LMS President’s Message, September 2018
Tuyen T. Tran, MD, MBA
One of the major challenges in healthcare is reconciling the tremendous gap in patients’ access to physicians. This is particularly true for our patients who reside in Eastern Kentucky. The Appalachian Regional Commission recently issued a very somber report showing that the Appalachian region has significantly higher mortality rates, increased incidence of heart disease, cancer, diabetes, depression, and more health risk factors (obesity, smoking, fewer physicians, drug use) than the rest of the country. More concerning, Eastern Kentucky has even higher morbidity and mortality. (See Figure 1 for comparison details.)1 Although there are many contributing factors to the access gap, physicians can positively impact the access problem by incorporating telehealth modalities into their practice.
Understandably, there are many doubting Thomas who want to know if there is any legitimacy to telehealth. AHRQ (Agency for Healthcare Research and Quality) recently conducted a diligent systematic review to examine the value of telehealth and remote monitoring of patients with the intention of expanding access to care and contain costs. (Senators Bill Nelson and John Thune requested the study.) The study reported improvements in outcome metrics such as mortality, quality of life, and reductions in hospital admissions. These benefits were consistently noted for counseling or remote monitoring of chronic conditions such as cardiovascular and respiratory disease. The authors recommended future research to broaden implementation and address barriers.2
Telehealth is collection of modalities which incorporates information and communication technologies to deliver healthcare services and public health remotely. There are four major categories:
1) Clinical Video Telehealth (CVT, Live Video, synchronous): This is real-time, remote, two-way interaction between physician and patient using audiovisual telecommunications technology. With the aid of specific equipment (see Figure 2) located at the patient site, the physician can conduct a limited exam of the patient. (To facilitate discussion, the encounter is traditionally described as Physician site and Patient site.) A technician and equipment such as the one shown in Figure 2 will reside at the Patient site. At the Physician site, there is a typical computer, a monitor (two are recommended), and a headset. The technician, located at the Patient site, will place the electronic stethoscope at the appropriate positions on the patient for the physician to remotely auscultate the heart and lungs. The technician has a small mobile camera (size of a small microphone) with 4K resolution which will allow physicians to visually inspect various body parts to include otoscopic and oropharyngeal cavities. And of course, there is live audiovisual interaction between the physician and patient. In addition to the diagnostic capabilities, this modality also facilitates consultative encounters. For example, the physician, located in Lexington, wants to discuss a very complex treatment plan with the patient located in Eastern Kentucky. But the patient wants to involve the daughter who is in Florida. Simply incorporate all members into a videoconference call. (To avoid security and HIPAA issues, establish a secure virtual room and only allow invited members to join the virtual conference room. The VA has created such a structure, called VA Video Connect.)
2) Store-and-Forward Telehealth (SFT, asynchronous): This is transmission of recorded health information such as pre-recorded videos (Echo, Ultrasound, gait analysis, neurologic exam) , digital images such as radiographs (X-Rays, CT, MRI, retinal scans), and photographs (skin lesion, rash, wounds, chronic ulcer monitoring) through secure electronic communications to a remote physician for evaluation. The value of this modality is analogous to text messaging. The patient, at his/her convenience, arrives at the Patient site for the technician to capture the respective video, image, or photo. The physician, located remotely and at his/her convenience, can review the transmitted health information to provide diagnostic and treatment recommendations.
3) Remote Patient Monitoring (RPM): This modality facilitates convenient and accurate collection of personal health and medical data which is transmitted via secure electronic communications to the provider. Depending upon the need, there are wearable devices for monitoring heart rate, blood pressures, EKG tracings for dysrhythmias, and even implantable devices for monitoring CVP in patients with severe heart failure.
4) Mobile Health (mHealth): This modality essentially supports communication between physician and patients using any device (cell phone, tablets, computers, PDA’s). Think “Facetime.” Obvious uses include quick follow-up with patients when you need to see something. Office staff can conduct medication reconciliation and see the medication bottles instead of guessing what the yellow pills are. Office staff can triage the patients more appropriately with visual aid, “No, please go to the Emergency Room for that.”
There are several major barriers to the implementation of telehealth. First, there must be adequate bandwidth to support this technology. High-speed internet is a struggle in large cities such as Louisville and Lexington. The infrastructure is sadly inadequate in rural Kentucky. While waiting for the development of internet infrastructure throughout Kentucky (please do not hold your breath), physicians can creatively partner with local businesses that already have internet access. For example, we can negotiate with the local Walmart, Rite-Aid, or CVS Pharmacy to provide medical services remotely. (These businesses are already contemplating on providing Urgent Care or Walk-in clinics.) Second, there are inherent technical, financial, HIPAA, and security issues (malicious viruses and hacking) which will require standardization and solutions. And finally, reimbursement for telehealth services will need attention. Dr. Alvarado has successfully introduced SB 112 – Telehealth Services which will require equivalent reimbursement of telehealth visits to face-to-face visits. This is a huge step for successful implementation of telehealth. Now, physicians need to assist our legislators with drafting proper regulations to prevent over restriction of our ability to practice.
Telemedicine is upon us. We can choose to view this new method of healthcare delivery as a challenge or opportunity. Regardless of our choice, the future practice of medicine will involve the use of telehealth. Kaiser Permanente reported that over 52% of their visits are via telehealth. Contrary to current myth that telehealth visits are for the easy runny noses, most of the benefits as evidenced by quality metrics are from management of complex chronic diseases. And with threats such as increasing numbers of older patients who will most likely have more chronic illness, significant physician shortage forecasts, and rising cost of healthcare, the gap to healthcare access in Kentucky will worsen.
1Health Disparities in Appalachia. Marshall et al. Appalachian Regional Commission. https://www.arc.gov/research/researchreportdetails.asp?REPORT_ID=138 Published August 2017. Accessed August 15, 2018.
2Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. Totten AM, Womack DM, Eden KB, McDonagh MS, Griffin JC, Grusing S, Hersh WR. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Jun.