Increased collegiality among physicians, happier patients,
lower costs…
Could telemedicine turn out to be as revolutionary as the
technology that makes it possible?
by Jeffrey Mortimer
Rashid Bashshur |
When asked about the medical profession's less than passionate
embracing of telemedicine to date, Rashid Bashshur likes to
tell the story of the stethoscope's stormy entry into the practice
of medicine.
"The doctors who were using it initially," he says,
"had to hide it under their tall hats. Before the stethoscope,
the doctor would put an ear right on the patient's chest. Now
there was a wooden device that separated them, so the argument
was that this would destroy the doctor-patient relationship
because of the lack of touch."
Needless to say, the stethoscope, with many improvements, eventually
gained acceptance and became an essential tool in clinical practice.
Bashshur's point is that physicians today are at least as resistant
to new technology as others have been in the past and are, in
this respect, no different from professionals in other fields.
From his own perspective, he predicts that people will some
day be telling such stories about telemedicine, and that that
day may not be so far off.
Bashshur, a professor of health management and policy in the
U-M School of Public Health who over the course of his teaching
life has helped launch about 50 Ph.D.s into public health careers
around the world, has also been, since last July, the director
of telemedicine for the U-M Health System. This was largely
a matter of formalizing a pre-existing arrangement: Medical
School physicians testing the waters of information technology
in their practices would solicit the names of experts in the
field from their colleagues around the country, who would tell
them, "Well, there's this professor in public health right
in Ann Arbor…"
Riley Rees |
He became, as he puts it, an "informal consultant"
to a handful of initiatives by individual faculty members: Dr.
Norman Alessi in child and adolescent psychiatry, Dr. Michelle
Nypaver in pediatric emergency care, Dr. Riley Rees in chronic
wound management, and Dr. Daniel Teitelbaum in pediatric surgery.
"These individuals piloted telemedicine projects pretty
much on their own," says Bashshur. "What we are now
trying to do is to develop an institutional framework for supporting
these various initiatives and to make sure that the infrastructure
that needs to be put in place can be shared by the various applications."
In addition to his other duties, Bashshur is also the editor-in-chief
of Telemedicine Journal, the official publication of the American
Telemedical Association. Twenty-five years ago, in Ann Arbor,
he convened the first national conference on telemedicine, under
the auspices of the National Science Foundation. All of a dozen
people showed up.
But, for various reasons both social and political, the idea
of "practicing medicine at a distance," the literal
meaning of telemedicine and a good starting point (there are
both broad and narrow definitions), did gain increased acceptance.
In the 70s, the concept was tested in a number of sites, such
as urban clinics in Massachusetts and Illinois, rural networks
in Maine, Minnesota, New Hampshire and Puerto Rico, prison systems
in Florida and Indian health facilities in Arizona. Then, almost
as suddenly and long before any truly meaningful scientific
work could be completed, the funding ended and experimental
programs ceased to exist. Out of this early experience, Bashshur
edited the first book on telemedicine and maintained his interest
by continuing to publish papers on the topic. A few other individuals
around the country, including Ken Bird in Massachusetts, Jay
Sanders in Florida and Max House in Newfoundland, Canada, also
continued working in the area.
"We didn't learn much that was relevant to policy from
the first generation of telemedicine because the experiments
were not allowed to mature," says Bashshur. "We got
into it, got out of it, spent quite a bit of money as a nation,
and we dropped it as if it were a bad idea. We didn't really
reach that decision because of scientific study but because
the money ran out."
In the 70s, telemedicine was seen largely as a social mission,
a way to neutralize geographic inequities in the distribution
of medical care. In addition to the Department of Health and
Human Services (then Health, Education and Welfare), one of
its backers was the late Office of Economic Opportunity. In
the 70s, too, the available technology was only a primitive
shadow of what it was to become, and cumbersome and expensive
to boot. Most of the tools now within the scope of telemedicine
— including the Internet, digitized audio and video, fiber
optic transmission lines, and personal computers — either
didn't exist or were not yet available in the marketplace.
The development of such technologies, and their ongoing evolution,
is one of the factors Bashshur cites for telemedicine's resurgence.
"The extraordinary speed of advances in information technology
and accompanying decreases in cost made the argument for looking
at telemedicine anew more and more compelling; there was no
longer any question about the wisdom or the appropriateness
of trying to establish these systems and test them and utilize
them," he notes. Moreover, these advances could still serve
societal ends, including the very ends for which telemedicine
was initially envisioned.
"We in the United States claim that we have the best medical
care in the world, which is only partly true," says Bashshur.
"While we generally have the finest quality care available
anywhere, not everyone has access to it."
"Overall, we don't do as well as 13 or 14 other countries
by major indicators of quality outcomes, such as infant mortality
or life expectancy," he says. "Certain segments
of the population still have limited access to care -the
uninsured, the remote, the isolated. We have been dealing
with these kinds of problems for at least five decades and
haven't solved them yet. Quality of care is geographically
uneven, and costs continue to escalate. Telemedicine offers
an attractive technological solution that might — I use the
word advisedly — address all three problems simultaneously.
Disparities in quality can be diminished through ongoing
interactions between remote providers and consultants, the
underserved may be helped by making care available closer
to where they live, and cost inflation may be contained by
substitutions, by eliminating unnecessary visits to the emergency
room, and by reducing unnecessary and redundant diagnostic
tests."
These factors, and the educational possibilities, soon made
a telemedicine advocate of Dr. James Woolliscroft, now associate
dean for graduate medical education and then the assistant dean
for clinical affairs. "None of these efforts was coordinated
and they all required the same infrastructure," he says.
"If you're going to be successful, you have to have bureaucratic
support to keep the machine running. In addition, we had an
internationally renowned expert in telemedicine in Rashid, whom
individuals here would contact, but we had never built on the
expertise he had developed."
An experience with one of his children helped lift the veil
from Woolliscroft's eyes. Two years ago, when his son was in
seventh grade, he participated in a program where students were
given laptops for six months. The youngster was assigned to
do a report on Gen. George Patton and "pulled pictures
off the Web of real battles, pictures of Patton, sound bites,
and while he talked, he had this device that showed all this
stuff on a screen behind him," Woolliscroft marvels. "And
that was just the norm; that's what every kid in the class did.
"When I saw that is when I sort of got interested in this,"
he says. "I said, whoa, if that's what they're doing and
that's where they're used to going for information, it's just
a whole different mind set."
He chuckles. "Maybe that's what it will take [for telemedicine
to be accepted]. All the old fogies have to die off."
Michelle Nypaver |
"The number one barrier is people and previous ideas and
beliefs about the way they should practice medicine," says
Nypaver, who is preparing a report on the successful linkage
of the U-M Health System's pediatric emergency clinic and the
emergency room at Foote Hospital in Jackson. "Telemedicine
isn't a new specialty in medicine, it's just a medium for doing
what we already do."
Actually, just as Bashshur's appointment was an acknowledgment
of what was already happening informally, many in the field
anticipate that telemedicine will become as ordinary as stethoscopes
and as ubiquitous as pagers. Its use is already routine in some
areas, like the transmission and sharing of test results, radiological
data, and any other information that can be digitized. Those
who have tested the waters at U-M say it will continue to grow
because the technology will improve, it will serve institutional
goals by expanding the reach of existing resources, and patients
will demand it.
The technology itself fuels that demand, as patients have access
to an abundance of Web sites offering medical information (of
widely varying quality, to be sure, but that's another story).
"The patients as consumers are going to demand different
things from medicine and they're going to become the driving
force in the next 20 years," says Alessi, who has been
involved in several telemedicine projects, including helping
to develop the Web site for the American Academy of Child and
Adolescent Psychiatry (AACAP). The AACAP Web site's surprising
popularity was an eye-opener for Alessi. "In the first
year and a half, its usage went from 2,000 hits a month to 300,000,"
he says, noting that "people are going to force medicine
to adopt the technology. They want their medical care to be
at least as good and responsive as amazon.com (the popular on-line
bookseller). People are going to force medicine to adopt the
technology."
Norman Alessi
|
Dr. Alessi recalls that when he started medical school in 1972,
"patients weren't allowed to go into medical libraries
and read textbooks. They were almost like the Holy Grail."
Now they can point, click, and access everything from the John
Hopkins newsletter to sites devoted to specific diseases. "According
to at least one survey, 70% of doctors don't like the Web,"
says Dr. Alessi, "but I think it's probably the greatest
thing that's ever happened for patients, and will only get better."
"Information technology has a life of its own that is
not dependent on health care," says Bashshur. "The
best health care can do is catch up with information technology,
not lead it."
So far, physicians on the Medical School faculty have caught
up with it sufficiently to:
|
provide some "just in time" learning options
for students, and other providers as well.
("Just in time" is a phrase borrowed from the
auto industry which, in the case of medical education,
means giving practicing physicians information when they
need it as opposed to asking them to commit to memory
information that they may never need or will need only
rarely.) "All you have to do is look at the Internet
and you will see that 90% of telemedicine is educational,"
says Nypaver. "In a teaching hospital we see a highly
variable population. What if you now had a tool where
you could see all kinds of things no matter where you
were?" She uses as an example a case she incorporated
into a study: a young infant with an unusual reaction
to poison ivy, not a common thing in such a young child.
"You take pictures, save them, and then in your next
dermatology lecture you say, 'Look at this,' and kind
of pump the students with what age group would this be.
And then you say, 'No, it's six weeks. Life's not a textbook.'
This is really a powerful tool."
"The long-term goal is for interesting or unusual
procedures, as well as general procedures that all residents
and medical students need to view, to be electronically
stored on a database," says Teitelbaum. "Then
someone who wants to learn a particular procedure can
simply go to a computer, click on an index, find the procedure
they want to see and view it prior to performing it."
test its value in monitoring home health care.
"We're increasingly sending home highly complex patients,
with Mom having to perform difficult tasks such as giving
tube feeds, IV nutrition and medication, and changing
wound dressings-procedures with which she has no experience,"
says Teitelbaum. "If we send our own nurses out,
which we typically do, it costs a huge amount of money,
little of which is reimbursable. Insurance companies are
not only asking patients to leave the hospital earlier
but they're also not paying for many of these home visits.
The families are stranded out there. What we would like
to do is place a low-end telemedicine unit in many of
these patients' homes and keep the other end with our
nurses in home care, and have them tune in a couple of
times a day to the patients' homes and watch what they're
doing, answer questions, make sure they're doing procedures
correctly."
Rees' wound care facility is visited annually by hundreds
of disabled patients suffering from pressure sores. Ideally,
such patients should be evaluated weekly, but they usually
visit monthly because such trips are "a huge expense,
both financially and emotionally, for me to say the wound
is clean," he says. The extended period of time between
visits heightens the role of the home care giver, who
is responsible for the daily dressing and monitoring that
such lesions require.
And that's why Rees and his associates sought, and received,
funding from the Veterans Administration for a pilot project
in which patients will be "seen" via digital
cameras and the Internet. "In addition to developing
data matrices to keep track of the status of the pressure
sore, you also are able to use it as a powerful educational
tool to teach nurses the standards of wound care practice,
to apprise them of the dressings you're using on these
patients, and allow them to learn new technologies for
the treatment of the patient," he says.
"I'm convinced we can effectively manage the patients,"
adds Rees. "You can tell, via digital camera and
the Internet, when a wound looks bad. In patients who
develop bone infections, the average hospital cost is
about $48,000. That's not including home health visits
or the antibiotics or outpatient or physician charges.
If you can save four or five patients from that expense,
you've saved enough money to make it worthwhile. And,
most important, you're improving the health outcomes for
the patient."
lower costs-financial, temporal and emotional-for
patients by eliminating needless trips and reducing the
number of patient visits.
Teitelbaum has been teleconsulting for about a year with
both a group of pediatricians in the Upper Peninsula and
the REMEC telemedicine consortium based in Traverse City.
"I would say it has probably helped keep the patient
in his or her home town more often than it has led to
the transfer of patients," he says. "Nevertheless,
the patients it has brought in are patients who really
need a children's hospital for their level of care. Several
other times, we've utilized the facility to follow up
on patients who have already been cared for but are now
back in their home town. Instead of having them come back
for X-rays or a wound check, we simply examine them through
the system."
|
Alessi, working closely with John Bennett, ACSW, has seen this
borne out in two of his projects, one for the Michigan Department
of Corrections and the other for the Huron Valley Child Guidance
Clinic. "We installed units at the prison system and one
in our department," he says of the first project. "We
did a very detailed process analysis of its use in the evaluation
of prisoners, and found that every time they used it they were
potentially offsetting up to $4,500 in cost. The transportation
of a prisoner is no small feat. Potentially, for them, they
could easily pay for the unit in three to four uses."
At the child guidance clinic, all the Medicaid cases that came
into the inpatient child and adolescent psychiatric unit were
managed "with the patient's case manager being present
at our meetings via teleconferencing," says Alessi. "We
did this for maybe 48 to 50 cases, a total of a hundred or so
sessions." Figuring that the review via teleconferencing
of each patient saved two to four hours of "transition
time, travel time, waiting time, finding-parking time"
for each visit the social worker was spared, "we probably
saved them several hundred hours," he calculates.
Beyond the savings in dollars, and wear and tear on patients
and providers alike (Rees says his clinical coordinator has
twice been treated for hernias from lifting patients), the perception
is that the quality of care thus administered is at least as
good, and possibly better, than what would be available from
moving flesh and blood through time and space. "We can
more effectively communicate with the person with no delay,"
says Alessi. "There don't seem to be any complaints, or
any decay in the transfer of information. People are very interested
in doing this as team management of complex cases."
Daniel Teitelbaum |
This corresponds with Teitelbaum's observation. "Typically,
when we do the consultations, one or both parents are there
plus the child's pediatrician and the child and often the nurse,"
he says. "What's great about it is not only do they save
themselves a visit, but we're able to spend more time talking
to them. The average clinical visit is 10-15 minutes. The average
telemedicine consultation is 27 minutes. We actually spend more
time with the family via one of these units. Secondly, it's
not uncommon to have more than one specialist down there at
one time. Instead of this family having to make three clinical
appointments and spend two days down here, they see all the
physicians at one time, without leaving home. The parents really
appreciate that." Telemedicine has also occasioned a greater
collegiality and coordination of care than was hitherto possible,
much less likely, between referring physicians and U-M consultants.
"I think that's a big advantage, probably the biggest advantage
of this for us," says Teitelbaum. "It develops a lot
of ties throughout the state."
"Now they know who they're talking to when they call us,"
says Nypaver. "They're less worried about calling us and
asking a question. I feel that every time I talk to that other
physician, we share knowledge and we will both benefit from
it as we treat other patients. You remember more from each case
you see and the complications of that case than you will ever
learn from a textbook. If we can share knowledge about every
patient we have a question about, two heads rather than one,
that helps both of us in the future. While it's difficult to
put a price tag on that, I think the benefit is immeasurable."
"Immeasurable" is how telemedicine's most sanguine
devotees would describe its potential. Neighborhood clinics
staffed by volunteers in remote regions could be linked electronically
to leading specialists. Leading surgeons could sit at their
desks and skillfully operate on patients thousands of miles
away with extraordinary precision (thanks to robots).
"Exploring telemedicine has allowed me to live farther
out in the future than I ever imagined," says Alessi, "and
I don't know if it's good or bad. The potential is overwhelming
but the resistance by people who live in a 'today' time-frame
is pretty stultifying."
In the foreseeable future, Bashshur envisions an electronic,
statewide, integrated health care network, organized in a hub-and-spoke
site, making the clinical expertise of the U-M Health System
available to patients throughout the network. The network would
offer uniform quality as well as greater convenience.
He poses two questions whose answers, he says, "would
be the truest test of the integration of a system: How do you
take a multi-site, geographically dispersed system like the
U-M Health System, that has 50-some clinics spread throughout
the state of Michigan, and have it function as an integrated
system? And how can patients who come to one of the remote sites
in the system be assured they will get the same standard of
care they would get if they were in Ann Arbor?"
"I'm not claiming we are there yet," he says, "but
once we have the system in place, patients coming into any of
the sites would be connected with this network, triaged to the
most appropriate site of care, and they would receive the services
according to uniform standards of care. They will be given the
same type of service regardless of their location, and they
will have access to the expertise and intelligence available
throughout the system."
And, in the spirit of the Web's fabled democracy, this will
not, says Bashshur, be a top-down operation. "Our plan
is not to design it from Ann Arbor and distribute it within
the state, but rather talk to our partners, determine the nature
of their needs, and figure out the best ways of satisfying those
needs."
James Woolliscroft |
Time is on his side. The tools of telemedicine fit more comfortably
in the hands of younger caregivers. "I just think they're
ahead of us," says Woolliscroft. "One of the hardest
things is to not be limited by your experience. We've got a
whole generation that's at most five or six years removed from
interacting with their college professors. They'll blow right
past the faculty when they get to campus, just as they're blowing
right past their teachers in the junior high and high schools
right now."
But as Bashshur and his colleagues constantly reiterate, the
promise of telemedicine will only be realized if it leads to
improved quality and accessibility of medical care at affordable
prices. In the meantime, it's already providing a wealth of
satisfaction to those who have embraced it. Says Nypaver: "You
see situations where it absolutely solves the problem and you
say, "Oh, this is good! This is the way we're supposed
to do this.'"
Also:
Will
E-Mail Help Doctor-Patient Communication?
A New U-M Study Hopes to Find Out
Telemedicine:
Caveats and Questions
|
