fact that this is a 20% decrease, in simple human terms 100 people are alive who would not have survived their hospital stay under the pre-study conditions
- Reduction in infection rate from 13% to 1.6% -- 88% reduction in infections
- "The vast majority of hospitals do not have an ICU specialist working at night or on weekends, despite studies showing that when intensive care doctors manage patients, their mortality rates drop by an average of 30 percent"
What is an eICU ?
An eICU is a remote monitoring center. An intesive care specialist sits at a desk and receives data from the various machines connected to patients. They have access to heart monitors, breathing data, and can even look in on the patient with a webcam. Think of it like a home security company, except that instead of waiting for an alarm from a sensor that a door has been opened, they proactively monitor status, care and add a second pair of eyes to the ICU 24x7. Like a security company, they can watch over patients in multiple locations simultaneously.
Why does this matter?
UMass Memorial, where the study was conducted, is a teaching hospital with sophisticated experience and multiple ICU facilities, making big improvements in patient outcomes much harder than, for example, a rural hospital with limited access to specialty care.
The article includes comments by critics who note three key challenges to the overwhelmingly positive picture painted by the study data:
- The eICU was not an experiment conducted in a vaccuum, other initiatives may have contributed to the gains
- Would this translate to a rural setting where the eICU doctors are not familiar faces, but "outsiders"?
- Why not just hire an extra intensive care doctor and put them "in-person" in the ICU?
- Unmentioned in the article, but additional challenges include:
- If the remote specialist sees something and needs to communicate to an onsite care provider, can they reach the right person fast enough?
- Is there enough onsite staff to accept these remote alerts in addition to their normal workload?
- Will the onsite staff prioritize based on the remote specialist's opinion and should conflicts between the two be resolved?
- When (not if) the eICU equipment breaks down, how long does it take to fix and what level of coverage is lost in the interim?
- What additional requirements does eICU lay at the feet of a hospital's technical staff and what is the learning curve for mastering them?
All good questions. Here are a few starting points for answers:
- Hard to dispute that other factors could have come into play. The researcher should have controlled for external factors in the research design. The peer commentary process will undoubtedly tease this out.
- This is a key challenge of telemedicine anywhere, establishing the rapport among colleagues even though one party is working remotely. It would be interested to see the study replicated in rural settings. Data talks.
- This one is the easiest to knock down. You don't know which ICU will need the extra staff on any given day, much less at any given minute, so having a doctor that can instantly be anywhere is the ultimate in flexible staffing.
- All depend on the technologies and processes used. It is important to think through the issues involved from a process design standpoint, rather than simply buying a piece of technology.
What do you think ?
The Health Resources and Services Administration (HRSA), a division of Health and Human Services (HHS) has a database where you can search for information about shortages of access to primary care, dental and mental health services. A quick search for mental health services reveals a significant shortage in almost every area across the nation.
Top 5 Reasons Why TelePsychiatry is a Killer App for Video Conferencing
1) Mental health services means different things to different people, but the vast majority of these services are easily conducted via video conference, provided the quality of the interaction, reliability of the system and ease of use can compare to the physical movement of people from home to clinician's office, or of clinician to clinic.
2) There is a nationwide shortage of clinicians, but the shortage is not evenly spread. TelePsych could help balance the shortage, making quality care more accessible in the most underserved areas.
3) Some clinicians travel, spending hours getting from their home base to rural access clinics. These travel hours could be productively used seeing patients.
4) Many mental health issues include a social stigma that inhibit patients from seeking care. A secure video conference from their home, rather than going to a clinician's office, is a far less threatening medium to seek help.
5) Some mental health issues involve group support. The availability of group members in the same place at the same time limits the groups ability to meet and provide support.
How to move a TelePsych program forward
VeaMea created a 3 page whitepaper to help you think about the nuts and bolts of a video conferencing implementation for TeleMental Health.