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While not cheap to implement, telerehab can result in cost savings
It’s a standard topic of grumbling among administrators and physicians alike: Too often, consumers pick convenience over quality when choosing a doctor or hospital. Patients rarely are willing to drive more than 15 minutes for a visit — an important factor when you consider the multiple visits many rehab patients require for outpatient therapy.
But lack of proximity can be overcome with technology, as many rehab managers are finding out. Increasingly, managers are turning to telemedicine as a way to reach patients in rural communities who otherwise would not have the time, means, or inclination to travel for therapy sessions.
Consider the benefits telemedicine can offer:
• improved relationships with referral sources in rural communities;
• an opportunity to reach patients in rural communities who don’t have ready access to rehabilitation expertise;
• increased access to patients from nearby communities for outpatient treatment after their discharge from the hospital, or for ongoing educational needs for patients with chronic conditions like arthritis;
• improved communication between therapists and other providers at satellite facilities or those employed by affiliate institutions;
• in some cases, improved patient satisfaction.
Two trends regarding telemedicine in rehab are clear. First, the industry leaders are instituting telemedicine programs. The Rehab Institute of Chicago, the National Research Hospital in Washington, DC, Shepherd Spinal Center in Atlanta, and others that are highly regarded in the field all have telemedicine programs in place or are in the process of starting them.
Second, although rural telemedicine is in its infancy, it is expanding quickly. Based on the latest data available — a February 1997 study conducted by the U.S. Department of Health and Human Service’s Office of Rural Health Policy, Exploratory Evaluation of Rural Applications of Telemedicine:
• Nearly 30% of rural hospitals were using some sort of telemedicine technology to deliver patient care by the end of 1996.
• Orthopedics is the third most common clinical application of telemedicine, finishing behind radiology and cardiology.
• The cost of telemedicine remains high. Average equipment purchases for hospitals surveyed ranged from $134,378 for spoke sites (affiliate institutions) and $287,503 for hub sites (the main institutions providing the centralized transmission, hardware, and software) — and that’s not including costs for switches and telephone lines. Reported annual transmission costs ranged from an average of $18,573 for spokes and $80,068 for hubs.
But don’t let the costs stop you from investigating the possibilities of telemedicine, says Logan Ludwig, PhD, director of the health sciences library, media services, and telehealthcare for Loyola University in Chicago. Lots of grants are available to assist institutions with start-up costs, he points out (see related story on p. 55 for more information on grant opportunities). Although costs vary widely depending on an institution’s needs, Ludwig recommends that medical facilities use a system with a minimum of 384 kilobytes in order to get a sufficiently sharp image resolution.
In addition, telemedicine can be looked at in terms of its ability to defray costs and even as a revenue generator, Ludwig and others tell Rehab Continuum Report. Often, a patient is more likely to come back for a follow-up visit with a therapist, for example, if he or she can drive 10 minutes to a local hospital with a telemedicine link to your institution instead of spending one hour driving to your facility. If your institution conducts inter-departmental meetings between satellite facilities, telemedicine can save staff members the travel time commuting between institutions.
Ludwig says the costs of instituting a telemedicine program don’t necessarily outweigh the costs of staff travel, if your utilization is high enough. Loyola has instituted telemedicine programs through multiple affiliations with other providers for this reason, he says. The more the system is used, the more per-unit costs go down.
In addition, the costs associated with staff travel lie not just in transportation fees, but in the lost revenue physicians or therapists could be generating if they were seeing patients at the hospital instead of traveling.
Loyola is one of several educational institutions interviewed by Rehab Continuum Report that are participating in tele-rehab. Although the facility has previously used its telemedicine capabilities for communication between physicians and specialists or videoconference training of students, Loyola recently entered an alliance with the Rehab Institute of Chicago and Southern Illinois Healthcare, located 400 miles south of Chicago.
The telemedicine project — which should be up and running by June — will allow the Rehab Institute of Chicago and Loyola to provide community education seminars to patients in rural Chicago on topics such as preventing lower back pain and other job-related injuries, says Joanne Smith, MD, senior vice president and chief operating officer of the corporate partnership division of Rehab Institute of Chicago. In addition, the project will allow physicians in Chicago to share leading-edge technology with nurses and other clinicians employed in the inpatient rehab unit of Southern Illinois Healthcare.
Provider education also is an important component of the Mid-Nebraska Telemedicine Network, funded through a $1.4 million grant from the U.S. Office of Rural Health. In one case, an occupational therapist at Good Samaritan Hospital (the hub institution) in Kearney, NE, did a telehealth consultation with a patient who was about to be discharged and therapists at a hospital in nearby Cambridge, where the patient was to receive outpatient care following discharge from Good Samaritan.
"The occupational therapist demonstrated to the Cambridge folks the exercises she was asking the patient to do, and also asked the patient to actually perform the exercises on-camera," says Wanda Kjar, RN, interim director of the Mid-Nebraska Telemedicine Network. By seeing the patient perform the exercises, the rural health care team was able to get a more accurate assessment of the patient’s condition and areas she specifically needed to work on, Kjar says.
At the University of Texas Medical Branch at Galveston (UTMB), the rehab department uses a team approach in its telemedicine project, which allows caregivers to treat hundreds of youngsters in rural and medically underserved areas in east Texas. The program — a collaborative venture between UTMB, Lamar University, and Stephen F. Austin State University — was recently awarded a $1 million grant from the Texas Telecommunications Infrastructure Fund Board.
The entire provider team — including UTMB physicians, nurses, dieticians, occupational therapists, physical therapists, social workers, and speech pathologists — is present for every exam, says Kim Conner, a pediatric occupational therapist at UTMB. "This allows us to be sure that we’re all on the same page, reducing the chance for miscommunication by the patient, the parents or the caregivers," she says.
UTMB’s pediatric project, established five years ago, allows pediatricians and other providers to work with chronically ill patients. "We work with children who are technologically dependent or have other chronic physical and mental conditions," says Sally Robinson, MD, professor of pediatrics and chief of the special services division of UTMB. "We see kids who need ventilators or respirators to breathe; kids with spina bifida and cerebral palsy and other neuromuscular disorders; kids with traumatic brain injuries, metabolic disorders or feeding problems. It’s really difficult for parents to travel back and forth with these kids who are hooked up to all kinds of equipment."
Because children and elderly patients often are so tired from long trips to providers for rehab that they cannot perform exercises effectively, using a telemedicine program can provide an added benefit in a rehab setting, says Cathy Wasem, MN,
RN, director of the telemedicine and telehealth programs at the Rockville, MD-based Office for the Advancement of Telehealth. "Are you really getting your best evaluation when the child has had to travel two or three hours to see a specialist?" she says. "The trip can be taxing. Once the patient gets there, he or she may not be at their best or able to react in the normal way."
Patient satisfaction with the telemedicine process is high at Good Samaritan, Kjar says. "We’ve had something like 19% to 27% [of patients] tell us that they actually like this encounter better than seeing the doc in person," she says. "We decided that’s because in telemedicine, you often have all your caregivers in the room at the same time. And after a while, the TV goes away. You’re talking to the person, and it’s just like being there with them."
More than 3,000 patients have been treated through telemedicine since it was implemented in December 1995, Kjar says. One such offering is the arthritis program, which includes a monthly support group for patients and individual patient and provider consultations, says Janet Reise, RN, Good Samaritan’s arthritis coordinator. "Our primary and secondary market is over 200 miles," Reise explains. "My patients really like it because they don’t have to travel. And because it’s done under a grant, there is no charge to them [for visits]."
Kjar says she believes the telemedicine efforts also have brought in additional revenue through increased referrals from clinicians and other clinicians. "[Referring] physicians are sometimes fearful that once they refer a patient, the patient never comes back. By telemedicine, you can keep the patient in their hometown facility, and even allow the physician to take part," Kjar says. "And it builds confidence in our clinicians once physicians and nurses see them in action. They feel more comfortable with us."