Extending the Reach of Care Through Telehealth

Aug. 18, 2014
Experts from Manitoba and Minnesota share their perspectives on important new trends in telehealth on both sides of the U.S.-Canadian border

Telehealth has finally overcome a major hurdle for widespread use with the proliferation of mobile tablets and smartphones and the ability to share high resolution photos and videos via low cost communications services throughout most of North America. With parity reimbursement laws in place in 19 states, and a bevy of bipartisan supported telemedicine legislation introduced in this session of Congress, including the proposed Medicare Parity Act of 2014, the financial obstacles relating to payment for telemedicine services are starting to crumble.

The scope of telehealth includes telemedicine services to patients, healthcare provider-to-healthcare provider specialist consultation, and health-related education. Professionals working in the field of telehealth expect it to proliferate in the next few years.The emphasis by the Affordable Care Act to have healthcare providers organize health care teams, technology, and knowledge around patients’ needs to achieve healthcare delivery’s full potential will be a stimulus to its expansion.

The upcoming Health IT Summit sponsored by the Institute for Health Technology Transformation (iHT2) being held August 19-20 at the Seattle Waterfront Marriott includes a panel on the topic of “Extending the Reach of Care through Telehealth." Since December 2013, iHT2 has been in partnership with Healthcare Informatics through HCI’s parent company, the Vendome Group LLC. HCI spoke with three of the panelists about their experiences and perspectives.

Canada spearheaded the pragmatic use of telemedicine in the early 1980s. Standard telephone lines slowly transmitted single video images – or “freeze frame” video – of injured people living in rural villages in Northwest Ontario and on offshore drilling rigs in Newfoundland. Physicians provided desperately needed triage advice and made assessments if evacuation would be need, and if so, at what level of urgency. Since then, every province has utilized telehealth in some capacity.

Trever Strome is an assistant professor in the Department of Emergency Medicine at the University of Manitoba College of Medicine. He also is a process improvement lead in the Emergency Program at the Winnipeg Regional Health Authority (WRHA). In this capacity, he works at identifying ways to leverage technologies to reduce unnecessary emergency department (ED) visits and to improve the efficiency of care for the patients who do present to the ED. This includes investigating how telehealth-related systems can help reduce ED overcrowding and prevent some ED visits altogether.

Approximately 60 percent of Manitoba’s residents--about 700,000--live in greater Winnipeg, according to 2013 estimates from Statistics Canada, with the remainder living in small towns in that vast 250,000-square-mile province. A Manitoba Telehealth network connecting 23 healthcare facilities started in 2002 to provide access to medical specialists to both patients and physicians living and practicing in rural areas.

Strome is currently researching ways to use telehealth by the emergency departments of community hospitals outside the Winnipeg region, including investigating ways for these departments to obtain specialist consultations during night and weekend hours. One of the objectives is to be able to minimize the need for costly emergency patient transport to tertiary hospitals.

Questions about when it is appropriate to use telehealth for emergency services today are being seriously evaluated . “We need to make sure that we are doing the right things, the best way for the patient,” Strome says. “Telehealth has a great set of technologies to use, but like any other medical intervention, we need to determine if and what is most appropriate. When implementing any telemedicine application that would be a substitute for an on-site visit to a healthcare provider, it is important to determine in advance if this is comparable to a face-to-face visit. We have done well providing telemedicine services to more remote healthcare centers, but it is important to start quantifying this experience to ensure that patients are receiving the best care possible.”

Pediatric patients living outside the five major cities of Montana are receiving better health care thanks to telemedicine, according to Doris Barta, director of telehealth services in the Partners in Health Telemedicine Network (PHTN) at St. Vincent Healthcare in Billings. She explains that “there are only 17 licensed pediatricians in Montana, all of whom practice in the state’s five largest cities. Children living outside these areas either receive care from primary care physicians and clinical staff working in rural healthcare facilities or travel great distances. In the last few years, we’ve really escalated tele-emergency care provided by pediatric intensivists. We have the only 24/7 staffed pediatric intensive care unit in the state. We believe that sharing this expertise has reduced the number of transfers of pediatric emergency department patients to tertiary hospitals.”

St. Vincent Healthcare also actively uses telemedicine to treat Native American children living on four reservations in the state. The U.S. Indian Health Service (IHS) does not have pediatricians on staff and contracts with St. Vincent to provide them. Pediatrician Dr. Santha M. Chamberlain, M.D. conducts regularly scheduled on-reservation clinics to treat the patients. Hands-on treatment is augmented with regularly scheduled telemedicine appointments. Telemedicine also connects pediatric specialists with these Native American children, as well as with children throughout the state.  

“Physicians with rural practices and rural clinics and hospitals are very pleased to be able to augment their services with one-on-one telemedicine consultations with pediatric specialists," Barta says. "To name a few, these include a cardiologist, perinatologist, and endocrinologist. But access to specialists is important for adult patients who go to rural facilities," she adds.

"Interactions are quite sophisticated," Barta continues. "For example, when there is an appointment day with our sleep study specialist, appointments are set up so that they alternate from site to site. Each facility has a ‘telemedicine appointment videoconferencing room’. By alternating appointment time slots, after a room at one facility is vacated, there is time to prepare it for another patient without losing any time for the specialist or the network. This is a super-efficient use of resources. Our offices do the central scheduling activities. It is important to make telemedicine as easy as possible for all participants. This is one key to success,” she emphasizes.

The network also makes life easier for cancer patients because they can get chemotherapy treatment at their local healthcare facility. Oncology patients visit St. Vincent for diagnosis,  surgery and/or radiation therapy -- and chemotherapy treatment planning. Chemotherapy is administered locally. On the day of treatment, labs are done, and vitals are recorded by a nurse or physician’s assistant. The patient then has a scheduled remote office visit with the patient, a service that is also available between treatments. The patient, often weak and tired, gets to avoid an up-to-200 mile trip to see his or her personal oncologist.

Barta said that this use has increased with the implementation in 2014 of a parity law that requires full payment comparable to an in-person consultation or treatment. This is one example of telehealth which for the patient is not just comparable, but immensely better in terms of comfort and convenience.

Barta works with three other large telemedicine networks that connect all 56 critical access hospitals. She notes that each network is designed around specific service delivery areas, but that there is a lot of cross-network activity. In addition to providing telemedicine services to patients, and consultation by specialists with primary care providers, PHTN also provides education and training to patients, such as regular diabetes workshops.

Barta looks forward to the expansion of patient education beyond the T-1 networks with the increasing availability of mobile devices and the broader bandwidth communications networks that serve them. “Smartphone video will make it possible for us to watch how a patient is getting an injection at home for the first time, or assisting a diabetic patient with food preparation step by step using a mobile tablet. Mobile devices are creating opportunities for patients to feel more engaged in their disease management process as well as creating some visual educational opportunities that they otherwise never would have had,” she says with excitement.

Nancy Vorhees is both the chairman of the multi-organizational Northwest Regional Telehealth Resource Center and the chief operating officer of Inland Northwest Health Partners, part of the nonprofit Spokane headquartered Inland Northwest Health Services. One of its divisions is Northwest TeleHealth that connects about 65 sites with 100 end points across all of eastern Washington.It works with physicians at these sites to help them develop their telehealth programs. Northwest Telehealth is highly involved in education and training, logging about 20,000 hours in 2013.

Vorhees foresees epic changes in telehealth in this decade of mobile devices and low cost broadband communications. “For over 20 years, telehealth provides geographically isolated communities with excellent services delivering specialized care. With reimbursement for services issues slowly being overcome – ironically Washington does not have  a parity law – and federal healthcare reforms focusing on better patient care at lower cost, there are many opportunities for telehealth to expand. She believes telehealth will be ideal for home health services, monitoring and communicating with patients, particularly those who were recently hospitalized to better oversee their care so they will not need to be readmitted.

“Healthcare providers are starting to realize that consultations can be done on a more economic basis. Patients in rural areas do not want to spend the time travel long distances, or pay for the expenses to do so. Even patients in cities do not want to go into a doctor’s office, clinic, or hospital because they are concerned about catching a disease," Vorhees says. "In many cases, telehealth is ideal for follow-up visits and many types of consultations. I foresee the use of telehealth doing nothing but increase."

What creates strong telehealth programs that succeed?  A defined need. Careful planning. A program that fills the need. Obvious benefits for patients, caregivers, communities, payors – whoever is involved. Vorhees referenced one program that began with a simple request: a single session of advanced training for ambulance emergency medical specialists(EMS) to meet continuing education requirements. “We planned a one evening program allowing for interactive discussions by all participants," Vorhees says. "Ten years later, the monthly series ‘EMS Live at Night’ is going strong, engaging 100 and 300 EMS specialists located in five different states. It is incredibly successful. It has filled a need.”

There are so many needs in healthcare that creative telehealth programs could fill. In today’s economic climate, with today’s technology, it’s just a matter of time.

These and other topics will be discussed this coming week in Seattle. To learn more, please check out the Health IT Summit in Seattle, August 19-20,, sponsored by the Institute for Health Technology Transformation.

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