Telehealth use expands in consultation, education
Barriers to international travel instituted since the 9/11 terrorist attacks have helped drive the use of telehealth for international clinical consultations and continuing medical education, while the intricacies of state medical licensing have made it easier for a doctor in New York to use the technology to talk with a patient in New Delhi than to help one in New Mexico.
Technology now allows physicians to consult with patients or colleagues, view diagnostic images, even perform remote surgery using robots, but if a doctor licensed in New York—while attending a conference in Nevada—refills the prescription of a patient vacationing in Florida after a discussion on the telephone, they may be skating on some thin legal ice and could be putting their medical license at risk.
“The states are steadily evolving in this area, and we’re seeing more medical boards exploring an expedited licensure process to facilitate interstate practice, including the expansion of telemedicine services across state lines,” Humayun Chaudhry, president and CEO of the Federation of State Medical Boards, says in an e-mail. “This expedited licensure process is supported by enabling tools such as a uniform medical licensure application being implemented in several dozen states and enhancements to a centralized credentialing process.”
Alexander Nason, director of telehealth for Johns Hopkins Medicine International, says this is not a concern when Johns Hopkins physicians regularly collaborate with their colleagues at affiliated institutions in Chile, Lebanon, Panama, Turkey and the United Arab Emirates. At the UAE’s Tawam Hospital in Al Ain City, Nason says biweekly tumor board teleconferences are held linking Johns Hopkins experts so they can discuss patient cases.
“That’s been a great project for us,” Nason says. “The physicians know each other, they communicate regularly and the physicians here go over there and teach.”
Nason says telehealth has two forms: Live video conferencing and “store forward” material that is sent or posted to be viewed by a recipient at their convenience.
“Logistically, the time zone difference is definitely the biggest issue—particularly when we change our clocks for daylight saving time and other parts of the world don’t,” he says.
Nason recalls one instance a few years ago during early autumn when a consult was scheduled with an Ethiopian hospital and no one was there to consult with after the electronic connection was completed. “Our clock fell back, and theirs didn’t move,” he says. “Lessons learned.”
Live interaction is preferred and is usually workable when there is up to a 10-hour time
difference, Nason says, noting that when it’s 7 a.m. on the East Coast of the U.S., it’s 5 p.m. in India. When the time difference gets beyond that, however, it becomes inconvenient for both sides. “That’s where ‘store forward’ comes in,” Nason says. Johns Hopkins has instituted a store-forward “second-opinion service,” which is now handling some 600 consults a year with both affiliated and nonaffiliated hospitals around the world.
“On the clinical side, it’s having a big impact,” Nason says.
Nason says he came to Johns Hopkins 10 years ago and his work focused on international consulting, but he had a “side passion” for healthcare technology and, after the terrorist attacks of Sept. 11, 2001, the two fields converged as international travel became more arduous.
“Prior to 9/11, we received a lot of patients for treatment from the Middle East,” he says. “Our physicians were also traveling there frequently to provide treatment or consults.”
Telemedicine technology is still used mostly for education, Nason says, with Johns Hopkins presenting some 300 live video lectures a year to remote international locations where from a dozen to “a couple hundred” individuals may be watching.
“The work we’re doing is cutting edge,” he says, and cutting edge clinical experience is something physicians in other countries may lack—even those in countries that have plenty of other resources.
The equipment used runs the spectrum from “a webcam and Skype,” to robots, high definition and streaming videos.
“The pricing of these technologies continues to drop,” Nason says, noting that systems that cost $20,000 to $30,000 five years ago can be purchased for $5,000 today.
“You can’t really talk about return on investment,” he adds. “I’m talking about gadgets, toys and robots, but at the end of the day, we are talking about people’s lives.”
In the December issue of the Telemedicine and e-Health journal, Anne Burdick, University of Miami associate dean for telehealth and clinical outreach and a professor of dermatology, notes the many factors that needed to be calculated in order to assess a telehealth program’s ROI. These included reduced staff travel, reduced patient travel and lost work time, faster diagnosis and treatment, increased access, reduced morbidity, avoided mortality, increased medication adherence and avoided hospitalizations.
The University of Miami Miller School of Medicine’s telehealth program started in 1973, and today it conducts live teleconferencing lectures with physicians all over the world—including monthly Pan-American Virtual Conferences in Dermatology with participants in Argentina, the Bahamas, Brazil and Mexico as well as Alaska, Hawaii and Guam.
On May 1, the school will begin a teledermatology program for the 20,000 people who work on Royal Caribbean Cruises’ 30-plus ships. Burdick says it was expensive and inconvenient for crew members to wait until they were in port to see a doctor and often difficult to get an appointment on weekends.
The department has provided similar dermatology services since 2005 for the U.S. military and has partnered with the Army Trauma Training Center to study the use of telemedicine and robotics on the battlefield.
The school’s telemedicine expertise was recently put to the test treating patients in the aftermath of the massive Jan. 12 earthquake in Haiti. Enrique Ginzburg, a University of Miami professor of surgery and chief medical officer at the field hospital set up in Port-au-Prince by the university and the Miami-based Project Medishare charity, was among the first physicians on the scene, caring for some 250 patients housed in four huge tents.
As the weeks wore on, “volunteers were dropping off,” and there was a shortage of specialists needed to staff a pediatric intensive-care unit that had been set up—although there were several generalist pediatricians and nurses on hand.
“We felt telemedicine would be the perfect way to handle it—even if we just had regular nurses and pediatricians with no special ICU training,” Ginzburg says.
Eventually, a telehealth network was hooked up between 15 Haitian hospitals, the University of Miami and the University of Virginia Health System, Charlottesville. The network was financed in part by the Swinfen Charitable Trust, based in the United Kingdom, and Ginzburg says Cisco Systems has donated the use of its equipment for nine months.
Arriving soon will be a robot capable of serving as physicians’ “eyes and ears,” Ginzburg says. “You can hear and see patients, and look at monitors” by using the robots, Ginzburg says. “It’s the next best thing to being there.”
Ginzburg: Telehealth’s capabilities were put to the test in Haiti.