In the online edition of Nature Reviews Neurology is the following abstract:
Department of Neurology, Medical College of Georgia, Georgia Regents University, 1120 15th Street, Augusta, GA 30912, USA.
This Review focuses on the application of telemedicine to the care of patients with acute stroke (telestroke), from the prehospital setting through hospitalization. Telestroke has grown remarkably in the past decade and has entered mainstream care for patients with acute stroke. Telestroke enables such patients to be remotely evaluated, thereby allowing optimal treatment and management even in clinically underserved areas and removing geographical disparities in access to expert care. Telestroke systems enable thrombolytic treatment to be administered in community and rural hospitals, and facilitate the appropriate transfer of patients with complex conditions (who require critical care services and neurosurgical or intra-arterial interventions) to a comprehensive stroke centre. Decision-analytic models show that telestroke is cost-effective from both a societal and a hospital perspective. Limitations to the use of telestroke in the USA include the need for state licensing and credentialling of physicians, and the technical requirements of a minimum network bandwidth (which is still lacking in some regions). However, the opportunity exists for telestroke to become the backbone of an electronic stroke unit and to be used to identify and enrol patients in clinical trials of acute stroke treatment. The use of telestroke in the prehospital setting has been hampered by limited telecommunication availability, but these problems might be mitigated by fourth-generation cellular data networks.
In the May 10th issue of Healthcare IT News, the presentation of Dr. Herb Rogove, CEO of C3O Telemedicine is reported by J Thompson:
“Destination ATA 2013 is a digest of news and information from the ATA’s 18th Annual International Meeting & Trade Show. This content is jointly produced by the American Telemedicine Association and Healthcare IT News.
After 25 years, virtual critical care is getting a closer look.
The time is right for tele-ICU. The need for more intensive-care beds is acute. The cost of caring for critically ill patients has never been higher. Intensivists are in short supply, and only getting scarcer as the population gets older.
That was the case made in a Tuesday afternoon session at the American Telemedicine Association’s 18th Annual International Meeting & Trade Show titled “The Tele-ICU: How to Communicate, Compare and Evaluate Models of Care, Technology and Value?”
Herb Rogove, DO, chief executive officer of Ojai, Calif.-based C3O Telemedicine, laid out the numbers: There are 5,800 acute care hospitals in the this country of 312 million people, with some 67,000 ICU beds. More than 55,000 ICU patients are treated each day, he pointed out.
And even though there are more than 40 million people aged 65 and older in this country, there are fewer and fewer physicians who can care for them as they age.
“By the year 2020, we’ll be 22 percent shy in number of intensive care physicians needed,” said Rogove.
Enter the tele-ICU, a concept that’s been around for a quarter-century but has only recently started to get the attention it deserves.
There’s more than one way to approach a tele-ICU initiative, said Rogove.
There’s the centralized model, in which “you a have a facility – a bunker – in which you have nurses, a doctor and administrative support that goes out to your spoke hospitals and provides that level of care,” he said.
Then there’s the decentralized approach, which allows physicians to “be anywhere,” said Rogove. “Intensivists can be in their office, they can be in their car, they can be at home, using various modes of technology to communicate directly with that hospital.”
There are seemingly obvious benefits to implementing one version or the other, he said, such as a reduction in mortality rates and hospital lengths of stay and a positive return on investment. But it’s true, too, that there are skeptics who want to see hard evidence. Does mortality really go down? Reduced length of stay? “Prove it.”
It’s sometimes “difficult to assess financials,” he said, and for some facilities the “long-term economic benefit is not clear.”
Those barriers so common to other types of telemedicine initiatives can be a huge headache, too, said Rogove. Licensure is “absolutely the most agonizing, ridiculous, costly process you can ever go through,” he said. He recalled that one such process took 14 months. Reimbursement is often problematic, of course. And credentialing can be “another costly three-month process.”
Even still, it’s usually worth it in the end, Rogove argued – as long as an organization is clear about which path to take, and ensuring it’s the right one. It’s important to ask tough questions, he said, and lay out a clear roadmap about how – and how far – to deploy the IT.
“It’s disruptive technology, of course, but we don’t want to disrupt the process and flow of patient care; we don’t want to add more,” he said. “A good tele-ICU program provides satisfaction because we’ve made it easier for the people that are on the front lines, getting the support from the ICU to make it a fully-integrated system that works seamlessly.”
These are essential things to ponder, said Rogove: “Do you want a model that’s continuously monitoring the patient and intervening? Or do you want an as-needed, coverage at night? Do you want to untether your doctors from their computers and just use smartphones and tablets?”
A centralized tele-ICU works best with larger populations and with more sophisticated IT networks. It means that “a tremendous amount of data is collected” and is well suited for vertical growth.
The decentralized model is cheaper – there’s less cost for real estate because “people are on the go.” It might be a good fit for smaller organizations – one or two rural hospitals, say. Its open architecture means it’s relatively easy to add other specialties, and it’s a good candidate for vertical growth.”
In the closed model, “physicians are taking care of patients in their own hospital, and specialists – from the neurologist all the way down to the neurosurgeon – have to call down to the center to find out what’s going on,” said Rogove. “They can’t take a look at the ventilator waveforms or the EKG monitor: they’re really dependent on the physicians and nurses to give them information.”
In the open approach, “you have an ICU doc that can beam in,” he said. “You have specialists that could be anywhere remotely – in a car, even. We’ve done consultations at rest stops in Texas, off the 405 freeway in Los Angeles, at LAX. Thanks to broadband, we’re able to give tPA or take care of a critical patient.”
“Your tele-ICU can be whatever you want it to be,” said Rogove. “It’s up to you, because it’s your tele-ICU.”
Theresa Davis, RN, clinical operations director for the enVision eICU at Inova Health in Falls Church, Va., said her organization drew up its own specific definition of its own tele-ICU: “A network of visual communication and computer systems which provide the foundation for a collaborative inter-professional care model focusing on critically ill patients.”
But it’s about so much more than mere technology, she said.
Conceiving and building a tele-ICU “is the most major relationship-building experience of your life,” she said. “When you come into it, you’re thinking about the technology, but the technology is a just communication tool. The relationships last a lifetime. The way you build trust to be able to work from a remote site is key to building those relationships.”
Yes, the return can be hard to gauge, sometimes.
“ROI is the most challenging piece of all of this, because it’s hard to prove where those benefits occurred. Was it the tele-ICU? Or the ICU? Or was it what the tele-ICU and the ICU did together?” said Davis.
“But I’m here to tell you, it’s the last one,” she said. “If you build those relationships and you integrate those teams and you use the technology, you will see improved outcomes.”
NEW ORLEANS – Hospitals with palliative care programs had lower treatment intensity on average at the end of life than did those without palliative care, in a national sample of 3,593 hospitals.
ICU length of stay in the last 6 months of life was 0.4 days shorter (Pless than .001) and hospice length of stay 1.6 days longer (P = .013) at hospitals with palliative care versus those without.
The study strengthens claims that palliative care cuts costs, and is the first to examine the impact of palliative care in such a large national sample of hospitals, Jay R. Horton said at the annual meeting of the American Academy of Hospice and Palliative Medicine.
Prior studies focused on the effects of palliative care. Mr. Horton’s study considers outcomes for the entire older adult population in the hospital.
Covariates predictive of outcomes such as age, sex, race and comorbidities were already corrected for in the Dartmouth Atlas. Propensity scoring was used for variables predictive of outcomes or the presence of palliative care in the AHA survey such as Joint Commission Accreditation and total bed count. Finally, propensity scores were used to reweight the sample to reduce selection bias.The researchers considered data from 3,593 hospitals with a palliative care status noted on the 2008 American Hospital Association survey. In all, 1,657 hospitals had palliative care programs and 1,936 hospitals did not. The researchers then linked the hospital data with the data from the Dartmouth Atlas on 896,097 fee-for-service Medicare patients, aged 67-99 years, with one or more chronic illnesses, who died in 2007. Patients were assigned to a hospital where they received the majority of their care in the last 2 years of life.
The effect of palliative care would very likely be stronger if the data had identified those patients who actually received palliative care, said Mr. Horton , director of the palliative care consult service at The Lilian and Benjamin Hertzberg Palliative Care Institute, Icahn School of Medicine at Mount Sinai Hospital, New York. Ongoing research uses data from the National Palliative Care Registry to better identify palliative care programs and socioeconomic factors to further reduce potential selection bias.
Treatment intensity for patients with serious illness varies widely across the country. One study showed that more than 40% of the variation is due to the supply of specialists and hospital capacity (BMJ 2002;325:961-4). Put another way, the greater the supply of physicians, the greater the utilization, even after adjustment for factors that should drive utilization, such as patient preference and disease severity.
“This supply-sensitive care, as it is sometimes called, is at the discretion of clinicians and to a certain extent at the discretion of patients, but more troubling is that much of this care may be unnecessary,” said Mr. Horton.
Mr. Horton reported having no financial disclosures.
This story brings up the important point that C3O Telemedicine offers Tele-Palliative care headed by Sharon Lucas, MSW who is an expert in compassionate care and has worked closely with C3O’s CEO Dr. Herb Rogove in the past. We believe this type of service only augments the TeleICU program.
Dr. Herb Rogove, CEO of C3O Telemedicine, will be speaking on The Tele-ICU: How to Communicate, Compare, and Evaluate Models of Care, Technology, and Value? at ATA 2013, just one of the many exciting topics that will be covered at this year’s Annual Meeting. For 18 years, the ATA Annual International Meeting & Trade Show has been the premier forum for healthcare professionals and entrepreneurs in the telemedicine, telehealth and mHealth space. The world-class, peer reviewed program includes 500 educational sessions and posters highlighting the latest innovations, applications and delivery models in telemedicine. And, with over 6000 projected attendees, there’s no better place to meet and network with your peers and leaders in the field. Register today and I’ll see you there: http://www.ata2013.com
C3O Telemedicine and Community Memorial Health System: Improving access to stroke care in Ventura County
Reported by C. Thielst
Ventura, CA, United States, April 12, 2013 (PressReleasePoint) - C3O Telemedicine (formerly C3O Medical Group) is pleased to announce the successful launch of if its latest telehealth program in California, a partnership for Tele-Stroke services with Community Memorial Health System in Ventura, CA. C3O’s Acute Neurology Telemedicine Program, designed to improve access to specialists for stroke patients and other neurocritically ill patients was successfully implemented at the health system’s Community Memorial Hospital facility. Utilizing technology from InTouch Health based out of Santa Barbara, the program allows C3O’s board-certified neurologists and neurointensivisits to reach the hospital’s patients and provide care remotely utilizing the Internet. With an average response time of 5 minutes or less, and access to the hospitals’ electronic medical record system, the remote physicians can now provide critical, often life saving care to patients within moments and in a fraction of the time required for physicians to drive to the hospital and/or for a patient to be transferred to a nearby facility with access to Neurology services. The “Tele-Stroke” program marks an important expansion of access to highly skilled neurologists and neurointensivists for community patients.
Dr. Herb Rogove, President and CEO of C3O Telemedicine, and board member of the American Telemedicine Association, states” C3O is privileged to provide acute neurology care via telemedicine to the county’s premier healthcare facility. Community Memorial is committed to serving the neuroscience needs of individuals in Ventura and surrounding communities and we are excited to partner with them in this new program. C3O strives to be the premier California-based telemedicine solutions provider to California hospitals and the opportunity to provide care right here in the backyard of our headquarters, is a privilege and an important step for our company’s growth.”
Bobbie McCaffrey, RN, MA, Vice President and Chief Nursing Office of Community Memorial responds “After evaluating multiple telemedicine providers, we confidently partnered with C3O Telemedicine due to their strong commitment to high quality care and the unique physician-focus and clinical leadership C3O is able to provide. Dr. Herb Rogove and his physician team provide a quality-focused solution that was custom tailored to meet our needs and to improve our patient’s access to specialty care when faced with an emergency”.
According to the National Stroke Association, stroke is the third leading cause of death in the United States and stroke-related healthcare costs total $73.7 billion. Expediting the presence of a skilled neurologist to the bedside to assess for the appropriateness of the lifesaving medication tPA can dramatically improve healthcare outcomes. Telemedicine technologies have been proven clinically and cost-effective methods for supplying this care and can often expedite the time in which a patient receives the care they need.
C3O Telemedicine and its physicians have been providing Tele-Stroke and Tele-Neurocritical Care along with other remote multispecialty services to California hospitals since 2008.http://c3otelemedicine.com/ .
An article in the April 14th edition of the NY Times raises questions about the value of the Tele-ICU. As in any area or topic in medicine, one will always find agreement and disagreement for many reasons. The NY Time’s article is focused only upon e-ICU and not the de-centralized model that utilizes different technologies. The entire topic related to this timely article will be discussed at the ATA’s annual meeting in Austin Texas May 4-8, 2013. Dr. Herb Rogove, CEO of C3O Telemedicine will moderate and present along with Terry Davis, RN, CCRN, PhDc and director of the telemedicine center at Innova Health in Virginia along with H. Neal Reynolds, MD, FCCM from the University of Maryland’s Shock Trauma Center.
Panel Title: The TeleICU:How to Communicate, Compare, and Evaluate Models of Care,Technology, and Value?
Date/Time: Tuesday May 7, 2013 11:00 AM 12:00 PM
Location: Meeting Room 17 A/B
On Scientific America’s website there is an interesting article of the increased recognition of telehealth in providing care for patients at home and in particular as a means to prevent the problem of a readmission yet alone the $17 billion price tag just for Medicare patients.
“Technologies most likely to help hospitals lower readmission rates and limit penalties include so-called “telehealth” systems that connect patients with physicians, nurses or other care managers after checkout, microchipped pills that indicate whether patients take their medicine as prescribed and software that improves the management of electronic health records (EHRs).”
In an article from the Washington Post by Sarah Halzack, the reaches of telemedicine expand to the Antartica:
“When the doctors at University of Texas Medical Branch are reading an ultrasound, examining an X-ray or evaluating an echocardiogram, the patient they are treating is not necessarily right in front of them.
Instead, the patient is often in one of the farthest-flung corners of the Earth: a scientific research station in Antarctica.
Using telemedicine, Galveston, Tex.-based physicians provide treatment to scientists and support staff who would otherwise have access to only very basic medical care. With the help of videoconference technology and specially designed medical instruments, doctors can diagnose heart attacks, inspect a lesion or even provide psychiatric counseling to National Science Foundation workers from thousands of miles away.
“We can really be virtually looking over their shoulder,” said Scott Parazynski, director of UTMB’S Center for Polar Medical Operations.
Although telemedicine has been practiced for decades, a burst of innovation in recent years has greatly improved its quality: Higher video and image resolution help lead to more accurate diagnoses, while more efficient use of bandwidth has led to more reliable connections. And the increased adoption of electronic medical records allows documentation to be shared more easily and quickly.
The way that telemedicine technology is being applied in Antarctica offers a window into its potential to reshape health care in less remote parts of the world.
Helping fill the gaps
The capabilities of the health facilities at the United States’ three Antarctic research stations are limited.
“They can treat most primary care issues and some emergencies, at least in terms of initial stabilization,” said Michael Montopoli, the chief medical officer at NSF’s division of polar programs.
But they are not equipped to give CT scans or MRIs, nor do they have a surgical center or postoperative facilities.
Telemedicine can help fill the gaps. A secure video conference can allow a specialist to talk to the patient and on-site caregiver to assess symptoms. The same technology can also be used to have a specialist coach an on-site clinician through a highly skilled procedure such as an echocardiogram.
A new array of tools can also help the remote doctor work as if she is in the exam room. Stethoscopes equipped with microphones enable a far-away doctor to instantly hear a patient’s heart or lungs. Special ophthalmoscopes, which come with a light source and a camera, allow the doctor to see inside a patient’s eye in real time.
Polycom, the maker of the telemedicine products used by UTMB and NSF, has made this set of equipment fit inside a case small enough that it could be stowed in an overhead bin on an airplane.
Telemedicine capabilities have been influential in how NSF health centers deliver care.
“It’s allowed us to make critical decisions about either treating the patient there at the clinic or launching a medevac operation,” Montopoli said.
The difference between those two courses can be important, not only for a patient’s health but also for a client’s bottom line.
Leaving Antarctica can be an outright odyssey: Flights are limited because it is often so cold that airplanes cannot function. In winter, the surface of the ice runway at McMurdo Station requires special preparation to accept aircraft.
And those are just the obstacles to departing a coastal facility. Travel out of the inland South Pole station is sometimes nearly impossible.
Accordingly, Montopoli said a medical evacuation from Antarctica can cost “several hundred thousand dollars.”
While telemedicine has broadened health-care options in Antarctica, physicians and patients still must contend with some limitations. Amundsen-Scott South Pole Station only gets Internet access for about 12 hours a day because of the positioning of the satellites that provide connectivity.
“We can provide very good technology on each end that provides the most effective use of bandwidth, but if there’s nothing to run it over, there’s a challenge,” said Ron Emerson, global director for health care at Polycom.
Closer to home
In the same way telemedicine has flung open the doors for more and improved care in Antarctica, its practitioners and advocates say it could have the same power closer to home.
In America’s rural areas, it can often be difficult for residents to get access to specialist physicians. As the Affordable Care Act extends health insurance to millions of Americans who previously did not have it, experts say that shortage is likely to be felt even more acutely.
Polycom and UTMB say telemedicine could help meet the swell in demand.
“The financial incentive is going to be there,” Parazynski said, for his hospital and other health providers to increase their telemedicine offerings.
In fact, UTMB pediatricians already use telemedicine technology to serve children in rural areas.
Oliver Black, systems analyst services manager at UTMB, said telemedicine could also be used in the future to monitor patients with chronic conditions in their homes.
Still, there are obstacles to more widespread use of telemedicine. A telemedicine consultation is not typically billable in the same way an office visit would be, which can create difficulties for physicians wishing to practice this way.
And there are some aspects of an in-person physician-patient interaction that telemedicine can not quite replicate.
“You’re relying on the person on the scene to pick up on the subtle changes in facial expression,” Parazynski said. “And you miss out on touch.”
Technologists and practitioners say they still see room for innovation that would also further telemedicine’s reach. Advancements in surgical robotics, for example, could make it possible for operations to be done from afar, rather than just consultations and examinations.”
Telestroke programs substantially improve access to life-saving stroke care, extending coverage to less populated areas in an effort to reduce disparities in stroke care access. A new study by researchers from the Perelman School of Medicine at the University of Pennsylvania, being presented at the American Academy of Neurology’s 65th Annual Meeting in San Diego March 16-23, 2013, found that telemedicine programs in Oregon pushed stroke coverage into previously uncovered, less populated areas and expanded coverage by approximately 40 percent.
The study evaluated all hospitals in Oregon, finding that 43 percent of the population could reach a stroke center in person within 60 minutes, 76 percent had telemedical access, 40 percent had access to both, and 20 percent had no access to stroke care within an hour.
Researchers noted that in-person stroke care was clustered in urban areas, and while telestroke care was also available in urban centers, it also reached less populated areas with low rates of uninsured.
The message is loud and clear that disparity of medical care based upon geographic should no longer be a reason for these patient population from obtaining the best care possible.
According to the ATA in a statement just released:
“Medicare beneficiaries in 97 counties—across 36 states and territories—are slated to lose telehealth benefits because of updated federal delineations of Standards Metropolitan Statistical Areas (SMSAs). The new federal urban/rural categorization effectively revokes the option for Medicare recipients to receive healthcare services via videoconferencing—one of the most common and cost-effective forms of telehealth. Hundreds of thousands of beneficiaries are negatively impacted by this statistical realignment.
Medicare coverage is not available for video visits to beneficiaries living in metropolitan areas–where over 80% of recipients live. The new SMSA rules designate 28 additional counties as “non-metropolitan,” qualifying their residents for telemedicine services under Medicare. However, the same adjustments increase the total number of counties, population and patient base that are precluded from the benefits of telemedicine.
”When it comes to telemedicine, Congress has long overlooked the need for telemedicine services to residents of urban counties, despite the fact that they often suffer similar problems accessing healthcare. Now, because of a statistical quirk, even more people will lose coverage of these services, reducing access and care,” said Jonathan Linkous, CEO of the American Telemedicine Association. “Medicare should cover remote health services for all beneficiaries, regardless of location. We call on Congress to ensure that existing beneficiaries will not lose coverage for these services.”
97 Counties to Lose Medicare Telehealth:
- Alabama: Pickens County
- Arizona: Cochise County
- Arkansas: Little River County
- Connecticut: Windham County
- Delaware: Sussex County
- Florida: Citrus County, Gulf County, Highlands County, Sumter County, Walton County
- Georgia: Lincoln County, Morgan County, Peach County, Pulaski County
- Hawaii: Kalawao County, Maui County
- Idaho: Butte County
- Illinois: De Witt County, Jackson County, Williamson County
- Indiana: Scott County
- Iowa: Plymouth County
- Kansas: Kingman County
- Kentucky: Allen County, Butler County
- Louisiana: Iberia Parish, St. James Parish, Tangipahoa Parish, Vermilion Parish, Webster Parish
- Maryland: St. Mary’s County, Worcester County
- Michigan: Midland County, Montcalm County
- Minnesota: Fillmore County, Le Sueur County, Mille Lacs County, Sibley County
- Mississippi: Benton County, Yazoo County
- Montana: Golden Valley County
- Nebraska: Hall County, Hamilton County, Howard County, Merrick County
- New York: Jefferson County, Yates County
- North Carolina: Craven County, Davidson County, Gates County, Iredell County, Jones County, Lincoln County, Pamlico County, Rowan County
- North Dakota: Oliver County, Sioux County
- Oregon: Josephine County, Linn County
- Pennsylvania: Adams County, Columbia County, Franklin County, Monroe County, Montour County
- Puerto Rico: Utuado Municipio
- South Carolina: Beaufort County, Chester County, Jasper County, Lancaster County, Union County
- South Dakota: Custer County
- Tennessee: Campbell County, Crockett County, Maury County, Morgan County, Roane County
- Texas: Falls County, Hood County, Hudspeth County, Lynn County, Martin County, Newton County, Oldham County
- Utah: Box Elder County
- Virginia: Augusta County, Buckingham County, Culpeper County, Floyd County, Staunton City, Waynesboro City
- Washington: Columbia County, Pend Oreille County, Stevens County, Walla Walla County
- West Virginia: Fayette County, Raleigh County
- Wisconsin: Green County
28 Counties Gain Medicare Telehealth:
- Idaho: Power County
- Indiana: Franklin County, Gibson County, Greene County
- Kansas: Franklin County
- Kentucky: Nelson County
- Massachusetts: Franklin County
- Michigan: Ionia County
- Mississippi: George County, Stone County
- Missouri: Howard County, Washington County
- North Carolina: Anson County, Greene County
- Ohio: Erie County
- Tennessee: Stewart County
- Texas: Calhoun County, Delta County, McLennan County
- Utah: Summit County
- Virginia: Cumberland County, King and Queen County, Louisa County, Pittsylvania County, Danville City
- West Virginia: Morgan County, Pleasants County