Professor Vijay Govindarajan is the Earl C. Daum 1924 Professor of International Business at the Tuck School of Business at Dartmouth. He is coauthor of Reverse Innovation (HBR Press, April 2012) believes many lives can be saved by Telemedicine.

Here is a preview from the Harvard Business Review Blog:

“If you’ve not yet heard of telemedicine or think that it’s not a great way to deliver quality health care, you may want to read this. Telemedicine, made possible by the availability of mobile networks, is revolutionizing health care. But not in the U.S.

You have to look to India, where telemedicine is already widely used in the delivery of health care — and is saving lives even in the most rural corners of the country. It is especially used in peritoneal dialysis (PD), a key treatment option for patients with severe and chronic kidney disease, so-called end-stage renal disease (ESRD). Under this procedure, fluid is introduced through a permanent tube in the abdomen, and flushed out either every night while the patient sleeps, or via regular exchanges throughout the day. It is home-based care. The alternative treatment is hemodialysis (HD). Compared to HD, the primary advantage of PD is the ability to deliver treatment without visiting a hospital; it is thus more cost-effective. The primary disadvantage is that it can cause complications due to infections, since PD permanently attaches a tube to the abdomen.”

Then the blog concludes:

But in the U.S. it’s a different story. Over 90% of patients in the U.S. with ESRD use HD as their treatment. However, that is a procedure that requires the patient to go to the hospital three times a week. This is more cumbersome, more expensive, and hampers the patient’s lifestyle and work/family obligations. What is the primary driver of this system-wide inefficiency and cost? Most health care providers would agree that it is physician “mindset:” higher physician reimbursement for HD than PD, and concerns about accessibility in a geographically vast country contribute to historically low use of PD in the U.S.

It doesn’t have to be this way. The “distance” between the patient and the PD unit can be overcome, at a dramatically low cost, by efficient use of the internet, mobile phones, and a strong home visit protocol. To quote Dr. Nayak: “Our success can easily be replicated in the U.S. Conservatively, even if 15% of ESRD patients choose PD over HD, cost savings for Medicare and Medicaid will run into many millions of dollars every year.”

Why can’t we adopt this in the U.S.?

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The medical community is always in search of mechanisms to insure the safety of  patients. An area of frequent discussion centers on the communication of patient information to fellow physicians including patient stability, case management planning, relationship with family members, therapies that need to be evaluated or discontinued, results of diagnostic tests and prognosis. Too often this form of communication is less than optimal between primary care physicians or specialists and not too infrequently among members of the same group who take call during nights or weekends.

With the introduction of telemedicine a new factor must be considered in the equation of patient safety. How does one optimize the handoff of information about a patient between the onsite physicians and the telemedicine physicians? Over the past four years, C3O Telemedicine has been a ardent believer in both the importance of and the sustainability of a  secure and quality driven method for the handoff. While not without difficulty, here are several mandates to insure patient communication among physicians becomes an important priority as a practice habit:

1. The onsite physicians know that a telemedicine service exists, how it functions, and have a working relationship with the members of the telemedicine team.
2. A well-delineated policy is established that gives the telemedicine physician a clear idea as to how long and to what extent they participate in the care of the patient that they have been consulted.
3. The telemedicine physician always includes their preferred method to be contacted and it is listed at the end of the documented consult or progress note. In some cases an encrypted email system or cloud based secure file provides easy and quick access to patient handoff information.
4. Contact information is available to both parties from the outset of the program.
5. A predetermined “communication time” between the onsite and telemedicine physician each day can be developed prior to implementation of the program.
6. The nursing staff must also understand the system and can remind the onsite physician that the telemedicine physician has implemented specific orders and the results are pending or report how the patient has responded to therapy.
7. Not to be left out, the pharmacist, respiratory therapist, and other healthcare professionals involved in the patient’s care should also be familiar with and have access to the telemedicine physician to raise questions or report results that require immediate attention. The team approach to patient care is then reinforced.

A study in the Journal of Hospital Medicine recently released “included 356 patients admitted at three different hospitals who had low or medium risks of dying within one year. Patients were followed from 2003 to 2009. During the study, there were no differences in survival for patients who had an end-of-life discussion and those who had not; there also were no survival differences for those who had a living will in their medical record and those who did not.”

“Our findings are reassuring. They support health care providers, who can initiate these discussions, and policy makers, who seek to reimburse these time consuming discussions,” said lead researcher Stacy M. Fischer, MD of the University of Colorado School of Medicine. “Most importantly, our findings are reassuring for patients and families who desire these discussions with their health care providers.”

Hopefully this study will quell the  hysteria created by politicians that grandma and grandpa will be removed from life support without their approval. The whole concept of Palliative Care should be an essential part of the care plan for all patients. Sharon Lucas, C3O’s director of Palliative Medicine, has been a leading advocate and supporter of the dignity of patients as they make end of life decisions. That is a significant reason that C3O has embraced Palliative care as an integral component of telemedicine care. Patients and families making their own well informed decisions is paramount and most importantly, respectful.

In the October, 2011 edition of Health Management Technology, Christina Thielst reports on the experience of C3O in caring for stroke and septic patients. Improved availability equals quicker times for patients to receive the life-saving drug t-PA resulting in better outcomes for stroke patients. Likewise, the C3O tele-ICU solution addresses highly reversible conditions such as sepsis including septic shock. Many patients, particularly patients with cancer, AIDs, and elderly patients are all at risk to develop infections which can be life-threatening. Even young 20 year olds who are previously healthy have been victims of the “flesh eating” streptococcal infections.

With the use of early therapy many more patients will survive and in some instances may never require an ICU. Making the right diagnosis at the right time means a happy and better outcome for our patients. Delivery of the right specialists, be it an ICU or stroke specialists, is now available anywhere in this country through the use of the C3O telemedicine solution and should be the standard we should all expect.

In a recent article in the Annals of Internal Medicine, Kuo and Goodman studied a 5% sample of Medicare enrollees during a five year period. The results revealed the well known concept that hospitalists decrease length of stay and costs. The new revelation was that hospitalist patients were more likely to go to a nursing facility rather than home. Additionally, these same patients were more likely to return to the Emergency Department and be readmitted. Because of these post-discharge costs, the initial hospital savings were offset by these readmissions. Hence, the role of telemedicine might play a role in allowing all the good and efficient hospitalist care be sustained by remote care in skilled nursing facilities by these same hospitalists. Working in concert with case managers and programs for follow-up care, the reasonable cost of a telemedicine program is a logical solution to the identified problem for both increased readmissions and higher costs.

Over this past weekend, my mentor, colleague and friend Dr. Hal Weil died. I had the privilege of being a critical care fellow while at the University of Southern California. Not only was he brilliant and a founder of critical care medicine, he was a strong advocate for the best in patient care. Noted for his work in sepsis and CPR he also did research and developed the use of capnography during cardiac arrest and with portable defibrillators. Until the end, he was always coming up with new ideas and never stopped being the giant he was for so many of us who trained under him. We shall all miss him and are grateful for all that he has done for medicine and in particular critical care medicine.

Anthem Blue Cross has just committed to training healthcare professionals on diagnosing and treating septic patients – of which there are close to 800,000 Americans annually. The program will be administered through the hospital associations in California. This is a three year program which will cost $6 million. What an opportunity to employ telemedicine into the fold for the training piece. Having been the lead physician in Southern California for the Surviving Sepsis Campaign sponsored by the Society of Critical Care Medicine and having to travel to small as well as large audiences, teaching about sepsis is easily achievable through telemedicine. That doesn’t negate any need for on-site coaching. Can we see the details of where the $6 million is going?

A long time belief that we have held is that provision of specialists for certain needs such as vacations, retirement, or relocation is an exceptional way to leverage telemedicine for hospitals in need. With all the cost of obtaining a locum tenens or recruitment, what better solution to a problem? Recently in FierceMobileHealthcare, Sarah Jackson reported that a hospital in need of several psychologists who suddenly left the area was able to utilize telemedicine to work with onsite staff to address this exact need of  lost coverage. This same model can be applied to any specialty where need exists. The uses for telemedicine keep expanding as experience grows and is supported by access to care for all.