Telehealth and Health Informatics: How They Should Work Together


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Ronald S Weinstein
Arizona Telemedicine Program
(Wednesday, Telehealth Workshop)

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  • 2007 © Arizona Board of Regents Elizabeth thank you for the warm introduction. Today’s topic is the clinical applications of telemedicine. This is really what it’s all about, providing the clinical consultation.
  • 2007 © Arizona Board of Regents Clinical care may be sub-specialty care or primary care. Part of what we need to do as we provide that care is to evaluate it. We want to make sure that what we are doing is at least as good as what can be done in person. We need to understand how the technology helps us; (or) how the technology serves as a barrier; and how we can overcome those barriers to enhance the technology’s use. The other application that we often do not think about for improving medical care is education. Education to the communities, to the physicians, to the nurses, and to the healthcare team is very important in order to enhance clinical care. We know that many times when things are not thought about in clinical practice, it is because it may be new knowledge that has not been incorporated by that clinical team yet. So education is very important to the provision of care.
  • 2007 © Arizona Board of Regents As important as it is to know who your tele-consultants are, it’s equally important to know and understand your referral population. Who are the referring clinicians? Who are the main providers of care? Are they physicians? Mid-level providers? Psychologists? Dentists?
  • 2007 © Arizona Board of Regents It’s important to think about how to structure the teleclinical service, the hub and spoke sites. Both the hub site and the spoke site have a similar organizational structure. It is necessary to have a site coordinator and a medical director at both sites. These are the key people who interface with the clinicians and the referral community, at each of the sites. At the spoke site, the referring clinicians are interacting with the site coordinator and the medical director. At the hub site, the site coordinator and the medical director are interacting with the teleconsultants.
  • 2007 © Arizona Board of Regents How do we set up the teleconsultations? What does it mean to have a telemedicine appointment? Telemedicine appointments may be accomplished in either store-and-forward or real-time fashion. They may be scheduled on an Ad Hoc basis or within a telemedicine clinic that is scheduled weekly or monthly dependent on demand.
  • 2007 © Arizona Board of Regents How does one decide which services to offer as a standing teleclinic? Think about the greatest need. In general, in most of our country and most of the world, psychiatry and dermatology are the most prevalent applications of telemedicine technology. Additional areas that have been established as standing teleclinics are rheumatology, a multi-disciplinary pain service and cardiology.
  • 2007 © Arizona Board of Regents It is important that patients are presented in a standardized fashion so protocols should be developed. This slide gives examples of areas where protocols have been developed.
  • 2007 © Arizona Board of Regents We’ve talked about the structure to support a teleconsultation service. What is the goal for providing telemedicine consultations? What is needed to implement the service?
  • 2007 © Arizona Board of Regents One goal may be to assist in triage. For example, if there’s a patient at a distant site who experienced a cervical spine injury in a car accident, the attending physician may use the teleconsultation to help decide if the patient can stay or if she or he needs to be evacuated. The clinical information necessary to make that decision will be different from the kind of information needed when the goal is to increase access to specialty care or to confirm a diagnosis.
  • 2007 © Arizona Board of Regents And what makes a successful teleconsultation? The most important step toward a successful teleconsultation is to have complete information. Incomplete clinical data results in an incomplete consult. The quality of the images transmitted to the teleconsultant should be double checked. It is important to have the case file reviewed for completeness of patient information by the Site Coordinator and by the Medical Director before it is reviewed by the teleconsultant, to determine the suitability of telemedicine for this type of consult.
  • 2007 © Arizona Board of Regents This is the way that I think about the kinds of teleconsultations that lend themselves well to telecommunications technology. The visual specialties are very successful. If the technology can provide images or sounds that can be diagnostically interpreted, teleconsultation will be feasible. If the teleconsultation is of the type where the talk is the treatment, then the technology will likely be useful as well.
  • 2007 © Arizona Board of Regents These are some applications of telemedicine where visual information is important for the diagnosis. In order for the teleconsultation to be successful, the clinician or her/his designee must be available to illustrate the visual physical findings. The telepresenter must have a clinical background and technical training. The technical training may be provided by the telemedicine program in formal training events prior to actual clinical use of telemedicine. Doing telemedicine requires special training.
  • 2007 © Arizona Board of Regents Unquestionably, teleradiology is the killer application in telemedicine. Teleradiology has established guidelines, protocols, and requirements for diagnostic imaging. Although teleradiology services may be used to access MRI or CT scans, most common applications are for the evaluation of chest and bone radiographs. The Arizona Telemedicine Program has handled over a million teleradiology cases coming from dozens of rural hospitals.
  • 2007 © Arizona Board of Regents Teledermatology is a visual specialty that lends itself well to the technology. The slide illustrates vesicular lesions. In order to assure a successful teledermatology consultation, clear images must be taken and transmitted. Our program has undertaken exhaustive comparison of a variety of cameras to ensure photographic fidelity in capturing images of dermatologic lesions. Teledermatology is another area that requires careful training and protocols.
  • 2007 © Arizona Board of Regents These images depict tele-rheumatology consultations. For example, range of motion can be easily demonstrated with the video technology, as illustrated in the lower left portion of the slide, but other techniques such as checking for strength are more subtle and require protocol development and training of the telepresenter by the teleconsultant. The lower right photo shows a physician evaluating the patients wrist for rheumatoid arthritis.
  • 2007 © Arizona Board of Regents Teleneurology is another visual specialty. As seen in the left hand side of this slide, it is possible to observe the patient’s difficulty getting in and out of the chair. In the upper right photo, reflexes are being assessed. In order to demonstrate reflexes, the images are taken laterally so that the reaction is seen more easily by video than if it had been viewed face on.
  • 2007 © Arizona Board of Regents Cardiology, pulmonary, otorhinolaryngology, retinal screening, colposcopy, radiology and pathology. These are additional application that work. The first two, cardiology and pulmonary, utilize both images and sounds. The sounds come from an electronic stethoscope.
  • 2007 © Arizona Board of Regents Heart sounds, lungs sounds and bowel sounds can all be transmitted for diagnostic purposes. Protocols are in place for each of these exams. The electronic stethoscope can be successfully used in both the adult and the pediatric setting.
  • 2007 © Arizona Board of Regents Tele-echocardiography is a successful application for both the adult and the pediatric patient. The studies are done in real time with direct teleconsultant supervision of the echo technologist. The Arizona Telemedicine Program has had extensive experience providing tele-echocardiolography services to the 20-bassinette neonatal intensive care unit at Yuma Regional Medical Center, 300 miles away from Tucson. We’ve handled over 425 cases to date.
  • 2007 © Arizona Board of Regents Evaluation of ear, nose, and throat health is an area of interest especially for school based clinics. The way the school based clinics have been set up is that instead of having the nurse practitioner travel, the children from multiple schools can have virtual appointments with the nurse practitioner. If the nurse practitioner has a question, she or he can connect with a pediatrician as backup via telemedicine. In the past, the child might present to one school and if the nurse practitioner wasn’t there they might be sent to another school with a school based clinic or to an urgent care center.
  • 2007 © Arizona Board of Regents On the left side of this slide, digital retinal examination is being performed. On the right, a frindoscopic image of the retina is seen, illustrating diabetic retinopathy. For teleophthalmology, it is important that enough training time is allotted to assure that high quality images will be obtained to assess for diabetic retinopathy. The leader in the teleophthalmology field is Josilyn Clinic in Boston.
  • 2007 © Arizona Board of Regents Fetal ultrasound may be accomplished to check for gestational dates; however, many sites have this technology. What is needed is access to higher level fetal ultrasounds to evaluate the fetal heart or the neural cord. The primary benefit of this technology is that the patient and her family receive the results of the ultrasound at the time of the study.
  • Of course, there has to be a lot of sensitivity in performing ultrasounds, since the expected mother, the tele-ultrasound technician and the nurse will be in the exam room. For example, the patient may not want to know the sex of the fetus. Discretion and privacy are important. Incidentally, this is a boy.
  • 2007 © Arizona Board of Regents There are some specialties where the talk is the treatment. Psychology and psychiatry fall into this category. Genetic counseling, pain management, nutrition, support groups and hospice care are also clinical encounters where the focus is communication which can be done with videoconferencing.
  • 2007 © Arizona Board of Regents Telepsychiatry is a very successful application. Initially there was some concern that patients would not be comfortable talking to a screen. Would they be comfortable talking to a camera about some intimate issues? And you know what? They are. And I think some of that really speaks to the iniquitousness of television in patients’ lives. If you look carefully at the slide, you can see that the psychiatrist can see himself on the screen at the same time he sees the patient. Similarly the patient can see him or herself. Often what patients comment on is they really feel they have the psychiatrist’s full attention and that may be part of the virtue of the technology, that you see the clinician is really focused on the case. So it’s a very successful application and a very accepted application by patients.
  • 2007 © Arizona Board of Regents Genetic counselors and certified cancer counselors are few in number so by increasing access to their services via telecommunication technology provides a great service to a referral community.
  • 2007 © Arizona Board of Regents Tele-mammography facilitates access to expert mammography services to remote communities. By improving turnaround times, telemammography increased follow-up of abnormal mammograms. We’ve handled over 9000 expedited telemammography cases, providing women with their results in under an hour.
  • 2007 © Arizona Board of Regents Genetic counselors and certified cancer counselors are few in number so by increasing access to their services via telecommunication technology provides a great service to a referral community.
  • 2007 © Arizona Board of Regents Genetic counselors and certified cancer counselors are few in number so by increasing access to their services via telecommunication technology provides a great service to a referral community.
  • This slide illustrates a multi-site physical therapy session. For support groups, the technology can work well with at least 2 people at the spoke site. Virtual support groups have been demonstrated to be successful, perhaps partly because of the anonymity that the technology allows.
  • 2007 © Arizona Board of Regents Where should the telemedicine unit be placed? Generally, we had placed units in hospital settings. We then expanded to community health centers. So think about where the patients are going for care and where does it make sense for the patients to be seen for teleconsultations? This may include office practices or the home. As different settings are identified, different technologies will be utilized and will need to be assessed with regards to clinical and cost efficacy.
  • 2007 © Arizona Board of Regents For home healthcare, this technology has been used for wound care, whether traumatic or surgical, for post operative care, for organ transplantation, for follow up before organ transplantation and for physical therapy. Note the attachments: stethoscope, blood pressure cuff, and glucometer.
  • 2007 © Arizona Board of Regents This image shows a gaping wound in the process of healing. Wounds can be assessed with digital images. This application increases access to wound specialists who are able to guide the home health nurse in caring for the patient. Wound management is particularly challenging in diabetes.
  • Smartphones are emerging as the telemedicine work station of choice in certain circumstances. We’ll be talking a lot more about that a year from now.
  • The U.S. Food and Drug Administration has cleared Baltimore-based health software company WellDoc to begin marketing the DiabetesManager ® System, a mobile phone application designed for patients and healthcare providers who are dealing with type 2 diabetes. The company, founded in 2005, plans to start selling the product early next year. And, in closing, I would point out that hundreds if not thousands of medical apps are popping up on the Internet. Clearly telemedicine has morphed into e-health and its future looks very bright.
  • It’s interesting that Apple stores are now selling medical devices. This reflects the extent to which healthcare is becoming a commodity.
  • 2007 © Arizona Board of Regents So a lot of what telemedicine is sometimes sounds to people like Star Wars. It’s off in the future somewhere, but I would bring to you, the future is now.
  • Telehealth and Health Informatics: How They Should Work Together

    1. 1. Ronald S. Weinstein, M.D.Director, Arizona Telemedicine ProgramUniversity of Arizona, Tucson, AZ, USA
    2. 2.  Clinicalcare Evaluation/research Continuing education
    3. 3.  General ◦ MD/DO/PhD/DDS ◦ NP/PA
    4. 4.  Hub Site ◦ Medical Director ◦ Site Coordinator Spoke Site ◦ Medical Director ◦ Site Coordinator Referring Clinicians
    5. 5.  Teleclinic Appointment Ad Hoc Appointment
    6. 6.  Psychiatry Rheumatology PainClinic Cardiology Dermatology
    7. 7.  Pulmonary  Psychiatry Cardiology  Dermatology Neurology  General Medicine Musculoskeletal
    8. 8.  Increase access to specialty care ◦ rheumatology Confirm diagnosis ◦ polymyositis Assist in triage ◦ cervical spine injury
    9. 9.  Complete data ◦ Avoid the incomplete consult! Diagnostic images Steps in review: ◦ Site Coordinator ◦ Medical Director ◦ Specialist
    10. 10.  Visual specialties ◦ i.e. range of motion Technology provides images/sounds ◦ echocardiography “The talk is the treatment” ◦ telepsychiatry
    11. 11.  Rheumatology Orthopedics Dermatology Neurology Radiology Pathology
    12. 12. Teleradiology
    13. 13. Teledermatology
    14. 14. Teleneurology
    15. 15. Telepresence
    16. 16.  Cardiology Pulmonary Otorhinolaryngology Retinal screening Colposcopy Radiology Pathology
    17. 17. Tele-echocardiography
    18. 18. Fetal Ultrasound
    19. 19.  Psychiatry/psychology Genetic Counseling Pain Management Nutrition Support group Hospice care
    20. 20. Tele-urgent care Teletrauma Telestroke Teleburn eICUs© 2010, Arizona TelemedicineProgram
    21. 21.  Teleconsultation system in: ◦ Hospital ◦ Community health center ◦ Office practice ◦ The Home
    22. 22.  Wound care Post-operative care Pre-organ transplantation Physical therapy
    23. 23. The Future is Now!