Telemedicine

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Telemedicine is the use of information technologies to provide health care when distance separates the medical professional from the patient. (IOM 2001)

Introduction

Most of developed countries have robust telemedicine programs however, the most wide stepping countries in this field are USA, UK, Sweden, India and Philippines.

Telemedicine is nearly used in all medical fields. The most prominent uses for telemedicine are:

  • Telemedicine and teledermatology (actual physical examination of the patient)
  • Endocrinology (review for the lab results).
  • Teleradiology (reading still and full motion radiographic images)
  • Tele-ophthalmology (Screening for diabetic retinopathy and retinopathy of prematurity)
  • Telepathology ( analysis of tissue histology samples)
  • Geriatric care and monitoring at home
  • In-patient ICU and infectious disease consultation
  • Real-time emergency care
  • Telepsychology
  • Telepharmacy and teleinterpreting
  • Surgeries and surgery fields [general surgery, GIT surgery and special surgeries as vascular, orthopedics, pediatrics, plastic …] are still at early stage of dependency on telemedicine.
  • Robotic Telepresence
  • Depression
    • Depression is a relatively new area of telemedicine with promising results that all informaticists need to be aware of, as do mental health professionals. It is an area to keep an eye on for the hopefully promising successes to be seen.
  • Telestroke
  • Health coaching
  • Traumatic Brain Injury (SMS)
    • Diagnoses of TBI are increasing among US soldiers returning from recent conflicts. (SMS)

How telemedicine is used

  1. Digital Images: Digital images are taken and forwarded to another location (store and forward), used for x-rays, CAT Scans, MRIs any other digital image. Also can be used for non-emergency situations.
  2. Two-way Interactive Television: Teleconferencing is used with the patient in the room; it allows “real time” consultations to take place.

Technologies employed in telemedicine

  1. Facsimile
  2. Medical data transmission
  3. Audio –telephone and radio
  4. Still images
  5. Full motion videos
  6. Recently Robotics and virtual reality interfaces have also been introduced


Peripherals used in telemedicine

  1. Non-medical : VCR, video cameras…
  2. Medical: auscultation, imaging, biometric data collections, otoscope, ophthalmoscope, dermoscope, thermometers , blood pressure cuffs, ECGs , spirometers, pulse oximeters for continuous data collection and maintaining records of patients.
  3. Special devices and larger bandwidths are required to transfer a video image ( with frame rate of 30/sec or more ) so that examining physician can perceive it as a smooth image.


Causes for the increased demand of telemedicine

  1. Increased healthcare expenditure globally [in USA it’s up to 16% of GDP] and the need for a way to reduce this % without affecting the quality of medical services.
  2. Limited healthcare resources in the form of physicians, nurses, technicians and workers.
  3. Increased number of population relatively to the number of available doctors and increased area of housing that will take much time for the provider to move to.
  4. Increased number of people with chronic illness who need continuous care that might be sometimes defective. In a study condtucted by Margolis et al, the authors used home BP telemonitoring device with pharmacist case management for patients with high BP. the patients had controlled BP and improved lifestyle in the 6th, 12 and 18 month primary care visit follow up.
  5. Some countries whose nature is full of mountains and/or rural areas.
  6. Revolution in IT [e.g. internet, GPS…] and communication infrastructure.
  7. lower cost of bandwidth and improvements in video and data compression standards
  8. Further advancement is by using satellite technology to broadcast a medical or other consultations in two countries by videoconfercing facilities-mostly in military settings.

Advantages of telemedicine

  1. For the patient:
  • Reduced physician’s fees and cost of medicine
  • Reduced travel expenses
  • Treatment by qualified physician, iinterpretation of imaging & histopathology, when professionals are distantly placed
  • Early detection of diseases
  • Reduced burden of morbidity
  • Saves work-loss time and increase productivity
  • Home health care by using telemedical home monitoring device for chronic case
  1. For the doctor:
  • Telemedicine is an excellent opportunity to share the knowledge between physicians all over the world.
  • Joint consultation with expert physicians and surgeons for better management of complicated disease.
  • Local doctors can be updated at any time with the most recent advancement in medicine.
  • Medical education in the form of teleconferencing.
  • Ability to provide care while reducing travel, allowing them more time with their families/at their practice. (SMS)
  1. For the government:
  • Reduced rush to the medical facilities in the cities
  • Improve monitoring facilities at the rural based centres
  • Increased reliance on the government health care system
  • Increases stuff productivity
  • Economizes resources (optimal use of instruments and surgical facilities).
  • Reduces expenditures on healthcare - the Veterans Administration pays for veterans' travel to VA hospitals. Reduced travel = conserved funds. (SMS)

Disadvantages of Telemedicine

  1. The laws and regulations have not caught up with the technology.
  2. Reimbursement issues (Many advocates argue telemedicine will not reach its potential without reimbursement so now there is growing advocacy for increased reimbursement in the political arena).
  3. Insurance issues (Most health insurance payers do not cover telemedicine services).


Constraints of Telemedicine

  1. Different technological standards, infrastructure and regulatory mechanisms.
  2. Different medical cultures, approaches, standards and different medical care resources.
  3. Socio-Economic factors such as political and bureaucratic barriers, different languages and literacy levels.

Telehealth or telemedicine is a fairly new field which combines technology and expertise to evaluate and treat patients in underserved areas. Rural areas do not have the needed specialists, yet there is technology available to allow these patients to be treated in their own communities by experts in the field. In rural settings, a telemedicine based collaborative care intervention for depression is effective but can be expensive (Pyne, MD et al., 2010). Patients in rural settings suffering from depression or other mental health conditions do not have options for care, and often do not have the funds or means to travel to cities where they may be able to access the care they need. Telemedicine allows for collaboration among healthcare professions through educating patients, monitoring adherence to therapies, and evaluating and adjusting treatment (Kroenke, MD et al., 2010).

Telemedicine is a field used for many disciplines where specialists are not readily available, and is showing particular value for patients suffering from depressions who can meet with their therapist or counselors over the Internet in much the same way they would in a regular office visit. Because of the high risk nature of the depressed patient it is important that there is a local team involved to help manage the care of the depressed patient and to monitor their progress and compliance. The Veterans Administration (VA) is involved in evaluation of therapy for their depression patients and for those working with a diagnosis of post traumatic stress disorder (PTSD). According the Veteran’s Affairs Department it is the belief that treatment options should be widely available and uniquely tailored to the individual needs of each Veteran (veterans.senate.gov).Many soldiers returning home from service are finding value in the telemedicine programs that allow them to remain close to their families and whole support system rather than having to go to a large VA institution.

Examples of telehealth

By far the most prominent example of telehealth in the US comes from the Department of Veterans Affairs (VA) Veterans Health Administration. One of the growing areas of telehealth care is the identification of Traumatic Brain Injury (TBI) in soldiers and veterans, including their recovery care and support services. TBI has been diagnosed more frequently in soldiers returning from recent conflicts. (SMS)

To meet this growing need, the Department of Defense created the National Center for Telehealth and Technology (T2) within the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury. A focus of T2 is to develop new ways to provide care and information to service members in the field and at home through interactive video-teleconferencing (VTC), cell phones and computers. Teletherapy has been found to improve the physical and cognitive functional outcomes in patients with TBI. These technologies allow providers to ‘check-in’ on their patients more regularly without the expense of travel, sometimes to very distant rural areas. (SMS)


References (rev1)

  1. Kroenke, K., MD, Theobald, D., MD, Wu, J., MS, Norton, K., BA, Morrison, G., PhD, Carpenter, J., PhD, RN, & Tu, W., PhD (2010, July 14). Effect of telecare management on pain and depression in patients with cancer. Journal of the American Medical Association, 304, 163-171.
  2. Pyne, J., MD, Fortney, J., PhD, Tripathi, S., MS, Maciejewski, M., PhD, Edlund, M., MD, & Williams, K., PhD (2010, August). Cost-effectiveness analysis of a rural telemedicine collaborative care intervention for depression. Archives of General Psychiatry, 67, 812-819. Retrieved from http://www.archgenpsychiatry.com/veterans.senate.gov/hearings.cfm?action=release.display&release_id=0608c8d9-d3ca-437c-912c-743b8ad9d2bd

Submitted by Marie Lowery


References (rev2)

  1. Diagnosis, access and outcomes: update of a systematic review of telemedicine services William R Hersh_, David H Hickam_w, Susan M Severance_, Tracy L Dana_, Kathryn Pyle Krages_ and Mark Helfand_w Journal of Telemedicine and Telecare 2006; 12 (Suppl. 2): S2: 3–31
  2. Whitten, P., Mair, F., et al. (2002). Systematic review of cost effectiveness studies of telemedicine interventions. British Medical Journal, 324: 1434‐1437.
  3. Stachura, M. and Khasanshina, E. (2007). Telehomecare and Remote Monitoring: An OutcomesOverview. Washington, D.C., Advanced Medical Technology Association. http://www.advamed.org/NR/rdonlyres/2250724C‐5005‐45CD‐A3C9‐0EC0CD3132A1/0/TelehomecarereportFNL103107.pdf.
  4. Speedie, S. and Davies, D. (2006). Telehealth and the national health information technology strategic framework. Journal of Telemedicine & Telecare, 12(Supp 2): 59‐64.
  5. Seto, E. (2008). Cost comparison between telemonitoring and usual care of heart failure: a systematic review. Telemedicine and e‐Health, 14: 679‐686.
  6. Mair, F. and Whitten, P. (2000). Systematic review of studies of patient satisfaction with telemedicine. British Medical Journal, 320: 1517‐1520.
  7. Jerant, A., Azari, R., et al. (2001). Reducing the cost of frequent hospital admissions for congestive heart failure: a randomized trial of a home telecare inte. Medical Care, 39: 1234‐1245.
  8. Hersh, W., Helfand, M., et al. (2002). A systematic review of the efficacy of telemedicine for making diagnostic and management decisions. Journal of Telemedicine and Telecare, 8:197‐209.
  9. Hersh, W., Hickam, D., et al. (2006b). Diagnosis, access, and outcomes: update of a systematic review on telemedicine services. Journal of Telemedicine & Telecare, 12(Supp 2): 3‐31.
  10. Hersh, W., Helfand, M., et al. (2001). Clinical outcomes resulting from telemedicine interventions: a systematic review. BMC Medical Informatics and Decision Making, 1: 5. http://www.biomedcentral.com/1472‐6947/1/5.
  11. Grigsby, J. and Bennett, R. (2006). Alternatives to randomized controlled trials in telemedicine. Journal of Telemedicine & Telecare, 12(Supp 2): 77‐84.
  12. Defining Obtrusiveness in Home Telehealth Technologies: A Conceptual Framework Journal of the American Medical Informatics Association Volume 13, Issue 4, July-August 2006, Pages 428-431
  13. Web-based telemedicine systems for home-care: technical issues and experiences Computer Methods and Programs in Biomedicine, Volume 64, Issue 3, Pages 175-187 R.Bellazzi
  14. JAMIA 1997;4:69-70 doi:10.1136/jamia.1997.0040069 ;Telehealth; The Need for Evaluation: Daniel R Masys.
  15. JAMIA 2002;9:89-91 doi:10.1136/jamia.2002.0090089 ,Telehealth;The Need for Evaluation Redux:William R Hersh,Patricia K Patterson,Dale F Kraemer.
  16. JAMIA 1996 3: 245-246 William W Stead Informatics of Medical Imaging for Papers on Telehealth and the Focus on the Frontiers of Informatics.
  17. http://www.citris-uc.org/system/files/James_Marcin-Telemedicine.pdf
  18. http://www.hsi.gatech.edu/2007studentsymposium/gt-si_jattokaren_telemedicine.pdf
  19. http://www.telemedindia.org/eseminar/Telemedicine,%20EMR%20&%20Remote%20Connectivity.pdf


Submitted by: Tariq Mohasseb

References (rev3)

  1. Bush N, PhD, Fullerton N, MSW, Crumpton R, MBA, LPN, Metzger-Abamukong M, BS, & Fantelli E, BS. Soldiers’ Personal Technologies on Deployment and at Home. Telemedicine and e-Health, 2012 May;18(4):253-63.
  2. Girard P, MS. Military and VA telemedicine systems for patients with traumatic brain injury. Journal of Rehabilitation Research & Development, 2007;44(7):1017–1026

Submitted by: Sara Marinucci-Seevers