Issue: November 2014
November 01, 2014
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Telemedicine shows significant potential in ID, other specialty care

Issue: November 2014
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New technologies are allowing physicians, including infectious disease specialists, to help patients without seeing them in person during an office visit.

Saving time and saving money, telemedicine and telehealth services are especially helpful in rural areas where subspecialists may not be readily available. Either by treating patients directly via real-time video and audio, or working in conjunction with primary care providers to assist them in providing specialty care, remote health care services have the potential to expand access to care significantly.

It may sound futuristic, but in reality, telemedicine is not new. According to Jeremy Young, MD, MPH, assistant professor of medicine and infectious disease specialist at the University of Illinois at Chicago, telemedicine, typically defined as a remote visit between a health care provider and a patient, has been around for decades.

“Telemedicine began in the 1960s with NASA, when astronauts fell ill in space and needed to be seen by physicians,” Young, who also leads the Telehealth Program at the University of Illinois, told Infectious Disease News. “Over the 1970s, the concept of telepsychiatry was picked up with the development of the Internet. So it has been around for a while, but it’s increasing in significance lately due to improvements in technology as well as policy changes surrounding telehealth.”

Jeremy Young, MD, MPH, assistant professor of medicine and infectious disease specialist at the University of Illinois at Chicago, said telemedicine has been around for decades.

Image:Young J

Infectious Disease News spoke with several experts about telemedicine and the barriers and benefits of remote health care services.

Models of telemedicine

Young said there are two types of telemedicine visits: synchronous and asynchronous. In synchronous visits, physicians and patients engage in a real-time video and audio visit. The patient is typically in a health care setting with a health care professional, such as a nurse, while communicating with the physician virtually.

For these types of visits, there is specialized equipment, including electronic stethoscopes and otoscopes, and high-definition cameras that allow a physician to conduct a thorough, accurate and reliable physical examination on a patient.

“The only thing missing is that you can’t touch the patient, which may make telemedicine difficult for some specialties such as rheumatology,” Young said. “But for infectious diseases, even immunocompromised patients with AIDS, there really is no downside.”

Neil E. Herendeen, MD, MS, associate professor of pediatrics at Golisano Children’s Hospital and the University of Rochester Medical School, has been pushing telemedicine, as he believes it is the best use of patient-centered care available.

“There’s nothing more patient-centered than going in and doing a virtual house call,” Herendeen told Infectious Disease News. “It saves time on my end because I see each patient in my waiting room by clicking on my computer. It still delivers that personal care.”

Telemedicine also encompasses asynchronous visits, Young said. In these visits, a health care professional, such as a PCP, receives the patient and inputs clinical information and/or photos onto a computer network. A specialist reviews the data within 24 to 48 hours and sends their consults back.

Also known as “store and forward telemedicine,” this approach involves information from tests being stored on a computer and then forwarded to another hospital that practices telemedicine for a physician’s review, according to Jeffrey R. Kile, MD, MHA, of Pediatric Associates of Kingston in Kingston, Pa.

“The physician gives it a read and then sends it back,” Kile told Infectious Disease News. “That is more static because it’s not in real time.”

Technology-enhanced telemedicine

Today’s telemedicine includes real-time video and audio so a physician can directly monitor a patient with the help of someone trained in the technologies. These include attachments for cellphones, stethoscopes, otoscopes, cameras and other devices that send pictures to the reviewing physician.

Herendeen said with technology-enhanced telemedicine, the attachments allow technicians to further examine a patient.

“That’s where we’ve come up with this telemedicine assistant role,” he said. “A lot of programs are using nurses in that role. We’ve taken it a step lower and trained someone to use the cameras.”

James P. Marcin, MD, MPH, professor of pediatric critical care at the University of California, Davis School of Medicine, and UC Davis Children’s Hospital in Sacramento, Calif., said the available technology should be used to improve the quality of care delivered to these patients when specialists are not available in their community.

“People say a picture is worth a thousand words,” he said. “With medicine, videoconferencing brings us right to the bedside, allowing us to see what’s happening and collaborate with on-site doctors and nurses to provide the best possible care to our patients.”

Michael R. Slaper, MHSA, who is the telemedicine program coordinator at Nationwide Children’s Hospital Center for Telehealth in Columbus, Ohio, said this technology truly enables patients and physicians to connect in real-time without having to worry about geographic distances.

“If you implement virtual clinics, it could alleviate a lot of constraints on families or patients if they have to drive several hours to an outpatient visit,” Slaper told Infectious Disease News. “Instead, they can theoretically stay in their local community and miss less time at school or work, and because they are close to home, get back to their daily life sooner.”

Reaching the underserved

The University of New Mexico (UNM) developed a telehealth model to train PCPs for underserved populations to treat complex health problems, including infectious diseases such as hepatitis C virus and HIV.

According to Karla Thornton, MD, MPH, professor of medicine at UNM’s Health Sciences Center, the Extension for Community Healthcare Outcomes (ECHO) model uses videoconferencing to train PCPs to treat patients in rural and underserved areas, thus improving their access to specialty care. PCPs throughout the state partake in a weekly telehealth clinic that includes a multidisciplinary team from UNM.

“The PCPs present cases to us, and we give guidance on how those patients should be treated,” Thornton, who also is associate director of Project ECHO, told Infectious Disease News. “Over time, they learn how to treat the patients themselves. The goal is to educate these PCPs in treating HIV and HCV in settings where there is no access to specialists.”

James P. Marcin

James P. Marcin

Although the UNM Project ECHO focuses primarily on patients with HCV, another Project ECHO through the University of Washington in Seattle focuses on patients with HIV throughout Alaska, Idaho, Montana, Oregon and Washington.

According to Brian Wood, MD, assistant professor of medicine at the University of Washington, and medical director of the Northwest AIDS Education and Training Center (NW AETC) HIV ECHO Telehealth project, the university is one of the only academic medical centers serving a vast geographic region, which led to the NW AETC HIV ECHO project.

“Our goal was to create partnerships between the PCPs on the frontlines in rural and underserved areas to create a channel for sharing best practices,” Wood told Infectious Disease News. “We try to provide training and longitudinal mentorship for providers who work in areas with limited access to specialists.”

Similar to the UNM model, the NW AETC HIV ECHO project involves a core group of providers who call in weekly and discuss cases.

“We’ve found that over time, the power of ECHO is in developing relationships and partnerships for support,” Wood said. “Creating a network of support is key.”

Patient outcomes

The Project ECHO team in New Mexico conducted a prospective cohort study comparing treatment for HCV at the UNM HCV clinic with treatment by a PCP at the 21 ECHO clinics in rural areas and prisons in New Mexico. The study, published in The New England Journal of Medicine, included 407 patients with no previous treatment.

They found that 57.5% of patients treated at the university clinic and 58.2% of those treated at ECHO sites had an SVR, showing no difference in efficacy between the sites of treatment. There also was no difference in safety.

“We know that prior to ECHO, there were very few people in the state being treated for HCV because there wasn’t any place to be treated other than our HCV clinic in Albuquerque,” Thornton said. “We have treated many patients as a result of ECHO, and we now can say that there is increased access to care in some of the communities.”

Young and colleagues evaluated the impact of a telemedicine program within the Illinois prison system for inmates with HIV. They evaluated rates of virologic suppression among 514 inmates with HIV from July 2009 to June 2010, before the implementation of a telemedicine program for this setting, with the rates among 687 inmates from July 13, 2010 to June 30, 2012. They published their findings in Clinical Infectious Diseases.

They found that the proportion of patients with complete virologic suppression during the first six visits was significantly greater among those in the telemedicine group: 91.1% vs. 59.3% (OR=7; 95% CI, 5.1-9.8). In addition, the data suggest a higher increase in CD4 counts among patients who received care by telemedicine.

“Prior to 2010, HIV patients in prisons were managed by onsite general physicians who typically aren’t trained in HIV,” Young said. “Our data show that with telemedicine, patients experienced a significant improvement in virologic suppression.”

Benefits of telemedicine

Wood said that in the NW AETC HIV ECHO program, there has been significant subjective feedback from the PCPs who say the program has increased their knowledge of HIV, improved their care for patients and helped make them feel more connected to their colleagues. His group is looking to evaluate these factors more objectively.

When the telemedicine program began at Golisano Children’s Hospital, Herendeen and colleagues conducted a head-to-head comparison of children who walked into the clinic to see what could be diagnosed by telemedicine and what could be diagnosed in person.

“We found there was very little we couldn’t do [with telemedicine],” he said. “We could do anything except abdominal pain and gastroenteritis. I can’t get a great listen with the stethoscope to bowel sounds. I can watch a video clip of someone pushing on the patient’s stomach for me, but it’s different than me putting my own hand on their stomach and feeling.”

At worst, Herendeen said telemedicine can provide a second-level triage of these types of problems. However, he added, that is not what he does most of the time, and 96% of telemedicine visits are able to be successfully completed.

“It doesn’t seem to impair us to say that there are certain conditions we’re unable to do by telemedicine,” he said.

Michael R. Slaper

Michael R. Slaper

Slaper said telemedicine has the ability to improve the relationship between the provider and patient.

“Patients have a very finite amount of time with their provider when they come in for an office visit or a sick visit,” he said. “Technology can be used as an extension of that relationship in a way that providers can educate their patients and have them self-manage themselves when they’re out of the four walls of either their physician’s office or the hospital.”

Cost, licensure and technology

Young said the obvious barrier to telemedicine is cost.

“In very remote areas, access to the Internet and mobile data systems is difficult, and even in the rural United States, the telemedicine equipment for synchronous meetings can cost at least $15,000, depending on how many peripherals you get,” he said. “It’s not cheap, but it’s definitely cost-effective.”

Another barrier deals with physician licensure. Physicians are licensed by the state and are unable to practice medicine in states where they do not have a license.

“The American Telemedicine Association (ATA) is pushing for a change in physician licensure,” Young said. “It may be that physicians will be able to get a federal license to practice anywhere, or there may be a specific telemedicine license with its own regulations.”

Young said there also has been discussion about developing a telemedicine subspecialty, but at this point, there is no specific certification, regulatory board or board exams.

Herendeen said most electronic medical record models are not geared toward images and sound waves, although they are easily downloaded, but meant for typing and documenting words.

“Right now, the big companies that have done electronic records have not gone out of their way to make the interface easy,” he said. “Even when they do open that portal so we can transfer them, you get back to your local information specialty group who says there may be viruses and won’t download the images.”

From a security standpoint, Herendeen said some system manufacturers are reluctant to add more images onto their system.

“The reluctance there is how you manage all of the data and that size of information,” he said.

Reimbursement issues

“There’s nonuniform reimbursement right now, and each state has its Medicaid program set up a different way, if at all, to reimburse for services for telemedicine,” Slaper said. “Private payers are just starting to wade in the waters to say they will reimburse for limited services, but even with them it’s not uniform across the board.”

According to a report by the ATA, 21 states and the District of Columbia have telemedicine parity laws for private insurance plans. There are 47 states that have some type of telemedicine coverage through their Medicaid programs.

“Over the past 3 years, the number of states with telemedicine parity laws — that require private insurers to cover telemedicine-provided services comparable to that of in person — has doubled,” the ATA wrote in the report. “While there are some states with exemplary telemedicine policies, lack of enforcement and general awareness have led to a lag in provider participation.”

Despite the issues related to billing and licensure, Young said the response to telemedicine has been very positive, both from patients and clinicians. A study on patient views on telemedicine among patients in the prison clinics is on the docket, Young said.

“Patient satisfaction is an important area that needs to be addressed on a large scale because telemedicine is a totally new model of health care,” Young said. “It’s taking off, especially as the number of people with access to the Internet increases each year. I think it will take off significantly for many patient populations.” — by Amber Cox and Emily Shafer

References:

American Telemedicine Association. State Telemedicine Gaps Analysis: Coverage & Reimbursement. Available at: www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf?sfvrsn=6. Accessed: Oct. 22, 2014.
Arora S. N Engl J Med. 2011;364:2199-2207.
Young J. Clin Infect Dis. 2014;59:123-126.

For more information:

Neil E. Herendeen, MD, MS, can be reached at: 601 Elmwood Ave., Box 632, Rochester, NY 14642; email: neil_herendeen@urmc.rochester.edu.
Jeffrey R. Kile, MD, MHA, FAAP, can be reached at: Pediatric Associates of Kingston, 425 Tioga Ave., Kingston, PA 18704; email: jeffkilemd@hotmail.com.
James P. Marcin, MD, MPH, can be reached at: UC Davis Department of Pediatrics, 2516 Stockton Blvd., Sacramento, CA 95817; email: jpmarcin@ucdavis.edu.
Michael R. Slaper, MHSA, can be reached at: 700 Children’s Drive, Columbus, OH 43205; email: michael.slaper@nationwidechildrens.org.
Brian Wood, MD, can be reached at: Northwest AETC Mailstop 359932, Harborview Medical Center, 325 9th Ave., Seattle, WA 98104; email: bwood2@uw.edu.
Jeremy Young, MD, MPH, can be reached at: 808 S. Wood St., #888, Chicago, IL 60612; email: young@uic.edu.

Disclosure: Herendeen, Kile, Marcin, Slaper, Thornton, Wood and Young report no relevant financial disclosures.

Does telemedicine have a place in routine care in pediatrics?

POINT

I use these devices and find them helpful.

As Medical Director of the Arizona Telemedicine Program, I have used and worked with clinicians who have used multiple electronic diagnostic devices, including stethoscopes, otoscopes and hand-held cameras.

The electronic stethoscope is useful for the diagnosis of murmurs, wheezes and other abnormal sounds. It is also a great teaching tool that can record heart sounds that may be unknown to a learner and be used for later review. The quality of the electronic stethoscope has made it both my daily stethoscope as well as my telemed stethoscope. It’s just what I carry in my pocket now!

Ana Maria Lopez

The electronic otoscope is the mainstay for many nurse-based school clinics. The tele-otoscope is not a direct translation from the otoscope we learned to use in medical school. The examiner must look at the video screen and not toward the patient’s ear, all while advancing the instrument into the patient’s ear. Like in medical school, we all practice on ourselves first.

The hand-held camera has multiple purposes, including for dermatology and, with appropriate disposable covers, oral care.

All of these tools serve to extend the clinicians’ reach and provide care to patients who are in areas otherwise not served.

Ana Maria Lopez, MD, MPH, FACP, is medical director for the Arizona Telemedicine Program and professor of medicine and pathology at the University of Arizona Cancer Center in Tucson. Lopez can be reached at alopez@uacc.arizona.edu. Disclosure: Lopez reports no relevant financial disclosures.

COUNTER

I don’t use these devices and I see no benefit to them.

We have minimal experience with this telemedicine format in our office. I know that our hospital uses a robot for night coverage of adult patients, which can show the distant on-call doctors the patient and discuss care with them. The pediatric exam of the infant and young child, and the teenager, could never be supplanted by a videoconference machine. I could only see its role in psychiatric and counseling issues. But even half of these visits involve the parent who mentions casually, “Oh, by the way, he is ... coughing, has a sore throat, a bellyache, etc.”

I personally believe that I see too many critical findings and subtleties on my examinations, including demeanor and affect and rashes that would never show up on any telemedicine. I also spend all day playing “divert and distract” in my anxious or crying infants and children.

Stan L. Block

Furthermore, I can see minimal — if any — role in the high percentage of my complicated ill patients. For example, I have had children come in for a mild sore throat for 2 hours, and the next day may be on death’s door. The teen in for headache, who by the way has innumerable self-inflicted cuts on her abdomen or arm. A few petichiae on the back, which are due to early meningococcemia and the incidental discolored mole, which is pre-melanoma. There are many examples of this disparity in severity every day.

I have used a superb ($10,000) tele-otoscope in a clinical trial. It is very impractical and time-consuming to routinely use in any child less than 3 years old (peak age for most acute otitis media) because the child must be held totally still, all ear cerumen must still be removed from these small ear canals, and then the data must be transmitted from an extra computer. Who will do this? I do not trust this technology for everyday pediatric practice in community offices yet.

Stan L. Block, MD, FAAP, is in private practice in Bardstown, Ky., and is also professor of clinical pediatrics at the University of Kentucky College of Medicine in Lexington, and at the University of Louisville Medical School in Louisville. Block can be reached at slblockmd@hotmail.com. Disclosure: Block reports no relevant financial disclosures.