A group of fifteen physicians compared interpretation of chest x-rays using established 23 major findings from cardiology, radiology, and pulmonary-critical care via Google Glass screen, viewing on Google Glass and interpreting on a mobile device, and viewing the original chest x-ray on a desktop computer screen. A top score was maximum 23 points.
Google Glass: 14.1
Google Glass photo on mobile device: 18.5
Desktop computer: 21.3
Of the 15 physicians, 11 (73%) felt confident in detecting findings using photographs taken by Google Glass as viewed by mobile devices.
Remote chest x-ray interpretation using hands-free Google Glass is less accurate than description using a desktop computer or a mobile device. Further technical improvements Google Glass are needed before widespread application and acceptance.
What others say
Google Glass is revolutionizing the healthcare world. As in fields like higher education, third-party application developers and users are embracing Glass to deliver highly empowering, meaningful Glassware with amazing results. Mark Taglietti, head of ICT delivery services and vendor management at London University College Hospitals says, “Google Glass represents a step change in technical innovation, wearable technology, and the convergence of personal devices in the workplace. The healthcare applications of Glass are wide-ranging, insightful and impactful, from enabling hands-free real-time access to clinical and patient information, to the transmission of point of view audio and video for surgical research and educational purposes. Glass marks the beginning of a remarkable journey for technical innovation within healthcare, enabling providers to improve the delivery of care, as well as overall quality and patient experience.”
The nature of telemedicine is to connect doctors to patients on-demand. The range of telemedicine scenarios is vast. Glass can provide synchronous video conversations with physicians at remote locations. Remotely-conducted procedures can be recorded and embedded in patient records for future reference. With Glass, physicians at rural hospitals can consult with specialists located anywhere in the world in real-time to provide world-class service to their patients. Telemedicine also plays a significant role in streamlining care to hospice patients. Care providers can communicate with physicians remotely and proactively monitor patients whose EHRs can be transmitted in real-time. The seemingly high $1,500 price of Google Glass is significantly less than other types of hospital videoconferencing, which can run upwards of $40,000.
More work in developing the technology may result in radiology’s quick acceptance and adaptation.
Urgent telehealth care quality varies by commercial provider. Quality may vary in six frequent conditions but the mode of delivery videoconferencing, telephone, and web chat was not a cause for variation in quality.
The 6 conditions included: ankle pain, streptococcal pharyngitis, viral pharyngitis, rhinosinusitis, low back pain, and recurrent female UTI.
The eight providers of telehealth selected by the University of California at San Francisco included Ameridoc, Amwell, Consult a Doctor, Doctor on Demand, MDAligne, MDLIVE, MeMD, and NowClinic. The selection was based upon data obtained from the most frequently used sites.
Primary outcomes were based upon a complete history and physical, correct or incorrect diagnosis, and compliance with national guidelines. Sixty-seven standardized patients were used for a total of 599 virtual visits. The standardized patients were either an actor with experience in the simulation center at UCSF or medical students. Completeness of the exam occurred in almost 76% of the patients. Of the eight companies, completeness varied from 51.7 to 82.4%. Correct diagnosis varied from 65.4% to 93.8%. Compliance with guidelines ranged from 34.4% to 66.1%.
For making the correct diagnosis, videoconferencing (85.8%) and telephone consults (77.7%) were better than webchat (66.1%).
The authors noted that variability of care is also seen in the traditional setting. A prominent example is the prescription of antibiotics. Interestingly, the ordering of tests was lower in the virtual care compared to the traditional setting.
At odds with the Texas medical board, which has outlawed telephone consults, this study found no statistical difference in adherence to national guidelines based upon a mode of consultation.
The variability of the different providers supports the need for improvement and perhaps the need for accreditation as is available through the American Telemedicine Association.
Finally, the limits of the study are that we do not know if a telemedicine visit is inferior or superior to an in-person visit. Since this is the first study of this nature, additional research is needed.
Secure messaging can have a positive impact on diabetes clinical outcomes according to an ahead of publication posting on Telemedicine and e-Health. According to this new review, “President Barack Obama signed into law the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. HITECH stated that from 2011 to 2015, healthcare providers would be offered financial bonuses for meaningfully using electronic health records (EHRs) and penalized for not doing so. ‘‘Meaningful use’’ (MU) is meant to improve care quality and engage patients while maintaining privacy of information, to obtain better clinical outcomes, population health outcomes, and increased efficiency. There are three stages. One of the stage 2 core objectives introduced in 2014 was for eligible providers to use secure electronic messaging to communicate with patients.”
However, earlier EHR studies reveal only limited evidence for the value of these tools in managing chronic diseases. One systematic review of articles assessing the value and clinical outcomes of using EHRs in chronic disease management published between January 2000 and September 2010 found only three prospective randomized trials, all centered around diabetes care. The authors from the University of Miami, reviewed the more recent studies to determine outcomes for diabetes management.
In this pre-publication review slated for September release, “evidence from 7 of the 11 included studies suggests significant improvement in patients’ hemoglobin A1c (HbA1c) with the use of secure messaging. However, improvements in patients’ secondary outcomes, such as blood pressure and cholesterol, were inconsistent. Further work must be done to determine how to best maximize the potential of available tools such as secure messaging and EHRs to improve patient outcomes.”
The ideal stroke network with telemedicine is described in Endovascular Today (February, 2016). C3O’s Dr. Jeff Wagner, estimates that more than 10% of ischemic strokes are due to large vessel occlusion (LVO), and many of these strokes will not be effectively treated with IV tPA alone. Enter intra-arterial (IA) therapy which can be effective in such patients.
“Because strokes are time-sensitive hospitals must be able to quickly obtain CT imaging to exclude a hemorrhage and efficiently prepare and administer IV tPA. When necessary, transfer to a hub hospital must be rapid for IA and other advanced therapies.”
Rapid response by teleneurologists neurologists, are the single most important factors that drive performance of a stroke system of care, especially at hospitals without onsite neurologists.
Table 1 from the Endovascular Today article “details some key quality metrics Dr. Wagner tracks to measure our performance. Each of the listed metrics has improved annually over the past 5 years, and many other metrics are evaluated, which has allowed us to identify areas of inefficiency.”
BENEFITS RESULTING FROM NETWORK DEVELOPMENT
- Improved delivery of therapies for acute stroke
- Increased IV tPA delivery at spoke hospitals results in increased reimbursement to the spoke hospital.
- A decreased transfer rate from spoke to hub hospitals results in less revenue lost by spoke hospitals.
- Improved stroke quality metrics, which are likely to factor into hospital reimbursement for services rendered in the future.
- Liability is shared as though the stroke specialist is physically present in the emergency department of the spoke hospital. Our malpractice insurance provider is increasingly recommending stroke telemedicine coverage when in-person stroke specialist coverage is not available due to reduced liability exposure.
- From a public health perspective, reducing unnecessary transfers, many of which involve an emergent critical care air ambulance, confers significant savings to the health care system as a whole. Medicare-funded studies are ongoing to determine the cost-effectiveness of telemedicine in neurology and neurosurgery as compared to availability of specialists by phone.
Jeffrey C. Wagner, MD, is Medical Director at the Swedish Comprehensive Stroke Center and CODOC Telemedicine Program, and is affiliated with Blue Sky Neurology in Englewood, Colorado and C3O Telemedicine. He has disclosed that he is on the speakers bureau for Genentech. Dr. Wagner may be reached at firstname.lastname@example.org.
Telehealth growth accelerates as challenges in workflow, interstate licensing and reimbursement continue to be addressed . Dr. Naomi Watts of Biogen Idec says “patients clamoring for physician access”.
Dr. Roy Schoenberg, CEO of AmWell says telehealth is providing the right way of getting in front of a physician.”The value of seeing a patient – visual is key” says Schoenberg.
Jason Sibley of Flare Cap Parnters believes telehealth’s business is to build a system that meets the needs of specific group of patients. One group that comes to mind is the large number of patients with chronic diseases such as Diabetes, Heart Failure, and Hypertension.
John Moore, MD, PhD of Twine Health noted that patients want to have “a low friction channel to access physicians particularly when they are experiencing an emotional need”.
This has been a preview of what’s to come at HIMSS at the end of February and is reported by Brian Dolan of Mobihalth News.
One story which never made the mainstream press is the humanitarian gesture of a group of ICU Telemedicine specialists providing civilian ICU care in war-torn Syria. Reported in the February issue of the Annals of American Thoracic Surgery, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The program utilized inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Launched in 2012 and within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. What would normally take numerous committee meetings including budgetary constraints was done on an all volunteer basis at a much lower than expected cost.
The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country.
The critical care community and the world will be waiting to see data from this extraordinary and courageous endeavor. Congratulations to Drs. Moughrabieh and Weinert from the University of Minnesota Medical School, Minneapolis, Minnesota.
A group of pediatric intensivists at the duPont Hospital for Children in Wilmington Delaware published the results of evaluating telephone versus telemedicine evaluation of pediatric patients with moderate to severe critical illness being transported between hospitals. Findings were as follows based upon the opinions of the medical command center physicians:
- Connection and audio quality were equivalent and there were no dropped calls.
- Average call duration in the phone group was 186 versus 139 seconds in the video group (P = 0.055).
- The MCO survey results were the following: 100% found video intuitive, 92% felt that disposition based on phone report was difficult, 80% felt that video provided better understanding of patient condition, 70% felt that video assisted disposition, and 80% believe that video should be used for transport.
- The iPad system offers a significant savings when compared with conventional telemedicine.
This was a prospective randomized study of a total of 50 patients divided between call only versus video conferencing. An iPad tablet was the technology used which the authors conclude is much more cost effective than other technologies.
Lancet Psychiatry. 2015 Aug;2(8):693-701. doi: 10.1016/S2215-0366(15)00122-4. Epub 2015 Jul 16.
Many older adults with major depression, particularly veterans, do not have access to evidence-based psychotherapy. TelePsychotherapy could increase access to best-practice care for older adults facing barriers of mobility, stigma, and geographical isolation. We aimed to establish non-inferiority of behavioural activation therapy for major depression delivered via telemedicine to same-room care in largely male, older adult veterans.
In this randomised, controlled, open-label, non-inferiority trial, we recruited veterans (aged ≥58 years) meeting DSM-IV criteria for major depressive disorder from the Ralph H Johnson Veterans Affairs Medical Center and four associated community outpatient-based clinics in the USA.
- Between April 1, 2007, and July 31, 2011, we screened 780 patients,
- Treatment response according to GDS did not differ significantly between the telemedicine and same-room groups.
- Response on the Structured Clinical Interview for DSM-IV, clinician version, also did not differ significantly
- Results showed that no significant differences existed between treatment trajectories over time for BDI and GDS. The criteria for non-inferiority were met. We did not note any adverse events.
TelePsychotherapy for older adults with major depression is not inferior to same-room treatment.
This finding shows that evidence-based telepsychotherapy can be delivered, without modification, via home-based telemedicine, and that this method can be used to overcome barriers to care associated with distance from and difficulty with attendance at in-person sessions in older adults.
US Department of Veterans Affairs.
The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents.
MATERIAL AND METHODS:
- We performed a prospective cohort study over 3.5 years.
- Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls.
- Consenting patients at intervention facilities could access telemedicine for acute illness care.
- Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses.
- The primary outcome was the rate of ED use.
- We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group;
- 1,058 subjects served as controls.
- Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home.
- Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction).
- Primary care use and mortality were not significantly different.
High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.
COMMENT: A very nice introductory cohort study on a very pertinent topic. Hopefully to follow will be a prospective randomized study looking at both outcomes and financial data. Additionally, for those seen through telemedicine, following the ED admission course would be important.
Martin Luther King, Jr. Community Hospital has chosen C3O Telemedicine to provide acute teleneurology coverage. Dr. Herb Rogove, CEO of C3O, says “we are extremely delighted to have been chosen as MLK Jr. Community Hospitals telemedicine service provider”. MLK has built their hospital with the 21st century in mind as they are a true telemedicine facility according to Rogove.
The key strengths of C3O are:
- Rapid response times
- A virtual who’s who of teleneurologists from leading medical centers
- Proven achievement of quality metrics and excellent outcomes
Located in the Second District of the Los Angeles County, the brand new Martin Luther King, Jr. Community Hospital (MLKCH) is a priority project for local authorities. It is expected to serve 1.2 million residents from all over South Los Angeles and to create more than 900 jobs in the area.
MobileSmith is the provider for mobile apps.
“Our strategy is to get into mobile extremely quickly, without overly burdening our IT staff or infrastructure,” said Sajid Ahmed, Chief Information and Innovation Officer at MLKCH. “With its powerful capabilities and easy learning curve, the MobileSmith Platform is the ideal solution for us. We are looking forward to launching many great apps.”