Skype for Telemedicine

This could open up new possibilities, Skype for Telemedicine. I see charging patients a flat monthly fee as a better option than charging per visit.

Telemedicine in Pediatric ICU care

Mass General Hospital for Childern in partnership with Partner's Healthcare Center for Connected Health is using video conferencing technology in caring for pediatric ICU patients. Senior physicians are available to evaluate patients at the bedside remotely using video conferencing technology. The on site clinical team which includes nurses, resident physicians and interns, are all able to be join the senior physician in the bedside evaluation of the patient. They have plans to expand this model of care to the other wards and to use it for adult inpatient care as well. Read more...

Telemedicine Studies

Telemedicine via video conferencing is comparable to face-to-face doctor-patient encounters:

Study finds virtual doctor visits satisfactory for both patients and clinicians, May 2009 issue of the Journal of Telemedicine and Telecare
"There is growing evidence that the use of videoconferencing in the medical environment is useful for a variety of acute and chronic issues," says Ronald F. Dixon, MD, an internist at Massachusetts General Hospital
"Videoconferencing between a provider and patients allows for the evaluation of many issues that may not require an office visit and can be achieved in a shorter time."

Medicare Reform: Denying payment for 30 day re-admissions

Connected Health: Expanding its Role to Prevent 30-day Hospital Readmissions

Friday, August 22, 2008 | Allison McDonough, MD

Dr McDonough makes the following Points:

• "Connected health can contribute significantly to preventing such readmissions by improving monitoring of patients after discharge."
• "May provide additional benefit by assisting with access to timely ambulatory care for high risk patients."
• "There is ample room for improvement in 30 day readmission rates."

• "In 2005, an average of 18% of patients were readmitted within 30 days of their hospital discharge, with a range of 14% at the 10th percentile to 21% at the 90th percentile (Commonwealth Fund National Scorecard on U.S. health system performance, 2008)."
  
• "Medicare estimates that 13% of these readmissions were “potentially avoidable,” based on the IPPS rule, with major areas of concern including poor communication with patients at discharge, especially around medications, and inadequate post hospital discharge monitoring."
• "Prevention of these avoidable readmissions could save Medicare about $12 billion per year. (Report on Medicare Compliance, Volume 17, Number 24, June 30, 2008)"

• "Post Hospital Discharge Monitoring: Remote daily measurement of vital signs and symptoms in the heart failure population has shown great promise already in reducing readmissions, through improved monitoring as well as patient education."
  
• "IT platforms which facilitate interactions with Primary Care Providers will enhance the effectiveness and efficiency of telemonitoring."
  
• "These interactions may also improve patients’ access to timely ambulatory care, avoiding Emergency Department visits and readmissions."

Great comments made by some readers:

"I would like to also suggest hospital/physician referral's to Skilled Nursing Facilities. Many people still have the idea that a "Nursing Home" is the end of the road of life, however this is no. Most SNF's can handle much higher levels of care post-acute and most offer wonderful rehab programs and all disciplines (PT, ST, OT). It would be nice to develop a "circle" of care. From Hospital to SNF and then home with home health. This would really help deter the emergency room visits and the costs asscoiated with such visits. Also, a way to educate about the Medicare 30 day window, post hospital stay, for patients and the hospital staff would be very beneficial. Most of the hospital case managers and ER staff are not aware of this benefit."
Posted by: Robin Davis



Comments by the Author: Allison McDonough, MD

• "There is clearly a vital role for the visiting nurse in caring for our sickest patients. SNF and Rehab facilities are also an essential part of the continuum of care. However, as you know, many very sick or complicated patients are still not homebound, and do not qualify for VNA services. I see connected health as one way to fill this gap."
• "...dangers patients face in periods of transition, e.g. hospital or SNF to home."
  
• "Research from Kaiser found that >90% of hospital discharge medication lists contained errors (such as duplicative medication classes, interactions, inappropriate dosing)."
  
• "Patients often feel, and sometimes are, abandoned."
  
• "Economic incentives to discharge early mean that patients are frequently sent home while they are still fairly ill."
  
• "we need to embrace the patient and guide them through the entire continuum of their care"

Telepsychiatry, the next growth area...

Telepsychiatry is being touted as the next growth area in telemedicine. It is widely recognized that there is a shortage of psychiatry nationwide, especially in the in-patient, emergency room setting. Telemedicine would enable psychiatrists and other mental health professionals to provide care to a wider group of patients across multiple settings. Read this article for more information.

Telemedicine in Action

Interesting article on a Telemedicine Pilot by Dr Siddiqui, who is using it for infectious disease and wound care remote consultations. Its becoming clear that we will be experiencing a severe doctor shortage in the next few years. In my own community, I do not see any new physicians starting their practices. Our local hospitals have become frustrated in their attempts to recruit new primary care physicians and specialists. Over the next 5 years, I see a significant number of physicians retiring or winding down. In order to efficiently use our limited physician resources, telemedicine will need to be more main stream. Dr Siddiqui has presented an excellent case study and I look forward to reading his findings when they are published.

...Partnering with Dr. Javeed Siddiqui of UC Davis Medical Center, the staff at
Sonoma Valley Hospital is routinely able to get expert opinion on infection
cases using the state of the art technology."Programs like this are great
because they allow us to offer high quality medical care in this small community
that we would never have been able to offer otherwise," said Carl Gerlach, chief
executive officer at Sonoma Valley Hospital. "When we don't have that particular
specialist on board, telemedicine allows us to reach out to the best medical
centers for their expertise.".....hospital partnered up with Siddiqui, an
infectious disease specialist, who agreed to help guide the hospital's response
to infection.
To date, Siddiqui has consulted on dozens of infection cases
ranging from diabetic foot ulcers and wound checks to pneumonia and
osteomyelitis. McMahon said the technology is almost as good as having the
doctor in the room, because he can use the camera to zoom in to get an up close
look and talk to the patients in real time.

Telemedicine data

This diagram shows how telemedicine data is just another type of data within the complete clinical dataset. This was taken from a recent telemedicine presentation.

Telemedicine EMR

Here is a screenshot of an EMR used in Telemedicine. It was taken from an ATA 2001 conference presentation. Please refer to Healthcare Vision Inc for information on their products.

Here is a recent presentation (5/2007) and has great EMR screeshots: TeleHealth and EMRs

Dermatology Telemedicine Application (contains very good screenshots):

Custom-Made Telemedicine Application for Department of Dermatology and Emergency Medicine

Telemedicine Wound Care Video Clip

Wound care is a really neat application of telemedicine. Here is a video clip on the use of telemedicine for wound care. Notice the use of Microsoft's new Ribbon style user interface (Office 2007) in the wound care application.
I wonder if they are using an Office 2007 based application (Infopath or Access) or have developed their own application from "ground-up" ?



A Wound Medicine Project document. Good detailed technical discussion on the design of a wound management application. Allows for on screen measurement of wounds using laser pointers.

Telemedicine Video clips

Here are a few good video clips on Telemedicine:
Clip #1: A real-life story on the use of Telemedicine consultation in an emergency room where the onsite ER physician was instructed on how to perform a surgical procedure on a critically ill pediatric patient who had just minutes.


Clip #2: Real demo of a Patient's experience with a tele-consultation. This patient presented to a clinic with an ear ache. A nurse used an otoscope connected to the telemedicine equipment (cool) and consulted with a remote Ear Nose and Throat doctor who was able to see the image from the patient's ear.

Telemedicine Resources

Telemedicine is another area in health IT that interests me. Being a practicing physician with patients in multiple settings such as nursing homes and hospitals, I believe that telemedicine shows great promise and has yet to reach its potential in transforming how we practice healthcare . It's the combination clinical medicine and cutting edge healthcare IT that is really appealing to a techie physician. Telemedicine technology in many ways is about moving data around between patients and physicians, similar to a RHIO or an HIE.

To me, an HIE (Healthcare Information Exchange) is about moving and aggregating actionable clinical data from multiple data sources to a physician (or other healthcare provider) in order to provider patient care. Telemedicine is just another type of data that must be moved from the source (the patient from the remote location) to the physician.

I will be putting together a list of useful Telemedicine resources. please let me know if I should include anything else.

Telemedicine and Delaying Hospitalization: Interesting item on how telemedicine can reduce hospitalization of nursing home patients from a blog on senior care.

Some interesting points from the blog item:

• "...many doctors have skilled nursing facilities third on their to-do lists"


• “37 percent of the hospitalizations of long-term residents at urban nursing homes nationwide were potentially avoidable.”
• "A doctor can teleconference with a patient, see them via a monitor and make a decision as to what the patient needs."
  " Many nursing homes have found this reduces the need for unnecessary hospitalizations.."

More links related to Telemedicine and Hospitalizations:

• Treating Acute Infections by Telemedicine in the Home PDF
• New telemedicine program pairs comfort of home with heart care
• Treating Acute Infections at Home with Telemedicine Presentation on real implementation of telemedicine. Has pictures of the equipment used, list of costs for the equipment and benefits of the program: Shows the reduction in hospital days, costs savings, patient satisfaction etc.
• Telemedicine Information Exchange (TIE) website : Great resource with a wealth of information on Telemedicine.
• Boston Globe article on Nursing home deficiencies and cutting unneeded hospitalizations. How Telemedicine is being used to address these challenges.

Telemedicine in Wound Care

Wound care practice, Woundcare Consultants

Wound care in long term setting from Ostomy Wound Management

Telemedicine Wound care using cell phones

WoundMatrix, wound care EMR

Smith & Nephew's has a Device to measure Wound area. See their website for more information.

Laser device to measure wounds.

Telemedicine Liability: Unfortunately, liability and malpractice are issues that must also be considered even in telemedicine. Here are a few resources:

Blog item on Telemedicine Liability: contains a link to potential liability issues in teleradiology.

Telemedicine Risk makes the following points:

• "...while remote medical practice can bring efficiency and cost savings... it can increase liability."
• "Malpractice insurance is merely the first step in risk management for telemedicine, since local laws may be different on each end of the link..."

Regional Telemedicine Issues

A map of Telemedicine and Telehealth State-by-State: A map with links to each state's telemedicine related issues such as existing programs, reimbursement policies etc.

Arizona's Telemedicine Program, equipment description

Telemedicine in Dermatology

TeleDerm Guidelines

Study using TeleDerm. A comparison of TeleDerm with conventional dermatology.

Telemedicine in Nursing Home

Here is a 2006 presentation on the use telemedicine for nursing home care in the state of Maine.

Employing a Wireless Mobile Solution to Bring
Telemedicine to the Nursing Home Bedside
This is proposal to link three rural Michigan nursing homes via telemedicine.

Telehealth Wound Protocol

Northeast Telehealth Resource Center , Partners Healthcare Telemedicine, ME and VT state.

There is a set of document links on their resource page. I have provided them here for convenience.

Informed Consent Reimbursement Policy and Procedures Tele-mental health Protocol for Correctional Inmates Protocol for Medical ASL Interpretation for the Deaf--Video Relay Interpreting Tele-Wound Care Protocol for Nursing Home Residents Tele-Pain management Protocol Tele-pharmacy Protocol

Wound care in long term setting from Ostomy Wound Management

Telemedicine Solution Vendors

REACH Remote Stroke Care

The use a 100% web enabled solution using webs cams, telemedicine carts to deliver reote stroke care to hospital emergency rooms.

InteractiveCare Provides a complete solution for telemedicine. Focus is presently on hospitals but the solution can be deployed in multiple clinical settings. They have a good demo here.

Healthcare Vision Inc

ExhibitOne This company does high definition video conferencing for multiple applications including healthcare.

HealthPia America, Medical Device company. Their flagship product is the "All-in-One Diabetes phone, a cell phone with a built-in glucose monitor that essentially functions as a full-time nurse"

Second Opinion Telemedicine Software: A complete solution for telemedicine consultations.

Telemedicine Radiology:

Team Health is a Tele-Radiology group: "TeamHealth Teleradiology (THTR) was founded in 1991, in Durham, North Carolina, by a group of physicians from Duke University. At that time, the centralized interpretative services group offered reading expertise in MRI and CT for rural physicians who lacked access or experience in these modalities. The group provided 24-hour-a-day coverage, including nights and weekends. THTR was the first and the largest teleradiology company of its kind."

Telemedicine Presentations

TeleHealth and EMRs (5/2007) Makes a good case for telemedicine and its integration with EMRs. Also has a great set of EMR screenshots.

A. Hasan Sapci, M.D at the Telemedicine Resource Center at the University of Michigan Health System has included a comprehensive set of interesting telemedicine technical presentations on his online resume.

Telemedicine for developing countries, MIT developed solution

Telemedicine in Disease Management

Telemedicine in Diabetes

Diabetes Telemedicine/EMR product. Describes the benefits of telemedicine in diabetic care.

Comprehensive discussion of Telemedicine in Diabetes, and the endocrinologist's role

IDEATel- Informatics for Diabetes Education and Telemedicine

Home Telemedicine- A Practical Guide Addresses a number of issues: HIPAA, implementation, nurse case management, provider issues

Telemedicine RHIO

RHIOs, Telehealth & Interop (HIMSS Architects of Change 3/2006) Lists several RHIOs with Telehealth components

Telemedicine Technical Resources:

Store and Forward Technology

ICU Telemedicine

ICU Medical Service company using Visicu's technology

Article on Inova Health System, North Dakota adoption of Visicu.

The Value of Provider-to-Provider Telehealth Technologies, CITL

TeleHealth Technologies Report

Reducing emergency department transfers

Reducing transfers from correctional facilities to emergency departments and physician offices

Reducing transfers from nursing home facilities to emergency departments and physician offices

Replacing in-person consults with virtual consults

Reducing redundant and unnecessary laboratory tests

Telemedicine Market Article is a little dated, 2004, but does have an excellent market analysis.

Video Conferencing Solutions Vendors

New and Pre-owned equipment , Video Conference Store

Carries Sony Video Conferencing products

LifeSize, High Definition Video solution. This company has their own product which looks pretty slick. They have several excellent video demos of their product in action. Here is a review of their system.

Telemedicine Programs

MTN Missouri Telehealth Network

University of Iowa , Dept of Family Medicine: Samsung SDS of Korea, a development team at the University of Iowa has developed a Nursing Home Telemedicine system, Colonial Manor in Amana, Iowa. See their system diagram.

Karishma Telemedicine: Program based in India, their brochures are here.

Maine Telemedidine Services

Policies and Procedures for providing telemedicine services in Maine

Telemedicine Equipment

Alaska's AFHCAN user manuals