Integrating Telehealth and the EHR

Leaders at healthcare organizations across the country are finding innovative ways to use video conferencing devices to meet the specialty care needs of rural patients. A look at the Health Resources and Services Administration (HRSA) Office for Advancement of Telehealth (OAT) grantees shows that these organizations are making clear headway in linking their physicians and patients remotely, but work still needs to be done to digitally collect and document the remote consult within the electronic health record (EHR).

OAT administered grants to 36 telemedicine projects, totaling more than $10.3 million, from 2009 through 2011. Projects like these are contributing to a growing telehospital market, which was worth $8.1 billion in 2011 and is expected to grow to $17.6 billion in 2016, according to BCC Research (Wellesley, Mass.).

However, meaningful use did not specifically address telehealth; so even with this market’s growth, Gary Capistrant, senior director of public policy at the American Telemedicine Association, believes there will be many frontiers before integration can occur between telemedicine hardware and EHRs. “Ultimately, that’s an issue for the EHR vendors to deal with, not the hospitals,” Capistrant says. “[Hospitals] may want to be able to do it, but if [vendors] don’t provide functionality, it doesn’t happen. And what the [vendors] do is driven a lot by meaningful use, and telehealth doesn’t seem to be a priority by the ONC.”

Linking Remote Pediatric Network Consults
Many organizations, including the 118-bed University of California Davis Children’s Hospital (UCDCH) in Sacramento, have had to create workarounds to digitally document their telemedicine consults. UCDCH is halfway through the process of linking up 11 partners in Northern California to its existing Pediatric Emergency Telemedicine Network of eight emergency departments that offers remote critical care consults. Each site in the network has a high-resolution video-conferencing unit (Cisco) that uses a VPN tunnel to establish an encrypted, secure link between the two sites.

To keep information exchange between each rural hospital and UCDCH inexpensive and sustainable, the UCDCH physician asks the treating physician or nurse for vitals or lab results via phone, fax, or by simply looking at the monitors via video-conference. There are ways to create more IT integration within the program, but doing so adds expense and complications, says James Marcin, M.D., professor, pediatric critical care medicine, and director, Pediatric Telemedicine Center for Health and Technology, UCDCH. “You can theoretically have a repository where all the sites can be standardized and give it to the doctor, get the labs in a standard way, but those are resource-intensive programs,” he adds.

In the absence of IT integration, telemedicine equipment should at least maximize standard protocols for better intercommunication, says Juan Trujano, IT supervisor, Department of Pediatrics, UCDCH. His department ensured that it purchased teleconferencing devices that use the H.323 IP communication standard. “That’s very important to us because we want to call any other institution that has a similar machine,” he adds, “so [by using a] standard it doesn’t have to be brand [-dependent].”

Reaching Underserved Communities
Another organization that is facing challenges with digitizing its telemedicine efforts is the University of Arkansas for Medical Sciences (UMAS), which participates in the Arkansas START (System To Access Rural Telecolposcopy) program to offer telecolposcopy in three underserved rural communities, covering gaps in follow-up gynecological care for Medicaid patients.

As a part of the program, there are four telehealth sites that operate weekly, half-day clinics and can each provide up to 10 women, who have had abnormal pap smears, with real-time telecolposcopic evaluations. Since 2006, the START program has treated 3,023 patients.

When a patient visits the local telehealth site, she is seen by a technician. A gynecologist and expert colposcopist at UAMS in Little Rock, Ark. watch all the sites at the same time via a clinical teleconferencing system (Tandberg, New York, N.Y.) and a video colposcope (Welch-Allyn, Skaneateles Falls, N.Y.) that uses high-speed T1 data lines. The expert colposcopist speaks with the onsite colposcopist and then provides a colposcopic impression, recorded on paper at the hub site, and decides where to biopsy if needed.

Even though UAMS has an EHR, the colposcopy information cannot be input into the system without that patient receiving a bill, which would be against grant requirements; so all paper records from the rural site and UAMS are faxed, scanned on to secure hard drives, and placed in the patient’s folder. Currently, UAMS has a proposal to replace the inpatient and outpatient EHRs with an enterprise system to reduce paper processes.

Versatile Technology
Close to five years ago, the Boise, Idaho-based Saint Alphonsus Health System began developing its telemedicine network for multiple applications among its four-hospital, 714-bed integrated healthcare system that have, as of January this year, saved the system $1.7 million in medical transport costs and has allowed more patients to be treated in their local communities.

“We wanted to develop multiple applications for a single technology so we didn’t have equipment that wasn’t being used very frequently, and so the project would be more sustainable,” says Tiffany Whitmore, director of system development and telemedicine, Saint Alphonsus Regional Medical Center (SARMC).

Saint Alphonsus has implemented 16 remote-presence robotic systems (the RP-7i and RP-Lite, a dual-purpose workstation, from the Santa Barbara, Calif.-based InTouch Health) in 12 sites that provide a broad swath of medical and social inpatient and outpatient specialty services, including telepsychiatry, maternal fetal medicine, sign language interpretation, and even genetic counseling.

“When we were first looking at technologies, we wanted something that was versatile and that we weren’t limited to a point to point connection, so having a technology that ran off of a wireless platform was something we were very interested in,” says Whitmore.

Nichole Whitener, health system research administrator, stroke center director, SARMC, the only tertiary referral center for stroke in Idaho, says its telestroke program was initiated to help decrease death and disability from stroke by getting patients treated sooner.

Four neurologists in this program use an encrypted laptop to control a robotic video conferencing device to perform different assessments like zooming in to see pupil dilation or directing a patient to repeat sentences to check for slurred speech. If a stroke has occurred, then a stroke medication can be prescribed in the recommended one to three-hour treatment window.

If the patient stays at the local facility, the SARMC physician dictates into that rural hospital system’s dictation line, which is transcribed and input into the EHR. But if the patient is transferred to SARMC, the physician dictates into the SARMC system and copies the referring site. However, communication is still a challenge.

“One limitation to telemedicine is that it is difficult for remote physicians to be the admitting physician, so they have to communicate very clearly to the physicians who are going to be admitting that patient,” says Whitener. “We just need to make sure that all information is communicated.” ◆