Telemedicine

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Telemedicine

• Thomas Nesbitt, M.D., M.P.H.
• Associate Vice Chancellor, Strategic Technologies
  and Alliances
• Director, Center for Health and Technology
• Chief Scientist, CITRIS
• University of California, Davis

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There is a growing expectation that advanced
information technology will transform our health
care system.
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The explosion of new knowledge and information in
the health sciences is ironically creating
greater disparities in the quality of health care
services.
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If we discover a treatment for a disease, but
only half the people have access to it when they
need it, we have only discovered half the
treatment

• Medical Science, no matter how good it is, is
  worthless if not applied appropriately to
  patients where and when they need it

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Advances in telecommunications and advanced
information technologies can help to redistribute
health care information and expertise to where
and when it is needed
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One of the problems is that we are applying new
technology to a broken model of care instead of
using technology to facilitate a change in the
model of care
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These technologies can help facilitate a new,
more efficient model of care across the economic
and geographic spectrum.
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Accurate information about the patient

• For quality health care
• History of present illness
• Past medical history, ROS
• Family history, Social Hx,
• Meds, allergies, etc.
• Physical findings
• Current and past Imaging, lab, etc.
• Soon genetic information for personalized
  medicine
• EHR have been designed for this purpose
• Can lead to disease registries
• Some have built in decision support
• Health care providers still need access to
  current state of the art knowledge and expertise

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Access to current medical science for the next
clinical decision
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Elements of a Distributed, Technology Enabled
Health Care System

• Care at Home and in the Community
• Ambulatory, Clinic and Community Care
• Hospital Care
• Public and population health, disaster health,
  large scale emergency response

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Care at Home and in the Community
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e-Mail Communication with Patients by Physicians

• Internet use and e-mail communications between
  patients and providers a survey of rheumatology
  outpatients.
• Differences by age, gender, education
• Siva C, Smarr KL, Hanson KD, Parikh M, Lawlor K,
  Ge B.
• J Clin Rheumatol. 2008 Dec14(6)318-23.
• Patient-physician e-mail an opportunity to
  transform pediatric health care delivery.
• Over 90 enrolled, 57 faster response
• Rosen P, Kwoh CK. Pediatrics. 2007
  Oct120(4)701-6

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Chronic Disease

• More than 100 million Americans are currently
  living with at least one chronic health
  condition.
• Expenditures on chronic diseases account for more
  than 75 percent of the 2.3 trillion cost of our
  healthcare system.
• Productivity losses in workers with chronic
  disease, such as disability, unplanned absences
  and inefficiencies, are four times the cost of
  early treatment. (PWC)
• Chronic disease prevalence increases
  substantially with age, particularly for those
  over 65 years old.
• Unlike acute illnesses that may be amenable to
  short-term intervention, chronic diseases require
  long-term monitoring and management, lifestyle
  changes and adherence to medication regimens.
    E. Topol

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Traditionally we have used the same process of
care for managing chronic disease as we have used
for acute illnesses
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Home Telehealth VA Case Example

• Today
• 16,000 patients enrolled in daily home
  telehealth with Health Buddy
• Deployed in 120 clinical sites
• Over 100 programs for 30 chronic conditions

February 2006
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Care Management Process with the Health Buddy
System
Scripted messaging, monitoring and reporting
platform
Education, monitoring and feedback at home
Personalized, remote care management and support.
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VA Outcomes 2002 Telehealth Reduces Inpatient
Utilization

• 40 reduction in ER visits
• 63 reduction in hospital admissions
• 63 reduction in hospital bed days of care
• 64 reduction in nursing home admissions
• 88 reduction in nursing home bed days
• Significantly improved Quality of Life SF36V

1-Year Telemedicine Care Coordination
Demonstration
Published in Disease Management Volume 5,
Number 2, 2002.
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VA Outcomes 2005 Telehealth Improves Clinical
Outcomes

• Hospitalizations declined from 630 inpatient days
  pre to 122 during intervention period
• Bed Days Of Care fell from 8.63 to 1.65 (p lt
  0.001)
• Blood Pressure 129/73 to 119/69 (p lt 0.05)
• Weight 196 to 192 (p lt 0.01)
• Shortness of Breath 0-10 Scale 4.0 to 2.7 (p
  0.02)
• ACE Inhibitor Avg Daily Dose 24mg/d to 35 (p lt
  0.01)
• ?-Blocker Avg Daily Dose 84 mg/d to 94 (p
  0.05)

1-Year Telemedicine Care Coordination
Demonstration
Published in Telemedicine and e-Health Volume
11, Number 1, 2005.
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Can Technology Bridge Health Care Gaps and
Improve Patient Care?
Meet JL Atteberry
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In an ideal situation, complete information about
patient would be available to health care
providers continuously and captured in a database
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Remote Care Convergence of Sensors and Jewelry
Language Xlater
Body Aggregator
Pulse Oximetry
Blood Press.
Cell phone as gateway
Fashion addresses the stigmata of
care Patients bearing greater costs of
care Self care is a real possibility Approaches
that address quality, productivity, efficiency
and timeliness are needed.
Courtesy Paul Wright
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Heart Disease Example

• Traditional process
• Episodic visits
• Recall by patient for episodes
• Physiologic data taken in the MD office
• Body sensors
• HR, BP, oximetry, temperature, blood sugar done
  in real time
• Aggregates to mobile phone program
• Program has critical values, rings phone, sends
  to office personnel
• Interaction trends between parameters may also
  trigger earlier alarm (e.g. Slightly falling BP,
  with increase HR, with decrease in blood O2)
• May even cause autonomous treatment

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Similar to a pacemaker, the iPod-sized device is
implanted under the skin near the collarbone,
with wires that carry electrical signals to nerve
receptors along the carotid arteries in the neck.
The signals activate the body's own system for
lowering blood pressure. Washington University
School of Medicine
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Ambulatory, Clinic and Community Care

• Handheld Computers
• Online Medical Knowledge for Health Professionals
• Decisions support tools
• Online and Video-Based Education
• Telemedicine Consultation

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Spectrum of Information Delivery to Physicians
Store Forward Telemed
Video Telemed
Phone email
Texts Journals
Web PDAs
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Handheld Computers

• Education (ePocrates), schedule, email and
  records access
• Search PubMed using PDA
• PDA portal
• http//certif.nim.nih.gov8080/nlm
• WiFi or Blue Tooth
• Cell phone
• High Speed Network
• Regular Cell Network

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Online Medical Knowledge for Health Professionals

• Providers can access medical information
  electronically through logging into sites
  specifically designed to meet their needs.

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Online and Video-based Education

• Webcasts
• CME, CNE
• Conferences
• Online CME
• Grand Rounds
• Distance Education

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Telemedicine

• Interactive healthcare over distance using
  technology
• Telemedicine brings the expertise of a
  specialist to the point of care
  and allows that expertise to be customized to
  that patient

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Why Telemedicine Makes Sense for Rural Health Care
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Why has the Interest in Telemedicine Increased
Recently

• Quality of transmission
• Cost of transmission
• Cost of equipment
• Opportunities for funding
• Changes in reimbursement

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UC Davis Telemedicine Services

• Pediatric Critical Care
• Pediatric Sexual Abuse QA
• OB/GYN
• Pediatric Cardiology
• Surgical Oncology
• Allergy
• Occupational Medicine
• Child Development
• Burn
• Genetics
• Transplant
• Urology
• Pediatric Rheumatology

• Pulmonary
• Plastic Surgery
• Pediatric PMR
• Podiatry
• Hematology
• Pediatric Urology
• Pediatric Gastroenterology
• Oncology
• Pediatric Hematology/Oncology
• Surgery
• Cardiology
• Pediatric Endocrinology
• Pediatric Nephrology
• Gastroenterology
• Infectious Disease
• Pediatric Neurology

• Pain Management
• Pediatric Genetics
• Nephrology
• Psychology
• Rheumatology
• Neurology
• Hepatology
• Otolaryngology
• Pediatric Obesity
• Orthopedics
• Nutrition
• Endocrinology
• Psychiatry
• Dermatology

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Rural Teleophthalmology
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Evidence for telemedicine effectiveness

• Satisfaction
• patient satisfaction
• physician satisfaction
• Perceptions of quality of care
• Clinical Outcomes
• Cost effectiveness

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Evidence for telemedicine effectiveness
Satisfaction

• Many satisfaction studies done
• Teledermatologic consultation and reduction in
  referrals to dermatologists a cluster randomized
  controlled trial. Eminovic N, et al.
• No sig. difference in satisfaction
• Arch Dermatol. 2009 May145(5)558-64
• Child and adolescent telepsychiatry utilization
  and satisfaction. Myers KM, Valentine JM, Melzer
  SM
• High parental satisfaction with tele-psych
• Telemed J E Health. 2008 Mar14(2)131-

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Provider Satisfaction
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Clinical Outcomes

• Did Diagnosis or Treatment change because of
  consult?
• Did the patients medical condition improve?
• Few studies documenting improved outcomes or
  health status
• A few specialty specific studies comparing
  telemedicine with traditional care
• Home health showing decrease ER and inpatient
  utilization
• Access to care important consideration

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Select Focus Areas In Outcome Studies

• Dermatology
• Diagnosis agreement high comparing (differential)
  diagnosis via telemedicine and clinic-based
  examiners (Whited, 1999, 2001 Wootton, 2000)
• Teledermatology consults resulted in 76
  treatment changes, 52 diagnostic changes from
  those of the referring general practitioner
  (Lamminen, 2000)
• Clinical outcomes in skin cancer management via
  SF TM as measured by times to diagnosis and to
  surgical treatment can be comparable, if not
  better than, conventional management ( Hsiao J.
  et al. J Am Acad Dermatol 2008)

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Select Focus Areas In Outcome Studies

• Clinical Consultations
• Psychiatry
• Diagnosis and management plan agreement high
  between in person and telemedicine (Elford, 2000
  Ruskin, 1998)
• Psychiatric consultation and short-term follow-up
  can be as effective when delivered by
  telepsychiatry as when provided face to face.
  O'Reilly R, Bishop J, Maddox K, Hutchinson L,
  Fisman M, Takhar J. Psychiatr Serv. 2007
  Jun58(6)836-43
• Changes in diagnosis, treatment, and clinical
  improvement among patients receiving telemedicine
  consultations Marcin JP, Nesbitt TS, Cole SL,
  Knuttel RM, Hilty DM, Prescott PT, Daschbach MM.
• Telemed J E Health. 2005
  Feb11(1)36-43.

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Clinical Impact Study

• Methods
• 223 cases seen over telemedicine in 2000-2001
• Derm, endocrine and psych for initial and F/U
• Chart review for diagnosis change, treatment
  change and clinical improvement
• Two reviewers - excellent agreement (Kappa scores
  high)

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Change in Diagnoses and Therapy
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Improvement in Clinical Status
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Conclusion

• Telemedicine outreach results in diagnostic
  changes and treatment regimens that significantly
  impact the short term clinical outcome of
  patients

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Hospital Based Telemedicine
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Emergency Room Telemedicine
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Emergency Medicine Outcomes

• Efficacy of site-independent telemedicine in the
  STRokEDOC trial a randomized, blinded,
  prospective trial Meyer BC, Raman R, Hemmen T,
  Obler R, Zivin JA, Rao R, Lancet Neurol. 2008
  Sep7(9)787-95.
• Tele-stroke care -222 patient cases showed
  telemedicine evaluation led to better
  decision-making than telephone consultations
• A review of the evidence for the use of
  telemedicine within stroke systems of care a
  scientific statement from the American Heart
  Association/American Stroke Association. Stroke.
  2009 Jul40(7)2616-34. Epub 2009 May 7

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Remote Fetal Monitoring

• Pix fetal heart

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Inpatient Pediatric and Adult Critical Care
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Inpatient Pediatric and Adult Critical Care
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Remote Intensive Care Model

• Control room type model - video and sensors
• Continuous monitoring of many patients in several
  different locations
• Improves clinical outcomes
• Improves access to information
• Standardizes care
• Reduces costs (one intensivist for several sites)
• Rosenfeld BA et al. Intensive care unit
  telemedicine alternate paradigm for providing
  continuous intensivist care. Crit Care Med. 2000
  Dec28(12)3925-31.

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Remote Intensive Care

• Setting and MethodsFour ICUs from two
  metropolitan hospitals, the analysis were 4,088
  patients (1371 at baseline, 1287 in eICU wave
  one, and 1430 in eICU wave two). Mortality,
  length of stay, and total cost were evaluated.
  Age, gender, race/ethnicity, trauma status,
  APACHE III score, and physician utilization of
  the eICU were included as covariates.
• CONCLUSIONS In this study of gt4,000 patients
  representing two community hospitals, the
  investigators did not find a reduction in
  mortality, length of stay, or hospital cost
  attributable to the introduction of the eICU.
• Morrison JL, Cai Q, Davis N, Yan Y, Berbaum ML,
  Ries M, Solomon G. Clinical and economic outcomes
  of the electronic intensive care unit Results
  from two community hospitals Crit Care Med. 2009
  Aug 27

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UC Davis PICU Model

• Telemedicine consultations on critically ill
  pediatric patients in a rural adult ICU
• Mortality and length of stay outcomes were
  equivalent to PICU benchmarks
• High satisfaction with the quality of care among
  physicians, parents and nurses
• Marcin J. et al. Use of telemedicine to provide
  pediatric critical care inpatient consultations
  to underserved rural Northern California. J
  Pediatr. 2004 Mar144(3)375-80.

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Gero-Psychiatry Inpatient Model

• Psychiatry services provided to rural hospital
  via telemedicine
• Initial patient assessments
• Daily psychiatry rounds on rural patients
• positive correlation between patient/family
  satisfaction and perception of benefits of
  treatment
• Holden D, Dew E. Telemedicine in a rural
  gero-psychiatric inpatient unit comparison of
  perception/satisfaction to onsite psychiatric
  care. Telemed J E Health. 2008 May14(4)381-4.

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Telemedicine Ancillary Areas for Level 2 and
Level 3 care

• Tele-radiology
• Tele-pathology
• Tele-pharmacy
• Video interpreting

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Tele-Radiology

• Most common form of telemedicine
• History camera on a stick, digitization, direct
  capture, PACS
• Rationale
• Current practice of radiology departments
• Teleconsultations changed diagnoses in 30 of
  cases and treatment plans in 26 of cases (Lee,
  1998)
• Unnecessary patient transfers avoided, money
  saved (Balies, 1997 Goh, 1997 Fery-Lemonnier,
  1996)
• Business Models
• Night Hawk like programs
• Large Department use of specialty radiologists

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DICOM

• Digital Imaging and Communications in Medicine
  (DICOM)
• DICOM is a standard for transmitting information
  that enables hardware from multiple manufacturers
  to communicate such as into a picture archiving
  and communication system (PACS).
• Standard endorsed by the American College of
  Radiology

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Image in DICOM format from Wikipedia.com
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Tele-Pathology

• Less common than radiology
• Fewer providers need to view images
• Most PACS systems are controlled by radiology
• Has great potential benefits

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http//www.telepathology.com/
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Expert Second Opinion on Critical Lesions
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Telepharmacy

• Hospital Based
• On-line pharmacy informatics
• Decision support tools
• CPOE
• Video tele-pharmacist review of medications and
  medication orders

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Video Interpreting Services

• Links remote clinics and hospitals to bank of
  interpreters
• Many languages successful including ASL

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Public and population health, disaster health,
large scale emergency response
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Technology OpportunitiesRelation to Emergency
Surge Capacity

• Disaster area lacks sufficient number of medical
  care specialists or providers
• Hospital has capacity and equipment to care for
  patient, but patient needs a specialty consult
  not available at the facility
• Pediatric Burn Surgeon
• Infectious Diseases expert for a specific
  outbreak
• RFID tagging of patients and equipment

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Body sensors in disaster management

• Disaster site management
• Victims evaluated, RFID tagged
• Must be reevaluated frequently
• Body sensors can make emergency personnel more
  efficient
• Emergency room setting
• Local telemetry at capacity
• Similar issue, critical parameters on HE, BP
  pulse Ox.
• Algorithms combining sensor data
• eg. Falling BP, increasing HR, falling Pulse Ox
  

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Requirements for a sustainable technology
enabled healthcare system

• A ubiquitous, broadband networks with guaranteed
  quality of service (for TM)
• Broad distribution of hardware and software in
  the field
• Standards for Telemedicine and HIE
• Organization focused on policy and regulatory
  changes
• A trained workforce in advanced information tech
• Research and development program for device
  development, service delivery models and quality
  outcomes

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Essential requirements for an optimally
functioning technology enabled health care system
include widely distributed broadband
connectivity which is reliable, with explicit
quality of service (QOS), security, privacy
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FCC Rural Health Care Pilot

• Enhanced funding to help public and non-profit
  health care providers deploy broadband
• Deployment of state- and region-wide broadband
  networks for telehealth and telemedicine
• Funds up to 85 of the costs of deploying those
  networks
• Funds up to 85 of connection costs to Internet2
  or National LambdaRail (NLR) dedicated nationwide
  backbones and public Internet

From Commissioner Martins Presentation to AHIC,
Nov 13, 2007
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FCC Rural Health Care Pilot Program

• 400 million to deploy broadband health networks
• Reaching over 6,000 health care centers
• 69 programs across 42 states and 3 U.S.
  territories
• Robust connectivity to the Internet and a
  nationwide backbone

From Commissioner Martins Presentation to AHIC,
Nov 13, 2007
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Sites included in RHCPP
Commissioner Martin Presentation to AHIC, Nov 13,
2007
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Backbone Infrastructure
Commissioner Martin Presentation to AHIC, Nov 13,
2007
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Current Status of the CTN

• Award of 22.1M from FCC
• California Emerging Technology Fund (CETF)
  providing 3.6M for 15 match and start-up funds
• Letter of Agency process (completed)
• Original goal was 319
• Nearly 1000 locations represented in the received
  letters of agency
• USAC has qualified over 860 sites
• Proposal to an RFP have been received and are
  being evaluated
• An award should be made in the next 60 days

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Current Model
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California Telehealth Network
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California Telehealth Network
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How can this technology support research?

• What if you could use an entire telemedicine
  network as your research laboratory?

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Using Telehealth Technologies to Facilitate
Clinical Trials

• Recruit and/or follow-up subjects through
  telemedicine consultation clinic
• Identify subjects /assess interested in study
• Interview potential subjects and/or families for
  possible inclusion in studies/ provide informed
  consent
• Follow-up with patients over distance after
  participating in a study

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Using Telehealth Technologies to Facilitate
Clinical Trials

• Training individuals at remote sites to diagnose
  disorders and identify potential study
  participants
• Use telecommunications to conduct training
  sessions with physicians, nurses, and other staff
• To identify patients who potentially meet study
  criteria
• To review study with patients and families
• To do necessary physical exam
• To do appropriate lab, imaging, etc
• Refer qualified patients to Center for study

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How this all comes together

• All patients have a primary medical home
• Patients have fully portable EHRs
• All health providers able to exchange health
  information and connect via telemedicine
• Body sensors and home care are used for chronic
  disease management, falls prevention, monitoring
  the elderly, weight loss, etc.
• Data from sensors flow to EHRs and EHRs into
  accessible data repositories and disease
  registries
• Translational researcher can utilize all of these
  technologies to expand clinical trials

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Policy and Ethical Issues
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CMS Requirements for Hospital Medical Staff
Privileging

• The hospitals Governing Body must ensure that
  all practitioners who provide a medical level of
  care and/or conduct surgical procedures in the
  hospital are individually evaluated by its
  Medical Staff and that those practitioners
  possess current qualifications and demonstrated
  competencies for the privileges granted.
• This discourages TM consultants from providing
  services to smaller hospitals

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Anti-Kickback Statute

• Federal law makes it a crime to offer, solicit,
  pay or receive any remuneration intended to
  induce, or is in return for, the referral of
  patients or the ordering of items or services
  reimbursable by any federal health care program.
• Remuneration is anything of value.
• Law is violated if only one purpose of an
  arrangement is to induce referrals.

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Potential Violations

• Provision of free or below cost equipment or
  services
• Physician compensation arrangements that exceed
  FMV
• Free or below cost space / lease arrangements

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STARK Anti-Kickback Exception IT

• New exceptions/safe harbor for electronic health
  records and electronic prescribing
• Specific requirements that must be met
• Written agreement that specifies the items and
  services being provided and the donors cost of
  the items and services
• Providing replacement technology not allowed
• Restriction on use, compatibility or
  interoperability prohibited
• E-prescribing and E-records systems should be
  able to interface

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Medicare Today

• Medicare telehealth includes
• Consultation
• Office Visits
• Psychiatric Diagnostic Interview Examinations
• Individual Psychotherapy
• Pharmacologic Management
• End Stage Renal Disease Related Services
• Individual Medical Nutritional Therapy
• Neurobehavioral Status Exams
• Interactive audio and video telecommunications
  system required as a condition of payment

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Medicare Today

• Asynchronous telemedicine (SF) allowed for
  federal demonstration projects in AK and HI.
• Home telemedicine acceptable under Prospective
  Payment System, but cannot substitute for a
  covered home health service
• No coverage by Medicare. HHA may adopt
  telemedicine as part of the delivery of care when
  it promotes efficiency.
• Eligible originating sites must be
• Rural HPSAs
• Counties outside a MSA
• Federal demonstration projects as of 12/31/00

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Medicare Today

• Originating Sites must also be
• Physician or Practitioners Office
• Hospital
• Critical Access Hospital
• Rural Health Clinic
• Federally Qualified Health Center (FQHC)
• Hospital Based or Critical Access Hospital Based
  Renal Dialysis Center
• Skilled Nursing Facility
• A Community Mental Health Center
• Patient must be present and participating
• Presenting practitioner not required unless
  medically necessary

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Potential policy changes to make this work

• Extend safe harbor provisions to rural hospitals
  to include clinical telemedicine equipment
  including video conferencing units and associated
  peripheral clinical devices
• CMS to support reimbursement incentives to
  support new models for chronic disease management
  (home as originating site)
• Allow reimbursement for TM consultant to FQHCs to
  be considered care within four walls
• Allow for reciprocity for credentialing between
  CMS hospitals

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Ethical Issues

• How do you balance better access with almost as
  good as face to face ?
• To what do you compare TM in terms of quality?
  Ideal care or usual available?
• TM may provide access to expert diagnosis but
  maybe not to expert treatment
• Standards will address some of the issues such as
  those implemented by radiology

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Smartphone adds expertise to emergency room

• The images I saw on my phone gave me all the
  information I needed to recommend that the
  surgeon be called in. Javeed Siddiqui

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Summary

• Advanced Information and telecommunications
  technologies have a central role to play in
  transforming our health care system
• Currently there is an unprecedented financial and
  political investment in this approach
• Evidence based models of care, facilitated by
  technology potentially can improve access and
  quality across the economic and geographic
  spectrum
• Policy changes can help facilitate this
  transformation
• More research is required to develop appropriate
  quality standards

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Telemedicine Improving Care in the E.R.