The drama of Internet-enabled telesurgery has produced extraordinary results, allowing world-class surgeons to operate using a combination of secured Internet access and robotics on patients in remote areas of the world.
But of even greater import is the quiet advance of telemedicine into rural communities for use with everyday healthcare.
It certainly made a difference to Michael Harrigan, a financial advisor who suffered a stroke in April 2009 while driving on an interstate highway midway between Milwaukee and Madison, Wisc. Harrigan said that his face was feeling odd and that his breath was getting short. He managed to pull to the side of the highway and call 911 -- and was taken to the nearest available medical facility, a community healthcare center 22 miles off the highway.
“Paramedics from the town of Johnson Creek picked him up,” says Jacklynn Lesniak, vice president of patient services at the Watertown Regional Medical Center. “In the past, he would have been treated by a physician in the ER. Now, we activate our telemedicine protocols with a stroke alert over an Internet-enabled ERS [emergency response system].”
Thanks to the new telemedicine system, the alert traveled a T1 line to the University of Wisconsin Medical Center, which patched it through to a doctor who is a stroke specialist. He examined Harrigan remotely using a high-definition video link back to the Watertown ER. Within 90 minutes of his collapse, Harrigan had started IV treatment of the clot-dissolving drug tPA for his stroke -- a “gold level” response, given the three-hour window of tPA’s post-stroke effectiveness.
“This is very important to rural healthcare centers because often victims of stroke don’t get to the ER soon enough,” says Lesniak. “Then, if you don’t have a stroke specialist on staff, there is a hesitancy to use stroke treatment medications right away, since they also have their risks. You want to run all of the tests first.”
Justin Sattin, a neurologist at the University of Wisconsin, describes the previous difficulties for rural patients: “Before telemedicine, we were communicating with the physician in the emergency room via telephone. The ER physician would verbally describe to us how the illness was presenting itself and would report on what the exam results showed. Then he would tell us what the radiologists had told him. There was no visual contact with the patient or the family.” With treatment discussions going through second- and third-hand recountings, there was always the risk that critical factors were getting lost in translation. Meanwhile, the clock was ticking.
“Time is a critical element in the treatment of strokes,” says Sattin. “Awareness of stroke symptoms is absolutely critical. Sudden weakness or numbness on one side of the body, trouble speaking, a bad headache, incoordination, visual disturbances, slurred speech, or a droopy face are all signs of stroke -- and patients have to recognize that this is an emergency… Although there is new evidence that treatment can occur as late as four-and-a-half hours after the onset of stroke, the standard window is treatment response within three hours.” If you delay beyond that, the chances for a successful outcome diminish by 15 to 20 percent.
Sattin sees telemedicine as a way to level the treatment “playing field” between urban and rural areas. The University of Wisconsin Medical Center envisions a statewide network of telemedicine centers within the next five years.
The plan for a statewide net is a solid one, since licensure of physicians across state boundaries is a major legal hurdle for telemedicine. States have unique licensing requirements -- though federal agencies are reportedly working to create a model that would support interstate telemedicine.
The other legally active areas are security and privacy. “In the past, healthcare institutions, not their business partners, have been held accountable by the federal government to meet HIPAA [Health Insurance Portability and Accountability Act] requirements,” says Cheryl Camin, senior associate at law firm Fulbright & Jaworski LLP. “But with the new high-technology initiatives in the growth stimulus bill, the scope of HIPAA compliance is extended to healthcare business partners like telemedicine vendors, who will face civil and criminal penalties if they don’t comply."
New compliance requirements are likely to place pressures on vendors, but they are unlikely to deter adoption of telemedicine.
“Telemedicine is so promising,” says Sattin. “It gives us a much better chance to get to stroke patients in time.”
You've highlighted two very critical areas that are lagging the technology right now--the legal side of telemedicine, and also how insurance companies will deal with it.
These are major non-technical barriers that, once solved or at least understood, will also move telemedicine forward.
Mary, great article and example of future changes and progress in healthcare with the use of technology.
I definitely believe this will increase the access to all and address the inequities in the current system. I think that telemedicine use in specialty care (which is what raises the cost of an emergency room visit) is a great example. Strokes definitely require timely treatment. The ability to "manage" the treatment within the timeframe will result in significant savings as well as better health outcomes.
In addition to the alignment of issues regarding HIPAA, etc., I think now with the electronic and personal health records there will be further access to critical information and use.
As it relates to the legal issues, it becomes essential to evaluate the treatment in the context of alternative treatment options and the requirement for emergency care versus optimum care in non-emergency cases. What this really means is that we have to be smarter in our legal interpreations and begin to evaluate legal issues in the context of effective use of telemedicine and its contribution; physicians won't utilize technology if it increases their risk.
Unfortunately, litigation is this area (as in other healthcare areas) is likely to be as incurable as the common cold. This is why it's critical for legal, insurance and government to weigh in on this.
I have heard from some telemedicine practitioners that there is presently major government silence in this particular area--unusual when you consider the push for affordable, quality healthcare for all.
You are right, Mary. The limiting factor right now in undeveloped areas is broadband...and yes, if we can leverage this capability to include prescription drugs, shoes, etc., it could yield enormous cost benefits. I feel that the highest barrier to this will probably be polticial more than technical.
I would assume that someone treated with telemedicine would have it handled in the same way that any other specialist would be handled under their insurance coverages.
The big insurance question that I have is on the physician side. If you are treating someone remotely (or potentially, even in another state) what will your malpractice and/or liability coverage cover? There are also legal issues in the interstate practice area, since states independently license physicians.
Mary! If I understood correctly Michael Hurrigan was sure the guy who had good medical insuarance (a financial advisor- had to have it, didn't him?) But is the service of telemedicine available for other people? Should the telemedicine options be covered by the special insuarance or everyone can get this help?
Terry: Legal risks and issues like malpractice lawsuits are always present. In fact, even staying with the status quo (no telemedicine) might itself be grounds for a malpractice lawsuit! However, experience shows that good legal analysis, planning, policy and communication can make problems manageable as industry innovates with new technology. --Ben
In re "The history of cyberlaw is filled with stories of people believing the law prevents them from using technology to do something useful..." I'd argue the history of medicine is also filled with stories [malpractice lawsuits] of medical professionals believing believing technology and the potential exposure keeps them from doing something useful.
When telemedicine apps hit the market in earnest 20 years ago, doctors and insurers were still smarting from some major liability awards. Do we really believe that despite Web 2.0's many good, high-definition works that we've become any less litigious in the event of a couple misplaced bits in a digital x-ray or some more egregious, Web-borne error?
Abdlah: Your message makes yet another good argument for improved broadband in areas where infrastructure of all kinds is still weak.
It seems telemedicine could extend medical resources everywhere, not just in rural areas. There has to be some savings capabilities here in the overall scheme of healthcare reform in the U.S. If a patient could get renewals for regularly prescribed drugs, orthotic shoes, etc., by getting online instead of "on line" at the doctor's office," we might be looking at enormous savings for everyone.
Often parties like doctors, clinics, vendors and hospitals can address legal compliance issues (licensure and HIPAA prviacy) relatively painlessly, through education, good public communications and the crafting of intelligent policy. The history of cyberlaw is filled with stories of people believing the law prevents them from using technology to do something useful. Then, after they really study the issues, they find practical ways to deploy technology, while also staying in legal compliance.
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