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ICU Telemedicine and Critical Care Mortality


A National ICU Telemedicine Effectiveness Study

Just released ahead of publication is another study by Khan and group from the University of Pittsburgh. Using Medicare data only this is a pre and post icu telemedicine comparison which shows some slight benefit as described.

Med Care. 2016 Jan 13. [Epub ahead of print]

Kahn JM1, Le TQ, Barnato AE, Hravnak M, Kuza CC, Pike F, Angus DC.

BACKGROUND:

Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain.

OBJECTIVES:

To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals.

RESEARCH DESIGN:

  • A multicenter retrospective case-control study using 2001-2010 Medicare claims data.
  • Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach.

RESULTS:

  • A total of 132 adopting case hospitals were matched to 389 similar nonadopting control hospitals.
  • The preadoption and postadoption unadjusted 90-day mortality was similar in both case hospitals.
  • In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality
  • However, hospitals with a significant mortality reduction were more likely to have large annual admission volumes  and be located in urban areas compared with other hospitals.

CONCLUSIONS:

Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions.

 

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Posted by: C3O Telemedicine News

Posted on: January 15th, 2016

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Brain Death and Telemedicine


Inconsistencies with brain death criteria: telemedicine to help?

Is there a role for telemedicine in the determination of brain death? An article in JAMA Neurology December 28th included 52 organ-procurement organizations obtaining brain death policies from 492 qualified hospitals across the United States. The researchers evaluated the policies based upon:

  • who is qualified to perform the determination of brain death,
  • what are the necessary prerequisites for testing,
  • details of the clinical examination,
  • details of apnea testing, and
  • details of ancillary testing.

There remained significant variability across all 5 categories of data, such as excluding the absence of hypotension (276 of 491 policies [56.2%]) and hypothermia (181 of 228 policies [79.4%]), specifying all aspects of the clinical examination and apnea testing, and specifying appropriate ancillary tests and how they were to be performed.

Additionally the study revealed:

  • images

    Brain Death

    33.1% required specific expertise in neurology or neurosurgery for the health care professional who determines brain death,

  • 43.1% stipulated that an attending physician determine brain death;
  • 150 policies did not mention who could perform such determination.

CONCLUSION: Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters. Hospitals should be encouraged to implement the 2010 AAN guidelines to ensure 100% accurate and appropriate determination of brain death.

COMMENT: ROLE OF TELEMEDICINE?

The issue is what is the role of telemedicine, if any, in the determination of brain death? At first glance, one would think that the determination of brain death is such an emotionally challenging procedure that the presence of a physician would be expected. Working closely with families which at times requires the holding of the hand, the provision of a tissue or reassurance is an important aspect of providing care by both physicians and nurses. Can this be achieved remotely? One might easily agree that in hospitals that do not have a physician available, telemedicine as a proxy might be better than no physician presence. On the other hand, an Emergency Medicine physician who is trained in this evaluation could serve in the capacity of providing the proper assessment. The telemedicine neurologist or intensivist promote the utilization of the AAN guidelines. Most importantly as the study has shown, there is no reason why all hospital brain death policies should not be in compliance with the 2010 AAN guidelines.  In the end, telemedicine should serve as a clinical service that augments on site physicians and brain death procedures might be the alternative and not the preferred solution.

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Posted by: C3O Telemedicine News

Posted on: December 29th, 2015

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Tele-emergency: financial benefit for rural hospitals


The Journal of Telemedicine and e-Healthimgres published this article in the December edition.

Background: Tele-emergency is an expanding telehealth service that provides real-time audio/visual consultation delivered by an emergency medicine team to a remote, often rural, emergency department (ED). Financial analyses of tele-emergency in the literature are limited. This article expands the tele-emergency literature to describe the business case for tele-emergency. “Business case” is defined as a reasoned argument, supported by objective data and/or qualitative judgment, to implement or continue a service or product. Materials and Methods: To evaluate tele-emergency financing from the perspective of a critical access hospital (CAH), 10 financial analysis categories were defined. Telephone interviews, site visits, and financial data from the eEmergency program of Avera Health (Sioux Falls, SD) were used to populate the categories. Avera Health information was augmented with national data where available. Three financial scenarios were then analyzed for CAH profit/loss associated with tele-emergency. Results:Tele-emergency financial analysis demonstrated an $187,614 profit in a high revenue/low expense scenario, $49,841 profit in a midrange scenario, and $69,588 loss in a low revenue/high expense scenario. Conclusions: Tele-emergency may be a profitable rural hospital service line if the participating hospital adjusts ED processes to take advantage of increased revenue/savings opportunities afforded by tele-emergency. Savings due to tele-emergency primarily accrue when physician ED backup and physician ED staffing costs are substituted.

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Posted by: C3O Telemedicine News

Posted on: December 8th, 2015

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Telemedicine in Prehospital Stroke


Stroke care using telemedicine in prehospital careimages

JAMA Neurol. 2015 Dec 7:1-7. doi: 10.1001/jamaneurol.2015.3849. [Epub ahead of print]

Abstract

IMPORTANCE:

Mobile stroke treatment units (MSTUs) with on-site treatment teams that include a vascular neurologist can provide thrombolysis in the prehospital setting faster than treatment in the hospital. These units can be made more resource efficient if the need for an on-site neurologist can be eliminated by relying solely on telemedicine for physician presence.

OBJECTIVE:

To test whether telemedicine is reliable and remote physician presence is adequate for acute stroke treatment using an MSTU.

DESIGN, SETTING, AND PARTICIPANTS:

Prospective observational study conducted between July 18 and November 1, 2014. The dates of the study analysis were November 1, 2014, to March 30, 2015. The setting was a community-based study assessing telemedicine success of the MSTU in Cleveland, Ohio. Participants were the first 100 residents of Cleveland who had an acute onset of stroke-like symptoms between 8 am and 8 pm and were evaluated by the MSTU after the implementation of the MSTU program at the Cleveland Clinic. A vascular neurologist evaluated the first 100 patients via telemedicine, and a neuroradiologist remotely assessed images obtained by mobile computed tomography (CT). Data were entered into the medical record and a prospective registry.

MAIN OUTCOMES AND MEASURES:

The study compared the evaluation and treatment of patients on the MSTU with a control group of patients brought to the emergency department via ambulance during the same year. Process times were measured from the time the patient entered the door of the MSTU or emergency department, and any problems encountered during his or her evaluation were recorded.

RESULTS:

Ninety-nine of 100 patients were evaluated successfully. The median duration of telemedicine evaluation was 20 minutes (interquartile range [IQR], 14-27 minutes). One connection failure was due to crew error, and the patient was transported to the nearest emergency department. There were 6 telemedicine disconnections, none of which lasted longer than 60 seconds or affected clinical care. Times from the door to CT completion (13 minutes [IQR, 9-21 minutes]) and from the door to intravenous thrombolysis (32 minutes [IQR, 24-47 minutes]) were significantly shorter in the MSTU group compared with the control group (18 minutes [IQR, 12-26 minutes] and 58 minutes [IQR, 53-68 minutes], respectively). Times to CT interpretation did not differ significantly between the groups.

CONCLUSIONS AND RELEVANCE:

An MSTU using telemedicine is feasible, with a low rate of technical failure, and may provide an avenue for reducing the high cost of such systems.

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Posted by: C3O Telemedicine News

Posted on: December 8th, 2015

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Geisinger Ventures includes telemedicine


images

In 2003, Geisinger Health System formed a new group, Geisinger Ventures (GV), to accelerate the growth of new lines of business, such as telemedicine, that were extensions of the core mission of the organization. Careworks, the convenient care clinic line of business, began in early 2006 as one of the early components of the GV portfolio. Over the past nine years, Geisinger has tested several retail and walk-in models, including in-store clinics, separate retail sites, and models colocated with primary care practices and emergency departments. Each site and model presents different benefits and challenges with respect to patient care, marketing, staffing, and clinical integration. With the implementation of healthcare reform and a decision to participate in Medicaid’managed care, Geisinger’s strategic need for convenient care options has intensified, and new models, including e-visits and telemedicine specialty consultations, are being actively explored. Geisinger’s view is that healthcare is rapidly changing, being affected by demographic shifts, diagnostic and treatment options, payment changes, and communication technologies. Healthcare delivery must flex to adjust to these and other trends, and retail clinics are part of that response. Careful examination of the critical elements necessary for optimal care (including wellness, prevention, and management of chronic disease and severe multimorbid disease) and then matching those elements to the optimal mode and site of care will lead to a streamlined healthcare system. The historical–and still most prevalent–methodology of traditional office, emergency department, and inpatient care options are not ideal for all patients’ care needs in the twenty-first century. A thoughtful, deliberate extension of those options will be necessary. Rather than simply adding a static retail or virtual offering, medical professionals should develop a process to continually assess patients, technology, payment, and disease changes so that they are constantly adding exciting new options to the clinical delivery model. The ability to assess and respond to the changes that these varied inputs drive will be the most important element of success for the future.

Published in Front Health Serv Manage. 2015 Spring;31(3):16-31.

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Posted by: C3O Telemedicine News

Posted on: October 27th, 2015

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Telemedicine for home health care for ventilator patients


J Telemed Telecare. 2014 Dec;20(8):441-9. doi: 10.1177/1357633X14555620. Epub 2014 Oct 14.

Researchers from Boston Childrens/Harvard reported:

 WHAT? Was telemedicine  feasible in patients with special care needs on home ventilation, whether it affected the confidence of families about the clinical management of their child, and whether it supported clinical decision-making?
HOW? Videoconferencing software was provided free for 14 families who had a computer and webcam. Families completed questionnaires about clinical management before the addition of telemedicine and 2-3 months after they had used telemedicine. They also completed a questionnaire about their experience with videoconferencing. There were 27 telemedicine encounters during the 9-month study.
WHAT? Families reported:
  • Higher confidence in clinical care with telemedicine compared to telephone.
  • They also reported that the videoconferencing was high-quality, easy to use, and did not increase their telecommunication costs.
  • The telemedicine encounters supported clinical decision-making, especially in patients with active clinical problems or when the patient was acutely ill.
  • The telemedicine encounters prevented the need for 23 clinic visits, three emergency room visits, and probably one hospital admission.

Although the study was small, videoconferencing appears useful in the management of medically fragile patients on home ventilator support, producing high levels of family confidence in clinical management and value to clinicians in their decision-making.

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Posted by: C3O Telemedicine News

Posted on: October 9th, 2015

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ATA Telehealth Legislative Infographic


 

At the Fall Forum 2015, the ATA provide a very concise infographic on Telehealth legislative efforts both on a state and federal level.

ATA Legis Infographic_Page_1ATA Legis Infographic_Page_2ATA Legis Infographic_Page_3ATA Legis Infographic_Page_4

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Posted by: C3O Telemedicine News

Posted on: October 5th, 2015

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Robotics in Telemedicine


In the just released itmj.2015.21.issue-9.coverssue of Telemedicine and e-Health, Doan and Merrell’s editorial addresses robotics in telemedicine. The editors write “Telemedicine, telehealth, and robotics are a few innovative approaches to alleviating the stress on an overburdened system. While technology continues its march forward, often unabated, the culture of medicine has not changed as rapidly. There are many individuals and health systems across the United States and the world that are reticent to change. Perhaps it is a lack of understanding or a fear of change or even a level of trust in the technology. Clearly a robot in a nursing facility that is driven by a remotely located physician who is in contact with the on-site nursing staff can add tremendous value. Robots have added value both in clinical settings and in the educational setting.”

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Posted by: C3O Telemedicine News

Posted on: September 1st, 2015

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AMA starts new telehealth CPT services workgroup


The AMAama-logo is pleased to announce the formation of a CPT® Telehealth Services Workgroup, which will be chaired by members of the CPT Editorial Panel. The workgroup will be comprised of relevant medical specialties/organizations and industry stakeholders. The workgroup will recommend additions and changes to the CPT code set related to medical services utilizing telehealth technology. The charge of this ad-hoc workgroup is to:

  1. Recommend solutions for the reporting of current non-telehealth services when using remote telehealth technology (to include but not limited to E/M services). Considerations will include potential new codes, use of current codes without or with modifier, add-on code(s).
  2. Address the accuracy of current code set in describing the services provided when telehealth data is reviewed and analyzed, including potential code set revisions and/or education for:
    1. Appropriate code use (e.g., E/M versus data analysis codes);
    2. Potential code development to report analysis of transmitted data;
    3. Definition of data types whose interpretation will require differentiation and consideration of separate reporting of current E/M services/codes
    4. Potential new E/M services codes based on emerging new patterns for sites of service.
  3. Recommend whether any other telehealth service codes should be developed based upon services currently being provided.
  4. Develop new introductory language or modify existing introductory language to guide coding of telehealth services.

The workgroup will also help facilitate discussions with key stakeholders who may wish to bring forward telehealth services applications for consideration. According to the CPT Editorial Panel AdHoc Workgroup Organizational Structure and Processesguidance, all workgroup recommendations will be presented in a Code Change Application(s) for consideration by the CPT Editorial Panel. Participation in the Telehealth Services Workgroup does not preclude the submission of a separately developed code change application for consideration by the Editorial Panel.

 

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Posted by: C3O Telemedicine News

Posted on: August 20th, 2015

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Wall Street Journal Opinion Piece about Telemedicine


In the Wall Street Journal Opinion page onimgres August 3, 2015 , Dr. Richard Boxer who is chief telehealth officer of Well Via and former CMO for TelaDoc discusses the efficiency of getting a doctor on the phone within minutes, all courtesy of the utilization of telemedicine. He stresses a new found efficiency in a highly inefficient healthcare system. Emphasizing that over 100 million people are living in under served areas where major shortages of primary care physicians leave this population vulnerable, telemedicine helps to lessen the severity.

Economically, Boxer reports that 136 million ER visits could have been replaced by a $50 telemedicine consultation.  Coupled with the anticipated 52,000 primary-care physician shortage by 2025 the crisis has already begun. Looking to train more physicians won’t do it. Advanced practice nurses helps but is not the solution. Anticipated health workers graduating from community colleges is a feel good thought without real power.

While no one is stating or hoping telemedicine will replace the live physician encounter, states and the federal government need to address  how to engage and incorporate telemedicine into main stream medicine today, not tomorrow. How? Dramatic and commonsense inter-state licensure approval. Just as we have one drivers license good in all 50 states, with proper oversight why shouldn’t a California license be recognized in New York or any other state? After all, the European Union is light years ahead by recognizing other country medical licenses.

It is up to the public to jump on their legislatures to help move this along if they wish to avoid long waits or even worse, no access for their primary medical needs. Telemedicine is certainly a solution.

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Posted by: C3O Telemedicine News

Posted on: August 9th, 2015

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