TELEMEDICINE Medical Therapeutics

Medical Therapeutics Standard 16) Summarize information found in news media, professional journals, and trade magazines to examine how Telehealth has impacted the healthcare system and explain its benefits and challenges.

I. Telemedicine: The use of telecommunication and information technologies in order to provide clinical health at a distance The exchange of medical information from one site to another via electronic communications to improve patient’s health status

I. Telemedicine: It helps eliminate distance barriers and can improve access to medical services that would often not be consistently available in distant rural communities These technologies permit convenient and timely communications between patients and medical staff along with transmission of medical imaging (x-rays, MRI, CAT scans, ultrasound, etc images) and health informatics data from one site to another

II. Common Uses for Telemedicine: Videoconferencing between patients and healthcare staff Communications and advice during critical care and emergency situations Transmission of still images E-health including patient portals Remote monitoring of vital signs Continuing medical information Nursing call centers

Types of Telemedicine: 1. “Store-and-Forward”: AKA Asynchronous Involves acquiring medical data (i.e. imaging, biosignals, etc…) and then transmitting this data to a physician or medical specialist at a convenient time for assessment offline It does not require the presence of both parties at the same time

1. “Store-and-Forward”: Dermatology, radiology, and pathology are common specialties that use “store-and-forward” telemedicine A thorough medical record, preferably in electronic form, should be a component of this transfer This process requires the clinician to rely on a history report and audio/visual information in lieu of a physical examination

2. Remote Monitoring: AKA Self-Monitoring or Testing Enables medical professionals to monitor a patient remotely using various medical devices Primarily used for managing chronic diseases or specific conditions (i.e. heart disease, diabetes mellitus, or asthma) These services can provide comparable health outcomes to traditional in-person patient encounters, supply greater satisfaction, and may be cost-effective

3. Interactive Services: AKA “Real-Time” Provide real-time interactions between patient and provider Includes phone conversations, on-line communications, and home visits

3. Interactive Services: Many activities, such as history review, physical examination, psychiatric evaluations, and ophthalmology assessments, can be performed comparably to those done in traditional face-to-face visits Also, these services may be less costly than in-person clinical visits

Compare types of telemedicine: Pros ________________ Cons __________________

IV. Benefits of Telemedicine: Beneficial to persons living in isolated communities and rural or remote regions: Gives these persons the opportunity to receive care from virtually all medical domains Physicians/specialist can provide an accurate and complete examination without the patient traveling long distances Allows healthcare professionals in multiple locations the ability to view, discuss, and assess patient issues as if they were in the same room

2. Teaching Tool: Experienced medical staff can observe, demonstrate, and instruct medical staff in another location a more effective or faster examination technique Provides continuing medical education credits for health professionals Special medical education seminars can be offered to targeted groups in remote locations (public groups or medical groups)

3. Reduces healthcare costs by: Increasing patient care of chronic diseases Better management of chronic diseases Shared health professional staffing Reduced travel time

Fewer and shorter hospital stays: Patients who were routinely monitored in a hospital can now be monitored in the home The patient can have a variety of monitoring devices in the home to collect data (i.e. glucometer, blood pressure cuff, heart monitor, etc..) The results of these devices can be transmitted via telephone or computer to the healthcare provider This reduces cost of care to the patient and hospital

5. Both subjective and objective information can be collected: Healthcare staff can collect the same forms of data without the travel, that a routine office visit provides Verbal communication can take place via phone or a tele-monitoring on-screen device

5. Both subjective and objective information can be collected: Objective information can be collected and transmitted through a variety of devices The provider can then make decisions about the patient’s treatment based on a combination of subjective and objective information similar to an on-site appointment

Telemedicine Services: 1. Telenursing: The use of telecommunications and information technology in order to provide nursing services This can occur between patient and nurse, nurse-to-nurse, or nurse-to-other healthcare provider

Telenursing is achieving significant growth rates in many countries due to several factors: A preoccupation in reducing the cost of healthcare An increase in the number of aging and chronically ill population The increase in healthcare coverage to distant, rural, small, or sparsely populated regions

Benefits of telenursing: May help solve increasing shortages of nurses Reduce distances and save travel time Keep patients out of the hospital

2. Telepharmacy: A growing trend for providing pharmaceutical care to patients at remote locations where they may not have physical contact with a pharmacist

Telepharmacy encompasses: Drug therapy monitoring Patient counseling Prior authorization Refill authorization Monitoring compliance Patient education Staff training Managerial services

Example: Community Health Association of Spokane, WA (CHAS) Program utilized videotelephony for dispensing medications and patient counseling at six urban and rural clinics

CHAS Process: The prescription is sent from one of the remote clinics to the base pharmacy The base pharmacist verifies the prescription and enters the order A label is generated and the label queue is transmitted back to the ADDS (medication dispensing cabinet) at the remote location

CHAS Process: The authorized person can access the medication from the ADDS followed by medication barcode scanning and the printing and scanning of labels The remote site personnel are connected to the base pharmacist via videoconferencing for medication verification and patient counseling

3. Telerehabilitation: The delivery of rehabilitation services over telecommunication networks and the internet

Two categories of telerehabilitation: Clinical Assessment—identifying the patient’s functional abilities in his/her environment Clinical Therapy—actions to rehabilitate a patient in a remote environment

Several fields of telerehabilitation: Neuropsychology Speech-language Pathology Audiology Occupational Therapy Physical Therapy

Telerehabilitation: Can deliver therapy to people who cannot travel to a clinic because the patient has a disability or because of travel time Ground-breaking research in telehaptics (sense of touch) and virtual reality may broaden the scope of telerehabilitation in the future

4. Telecardiology: Includes the transmission of electrocardiograph (ECG) readings via the telephone or wirelessly This system is also used to monitor patients with pacemakers in remote areas Also electronic stethoscopes can be used as recording devices for diagnosis, treatment, or evaluation

5. Telepsychiatry: Utilizes videoconferencing for patients residing in underserved areas to access psychiatric services

Services to patients and providers include: Consultation between psychiatrists or psychiatrist and patient Educational clinical programs Diagnosis and assessment Medication therapy management Routine follow-up meetings

6. Teleradiology: The ability to send radiographic images from one location to another

For this process to be implemented three essential components are required: An image sending station—an image is scanned and then sent to the receiving station A transmission network—i.e. high speed broadband internet A receiving-image review station—the computer must have a high quality display screen that has been tested and cleared for clinical/healthcare purposes

Teleradiology: The most popular use for telemedicine and accounts for at least 50% of all telemedicine

For teleradiology to be implemented 3 essential components are required: An image sending station—an image is scanned and then sent to the receiving station An transmission network—ie. High-speed broadband secure Internet A receiving-image review station—this computer must have a high quality display screen that has been tested and cleared for clinical/healthcare purposes

Radiology: Teleradiology is the most popular use for telemedicine and accounts for at least 50% of all telemedicine usage

7. Telepathology: Uses telecommunications technology to facilitate the transfer of image-rich pathology data between distant locations for the purpose of diagnosis, education, and research It requires that a pathologist select the video images for analysis to develop a diagnosis

8. Teledermatology: Telecommunications technologies are used to exchange medical information concerning skin conditions and tumors of the skin over a distance using audio, visual, and data communications One of the most common applications of telemedicine and e-health Applications include diagnosis, consultation, treatment, and continuing education

Telesurgery— AKA remote surgery: Allows a physician to perform surgery on a patient even though they are not physically in the same location Combines elements of robotics, cutting edge communication technology, and elements of management information systems Promises the expertise of specialized surgeons to be available to patients worldwide without the need for patients to travel beyond their local hospital

VI. Technologies Enabling Telemedicine: Videotelephony Health Information Technologies (HIT)

1. Videotelephony: Includes the technologies for the reception and transmission of audio-visual signals by users at different locations, for communication between people in real-time Currently it is particularly useful to the deaf and speech-impaired who can use them with sign-language

2. Health Information Technology: Provides the umbrella framework to describe the comprehensive management of health information across computerized systems and its secure exchange between consumers, providers, government, and insurers It is increasingly viewed as the most promising tool for improving the overall quality, safety, and efficiency of the health delivery system

Broad and consistent utilization of HIT will: Improve health care quality Prevent medical errors Reduce health care costs Increase administrative efficiencies Decrease paperwork Expand access to affordable care

Interoperable HIT will improve individual patient care, but it will also bring many public health benefits including: Early detection of infectious disease outbreaks around the country Improved tracking of chronic disease management Evaluation of health care based on value, enabled by the collection of de-identified price and quality information that can be compared

US Licensing and Regulatory Issues: Restrictive licensure laws in the US require a practitioner to obtain a full license to deliver telemedicine care across state lines Typically states with restrictive licensure laws also have several exceptions (vary from state-to-state) that may release an out-of-state practitioner from the additional burden of obtaining such a license A number of states require practitioners who seek compensation to frequently deliver interstate care to acquire a full license

Even if a practitioner never practices medicine face-to-face with a patient in another state, he/she must meet a variety of other individual state requirements including: Paying substantial licensure fees Passing additional oral/written examinations Traveling for interviews and examinations

Licensures and Regulations: Physicians who will be prescribing over the Internet should mandate strict controls on their practice to insure they stay compliant with the various State Medical Board Regulations concerning Internet prescribing