The use of Telemedicine as an effective tool to deliver care in the 21st Century.
By Maxime Coles MD
Consumers and employers are embracing Telemedicine because of it quick and easy access to doctors and better technology at a lower cost than the traditional healthcare system.
Telemedicine is also referred as Telehealth and define the remote delivery of healthcare via electronics and digital communications, making it easier to receive care, improve health outcomes with cost saving in using little resources.
Telemedicine has evolved into an attractive initiative and let us expose some facts:
1- Realtime Interactive Medicine used for Physical exams and Physiotherapy.
2- Remote monitoring with information uploaded and provided by the patient for the provider analysis
3- Mobile Health with more options including cardiac monitoring, blood monitoring
4- Telemedicine can increase team communication via video conference or teleconference
5- Telemedicine help patient in monitoring themselves.
6- Telemedicine to teach medical students and healthcare provider in different country where the quality of care is inadequate.
7- Telemedicine has evolved to fight the shortage of Physicians and healthcare specialists and to extend care in remote area
8- Telehealth includes a wide range of applications. Including virtual psychotherapy sessions, early stroke interventions, and remote cardiac surgery. It is satisfactory and cost effective in the treatment of non-displaced pediatric elbow fractures.
9- Telemedicine has quickly progressed as one of the fastest growing in the healthcare industry.
In 2015, the worldwide telemedicine market was estimated at 23.2 million and is expected to grow to 66.6 million by the year 2021, with the potential in being able to instantly deliver healthcare anywhere.
Telemedicine is the use of telecommunication and information technology to provide clinical healthcare services from a distance. It is used to overcome distance-barriers and to improve access to medical services unavailable in faraway or rural communities. Nowadays, it is also used in critical care services and in emergent situations. Recently AMHE and Louis Auguste Jr have transmitted pathology slides via internet and received confirmation of diagnosis from far away pathologists to help expedite urgent treatments in the underprivileged population of the north of Haiti especially Cap Haiti. As well, a specific design using a phone, implemented a way to perform biopsies from breast and uterus and then relayed the specimen on slides, via telephone and internet to a remote pathologist / specialist who instantly diagnosed, creating a model of Telepathology. This system is being patented and prototyped in India. We thank Louis for choosing the AMHE to assure the feasibility of this interesting project.
The origins of Telemedicine go as far as the 1900’s when the people living in remote areas of Australia used two-way radios powered with dynamos to communicate with the Royal Flying Doctor Service. In the USA, the first Telemedicine clinic was founded by Kenneth Bird at Massachusetts General Hospital to deliver occupational and emergency care to employees and travelers at Boston International Airport. 1000 patients were found on records to have benefited from treatment at the facility. Later, the Bird Telemedicine clinic was created mainly by NASA for physiologic monitoring of the astronauts. Other programs soon followed but the first interactive telemedicine system operating over standard telephone lines was developed for cardiac resuscitation (defibrillation) by Mediphone Corporation until they were able to provide the first cell phones permitting communications between patients and medical staff in allowing the transmission of medical, imaging and health informatics material from one side to another.
Healthcare forms produced by telephone and radio have already supplemented videophone and other telemedical devices produced for in-home care.
The World Health Organization definition of Telemedicine is a little controversial because it uses all aspects of healthcare including preventive care. The American Telemedicine Association uses it interchangeably with Telehealth.
eHealth is also a related term used in the United Kingdom and Europe relating to telehealth, electronic medical records and other components.
Telemedicine can be beneficial to patients in isolated communities and in remote areas allowing them to receive care without being obligated to travel to the facility. Recent developments with mobile collaboration technology have allowed healthcare professionals to share information and discuss cases between patients and medical staff.
Telemedicine will increase the cost of telecommunication and data management equipment as well as technical training for medical personnel. Virtual medical treatment decreases human interactions between medical professionals and patients but increases the risk of errors in absence of registered professionals. Protected health information may be compromised through electronic storage and transmission. There may be also concern that Telemedicine can decrease time efficiency especially with Tele dermatology consults requiring up to 30 minutes. Poor quality of transmitted medical records or images can compromise the quality of patient care
A disadvantage of telemedicine is the inability to start treatment immediately, by example to treat an infection with an injection and observe any allergic reaction.
There is different type of Telemedicine: The store-and-forward, Remote patient monitoring and Real-time interactive services.
1- The store-and-forward telemedicine is responsible for accessing medical data like images and transmitting them to a physician or a medical specialist in Dermatology, Radiology. Pathology etc. It requires the clinician to rely on a history report and audio/video information in lieu of a physical examination.
2- The remote patient monitoring is the self-monitoring or testing using technological devices for Heart disease (blood pressure monitoring) or Diabetes Mellitus (Blood sugar), Asthma, Kidney failure (dialysis).
3- The Interactive services is based on telemedicine services between patient and provider vis videoconference to diagnose, counsel or monitor patients.
Since 2006, the US Navy Medical teams have handles telemedical devices as well as the Emergency Telemedicine in France, Spain, Chile and Brazil have also used SMAU Regulators.
We need to admit the existence of barriers with the adoption of Telemedicine in Emergency and Critical Care units:
- The cost in obtaining licensure in multiple states, malpractice and privileges
- The problem in Insurance re-imbursement in the healthcare system
- A lack of desire of physicians to adapt to Telemedicine
Telenursing is helpful in reducing the shortage of Nurses and in keeping patients out of the hospitals. It also deals with telemonitoring and Information technology. In Melbourne, Australia in 2014 a Google first hands free breastfeeding class for new mothers was initiated allowing mothers to nurse their babies while viewing instructions or call a lactation consultant.
Tele-Pharmacy delivers pharmaceutical care via telecommunication to patients in remote locations where there is no contact with a pharmacist. This include drug therapy monitoring, patient counseling, video conferencing for education, training and management services with remote dispensing of medications. Medications can be delivered at hospital sites or other medical facilities.
Tele-Rehabilitation is the delivery of rehabilitation services in Neuropsychology, speech therapy, Audiology, Occupational therapy, Physical therapy using videocams, videoconferencing, phone lines. The use of wheelchairs, braces or artificial limbs. Medicaid and some insurers may re-reimburse you for such services.
Tele-Trauma can allow a physician to interact with the personnel on the scene, in a disaster situation or in a mass casualty using mobile devices to obtain clinical assessments. A remote trauma specialist can do the same. Telemedicine can be useful in intensive care units for rounds and in reducing the spread of infections. A Video conferencing system can entertain a two-way conversation. Many trauma centers may deliver educational lectures worldwide providing fundamental principles to the audience. Tele-Medicine can be used in the operating rooms as well allowing transmission to a remote location to assure better patient care.
Tele-Medicine can facilitate specialty care through PCP (primary Care Physicians) and even advise on Treatment of Hepatitis C.
Tele-Cardiology will allow EKG (Electrocardiographs) to be transmitted by phone or wireless but it is well known that in 1906, Einthoven, the inventor of the ECG was able to transmit the results through a phone allowing then ventricular Fibrillation to be treated remotely.
In 1975, Gwalior established the oldest known telecardiology systems for tele-Transmissions of ECGs at GR Medical College and was able to transmit ECG from the ICU Moving van or patients home to the central station wireless and to the telephone lines. A demodulator reconverted the sound into ECG and sound waves with a frequency varying from 500Hz to 2500 Hz at baseline allowing to monitor patients with pacemakers in remote areas with arrythmia. Finally, electronic stethoscopes can be used to better the system.
Three projects initiated in Pakistan with Oratier and PakDataComm using 3 hub stations hooked to a satellite allowing other hubs stations like The Mayo Hospital to join, in Asia, have allowed them to treat 1500 patients per hub. The project is still running smoothly after 2 years.
Tele-Psychiatry also uses videoconferences to reach patients residing in underserved areas for consultations and assessment, diagnosis and medication therapy management or simply routine follow-up. Hilty in 2013 and Yellowlees in 2015 confirmed that Tele-Psychiatry is useful in providing consultations and in treating disorders such as Depression, Post Traumatic Stress Disorder. Since 2011, the USA has implemented some model programs in the rural areas:
1- University of Colorado Health Sciences Center (UCHSC) for American Native and Alaskan Native populations
2- Walter Reed Army Medical Center
3- University of South Carolina School of Medicine
4- University of Virginia health System
Tele-Radiology is the ability to send images like X-Rays, CT’s, MRI, PET.CT, SPECT/CT, MG, US mostly via 2 computers connected via internet. An image reviewer will allow the visualization. This is the most popular use for Telemedicine and account in more than 50% of usage in Tele Radiology.
Tele-Pathology is the practice of Pathology at distance using telecommunication technology to facilitate transfer of pathology data to help confirming or assess a diagnosis, educate or perform research. The pathologist will select video images for analysis and uses television microscopy not requiring physical or virtual “hands on” involvement. In 1986, a pathologist Ronald Weinstein coined the term “Telepathology” and published the first scientific paper on Robotic Pathology. In Norway, Eide and Nordrum implemented the first clinical telepathology service in 1989. The same was repeated in North America, Europe and Asia. Digital pathology imaging including virtual pathology is the mode of choice for Telepathology.
Tele-Dermatology uses remote consultations or visual and data communication. The dermatologists Perednia and Brown was the first to coin the name in 1995.
Tele-Dentistry uses telecommunications with informative technology for dental care and public awareness in the same manner as Telemedicine and Telehealth for the underserved population.
Tele-Audiology will provide audiological services. Gregg Givens MD was the first to use the term in 1999 to a system developed in North Carolina USA.
Tele-Ophthalmology delivers eye care through digital equipment and telecommunications technology. It will provide access to eye specialists for patients in remote areas, helping in diagnosing ophthalmic diseases with screaming and monitoring. Between 2011 and 2015, 10000 patients benefited from examination, but surgery were done on appointment.
In United States, a full and unrestricted licensure is required to practice where you are providing care although there are also restrictive laws with numerous exceptions. Many states will impose written and oral examination with travelling interviews to obtain such license. In 2008, the Ryan Haight Act required face to face or a valid telemedicine consultation to receive prescriptions.
State medical Licensing boards have often opposed telemedicine like it happened in Idaho where electronic consultations were illegal in 2012. In 2015, the state legislature legalized electronic consultations. Teladoc filed suit against Texas Medical board over in-person consultations.
In the USA the major Companies offering Primary care for non-acute Illness include Teladoc, American Well, and PushCare. Grand Rounds offer remote access to specialty care. In 2015, United healthcare announced that they will cover a range of video visits from Doctors on Demand. In 2017 PushCare launched the pre-exposure prophylaxis therapy for the prevention of HIV, in providing consistent online doctor’s visits, regular laboratory texting and prescriptions.
Tele-Surgery is the ability for a physician to perform surgery on a patient not present in the same location. This require Robotics, cutting edges communication, high speed technology, haptics and management information systems. Most of the robots are controlled by local surgeons benefiting of the expertise of remote specialized surgeons available to patients worldwide. Remote surgery or Tele-Surgery is performed in areas where the surgeon is not physically available in the operating room but using a robotic teleoperator providing tactile feedback.
Videotelephony is useful for the deaf and speech-impaired patient who can use sign language and video relay service and tele-educational services at a remote location.
Telemedicine and eHealth is the mean of delivering Healthcare in remote areas of many African countries where the lack in healthcare professionals is well known. The Satellite African eHealth demonstration project in remote area with low population density is hampered by the lack of communications infrastructure with no landline phone or internet connection and often no reliable electricity supply. The satellite African eHealth project started in 2010 providing solar-powered nternet terminal to rural villages to facilitate Telenursing at distance, encouraging training to personnel and helping in diagnosing. In 2014, Luxembourg with German Doctors and Medecins-sans-Frontieres, established SATMED, an eHealth platform to improve public health in remote areas of Sierra Leone helping the fight against Ebola.
Tele-Medicine maybe the way to offer Medical care in Haiti. If AMHE has collaborated in the Telepathology project presently implemented in Cap Haiti and Justinien Hospital, we would have like more governmental cooperation to see such project extended to the entire country. The government is placing a lot of efforts in proper teaching among our healthcare professionals. Many University Hospitals have implemented programs allowing students to acquire better knowledge.
Tele-Medicine is certainly the way to deliver care in underdeveloped countries. Statistics have shown that patients in the telehealth group have a higher satisfaction rate and spent only one third of the time for their clinical encounter and passed far less time travelling.
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