The Future of Healthcare Delivery: An Introduction to Telemedicine

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The Future of Healthcare Delivery An
Introduction to Telemedicine

• Erik Southard, RN, MSN, C-FNP
• Director of Special Projects
• Richard G. Lugar Center for Rural Health
• Terre Haute, Indiana

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Presentation Objectives

• Introductions.
• Definition of Telehealth.
• Definition of Telemedicine.
• What is the internet?
• Discussion of telemedicine applications.

• Statistics on telemedicine activity.
• Telemedicine programs throughout the state.
• Next steps.
• Whats going on now?
• Q A.

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Understanding Rural
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Telemedicine and College

• Can I be successful?
• Many have gone before me (successfully).
• Is this the right thing to do?
• This can be expensive.
• Fear of failure?
• Is it sustainable?
• Experimentation?
• Encountering Naysayers.
• Personal support, hard work, and collaboration?
• Success.

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Audience Participation

• Who is currently involved with some form of
  telemedicine?
• Who thinks that telemedicine is impractical and
  cant be sustained?
• If you have considered telemedicine, what is your
  greatest specialty need?
• Can telemedicine help us improve access to care
  for Indiana and more specifically Indianas rural
  residents?

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Lugar Center Mission

• The mission of the LCTR is to prepare and train
  primary care physicians for successful rural
  practice and to expose individuals not yet
  decided on a career to the rewards of delivering
  health care services in a rural area.

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Key Success Factors

• Rural Training Track (RTT), a specially designed
  hands-on curriculum for future rural health
  providers.
• Commitment to a multidisciplinary team approach
  to providing health care.
• Incorporation of computer and communications
  technology to support rural providers.

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Importance of Technology

• Professional isolation.
• Lack of specialist support.
• Continuing Medical Education.

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How Technology Transforms Conventional Wisdom

• Charles Duell, Commissioner, US Office of
  Patents, 1899.
• Everything that can be invented has been
  invented
• Thomas Watson, Chairman, IBM, 1943
• I think there is a world market for maybe five
  computers.
• Ken Olson, Founder/Ceo, Digital Equipment Corp,
  1977
• There is no reason anyone would want a computer
  in their home.
• Bill Gates, Co-Founder, Microsoft, 1981
• 640 K ought to be enough for anybody

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Significant Advances of Technology

• Vacuum Tube (Lee De Forest, 1906)
• Transistor (ATTs Bell Labs, 1947)
• Computers (1925)
• Satellite (1962)
• Fiber Optics (1966)
• Internet (1983, made available mid-1990s)
• Digital Routing for voice and data (1990s)
• Cell Phone High Speed

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What is the internet?
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A Bit about Bytes
bit bit 0 or 1
byte B 8 bits
Kilobyte KB 1,000 bytes
Megabyte MB 1,000 Kilobytes
Gigabyte GB 1,000Megabytes
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Bandwidth
Name Speed Capacity Example
Dialup Low-bandwidth Up to 56Kbs Using phone line Store and Forward
DSL Wideband 128Kbs up to 1.54Mbs Usually around 384Kbs. Store and forward some live, depending on bandwidth, shared
T1 Wideband 1.54Mbs (24 64Kbs channels) Dedicated lines.
T3 or DS3 Broadband 44.736Mbs (28 T1 Lines) The Rolls-Royce of connectivity
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File Transfer Times
Type of Document File Size 56K T1 T3
Patient Record 100K 14.63 s 0.53 s 0.02s
Patient Record 250K 36.57s 1.33s 0.05s
Single Image 300K 43.89s 1.59s 0.05s
Average Procedure 1MB 2m 29.8 s 5.43s 0.19s
Large Procedure 750MB 1d 7h 12m 1h 7m 2m 21s
Average CT 250MB 10h 24m 9s 23m 46.8s
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Telemedicine began . . .

• In 1924, with the concept of a physician seeing
  his patient over the radio using a television
  screen.
• First wave of telemedicine programs started in
  the 1950s with Wittson, Affleck, and Johnson.
• Now in our third wave.
• Most programs that began in the 1960s-1980s no
  longer exist.

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Telemedicine Now

• The 1990s saw a doubling in number of two-way
  interactive video programs.
• Teleradiology, store-and-forward, remains most
  common application.
• Technology is rapidly changing and costs are
  decreasing.
• Correctional is heaviest use.
• Moving into private physicians use.
• Expanding applications.

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Telemedicine and Telehealth

• Telemedicine and telehealth both describe the
  use of medical information exchanged from one
  site to another via electronic communications to
  improve patients health status
• http//americantelemed.org/ICOT/Terminology.pdf

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Types of Telemedicine

• Synchronous-Describes interactive video
  connections because the transmission of
  information in both directions is occurring at
  exactly the same period. (Live Telemedicine)
• Asynchronous-Describes store and forward
  transmission of medical images or information
  because the transmission typically occurs in one
  direction in time. (Store and forward
  telemedicine)

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Store and Forward

• www.RuralConsult.com

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Store and Forward
ADVANTAGES DISADVANTAGES

• Limited Specialties.
• Delay in getting feedback.
• No patient provider interaction.
• Incomplete view of the case.

• No scheduling constraints.
• Less burdensome technical requirements.
• Low connection and equipment costs. (POTS)
• Information stored centrally, more secure.

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Live Telemedicine Equipment

• General Examination Camera
• E-Stethoscope
• ENT Scope
• Ophthalmoscope
• X-Ray Digitizer
• 12 lead ECG machine
• Spirometer

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Live Telemedicine
ADVANTAGES DISADVANTAGES

• Scheduling constraints.
• High equipment costs.
• Expensive line charges.

• Multiple specialty use.
• Interactive.
• High quality video and audio.
• Patient provider relationship.

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Telemedicine Equipment
Power Zoom Push-button 1-50x zoom allows both
close focus and wide angle images. Auto Focus
The camera automatically stays in focus for ease
of use. Freeze Frame Freeze frame produces the
clearest possible image, making it ideal for both
low- and high-bandwidth solutions. Accurate
Colors One button white balance sets highly
accurate colors quickly and easily. Polarization
Elimination of surface skin reflection allows
camera to see into epidermal layers. Touch and
View The AMD-2500 includes manual or automatic
iris control to maximize image brightness.
AMD 2500 General Examination Camera
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Quality Images
Pictures taken by AMD 2500 General Examination
Camera
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• Findings from HRSA Telehealth Inventory

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• Type of Telehealth Activities Reported from HRSA
  Telehealth Inventory

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Why Telemedicine?

• Access
• Provide primary healthcare that would not be
  available otherwise.
• Specialty care consultations for isolated
  specialists, practitioners, and other health care
  professionals.
• Eliminate expensive travel and isolation.
• Reduce need to move patient.
• CME for isolated health care providers.

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Telemedicine Settings

• Rural
• Schools
• Clinics
• Hospitals
• Prisons
• Nursing Homes/Assisted living

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Emerging Applications

• Telepharmacy
• Broader Home Health
• Remote Surgery

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Core Principles of Telemedicine

• Its only a tool.
• Must have a program champion.
• Must be integrated into established clinical
  operations and routines.
• Physician-patient relationships must be
  preserved.

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Creating a Successful Program

• Define the need.
• Who are the key people that need to participate.
• What services are needed.
• What are the most logical sites or personnel to
  have involved?
• When are the services needed?
• How are the services best supported?

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Assess Equipment Options

• Store and Forward.
• Live Telemedicine.
• Necessary Peripherals.

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Assess Transmission Options

• Plain Old Telephone System (POTS)
• Integrated Services Digital Network (ISDN)
• Internet Protocol (IP)
• Digital Subscriber Lines (DSL)
• OCRA
• OUCC

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Estimate Costs

• Employees.
• Line Charges.
• Equipment Costs.
• Reimbursement and Revenue Streams???

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Address Policy Issues

• Health Insurance Portability and Accountability
  Act (HIPAA)
• Joint Commission on the Accreditation of
  Healthcare Organizations (JCAHO)
• Licensure
• Liability

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Operational Organization

• Institutional Commitment.
• Staffing Concerns.
• Map out clinical, technical, and administrative
  activities.

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Implementation Timelines

• Create Protocols.
• Legal Counsel review.
• Solicit equipment bids.
• Research equipment.
• Order equipment and telecom. lines.
• Preliminary testing.
• Training site coordinators and staff.

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Outcome Measures

• Clinical Outcomes.
• Process Measures.
• Participant Acceptability.
• Costs.

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Telemedicine in Indiana

• Programs are few in number.
• Acceptance among providers is growing.
• Indiana, a leader in electronic medical records,
  is working to increase telemedicine activity.
• Six main programs.

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NeuroPsychOnline

• Started in 2003.
• Completed 250 consults.
• Provides online interactive cognitive
  rehabilitation services for those with brain
  injury from injury, disease or other neurological
  anomaly.
• For more information contact Odie Bracy at (317)
  257-9672.

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Community Behavioral Care Services

• Psychiatric Consults.
• Connects North Campus to South Campus.
• Assessments for admission.
• Small program but looking to expand.
• For more information contact Travis Lozier, IT
  Site Director [phone]

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St. Vincent Health

• Home monitoring project for congestive heart
  failure patients palliative care.
• Distance learning and education programs.
• https//secure.stvincent.org/distancelearning/defa
  ult.aspx
• Live interactive telepsychiatry services.
• For more information contact John Winenger
  [phone].

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St. Vincent Health

• Remote Monitoring for Group Homes starting in
  March 2007.
• Tele-OB services with CAH (In progress).
• EMS intermediate class with St. V. Williamsport
  via remote connection.
• NP to MD consults via video connection to Clay
  City.

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Clarian Telemedicine

• Program began in 2003 with HRSA grant.
• Offers live, interactive consults between
  patients and providers.
• Clarian Telemedicine has facilitated over 756
  cases and completed 249 live interactive
  consults.
• Clinic sites in Bedford, Terre Haute, South Bend,
  Fort Wayne and Evansville.
• For more information contact Rebecca Salley at
  [phone].

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RuralConsult.com

• Store and forward telemedicine program.
• Created by Union Hospitals Richard G. Lugar
  Center for Rural Health in December of 1999.
• System provides online access to 12 medical
  specialists as well as continuing medical
  education credits.
• RuralConsult.com has over 150 registered
  providers and has completed over 350 consults.
• For more information contact Hicham Rahmouni, IT
  Specialist at [phone].

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Whats New In Indiana?
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Telehealth Advisory Consortium

• Formed by Greg Beck in May 2005.
• Volunteer group of more than 20 members
  representing 10 different organizations.
• Mission To advance telehealth services in
  Indiana communities through collaboration,
  advocacy and education.
• www.indianatac.org

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Fostering Collaboration

• Indiana Rural Health Association Annual
  Conference June 6th and 7th will feature a
  telemedicine track sponsored by ISDH and the
  Telehealth Advisory Consortium.

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Critical Access Hospital Survey

• The Indiana State Department of Health has
  partnered with BecknCall to complete an onsite
  telehealth survey with CAH administrators.
• Greg Beck MHA, initiated the Clarian telemedicine
  program and was instrumental in getting
  reimbursement talks initiated.
• Greg Beck serves as the Chairman for the TAC.
• For more information contact Greg at (317)
  536-2601.

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FCC

• State Opportunity.
• Collaborative Approach.
• Contact Elizabeth Morgan at ISDH.

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The Barriers

• Equipment costs.
• Connectivity costs.
• Reimbursement.
• Practice Patterns.
• Liability Concerns.
• Lack of Knowledge.

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Getting Better

• Declining equipment costs.
• Shared connectivity.
• Improving reimbursement.
• Increased Awareness.

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Benefits of Telemedicine

• Allows patient to receive medical care in their
  own community.
• May lessen the amount of travel time for both
  patients and specialists.
• Reduces sense of isolation felt by rural
  providers.
• Enhances continuity of patient care.

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What Indiana Needs to Do

• Track all outcomes.
• Inform others and be informed.
• Contact your legislators.
• Get Connected.

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Excellent Resource

• A Guide to Getting Started in Telemedicine
• Completed by funding through the Office for the
  Advancement of Telehealth (OAT) and Health
  Resources Services Administration (HRSA)
• http//telehealth.muhealth.org/geninfo/TAD.html
• Click on Telemedicine Technical Assistance
  Documents

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Telemedicine Scenarios

• Nursing Home.
• Medicaid Child in Need of Psychiatric Services.
• Stroke patient in Rural Indiana.
• Stories from the field????

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• There are three steps in the revelation of any
  truth first, it is ridiculed, in the second,
  resisted in the third, it is considered
  self-evident.
• Schopenhauer (1788-1860)