Donald Berwick, recently appointed as Administrator of the Centers for Medicare and Medicaid Services, recalls the childhood experience of his father's car starting in the middle of the night. His father, the one doctor in the tiny village of Moodus, Connecticut, did everything in those days, from delivering babies to caring for heart attacks. While that mode of practicing medicine is virtually unknown today, the ethos of concern for the individual patient was the theme of his speech at the American Telemedicine Association's Fourth Annual Mid-Year Meeting, where it drew a standing ovation from the assembled doctors, nurses and entrepreneurs. With the twin goals of improving outcomes and reducing costs on everyone's agenda, telemedicine appears poised to do both while preserving the human element. While telemedicine has its origins in connecting doctors to patients in remote environments such as rural areas or distant battlefields it is now being employed in urban environments and even in the homes of individual patients.
Some of the applications I learned about in presentations, on the exhibit floor, and in hallway conversations were:
- Central monitoring of patients in intensive care. Previously, providing care in the middle of the night would require an on-call intensivist to race from one hospital to another, now the real-time vital signs and a video feed can be transmitted to a central location where problems can be recognized more quickly and on-site still given detailed instructions in real time.
- Psychiatric care for patients in rural areas who would otherwise need to drive four hours for an in-person appointment.
- Pediatric cardiology consultations which save the infant and parent from a lengthy drive, and providing either quick reassurance that everything is OK or rapid treatment for a problem that might otherwise have gone unrecognized.
- Dermatology consultations which use store-and-forward images from the patients own digital camera.
- Speech therapy provided over video to patients in developing countries.
- Remote gathering and transmission of vital signs to monitor chronic conditions such as diabetes and congestive heart failure, reducing the incidence of complications and re-hospitalizations.
While a steady volume of data is accumulating on the benefit to patients, the economic benefit is proving more difficult to evaluate and reimbursement for telemedicine services slow to be approved. According to some long-term ATA members, speakers at previous conferences spoke of the need to lobby Washington for more rational regulations and more "CPT-4 codes" for reimbursement. With this meeting being held in the outskirts of the nation's capitol, the policy makers showed up in person and it while it appeared they have been listening, they had some advice of their own. Mark McClellan, Berwick's predecessor at CMS and now a self-described "policy wonk" stressed that the wave of the future was payment for outcomes and that health-care providers would do better that way than by getting compensated for more procedures.
The exhibitors illustrated the breadth of what constitutes the telemedicine industry:
- Traditional videoconferencing vendors who see health as a vertical market to be addressed. Tandberg, Polycom, and Vidyo were the only ones who had booths, although at least one vendor was using LifeSize inside their product.
- System integrators who combine hardware, software, and service in a hospital-friendly package. Some, such as MedVision, provide a cart (right) that can be rolled into an operating room. Others such as Nuvimedix offer a battery-operated solution in a portable carrying case.
- Software for scheduling and managing remote consultations, such as OTN and Medweb.
Perhaps the largest category was home health monitoring, which includes large companies such as Philips and Bayer and numerous startups like WellDoc and Ideal Life. Usually devoted to managing one or more chronic conditions such as diabetes or CHF, these companies offer a combination of hardware peripherals to measure weight, blood pressure, pulse, oxygen and glucose, hardware to transmit the data to a central location, and software to detect out-of-bounds conditions, send alerts, and provide automated coaching.
In all of the above categories, the actual data can be as low-tech as asking the patient to key in how many calories they ate for breakfast or as intensive as multiple HD video feeds from an operating room. Judging from the comments I heard from the audience and in the hallways, there is a small but growing body of practitioners who are making use of this technology today and a much larger number who are eager to try it out. As with most technology adoption, the gating items are often low-tech issues such as who will pay for it and how does it get integrated into existing workflows and business models. As all of those things are set for massive disruption in the coming years, this could be a time of great opportunity for telemedicine.
