Thomas S. Nesbitt, M.D., M.P.H.
University of California, Davis, Health System
What is the rationale for telehealth? One of the landmark publications of the past couple of decades, Crossing the Quality Chasm, stated, “information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved” (IOM, 2001, p. 16). Nowhere is this more true than in rural communities. New knowledge and new science are being developed all the time. When some people have access to that new knowledge and expertise and other people do not, disparities grow. Advances in telecommunication and information technology can help overcome some of these disparities by redistributing that knowledge and expertise to when and where it is needed.
Health care in the home-based setting has a long history. For example, an 1879 article in the Lancet talked about using the telephone to reduce unnecessary office visits. In 1925, a cover of Science and Invention magazine showed a doctor diagnosing a patient by radio, and within envisioned a device that would allow for the video examination of a patient over distance. Home monitoring developed more fully in the Mercury space program when the National Aeronautics and Space Administration (NASA) began performing physiologic monitoring over a distance. NASA further developed this technology with a pilot with the Papago Indians, the Space
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3 The Evolution of Telehealth: Where Have We Been and Where Are We Going? Thomas S. Nesbitt, M.D., M.P.H. University of California, Davis, Health System What is the rationale for telehealth? One of the landmark publications of the past couple of decades, Crossing the Quality Chasm, stated, "infor- mation technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved" (IOM, 2001, p. 16). Nowhere is this more true than in rural communities. New knowledge and new science are being developed all the time. When some people have access to that new knowledge and expertise and other people do not, disparities grow. Advances in telecommunication and information technology can help overcome some of these disparities by redistributing that knowledge and expertise to when and where it is needed. HOME- AND COMMUNITY-BASED CARE Health care in the home-based setting has a long history. For example, an 1879 article in the Lancet talked about using the telephone to reduce unnecessary office visits. In 1925, a cover of Science and Invention maga- zine showed a doctor diagnosing a patient by radio, and within envisioned a device that would allow for the video examination of a patient over distance. Home monitoring developed more fully in the Mercury space program when the National Aeronautics and Space Administration (NASA) began performing physiologic monitoring over a distance. NASA further developed this technology with a pilot with the Papago Indians, the Space 11
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12 THE ROLE OF TELEHEALTH Technology Applied to Rural Papago Advanced Health Care (STARPAHC) project. The biggest need in home- and community-based care relates to chronic disease. The 100 million Americans with chronic disease account for about 75 percent of health care expenditures. Traditionally, chronic disease has been managed through an episodic office-based model rather than a care management model, which uses frequent patient contact and regular physi- ologic measurement. More than a decade ago, the VA developed a care management program that offered personalized education, monitoring, and feedback at home from a remote disease management support team. Use of technologies for chronic disease care management has been associ- ated with reductions in hospitalizations, readmissions, lengths of stay, and costs; improvement in some physiologic measures; high rates of satisfaction; and better adherence to medication. Studies of home monitoring programs have shown specific improvements in the management of hypertension, congestive heart failure, and diabetes. However, more and higher-quality studies are needed. In the future there will likely be more laptop-based and tablet-based devices used in the home. In addition, there will likely be even smaller devices used for physiological monitoring. For example, companies are developing wearable wireless devices that can combine an accelerom- eter, stethoscope, electrocardiogram, and other functions to collect data from continuous monitoring. There may also be watches or rings that can measure blood pressure and heart rate. Patient preference and acceptability is one challenge in home-based telehealth. Many studies show attrition with the use of these technologies after the pilot ends. More information is needed regarding what kinds of devices people want to use and how much intrusion they are willing to ac- cept in their lives. We also need to determine how to best involve patients and their families in care. Another challenge is to determine how to use off-the-shelf devices (e.g., mobile phones, gaming systems) in care. Further- more, how can we manage the data flowing in from all these devices and transform it into information that is actionable by a clinician? Many physi- cians do not have disease management teams, so how does the small rural doctor's office use the data in a meaningful way? Finally, policy changes are needed to enable the use of these technologies. OFFICE-BASED TELEMEDICINE Telemedicine has also been used for decades in clinical settings. In 1906, the inventor of the electrocardiogram published a paper on the tele- cardiogram. Since the 1920s, the radio has been used to give medical advice to clinics on ships. Alaska has been a model for the development and use of telemedicine for decades. For example, community health aides in small
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THE EVOLUTION OF TELEHEALTH 13 villages can perform otoscopy and audiometry, and the information can be sent to specialists in Anchorage or Fairbanks to make the determination of whether a patient needs to travel to the specialist for more definitive treatment. Today, we think of office-based telemedicine as flat-screen, high- definition units with peripheral devices that can aid in physical examination of the patient. There are a lot of these units out there, all of which do not talk to each other, and some of which use proprietary communications methods. If telemedicine is to become as ubiquitous as the telephone, com- munications standards will be needed. Store and forward (S&F), or asynchronous, technologies have been a great advance. For example, in ophthalmology and optometry, non- mydriatic cameras can be used to perform retinal screenings in diabet- ics without needing to dilate the eyes; this has increased screening rates. Teledentistry has been used to by dental hygienists and dentists to improve access to oral health care. Dermatology and psychology are two of the big- gest areas for telemedicine. Since the 1990s, studies have shown high rates of agreement between diagnoses made in person and diagnoses made via teledermatology. Other studies of teledermatology show high satisfaction rates and no delay to definitive care. However, barriers to its adoption by dermatologists have a lot to do with reimbursement. Similarly, studies show good agreement between diagnosis and treatment plans with in-person mental health care and those developed using telehealth technologies; these studies also show high satisfaction rates, even among parents of children with psychiatric illness. Telemedicine equipment will continue to evolve. For example, there is already an otoscope that connects to an iPhone. Also, there will be more integration of telemedicine and decision support systems into electronic health records. Office-based care has many challenges and opportunities in the future. For example, what is the best use of nontraditional providers? How do we use new telehealth models that build community clinical expertise? Can we improve interfaces, such as through high-definition or three-dimensional images? How can we use less-costly equipment such as handheld devices (e.g., smartphones)? We need to continue to develop evidence-based stan- dards for care, and determine reimbursement models that can support telemedicine to rural and remote communities. ANCILLARY TELEMEDICINE SERVICES Teleradiology Teleradiology has been used for at least 60 years. In the past, film was passed through a digitizer; now most systems use direct digital capture, which allows images to be read overnight in other countries. Radiolo-
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14 THE ROLE OF TELEHEALTH gists have promoted the Digital Imaging and Communications in Medicine (DICOM) standard for transmitting and storing data. By the late 1990s, studies showed that teleradiology reduced transports for head injuries out of rural areas and that the availability of teleconsultation with a radiologist significantly affected diagnosis and treatment plans. Telepathology Telepathology is less common than teleradiology, but digitization of pathology slides is becoming much more common. These are very large files, which require the ability to view color images under different mag- nifications. A lot of people were concerned about moving these large files across firewalls, but now a number of models being developed have the image sitting on a server and the image can be viewed over distance without needing to be moved. Studies have shown the value of telepathology. One study demonstrated that a specialist pathologist via telemedicine was better than a staff pathologist onsite. In 74 percent of cases, the diagnosis was more precisely done (Liang et al., 2008). Telepharmacology Pharmacy has been practiced over distance for a long time. Telephar- macy is facilitated by computerized physician order entry, remote review, and even remote dispensing. Combining that with video, being able to review medications, and conducting a video consultation with a patient allows the whole pharmacy visit to occur over distance. In one recent study on 47 cancer patients, 27,000 miles of travel were saved because of telepharmacy (Gordon et al., 2012). Another study of six rural hospitals showed that with telepharmacy, about 19 percent of patients had one or more medication errors that were picked up by the remote pharmacists (Cole et al., 2012). HOSPITAL-BASED TELEMEDICINE Probably one of the earliest and most famous uses of hospital-based telemedicine was in the late 1950s and early 1960s when a closed-circuit television link was established between the Nebraska Psychiatric Institute and Norfolk State Hospital for psychiatric consultations. Hospital-based telemedicine is growing quickly in two areas: stroke care and care in the intensive care unit (ICU). Evidence shows that with good imaging, high- quality stroke exams can be done over distance. Although the literature on tele-ICU has been mixed, recent studies indicate associated reductions in
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THE EVOLUTION OF TELEHEALTH 15 length of stay, mortality, and costs. However, the specific elements of tele- ICU that make a difference are not clear. A number of devices are being used in inpatient setting as well as in skilled nursing facilities. Telemedicine reduces avoidable visits to emergency departments for skilled nursing patients. Some rural skilled nursing facilities exist in communities that do not have physicians, and getting physicians there urgently can be a challenge. Recent studies show strong evidence of clinical benefit and savings with increased use of telehealth in nursing homes, and that families and nursing home personnel were very positive about the use of telepsychiatry for geropsychiatric care. Looking toward the future, telesurgery has been used on a small scale. Future challenges and opportunities include determination of the key ben- eficial elements of tele-ICU and how it can be tailored to smaller hospitals. In terms of development, a lot of the expansion of hospital-based tele- medicine has been with for-profit companies offering stroke and ICU care to hospitals that can afford those models. How can we build incentives to expand those models, so either private companies or public institutions can afford to offer these services in rural communities? Also, as payers stop paying for readmissions, there may be more incentives for the use of tele- medicine in skilled nursing facilities. Finally, telementoring and telerobotic surgery may increase as a method to capitalize on experts' technical skills and knowledge. CONCLUDING REMARKS Nesbitt concluded that advanced telecommunication and information technologies have a role to play in transforming the health care system. Evidence-based models facilitated by these technologies can improve access to and quality of health care across the geographic and economic spectrum. To date, we have been attempting to layer these technologies onto a health care system that does not have the necessary incentives. However, the pas- sage of ACA and other policy changes can help facilitate this transforma- tion. Overall, more research is required to develop appropriate quality standards in all these areas of care.
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