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Monday, March 28, 2011

Telemedicine Big-City Specialists Connect with Rural Patients


Telemedicine connects big-city specialists and rural patients

Monday, March 28, 2011

On the top floor of St. John's Mercy Medical Center, doctors and nurses watch banks of video feeds, peering in on intensive care patients at rural hospitals across the Midwest.
Two critical care doctors and nine nurses in the St. Louis area oversee more than 400 patients at St. John's Mercy and a dozen other hospitals in four states. In round-the-clock shifts, they scan patients' vital signs and review their medications, lab work, X-rays and medical records. They conduct real-time quality control audits to ensure best practices are being followed.
From this control room, they can operate high-resolution cameras mounted in doorways of patients' rooms — and even zoom in to examine a patient's eyes or wounds. With two-way cameras, they talk directly with rookie nurses at the bedside of patients — or consult with patients themselves — at far-flung hospitals in places like Independence, Kan.
"We help save lives," said Lisa Manion, who worked as an intensive care unit nurse for more than a dozen years before joining the Mercy SafeWatch Center, one of the nation's largest teleICU units. "We do catch some things that the (bedside) staff, who are overworked, may not catch in time."
St. Louis area hospitals and health care systems based in the region are increasingly taking advantage of "telemedicine" — the use of computers and telecommunications to connect big-city hospitals to often underserved rural areas, where specialty doctors are scarce. Besides electronically monitoring the intensive care units of remote hospitals, such technologies are also being used to link specialists with patients, including stroke victims and women with high-risk pregnancies.
Telemedicine is hardly new. Major hospitals on the East and West coasts have capitalized on these communications devices in recent years, and specialists practicing in rural areas of Missouri and Illinois have relied on telemedicine for more than a decade for their consultations with remote patients. But it's a relatively new phenomenon in the St. Louis area, where specialists affiliated with the Sisters of Mercy Health System, SSM Health Care, BJC HealthCare, and Washington University have begun using these communications technologies to reach out to outlying areas.
joystick medicine
At Parkland Health Center in Farmington, Mo., a robotic device on wheels helps on-call specialists in St. Louis quickly interview patients who have suffered a stroke.
The stroke specialist uses a computer with a joystick to drive the robotic two-way video system down the hallway to the patient's room in the emergency department. Talking directly with the patient through the video monitor, the specialist performs a neurological exam to determine whether blood-clot busting drugs need to be administered and whether the patient should be transferred to Barnes-Jewish Hospital, also part of the BJC HealthCare system.
The patient is asked a series of questions to assess brain function and ability to speak and also asked to describe a series of still images on the video monitor. The patient's physical abilities and reflexes are also assessed with a nurse's help.
"The technology has gotten so much better and so much cheaper over time," said Dr. Karen Edison, director of the Center for Health Policy at the University of Missouri. "We really see this as the future: taking health care to patients wherever they are."
Edison, a dermatologist and medical school professor, began using video teleconferencing to serve remote patients in 1995. Many of her colleagues — including specialists in cardiology, psychiatry, neurology and those who attend to children with special needs — are also using these methods to consult with patients.
In recent years, the financial barriers for telemedicine have crumbled. Medicare and Medicaid reimburse doctors the same basic rate for in-person patient care as a video conference with a remote patient. Private payers, including health insurance companies, large employers and health maintenance organizations, also pay for many telemedicine services.
"It's a much more patient-centered way of bringing health care to people in rural areas, patients where they live," Edison said. "People can't always leave their homes. A lot of people work in low-wage jobs. ... If we can use technology to keep people in their homes and healthier longer, we should do it."
black boxes
Edison and other health experts say telemedicine helps deliver a valuable form of preventative care that, although it requires an investment in new technologies, could save the U.S. health system huge sums of money by preventing hospitalizations.
"It's our opinion that it will save money by providing more quality care. And by improving quality, you reduce cost," said Dr. Tim Smith, vice president of research for Mercy's Center for Innovative Care. "We have to be better at being innovative and trying to find better ways to deliver care."
He said that although health care providers may spend more money up front on telemedicine equipment and nurses' time, the costs are minuscule compared with emergency room admissions, intensive care visits, prolonged hospitalizations and nursing home care.
He said that many of those served in rural areas are Medicare and Medicaid patients, and a lot of federal and state dollars go toward long-term hospitalizations.
The Mercy system recently won a $495,926 federal grant that will enable the hospital chain to begin installing medical monitoring devices as well as "tele-home" converters in 900 patients' homes in small towns in southwest Missouri and northwest Arkansas.
The monitoring devices can record the daily readings — such as blood sugar, breathing levels, body weight and physical activity — of patients with chronic illnesses or conditions such as asthma, diabetes, emphysema and congestive heart failure.
The converter boxes transmit these daily readings to a doctor's office. If, for instance, a patient's readings are subpar three days in a row, it might warrant a call from the doctor's office. If no readings are recorded, it might also prompt a call from the doctor.
"It's a way for us to reach out to a patient in their homes in a less obtrusive way than calling a patient every day or sending a nurse there," Smith said. "And the more engaged a patient is in their own health care, the more likely they are to be adherent to good health priorities like diet, health and exercise."
improved images
Dr. Jim Bartelsmeyer, director of maternal fetal medicine at St. John's Mercy, began using video teleconferencing two years ago for his consultations with women who have high-risk pregnancies.
SSM's "teletouch" program, which began last year, uses video streaming to enable maternal fetal specialists at a control center at St. Mary's Health Center in Richmond Heights to examine patients and review their "Level 2" ultrasounds at community hospitals in Rolla, Mo., Breese and Maryville.
"The moms appreciate not having to come into the city," said Susan Staub, executive director of SSM's maternal and pediatric services. "Telemedicine is becoming much more acceptable because the images are so much better than they used to be."
Surgeons also have used video technologies to consult with rural patients about their post-operative recoveries and examine their wounds.
Meanwhile, some health providers are using "telemobile" services to send messages to the computers and cell phones of diabetic teenagers about the benefits of good diet and exercise.
By offering specialists' services remotely, telemedicine also is saving the state money by decreasing the transportation costs of inmates sent to off-site medical clinics.

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