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The Doctor Is In – Or At Least, Online

TAMPA (FOX 13) – From his office in Fort Myers, using a protected internet connection, Dr. Nima Mowzoon (CEO of TeleSpecialists) spoke to us from the emergency department of the Medical Center of Trinity, 140 miles away.

“When patients have a stroke, the clock is ticking. There’s data that suggests that almost 2-million nerve cells die each minute,” the tele-neurologist explained.

Saving brain cells may involve clot-busting drugs. The goal is to start them within 60 minutes after patients hit the door. But first they need a thorough workup.

“The advantage of actually doing telemedicine is we can multi-task and do many things. We can be looking at the C.T. obtaining history on one side, looking at the labs as they come up,” Dr. Mowzoon explained.

He says although he can’t perform the physical exam personally, he can observe as it’s being performed.

E.R. physician Dr. Onier Villarreal says the tele-neurologists not only help expedite the process, they’ve increased the number of patients getting clot-busting drugs.

“It’s definitely something that has improved the way we take care of stroke patients by leaps and bounds,” Dr. Villareal said.

“It’s a brave new world,” offered Dr. Larry Feinman, the CEO for HCA West Florida. He says the telestroke program is becoming their standard. “We have 11 hospitals on this platform.”

Along with evaluating stroke patients, the Trinity E.R. uses telemedicine to evaluate psychiatric patients — saving time, money and improving care.

“If we have a patient that comes in with the Baker Act, for example, in many hospitals, since you don’ t have a psychiatrist on board, they tend to stay in the emergency room for a long time,” he said.

Elsewhere, virtual specialists are making their mark in intensive care units.

“In the critical care world, so much of what we do is based upon technology,” explained Dr. Dellice Dickhaus, medical director of Advanced ICU Care. His St. Louis-based company services more than 60 hospitals across the country, including Florida Hospital Carrollwood in Tampa.

Special software helps process the patients’ vital signs and data while a remote camera zooms into the patients’ rooms.

While Dr. Dickhaus can’t be hands-on, she says being able to virtually see the patient is a plus.

“It makes all the difference in the world. Having someone tell you that a patient is short of breath. It means something different when you can actually see the patient and judge the degree of the shortness of breath,” she stated.

“I was very skeptical, actually, because I wasn’t sure how someone sitting in St. Louis or New York can assess my patient,” ICU medical director Ashok Modh admitted.

Before the virtual docs — for the past 30 years, in fact — Dr. Modh and others had to cover calls from home. After spending time in a different hospital to see how it worked, he was sold.

“They can look at the X-rays, they can look at vital signs, they can look at the patients’ lab work.”

He says the 24/7 nursing access to the critical care experts is improving outcomes for patients.

Along with treating more serious illnesses, Tampa General Hospital’s senior vice president believes it is also the wave of the future for minor ones.

“We see telemedicine, telehealth as a real growth part of medicine,” Michael Gorsage stated.

TGH is now partnering with a national group allowing patients to “see” primary care physicians for $49. Specialists like psychiatrists cost a little more.

Gorsage believes the benefits outweigh the cost.

“Many people think that this is the wave of the future for mental health because of the stigma attached to going in and out of a psychologist or psychiatrist’s office.”

With home monitoring systems for heart rhythm, blood pressure, and weight becoming more available, home health care is also adopting a tele-medicine approach. One major goal is to help keep heart-failure patient admissions to the hospital in check — A goal that will improve quality of life and also greatly reduce health care costs.

Doctors must be licensed in the state where they are offering services. And like all medicine, mistakes may happen with remote consultations. One lawsuit in California was won because the tele-neurologist was not consulted, resulting in an alleged missed opportunity to provide the clot-busting medication.

But with all the potential applications, and as technology improves, expect this tidal wave of telemedicine to eventually become a tsunami.

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Telemedicine in Senior Living Communities to Reduce ED Visit

-Gillespie, SM, et al. Telemedicine and e-Health. January 2016.

A group of researchers from the University of Rochester School of Medicine recently published an article looking at high intensity telemedicine in senior living community residents and its effect on emergency department utilization.   They looked at data from a prospective cohort study and compared the annual rate of change in ED use among patients who resided in communities that were more engaged in telemedicine services with those who resided in less engaged communities.

During the study there were a total of 503 telemedicine visits, with 72% in the more engaged community and 28% in the less engaged.  For those residing in a more engaged community, they found that ED use decreased at an annualized rate of 28% whereas those in the less engaged there was no significant change in ED use.

This study provides promising results on a means to improve ED utilization in a high risk population, senior citizens, using telemedicine.  Hopefully, this will lead to further research on ways to expand the use of telehealth to other patient populations.

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A New Concept for Home Monitoring of Heart Failure Patients

-Bennett, MK et al. J Telemed Telecare. December 2015

Patients with heart failure are considered a high risk population for admission and readmission after an exacerbation requiring hospitalization.  Using telehealth to monitor these patients is one of the primary areas of interest in telemedicine research.   The hope is to identify early physiologic parameters that may allow for intervention before a readmission occurs.  Recently, a group published a study using a new under- the- mattress piezoelectric sensor to monitor patients with heart failure to test the feasibility.

The group studied 30 patients recently discharged from the hospital with heart failure.  The sensor placed under the mattress is able to report heart rate, respiratory rate, rapid and shallow breathing patterns, and movement rate.  They were able to obtain data on 29 patients. There were 9 readmissions in the group.  They found that, patients readmitted for heart failure had higher average heart and respiration rates, and more respiratory variability.

The authors conclude that they have provided evidence that physiologic data can be obtained using this technology that helps to identify patients that may be at risk for readmission. They further hope that their study serves as a foundation for more studies using this new telehealth home monitoring equipment.

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Telemedicine in Prehospital Stroke Evaluation

Itrat, A. et al. JAMA Neurol. December 7, 2015.

A group of physicians from the Cleveland Clinic Mobile Stroke Treatment Unit released a study this month in JAMA Neurology looking at the use of telemedicine to improve efficiency and time to thrombolysis in stroke care.   The group sought to test whether telemedicine would be reliable and remote physician presence adequate for stroke treatment in Mobile Units.

The study was a prospective observational study on 100 residents of Cleveland with acute stroke like symptoms.  A neurologist evaluated the patients in the Mobile Unit via telemedicine and a radiologist interpreted the CT images obtained by the mobile unit.  The data obtained was compared to a cohort of 100 patients brought to the ED via ambulance for evaluation of stroke during the same year.

In the telemedicine group, ninety –nine out of 100 patients were successfully evaluated with 1 patient not evaluated due to equipment failure.  There were a total of 6 telemedicine disconnections but none of these affected the evaluation.   The times to CT completion and time to thrombolysis were significantly shorter compared to the control groups (13 minutes vs. 18 minutes to CT and 32 minutes vs. 58 minutes to thrombolysis).

The group concluded that prehospital stroke evaluation using telemedicine was feasible and likely cost effective and efficient allowing physicians to remotely cover multiple mobile stroke units and a larger geographic area.

Sepsis and Telemedicine

Eric Wicklund

OSF Healthcare of Illinois is about to embark on a project using a $750,000 grant from the Agency for Healthcare Research and Quality to combat sepsis at rural hospitals. The plan is two-fold in its approach. The first step involves using simulation to train rural clinicians to recognize the early signs and symptoms of sepsis. The second step involves teaching the clinicians to use the platform to connect with specialists using video-conferencing. The project is intended for three years and is a collaboration between JumpTrading Simulation & Education Center, Illinois College of Medicine at Peoria, and Northwestern.

OSF wants to ensure accurate application of these [sepsis] bundles in rural emergency departments by using telemedicine,” they said. “The idea is for rural clinicians to consult with specially trained critical care medical staff over videoconferencing as they treat patients presenting with sepsis. Transitions of care to the ICU may also be improved.” The hope of the project is that if this project can improve sepsis care, the model can be applied to other conditions such as stroke, acute MI, pediatric critical care, and trauma.

More Telehealth Grant Money to Rural Providers

Jessica Davis

The US Department of Agriculture announced it will add $23.4 million in funding for telehealth through its Rural Development Distance Learning and Telemedicine Program. The additional money will go towards assisting 75 projects in 31 states.

“Rural communities often lack access to specialized medical care or advanced educational opportunities,” said Tom Vilsack, secretary of agriculture.

Some examples of projects include Baptist Health System in Kentucky using $180,000 to purchase and set up videoconferencing equipment for patients in Kentucky and Tennessee; Alaska using $420,000 to buy equipment and use it to link clinics and a hospital; and Baptist Health in Arkansas will set up a critical care network for 6 medical centers.

The USDA has provided more than $213 million in grants and loans for learning and telemedicine projects in rural areas since 2009.

New Bill To Facilitate VA Telemedicine Visits

Andis Robeznieks

A new bill is being considered by the Senate which would ease licensure requirements in order to facilitate mental health visits using telemedicine for Veterans’ Affairs patients. The bill would waive state licensure requirements if both the patient and physician are located in a federal facility during the telemedicine visit. Additionally, home mental health telemedicine visits would also be allowed regardless of the state where the VA physician is located or licensed.

Approximately 677,000 veterans received telemedicine visits last year including 122,000 who received home mental health visits. “Telehealth care is an innovative and important means to meet the wide-ranging needs of veterans in Iowa and nationwide, including the invisible struggles of mental healthcare,” said Senator Joni Ernst (R-Iowa), the bill’s sponsor.

The bill also calls for reporting of quality metrics such as patient and provider satisfaction, frequency of use, wait times, and effect on access to care. The bill has been endorsed by the Veterans of Foreign Wars, Paralyzed Veterans of America, the American Legion, Concerned Veterans for America and the American Telemedicine Association

Family Physicians Surveyed on Telemedicine Usage

Heather Landi

A survey recently released by American Academy of Family Physicians provides insight into the thoughts of family physicians towards telemedicine and telehealth. According to the survey 87% of uses and 64% of non-users of telehealth services would use telehealth to connect patients to specialists if telehealth were available. 1557 family physicians responded to the survey.

Compared with non-users, users of telehealth were more likely to practice in rural areas, be younger, have practiced less than 10 years, and use and EHR. The physicians who incorporated telemedicine reported using it for diagnosis or treatment (55%), chronic disease management (26%), follow ups (21%), and second opinions (20%).

“The findings also suggest that telehealth is on the cusp of advancing from a tool used occasionally to a tool implemented on a routine basis. However, use of telehealth services will not become widely adopted until health systems are reformed to address barriers. Specifically, practice training and support need to be reformed to include telehealth education; technological platforms need to be updated with tools to support telehealth; reimbursement for telehealth services needs to be expanded; and licensing and credentialing need to be clarified to allow for interstate provision of telehealth services,” the survey report authors wrote.

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AMA Meeting to Develop New Telemedicine Codes

Jonah Comstock

The American Medical Association has recently created a working group tasked with creating CPT codes for telemedicine to support reimbursement. Currently there are multiple CPT codes originally used for face to face encounters that can be used for various telemedicine visits. However, specific telemedicine codes may improve physician comfort in seeking reimbursement for the encounters. The working group is composed of physicians, health professionals, telemedicine innovators, and insurers.

“The CPT code set is the foundation upon which every participant in the medical community — physicians, hospitals, allied health professionals, payers and others — can efficiently share accurate information about medical services,” AMA President Dr. Steven J. Stack said in a statement. “Input from the Telehealth Services Workgroup will help the CPT code set reflect new technological and telehealth advancements available to mainstream clinical practice, and ensures the code set can fulfill its role as the health system’s common language for reporting contemporary medical procedures.”

The working group met for the first time in Philadelphia this month. The workgroup now intends to subdivide and determine those areas most in need of codes.

Telemedicine At Sea

In International Shipping News

ClipperTelemed+ offers advanced telemedicine services 24/7 from emergency physicians to crew members of merchant ships, super yachts, and individual yachtsmen.  Recently ClipperTelemed+ assisted 2 crewmembers aboard yachts racing around the world.  The first patient was a 68 year old made suffering from symptoms that were suggestive of a possible heart attack, however, after consultation with the telemedicine service, he was treated for heat exhaustion and was able to continue the race.  The second patient suffered a large arm wound. The telemedicine physician was able to guide other members of the crew on stitching and setting the injury.

In both instances, a diversion and medical evacuation was avoided. The physicians can help diagnose and treat anything from broken bones to infections, collapsed lungs, dislocated shoulders and abdominal injuries while giving advice on using/administering medicine from the on board kit they also provide.