Long-dis­tance re­la­tion­ships

Tele­health use ex­pands in con­sul­ta­tion, ed­u­ca­tion

Modern Healthcare - - International Healthcare -

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.

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