Extending Expertise While Providing Improved Patient Care
As noted previously, there is a shortage of physicians of all types in many parts of the world, particularly in rural and remote areas. The next six examples demonstrate how video, and now TelePresence, is being used to extend medical expertise and services across town, across countries, and around the globe (everything from rounds to regular checkups to lifesaving to critical care).
Robots Enable Physicians to Be in Two Places at One Time
UCLA and Johns Hopkins are world-renowned medical facilities; they stay that way in part because they focus on using innovative approaches to treatment. In the past few years, both organizations have begun to use remote presence robots to improve patient care. With systems from a company called InTouch Technologies, doctors can now project themselves to another location via remote-controlled mobile robots, which enable them to move, see, hear, and talk as though they were actually there (see Figure 12-2).
Figure 12-2 InTouch Remote Presence Robot Enables Doctor and Nurse to Discuss Patient Case
The 5-foot, 4-inch robots feature a flat-screen computer monitor and a two-way audio/video feed. They are guided by a physician using a joystick from a computer console in another location, such as an office, clinic, another hospital, or even home. The robot enables physicians to "beam in" to the hospital, visit with patients, and consult with colleagues and staff; the physicians can move, see, hear, and talk as though they were actually there. The screen rotates 340 degrees and pivots up and down, enabling the physician to see and hear everything going on around the robot, and to check injuries and monitor equipment readouts. The robot is not meant to replace important daily interaction between patients and physicians, but it does serve as an extension to traditional patient-physician interaction, improving communication and increasing patient (and family) satisfaction. The robots provide the organizations with a wide range of benefits, including the following:
- Providing consistent, high-quality services more effectively to a greater number of both patients and staff: When travel time is reduced between all the locations they serve, physicians can be more available for consultations.
- Extending healthcare professionals' presence to anywhere they might be needed at the right times: For example, a specialist might not always be available onsite when a patient needs a procedure, dressing change, or emergency surgery, but a specialist can be available via video.
- Making expert consultation available during off hours: Many specialists are generally available on an on-call basis during overnight shifts. Hospital staff can typically access them only by phone for consultations, requiring the specialist to rely on verbal descriptions to make a diagnosis. The robots allow specialists to go into the patient room directly as if they were there and examine the patient for themselves.
- Increasing the frequency of patient contact: Today, specialists are onsite only about 40 percent of the time. However, the efficiency of the robots enables physicians to conduct "telerounds," adding another round of patient visits per day. When specialists are "available," particularly in wards such as the ICU, the rates of morbidity and mortality, length of stay, and cost of care all decrease.
- Extending expertise for training and supervisory purposes: Physicians can conduct training and supervise medical student procedures even from remote locations.
Survey results from physicians who have used the robots indicate that
- 96 percent said the technology allows them to advance or improve patient care and learn more about their patient's condition.
- 88 percent said the robots save time, increasing physicians' overall efficiency.
- Three out of four said the systems allow them to accelerate the time of patient discharge.
Bringing Life-Saving, Specialty Care to Rural Regions: Ontario Telemedicine Network
The Ontario Telemedicine Network (OTN) in Ontario, Canada is another excellent example of both extending medical expertise. In this case, OTN extends medical care to an underserved rural population using video, and the technology helps to improve the speed of care in critical, life-or-death situations.
The northern part of the province is physically the size of Texas and California combined, but its population numbers just a few million. Consequently, there is a shortage of specialists throughout most of the province. In response, public and private sector partners joined together in 1998 to establish what is now known as the Ontario Telemedicine Network, an extensive telehealth service designed to provide remote consultations, medical education, and patient support to remote hospitals and clinics. Two other telemedicine networks also came about during this same period, but all three were challenged by technology incompatibility issues. In 2006, the three merged into a single secure platform known as Ontario Telemedicine Network. OTN uses a private IP network (dedicated to healthcare applications) to link nearly 400 sites in the north to large urban teaching hospitals. They currently facilitate more than 32,000 video consultations per year (see Figure 12-3), and run an extensive number of educational broadcasts using the same technology. A government grant allows them to directly pay consulting physicians, bypassing the typical billing problems for remote telehealth consultations.
Figure 12-3 Dr. Soucie Uses the OTN to Consult with a Nurse and Patient from His Office (courtesy of Ontario Telemedicine Network)
Although patients can access more than 30 specialties, perhaps the most dramatic application of the power of the application is within the neurology and cardiology practices. Because winter in Canada features lots of snow and ice, a trip from more rural areas to see a specialist in Toronto can be not only a long trip, but a potentially dangerous one. The treacherous roads also mean that a patient who needs rapid treatment, such as in the case of a heart attack or stroke, might not be able to reach a specialist in time before the damage becomes irreparable. The telemedicine application enables patients to go instead to their local hospital, connect via video to a specialist in a major city, and be diagnosed at the earliest onset of symptoms when life-saving treatment can still be administered. Some of the physicians affiliated with OTN are also equipped with virtual private networked laptops, enabling them to do consulting from their personal office or even from home (see Figure 12-4). Of patients who have used OTN's capabilities, 96 percent reported that they were satisfied or very satisfied, and would use it again if appropriate. It has significantly reduced the cost of delivering service and transporting patients by $8 million, and has reduced hospitalizations among people in the region.
Figure 12-4 Doctor Frank Silver Uses a Networked Laptop and the OTN to Conduct a Video Consultation from His Home Office (courtesy OTN)
Video Brings Critical Care to the Littlest Patients: Adena Health System
Adena Health System, a healthcare organization that serves the residents of a 10-county region in southern Ohio, deployed a Cisco networked video solution that included high-definition videoconferencing and clinical imaging. With this solution in place, Adena Health System can now link its main facility, Adena Regional Medical Center, to Nationwide Children's Hospital in Columbus as part of an ongoing initiative to provide a higher level of care for patients, particularly expert neonatal care.
Adena Health System's telemedicine initiative began in 2006 when it connected its neonatal department with Nationwide Children's Hospital's neonatal ICU via video. Adena Regional Medical Center provides outstanding care for mothers and newborns, but it has limited access neonatal critical-care specialists. For that reason, Adena doctors typically had little choice but to transfer any newborn that might need critical care to Nationwide Children's Hospital, located 70 miles (113 km) north. Adena typically transferred more newborns to Children's Hospital than any other provider outside Columbus. These transfers placed significant emotional and financial strain on families and newborn patients, and often separated newborns from still-recovering mothers.
Using video, specialists at Nationwide Children's Hospital can evaluate newborns with their own eyes. Therefore, they can make more accurate diagnoses, share test results and imaging films, and fully participate in treatment as if they were standing in the same room. For families, it means advanced care close to home and fewer newborns that need to be transferred. In just its first year of operation, the project helped cut the number of patients transferred in half. For those who are transferred, the medical staff at the receiving end are much better prepared to provide treatment; they have truly "seen" the child before he or she arrives at their door (see Figure 12-5). Families of transferred children can also use the videoconferencing system to see their little ones and keep up-to-date on their care without having to make a trip to do so.
Figure 12-5 Doctors in Adena Health System Use High-Definition Video to Provide Neonatal Care
As Adena Health System focuses on enhancing patient care, delivering cost savings, and increasing productivity, they are exploring other advanced uses of video. One area being explored is virtual classrooms in the campus near the medical center. The campus will comprise a four-year nursing school in collaboration with Wright State University in Dayton, Ohio University in Athens, and other Adena educational partners. In these virtual classrooms, physicians from anywhere in the world will use a telemedicine application to teach remote students. The new facility will also support video recording and broadcasting.
The impact of Adena's success with this project is already being felt on a broader scale. The Federal Communications Commission recently awarded a $14 million grant to build a fiber-optic network connecting healthcare providers across 15 counties in southern Ohio. Based on their own success, Adena was chosen as one of the organizations that will oversee the new project.
Beyond Videoconferencing: TelePresence Becomes the Next Step in Telemedicine in Scotland and New Zealand
In 2008, the Scottish Centre for Telehealth (SCT) and the National Health Service began the world's first trial of Cisco HealthPresence, a new patient-care delivery concept based on Cisco TelePresence technology. SCT develops and disseminates best practices, standards, protocols, and processes that support telehealth solutions. It supports a range of projects that contribute toward preventive care, improved standards, and speed of care.
Cisco HealthPresence combines life-size high-definition video, rich audio, and call-center technology to create a virtual face-to-face experience for patients and caregivers who are remote from each other (see Figure 12-6). The HealthPresence platform also interfaces with medical diagnostic equipment, such as stethoscopes and otoscopes, and monitors that can measure weight, blood pressure, temperature, pulse rate, and lung function to capture the physiological condition of the patient. An attendant is available to operate the medical devices on behalf of the caregiver/patient and to maintain the technology.
Figure 12-6 Cisco HealthPresence Enables Patients and Medical Staff to Meet Virtually "Face to Face"
The trial is designed to test the effectiveness of HealthPresence and patient and caregiver satisfaction. The goal is to improve the quality of what had previously been telephone-only advice and triage. It also brings healthcare services to remote and rural areas, where recruitment and retention of medical personnel is proving increasingly difficult, and helps extend healthcare beyond traditional doctors' office hours. Clinicians believe that being able to see patients and have all of their physiological parameters at the same time will improve patient care. Early reaction has been very positive, with physicians citing its ease of use and simple setup.
Gordon Peterkin, director of the Scottish Centre for Telehealth, spoke of his experience:
- In our efforts to provide better patient care and utilize our medical staff to the full, solutions such as HealthPresence enable us to offer convenience for patients and service efficiency for our doctors. We look forward to drawing upon the results from this trial to optimize our regional and national healthcare delivery resources.
Building upon the trial in Scotland, New Zealand's West Coast District Health Board (DHB) announced in July 2008 that it would begin the first global trial of Cisco HealthPresence between two different organizations: Buller Health, in the town of Westport; and Grey Base Hospital, about 60 miles (97 km) away. This trial will help enable medical providers in two remote locations to better scale resources, collaborate on cases, and provide patients with more convenient access to the medical expertise of a multispecialty team.
DHB provides patient care to more than 32,000 people throughout some of the most remote areas of New Zealand. Cisco HealthPresence enables medical professionals to break down the distance barrier and provide direct support to these areas. Some patients can now be assessed by specialists without travel, reducing patient transfers and related costs. Specialists also benefit. Using the technology allows them to see more patients than they previously could, because they do not need to spend much time traveling to and from remote locations. It will also make medical services more sustainable and resilient to fluctuations in workforce availability and patient demand.
Improving Healthcare and Quality of Life: Afghanistan's Telemedicine Project
In 2007, Roshan, the leading telecom operator in Afghanistan, launched a first-of-its-kind telemedicine solution to expand healthcare access and delivery across the country. Using broadband technology, wireless video consultation, and digital image transfer, the telemedicine project is providing hospitals with real-time access to specialist diagnosis, treatment, and training expertise from abroad. Broadband technology provides high-speed access for the transfer of medical imaging, video, data, and voice. Applications include the capability to send X-rays, ultrasound and CT scans for evaluation in real time, and the technology enables e-learning and training through video consultation.
Even though the service is new, the expectation is that there will be an average of 10 to 15 videoconferences between hospitals per month, with the numbers increasing over time. Capabilities will be gradually expanded to address different services and procedures, including evaluation of tissue samples and the online performance of medical and surgical procedures.
Amirzai Sangin, the minister of communications and information technology, offered the following:
- Our government is striving to improve the quality of life of our people, and providing quality healthcare is one of our top priorities. Telemedicine is the perfect marriage of the speed, convenience, and cost-effectiveness of wireless and broadband technology. This innovative use of technology and telecommunications to enhance healthcare delivery will help underpin our efforts to meet the nation's other development challenges.
These case studies provide great examples of how video extends medical expertise whenever and to wherever it is needed, and in a wide range of applications. In every case, it benefits the medical staff and patients alike; it improves the speed, depth, and quality of care while lowering costs, travel times and stress involved. Patient acceptance and satisfaction is quite high, and with high-speed bandwidth becoming more and more ubiquitous, it becomes hard to imagine a place where video could not be used to provide medical care in a similar way.
The last two examples in this chapter address innovative uses of video in healthcare environments, where organizations chose to think differently about their basic operating processes and chose to invest in video in ways that would help them scale, improve existing patient services or provide new ones, and in both cases, improve their own image with the local area that they serve.
Connecting Clinicians and Patients with Innovative Services: California's Healthcare Interpretive Network
Language barriers are of particular concern in healthcare, where life-and-death decisions are made and medical regimens are agreed on through discussions between healthcare professionals and patients. Without good communication, patients' knowledge of their disease, treatment advice, and complications are compromised, while doctors struggle to understand symptoms or recommend treatment. This is why interpretive services are so critical.
In California, 40 percent of its residents now speak a language other than English. In response to this growing dynamic within the state, the Health Care Interpreter Network (HCIN) of Northern California was created in 2006. The HCIN is a system of shared remote interpreter services operated by seven Northern California public hospitals. Using an IP-based call center to provide access to trained interpreter services, participating providers use interpreters at their own hospitals or at other hospitals through videoconferencing and other telecommunications technologies. Figure 12-7 shows an example of the type of portable equipment that is brought into the patient's room to connect the healthcare provider with an interpreter. Calls are routed by several criteria including the hospital that initiated the call, special interpreter skills requested (such as particular language), special medical expertise required, or by male or female interpreter. These technologies enable member hospitals to eliminate time, distance, and language as barriers to effective communication between clinicians and patients. This program offers hospital staff rapid access to trained interpreters among all participating providers, and interpreters no longer have to travel between the facilities they support. Manual searches for an interpreter used to take up to an hour, but responses to a call now average just 22 seconds, and no response takes longer than 3 minutes. The service is also available 24 hours a day, and emergency calls can be "bumped" to the head of the call queue if necessary.
Figure 12-7 Patients and Physicians Can Talk with One of Many Skilled Interpreters Using Portable, Rollabout Video Carts
The interpreter network currently handles approximately 3500 video-conference and phone calls per month. Before this solution was available, 42 percent of hospital staff said that difficulties getting an interpreter posed a serious problem in the provision of care, and 79 percent of physicians said patients lacked understanding of medications, preventive care, and self-care instructions because of a language barrier. Since implementation, fewer than 20 percent of providers reported that they perceive confusion over procedures as the result of a language barrier. Every staff member surveyed found that HCIN was convenient, made them more productive, simplified patient communications, and improved the quality of patient care. There are now plans to expand the service to other languages, including American sign language.
HCIN hospitals are not alone in this success. Alameda County Medical Center and San Francisco General Hospital have implemented a similar video medical interpretation project of their own. Despite having a large in-house staff, wait times for an in-person interpreter used to be as long as two hours. Using the video-based solution, a clinician instead rolls a portable video station into the room and places a video call to the call center, which transfers incoming requests to the appropriately skilled interpreter. With the solution in place, wait times have been drastically reduced, and patients are very happy. Post-visit surveys indicate that patients feel like they are seen faster. When patients were asked to rank video services on a scale of 1 to 3, with 3 being "completely satisfied," the average score was 2.9. Both Alameda and San Francisco General found that they could make better use of their interpreters, too. Because they no longer need to travel to see each patient in person, less time is spent on each request. In fact, the average request time has been reduced from 37 minutes to just 17 minutes. Further analysis showed that the solution saves approximately 14,500 hours per year, or the equivalent of 7 full-time interpreters at a cost of more than $400,000. With these savings, language services can also be provided to departments that did not have professional interpreters before.
In both of these examples, the cost savings from not having to rely on commercial interpreter services or hiring additional staff simply to keep up with demand is a significant benefit. Instead, the organizations in these examples have chosen to think differently about how they can use their resources more effectively and improve the quality of the patient experience at the same time. These results are particularly important to public hospitals because they have to demonstrate commitment to patient services, good use of taxpayer dollars, and compliance with regulatory requirements such as equal access laws. Figure 12-8 shows video interpretation being conducted using sign language.
Figure 12-8 Sign Language Interpretation Being Provided over Video
Innovation Improves Image and Patient Care: Arras Hospital
Arras Hospital in northern France has 1200 beds and 2000 staff, treating more than 100,000 patients each year. Back in 2001, however, its extreme difficulties in providing care and maintaining financial viability prompted its leadership team to undertake an ambitious project to renovate many of its facilities. As part of this renovation, Arras conducted a complete upgrade of its network infrastructure, moving to a converged network for data, voice, and video. Its primary video application was to support digital imaging (PACS), but expanded bandwidth and video capability enabled Arras to add three other important applications.
First, they added videoconferencing capability with neighboring hospitals in France to expand the pool of medical experts who could contribute to patient care on difficult cases (see Figure 12-9). They made their own systems and records available to these remote physicians to encourage collaboration.
Figure 12-9 Doctors Discuss a Patient's Case Using a Desktop Video Phone
Second, they were able to add video surveillance to the hospital complex, with the goal of maintaining safety in certain patient wards, such as clinical psychiatry.
Third, in 2004, Arras began a pilot program in which mothers could monitor their babies in the neonatal ICU via video. The pilot was so successful that the hospital has begun expanding this capability to other patient units to enable those undergoing longer stays to maintain links to family, school, and work. Arras is also reaching beyond hospital boundaries to begin remote telemedicine projects with the regional jail system and with regional patients engaging in ongoing rehabilitation and chronic-care services from home.
Reaction to the new capabilities from patients, physicians, and the public has been overwhelmingly positive. Arras's innovative approach has even garnered them two unique endorsements from the French National Health Authority. They have also been asked to report their results in improved quality of patient care, improved physician access, and cost optimization in an upcoming parliamentary session.