Telemedicine
Linking us all together for the good of
our patients
What is Telehealth? What is
Telemedicine?
• Telemedicine: The use of medical information
exchanged from one site to another via
electronic communication to improve a
patient’s clinical health status.
• Telehealth: Broader scope that does not
always include clinical services such as
education or EMR; examples would be
webMD or an online pre-op education.
CMS: Telemedicine
• Telemedicine seeks to improve patient health
by permitting real time interactive
communication between the patient and the
practitioner at the distant site.
• Distant or Hub Site
• Originating or Spoke Site
Advantages
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Money Saved
Travel Worries
Rural
Technology Improving
Hometown Revenue
Rapid Response
Data Sharing
Disadvantages
• Start-up Costs
– REACH est. total costs since 1995 over 5 million
– Single cart $10,000 and $25,000
• Loss of Direct Human Contact
• Inability of Patients/Providers to use
Equipment
• Equipment Malfunction
How we got to this place
HISTORY OF TELEMEDICINE
1860’s
Telegraphs sent by Union on battlefields to rear areas with casualty
reports and to order medical supplies.
Around 1906, Dr Willem Einthoven used telephone wires to transmit an
EKG from one part of a hospital to another .
Wireless
2-way radio communication was used by military in WWII and Korea to
send word to hospitals/hospital ships about casualties.
1960’s
• Nebraska State Hospital used 2-way closed
circuit TV to another hospital 112 miles away
for consultations and education.
• NASA developed telemedicine for astronauts.
• Boston’s Logan Airport used closed circuit
black and white TV to link its clinic with Mass.
General Hospital.
– Study of 1000 patients. First Telenursing report.
STARPAHC
• 1972 to 1975 NASA begins trials of STARPAHC
(Space Technology Applied to Rural Papago
Advanced Health Care) on reservations in
Arizona using 2-way microwave transmissions
to connect rural areas, both stationary and
mobile, with medical centers in Phoenix and
Tucson.
1980’s saw little growth in telemedicine. One notable achievement was
in 1989. U.S. set up satellite communications between 4 U.S. medical
centers and hospitals in Armenia following the Armenia earthquake
• Then came the 1990’s
1990’s and Internet
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Digital Images and Sound
Video Devices Smaller/Better Picture Quality
Infrastructure Development
1993 American Telemedicine Association (ATA)
Formed
• Cell phone Technology
• 1997 “Telemedicine Report to Congress”
2000’s
• 2001 Update to the “Telemedicine Report to
Congress”
– This included concrete recommendations
– Action plans for specific government agencies
– Established O.A.T. (Office for Advancement of
Telehealth) under Department of Health and
Human Services.
– Medicare and Medicaid
– Veterans Administration
2000’s Cont.
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HD video and flat-screen monitors.
Improved bandwidth fiber optic cable.
Military applications in Iraq and Afghanistan.
More rural connections.
Entire states becoming wired for telehealth
services.
• Smart phone technology
• Information over Internet increasing (webMD)
How we make it work
USING TELEHEALTH
Types or Disciplines of Telemedicine
• Live or Clinical Interaction
• Store and Forward:
– Radiology
– Dermatology
• Websites $80.00 send a photo, they send back diagnosis and
treatment advice.
• Also uses live interactive telemedicine
– Ophthalmology
• Benefis NICU
– Retinopathy of Prematurity (ROP)
• Dr Weaver and Dr Murdock study 2007 to 2012
• Kept NICU accredited and cost savings of 14 transports
$157,500 vs. 176 transports $1.5 million
Tele-ICU
• Becoming more common as Intensivists
become rarer.
– 6,000 ICU’s; only 5,500 board certified Intensivists
• start-up costs: $ 2 million, $600,000 to
$1,000,000 yearly operating
• ROI by keeping patients in local hospitals
Tele-ICU cont.
Tele-Nursing
• Hospital
– Critical care
– ER
• Home Health
• Wound Care
• Education
Tele-ER
• South Dakota.
– 860 eEmergency cases in 2012
• University of Utah Burn Center
– Burn transfers from regional hospitals
– Over or under estimating percentage by >500%
– Burn calculation by burn specialists in person and
by video within 1%
Home Health
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Readmission penalties
CHF and Diabetes
Ease of use for patients
Daily reminders
Other Disciplines
• Tele-Pharmacy
– Retail
– Hospital
• Occupational Therapy
• Speech Therapy
Telemedicine Regions
Montana Telehealth Networks
REACH Network
Getting Connected
Rattlesnake Bite
Wagner, South Dakota
• Pre-Teen girl bit on ankle
• 30 mins. from hospital (POV)
• Hospital staffed by Physician small nursing and
support staff.
• Patient in shock on arrival activated
Telemedicine connection to Sioux Falls
Hospital ER
Wagner Continued
• Anti-venom given along with shock support.
• Developed anaphylaxis
• Unable to intubate and had cricothyrotomy
performed.
• Went into cardiac arrest with defibrillation
done.
Wagner: Continued
• Staff commented afterward, support from the
nursing and ancillary staff at the hub site.
– Nurses checking doses
– Code record with times
– Keeping flight crew informed
REACH and North Central Montana
• Since 2003 REACH community members have
been saved 1.5 million miles of travel. Almost
60 times around the world at the equator.
• Kept families from traveling to out of state
Medical Centers for monthly follow ups.
• In one day there were 11 patients at a
Cardiology Clinic that saved over 1100 miles of
travel.
• Practitioner in Havre seeing patients in Malta
New Cardiac Patient
• 67 y/o male. No previous cardiac Hx. Strong
family history. 2 months of exercise induced
chest/neck pain.
• Was seen at 3 separate outpatient clinics in 3
separate towns, including stress test within
last month.
• New patient to cardiologist
Cardiac Continued…
• Had a one hour visit via telemedicine with
results other clinics and stress test available to
cardiologist
• Telemedicine encounter same day as winter
storm hit North Central Montana
• Had a heart catheterization done within one
week and one stent in 99% occlusion in RCA
REACH into the Future
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REACH/ER
Education Opportunities/CEU’s
Neurology/Stroke
Post-Operative Follow-Up
Pre-Hospital Video
Where do we go from here?
• Home Health
• Smart Phones
• Wireless
– Pre-hospital
– Inter-hospital transfers
• Web based programs
– Clinical/Direct patient
– Educational
– Virtual
REACH Team at Benefis
• Education: In state or out of state.
• Connections other than to Great Falls
• Technical advice
Questions?
• http://reach-montana.org/
Brian Christensen, RN
Clinical Telehealth Coordinator
REACH/ER
406-455-4282
BrianChristensen@benefis.org
Bibliography
1. CMS.gov
2. Wheeler, Tom. 2006. Mr. Lincolns T-Mails: How
Lincoln used Telegraphs to Win the Civil War.
3. Roger Allan.2006.ABrief History of Telemedicine.
Electronic design
4. History of Telemedicine. Health Information
Technology Data base
5. Telehealth Nursing fact Sheet. 2011 ATA Nursing SIG.
6. PSU.edu. Telenursing. Chiaraluna et al. 2010
7. Avera ecare.com
8. Saffell et al. J of Trauma.2004 Saffell et al. J of
Telemedicine 2006 and 2009
9. Rafika.2012. American College of Cardiology
Bibliography (Cont.)
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10. Kumar et al. 2013. AHIM.org
11. Avera ecare.com
12. Saffell et al. 2004 J. Trauma
13. Saffell et al. 2006 and 2009 J. Telemedicine
14. Mashima et al. 2003. American Journal of Speech Pathology.
15. Szivek, Pamela, Pediatric O.T.; Telehealth’s New Entrant: Occupational
Therapy. NRTRC Conference; 2013
• 16. Telehealth Resource Center web site.
• 17. CardioSource. 2013
• 18. Telemedicine and eHealth. Latifi. 2012