2 sides of telemedicine implementation:

Dec. 19, 2013
Clinical users

One of the biggest drivers for telemedicine has been radiology. Radiology was the first department in most hospitals to go electronic with the implementation of dictation through speech recognition software, PACS (picture archiving and communications system) and RIS (radiology information system). This helped to lead the change to digitize records in healthcare by going from printed images to electronic images. Nowadays, a radiologist typically spends most of his or her day in front of a PACS workstation, working off an electronic list of patients managed by the RIS and reviewing and dictating digital images using speech recognition software.

Radiology private practices were among the first to implement telemedicine. In fact, a small hospital that needs a group of 24/7 radiologists may hire an off-site radiology private practice. The hospital acquires images from on-site MRI/CT scanners, sends the images electronically to the private practice and the private practice sends the finalized report back to the hospital. There has been tremendous progress on the initial headaches of integrating multiple modalities and IT systems by the introduction of HL7 and DICOM standards.

One of the recent advancements in telemedicine has been image sharing in radiology. The Radiological Society of North America (RSNA), supported by an NIBIB (National Institute of Biomedical Imaging and Bioengineering) grant, has led the implementation of an Image Share network to enable radiologists and hospital personnel to share medical images with patients and between institutions. The image-sharing network has been a tremendous success, integrating tens of vendors to work together as personal health record (PHR) systems, and is currently in place at several large health systems: Mayo Clinic, Mount Sinai Medical Center, University of California San Francisco, University of Chicago Medical Center and University of Maryland Medical Center. Additionally, several startups are pushing the technology to “upload images” further by enabling patients to get second opinions on their medical images from the doctors of their choosing online.

Getting personal

It is apparent that the future is bright for personalized medicine, which may serve as the primary driver of technological advances in telemedicine. EMR systems are making progress on making their systems more available for a different kind of end-consumer: the patient. Epic’s myChart is a great example of how a patient can be better kept in the loop and have access to their health data.

Another angle set to play an increasing role in personalized medicine is the ability for patients to feed personal health data directly into the EMR. For example, some EMR systems are starting to enable fitness tracking devices to electronically submit information into the patient’s digital record, and there are emerging start-up companies that are enabling patients to submit information via their mobile devices. There are a number of companies that are part of these mHealth (mobile health) initiatives and accomplishing various goals, from reminding patients to take their pills to taking videos of patients as part of social work assessments. 

Lastly, telemedicine is transforming the internal and external communications in healthcare environments. Critical result management systems (CRMS) enable physicians within a hospital to better communicate life-threatening and incidental findings and ensure follow-up. It is natural for these systems to go outside a hospital and be part of a healthcare information exchange (HIE) or more. Video teleconsultation systems such as REACH, displayed by Johns Hopkins at the RSNA 2013 conference, enable any two parties, such as a radiologist and a clinician, or a radiologist and patient, to have a face-to-face conversation with each other while looking at the same stack of images. Such state-of-the-art systems are spreading rapidly throughout academic institutions and appear poised to expand more broadly in healthcare in the near future.

The future for telemedicine and personalized medicine is exciting, with empowered patients that have better access to their health information and advanced technologies that enable better collaboration between physicians – and with the ultimate goal of enhancing patient safety and outcomes by delivering more efficient and better quality healthcare.

Gorkem Sevinc, MS, CIIP, is systems development manager and research associate, Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medical Institutions, and CTO, Radiology Response.
Paras Khandheria, M.D., is resident physician, clinical informatics fellow, Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Medical Institutions.

Solutions providers

Telemedicine undoubtedly will be an integral part of future healthcare delivery models – in fact, it may become the predominant mode of care delivery. Also called telehealth, telemedicine allows for more effective and efficient ways for doctors and other healthcare providers to treat patients and improve health outcomes. Telemedicine is not only more convenient for patients and their caregivers, but it enables patients to receive specialty care much more quickly than traditional modes of healthcare delivery. 

While the opportunities for enhanced outcomes and reduced costs are tremendous through telemedicine solutions, obstacles remain. How can providers overcome the barriers to telemedicine use, choose the right system and gauge its success? 

Top roadblocks to adoption and implementation include limited or absent reimbursement for telemedicine services and resistance to make the shift from traditional face-to-face care delivery models. 

Progress is being made on the payment issue – more than 20 states now require reimbursement for telemedicine use, which is resulting to a gradual increase in telemedicine use. Financial barriers will continue to melt away as payment models shift and the industry recognizes that telemedicine can result in better outcomes, reduced costs, improved access for patients and decreased hospital readmissions. 

As for the cultural shift needed to implement a telemedicine solution, the IT team of an organization needs to work with clinical staff to ensure the new system integrates with the existing IT and health information infrastructure. If this does not occur, the result could be the fragmenting of patients’ health information into isolated stovepipes. IT staff are essential to ensure the seamless exchange of patient health information.

While it’s vital that IT staff and clinicians are both involved in the adoption and implementation process for telemedicine, clinicians should decide the requirements since they are the ones using it to deliver the clinical care. One approach is to find and work with a clinical champion – an early adopter who sees the value of telemedicine from a cost and quality perspective – and by starting small and then growing into a more broad-scale implementation.

A telemedicine solution itself is unlikely to fit the clinical workflow unless clinicians are equal participants in the prioritization, solution selection and configuration, and adoption process. The initiative has a much higher risk of failing if IT personnel are the people driving the project.

Seek adaptable solutions

Telemedicine solutions simply cannot be static. Our nation’s healthcare delivery models are constantly evolving, and our solutions must be able to adjust. Healthcare providers should choose telemedicine products that are responsive to their current and anticipated clinical workflows, keeping in mind that predicting these changes is a guess at best. While a specific telemedicine technology solution might work well today, in six months clinicians likely will want to make improvements as they gain experience and their needs advance. 

It is vital the products are able to adapt and change quickly – and affordably – when new needs arise. It would be a costly mistake to purchase a telemedicine solution that isn’t adaptable, and IT personnel should work with their clinical staff to help their organization make the right choice.

Gauging success

The way to gauge your success depends on which telemedicine functions you implement. What is your organization trying to accomplish? It might be increasing access to care, providing post-acute care or managing high-cost healthcare users. 

Take referral consultation telemedicine, for example. A provider may use this method to improve patient access to specialty care providers, especially those being treated in rural and underserved areas. Such care can be provided with real-time video interactions between patients in a clinic with specialists at remote locations or with a store-and-forward application that captures information and sends it to be reviewed by the specialist at a later time. Success with referral consultation may be assessed by the reduction in the time it takes for a patient to be seen by a specialist and the time it takes to resolve or manage a condition.

Another example is use of home or mobile health monitoring to focus on the highest utilizers – the 5 percent of patients who account for almost 50 percent of the healthcare costs. A remote health monitoring solution is often used as an adjunct to case management in these cases. Success measures for this telemedicine function might be a decrease in ED visits or a decline in the hospitalization rate for those high utilizers.

If all parties involved work as a team to overcome barriers to implementation, and solution providers can continue to provide products that adapt to evolving needs, workflows and healthcare delivery models, our nation has the potential to greatly enhance outcomes and the health of Americans while reducing costs.

Robert Kolodner, M.D., is vice president and chief medical officer, ViTel Net, and former National Coordinator for Health IT in the Department of Health and Human Services.

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