By Mark Olshaker
The costs of care at a distance
Telehealth has become a widely accepted and important component of the overall healthcare structure in the United States.
The Harry and Jeanette Weinberg Foundation of Owings Mills, MD, made a grant of more than $1.3 million to the Westchester Public-Private Partnership for Aging Services to support the Telehealth Intervention Program for Seniors (TIPS) that provides health-monitoring services at 15 community sites in Westchester County, NY (ten locations), and Lackawanna and Wayne Counties, PA (five locations). The foundation is dedicated to aiding the larger field of aging through investment in technology by connecting older adults with supports and services, monitoring health and maintaining independence. Other philanthropic organizations are coming on board to see how Telehealth can enhance affordable and senior residential living and aging in place.
It also has become big business. Cisco, through its Healthcare Business Transformation Team, is investing heavily in what it terms “care at a distance,” with the aim of: reducing costs, improving patient services, avoiding hospital readmissions and associated Medicare reimbursement penalties, providing improved access to specialists, educating patients and expanding the geographic footprint of client hospitals, other healthcare organizations and residential properties.
Telehealth has come a long way, but it is still very much a work in progress. In senior care and other aspects of affordable housing, it is becoming a major initiative in keeping people healthier and maintaining them in independent living longer.
“Mr. Watson, come here! I want you!”
– Alexander Graham Bell, March 10, 1876
Though there is some dispute over the exact wording of the first voice transmission by telephone, if one is to believe Thomas A. Watson’s account of the incident, Mr. Bell had spilled battery acid on his trousers and was requesting his assistant’s immediate help. If so, it may be considered history’s first application of Telehealth.
Before long, physicians were diagnosing diseases after having the symptoms described to them over the telephone. Decades before that, telegraph messages transmitted lists of sick, injured and dead soldiers during the Civil War, but this was merely informational – no medical action could be taken as a result.
By the early 1930s, organizations, such as Australia’s Royal Flying Doctor Service, were using radio communication to learn of medical problems and disease outbreaks and know where to dispatch its fleet of small airplanes. By the 1960s, the National Aeronautic and Space Administration was using telemetry to monitor the vital functions of astronauts, and most major American airports had direct links to at least one hospital in their areas for quick consultation about medically distressed passengers.
At the time, these services were generally lumped under the heading of Telemedicine, which was mainly related to remote diagnosis, monitoring and information sharing among medical personnel. Telehealth is the more modern term, embracing techniques and methodologies that not only diagnose and monitor but also prevent and treat medical conditions, as well as promote good health, exercise and nutritional practices.
Clearly, the dawn of the Internet age promised greater growth and expansion for Telehealth, and within that growth potential, the greatest factor has been increasing bandwidth, which means more data can be sent and received and a more robust infrastructure established, with a commensurate increase in reliability and economy.
The Current Scene
At present, there are four basic Telehealth modalities: Live, or synchronous; Store and Forward; Remote Patient Monitoring; and Mobile Health. But the range of services is expanding all the time.
Live video links can take the place of face-to-face meetings between a patient and doctor, nurse or other caregiver, and can save time and travel costs. Storing and forwarding data is now a common practice through which collected and recorded information is sent on to a care provider to be analyzed and acted upon. Remote patient monitoring is similar to telemetry in that a patient’s data can be evaluated on a continuous and real-time basis for any changes or progressions in a condition. This can be an important component of a rehabilitation program, for example, or keeping track of an elderly patient with a chronic condition. And mobile health refers to education, monitoring or care that is facilitated through the use of mobile devices, such as smart phones and table computers. This can include reminders of upcoming appointments, medicine schedules and protocols, or the conveyance of test results.
There is a growing body of evidence that when patients are involved or invested in their own health monitoring, they tend to adhere more closely to their treatment plans and take greater care of their own physical well-being. The flip side of this is the learning curve inherent in the use of digital programs and applications. For much of the population, this isn’t a major problem. But for the senior and elderly cohort, to whom much of the technology is directed, this can be a daunting hurdle. In fact, many companies that manage senior affordable housing and have invested in Telehealth for their residents say that educating them in how to use smart phone or table remote diagnostic or monitoring systems has been among their greatest challenges in implementation. Hopefully, as digital technology becomes more and more transparent, user friendly and voice command responsive, this will become less of a problem.
An Instructive Example
The medical field in which Telehealth has made the greatest strides is radiology, and it is therefore the best place to drill down into the realistic capabilities and the significant challenges that lie ahead for the future of Telehealth in all fields.
By the late 1990s, with the common use of such innovative technologies as ultrasound and CT, or CAT (computerized axial tomography) scans, it became possible to transmit high-definition digital images in large volumes via phone lines and then the Internet, and teleradiology came into its own. It was now possible for radiologists to read studies from remote computer workstations, specifically designed to give them the same quality images and ways of working through them as they had in their hospital departments.
It is also interesting to note that one of the first practical applications of voice recognition technology was in radiology. The field was perfectly suited to this application in that the program would be working with a limited population of voices, a consistent technical vocabulary, and short, direct sentences. Reliable voice recognition made radiologists much more efficient, able to dictate their readings in real time rather than having to handwrite or type their reports.
Recognizing the new technological capabilities, a group of radiologists in Coeur d’Alene, Idaho, figured out the next new thing and formed NightHawk Radiology. The idea was based on the reality that hospitals need radiologists on call 24 hours a day, particularly for emergency room and ICU cases in which attending physicians could not wait for morning to get a result.
Rather than having to have radiologists on-site or on call nearby overnight at a huge cost, NightHawk hired and outfitted a group of radiologists in Australia, where it was daytime while it was night in America, who could service numerous hospitals at a time. The idea caught on and NightHawk became a huge business success, followed by other companies setting up shop in Australia, India and other countries.
There were two large conditions, however, attached to this practice. First, the radiologist reading the imaging study had to have American medical licenses, regardless of from where they were reading, and they could only perform “wet readings,” meaning looking at the study and giving an instant diagnostic opinion. The official, final written report had to come from a radiologist on-site or attached to the hospital.
Now, remote radiological analysis includes final reports, but again, with two common conditions mandated by Medicare, Medicaid and various other payees: The reading doctor must be physically within the United States, and he or she must be licensed in the state in which the hospital, clinic or physician’s office is located. This was considered necessary to prevent a wholesale move of the radiology discipline overseas to more economically attractive locations, like India or even China.
And this brings up issues that affect the entire field of Telehealth and are still being worked out. If a patient “visits” or consults with a doctor remotely rather than physically in the office, should the doctor have to be licensed in the state where the patient lives, or merely in the state in which he or she practices? Many similar types of questions are still to be resolved as Telehealth matures.
Going one step farther, it is easy to see that the future of Telehealth will evolve from where it is now in consultation, monitoring and diagnosis into actual procedures and complex surgeries. For example, the da Vinci Surgical System developed and marketed by Intuitive Surgical, Inc. of Sunnyvale, CA, is a robotic apparatus that features a magnified 3D high-definition monitor and precision instrumentation that can bend, rotate and operate with far greater exactness than the human hand. So the system translates the surgeon’s hand movements into the manipulation inside the patient’s body. This allows for smaller incisions, less bleeding and collateral trauma and faster recovery. At present, the system is operated from the surgeon’s position close at hand.
But it is not difficult to envision in the near future a time when a da Vinci-like system could be operated from anywhere. This would mean that for surgical procedures for which da Vinci is designed – which currently include certain cardiac, colorectal, general, gynecological, head and neck, thoracic and urological procedures – a highly experienced, specialized surgeon could operate on anyone from virtually anywhere. As is often the case, the technology is ahead of the regulatory response. HIPAA (Health Insurance Portability and Accountability Act of 1996) patient privacy requirements will also present more of a challenge. Will we have to change malpractice liability standards or insurance?
This, in turn, points to a significant philosophical question as Telehealth technology advances: Is this brave new world all a good idea or the best standard of care? Many primary care physicians argue that there is an intangible or not easily measured benefit in person-to-person contact that cannot be replicated through remote consultation. In this era of increasing depersonalization, doctors are often able to pick up nuances and establish a better relationship with their patients if they can see them face-to-face and practice the ancient ritual of the laying on of hands. Does a senior who already suffers from a sense of loneliness and isolation actually benefit from a remote consultation? Will a machine cure an individual’s depression?
With the costs of healthcare what they are, combined with ever-increasing technology, there is tremendous pressure on the industry to cut costs wherever possible. And this has led to cutting out the human being wherever possible. Just as computer programs, like Dragon, have obviated the need for human transcriptionists in radiology, will the radiologists themselves one day be replaced by computer programs? Instead of a hospital needing a team of radiologists, will it soon need only a network of computers with every possible disease or condition programmed in and only need a single human radiologist to supervise all readings and make a judgment on rare ambiguous cases?
In sum, Telehealth can be of tremendous benefit toward expanding healthcare and making it more efficient . . . as long as it doesn’t ultimately forget the needs and values of the actual human beings on each end of the stethoscope.