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 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.
Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain.
To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals.
- 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.
- 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.
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.
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:
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.
The Journal of Telemedicine and e-Health 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.
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.
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.
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.
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.
U.S. Senators Joni Ernst (R-IA) and Mazie Hirono (D-HI), led eight co-sponsors, in introducing the bipartisan Veterans E-Health & Telemedicine Support Act of 2015 (VETS Act), legislation to improve health care access for disabled or rural veterans by expanding telehealth services provided by the Department of Veterans Affairs (VA).
As defined by the Department of Health and Human Services telehealth is, “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”
Under current law, the VA may only waive the state license requirement for telehealth services if both the patient and physician are located in a federally owned facility. In addition, the VA may only perform at-home telehealth care when the patient and physician are located in the same state. These barriers are a deterrent for disabled or rural veterans who are seeking treatment from a physician in another state, in some cases forcing veterans to travel great lengths to a federal facility before receiving telehealth services by camera or phone.
The VETS Act would address these deficiencies by allowing qualified VA health professionals to operate across state lines and conduct telehealth services, including mental health care treatment, for veterans from the comfort and privacy of their own homes.
Telehealth is one of the VA’s major transformational initiatives, and the number of veterans utilizing telehealth services continues to climb. In fact, VA telehealth care grew by 18 percent among veterans in Fiscal Year 2014 and in turn more than 12 percent of veterans received elements of their care through telehealth services. According to the VA, 88 percent of veterans who utilized the VA’s telehealth services were satisfied with the care they received. Telehealth services are effective and affordable as veterans save on average $2,000 per year in health care related costs, including travel to a VA medical facility.
“The bipartisan Veterans E-Health & Telemedicine Support Act moves us one step closer to achieving more affordable, patient-centered health care that our veterans deserve by embracing telehealth services to offer physician care and health treatment beyond the walls of a VA facility,” said Senator Ernst. “Telehealth care is an innovative and important means to meet the wide-ranging needs of veterans in Iowa and nationwide, including the invisible struggles of mental health care.”
“Our nation has a moral obligation to provide the best care for all veterans,” said Senator Hirono. “This legislation would eliminate the added burden of traveling long distances, or even to different states, in order to see a doctor. The VETS Act will build on a VA telemedicine program that is proven to work and removes barriers to accessing care particularly for veterans in rural areas like Hawaii’s Neighbor Islands.”
Additional cosponsors to the bipartisan VETS Act include: Senators Kelly Ayotte (R-NH), John Boozman (R-AR), John Cornyn (R-TX), Chuck Grassley (R-IA), Mike Rounds (R-SD), Jeff Sessions (R-AL), Thom Tillis (R-NC), and Tom Udall (D-NM).
The VETS Act is widely endorsed by the Veterans of Foreign Wars, Paralyzed Veterans of America, the American Legion, Concerned Veterans for America, and the American Telemedicine Association.
The companion bill in the U.S. House of Representatives was introduced by Congressmen Charles Rangel (D-NY) and Glen Thompson (R-PA).
Click here to read the full text of the VETS Act.
- Allows VA health professionals to practice telemedicine across state lines if they are qualified and practice within the scope of their authorized federal duties.
- Ensures the VA and Congress provide oversight of the VA’s telehealth program by requiring the VA to measure program effectiveness.
Benefits of VA Telehealth Services in Fiscal Year 2014:
- Provided veterans telehealth care from more than 150 VA Medical Centers and over 750 Community Based Outpatient Clinics.
- More than 12 percent of veterans received elements of their care through telehealth services.
- More than 717,000 veterans participated in over 2.1 million telehealth care interactions.
- 45 percent of veterans who used telehealth services lived in rural areas.
- Reduced hospital bed days of care by 54 percent.
- Reduced hospital admissions by 32 percent.
- VA telehealth care grew by 18 percent among veterans in Fiscal Year 2014.
- Patient satisfaction for clinical video telehealth averaged 94 percent.
- Patient satisfaction for overall home telehealth services averaged 88 percent.
- Home telehealth services save veterans on average $2,000 per year.
Researchers from Boston Childrens/Harvard 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.
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.