Reaching the remote: Telemedicine gains ground

Services that provide specialists to patients in underserved areas are likely to expand as demands on the health care system increase.

By Carolyne Krupa — Posted Nov. 22, 2010

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Every Wednesday afternoon, Thomas Magnuson, MD, goes to a designated room at the University of Nebraska Medical Center to meet with patients in nursing homes around the state via an interactive video screen.

Many of his patients have Alzheimer's disease or other forms of dementia. Using teleconferencing technology, he is able to see and talk with patients, nursing home staff and family members.

The technology allows him to treat people who are hundreds of miles away and don't have easy access to a specialist. Through telemedicine, it's as though they are in his office.

"I live in a state that has not a lot of people, but a lot of area," said Dr. Magnuson, a psychiatrist specializing in geriatrics and an assistant professor at the medical center. "We have a lot of isolated places. We just had a big patient population out there that wasn't being seen."

Nationwide, telemedicine increasingly is being used to bridge gaps in access to care in rural and other medically underserved communities that have a hard time recruiting physicians. The technology provides primary care physicians and patients a vital link to specialists at large urban medical centers.

Such consults reduce patient transfers, allow local doctors to respond more quickly to their patients' needs, and save patients time and money by eliminating the need to take off work or school to travel long distances for care.

Telemedicine also is good for the well-being of communities, because the lab work, imaging and pharmacy services are done locally, said Debra Lister, MD, director of the Coffee Regional Medical Center Walk-In Clinic in Douglas, Ga.

"The patients stay in the community and don't get lost to an outside specialist," she said. "And local doctors keep control of their patients."

Telemedicine ranges from patient consults by phone, e-mail or interactive video to surgeons using remote-controlled robots to operate on patients thousands of miles away. "Whether the doctor's in the next room or 3,000 miles away is irrelevant," said Gary Capistrant, senior director of public policy for the American Telemedicine Assn.

The practice is used nationwide, and many rural hospitals have some telemedicine connection, Capistrant said. A few of the most common applications are psychiatry, radiology, pathology and neurology. But the technology has been slow to spread to some areas that are resistant to change or lack broadband infrastructure.

Telemedicine will become more common, however, as the country moves forward with health system reform, which will require that services be made available to patients regardless of geographic barriers, said Curtis L. Lowery, MD, chair of obstetrics and gynecology and director of the Center for Distance Health at the University of Arkansas for Medical Sciences.

The Centers for Medicare & Medicaid Services is making changes to promote telemedicine. In June, the agency proposed new policies that would make it easier for hospital officials to credential physicians who provide telemedicine services at their facilities. And in January 2011, CMS will expand Medicaid coverage for remote services, including disease management training for patients with diabetes or kidney disease.

Reliance on providing care from afar will increase due to expected shortages of physicians. By 2020, the nation may be an estimated 91,500 physicians short due to expansion of coverage to more than 30 million uninsured Americans and increased demand from an aging population.

Without enough doctors to deliver care, many rural health facilities increasingly will be staffed by nonphysicians, such as advanced practice nurses. And because nonphysicians lack a broad medical education, they will need the support of specialists via telemedicine, Dr. Lowery said.

"This is going to be a huge tool in trying to manage health care reform," he said. "The role of subspecialists becomes more important."

Health reform also means an increased focus on efficient and cost-effective care, said Alan Morgan, chief executive officer of the National Rural Health Assn. Policymakers will work to remove barriers to expansion of telemedicine such as inconsistent payment structures, he said.

Ensuring access to care

Douglas is a town of about 11,500 in southern Georgia, more than two hours southeast of Macon and 50 minutes from the nearest interstate. The Coffee Regional Medical Center Walk-In Clinic sees about 1,000 patients a month from Douglas and surrounding communities.

About 30 to 40 patients use the clinic's telemedicine services monthly. As part of the Georgia Partnership for Telehealth, they're able to access specialists who aren't available locally, including dermatologists, endocrinologists and pediatric cardiologists.

"It's so far for our people here to get to a specialist," Dr. Lister said. "Some of these people just can't travel -- some of our elderly and poor people couldn't have made the trip. An awful lot of them would not have received care."

Via remote, the clinic usually can get a patient an appointment with a specialist within two months. It would take four or five months for an in-person appointment.

Telemedicine requires collaborative relationships, and having a statewide agency to assist in building those relationships helps. For example, the Georgia Partnership for Telehealth is a 5-year-old nonprofit corporation formed to promote telemedicine and build networks statewide. It has grown from 42 facilities to 171 in the last two years and includes hospitals, clinics, jails, child advocacy facilities and senior centers, said Paula Guy, the partnership's executive director.

Telemedicine also is used to boost efficiency in emergency care, when getting patients the care they need quickly can mean the difference between life and death.

The University of Mississippi Medical Center has had its TelEmergency program for eight years. The system makes emergency physicians available around the clock to 13 rural hospitals via remote, said Bob Galli, MD, the program's director and a professor of emergency medicine at UMMC. "Like so many poor, rural states, we have such a hard time recruiting physicians. This is a great way for the university, as the only academic medical center in the state, to extend its reach."

The University of Arkansas for Medical Sciences offers rural emergency departments access from afar to specialists in high-risk pregnancies and burn experts, said Dr. Lowery, a maternal fetal medicine specialist. The medical center's stroke program provides 24-hour access to a neurologist so that emergency physicians can get the consult they need to administer potentially lifesaving tissue plasminogen activator to stroke patients within the medicine's time constraints.

One of the most common uses of telemedicine is for psychiatry, because it doesn't require physical contact with a patient.

The University of Nebraska Medical Center matches psychiatrists with about 37 hospitals around the state. The effort is part of the Nebraska Statewide Telehealth Network, which connects all 83 of the state's nonprofit hospitals, said Dale Gibbs, network chair and director of outreach and telehealth services at Good Samaritan Hospital in Kearney, Neb.

Of Nebraska's 93 counties, 89 have a shortage of mental health professionals, said Laura Meyers, consultant to the network and grant project manager with DKG Consulting. In addition to geography, the state's harsh winters make travel difficult for patients who must drive 250 miles or more to see a specialist.

"There are only six to eight months a year you can do that," said Dr. Magnuson, a psychiatrist at UNMC. "It really imposes a huge burden on these families and on these facilities."

Offering patients access to care in their own communities saves money on both ends and improves patient compliance, said Wanda Kjar-Hunt, program manager for telehealth at Good Samaritan. "They won't miss as many appointments, because they don't have to travel."

Cutting costs and extending reach

Many agencies use telemedicine to streamline services, reduce costs and improve patient care.

The Dept. of Veterans Affairs began offering mental health services remotely more than 30 years ago and has expanded services to other specialties greatly in the last 20 years, said Adam Darkins, MD, MPH, chief consultant for telehealth services with the Veterans Health Administration. Nationwide, 140 of 153 VA hospitals have telemedicine capabilities.

More than 300,000 people received telemedicine care through the VHA in 2009. About 48,000 chronic disease patients are being monitored remotely in their homes through technology that allows physicians to track patients' health indicators, such as blood glucose level and heart pressure.

Such monitoring has allowed the VHA to significantly reduce hospital admissions, Dr. Darkins said. The technology will become even more common as chronic disease rates rise, he added.

"The closer you can get to real-time collection and real-time analysis, the better you can control a disease process, as opposed to the traditional model where we only collect information when they come into the office," said Wes Valdes, DO, a wound care specialist and medical director for telehealth at the University of Illinois College of Medicine, which has offered telemedicine services for about a decade.

But telemedicine has limitations, including the types of care that can be provided and the fact that many medical centers house telemedicine facilities separate from other care centers.

Physicians and patients typically must leave regular patient care areas to go to designated rooms that house the communications equipment, Dr. Valdes said.

As technology continues to improve, having the capability readily available through handheld devices, such as smartphones and iPads, will make it more convenient and more likely for physicians to participate.

Other barriers to expanded use of telemedicine include the cost of the technology and payment structures, said Brock Slabach, MPH, senior vice president for member services with the National Rural Health Assn. Payment for telemedicine is inconsistent nationwide. Though several states require insurance companies to pay for such care, many insurers and policymakers are still working out how to pay for remote services.

At its Annual Meeting in June, the American Medical Association's House of Delegates approved a policy asking national specialty societies to develop telemedicine practice parameters. The policy says that medical boards should require physicians practicing telemedicine in their states or territories to have full, unrestricted licenses there.

But medical licensing by state makes it difficult for physicians to provide telemedicine across state lines, because doctors have to maintain licenses in each state, said Deanna Larson, vice president of quality initiatives at Avera Health, a health system that offers telemedicine services in Iowa, Minnesota, Nebraska, North Dakota, South Dakota and Wyoming.

Telemedicine's potential is far from being realized, but it never will replace traditional in-person doctor visits completely, physicians say. "It can't replace all health care," Dr. Darkins said. "There is an obligate need to why people need face-to-face care."

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Telemedicine brings health care to prisons

Prisons are using telemedicine to bring health care to ill or injured inmates as modern technology eliminates the need to transport many patients.

In many ways, corrections is ideal for telemedicine, said Edward Harrison, president of the National Commission on Correctional Health Care.

"There are roughly 3 million people incarcerated on any given day," Harrison said. "Many of those people have health issues that require specialty care, so the advantage of telemedicine is obvious when you think of finding health staff to work in the more rural, isolated areas, which is extremely difficult."

Using telemedicine gets inmates care more quickly and eliminates the risks of transporting offenders prone to escape or lash out in public, said Louis Shicker, MD, agency medical director for the Illinois Dept. of Corrections and the Illinois Dept. of Juvenile Justice.

It can be disruptive to have an inmate come to a physician's office with armed guards and shackles, he added.

In Illinois, Wexford Health Sources, a company the state contracts with to provide health care to inmates, uses telemedicine for consultations in specialties such as cardiology and nephrology. The state also contracts with the University of Illinois Medical Center to provide care for inmates with HIV and hepatitis C.

"This is a way to ... predictably address common issues in the prison system," said Jay L. Goldstein, MD, professor and vice head for clinical affairs at the University of Illinois College of Medicine.

But telemedicine has challenges, too. There are limits to the care that can be provided, and coordinating schedules can be tricky, Dr. Shicker said. Even so, telemedicine in prisons is expected to grow. "This is the wave of the future," he added.

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