E-health grows gradually despite roadblocks
E-health grows gradually despite roadblocks
Telemedicine projects increase patient care
In the not-too-distant future, you may say goodbye to a patient in one examining room and walk into another room and examine a patient who is 300 miles away, using a computer and an ordinary telephone line while being assisted by a nurse you’ve never met in person.
Or you may get an e-mail alert that one of your congestive heart failure patients needs a change in medication or should be scheduled for an office visit.
These scenarios aren’t just 21st century pipe dreams. They are happening now in demonstration projects across the country:
In Kansas City, KS, children in 11 elementary schools routinely are "seen" by a doctor through telemedicine equipment in the school nurse’s office.
Through interactive video technology, 40 Southfield-based Hospice of Michigan in patients can have face-to-face, real-time interactions 24 hours a day with their clinical team that may be hundreds of miles away.
Rural and inner-city residents in New York state will soon be treated for diabetes through a telemedicine project funded by a $28 million grant from the Health Care Financing Administration. (For details on the telemedicine projects, see related articles, pp. 107-109.)
"We don’t think that telemedicine is going to be the answer to everything. It’s not going to replace face-to-face contact and the real relationship between patient and doctor. But we do think it will revolutionize medicine," says Steven Shea, MD, Hamilton Southworth Professor of Medicine in Public Health at Columbia University College of Physicians and Surgeons in New York City. He also is director of the division of general medicine at Columbia Presbyterian Medical Center of New York-Presbyterian Hospital, also in New York City. Shea heads up the hospitals’ IDEATel project to provide diabetes management in economically disadvantages areas of New York state.
Telemedicine literally may prove to be lifesaving for patients who live in rural or low-income areas where they have limited access to health care.
"Patients who live in an urban area don’t necessarily have access to transportation. Or they may be able to get to the hospital but not to the doctor’s office. Providing care is a real challenge in urban areas, as well as in economically disadvantaged rural areas," says Pam Whitten, PhD, assistant professor of telecommunication at Michigan State University in East Lansing and lead researcher on the Telehospice Project of the Hospice of Michigan.
In addition to its hospice project, Michigan State is starting a home health project for patients with chronic pulmonary obstructive disease and congestive heart failure.
Telemedicine technology has the potential to help patients participate more effectively in self-care for chronic diseases such as diabetes, asthma, and depression, Shea says. It can give the patients access to information when they need it and not when it’s convenient for the doctor of the nurse, he adds.
"We hope the new technology is going to lower the cost and improve the quality of care and do it in the way that patients like and health care providers like. It could be a win for everybody," Shea says.
Doctors already are under tremendous pressure to move patients through their office, and it’s often difficult for patients to come in for office visits, particularly when it’s for a blood pressure or blood sugar check for a chronic disease.
"We think that patients want to be able to interact with doctors without coming to the office. It’s very inconvenient for them to take time off from work and sit in the waiting room," he says.
When a physician practices medicine through video conferencing, he or she will still get a history and physical, ask the same questions, and do the same steps necessary to make a diagnosis. "We are emphasizing the empowerment of patients but it doesn’t mean that health care providers are going to stop providing care," Shea says.
The difference will be that the physician will need a trusted proxy to move the stethoscope or other equipment, Whitten points out. "In some ways, delivering care via technology is not such a radical change in how health providers give care. Larger issues, such as liability and confidentially issues and how to handle licensure, are going to be bigger issues in how physicians will provide care."
The Center for Telemedicine and Telehealth at the University of Kansas Medical Center in Kansas City is involved in a number of tele-medicine projects in various clinical practices, says David Cook, PhD, acting director of the telemedicine center. Most of the patients are in remote areas and physicians rely on local nurses to assist in the examination, he says.
"In telemedicine, the nurse is the doctor’s hands in the process, and they have to develop a rapport and trusting relationship," Cook says.
One roadblock to the future of telemedicine is funding. Third-party payers tend to be reluctant to cover telemedical treatment, and when they do, the reimbursement structure isn’t realistic.
Michigan State has gotten approval from some payers, including Medicare and Medicaid, to reimburse some telemedicine programs, but the reimbursement has been sporadic and unrealistic, Witten adds. "We can come up with the tools to provide e-health, but if nobody will reimburse for it, we’re not going to be able to provide care that way."
"The bottom line is that while reimbursement is so piecemeal, providing care by telemedicine is more challenging than it should be," Whitten says. Some projects are not as far along as predicted because they are constrained by the reimbursement structure, she adds.
The Telehospice Project doesn’t have such problems because the Hospice of Michigan is reimbursed on a per-diem basis to care for hospice patients at home. The program makes it possible for the hospice to provide more care at the same cost, she adds. "A lot of people think that in a capitated environment, telemedicine makes a lot of sense. If you can access people more frequently and cheaply and keep them healthier, you can save yourself some money in the end. People think that’s where telemedicine will really shine," Whitten says.
Since telemedicine is still in its infancy, researchers have a lot to learn, Shea says.
"When taking care of chronic patients, we don’t know the right mix of self-care, electronic interaction, or office visits. We do know that patients want it and doctors are prepared to use it. But there are questions about whether insurers will pay for it or should pay for it. The only way to find the answers is through carefully experimental research," Shea says.
Setting up a telemedicine program requires so much behind-the-scenes work that it’s not practical for an individual physician practice to consider it at this time, Cook explains. "A successful telemedicine program needs to have a dedicated group of people to champion it. It’s not about a doctor who says he wants to connect with a nurse. You have to have a group of people who have the time to build relationships. Physicians don’t have that kind of time."
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