Telemedicine becoming a reality in today’s ED
Once just a prospect in the distant future, the practice of telemedicine has already begun in several EDs. Telemedicine is best-suited for emergency medicine, says William Bickle, MD, FACEP, an emergency physician at St. Francis Hospital in Tulsa, OK, where more than 5000 telemedicine consults have been done. "We’re always there in the department, so there is contiguous access as opposed to dealing with clinician’s schedules. We’re also used to dealing with physician extenders," he notes. "You can do a very comprehensive workup with telemedicine, you can look at the eyes, ears, nose and throat, listen to breath sounds, and do everything but palpate."
Using advanced technology that allows the transmission of video images and data at high speeds over telephone lines or satellite links, ED clinicians at small, community hospitals and clinics can consult with their colleagues at larger, more sophisticated institutions.
St. Francis is hooked up to three rural EDs and two prisons, with both the telemedicine suite and teleradiology next to the ED. The physician’s assistants who staff the rural EDs are put through a training program for critical care similar to flight nurses, an extensive airway program, cardiac resuscitation, pediatric resuscitation, trauma resuscitation, wound management, and a critical care skills lab. "Our goal is to have patients who go to that rural ED experience no difference in the standards of emergency medical care they receive than if they came to our own hospital," says Bickle.
Rural EDs often cannot afford to staff with a physician 24 hours a day. "You just can’t afford to put a board-certified emergency physician in a small, rural ED," says Bickle. "Until now, they had two choices: to go without coverage and just call in a local physician if needed, or contract with a group for coverage."
The eight PAs who staff the rural EDs also work in the main ED at St. Francis. "They need to have constant exposure to a major medical center for skill maintenance," says Bickle. "It’s also it’s important that we’re familiar with them and their work habits, it’s helpful if you’re working with someone you know and trust and have trained."
Telemedicine enables physicians to treat patients in remote regions that previously had very limited access to medical care. For example, it’s being used to span distances in the middle of the winter in Minnesota, says Stephen Holbrook, MD, MBA, FACEP, an emergency physician and operations officer at DeKalb Medical Center in Atlanta and principle investigator in a recent telemedicine study at Emory University. "Your choice is sending the image or sending the patient. Once you start talking about inaccessible distances, telecommunication starts to make a lot of sense."
The ED at St. Francis in Tulsa does an average of 15 consults a day. Frequent use of telemedicine consults are a key to the program’s success, stresses Bickle. "If it’s not integrated into the system of care, and you only use it rarely for physician-to-physician consults, you’re in big trouble," he warns. "We’re doing consults every day, so our system is well-honed, and everyone is comfortable with the technology. If we only used it once every few months, we’d have to sit down and figure out how to use it, and the hassle factor would be a problem."
Rural EDs benefit
Buffalo (MN) Hospital’s ED began telemedicine consults in early 1996 and is currently connected with three rural EDs in the state of Minnesota, ranging from 70-150 miles away. Since its inception, there have been over 900 emergency consults. "Patients who come in with sore throats or fever are all very easily seen using telemedicine," reports Deb Gorder, LPN, coordinator for the ED’s telemedicine services. "The rural sites have on-call physicians, but they try to utilize telemedicine so their family physicians can get a good night’s sleep and be more productive."
Since Buffalo’s ED only sees about 10,000 patients a year, the physicians on staff have time to do telemedicine consults. "Since our volume is low, the telemedicine services are a way to keep our physicians busy," notes Gorder. The telemedicine exam takes about 30 minutes on average. During the ED’s busiest times, the rural site is notified to call in the local physician instead of doing a telemedicine consult.
The hospital charges the rural facilities $5 per hour to cover their ED. "For $30,000 a year, they have 24-hour coverage, which is very cost-effective for them," says Gorder. Buffalo’s telemedicine room contains two large TV monitors, a camera, a document stand, and peripheral equipment, such as a pen pad which enables physicians to control camera angles. "If the physician thinks the person who brought the patient in has additional information about their condition, they can move the camera to show them as well, or zoom in on a patient’s skin lesion," she explains.
When a patient comes to the rural ED, the vital signs are faxed to Buffalo’s ED, and a time is arranged with the physician to do a telemedicine consult. "If the physician in Buffalo feels a strep test needs to be done, the nurse would do that first before connecting," Gorder explains.
The physician observes as the nurse in the rural ED examines the patient. "The urse can look in the patient’s ears with special peripheral equipment which magnifies the image, so the physician has better visibility than if the patient were here," Gorder says. "At any time, the physician can save a photo image." A receiving stethoscope enables the physician to hear the patient’s heart and lung sounds.
Medications can be prescribed immediately. "The nurse can take 10 tabs of 500 mg prepackaged amoxycillan and put it underneath the document stand so the label can be read by our physician," Gorder says. "At that time, the nurse takes the medication out of the bag and the camera zooms in on that, so the physician in Buffalo can verify it." The prescription is then faxed to the rural ED.
In some instances, the local physician still needs to be called in, but telemedicine is used to consult with a Buffalo physician in the meantime. "If a patient comes in with chest pain, the telemedicine consult is used until the local physician arrives," Gorder says.
Even if the patient needs to be transferred for a procedure such as a thorocotomy, the consult facilitates the process. At a rural ED, when a man with acute MI went into defibrillation, the telemedicine consult with St. Francis expedited his care. "Without that system in place, there would have been significant delays each step of the way totaling several hours," says Bickle. "Some rural providers have the mistaken notion that they need to have workups done before they call to transfer trauma patients."
Patient satisfaction surveys in Buffalo showed high satisfaction rates with the telemedicine consults. "On a scale of one to five, five being excellent, 77.5% of patients rated it as excellent, and 13.5% rated it a number four," says Gorder. "One area patients don’t answer as highly is, Are you comfortable with the technology?’ That’s mainly because it takes them awhile to get used to seeing themselves on television, except for children, who love it."
Advanced training is a must
At the rural EDs that consult with Buffalo’s ED, first-rate nursing assessment is imperative, especially where abdominal pain is concerned, Gorder says. "It’s very difficult because our physicians aren’t there actually feeling the abdomens of those patients, so good assessment on the other end is extremely important."
An annual education program is provided to clinicians in the rural EDs. "You need to make sure people are comfortable with the technology," Gorder says. "It’s imperative that the nurses are able to troubleshoot, and know what to do if they can’t connect." The rural nurses are also invited to work an eight-hour shift at the Buffalo ED, she adds.
Expand the ED’s scope of service
Telemedicine will allow increased interface between EDs and prehospital providers, predicts Holbrook. "Through telemedicine, ambulance providers and home health nursing agencies can interact with EDs to provide better, more timely care, which makes tremendous sense," he says.
Such arrangements could have a significant impact on the ED’s bottom line. "This allows the ED to expand from just taking care of emergencies to having a presence in the home, which gives us a much bigger market," he argues. "To be the first one out there to do that gives you a tremendous competitive edge. Smart managers will make sure they are positioned appropriately for that, because it will happen. You’ll either be offering the service or left behind."
Telemedicine will allow EDs to become more integrated in the rest of medical system, he says. "This is a wonderful opportunity to use our unique strengths. We are the only part of medical care allowed to go into people’s homes and do prehospital work," he argues. "Why not use that strength and make it work for the patient’s benefit and our benefit?"
Instead of simply transporting a patient to the ED, paramedics could expand their scope of practice, says Holbrook. "Why can’t they go out into the community and do some follow up care, sending images back to ED?" he asks. "Traditionally with home health, the new nurses will go to see the patient on Saturday, and they might have a wound which looks bad. Instead of just taking them to the ED, they would be able to call up the image from yesterday and the days before, and might see that the wound actually looks a lot better."
Portable systems for telemedicine consults are integral to that scenario. A trial conducted in 1994 at Emory University in Atlanta allowed ambulance service providers to send diagnostic images to the ED within seconds, to speed care of patients.1 "We were able to predetermine where the best destination would be while the patient was still in transit," reports Holbrook.
The portable telemedicine system has since been approved for use by the FDA, and is expected to be available in mid-1998. "It is a cost-effective triage and diagnostic tool," says Holbrook. "If a trained person who is used to seeing severe traumas can see images of accident scenes, they can predict fairly well what type of injury patterns you’re going to see. Certain car crashes look really bad, but you can predict the patient won’t have substantial injuries. This would enable you to determine that at the scene of the accident, before patients are brought to the ED."
Financial issues are problematic
ED managers need to be aware of their options, says Holbrook. "Managers need to understand that telemedicine isn’t just one thing, it’s a range of options, and you have to keep an open mind about what you can do," he advises. "There are basically three types of systems out there, and the costs are substantially different for each."
Although a telemedicine system is currently a significant investment, with costs ranging from approximately $6,000-$100,000, future technology may reduce its costs. "As individual proprietary systems are set up, it’s possible we won’t need the $20,000 system, and we’ll be able to use the PC to do consultations over the Internet, but that won’t happen for at least five years," says Bickle.
Reimbursement issues for the "virtual physician" still need to be ironed out. "Our state has passed a telemedicine act which allows us to bill for selected patients, which helps us immensely," says Bickle. "We’re somewhat ahead of other states, because being a rural state we’ve all recognized a need for this technology." Medicare reimbursement is still problematic, since the state statutes do not override federal law, he adds.
At Buffalo, the ED is not currently being reimbursed for telemedicine consults. "If insurance pays for the telemedicine consultations, we’re able to bill for them, but otherwise we will only bill the patient for any lab work or X-rays," says Gorder.
However, telemedicine consults financially benefit the ED in other ways. "You get transfers you may not otherwise get," says Bickle. "Since one of the rural EDs we’re connected to is roughly equally distant between Oklahoma City and Tulsa, normally half the patients would go to another facility."
Still, it’s important to give the patient a choice about which ED they are sent to. "You don’t want to be in a situation of coercing people to go in one direction or the otherthat’s an issue we struggle with," says Bickle. "The physician’s assistant has absolutely no financial incentive to send them to us, but it’s the path of least resistance, because it’s a lot easier to get an accepting physician to arrange the transfer."
Resources
• A document titled Telemedicine: A Guide to Assessing Telecommunications for Health Care (1996) is available from the National Academy Press. To order the $39.95 document (shipping and handling is $4.00 on the first book, and .50 for additional books), contact the National Academy Press, 2101 Constitution Avenue NW, Box 285, Washington, DC, 20055. Telephone: (202) 334-3313 or (800) 624-6242. Fax: (202) 334-2451. Internet: http://www.nap.edu
• Telemedicine Today publishes a Buyer’s Guide listing suppliers of telemedicine systems. To order the March 1997 Buyer’s Guide, contact Telemedicine Today, PO Box 11122, Shawnee Mission, KS 66207. Telephone: (800) 386-8632. Fax: (913) 268-3783. Internet: http://www.telemedtoday.com
• The American Telemedicine Association promotes improvement in health care delivery through the application of telecommunications technology. Individual memberships are $165 and include a subscription to the Telemedicine Journal, participation in task forces on the future of telemedicine, and support efforts to achieve reimbursement of telemedicine by the insurance and health care industry. For more information, contact the American Telemedicine Association at 901 15th Street NW, Suite 230, Washington, DC 30005. Telephone: (202) 408-0677. Fax: (202) 408-1134. Internet: http://www.atmeda.org
References
1. Holbrook S, Davis T. Real-time video image transmission by EMS. Acad Emerg Med 1995;2:384-385.
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