Can telemedicine deliver in emergency medicine?

Technology holds enormous potential for managed care markets

Is there a future for telemedicine in the ED? David G. Ellis, MD, dreams of the day when emergency physicians can make house calls on patients via closed-circuit television. The associate director of emergency medicine at Erie County Medical Center in Buffalo, NY believes telemedicine can help reduce overcrowding in the ED, cut waiting time, and eliminate unnecessary visits.

In Minnesota, William M. Goodall, MD, vice president for regional medical affairs with Allina Health System in Minneapolis, envisions a time when physicians can perform complete medical screenings on patients from two different hospitals at virtually the same time using a desktop personal computer. Medical screenings via PC screens, if you will.

These innovations may be years away for proponents of emergency telemedicine. But the implications for managed care are enormous, advocates claim. For one, the technology holds the potential to expedite the conventional emergency medicine consultation by immediately linking the patient's primary-care physician with the emergency specialist via television hook-up.

Clinical applications hold biggest promise

The technology has been in existence for some time and has won support in many areas, including patient markets served by Allina. But so far, it's proven itself mostly as an administrative and educational tool. Allina routinely holds teleconferences from its corporate office for executives at its far-flung network of facilities and provides patient education seminars for consumers via television.

But, according to proponents such as Goodall, the clinical applications hold the biggest potential for health care cost-savings, advocates say. For one, it keeps the patient under the PCP's care. And, except for a fee paid to the emergency specialist for the consult, the system potentially eliminates the need and expense of a conventional ED visit in the majority of cases, says Craig Lambrecht, MD, medical director of the Dakota Telemedicine System at Medcenter One Health Systems, an eight-hospital network based in Bismark, ND.

It's also convenient for the patient, Lambrecht adds. The diagnosis is immediate. It saves drive-time. Keeps the patient in the community. They can get answers to their medical conditions sooner. And both the PCP and emergency provider can complete the stabilization process in much less time than a typical visit to the ED takes.

In a recent survey involving 210 rural patients served by the Dakota Telemedicine System, 60% of patients who were involved in the telemedicine project had their dispositions changed by their PCPs as a result of the telemedicine consult. In most cases, the patients did not visit the ED.

Lack of research delays clinical use

And in 50% of cases, the patients' treatment plans changed from what had been originally anticipated. But Lambrecht did not specify whether the final treatment plan was ultimately less expensive than the one that would have resulted without the telemedicine consult.

Nevertheless, physicians such as Lambrecht and Goodall are bringing their early results to managed care organizations (MCOs) in hopes of igniting interest from health plans on the potential cost-savings in the closed-circuit technology. Why wouldn't MCOs leap at such a proposal?

One reason is that "despite the interest in distance medicine on the part of physicians, nurses, and [MCOs], relatively few patients have been treated with the use of these technologies," stated an editorial last year in the Annals of Emergency Medicine.1 "If these technologies are to be used successfully for patient care, difficult questions regarding efficacy, safety, and cost-effectiveness must be answered," the editorial concluded.

The lack of any conclusive research supporting the effectiveness of telemedicine in medical care, especially in emergency medicine, has been the single biggest drawback to the technology's widespread acceptance. But it isn't the only one.

Physicians, themselves, are skeptical of the danger posed by telemedicine in "distancing" the physician from the patient physically and emotionally, critic says. It ignores the value of the personal physician-patient relationship, which is the basis for the medical arts, argues Jamie Court, director of the non-profit Consumers for Quality Care, a health care watchdog group in Santa Monica, CA.

There may be a place for telemedicine in health care. But "as with drive-through deliveries and outpatient mastectomies, the medical establishment must set proper limits soon to curb the abuses of telemedicine before they get out of hand," Court says.

Goodall of Allina takes issue with such alarmist claims. "I don't disagree [with critics]. The eye contact, the personal touch, and the 'I really care about you,' is absolutely essential to medicine," he says.

But Goodall underscores the role played by the trained nurse practitioner, who is at the patient's side the entire time. The nurse or physician extender functions as the emergency physician's surrogate during the medical screening, providing the patient with the physical and emotional components of the treatment experience, he says.

Lambrecht of Medcenter One insists on having a physician at the patient's side to ensure patient satisfaction and avert future malpractice concerns or questions regarding who actually dispensed the medical care.

Technology is state of the art

For his part, Goodall defends today's telemedicine technology, which, he says, makes possible accurate, dependable assessments and decisions. To Goodall, the emergency physician is actually there with the patient via the telemedicine technology.

At Dakota Telemedicine, for example, the technology typically uses something called T1 broad-bandwidth telephone lines that can transmit 1.54 megabits of information per second. The rate is much faster than regular telephone lines. It's the equivalent of four ISDN lines working together, Lambrecht says. One ISDN line can transmit and receive heavy volumes of data generated by numerous computer modems, telephones, and faxes simultaneously.

On screen, the visual picture in some cases is better than the best television screen quality, says Goodall of Allina. The typical TV image involves a configuration of 480 pixels per line (the basic unit of a TV image) on 640 horizontal image lines. The minimum requirement for transmitting radiology film over telemedicine relays at Allina is 2,000 pixels by 2,000 lines, Goodall reports.

The system is also versatile. Physicians can either hold consults using a stationary camera in an office environment. Or they can move to the bedside to have the emergency specialist speak and examine the patient. The technology is so reliable, says Goodall, that the emergency physician can conduct an ear exam or visually examine a skin lesion or open wound as well as if the patient were physically present.

Specifications are not yet uniform

Although uniform standards don't yet exist for the technology's use in emergency medicine, there are some practice conventions. Here are some used by Lambrecht at Dakota Telemedicine:

    · The videoconferencing equipment at both the host hospital (hub site) and the patient's location (the spoke site) involve dual 27-inch Sony Composite/S video color monitors connected to an 8MB/210MB computer hard drive with 125 MHZ of power.

    · Each site has a one-chip Smart camera with pan, tilt, and zoom capability.

    · The screens have CIF resolution quality at 15 fps, capable of up to 30 fps, with a quick-frame option.

    · They also use two wired microphones and a one-chip VTEL model DOC368 document camera for transmitting written and graphic images.

    · The system can transmit data at a rate of 1.3 M bps, and its software resolution is at 500 horizontal lines per frame at a rate of 30 frames per second.

But are these positive attributes sufficient to make telemedicine an industry standard? Ellis of Erie County Medical Center acknowledges "there is still a long way to go before we can say we're there." At present, the technology is receiving its warmest welcome among rural providers, who desperately need ways of closing the physical distance that separates PCPs in rural hamlets from emergency physicians at larger hub hospitals.

Allina serves some 21 outlying rural sites in Minnesota. Erie County plugs into 16 rural providers although only three are presently active. It maintains its service from 9 p.m. to 9 a.m. when, according to Ellis, the need for acute care is most likely to occur.

Will it play in New York or Los Angeles? That's the question providers are pondering as they to come to terms with the extremely high cost of maintaining these programs. The cost factor is another one of the problems facing emergency telemedicine's pioneers.

Costs pose a large problem

For Dakota Telemedicine and Medcenter One, its underwriter, the program hasn't yet generated enough patients or revenues to make the program self-sufficient. "It's a need-driven system," says Ellis, who is also struggling at Erie County to become cost effective. The initial investment in equipment can range between $10,000 and $20,000 or more depending on the size of the network, which by itself isn't exorbitant, Goodall says.

Typically, the revenue generated from the patient visits aren't enough to offset the initial investments or the operating expenses. In most cases, the consulting physician is paid a fee by the spoke hospital or PCP for the consult. The physician can also submit a claim to the patient's health plan for the screening, using an evaluation and management (E&M) service CPT-4 code with a modifier that has been approved by the payer. The American Medical Association has yet to issue a separate CPT code.

But it's the operating costs that are most intimidating, Goodall says. Allina currently pays some $500,000 per year in expenses, mostly related to monthly charges for the use of the telephone company's access lines. "The telecommunications industry is really cleaning up on this," Goodall says. "Nevertheless, telemedicine is worth the investment. We're really just a blip on Allina's radar compared with the potential good behind this," Goodall adds.

Reference

    1. Schafermeyer, RW. Telemedicine and emergency medical care: Improved care delivery or just another video game? Ann Emerg Med 1997;30:682-687.

Sources

For additional information on current telemedicine research in emergency medicine, contact:

    · Craig Lambrecht, MD, medical director, Dakota Telemedicine System, Medcenter One Health System, 300 N. Seventh St., Bismark, ND 58506. Telephone: (701) 323-5614.

    · William M. Goodall, MD, vice president for regional medical affairs, Allina Health System, PO Box 9310, Minneapolis, MN 55440. Telephone: (612) 992-3047. E-mail: goodall@allina.com