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New regulations, lower costs may help growth
Ever since NASA began tracking the health status of its astronauts through its now-familiar telemetry systems, the ability to perform health-related diagnosis and therapy from a distance has intrigued health professionals around the globe. According to occ-health experts, however, their field is just starting to reap the benefits of telehealth and telemedicine, which NASA defines on its web site as "the integration of telecommunications, computer, and medical technologies."
"In occupational health, the use of telehealth is just starting," says Susan A. Randolph, MSN, RN, COHN-S, FAAOHN, president of the Atlanta-based American Association of Occupational Health Nurses (AAOHN). Randolph, who prefers to use the term telehealth as opposed to telemedicine, because "this broader term includes a variety of overall disciplines" such as health promotion and counseling, says she has seen a greater application in the past five years or so.
John Shober, ASP, CHMM (certified hazardous materials manager), who heads his own employee health and safety consulting firm, CE2, in Greely, CO, agrees. "One of the problems I see as a whole is that we are still in the infancy of incorporating these telehealth applications," he notes. "This is a learning curve issue and, to a certain extent, also impacted by cost and [data] transmission rate."
Jonathan D. Linkous, executive director of the American Telemedicine Association (ATA), in Washington, DC, even uses a broad definition for telemedicine, encompassing "the delivery of information affecting patient care over long distance using telecommunications."
The potential applications are extremely varied and potentially limitless, he continues. "On the one end is remote robotic surgery," he notes. "Telemedicine encompasses everything from patient monitoring in the home to interactive communications between patients and physicians, to sending medical images out to radiologists — even continuing medical education."
Some of the barriers that may have prevented widespread use of telemedicine in the past seem to be falling, say observers. "In particular, in the field of nursing, the National Council of State Boards of Nursing has passed what was called the Nurse Licensure Compact," notes Randolph. "This allows nurses with a license in one state to use that license to practice in others; this has opened the doors in many cases." Each state has to pass its own nursing licensure compact, she notes. As of this writing, she says, 20 states have adopted such legislation, and seven more have introduced but not yet passed such legislation.
Case management is one area of occ-health in which this may have a significant impact, says Randolph. "You may be responsible for sites in a variety of different states," she notes. "Now, you may be able to talk to workers in all those states and provide assistance, either telephonically, electronically, or with other sorts of delivery methods."
Cost is seen as another potential obstacle to the implementation of telehealth applications, but it doesn’t have to be, says Linkous. "The costs of doing telemedicine have several key components: equipment, lines, and personnel," he notes. "Each of those has huge variations, depending on the applications. You could be talking about just a desktop video camera used over the Internet to connect to some therapist, and then you’re only looking at a couple hundred dollars. On other end, robotic surgery uses multiple redundancy T3 lines with cameras, and can cost several hundred thousand dollars. But depending on what you want to do, costs can be moderate."
What’s more, a good deal of the costs can be borne by the providers or vendors, notes Karen S. Rheuban, MD, medical director of the office of telemedicine at the University of Virginia (UVA) in Charlottesville. "There are several ways to approach [costs]," she observes. "You can deliver services on site at the employer end, or a second opinion can be obtained by sending the employee to a regional telemedicine center." In the UVA network, she notes, there are 47 such sites. "We are connected with community hospitals, local centers, rural clinics and prisons, so a patient in a rural community or with a rural employer can actually save long distance travel and prevent lost wages."
As far as fees, the system accepts a sliding fee scale based on the site used, plus Medicare and/or Medicaid reimbursement. "When it’s an occ-health case, the employer or insurer may be paying for the care as well," she notes, adding that consultation with a specialist costs the same as if the patient had gone directly to the specialist’s office. "We’ve also gotten a large grant in Virginia from Anthem Blue Shield to cover the non-insured for services," she adds.
Shober sees similar opportunities, especially in ergonomics. "Therein lays the opportunity to utilize a lot of the resources outside of your company’s skill sets," he asserts. "If you don’t have an in-house occ-health person or ergonomist, you can connect to one."
Applications virtually limitless
If you can imagine a given telehealth application, it most likely either exists or it soon will, given the wide variety of uses cited by the experts. "Second opinion clinical services can readily be delivered, especially when the employee is at a distance," notes Rheuban. "This can include face-to-face consultation, with the integration of electronic stethoscopes, ophthalmoscopes, ocular evaluation and other devices, as well as the incorporation of digitally acquired radiographic images, CAT scans, MRIs, and so forth."
Her system currently provides services in 25 different specialties and 24-hour availability of staff. "We do OSHA-mandated training for remote areas, and we also have the ability to provide training for corporate health care entities," she notes. "We have one relationship with a major corporation for CMEs."
"We use telehealth for nurse practitioners and others to extend our services to 14,000 faculty and students," notes Kathleen Golden McAndrew, MSN, ARNP, CS, FAAOHN, an AAOHN vice president and executive director, university health services, and adjunct professor, college of nursing and health sciences, at the University of Massachusetts, Boston. "We have a commuter population, and our staff has more than eight-hour work days, so we have expanded our services through technology."
Health services have become web-based, she reports. There are many interactive health promotion and wellness activities available on the web, as well as a virtual library full of health information. "We also have the ability to have Q&A on health, and assessments on smoking, depression, anxiety, and substance abuse using nationally standardized tools. These can be completed in the privacy of clients’ homes," she explains.
In addition, one of the nurse practitioners carries a departmental cell phone at all times. "Instead of getting locked up in voicemail jails, patients can talk directly with whoever answers the phone, and triage proceeds from there," says McAndrew. "Very often they do not have to be seen, but the nurse practitioner has electronic medical records and can pull up their chart on the screen." She adds that the department also is employing epidemiological telehealth applications. "We recently had a large influx of influenza; so instead of having people come in, they call the hotline so they don’t contaminate a lot of well people."
Patients also can go on-line and track their appointments, or set them up during hours the clinic is closed. "This has definitely enhanced patient care, and freed us up to do what we should be doing — hands-on health care," says McAndrew.
Randolph sees a number of case management applications being used. "If you have an injured worker in another state you are responsible for, you can look at various referrals, advise them, and touch base with the care providers about return-to-work prospects," she notes. "Also, some professionals may be doing some counseling through virtual clinics," Randolph adds. "Or people involved in sales or on travel status may be able to check information through the Internet. A good deal of health promotion information can be shared as well."
More growth seen
The experts see nothing but growth ahead, both in their own practices and in the industry in general. "I think we will be using telehealth to assess workplaces for ergonomics," says Shober. He specifically envisions using store-and-forward video technology. This involves videotaping a job task, for example, and forwarding the tape via teleconference and reviewing it. "This way, you can locate problem tasks and movements and then formulate a solution," he suggests.
Shober also envisions using computers, software, and sensors to create marker sets that show how movements can be altered to prevent injury. "You can also use virtual reality for 3D modeling for designing workplaces," he posits. "We hope to do more and more," McAndrew says. "We’ve ordered laptops for all the nurse practitioners so they can do patient education, store libraries of pictures, access health education on the web, and look at all of this together with their patients, including evidence-based outcomes so the patient can make more informed choices."
For her part, Rheuban sees "broader deployment, cheaper costs, and more accepted reimbursement by more of the payers."
Shober predicts, "We are on the cusp" of significant growth. "As cable communications and fiber-optics continue to be installed, it will increase bandwidth to smaller companies."
"Currently, the largest use of telehealth is for remote imaging, X-rays, and pathology," notes Linkous. "Occupational health will have future growth based on what the patients do and what they need. Right now, what’s growing is anything from dermatologists looking at skin rashes to psychiatrists doing consultation. The integration of telemedicine with occupational therapy and physical therapy is growing."
In fact, he notes, his organization has a new special interest group called telerehabilitation, which involves vocational rehab with two-way video, home assessments, and a mobile rehab facility. The bottom line, says Linkous, is that future growth of telehealth will be dictated by these drivers:
[For more information, contact:
• John Shober, ASP, CHMM, CE2, Greely, CO. Telephone: (970) 330-8360. E-mail: firstname.lastname@example.org.
• Karen S. Rheuban, MD, Medical Director, Office of Telemedicine, University of Virginia, P.O. Box 800711,Charlottesville, VA 22908. Telephone: (434) 982-3635. Fax: (434) 982-1415. E-mail: email@example.com.
• Kathleen Golden McAndrew, MSN, ARNP, CS, FAAOHN, Executive Director, University Health Services, Associate Adjunct Professor, College of Nursing and Health Sciences, University of Massachusetts, 100 Morrissey Blvd., Boston, MA 02125-3393. Telephone: (617) 287-5666. Fax: (617) 287-3977.
• Jonathan D. Linkous, Executive Director, American Telemedicine Association (ATA), 910 17th St. N.W., Suite 314, Washington, DC 20006. Telephone: (202) 223-3333. Fax: (202) 223-2787. E-mail: firstname.lastname@example.org.
• Susan A. Randolph, MSN, RN, COHN-S, FAAOHN, President, AAOHN, 2920 Brandywine Road, Suite 100, Atlanta, GA 30341. Telephone: (770) 455-7757. Web: www.aaohn.org.]