While telehealth is still being tested in pilot projects in primary care in Australia it is beginning to be business as usual in secondary care, particularly for out patient services in rural areas and emergency care in regional areas, according to a review of this year’s Australian Telehealth Conference (ATC 2017) which concluded on Saturday. The article in Pulse+IT, puts the difficulty of getting telehealth into primary care down to the funding model in Australia.
The much admired Australian health care service is a mixture of public and private health care with, broadly speaking, the publicly (Medicare) funded hospitals providing a universal free service and the primary care being provided by a Medicare subsidised private practice service.
Until July 2014 telehealth services received incentives under the Telehealth Financial Incentives Programme. This programme was instrumental in introducing many telehealth trials through which the medical community learned the benefits and difficulties of telehealth first hand. Although these incentives have stopped, providers still receive higher Medicare benefits for approved telehealth services listed in the Medicare Benefits Schedule (such as video consultations between specialists and patients in telehealth eligible areas). However restrictions in eligibility for Medicare Benefits for telehealth usage have been shown to reduce the potential use of telehealth facilities (see our earlier item Should Australia review restrictions on use of telemedicine?).
Topics discussed at the conference included Telestroke, Innovations (Augmented Reality, AI), delivery models and virtual care. Many of the presentations given at the ATC 2017 are available at the ATC website here.
Almost exactly 14 months to the day since the press release announcing a pilot of a telemedicine service, the first patient is said to have undergone treatment using the Dubai Health Authority’s RoboDoc telemedicine system according to Middle East North Africa Financial Network. The patient was based in Hatta Hospital and the respiratory specialists were based at Rashid Hospital Trauma Centre according to the report. RoboDoc units, from InTouch Health, have also been installed at two primary care centres in Dubai.
In a previous TTA article this editor expressed surprise that telehealth would be of interest to Dubai which is only 1600 square miles in area. Having considered the details of the implementation the interest is partially explained by the fact that Hatta is an outpost separated from the rest of Dubai, 135 km (84 miles) from Rashid Hospital.
However, the other two centres at which the RoboDoc devices have been installed, Al Bashar Health Centre (15 miles from Rashid Hospital) and Nad Al Hammar Health Centre (7 miles from Rashid) (more…)
An article in MIT Technology Review takes a sideways look at telemedicine and asks if telemedicine is providing an easy route for people suffering from excessive anxiety about their health. The author, Christina Farr, suggests that the ease of contacting a doctor using telemedicine services in comparison to having to visit a doctor’s office and the ability use either insurance or direct payments makes these services more attractive to hypochondriacs (lately called those with somatic symptom disorder).
Views on the subject are quoted from the chief medical affairs officer at MDLive, Deborah Mulligan, and a board member of Doctor on Demand, Bob Kocher. While the first is able to relate an anecdote where a case of excessive anxiety disorder was identified and successfully referred to cognitive behavioral therapy, the latter says he isn’t aware of any patients with health anxiety regularly using the Doctor on Demand app.
Read the full article here.
The West Virginia legislature has been considering a new bill to expand the range of medications that may be prescribed in a telemedicine encounter. The bill was passed by the House of Representatives last week and sent to the Senate for consideration.
The House Bill 2509 proposes to amend the West Virginia Medical Practice Act to enable physicians to prescribe certain controlled substances when using telemedicine technologies. According to Mobihealthnews this would specifically include medication for mental and behavioral health, although bill itself does not refer to these conditions. A note at the end of the bill states “The purpose of this bill is to permit a physician to prescribe certain controlled substances when using telemedicine technologies.”
It seems that the legislation in the US dealing with telemedicine is fragmented and becoming more so. There was the issue of whether health insurance companies would cover telemedicine consultations, then the issue of medicare and medicaid covering the telemedicine consultations, then the state medical boards refusing cross border telemedicine and now issues on individual medications that can or can’t be prescribed. This will make it increasingly difficult for those practitioners who decide to enter the telemedicine arena.It is not a sustainable approach to pass a new law on every issue relating to telemedicine. Telemedicine is merely medicine practiced via a different route and regulation and standardisation of processes associated with telemedicine should be divested to a suitably established agency overseen by the legislature, similar to how the medical boards operate. In fact, this could easily be an additional responsibility given to the medical boards.
An agreement reached in the U.S. District Court in Idaho in January this year overturned Idaho’s ban of prescription of abortion-inducing drugs during a telemedicine consultation (see our previous article).
The settlement of the case before Chief District Judge B. Lynn Winmill, brought by Planned Parenthood of the Great Northwest and the Hawaiian Islands, required the Idaho legislature to repeal the laws that made such prescriptions over telemedicine consultations illegal. The repeals have to be carried out by the end of the 2017 session, else Judge Winmill will declare the laws unconstitutional and unenforceable, according to Mobi Health News .
Idaho legislature has accordingly started the process of removing the single line from the Telehealth Access Act which bans the prescription of abortion inducing drugs and repealing the law requiring the doctor to be physically present at the consultation when prescribing the drugs. This is to be achieved via the new House Bill 250, sponsored by the State Affairs Committee, named simply An Act relating to Abortion. The bill was introduced last Friday.
The wording of the bill emphasises the the view that the state believes that abortions induced by medicines prescribed via telemedicine consultations constitute “substandard medical care and that women and girls undergoing abortion deserve and require a higher level of professional medical care”. Planned Parenthood has said that it objects to this statement that telemedicine provides substandard care according to Boise Weekly.
The bill has made rapid progress having had its second reading yesterday and is currently filed for the third reading.
The bill to expand telehealth in Utah, which was amended by a Utah Senate committee on February 14th (see previous TTA article) has now been passed by both the Senate and the House of Representative in the state. The amended bill was passed by the Senate on Thursday last week and by the House the next day according to the Utah government website.
The original bill, HB154, sponsored by Rep. Ken Ivory, had a controversial clause restricting the prescription of abortion medication during a telemedicine consultation. The amendment removed this restriction on the basis that such restrictions have been successfully challenged in the courts in other states.
The bill is now being “enrolled” and is expected to be signed into law in due course.
The controversial topic of abortion has been the centre of discussion of a new telehealth bill in Utah. The bill, HB 154, introduced by Republican Rep Ken Ivory, primarily addresses the issue of insurance coverage for telehealth in Utah and proposes to amend two previous acts and the Utah Insurance Code to achieve this. However, the bill also contained a controversial final clause which stated “A practitioner treating a patient through telehealth services, as described in Title 26, Chapter 59, Telehealth Act, may not issue a prescription through electronic prescribing for a drug or treatment to cause an abortion, except in cases of rape, incest, or if the life of the mother would be endangered without an abortion”
Last week it was reported (in Healthcare IT News) that the bill was discussed in the Public Utilities, Energy and Technology Standing Committee. Similar restrictions on prescribing abortion medication following telemedicine consultations were legally challenged in Idaho by Planned Parenthood resulting in the ban being lifted at the end of January (mobilehealthnews, mhealthintelligence). Earlier, in June 2015, another legal challenge, this time in Iowa, went all the way to the Supreme Court which rejected a state requirement for doctors to see abortion patients in person and ruled that the regional Planned Parenthood unit could continue to provide abortion inducing medication using remote video consultations.
According to data published by the Guttmacher Institute, as of February 1, 2017, there are 19 states which require a physician to be physically present when abortion inducing medication is prescribed (see Medication Abortion).
This week, when the Utah bill was discussed in the Senate Health and Human Services Committee an amendment proposed by Republican Senator Brian Shiozawa removing the above abortion clause was accepted. Shiozawa expressed fears that a constitutional challenge could give negative publicity to telehealth as a whole. The bill now moves to the Senate for consideration.
Telestroke has expanded over the years and one of the most recent implementations is in New York at a group of hospitals in Hudson Valley. Health Alliance of Hudson Valley announced last week that its Kingston Hospital is now operating a telestroke service provided by Neurocall that uses a team of 40 “tele-neurologists” based in New York, Texas and Florida.
Stroke is one of those medical emergencies where the speed of diagnosis – usually within minutes of symptoms appearing – can have life-long impact on the patient’s ability to return to an independent life. What is particularly complicated in a stroke is that it can be caused by a blood clot or a burst blood vessel and the treatment for the two types are very different. When a specialist who is able to identify the type of stroke quickly is not available at the hospital, as is commonly the case, the ability to use telemedicine has proved to be a great boon.
A survey in 2012 identified 56 telestroke programs across the US and no doubt this has grown over the years with many well known health service providers such as the Mayo Clinic, Massachusetts General and Cleveland Clinic operating a telestroke service as well as acting as a hub to regional and rural hospitals.
Stroke is the fourth leading cause of mortality in the USA and the leading cause of serious long term disability according to the American Heart Association. With only 1100 stroke specialists in the US, half of US hospitals do not have a stroke specialist on the staff and nearly half the US population live more than 60 miles from a stroke centre according to “Telestroke—the promise and the challenge“, a paper published last year in the British Medical Journal. These factors have led to telemedicine being firmly established as an important part of acute stroke treatment.
The Consumer Electronics Show is half a century old this year and it is promising to be the biggest show yet. Here are some items that may be of interest to TTA readers.
The conference programme includes a Digital Health Summit and a Wearable Tech Summit (the organisers obviously haven’t been reading the TTA view on wearables so recently produced by Editor Donna). In the Digital Health Summit the top topics are going to be advances in genomics and precision medicine (not sure why this is digital health), Digital medicine and current trends such as “tele-everything”, wearables, aging, digital therapies (what’s that?) and VR. The wearable Summit top topics are the science of wearables, hottest wearable tech thus far and interactive jewelry.
There is a new “Sleep Tech Marketplace” presented by the National Sleep Foundation (no, really, I am not making this up) with 10 companies exhibiting everything from sleep tracking devices (Beddit), a system to mask noise during sleep (Cambridge Sound Systems), ultra thin earphones to wear in bed (Dubs Labs), a water mattress-topper to keep you cool while you sleep, an app to record your dream talking and snoring (Snail App) and a stress reducer.
If you are not attending between tomorrow and the 8th, then you could do worse than follow it on the official CES website or on engadget
Just before the signing ceremony of the 21st Century Cures Act in the South Court Auditorium of the Eisenhower Executive Office Building President Obama made special mention of his Vice President Joe Biden and his wife Jill who had spoken of the death of their son due to cancer. Obama also mentioned his own mother who had also died of cancer when she was two and a half years younger than he was himself now. The Act provides $1.8 billion for cancer research according to the Washington Post although the allocation is for biomedical research and is not specifically for cancer research.
What was unsaid at the ceremony was that the Act also has a section on telehealth. The telehealth section of the act requires the Centers for Medicare and Medicaid Services (CMS) to report within one year to Congress on populations of Medicare beneficiaries whose care may be improved by expansion of telehealth services. CMS is also asked to report on the telehealth related work already funded by CMS Innovation, make suggestions on the type of services which might be suitable for telehealth and indicate barriers to expansion. The Medicare Payment Advisory Commission (MedPAC) is asked to identify, by March next year, services for which payment is available through private health insurance plans but not under Medicare. MedPAC is then asked to recommend how to incorporate these into Medicare.
These measures look to expanding the role of and accessibility to telehealth for Medicare beneficiaries. Further, a note entitled “Sense of Congress” states that “It is the sense of Congress that eligible originating sites should be expanded …”. However, unlike the key elements of the 21st Century Cures Act, such as biomedical research, no specific funding has been allocated for the implementation of any telehealth related recommendations. Although some optimism has been expressed about the expansion of telehealth as a result of this Act (see, for example, comments from URAC in HIT Consultant and Healthcare IT News.), with the lower priority on health that is possible from the incoming Trump administration, only time will tell if such optimism is justified.
A new project to produce smart technical solutions to increase possibilities for the elderly to live at home without being dependent on children or in-home care has been launched in Europe. The collaborative project named FRONT-VL is led by the Swedish mobile phone operator TeliaSonera and has 21 contributing organisations working within the industry-driven European research initiative “Celtic Plus”.
The project is based on the premise that by enabling elderly people to live at home for as long as possible a good quality of life can be maintained while at the same time reducing care costs. The project proposes to develop predictive health related end-user services in fall prevention, mental health, rehabilitation and palliative care using machine learning and “big data” analysis together with IoT based data acquisition.
FRONT-VL has a budget of 7.2 million Euros and is due to run for 3 years beginning next month. The funding caters for just over 55 person-years of effort over the three year period.
The key innovations of the project will be in two areas. First will be to create a common service delivery framework able to provide Information Computing and Telecommunications based home care and health services to end-users and care professionals. Second is automated data collection to enable peer-to-peer learning and knowledge transfer.
The Celtic Plus initiative defines, performs and finances research projects in telecommunications, new media, future internet and applications and services. It is part of the wider Eureka Network that facilitates R&D projects across Europe.
New Zealand’s public health advice line is handling more inquiries than ever, with a 16% increase in the twelve months to September 2016. In a press release following the recent visit by the Health Minister Jonathan Coleman to one of the four call centres the Government said that more services will be added to the advice line in the coming months.
Seven advice lines, operated by multiple providers, were brought together a year ago and the 24/7 advice service now operates out of four call centres and employs 250 people, according to Dr Coleman. Known as the National telehealth service (bit of a misnomer), it is operated by Homecare Medical owned by ProCare and Pegasus Health, two of New Zealand’s largest health organisations. It brings together advisory services for queries relating to general health, alcohol and drugs, depression, gambling, immunisation, poisoning and quitting smoking. The advice can be obtained through phone, text and online programmes and some are delivered though partner organisations such as the National Poisons Centre.
This is similar to the UK’s non-emergency NHS 111 service that provides a 24/7 free advice line giving access to trained advisors supported by healthcare professionals, except that the UK service is probably more integrated.
Research carried out in Australia shows that a hospital with telemedicine facilities for outpatient consultations was using those facilities for only one in seven potential appointments. The retrospective study of outpatient appointments at Princess Alexandra Hospital in Brisbane showed that in a 12-month period 2.5% of outpatient consultations were carried out by telemedicine. Although 17.5% of the appointments were potentially viable via telemedicine, a policy of permitting telemedicine only for rural residents meant that, as the majority of the viable telemedicine consultations were with metropolitan residents they were carried out as hospital visits.
This raises the question whether expansion of the use of telemedicine for hospital consultations in Australia should now be reviewed. Currently there is a geographic requirement that the patient’s location must be outside of an Australian Standard Geographic Classification Remoteness Area 1 (a city) for a telemedicine consultation to be eligible for Medicare Benefits.
The research has been published in the Royal Society of Medicine publication Journal of Telemedicine and Telecare. The author, Monica Taylor, also presented the findings at Successes and Failures in Telemedicine 2016 in New Zealand where she was awarded the best paper award.
Intensive Care Units treat the most sick people in a hospital and requires round-the-clock staffing by doctors and nurses. 24-hour staffing, however, means shift working and an inevitable night shift. To make it fair on all staff the shifts are usually rotated so any doctor or nurse would do a period on one shift and then move to the next shift.
It is not surprising that the more senior staff manage to have less night work than newer, less experienced ones. On the other hand night shifts may have attractions such as extra pay and this may be more important to the lower paid less experienced staff than to the higher paid senior ones. Also, the cost of staffing nights with less experienced staff may prove cheaper for the hospital. Nevertheless, the patients’ needs are no less important at night than during the day. Another aspect of night-time care is the possibility that a doctor or nurse may not be as alert at night as they would be in the day-time.
Looking at these downsides of night-time ICU care staffing, an hospital in the US has come up with a novel idea – move the doctors and nurses to a zone where it is day-time when it is night-time at the hospital and use telehealth to connect them. This is counter intuitive and has its own drawbacks.
Georgia’s largest healthcare provider Emory Healthcare is sending some ICU doctors and nurses to Sydney, Australia, for tours of six to nine weeks at a time, in a trial to staff ICU at night with health staff in a daylight zone using telehealth. The six month trial in collaboration with Philips and Australia’s Maquarie Health has been underway for 3 months.
The reason this is counter-intuitive is that telehealth was invented to overcome the problems associated with healthcare professionals and patients not being at the same location and here the two are being artificially removed to two ends of the world. While telehealth is a good solution to the diagnosis and treatment from afar, most professionals are likey to agree that it is inferior to being face to face with the patient. So it will be good to see the conclusions reached by this trial on how any drawbacks of distance balances out with having more alert doctors and nurses.
See also mHealth Intelligence article here.
The American Red Cross has entered into a partnership to pilot the use of telemedicine during periods of disasters in the US. During the pilot a nationwide network of physicians will be available for consultation via video calls.
Through this pilot collaboration, physicians working with Red Cross partner Teladoc will be available to people helped by the Red Cross whose access to health care providers has been limited or is unavailable after large-scale disasters. Teladoc’s virtual physician visit services will be made available via web, Teladoc’s mobile app and phone to address the primary health care needs of individuals affected by disasters.
Teladoc is reported to have donated remote medical care during the recent Hurricane Matthew. This partnership is positioned as an expansion of such disaster relief efforts rather than an expansion of its commercial activities.
Use of telemedicine in disaster relief has been implemented previously in the US by the Department of Veterans Affairs (VA). In 2014 the Office of Emergency Management of the VA awarded a contract to use the JEMS Technology disaster relief telehealth system. Going back much earlier, following the December 1988 earthquake in Armenia and the June 1989 gas explosion near Ufa, a satellite based audio, video and fax link, known as the Telemedicine Spacebridge, between four US and two Armenian and Russian medical centres, permitted remote American consultants to assist Armenian and Russian physicians in the management of medical problems. Last year NATO tested use of telemedicine in disaster situations in a simulated disaster scenario in Ukraine.
Another system, Emergency Telehealth and Navigation, is deployed in Houston for helping with 911 calls. The Houston Fire Department has agreements with doctors so they have access to a doctor at any time to take calls from crew at emergency sites. They find that this avoids having to take some people to hospital when a doctor is able to determine that a condition is non-emergency where a paramedic may well have taken the patient to an Emergency Department.
- Telehealth has been confirmed as the way forward for sustainably treating the leading chronic diseases in Australia says a report published following a scientific study. The study, which analysed the effects of monitoring a mixed group of patients with chronic conditions using home-based telehealth equipment, concludes that use of home-based telehealth will not only reduce the hospital admissions but will also reduce the length of stay when admitted. The analysis of the data from the trial has shown that for chronically ill patients, an annual expenditure of AU$2,760 could generate a saving of between AU$16,383 and AU$19,263 representing a rate of return on investment of between 4.9 and 6. This is equivalent to a saving of AU$3 billion a year, says the report.
The Australian study, carried out by the Commonwealth Scientific and Industrial Research Organisation (CSIRO) is reminiscent of UK’s Whole System Demonstrator (WSD), the world’s largest randomised control trial of telehealth. Although the Australian study is much smaller with a total of 287 participants over 5 sites (covering the 5 States) compared with over 6,000 in the WSD, the principles are similar. Due to the smaller sample sizes and the need to have patients connected to the National Broadband Network (NBN) the selection of patients was not random but other techniques were used to obtain statistically significant results. Patients selected had unplanned acute hospital admissions indicationg one or more of Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease, Hypertensive Diseases, Congestive Heart Failure, Diabetes and Asthma.
The TeleMedCare Systems Clinical Monitoring Unit (CMU) was used as the home-based unit although not all features offered by the device were utilised in this study. The CMU system deployed in this study was developed in Australia, registered with TGA (Therapeutic Goods Administration) and has been extensively used and tested in previous trials.
Typically patients would have some or all vital signs measurements scheduled at a convenient time, typically in the morning. These measurements were blood pressure, pulse oximetry to measure arterial blood oxygen saturation, ECG (single channel), lung capacity, body temperature, body weight and blood glucose concentration. In addition to scheduled times, patients could take their vital signs at any time. A full suite of clinical questionnaires was also available.
The full report Home Monitoring of Chronic Diseases for Aged Care is available to download here.