Living in a rural community poses unique challenges to maintain one’s health. The realities of living far from primary care physicians or having a lack of access to medical specialties can elevate already complex care situations. However, the application and promise of telehealth can help patients, regardless of location, get timely care.
The concept of telehealth or telemedicine is nothing new. Since the explosion of wireless technologies, hospitals and healthcare providers have been testing the waters of telehealth. U.S. rural communities stand much to gain with appropriate application of telehealth services, including real-time, face-to-face videoconferencing and the ability to send digital images to specialists for evaluation. The federal government recognizes this. For one, the U.S. Department of Agriculture Rural Development provided $30.2 million to 34 states through its Distance Learning and Telemedicine program last December to improve healthcare access to rural areas.
Notably, outcomes research is showing a positive trend in treating the rural population with telehealth services. For example, a three-year study conducted at the 272-bed Billings Clinic in Billings, Mont., has helped to demonstrate a case for telehealth services to rural communities. The study, published October 2011 in Telemedicine and e-Health, compared diabetes care with and without videoconferencing. The 225-physician regional multispecialty group practice found that one year post-intervention, a comparison of telehealth with face-to-face patients resulted in increased self-reported blood glucose monitoring as instructed (97 vs. 89 percent) and increased dietary adherence (244 vs. 159 percent). Since the study’s conclusion in 2009, technologies at the Billings Clinic have been integrated into regular care to fuel a diabetes prevention program to identify people who don’t have diabetes but have risk factors that indicate the potential. Patient groups gather and have videoconference discussions on physical activity and diet, and their lab work is tracked by physicians, says Elizabeth L. Ciemins, PhD, MPH, research director at the Center for Clinical Translational Research at Billings Clinic.
Driving down drive times
The utilization of telehealth services is largely dependent upon the unmet healthcare needs of a community and the presence of a technology infrastructure to support those services. For rural and medically underserved communities, low doctor-to-patient ratio and lack of access to medical specialists are major impedances to care.
At Saint Francis University’s (SFU) Center of Excellence for Remote and Medically Under-Served Areas (CERMUSA) in Loretto, Pa., researchers have been studying the effects of using telehealth services to facilitate the care of in-home patients in need of a certified wound care nurse. The care is not cheap: the average cost of healing wounds at home is approximately $13,000 per treatment episode according to published reports (Health Manage Technol 2002;23(4):22-24). Therefore, establishing beneficial and cost-efficient wound care strategies is imperative.
The wound care study involves a visiting nurse using an iPhone to take photos of a patient’s wounds during a routine home visit, says Brenda L. Guzic, MA, RN, assistant director for telehealth at CERMUSA. These are immediately sent to a certified wound care nurse who is centrally located at the visiting nurse organization’s main office. The wound care nurse then evaluates the wound and instructs the visiting nurse on any necessary care changes. “By using this format, the wound care nurse has the ability to see patients more often, enabling more timely changes to the wound care treatment regimen,” says Guzic
Using cellular technology has saved approximately $17,500, according to Guzic. Most of those savings came from streamlining a suitcase full of accessories (tripod [$25], power strip [$12], video cable [$30], light for camera [$56], HandyCam [$797], etc.) totaling $22,605 into one hand-held smartphone. “The old camera system weighed approximately 19 pounds, with all of the add-ons. An additional 19-pound suitcase can be rather cumbersome and nurses may not want or be able to carry everything,” says Guzic. The iPhone approach costs $5,175. Also, the photos now are becoming a permanent part of the patient’s EHR. As a result, the wound care specialist can monitor the healing of the wound on an ongoing basis and does not have to rely solely on written documentation.
The camera also cut down on driving time for the wound care nurse since, says Guzic, he or she no longer has to travel around 13 Pennsylvania counties to visit patients. And yet, travel time is in the eye of the telehealth beholder. For example, 75 percent of Alaskan communities are not connected by road, says Cheryl Moon, MS, acting-director of Alaska Federal Health Care Access Network (AFHCAN) under the Alaska Native Tribal Health Consortium (ANTHC) in Anchorage. The lack of access to roads, coupled with expensive airfares and great distances, justifies telehealth services for many Alaskan communities.
The ANTHC telehealth program, begun in 1998, seeks to improve access to health services for federal beneficiaries in Alaska to improve access to health services for federal beneficiaries. Last year alone, statewide providers generated more than 33,000 cases using telehealth services, and over the past 10 years, more than 125,500 cases were created.
“Our main focus is to improve access to quality healthcare for patients living in remote areas,” says Moon. “We often manage to keep patients in their home community.” Almost 75 percent of their specialty consultations prevent the need for patients to travel to see a specialist. “Without telehealth, the patient would need to fly into Anchorage to be seen at the Alaska Native Medical Center (ANMC) for a specialty appointment,” she says. “For pediatric cases, for example, an adult would need to take off work, take the child out of school and potentially travel a great distance to see a specialist.” A roundtrip plane ticket from a outlying village to Anchorage can cost up to $1,200, and AFHCAN estimates that the use of telehealth now saves more than $9 million annually in travel costs for specialty and primary care.
Although telehealth has seen its fair share of success stories, there are still barriers to its adoption and use. For example, the growing demand for videoconferencing throughout Alaska presents challenges for AFHCAN and its partners when making connections between separate organizations and their networks, Moon says. While AFHCAN initially rolled out a “network of networks” for inter-organizational connectivity, the current focus is to develop a unified solution for naming conventions, addressing schemes and scheduling across organizations.
Connectivity is not the only challenge though. In a December 2011 IDC Health Insights report, the Framingham, Mass.-based research firm found 32 percent of respondents cited data security as an obstacle to telehealth, in addition to cost, which again, 32 percent stated cited as an obstacle. However, as the value of telehealth is demonstrated to a community, organizations may be more willing to foot some of the bill. Of the 108 counties serviced by Texas Tech University Health Sciences Center (TTUHSC), 22 have no physicians, 32 no hospitals and 75 percent of the region lives more than 90 miles from a comprehensive trauma hospital.
“Ninety-eight of those counties are considered rural and more than 50 percent are considered ‘frontier,’ meaning they have less than seven people per square mile,” says Debbie Voyles, MBA, director of telemedicine program at TTUHSC. With more than 400 patients per month treated for different specialties, including pulmonology, mental health and dermatology services, she says cutting driving time in favor of more frequent care proves value.
After grant funds ran out from a 2009 Children’s Healthcare Access for Rural Texas project, nine of the community clinics decided to take on the cost of DSL line connections and lease the telehealth equipment from TTUHSC. Also, it doesn’t hurt that the cost of technology is decreasing. When TTUHSC began their telehealth services in 1990, capabilities cost upwards of $100,000, but now, a high-definition videoconferencing unit costs approximately $35,000, says Voyles.
Costs vary with medical carts depending on the included equipment and their respective manufacturers. In Voyles’ $35,000 range, the peripheral devices make up most of the costs. The digital otoscope that TTUHSC uses comes with a price tag of $11,000, for example.
Lack of reimbursement amplifies telehealth’s cost barrier. However, the Centers for Medicare & Medicaid Services (CMS) is slowly changing the Physician Fee Schedule to reflect modern mobile clinical settings. The 2012 Physician Fee Schedule addressed changes to payment policies to ensure payment systems are updated to reflect changes in medical practice and the relative value of services. According to the final rule, CMS requires that telehealth services be equipped with an interactive telecommunications system, defined as a multimedia communications device which includes, at minimum, audio and visual equipment permitting two-way, real-time interactive communications between a patient and a practitioner at a distance site.
Currently, “Medicare telehealth services may be provided to an eligible telehealth individual notwithstanding the fact that the individual practitioner providing the telehealth service is not at the same location as the beneficiary,” reads the published rule. “An eligible telehealth individual means an individual enrolled under Part B who receives a telehealth service furnished at an originating site.”
According to the rule, certain services commonly furnished remotely using telecommunications are covered and paid the same as services delivered in person. The patient is not required to be in the same place as the practitioner.
However, a large part of who pays for telehealth services varies by region, and third-party payors are beginning to enter into the reimbursement game. David Guggenbuehl, RN, MBA, director of regional services at Gundersen Lutheran Health System (GLHS) in La Crosse, Wis., says GLHS is “fortunate” that payors like Blue Cross Blue Shield of Wisconsin are reimbursing for telehealth services. GLHS provides telehealth specialty services—including endocrinology, cardiology, medical oncology and radiology services—across 22 regional sites via a medical cart with capabilities including videoconferencing and digital cameras.
Additionally, Medicaid regulations vary by state and not all state programs, such as Wisconsin, pay for telehealth services. In Texas, eligible areas including rural counties (less than 50,000 population) and medically underserved areas are eligible for Medicaid telehealth service payments. Eligible medical services include consultations, office or other outpatient visits, pharmacologic management and psychotherapy. Texas insurance code generally requires health coverage providers to treat telemedicine consults as if they had occurred in a face-to-face environment, says Voyles.
But even if cost is overcome, other problems persist. “The No. 1 challenge is changing the culture of the way physicians practice,” says Guggenbuehl. Serving a half million people within a 100-mile radius around La Crosse, he notes that change management can be difficult as physicians put aside their traditional training. “There’s a learning curve on the clinical side when you don’t have your hands on the patient. Physicians have to be willing, able, interested and somewhat energetic to participate in these services.”
In addition to culture change, executives need to plan out their IT infrastructure before jumping into a telehealth initiative. “The rural environment is challenged in getting broadband circuits to supply the infrastructure needed,” says Brock A. Slabach, MPH, senior vice president of member services at the National Rural Healthcare Association, who adds that infrastructure foundation is critical and advises a 1GB circuit as the ultimate goal.
As adoption increases and cost goes down, more citizens in rural communities may soon be the beneficiaries of modern technology and telehealth services. Seemingly, there ain’t no mountain high enough; ain’t no valley low enough and ain’t no river wide enough to keep telehealth from getting to quality care.
Wireless monitoring devices help patients be healthier, live independently
By Lucas Mearian - December 07/2011 - Computerworld
Using remote monitoring technology to keep tabs on patients' blood sugar and cardiopulmonary disease can reduce the risk of patient mortality by up to 45%, according to a U.K. Department of Health study.
The preliminary findings (download PDF) showed that, if used correctly, TeleHealth can deliver a 15% reduction in emergency room visits; a 20% reduction in emergency admissions; a 14% reduction in elective admissions; a 14% reduction in bed days; and an 8% reduction in tariff costs.
More strikingly, the findings showed a 45% reduction in mortality rates. In the U.S., the federal government is aggressively pushing for electronic health records (EHR). Telehealth technology, which allows doctors to monitor their patients' health wirelessly in real time, could be combined with online health records for a highly accessible, interactive patient history.
Last year, a report from Accenture showed that the rise of inexpensive Internet connectivity and smaller, cheaper and "smarter" health electronics should deliver better, more efficient health care.
The U.K. Department of Health said its study was the first of its kind and one of the most complex and comprehensive studies it has ever undertaken. It involved about 6,000 chronically-ill patients at 238 healthcare practices across three counties in the UK. It took two years to complete.
The study looked at how the adoption of telehealth monitoring technologies could reduce the mounting financial burden of healthcare for the chronically ill. The study focused on patients with three conditions: diabetes, coronary heart disease and Chronic Obstructive Pulmonary Disease (COPD). It also showed how technology supports people who live independently, and how they can be more in control of their own health and care.
"The first set of initial findings ... show that, if delivered properly, telehealth can substantially reduce mortality, reduce the need for admissions to hospital, lower the number of bed days spent in hospital and reduce the time spent in [emergency rooms]," the Health Department saidn in a statement. "At least three million people with long-term conditions and/or social care needs could benefit from using telehealth and telecare."
Currently, six schools are evaluating the data, including City University London, University of Oxford, University of Manchester, and the London School of Economics. The study looked at the data under five themes -- service utilization; reported outcomes such as quality of life; cost effectiveness; user and professionals' experience; and influence of organizational factors to adoption).
Three TeleHealth technology providers were selected for the program, offering remote patient management systems for study:
· Philips HealthCare used its Motiva technology to monitor about 550 heart failure, COPD and diabetes patients in the London borough of Newham.
· Philips Motiva is an interactive healthcare platform that connects patients with chronic conditions to their healthcare providers through a home television and a broadband Internet connection.
· Newham, England is challenged with providing long-term healthcare for more than 17% of its chronically-ill population as well as being ranked as having the highest diabetes rate and death rate from stroke in the UK.
Lucas Mearian covers storage, disaster recovery and business continuity, financial services infrastructure and health care IT for Computerworld.
Disease prevalence, aging, and cost pressures seen as major factors in soaring demand for remote monitoring devices.
The global telehealth market is headed for explosive growth over the next decade, according to a new report from InMedica, a division of IMS Research. The main reasons are increasing disease prevalence, an aging population, and governmental pressure to hold down healthcare costs.
"Many public healthcare systems now have targets to reduce both the number of hospital visits and the length of stay in hospital," said Diane Wilkinson, research manager at InMedica, in a press release. "This has led to a growing trend for healthcare to be managed outside the traditional hospital environment, and as a result, there is a growing trend for patients to be monitored in their home environment using telehealth technologies once their treatment is complete."
HP's Chairman, Ray Lane, sat down for an exclusive fireside chat and discussed the company's strategy, product direction and some of the missteps in communicating all of that to its customers.In 2010, the report said, unit shipments of telehealth equipment worldwide were worth only $163.3 million, with North and South America accounting for $122.9 million of that amount. But in 2015, forecasts InMedica, the world total will be $990 million, and by 2020, the market will soar to $6.28 billion. At that point, the Americas will contribute just 36% of the total.
"By far the most established market for telehealth at present is the U.S., as evidenced by the Veteran's Health Administration's extensive home telehealth service, which aims to have 92,000 patients enrolled on telehealth services by 2012," Wilkinson commented. "There has also been some large-scale trial activity in Europe, most notably in the U.K. in 2010 and 2011, where [primary care trusts] have initiated some projects involving more than 2,000 patients." Asked why InMedica foresees telehealth growing so rapidly, especially after 2015, InMedica spokesman Wes Rogers cited several factors in an email to InformationWeek Healthcare. These included high acceptance of telehealth by patients and medical professionals, nationwide rollouts of telehealth systems in Western Europe, and expanded coverage of telehealth by Medicare and private insurers in the U.S.
Mary Beth Chalk, cofounder and chief marketing officer of Healthrageous, a Boston area startup that combines remote monitoring with health coaching, believes that InMedica's analysis is basically on target.
"We don't have the capacity in the U.S. system for people to simply passively get ill and then rely on the healthcare system to fix them," she said. "There aren't enough physicians to go around, and there's not enough money. So there really isn't any choice but to figure out how to leverage technology to enable consumers to become more effective in self-managing their illness."
Health insurers pay for some devices, such as blood pressure cuffs and glucose meters, which help people with chronic conditions track their health, Chalk notes. But what's needed to make remote monitoring a real business is for health plans to pay for "connected devices," including the systems that allow the transmission of data. She sees rising interest in this among health plans, but the prices of these systems will have to drop before there will be widespread coverage, she predicted.
According to InMedica, unit shipments of telehealth "gateways"--the equipment required to transmit data from home monitoring devices--totaled 67,000 in 2010. They're expected to grow to 561,000 in 2015 and to exceed 3.5 million units by 2020. The most common type of gateway is the "health hub," which sends data from a patient's home. However, there has been a surge in the use of mobile integrated gateways that allow patients to monitor their health with mobile devices. Peripheral devices for remote patient monitoring will also take off like a rocket, InMedica predicts. "In 2010, the combined unit shipments of home-use digital blood glucose meters, blood pressure monitors, weight scales, pulse oximeters, and peak flow meters used in telehealth applications were estimated to be around 134,000," the report stated. "By 2015, the unit shipments are forecast to grow to over 950,000."
In 2010, the biggest categories of peripherals were blood pressure monitors and weight scales, and these will remain tops in 2015 and 2020. Third place goes to blood glucose meters.
Wireless devices--most equipped with Bluetooth--accounted for about a third of the total in all categories in 2010, except for pulse oximeters and peak flow meters, where there was much less use of wireless. By 2020, shipments of wireless devices will form a much higher percentage of the total, surpassing shipments of wired blood glucose meters and weight scales, InMedica projected.
InMedica views the evolving telehealth market as a convergence of several major players, including telehealth companies, device manufacturers, healthcare agencies, healthcare providers, and telecommunications companies.
In a report earlier this year, the research firm predicted, "Consumer telehealth will be an extension of the current home-use medical device market, with manufacturers offering additional Internet-based services to people that purchase their monitors. These services are expected to include simple analysis of readings and some level of generalized feedback that may include dietary and nutritional advice."
Find out how health IT leaders are dealing with the industry's pain points, from allowing unfettered patient data access to sharing electronic records.
"I think the monitor was easy for me, because I don't have to go to the hospital every day to do my exercises, and at home I feel better, much much better."
Nativo Mira Esplugues is an active 85-year-old from Delta del Ebro, near Barcelona in Spain. He is recovering after having had a total knee replacement.
The unit shows the patient how to do the exercises. This is serious surgery, with a long recovery time. Nevertheless the wound is healing nicely, and he was discharged from hospital after just a week.
Normally Mr Esplugues would attend daily physiotherapy sessions. Instead, he is being monitored remotely through an interactive terminal at home.
He accesses the service through a touch screen interface, which shows him what to do.
"The application is no problem, you have only to touch the screen and that's all. The machine says to you what you have to do," he says.
It is connected to the internet by 3G, meaning the unit is not only portable, but accessible to people without broadband - which accounts for 85% of over-75s in Spain.
He straps on sensors containing accelerometers - devices which help ensure he is exercising correctly. They send data on his progress through the telemonitoring unit to his health care professionals.
Mr Esplugues is pleased with the system.
"Somebody has to take me to the hospital and back to my home. Here at home I feel better because I can choose my time, I can make my exercises at seven o'clock or eight o'clock or nine o'clock."
The technology has been developed by telecoms giant Telefonica.
An ageing - and expanding - population is presenting health care providers and governments with a budgetary crisis. In Europe about 7% of GDP is spent on healthcare, and in the US that figure rises to 15%.
Telecoms companies are also facing challenging times, with traditional markets reaching saturation, forcing them to explore other revenue streams. Vodafone, Orange, AT&T Wireless, Turkey's Avea, and Japan's NTT DoCoMo are all investing in mobile healthcare.
At the Institut Municipal d'Investigació Mèdica (IMIM), attached to Barcelona's Hospital del Mar, cardiologist Dr Josep Comín is talking to one of his chronic heart patients at home, using video conferencing.
The patient is being followed through the remote monitoring terminal. The device tracks weight and heart rate, with scales and a blood pressure cuff using bluetooth technology. If a test is missed, a nurse contacts the patient to find out why.
Dr Comín is leading a study evaluating the system. He has worked with Telefonica since 2008, refining the software and hardware.
The patients come from an existing programme monitoring those with high-risk chronic heart failure through out-patient appointments. This has seen mortality rates fall from 45% in the first year after admission to 8%, and Dr Comín hopes remote monitoring will continue this.
A third of patients are unable to attend appointments, due to infirmity or distance, he says. "[Patients] can reach professionals very quickly and easily, so there's no need to transfer patients to other hospitals. At the same time the tool enhances self-care behaviour, because the patient takes care of his own condition.
"In terms of cost-effectiveness, most of the interventions are made by nurses who have back up from cardiologists, it saves time as one nurse can take care of many patients at the same time."
"In the pilot study we've had patients without any literacy at all who have been using these systems." Telefonica's investment in eHealth has been considerable, with a dedicated research and development facility in Granada.
Other innovations include a system to monitor elderly people, who are tracked through their mobile phone and a web interface. If they stray from a defined area, or have a fall, a text message is dispatched to two designated numbers. For doctors, a video conferencing application allows them to share video and images.
Director of the eHealth unit, Álvaro Fernández de Araoz, feels that Telefonica's position as an integrated telecoms provider - both landline and mobile - is vital.
"One of the opportunities we have seen in the market is that patients are starting to be more aware of their diseases, there's more information," he says. "People are growing older. About 16% of the population of Europe is above 65 and people have more chronic diseases, which at the end of the day is about 75% of the cost of healthcare."
Breathe of life
It's not just telecoms companies that are finding innovative ways of using mobile technology in the sector.
Dr Victor Higgs is the managing director of UK-based Applied Nanodetectors, which has developed a way to use mobile phones to monitor the health of asthma patients. The condition affects one in 20 people worldwide and costs 40bn euros ($52.5bn; £34bn) a year to treat, says Dr Higgs. "If you think about your street, one in four houses, there'll be a family that suffers from asthma."
A chip that contains a nanosenor 100 million times more sensitive than a breathalyser is housed in an ordinary handset.
Each day, the patient breathes on the chip, which reads the gases in their breath, and sends the data to a healthcare professional for analysis. It is looking for nitric oxide, which is produced when the lungs are inflamed.
Once the analysis is complete the patient receives the results by text message - although they can choose email, a voice call or even messages through social media platforms such as Twitter and Facebook.
If there is a problem, the message may tell them to adjust their medication or visit their GP. Dr Higgs says both patients and healthcare providers benefit.
"The aim is to give the patient a tool to more effectively manage their chronic condition, so this will minimise the number of times they visit their GP, hopefully minimise the number of times they become quite ill, and also of course the direct benefit of this is reduced visits to the healthcare practitioners, reduced costs and fewer expensive drugs."
The chip is being trialled, and Dr Higgs is working with companies and hospitals to bring the product to scale, and possibly use it for other diseases including lung cancer.
Medical phone apps, are also booming. James Sherwin Smith is the chief executive officer of non-profit organisation d4, which recently partnered with medical app store Happtique.
"MHealth is a huge enabler for technology and healthcare. What's important is to make it portable and available, at point of care if you're a health care professional, or at home if you're a patient."
Developing mobile medicine
Sophie Powell, the editor of the Mobile Healthcare Summit, says that in 2010, the global healthcare market was worth $50bn to $60bn (38bn to 48bn euros; £39bn-£32.5bn). "Mobile health care is really starting to take traction and if you consider the high penetration of mobiles globally then they really are the future."
For the developing world, the implications of mobile healthcare are huge. In sub-Saharan Africa, 70% of people have a mobile phone.
Joel Selianko is a former Wall Street computer expert turned paediatrician and in 2004 he set up Datadyne with former Red Cross IT expert Rose Donna. Their Episurveyor application enables public health data collection in developing world countries. Initially the software worked on palm pilots, but Dr Selianko began to realise there was a more cost-effective option.
"I was thinking to myself how can we raise enough money to buy a palm pilot, and maybe a spare palm pilot, for every single health worker in sub-Saharan Africa. What saved me from going down that wrong path was slowly realising that every one of the workers I was looking at buying one for was increasingly likely to be walking around with a mobile phone on their hip."
Rather than software that needs to be installed, the Episurveyor app is available online. There are about 3,000 users in 150 countries.
"We put it online so there was no installation. We made it free so there was no barrier to adoption. And we made it simple - and this is super important - we made is so simple that no one needs to hire any consultants or programmers to operate it."
The charity Unicef also has a data collection app called Rapid SMS. In Rwanda it has cut the death rate among pregnant women and babies by 50%, by offering access to emergency care.
Erica Kochi is co-lead at Unicef's New York-based Innovations Unit. The NGO is keen to partner with telecommunications companies to develop their offering. "I think the mobile platform is incredibly important for the work of NGOs and development in general. It allows us to expand the reach of the programmes we have and create efficiencies within them."
David Bull, executive director of Unicef UK, is equally enthusiastic. "We're able to raise money through text messaging, to spend saving children's lives and mothers lives through the application of text messaging. It's a fantastic virtuous circle."
Mobile devices and services are transforming the way people all over the globe live, work, play, and provide or receive medical care. By some estimates, there are now more than 3.5 billion mobile phones in use worldwide, and it’s likely that figure will double in the next decade.
Because so many people can and do use mobile devices, this trend is having a major impact on the healthcare industry—giving spawn to two relatively new concepts: eHealth and telemedicine.
eHealth is probably best described as healthcare supported by electronic processes and communication, encompassing all medicine/healthcare information technologies such as electronic health records, health knowledge management, and healthcare information systems.
Telemedicine is the modern form of in absentia health care that involves using audiovisual media for medical consulting and sometimes even performing remote procedures or exams.
The telemedicine and eHealth trends are putting pressure on mobile service providers to enhance and expand their offerings to support portable delivery of healthcare. There is a symbiotic relationship at work here: technology now available supports mobile applications for healthcare, and this in turn drives demand for developing new and better technologies and services.
For services providers, the bottom line is that a huge business opportunity exists to support and drive the growth of mobile healthcare. This fits into the broader trend that providers can only realize full value from their networks by moving into the application space. If they don’t do this, they’ll be unable to sustain their businesses and will also face imminent obsolescence.
“The industry is facing an inflection point where costs are greater than revenues even though the cost per MB continues to decrease,” Alcatel-Lucent (News - Alert) noted in an analysis of current market trends.
Service providers unable to grow revenue as network traffic increases will soon be out of business. Mobile healthcare can be part of the strategy to address this challenge—but only through developing new business models built on partnerships. The assertion that partnership-supported services can help ensure business sustainability is backed up by research.
Here’s one example: Alcatel-Lucent reports that 71 percent of network providers launch less than five applications each month; providers that launch more than five apps are able to do so because they utilize a third-party hosted store or a developer platform.
Application developers are eager to form such partnerships; Alcatel-Lucent reports that 75 percent of them are willing to pay network providers for subscriber preferences and locations.
The writing is on the wall: meeting market demand for mobile healthcare services requires developing partnership-based business models.
Mae Kowalke is a TMCnet contributor. She is Manager of Stories at Neundorfer, Inc., a cleantech company in Northeast Ohio. She has more than 10 years experience in journalism, marketing and communications, and has a passion for new tech gadgets. To read more of her articles, please visit her columnist page.
Ever since Apple’s AppStore created a dedicated category for medical applications for the iPhone and iTouch, it seems that “the medical community is flocking to the iPhone,” as an Apple executive put it last summer.
Back then we cobbled together the first half of the timeline featured below. At the time the launch of the iPhone 3.0 operating system, was the talk of the mHealth town square, especially since Johnson & Johnson company LifeScan was featured onstage. The timeline included a number of the major milestones and interesting developments that related to the medical community and the iPhone.
Even though Apple announced this month the latest version of its operating system, iPhone 4.0, with no mention of medical or health apps, a few readers’ requests to update this Apple iPhone timeline. It now spans 18 months of health-related iPhone news.
Be sure to let us know what we missed in the comments. While extensive this list is far from exhaustive:
November 29, 2008: A medical student successfully lobbies Apple to create a “medical” category for applications in the AppStore that would include mostly applications for physicians, nurses and other healthcare workers. The new category took 82 applications from the still existing Health & Fitness category and marked the first spin-off category Apple has created.
January 22, 2009: Epocrates Essentials becomes available in Apple’s AppStore for iPhone and iTouch users.
February 12, 2009: During a question and answer period at a medical records event in Palm Springs, CA, the Food and Drug Administration’s Don Witters says that there may be circumstances where the iPhone should be considered a medical device and regulated as one.
March 17, 2009: At Apple’s special sneak preview of iPhone OS 3.0, Scott Forstall, SVP of iPhone Software at Apple gushed: “Now here’s a class [of services] that we think will be really interesting: medical devices.” Forstall explained that the new iPhone OS will allow application developers to sync medical devices like BP monitors via both Bluetooth and USB. “So imagine the possibilities,” Forstall continued. “We think this is profound.” Apple then invited a rep from LifeScan, a Johnson & Johnson company onstage to demonstrate how a Bluetooth-enabled blood glucose monitor synchs up to a diabetes management application running on the iPhone.
March 31, 2009: An iPhone developer uses Google Health’s API to create Health Cloud, which allows Google Health users to view their personal health record from their iPhone. Google has yet to take the PHR mobile itself.
April 8, 2009: AirStrip Technologies announced that the FDA had granted the company’s iPhone application, AirStrip OB, clearance to market the app to physicians via Apple’s App Store. AirStrip OB enables obstetricians to use their iPhones to remotely access real-time and historical waveform data for both the mother and the baby. The data set includes heart tracings, contraction patterns, nursing notes and exam status. The app pulls the data from the hospitals’ labor and delivery units. AirStrip has been planning its iPhone launch since July of 2008.
April 9, 2009: By many accounts, Sarasota-based start-up Voalte steals the show at the HIMSS event in Chicago with its iPhone-based voice, alarm, text service for physicians, nurses and other hospital workers.
April 15, 2009: Manhattan Research finds that twice as many doctors are using iPhones in 2009 than were in 2008.
April 17, 2009: A pediatrician in New York is the first to access Allscripts’ popular electronic medical record using the company’s new iPhone application.
April 21, 2009: The “medical” category in Apple’s iPhone AppStore becomes the third fastest growing category of applications for the first quarter of 2009, according to O’Reilly Radar.
April 30, 2009: Doylestown Hospital, located outside of Philadelphia, PA, recently outfitted its 360 independent physicians and hospital staff with 3G iPhones in an effort to help them save time, be more productive and provide better care for their patients.
May 1, 2009: Winner of the $10,000 DiabetesMine Challenge effectively turns the iPhone into the controller for a combined glucose meter + insulin pump.
May 5, 2009: At the height of the “swine flu” or H1N1 media frenzy, a number of quick coding developers created apps that helped people track swine flu cases’ locations, determine if their symptoms were signs of swine flu and more. The rush to create swine flu apps demonstrated the platform’s ability to offer timely applications to the market when needed, which could come in handy for future public health events.
May 29, 2009: Dr. Natalie Hodge emerges as “The First iPhone Doctor” by running a pediatrics concierge service called Personal Pediatrics almost entirely from her iPhone.
May 31, 2009: Scott Eising, director of product management for Mayo Clinic Internet Services, said the launch of the iPhone and the success of its AppStore convinced him and his colleagues that the time to figure out a mobile strategy is now.
June 8, 2009: At Apple’s World Wide Developer Conference AirStrip’s Dr. Cameron Powell takes the stage to demonstrate how the new iPhone 3.0 operating system lets “push” notifications from its remote wireless monitoring device transmit EKG systems to a doctor’s or clinician’s mobile phone. Apple’s Mark Wilson reportedly said that “The medical community is flocking to the iPhone” at the WWDC event during his introductory remarks for AirStrip.
June 9, 2010: Apple puts FDA regulatory onus on developers. Under the iPhone developer agreement section labeled “Regulatory Compliance for Health, Medical and Related Apps,” Apple writes: “You agree that You will not seek any regulatory marketing permissions or make any determinations that may result in any Apple products being deemed regulated or that may impose any obligations or limitations on Apple. By submitting Your Application to Apple for selection for distribution via the App Store, You represent and warrant that You are in full compliance with any applicable laws, regulations, and policies, including but not limited to all FDA laws, regulations and policies….”
June 15, 2009: Audi Lucas and Tim Gee debate whether Apple’s regulatory policy for its apps developers is reasonable.
June 19, 2009: Dr. John Halamka dubs mHealth the “Cool Technology” of the week: “The iPhone is quickly turning into a major resource for accessing mobile health applications. Although I find the iPhone a challenging device for data entry, it’s a great device for data viewing. Realtime viewing of waveform, imaging and text data via a handheld mobile device. That’s cool!”
June 19, 2009: Boston’s Children’s Hospital’s Informatics Program published a group of principles to guide the creation of a new health information infrastructure for the U.S. The piece was a follow-up on an article published in The New England Journal of Medicine in March. The latest article argued for the development of a platform model, very much like Apple iPhone’s setup, to encourage the development of “substitutable” health care applications.
June 24, 2009: Dr. David Kibbe predicted that successful EMR vendors should look to the iPhone for inspiration. Once EMR vendors begin to open up their APIs, the industry will begin to see thousands of new applications built on the EHR platform just like Apple’s AppStore, Kibbe predicted.
June 25, 2009: The USPTO grants Apple an iPhone-related patent that covers wireless remote monitoring of vital signs.
July 1, 2009: Apple’s senior director of worldwide product development for the iPhone recently left the company to join venture capital firm Opus Capital as a general partner. Bob Borchers, 43, previously worked at Nokia and Nike before joining Apple in 2004. Borchers told VentureWire he won’t be leaving the wireless industry: his focus at Opus will include wireless and medicine as well as mobile marketing technologies.
August 7, 2009: Aetna’s head of eHealth Product Management, Dan Greden: “The opportunity [with the iPhone] is we don’t have to ask [iPhone users] to wear another device to do this we can tap into their existing device they are already wearing,” Greden said. “Just add an app to it. Last I checked there were half a dozen iPhone apps that we are working on integrating now.”
August 11, 2009: Zepherella has added an iPhone app pilot to its online service, which aims to give physicians and patients an efficient and stress-free way to complete payment transactions online or through the iPhone.
August 25, 2009: Matthew Connor, a rising junior at Princeton University received a $100,000 grant from Center for Integration of Medicine and Innovative Technology (CIMIT) to build a more in-depth online portal for his diabetes management iPhone app, Islet, which Connor and his brother launched last September.
August 25, 2009: A survey of 1,000 medical students conducted by Epocrates found that 45 percent of the students that had a smartphone owned an iPhone — far more than any other type of smartphone. What’s more, nearly 60 percent of those medical students who did not have a smartphone planned on buying either an iPhone or an iPod Touch within the next year.
September 11, 2009: “The iPhone can be an integral part in advancing the fundamental science — the very complexities of biology and understanding of the human genome can be made accessible through tools like the iPhone,” Consumer genomics company Illumina’s CEO and President, Jay Flatley told Apple in a recent interview. “I think it is the convergence of the science and IT technology that today creates a unique possibility to manage our human health in new ways,” Flatley said. “It’s an incredibly exciting time.”
September 16, 2009: It was a hard fight to get insurance companies to cover dedicated text-to-speech devices for speech-impaired patients, but it finally happened in 2001, according to a report in The New York Times. Kara Lynn, an ALS, or Lou Gehrig’s disease patient, used to use a PC with text-to-speech software loaded on it because that’s what her insurance would cover. The computer had to be stripped down of all other capabilities to be eligible for coverage — no web browsing, email — nothing. As you might imagine, however, Lynn wanted to “take her voice with her” where ever she went, which wasn’t possible with a PC. Instead she bought an iPhone and an iPhone application that she believes works better. Insurers, of course, won’t cover it.
September 28, 2009: The US federal government’s first Chief Technology Officer Aneesh Chopra explains how he uses his iPhone to track his eating habits: “Everyday today when I visit a certain coffee shop, I enter into my iPhone — I click, click, click — and it tells me exactly what my sugar consumption patterns were from that grande vanilla nonfat latte, and it becomes very clear to me what this has done to my nutrition habits.”
October 8, 2009: Voalte announced this week a collaboration agreement with Sarasota Memorial Hospital that sees the care facility’s nurses using Voalte’s iPhone-based voice, alarm and text offering. The service allows Sarasota Memorial’s nurses to send and receive text messages, make voice calls, and receive critical care alarms through their iPhones in an effort to provide faster response times for their patients. The hospital began piloting the Voalte service in June.
October 14, 2009: “Last month, Stanford Hospital & Clinics, in Palo Alto, Calif., started a trial with Apple and Epic Systems … to test software that will let medical staff access patient charts on Apple’s iPhone,” the WSJ reported.
October 23, 2009: Earlier this month at the Body Computing Conference in Los Angeles, Boston Scientific showed off a concept iPhone app, called Latitude Connected, that is currently focused on cardiac rhythm care management, but its full range of functions enable physicians to access patient records, monitor implanted devices, tap into patient support networks and schedule follow-up care, according to a report from Fast Company.
November 4, 2009: During its third quarter conference call this week, WebMD announced that its Medscape Mobile iPhone application, which it launched in July, has already been downloaded more than 200,000 times. Medscape Mobile is an app the company created for physicians, but WebMD said the total number of downloads for its consumer iPhone apps now tops 1 million downloads — and its first consumer iPhone app was launched less than a year ago.
November 18, 2009: RidRx’s new iPhone peripheral, iStetho Adapter enables users to connect old stethoscopes to an iPhone or iPod Touch. The company also developed an iPhone app, iStethoscope Pro, and suggests that users look to iPhone apps iMurmur or iAuscultate to analyze the sounds from the stethoscope better.
November 30, 2009: Asim Choudhri, MD, a physician in the neuroradiology division at Johns Hopkins University in Baltimore presented a study 15 of the 25 patients were correctly identified as having acute appendicitis. These diagnoses proved accurate for 74 out of 75 interpretations, which is about 99 percent of the time. There was only one false negative — and no false positives.
December 1, 2009: Bradley Merrill Thompson explains how to get the FDA to clear a mobile health app.
December 11, 2009: Apple announced the top selling apps, songs, games and podcasts from 2009 in an iTunes feature it called iTunes Rewind 2009. Perhaps surprisingly, one medical iPhone app made the list of the top 30 selling iPhone applications in 2009: Proloquo2Go. The app, which costs $189.999, appears among apps that generated the most revenue in 2009, which seems to be how Apple created a list of the Top Selling apps for the year. “Proloquo2Go is a new product from AssistiveWare that provides a full-featured communication solution for people who have difficulty speaking.”
December 14, 2009: While Apple supports the Nike+ activity monitor and has demonstrated a connected blood glucometer made by Lifescan at its iPhone 3G unveiling, its movement toward championing peripheral health devices for the iPhone has been decidedly limited to date. However, a recent patent application points to the a lot of activity on the connected health front inside the company’s research and development teams: An Apple patent describes a couple of methods for using a wireless earbud to track a user’s blood oxygen level, body temperature, heat flux and heart rate. The patent application notes that the earbud could use infrared photodetectors to monitor the user’s biometrics.
January 6, 2010: Mayo Clinic has partnered with smartphone application developer DoApps to form a new start-up, called mRemedy, which is focused on creating health apps for smartphones. mRemedy’s apps will be based on Mayo Clinic’s research and services. The first mRemedy app, Mayo Clinic Meditation, launched last week for Apple’s iPhone and iPod touch.
January 13, 2010: After three months of rumors, details surrounding Epic Systems’ partnership with Apple for a mobile phone-based electronic health record (EHR) application have come to light: Just a few days ago, Epic System’s iPhone application, called Haiku, became available on Apple’s AppStore: “Haiku provides authorized clinical users of Epic’s Electronic Health Record with secure access to clinic schedules, hospital patient lists, health summaries, test results and notes. Haiku also supports dictation and In Basket access.”
January 20, 2010: American film producer, Dan Woolley, was trapped in the ruins of a hotel in Port-Au-Prince, Haiti during last week’s earthquake. Woolley used the light from his digital camera to examine his broken foot and head wound. He then used a medical application on his iPhone to look up how to dress his wounds, which included a broken foot and a head wound, according to the report. Woolley said that during the 65 hours that he spent in the ruined hotel’s elevator shaft, he also looked up symptoms for shock using his iPhone medical app.
January 27, 2010: Apple confirmed the rumors today and unveiled a tablet device, which looks like a giant iPhone, called iPad. While Apple CEO Steve Jobs and his team of presenters at Apple’s iPad launch event this morning did not mention the healthcare vertical as a key market for the iPad: It looks to be just that.
February 8, 2010: Epocrates surveyed 350 clinicians to gauge their interest in buying the iPad for use at work: “Nine percent of survey respondents plan to buy the iPad when it was immediately available, another 13 percent plan to buy it within the year, thirty-eight percent of respondents expressed interest in the iPad with the request of more information to solidify their purchase decision.”
March 15, 2010: MIMvista, the iPhone app the FDA asked to be taken out of the AppStore: In August of 2008, we submitted our first 510(k). We knew that the iPhone software raised new issues as compared to workstation software, specifically in terms of its intended use. On the iPhone, the images would be viewed under different circumstances than are typical for radiologists (reading rooms). This difference did raise new issues of safety and effectiveness. To be honest, this dramatically new direction for our company, and the speed at which it occurred, left us ill-prepared for the scope of the regulatory process that would unfold. Within only a few weeks of submitting, we were contacted by the FDA and told that our app could not be on the app store (despite the fact that it was both free and labeled as “not intended for diagnostic use”) because it served as marketing for a device that was not cleared for marketing. We promptly removed it.
April 8, 2010: The HHS and the Office of the National Coordinator for Health Information Technology (ONC) have awarded Harvard Medical School and Children’s Hospital a $15 million grant for a four year research project to “investigate, evaluate, and prototype approaches to achieving an ‘iPhone-like’ health information technology platform model.”
April 8, 2010: Apple announces the iPhone OS 4.0, which includes 1500 news APIs for developers and new features, including multi-tasking. iPhone users with the OS 4.0 installed will be able to keep more than one app running at the same time, sort of.
April 23, 2010: Nick Volosin, director of technical services, at Visali, California-based Kaweah Delta Health Care, has been piloting three Apple iPads for X-ray images, EKG results and other patient monitoring programs, according to a report from Network World. Volosin now plans to buy 100 more iPads for use by the care group’s home health and hospice care workers, nurses, dietitians and pharmacists.
Sanjiv Agarwal, CEO of teleradiology specialist 4 Ways Healthcare explains how teleradiology can help reduce the costs of radiology whilst improve working practice and patient care, helping Trusts avoid penalties.
With increasing pressure on radiology departments and a shortage of radiologists, just handling and reporting on the everyday flow of scans can seem an insurmountable task, and as we've seen in recent years, reporting backlogs can build with frightening rapidity, putting patients at risk and exposing the hospital Trust to the risk of penalties.
Radiologists are constantly multitasking, splitting their time between duties including; ultrasound scanning, interventional procedures, reporting multidisciplinary meetings and On Call. Clerical staff are stretched with making / changing appointments, report sending, referral scanning along with all the duties involved in a modern Radiology department. So often the Radiographers work extended hours to provide a superb service to fulfil the throughput of patients required for NHS service levels only to create backlogs in reporting.
Given this the idea of calling in additional expertise to help manage the workload makes sense. However with the annual cost to a Trust to employ a radiologist upwards of £100,000, this can be a squeeze on finances.
Teleradiology offers Trusts a solution which not only tackles the issue of resource, but also the issue of cost - an apparent win-win solution. But how exactly does calling in extra radiology expertise achieve this? And how do you ensure that the teleradiology service you choose will deliver on the promise? Lets take a look at the key benefits teleradiology offers.
Cutting costs Teleradiology provides a value for money offering which delivers cost savings to the Trust. Our analyses show that compared to employing full time radiologists, annually the cost of teleradiology to a Trust is 25% less and up to 50% less than providing locum cover.
Furthermore teleradiology service costs are predictable. There are no additional connectivity or IT costs, and being pay-as-you-go, you have the flexibility to use the service for as long or as little as you require it, meaning there are no long-term fixed overheads.
Resourcing Teleradiology also resolves the issue of staff shortages. With holidays and sickness, the average annual availability of a radiologist is 40 weeks, meaning there will often be times when reporting backlogs could build up. This can put patients at risk and expose the hospital Trust to the risk of penalties.
Being a turnkey service teleradiology can be adopted instantly, saving time and resource compared to the procurement of new staff, giving hospitals an effective quick fix solution for covering absenteeism. With access to a team dedicated to you, using teleradiology is not outsourcing, but resourcing.
Workload management using experienced clinicians Teleradiology gives you the flexibility to use the service as and when you require it. During busy periods where there is an unexpected influx of workload expert teleradiology can provide additional interpreting capacity to manage any extra work to help hospitals clear backlogs and keep up-to-date, and it can do this to the highest clinical standard, using experienced NHS consultants.
This helps ensure hospitals bridge any reporting gaps to maintain high levels of patient care and avoid unnecessary penalties.
SLA bound turnaround Teleradiology ensures scans are handled and reported on in the timeframe you require. Set SLA response times for problem resolution and image quality issues will ensure expectations and requirements of the service are clear- for both you and your service provider, giving you peace of mind that your provider's promise will meet performance, ensuring business continuity.
Quality assurance Any good teleradiology provider will demonstrate robust and tested clinical governance with real clinical audit data, giving assurance that the service you are receiving is of the highest quality. By sharing their knowledge, auditors can offer real benefits to reporting radiologists, promoting learning whilst giving them the opportunity to objectively demonstrate the quality of their work.
Expectations Now you know what to expect from teleradiology, what should you expect of your provider?
Your teleradiology provider should use UK-based NHS consultant radiologists with sub specialist interests, delivering a reporting service using a core team that is specific to your needs.
Your provider should also have a robust in-house system and be able to interface securely with existing NHS IT systems and processes, meaning you avoid the need to deploy new equipment.
And finally, your provider should be able to deliver reports in the format you require, with a fast turnaround - day or night.
In essence teleradiology providers should be at the centre of your radiology operation, playing an active role - not only in terms of interpretative services, but also with regard to clerical support, becoming an active part of your healthcare team.
About 4 Ways Healthcare 4 Ways Healthcare, is a medically led Specialist Diagnostic Service provider to both public and private healthcare sectors. The Company is headquartered in Hemel Hempstead, Hertfordshire, where its primary PACS hub is situated. Growing rapidly, the Company offers a wide range of services coupled with Career Opportunities in many areas. For more information, visit www.4whc.com.
By CATHERINE SAINT LOUIS The New York Times January 20, 2010
IMAGINE the ease. It’s 2 a.m. and you can’t stop thinking about your saggy midsection. You log on to SurgeonHouseCall.com and create a free patient profile declaring your wish to get a tummy tuck. You fill out a brief medical history and include photographs of the problem area.
In no time, three plastic surgeons offer detailed opinions on the best course of action — with price quotes. It’s as if SurgeonHouseCall.com co-opted the LendingTree slogan, “When banks compete, you win.”
In less than a year, SurgeonHouseCall.com has recruited 55 plastic surgeons nationwide to offer opinions. Meanwhile, dozens of plastic surgeons also offer virtual consultations on their own Web sites. But does a patient who gets a plastic surgeon’s recommendation before a face-to-face visit really “win?” Conservative plastic surgeons say it’s fine to send an e-mail message with general information about a range of procedures to a patient, but the practice of offering a diagnosis without ever having met a patient can be problematic.
What’s more, offering a surgical recommendation to a distant patient may violate state laws, if the plastic surgeon isn’t licensed in the home state of the patient, according to the Federation of State Medical Boards, a nonprofit group representing 70 boards in the United States and its territories. Critics also say that patients’ poor-quality pictures don’t provide doctors with adequate information. And patients seldom realize that no virtual recommendation is solid without an office consultation and medical clearance.
Advocates of virtual consultations suggest that they are convenient and that receiving multiple opinions online benefits a prospective patient. “It changes the first in-person consultation, empowering the patient with knowledge of the procedure, decreased anxiety level and financial readiness,” said Dr. Jason L. Mussman, the founder of SurgeonHouseCall.com. (Dr. Mussman, a resident at Loma Linda University in California, isn’t one of the board-certified plastic surgeons offering his services on the site because he hasn’t been certified by the American Board of Plastic Surgery.)
Out-of-town patients are the primary users of virtual consultations, in which a doctor may offer an opinion in a video chat, an e-mail exchange or a phone conversation. Convenience is the main draw, but a few surgeons also cited the anonymity of the situation, which is attractive to shy patients.
“They want a semi-anonymous type of evaluation,” said Dr. Dean P. Kane, a plastic surgeon in Baltimore who offers online consultations. “They want to know cost, and what you get for that cost before they make a commitment, before they walk through that door.” Most plastic surgeons don’t offer virtual consultations. However, in an age when many Web-savvy plastic surgeons answer questions at cosmetic enhancement sites like RealSelf.com, plenty feel comfortable dispensing opinions to patients they’ve never met.
Some promise to evaluate pictures quickly and to call back with their expert opinion. Others charge $100 to screen patients to see if they are appropriate candidates.
The Web site of Dr. Barry Eppley, a plastic surgeon in the Indianapolis area, promotes “Webcam consultations with Skype.” But in a phone interview, Dr. Eppley called them “online conversations” because, he said, “Technically it’s not a consultation. You’re not going to jump from an online consultation to surgery. You’re using the online thing as a connection.” And because those virtual connections bring in new patients, they are, in effect, marketing tools that some plastic surgeons consider crucial in this difficult economic climate.
Dr. Eppley said he often persuaded out-of-state patients after just 20 minutes of a Skype chat. “They do move ahead,” he wrote in an e-mail message. “Regardless of where they are geographically,” he said, “people will come to you because they connected with you.”
Experts like Dr. Loren S. Schechter, the chairman of the patient safety committee for the American Society of Plastic Surgeons, worry about patients getting a hard sell. Consultations “shouldn’t be about selling the surgery,” he said.
Providing a diagnosis to patients across state lines also raises legal issues. Dr. Humayun J. Chaudhry, the president of the Federation of State Medical Boards, said that according to its guidelines a patient-doctor relationship is “clearly established and begun when a physician agrees to undertake diagnosis and treatment of the patient, and the patient agrees.” Such a distinction matters, because usually doctors should only be able to care for patients in states where they are licensed.
All the plastic surgeons interviewed for this article insisted an in-office consultation took place prior to surgery. However, when doctors first examine out-of-towners — who often arrive 24 to 72 hours before the scheduled procedure — the doctor’s recommendation might change, or the cost might increase, said Carol M. Martin, an independent plastic surgery consultant who works on behalf of patients. On Skype, Ms. Martin said, the doctor might have stated, “It was going to be X, Y, Z and cost $10,000 but now that I see you in person, it’s going to be $13,000.”
Not being prepared for last-minute changes “seems like the biggest pitfall to me,” said Ms. Martin, who tells clients to meet with three to five surgeons before committing.
Angela Segal, a patient consultant, reviews quotes for women seeking plastic surgery and negotiates a price. (She also helps plastic surgeons with “online social networking marketing.”) But if a patient didn’t have an in-office consultation, she won’t even look at a price quote. “Nothing is more true and correct than actually seeing a doctor in person,” said Ms. Segal, who worked 12 years as administrator in two plastic surgery practices.
She doesn’t trust the pictures patients send in e-mail messages to plastic surgeons for evaluation any more than the ones the lovelorn post at online dating sites. “You expect the doctor to trust the pictures, which is ridiculous.” Since some family practitioners have begun using electronic visits, the American Academy of Family Physicians has established guidelines, including the stipulation that a physician should evaluate only established patients virtually, and only over “safe, secure, online communication systems.”
The American Society of Plastic Surgeons has no policy. Some plastic surgeons make it clear to their patients that communications through their Web site “are not necessarily secure” and that “you assume the risk of unauthorized use” of say, the topless pictures you send for evaluation.
Paramount in this brave new world is ensuring that patients receive the same standard of care online and in person, said Dr. Chaudhry of the medical board association. “It should be the same exact standard as if the patient was in your examining room. You can’t cut corners.”
Plastic surgeons are not the only doctors who do consultations on the Web. Radiologists and dermatologists do some that entail communicating with a far-flung physician; primary-care physicians also keep tabs on established patients virtually.
Dr. John W. Bachman, whose family practice department at the Mayo Clinic in Rochester, Minn., did a two-year pilot study of more than 2,500 online consultations, said the aim should be to improve the standard of online care. One issue that plagues any doctor is that they sometimes forget to ask a crucial question. A computer asked patients in the pilot study questions tailored to find potential oversights. A more structured virtual consultation might have helped Dr. Kane. The day before surgery, he saw an out-of-state woman with whom he had exchanged e-mail messages about rhinoplasty. It was only then that she mentioned her occasional cocaine use. “The problem here is it adds significant risk to the surgery,” said Dr. Kane, who canceled the operation. “Your expectations get knocked down and your patient’s expectations are knocked down.”
So why then does Dr. Kane even bother with virtual consultations? “If I don’t do it, somebody else will do it,” he said, citing the difficulty of having a solo practice in a competitive world. “The technology is there.”
Paula Fortner - iHealthBeat Senior Staff Writer - 10/08/2009
Although the U.S. health care system has dominated the media spotlight in recent months, innovative mobile technologies are helping to fundamentally transform health care in many developing countries.
Last month, the Rockefeller Foundation announced a $100 million initiative to strengthen health systems in Africa and Asia by building capacity, supporting policy interventions and promoting health IT applications. As part of its health IT strategy, the foundation intends to leverage mobile phone-based technologies to improve health care access, quality and efficiency.
Karl Brown, Rockefeller's associate director of applied technology, explained that the foundation sees mobile health technologies "as sort of the front lines of e-health." He said that although servers, databases and Web sites will be necessary to support the mobile phone applications, health workers can use the devices to extend their reach to regions that lack adequate health care infrastructure.
An Environment Ripe for Mobile Health
According to Brown, mobile health tools are particularly suited to meet the needs of developing countries. "The thing that is very compelling about the mobile phone is that it's an infrastructure that is growing very fast of its own accord, and it exists for the most part in a lot of these countries," Brown said. He added, "The mobile phone is much more suited to a lot of these environments in some cases than a computer or a laptop or an Internet connection because it doesn't use a lot of power."
At the AED Satellife Center for Health Information and Technology, staff members work with local and international nongovernmental organizations to develop mobile data collection and dissemination tools. Andrew Sideman, Satellife's associate center director, says many regions of developing countries do not have reliable access to the Internet or even electricity.
"One of the reasons that we were interested in using PDAs, and now mobile phones is that they are very stingy with power," Sideman said. "Because the batteries can last for seven or eight hours between charges, and then they charge very quickly from a solar charger, we can circumvent the issues of not having a strong electric grid infrastructure." Despite limitations in Internet and electricity access, most developing countries have some degree of mobile phone coverage. According to the U.N. Foundation, about 80% of the world's population lives in a region with mobile phone coverage and about 64% of all mobile phone users live in the developing world.
Brown explained that many people in developing countries already possess mobile phones and are familiar with basic functions such as making phone calls and sending text messages. Therefore, he said, it doesn't take long to train people to use new mobile phone applications such as Internet browsers or information systems.
Turning Mobile Phones Into Health Solutions
According to Brown, effective health system management requires active communication about regional health trends and medical needs. He said, "When we look at health IT systems [that] have been successful, it's really where they have been integrated horizontally and systematically so that a single piece of information is collected once, and then used for all sorts of different purposes." For example, mobile health tools could improve clinic management, facilitate disease surveillance, and enable clinical research, Brown said.
At Satellife, staff members are leveraging mobile phone applications to help health care workers access clinical research and collect information for local health ministries. For example, the organization's GUIDE system converts large clinical documents into formats that are easily readable on the small screens of mobile devices. Sideman says the system allows physicians and nurses in developing countries to access current medical research and literature. "The idea was to put it on a device that was small enough so that they could carry it around with them during their working day," he said.
Meanwhile, Satellife's GATHER system is an open-source mobile phone application that allows health care workers to electronically submit reports to district health centers or health ministries. Officials then can use the data to monitor health trends or diseases in a particular region.
Sideman says Satellife also is working with health information exchanges in Uganda and Mozambique. According to Sideman, "Both of these are two-way communication networks, so that as the health workers upload the data that they've collected, and they're sending it to the Ministry of Health, they automatically are receiving a download of health information to their mobile device."
What's Next for Mobile Health Technology?
According to Sideman, mobile phone technology is advancing so rapidly that the cost of using these devices in the developing world is falling every year. Sideman said, "Five years ago, we started by using PDAs and people would say to us, 'That's way too expensive, we can't do that.' And now, because of changes in technology, we've been doing similar kinds of things on cell phones that cost less than half of what we used to pay for the PDAs." He added, "And that's just technology; ... every two years things cost half as much."
Brown said he believes developing countries will see dramatic advances in mobile technology over the next several years as bandwidth access expands, connection speeds increase and costs go down.
He also noted that developing nations have the unique opportunity to benefit from earlier pilots of health IT tools in other countries. He said, "There's an opportunity to leapfrog, whereby you don't need to go through all of the learning of the past 30 years that we've done in the U.S., we can immediately jump to much more integrated, interoperable e-health systems that are based on open standards that already exist today."
Brown said he believes the next step will be to use mobile technology to promote patient-centered health. He said, "If you can put the patient at the center of the health care system and empower them to make better decisions, their portal and the way that they interact with the health system is going to be their mobile device."
Home health aide Carla Butler, left, helps her patient, Wilma Young, adjust the telehealth equipment that records her vital signs and sends the information to a computer in Coffeyville where it is monitored by a nurse. The technology has been effective in reducing hospitalizations and nursing home admissions among the frail elderly. Young and Butler live in McLouth. (Dave Ranney/KHI)
McLOUTH — Wilma Young, 76, can’t stand the thought of moving to a nursing home. “My doctor’s tried to put in me twice, but I beat him both times. I’d rather be right here,” she said, seated in the living room-kitchen of her tiny apartment in this town of about 835 people, 25 miles northeast of Lawrence.
Young is poor and in frail health. She has diabetes, high blood pressure and a weak heart. She has been able to avoid a nursing home because she has a Medicaid-funded home health aide who looks after her and because, every day, a nurse checks her weight, blood pressure, pulse, blood sugar level, and oxygen intake.
The nurse isn’t in McLouth. She’s three and a half hours away, in Coffeyville, sitting in front of a computer that helps her keep track of Young’s vital signs and those of 74 other senior citizens. Young, her aide, and the nurse are key players in a two-year, Kansas Department on Aging-funded project aimed at using telehealth technology to help the frail elderly remain in their homes, avoid having to move to nursing homes, and, ultimately, saving the state millions of dollars. Young’s home health aide services cost Medicaid about $1,400 a month. If she moved to a nursing home, the likely costs to the program would be $3,200 to $4,000 a month. Medicaid is one of the fastest growing portions of the state budget.
The monitoring technology — a cigar-box-size modem that plugs into Young’s telephone — sends her vital signs to the computer in Coffeyville where they are monitored for hints her condition may be worsening. “A month or so ago, the nurse noticed that Wilma’s blood pressure had been up for about five days in a row,” said Monte Coffman, who runs Windsor Place, the Coffeyville-based company that is monitoring Young. “So she called Wilma’s home health aide and, together, they called Wilma’s physician and he adjusted her medicine over the telephone,” Coffman said. “She’s been fine ever since.” Neither Young nor her aide was aware of the rise in blood pressure. “There’s no way to say for sure,” Coffman said, “but she could have suffered a stroke.”
Dramatic results reported
So far, Coffman said, the 75 Medicaid patients taking part in the telehealth project — all of them frail elderly — have experienced 70 percent fewer hospitalizations than they had in the previous year. “And here’s the best part,” he said, “only one of the 75 has had to go to a nursing home.” Coffman figures the project, which has cost about $290,000, has reduced the state’s Medicaid costs by about $1.5 million.
But Medicaid does not cover the sort of routine telehealth monitoring that Young and the others are receiving as part of the project, which is being paid for thanks to a Department on Aging grant funded by interest collected as part of a government loan program for nursing homes. Medicare, which Young also qualifies for, won’t cover the costs of her telehealth monitoring, either, though it would pay the bills for a hospitalization.
“There are home health-type agencies that are Medicare certified that provide post-acute care,” Coffman said. “They use telehealth to monitor their patients, but once they stabilize after, say, 30 to 60 days, the equipment is removed because Medicare won’t pay for it.”
Coffman said the project is saving both Medicare and Medicaid money, even though neither program will pay for the cost-saving services. “When we keep Wilma from going to the hospital, we’re saving Medicare money,” he said. “When we keep her out of the nursing home, we’re saving Medicaid money.” And it is relatively inexpensive to set up a home for telemonitoring. Coffman said his company could install the technology and train the aides for about $250 per household.
“After the equipment is installed and up and running, we think we can provide telehealth for less than $6 per day, per person,” he said.
The KDoA project is due to end in October. Coffman has proposed expanding it to include 1,000 Medicaid recipients, a mix of frail elderly and people with physical disabilities.
“It would take some time to get up and running, but the preliminary data indicates we could save the state about $20 million a year,” Coffman said.
But such an expansion would cost about $2.2 million. Department on Aging officials said they don’t have the money to expand the program. “Our budget is such that we can maintain our current caseloads without having to resort to waiting lists,” said KDoA Aging Secretary Marty Kennedy. “Something like this would be a budget enhancement, and those are very difficult to come by this year. But we are hoping to be able to continue to fund the pilot project.”
Earlier this year, the state-funded portion of KDoA’s budget was cut more than 30 percent. Kennedy said the department is leaning toward extending — not expanding — the current pilot project another year.
“We’re very interested in telehealth,” he said, “but I think another year of data would be helpful at this point.” Dr. Ryan Spaulding, director of the Center for Telemedicine and Telehealth at the University of Kansas Medical Center, Kansas City, plans to evaluate the project. “It looks promising, but it’s still a work in progress,” Spaulding said, noting that 75 participants constituted a “pretty small” sample. “We’ll know more in the fall,” when the evaluation is completed, he said.
‘Duck on a junebug’
The chairman of the House Aging and Long Term Care Committee is looking for a way to fund the expansion without tapping KDoA’s budget.
“I’m an avid supporter of this,” said Rep. Bob Bethell, R-Alden. “I’m working with Sen. Sam Brownback’s office to see if there isn’t some stimulus money we can get to fund this. I’m being told there’s a lot that hasn’t been decided. But as soon as I can get some clarification, I’m going to be all over this like a duck on a junebug.”
Dave Ranney is a staff writer for KHI News Service, which specializes in coverage of health issues facing Kansans.
Mobile teleconsulting is a feasible way to evaluate remotely located patients who have just had a stroke, according to a report in the current issue of the journal Stroke. Although researchers found that hospital-based, land-line systems still provide better quality communication.
In a study involving 2 stroke centers and 14 local hospitals in Germany, investigators analyzed telephone consultations performed at fixed telemedicine workstations using high-speed Internet connections and laptops that could be taken to remote sites.
Specifically, the researchers compared the technical parameters, acceptability, and impact on immediate clinical decisions of consultations performed with the mobile vs land-line devices.
The teleconsultants reported that the process took longer when the laptops were used, despite almost identical download time measurements. They also rated the video and audio quality to be better with the hospital-based system.
Although the technical quality of the mobile communication was rated worse on both sides, "this did not affect the ability to make remote decisions like initiating thrombolysis," a "clot-busting" drug treatment for stroke, and the mobile system was technically stable, the authors report.
"During times of low teleconsultation frequency, this service can be provided from home or from elsewhere," Dr. Heinrich J. Audebert from Charite Universitatsmedizin in Berlin told Reuters Health. "Currently, the technical quality of mobile teleconsultation is not equivalent to landline connections."
He and his colleagues point out while mobile devices are feasible in low-frequency circumstances, a hospital-based device would ensure optimal quality when teleconsultation frequency is high.
"Telemedicine in stroke care is only an instrument to make stroke expertise more available," Audebert stressed. It does not replace on-site, high-quality stroke treatment. "Therefore, a lot of specialized infrastructure, training, and quality monitoring are needed in telemedicine networks."
"We are currently investigating the use of telemedicine in pre-hospital stroke care," Audebert added. "We use telemedicine equipment in ambulance cars and patients are examined via videoconferencing before they are admitted to the hospital."
On a dresser next to the bed, a small electronic box is helping Ovelet Coates stay healthy.
Twice a day, the device instructs Coates, 91, to step on a scale and then to take her blood pressure. The scale and pressure cuff are connected to the box, which, in turn, is connected to the phone line in her spotless Bethesda Orchard apartment.
After Coates takes her vital signs, the information is transmitted to her home health nurse, who monitors the data daily to look for problems or patterns.
"It took a little while at first until I got used to it," Coates said. "It doesn't take but a couple of minutes."
Heralded as both time and money savers, telemonitoring and telehealth services are gaining a greater foothold in the increasingly costly health care market.
Telemedicine, which combines traditional health care services and telecommunications technology, can range from a surgeon operating on a patient hundreds of miles away to a nurse checking vital signs from the comfort of her home, according to the American Telemedicine Association.
The burgeoning field has spurred a growing interest in home-health strategies that can help curb costs by minimizing office visits and hospitalization — and may lead to better patient outcomes.
Nationally, telemedicine is being used to treat a wide array of patients, from those suffering from congestive heart failure and diabetes to mental health patients and complex maternity cases.
More than 200,000 Americans are using telehealth home-monitoring services, according to estimates by the telemedicine association. There are another 200 dedicated telemedicine networks nationwide, involving close to 3,500 medical and health care institutions.
"It's getting a lot of attention now in mainstream health care to help cut down on costs," said Carol J. Bickford, a senior policy fellow in the department of nursing practice and policy at the American Nursing Association. "It's been very successful when it's done well in reducing the hospitalization of patients, because you can reach something early." Monitoring systems allow physicians to constantly track the conditions of patients.
Coates is one of about a half dozen Cooperative Home Care patients using an in-home telemonitoring system. The St. Louis firm has used the technology for the last two years.
The box weighs less than two pounds and displays questions and information via a small screen. Some can run using only a cellular connection.
The system uses verbal cues to alert patients when it's time to weigh themselves, take their blood pressure or check their oxygen levels. The monitor also can be programmed by health care providers to ask a series of yes or no questions tailored to a patient's condition.
For example, Coates' monitoring station asks a series of seven questions after she obtains her vital signs, including whether she has fallen in the last day or is suffering from headaches or dizziness.
Most patients take their vital signs twice a day. Health care providers or patients can increase the frequency depending on need.
The data is transmitted through the telephone line and comes into the nursing station computer like an e-mail. Cooperative Home nurses check for reports at least once a day, although they can monitor results in real time if a patient's condition requires greater scrutiny.
They also receive a message if patients fail to take their vitals as usual.
Nurses forward the information to a patient's physician at least once a week, typically before a checkup. Providers can scan a month's worth of data before those office visits, allowing them to look for trends, said Lanora Barman, interim director of clinical operations at Cooperative Home Care.
"We're trying to keep them out of the hospital by keeping them healthier," she said. "It's an extra set of eyes and ears in the house. We know if something's going wrong."
Recent studies suggest telemedicine services reduce costs, office visits and hospitalizations by hundreds of millions of dollars a year.
Still, some people can be overwhelmed by the technology. Patients who might struggle to get on the scale or have difficulty getting to the monitor might not qualify, Barman said.
It's simple technology at heart, though, and rapidly becoming increasingly user-friendly, especially for seniors.
"The technology is becoming much more comfortable to them," Bickford said. "We've got to make sure that they're part of the solution."
She added that questions remain among some health care providers about who will be paid for which services in an age of telemedicine. Physicians and other health care experts may save time by using telehealth services, but skilled sets of eyes are required to analyze all of that data.
Grayce Callahan isn't sweating the revenue scheme. Callahan, vice president of emerging business at Cooperative Home Care, believes the technology provides a significant benefit for both physicians and patients.
"There are systems out there right now that monitor the heart, do EKGs and all of those things," she said. "It really just depends on how much detail you want to provide in the home. Even when we're not in the home, there's a supportive service that is there for the patient or their family."
Diagnosing and treating a critically ill or injured patient as early as possible can mean the difference between life and death. A new communications system between a moving ambulance and its hospital base allows the simultaneous transmission of bandwidth-hungry video and ultra-sonic images, telephone communications and patient data, all at the same time.
Medical teams can therefore gather vital and detailed information about the patient's condition and advise the ambulance team on patient treatment as they rush towards the hospital.
The ambulances transmit and receive high-quality data over wimax, a microwave access technology that can deliver data at up to 75 megabits per second over a range of 70km between fixed points (802.16.d), or its mobile version can provide 15mb/s over a four-kilometre radius (802.16.e).
"If you are transmitting data in high quality, it is very important that you don't lose any bit of information," says Enrico Angori, a leading researcher on the WEIRD project. "WiMAX is the cheapest channel to use and the channel that can deliver the best quality of service."
WiMAX is not new, but the research team on the EU-funded WEIRD project extended the resilience and flexibility of the WiMAX technology and created a user-friendly package that can easily be used in ambulances by non-computer specialists.
Practical and usable solutions
"The main part of our work is to make it easy for end-users to make use of the benefits of new technologies like WiMAX," explains Giuseppe Martufi, another member of the WEIRD research team.
The team achieve this by developing software that hides the complexity of the configuration of the end-to-end communication channel, whatever the different equipment or different versions of WiMAX used. It means that the paramedic onboard the ambulance can quickly and easily establish an end-to-end communication path without specialist training, allowing them to concentrate on what they do best - saving lives.
Bandwidth can be reserved for the ambulance's critical communications using a protocol called DIAMETER that identifies data traffic and prioritises it, ensuring communications are not blocked by low-priority data traffic, such as emails.
Seamless end-to-end connections
One of the most important features of the ambulance communications system is its ability to create end-to-end links between two points by seamlessly integrating the WiMAX signal with the other wireless communication technologies encountered, such as mobile telephony.
The WEIRD researchers developed software that takes advantage of the features of 'next-generation networks'. NGNs layer information, decoupling the applications from the underlying transport stratum. Whatever the underlying network, the ambulance's signals will be passed seamlessly, end to end.
A few years ago, developers had envisaged global WiMAX networks replacing our present communications infrastructures. Increasingly, WiMAX is being viewed as a complementary technology to existing wireless communication access channels.
So, the successful seamless integration of WiMAX with 'media-independent handover' is an important step forward.
Not all applications are designed to run on NGNs. For these, the research team built a series of adaptors - known as WEIRD agents or WEIRD application programming interfaces. WEIRD agents allow non-NGN applications to take advantage of the enhanced quality of service and seamless mobility features offered by the ambulance communications system.
BILBAO, SPAIN & HOLON, ISRAEL – April, 02 2008 - Aerotel Medical Systems, one of the world’s leading manufacturers of advanced telemedicine and remote monitoring solutions, announced today that Vodafone Spain in conjunction with Medicronic Salud have used Aerotel’s e-CliniQ™ Wireless Home Monitoring System with successful results.
The e-CliniQ™ Wireless Home Monitoring System enables patients to keep track of their health, 24 hours a day, 365 days a year. Using Bluetooth technology, Aerotel’s Tele-Modem™ Homecare Hub remotely monitors the patient’s vital signs from various homecare sensors, transmitting the data to Medicronic’s central receiving station via the Vodafone cellular network, where it is stored and analyzed by Aerotel’s Medical Parameters Monitoring (MPM™) software.
The seamless technology is being used successfully by MEDICRONIC-VODAFONE SPAIN, a joint venture between Medicronic Salud and Vodaphone, to monitor, for example, patients' blood pressure and other vital signs. Easy to use, the e-CliniQ™ system is activated at the touch of a button. Blood pressure readings are encrypted and sent via a Bluetooth-enabled mobile phone to the receiving center where the patient or doctor can directly access the information via the internet, using Aerotel’s MPM-Net™ technology. The system allows doctors to check that patients are adhering to their pharmaceutical treatments.
“Flexibility and adaptation to patient needs has been key to e-CliniQ’s success,” commented David Rubin, Aerotel Medical Systems President & CEO. “In the modern age of wireless telecommunications and anywhere connectivity via cellular and internet networks, there is no reason why we cannot provide our patients with full remote and non-intrusive monitoring care, saving time and money in unnecessary visits to doctors and hospitals.”
Dr. José Antonio Amérigo, Medical Director of MEDICRONIC-VODAFONE SPAIN, says that new cell phone technology, allows to control and follow up of Chronic Illness patients in many different ways, giving them full mobility and using e-CliniQ’s to check instantly their vital parameters no matter the time or the place they are.
In Spain where more and more old people use cell phones, it is easy for them to be connected instead of depending on a fixed place were the analogue lines exist like at home. Spain has the oldest rate of elder people at the European Union and with one of the higher number of Chronic Patients, most of them over 65 years old.
“The consistence of Aerotel´s technology,” says Dr. Amérigo, “is a good example to use in Chronic Disease Management, where the patient takes their own control of the situation, supervised from a distance by a group of doctors and nurses, at the MEDICRONIC-VODAFONE Call Center.”
Aerotel’s innovative technology also enables patients to monitor other values such as weight, blood glucose, ECG (electrocardiogram), cholesterol, blood oxygen saturation level (SpO2) and Spirometry.
About Aerotel Medical Systems
Aerotel Medical Systems is a world leader in cost-effective, high quality, user-friendly, medical diagnostic systems and devices for home care, eHealth and telemedicine. The company provides a complete disease management package; including transtelephonic devices designed for a variety of remote diagnostic, emergency services and monitoring applications, hardware and software platforms for remote monitoring call centers, as well as phone and web-based monitoring software. Aerotel enables patients to conduct tests comfortably while leading normal, mobile lives. With a client base in over 45 countries around the globe, Aerotel has been recently awarded the prestigious “Innovation and Growth Strategy Leadership of the Year Award 2007” by Frost & Sullivan.
Medicronic Salud is a leading telemedicine service provider in Spain. Together with Vodafone the company has established MEDICRONIC-VODAFONE SPAIN, a Medical Call Center Service, using both fixed and cell phone technologies, combined with vital parameters measurements to be managed by patients at home or at the Retiring Homes (more than 5.000 all over Spain), with or without Medical Services.
ADDIS ABABA (Reuters) - Troubled by a difficult case, doctor Asfaw Atnafu decides to seek advice.
He walks into a consulting room at Black Lion Hospital in Ethiopia's capital Addis Ababa and greets a doctor at the Care Hospital in the southern Indian city of Hyderabad.
Linked by a high-speed Internet connection, the doctors study X-rays and laboratory results.
Flipping between charts, they use light pens to point out important features. They can see each other in windows on their screens, while medical charts fill the rest of the display.
India launched this "telemedicine" project in Ethiopia last July at a cost of $2.13 million. The project links hospitals in Ethiopia with the Hyderabad-based Care Group of Hospitals, India's leading cardiac institute.
The scheme is part of the pan-African e-network, a 5.42 billion-rupee ($135.6-million) joint initiative between the African Union and India which was launched in Ethiopia last year to improve Internet links and communication.
India is likely to highlight its prowess in information communication technology (ICT) as a way of strengthening ties at summit of African heads of state in New Delhi on April 8 and 9 -- the first meeting of its kind.
"By using telemedicine, a country like Ethiopia, a Third World country with a problem with funding and manpower, can benefit greatly," radiologist Asfaw said.
There is just one doctor for every 37,000 people in Ethiopia -- sub-Saharan Africa's second most populous country and a land where vast distances separate rural communities.
"Rural parts of the country are devoid of medical care. This technology has already helped, but its scope is immense," said Asfaw.
Under the scheme, the Black Lion, Ethiopia's only teaching hospital, has also been linked to the remote Nekempte Hospital, 300 km (185 miles) west of Addis Ababa.
"We want Africans to share expertise with each other and for areas with few doctors to be linked to hospitals in cities so doctors there can fill the gap," said Ratan Singh, project director for the Indian government agency responsible for implementing the technology and training Ethiopians to use it.
Ethiopia's health problems are mirrored across Africa where doctors and nurses are often overworked and underpaid, villagers have to walk miles to the nearest clinic and drugs and treatment are often beyond the means of ordinary people.
Aggravating these problems, rich countries are poaching so many African health workers that a team of international disease experts recently said the practice should be viewed as a crime.
The Indian project aims to ease some of these burdens but it also dovetails with the country's drive to deepen its links with resource-rich Africa to secure energy supplies and markets.
With ambitious plans to connect Africa's 53 countries using satellites and fiber-optic links with each other and with India, India hopes TO sell more telecoms equipment and services to Africa's fledgling ICT markets before rival China steps in.
Since the one-year pilot project began in Ethiopia, doctors at the Black Lion hospital have used the link more than 50 times to discuss cases with Indian doctors, Asfaw said.
The Care Group is also in talks to extend the telemedicine program to Nigeria and Libya.
Indian officials estimate that 100 patients in Africa have benefited from the pan-African e-network which is plugged in to 12 specialist hospitals in India.
The Ethiopian project uses fiber-optic technology and a satellite hub is being built in Senegal, to be used once the pilot ends.
"Indian doctors have been very excited by this development," said India's ambassador to Ethiopia, Gurjit Singh. "They see it as providing the cutting edge of Indian healthcare and education at low-cost to Africans."
India plans to fund the projects and train Africans for five years before handing the scheme over to African countries.
At the Black Lion, patients throng the corridors and rooms, the lucky ones sitting on wooden benches while others lean against the peeling walls and some lie on the floor.
Cocooned from the chaos, the four rooms housing the Indian-funded telemedicine equipment are an oasis of calm.
Computer servers whirr in a corner as Indian technicians ensure things work smoothly and chat to colleagues back home.
Hyderabad's Care Hospital has also trained 12 Tanzanian surgeons, nurses and technicians in the past year, and treated children suffering congenital heart problems free of charge.
"Our doctors will go there (to Tanzania) and make the local surgeons conduct surgeries in their presence. This will boost their morale," L. V. Rajendra Kumar, who heads business development for the Care Group of Hospitals, told Reuters.
Ambassador Singh said India's involvement in these projects was separate from its attempts to capture a share of the continent's resources.
"We are the beneficiaries of a relationship between Africa and India that is based on long-term historical friendship," he said. "Colonization is a one-way street but I think the India-Africa relationship is most clearly two-way."
Chip Means, Web Editor - Scottish Centre for Telehealth - 31/01/2008
Aberdeen Royal Infirmary of Scotland, the Scottish Centre for Telehealth and the National Health Service of Scotland have launched a trial of a new telehealth tool that combines video, audio and call centre technology with medical diagnostic equipment.
The HealthPresence remote care tool, supplied by Cisco, uses equipment such as stethoscopes and otoscopes, as well as a vital signs monitor that can measure blood pressure, temperature, pulse rate and pulse oximetry to capture the physiological condition of the patient, Cisco said in a release.
The system was developed by Cisco's Internet Business Solutions Group and it is based on the Cisco TelePresence system, which was launched in October 2006. Some 100 providers in more than 40 countries implemented the TelePresence system within its first year of availability.
"HealthPresence is an asset to improve the quality of telephone advice and triage," said Aberdeen Royal Infirmary's Dr. Karyn Webster and Dr. Fiona Mair. "Being able to visualise and have physiological parameters on a patient will improve patient care."
The Scottish Centre for Telehealth establishes best practices and develops standards, protocols, and processes to support telehealth solutions. The centre supports projects that advance preventative anticipatory care in Scotland, such as sustainable and safe local medical services, care in communities rather than in hospitals, and improved standards and healthcare efficiency.
If standards for patient and caregiver satisfaction are met upon completion of the Aberdeen Royal Infirmary trials, HealthPresence may be tested in additional settings in Scotland and worldwide.
Gordon Peterkin, director of The Scottish Centre for Telehealth, said, "Solutions such as Cisco HealthPresence enable us to offer convenience for patients and service delivery efficiency for our doctors. We look forward to drawing upon the results from this pilot to optimise our regional and national healthcare delivery resources."
"By using the network as a platform, Cisco has a key role to play in the delivery of safe, affordable and accessible healthcare," said Nick Augustinos, Global Healthcare Solutions director for the Cisco Internet Business Solutions Group. "Joining forces with NHS and SCT has enabled us, together, to consider bringing healthcare services to remote and rural areas where recruitment and retention of doctors and nurses is proving increasingly difficult."
10 Jul 2007
Community-based health professionals in Nottingham have taken part in a successful three month mobile technology trial, using wireless broadband-enabled laptops from Dell to access and update patient records on the move.
The trial enabled staff to remotely access and update electronic patient records from the SystmOne primary and community care system supplied by TPP.
The results of the trial showed that on average staff had 38 minutes additional productive time per person per day with the potential to save 60 minutes a day. The trust saw a reduction in travel times of 32% and realistic additional potential to reduce commuting by 50%, with the potential for a 25% increase in productivity.
On average 96% of patient notes completed on the day, rather than a typical delay of up to 48 hours before. Users perceived an average of 70% improvement in facilities to do their job, Dell claims.
Staff involved included community-based clinicians and therapists, including: community matrons, paediatric physiotherapists, paediatric occupational therapists, paediatric speech and language therapists who spend a lot of time working outside of the trust’s premises.
Using high-speed wireless laptops securely connected to N3 authorised staff were able to log onto the Care Records Service using their NHS smartcard and can gain access to patient records on the move. They can also update these on the spot in patient's home, rather than having to return to the office to key in details of home visits.
Clinicians and therapists working in Nottingham were provided with 3G-enabled Latitude notebooks from Dell, which wirelessly connected to the NHS N3 network using its remote worker function over a secure Virtual Private Network.
The trial was carried out by Nottingham’s Health Informatics Service together with Dell, the first time the company has attempted this kind of secure mobile access over N3.
Users were given training on the technology and monitored throughout the trial. This included daily diary reports from the users and weekly telephone interviews to chart progress. Approximately 1,000 user days were analysed in total during the full trial programme.
Staff were given hi-tech laptops, which could automatically select either GPRS, 3G or 3G broadband network access dependent on availability and immediately saw the benefits of the new way of working.
A team of experts from within Dell, Intel and Vodafone developed the wireless laptop solution for the NHS. In addition to the initial research and development the solution was carefully evaluated by conducting interviews with clinicians to understand their working practices, identifying the technology required and providing training for end users.
Elaine Morris, community matron at Nottinghamshire County Teaching PCT, told E-Health Insider: “Mobile working has completely changed the way I work for the better and improved patient care. I don’t have to report back to the office throughout the day to write-up my notes and so my travelling time has substantially reduced and that really helps to reduce everyday stresses.
“I feel the service I am giving to my patients has really improved and they are reassured that I've got good current information to hand at all times. I wouldn’t want to give-up this way of working now.”
She added that patients welcomed clinicians using laptops with them, with no complaints during the pilot. Issues did arise due to poor signal at times, but this was countered when staff drove nearer to areas where coverage was stronger.
“All staff in the trust who work with patients and use the SystmOne system are able to log on using their restricted smartcards and go through records with patients and update them on the spot, instead of commuting back to the office. Patients and staff both appreciate this and I can’t see why any trust would not want to embrace this technology.”
Dell’s director and general manager for the UK public sector, Iain Campbell, told E-Health Insider: “Mobility is one of the key areas that we wanted to do a bit of testing in, as it is such an important requirement for both healthcare and education.
"Nottingham were long-standing customers of ours, and they wanted to explore how to use technology away from clinical settings, and what the potential was for labour and time savings, so we went about exploring mobile access with them.
“It was imperative that we found a way that authorised clinicians could get access to the data they needed for an individual patient, and could then store this on a record and not on the machine. Given the sensitivity of the data, it was important to ensure it remains secure and is available to the right people with the right robustness of security.”
Barbara Stuttle, NHS Connecting for Health's national clinical lead for nursing said: “The Dell mobility trial has helped to transform the way community clinicians and therapists work. Users have access to real time information, enabling them to plan their day better and have direct contact with colleagues and hospitals. This solution is helping to deliver the highest quality care for patients. Services like this will help improve the overall service the NHS provides by giving a more ‘joined-up’ approach to patient care.”
Dell’s sales manager for public sector health and emergency services, Richard Rawcliffe, told EHI: “We worked with the IT department in the trust to ensure that the VPN works wirelessly within their specific IT governance guidelines. Essentially, the security requirements needed to be controlled so unauthorised access could not be possible. Smartcard controlled functionality ensures this.
“The great thing is that because staff were used to SystmOne and most know how to use a laptop, the training was minimal and the benefits were easy to see. The response has been fantastic, and we have had support from CfH for our system.”
More consumer-driven wireless developments are on the horizon as mobile technology enjoys wider adoption in healthcare.
That’s one of the main predictions from Peter Kruger, principal analyst at Wireless Healthcare who says: “Companies are making straight for the consumer.”
He cites examples, such as the success of Resperate which claims to reduce hypertension through breathing training, as examples of the trend and HeartMath, a stress reduction system.
Remote monitoring devices have also found their place in the wireless repertoire. Many developments are based on mobile phones; for example, the Vitaphone which offers heart disease patients the facility to send readings over to a support centre if they feel unwell. The centre offers support right up to the level of calling an ambulance out if contact is lost with the patient.
But gaining entry to the market is getting tougher, according to Kruger. A few years ago, the mobile phone companies were happy to support e-health developments because they gave them a positive story to tell about health in the face of adverse press about possible risks from mobile phones.
Upheavals in the mobile phone sector changed this. “These projects have to stand on their own. They find they can’t go to O2 or Orange,” says Kruger. “They are trying to attract consumers themselves.”
One company has even found a niche in helping baby boomers now hitting their 50s and 60s to manage their decline; the Nintendo game, Brain Age, is a brain exerciser designed to aid mental agility.
Entrepreneurial breakthroughs in hospitals
For healthcare organisations, Kruger predicts continuing success for entrepreneurial solutions that spring out of innovative clinical practice. He cites Safe Surgery’s RFID tagging for surgery patients, championed by consultant surgeon, David Morgan, at Birmingham Heartlands Hospital, as an example of a this type of enterprise .
The work at the hospital has found favour with the Department of Health (DH) which is keen to adopt solutions that address some of the multiple patient safety issues in hospitals. Earlier this year health minister, Lord Hunt, launched guidance, ‘Coding for Success: simple technology for safer patient care’ on a visit to the Birmingham Heartlands NHS Trust.
Kruger speculates that disillusionment with slow progress on larger NHS IT projects may trigger interest in smaller projects produced by agile players in the market. He cites the example of iPlato’s mobile e-reminder solutions which, again, have captured attention at DH level by producing impressive reductions in ‘did not attend’ rates for appointments – a long-standing and wasteful problem.
“The question is ‘What can we add to this?’” Kruger says.
Stress monitoring and helping people to give up smoking are the newer areas where the mobile reminder seems destined to take its place among commonly-used strategies available to the clinician and patient.
Indeed iPlato recently announced the launch of a mobile stress service created with its strategic partner - the Atrium Clinic - that uses the latest Java technology to provide a rich experience for users. Triggered through a web-interface or through text message it offers users top 20 tips on dealing with stress.
Changes in the law on smoking in public places in force in Wales, Northern Ireland and Scotland and pending in England are likely to give a boost to mobile aids to smoking cessation.
Additional suppliers will boost English market
Kruger says that England’s National Programme for IT caused a slow down in wireless healthcare initially, but that innovative developers found the other routes to market he describes.
He feels the current crisis in medical recruitment is bad news for those championing technology-led change. Times when staff are worried about their jobs are typically also times when suspicion of IT rises. Less popular national programme developments such as Choose and Book have also alienated some doctors to IT.
However, the advent of the additional suppliers’ catalogue should free up budgets in a welcome way. Despite its problems, Kruger says that the national programme has brought a lot of money into the system and alerted the public more to what can be done with IT.
Um novo relatório exigindo “sistemas de TI de saúde com núcleo mais inteligente” informa que, embora os atuais modelos de e-health sustentem uma gama de dados relativos aos de sinais vitais do paciente, não são inteligentes suficientes para realizar diagnósticos vitais dos pacientes.
A empresa de tecnologia sem fio Wireless Healthcare alega no relatório que falta inteligência aos dispositivos de TeleHealth, de forma que possam identificar tendências, indicando os riscos de enfermidade de uma pessoa. Ao invés disso, os usuários sempre dependem de call centers para alertar os profissionais de Saúde sobre qualquer anormalidade.
“Atualmente, os pacientes estão sendo “empurrados” para longe dos prestadores de serviços de saúde. Na verdade, deveriam estar sendo orientados para o centro da rede de atendimento,” afirma o relatório.
O relatório cita a NHS Direct (UK) como um exemplo disto: “Uma pessoa que entra em contato com o serviço de atendimento online ou via telefone do NHS Direct, queixando-se de dores no peito, quase sempre será recolhida e levada ao hospital mais próximo.
Peter Kruger, analista sênior da Wireless Healthcare afirmou a publicação “E-Health Insider”: “A pedido de grandes empresas de saúde, analisamos as ferramentas de e-health e entrevistamos médicos clínicos ao redor do país. Descobrimos que existe uma grande lacuna entre as atuais inovações tecnológicas e aquelas que os médicos clínicos gostariam de ter."
Kruger acrescentou que a presente tecnologia de TeleHealth poupa tempo aos clínicos e prestadores de serviços médicos, evitando que tenham de verificar pessoalmente pacientes cronicamente enfermos, mas não é eficaz em ajudar os pacientes em casos de emergência.
“A tecnologia e-health está crescendo e sendo usada, cada vez mais, para monitorar pacientes. Mas o atual modelo é uma soluçãoi de curto prazo, ao invés de ser uma solução de longo prazo. O que faz hoje é liberar recursos dentro do sistema de saúde.”
O relatório afirma que futuramente os serviços de e-health deverão ser capazes de realizar diagnósticos e de monitorar pacientes remotamente. Os dados deveriam ser coletados por dispositivos e levados aos atendentes domiciliares pelos próprios pacientes.
“À medida que os dados possam fluir para a estrutura de TI dos prestadores de serviços de saúde, poderiam ser encaminhados, através de agentes inteligentes, para a parte mais apropriada da rede de saúde (por disciplina médica, por exemplo).
“Haveria um sistema centralizado de prontuário eletrônico de pacientes, acessível por médicos autorizados para monitorar com eficácia a saúde dos pacientes.”
Contudo, o relatório também reconhece que tal inteligência pode ser acrescentada à e-health se forem superadas as barreiras. Essas incluem (1) um uso mais amplo de e-health e (2) uma transição integral de toda a Rede para os prontuários eletrônicos.
Kruger disse: “Existem entre os profissionais de saúde um certo temor da tecnologia, principalmente em razão dos cortes de funcionários realizados na área bancaria, em função da tecnologia.
“É improvável que o atual modelo e-health possa trazer maiores problemas para o setor. Contudo, a tecnologia está mudando. Um exemplo disso são os terminais de cartões de crédito que recusam um cartão se houver suspeita de atividade estranha na conta. Da mesma forma, dentro dos próximos 15 anos, as máquinas de e-health provavelmente serão capazes de diagnosticar pacientes se suspeitarem de qualquer enfermidade", acrescentou.
Extraído do "The British Journal of Healthcare Computing & Information Management"- February, 2006
Traditionally, NHS patients have travelled to hospitals for tests and consultations with clinical specialists. With the UK population set both to grow and age, however and with the consequent greater demands for new healthcare procedures and treatments - this may no longer be possible. Long-established patterns of healthcare such as these may have to transform if the NHS is to the Government and patient expectations within its budget.
The reality, of course, is that healthcare has been changing for some time in order to reduce costs and increase efficiency. The need to liberate funds for reinvestment and to change spending priorities has been substantial. Specialist clinical resources are being relocated into regional or national centers, and an increasing number of hospitals no longer have specialists in every discipline. Patients are being monitored at health centers or in the community rather than in hospital, especially when suffering from chronic conditions.
The natural consequence of this has been some reduction in contact between the patient and the clinician. However, many believe that the innovative use of IT and network technologies can help redress this situation, and there have been many attempts to introduce telemedical and telecare services in recent years. Unfortunately many of these services have not been successful, often because of the lack of suitable network technologies. It is instructive to look at recent major advances in this area and see the huge potential for networking to drive advances in telecare.
Telecare services depend critically on the availability of standards, and on ready access to the right local (LAN) and wide-area network (WAN) services. In the past these have not always been available, hampering service development, but advances have recently occurred in three areas - interconnection and inter-working standards, high speed, vide-capable links between NHS sites, and high-performance network links into the home.
Interconnection and interworking standards.
Standards are critical for the development and effective delivery of all aspects of IT. Telecare requires standards for physical connection to medical devices and system end points, and for logical communication between end points. Physical connection to systems and end points is now, in practice, by Ethernet local area network (LAN), or by lEEE 802.11 wireless connection (WiFi). Both of these can be provided easily and cost-effectively in the hospital, clinic or at home, and many hospitals have already implemented overlay wireless LANs (WLANs) for telecare and other mobility projects. Logical communication between end points uses Internet Protocol (IP) - the communications protocol that drives the Internet and most networked IT applications. The information modes used in telecare - data, voice and video - are all now fully standardized to operate IP.
Hígh-speed, video-capable links between NHS sites
Many attempts to introduce telecare services in the past were based on the use of NHSnet - the old NHS national network - for communication between NHS sites. This was not always successful, as NHSnet did not provide sufficient bandwidth or adequate quality of service - both being prerequisites for voice and video traffic. Projects either had to change the scope of their services, or were forced to install special-purpose network links, the cost of which often eroded business benefits.
The Government has recognized the importance of enabling network infrastructure for all aspects of healthcare delivery. The NHS National Programme the for IT (NPfIT) will deliver N3, the new national network, to provide robust, secure and standardised network connectivity to all NHS clinical locations. N3 has the ability to support multimedia traffic for telecare, and positions trusts very favorably for the development of site-to-site telecare services.
Network links into the home
In the past it was only possible to link into patients’ homes via standard telephone connections. These connections were slow and inflexible, and furthermore affected patients’ use of their telephones. The Government’s Broadband Britain initiative, however, has accelerated the availability high-speed digital subscriber-line (IDSL) connections across the country. While DSL also uses existing telephone connections, it does not affect normal telephone use and can be provided in a matter of days without any changes to home wiring. DSL has the additional benefit of ever-decreasing cost points.
Within the home, medical monitoring devices can connect to a DSL service via very simple ‘plug and play’ methods - a simple Ethernet cable, or a WiFi connection for greater flexibility. In the future, DSL may not be required at all, at least in urban areas, as medical devices in patients’ homes will be able to connect directly to WiFi broadband services.
Business need and technology driving innovation
We have mentioned the business need for more efficiency in the use of clinical resources. The very substantial developments in network technologies and the availability of enabling network services through N3 make this now possible.
This combination represents a clear platform for innovation. If fully exploited in the future, it could lead to the next major step in the transformation of healthcare services after the current deployment of the National Programme’s IT applications suite. Indeed, it is possible that telecare services such as teleconsultation, telediagnosis and telemonitoring could be incorporated into the National Programme in the future.
Linking the patient and clinician
Teleconsultation services provide direct video links between patients and clinicians. This benefits patients by increasing access to specialists and reducing the need for travel. Teleconsultation over ISDN circuits is already in use in the NHS, for example for out-of-hours consultations between community and acute hospitals, although video quality can be poor. These services are likely to become commonplace with N3, which has been designed to support high-quality video connections. Video telephony now available in a form fully integrated with voice telephony, so there is no need to provide special-purpose networks for patients to consult clinicians. Looking to the future, 3G wireless telecommunications devices will support a suitable quality of video, and it will be possible to extend consultation directly into patients’ homes.
Centralising diagnostic services
Telediagnosis services permit a patient’s scan or image to be sent to a remote specialist for diagnosis and report. The benefit to the NHS of this approach is the more effective use of skilled and centralised clinical resources. The benefit to the patient will be faster reporting following scans and tests.
Scan images may be sent over IP via file transfer or attached to emails, but image files can be very large and require significant bandwidth. Images of external, eg dermatological, conditions can be handled photographically or over video links. N3 provides high bandwidth and is video-capable, offering an excellent vehicle for the development of these telediagnosis services.
Remote monitoring in hospital, clinic and in the home
Telemonitoring often referred to as telemedicine in the past, permits medical devices attached to patients to be accessed and controlled from a central monitoring statiun. The network links connecting device and monitoring statiun may take a variety of forms - wired or wireless LAN links within hospitals, links over N3 between clinical locations, and GPRS mobile-phone-network or DSL links from patients’ homes and in the community.
Telemonitoring can be found in many guises within the NHS. ln its simplest form it can provide a link between a beside medical device and a nurses’ statiun. Nowadays medical devices are becoming WiFi capable, permitting active monitoring as a patient is moved from ward to ward, or from ward to theatre. In the future, telemonitoring will be increasingly available in the community and in patients’ homes. This will be particularly important fur successfully managing chronic conditions without taking up valuable hospital bed space.
The NHS is witnessing the fortunate co-incidence of business need — to deliver healthcare services more cost effectively and the tools to do so — new network technology standards and highly capable, but low-cost, network products.
This offers an excellent opportunity fur NHS trusts to exploit networking for telecare to benefit patients and clinicians, particularly as the National Programme is providing the enabling N3 infrastructure.
There are already many examples of telecare in operation, particularly teleconsultatiun and telediagnosis, and every trust should have the development of business plans high on its priority list.
Chris Blenkhorn is a Consulting Systems Engineer with Cisco Systems Ltd and a member of Cisco’s UK public sector team, where he specialists in healthcare networking.
"The British Journal of Healthcare Computing & Information Management" - February 2006