With the increased availability of high-speed Internet connections in rural areas, the use of telemedicine to improve access to specialty care is growing. In rural areas, where a shortage of specialty care exists, telemedicine programs enable primary care providers to reach out to urban academic specialists hundreds of miles away to obtain advice about challenging cases. Other programs allow urban specialists to virtually “examine” patients in remote settings and consult with the patients’ local providers to establish a diagnosis and develop a plan of care. One award wining example of this collaborative model is the University of New Mexico Hospital‘s (UNMH) Project ECHO™ (Extension for Community Healthcare Outcomes), discussed below, where a multispecialty team hosts telemedicine clinics to treat complex medical problems, including chronic pain [Figure 1].
| FIGURE: The multidisciplinary team working with primary care physicians in the Project ECHOTM pain clinic. |
Many studies show the benefits of telemedicine
Over the past several decades, telemedicine has been demonstrated to:
> Improve access to healthcare for a wide range of conditions, including heart and cerebrovascular disease, diabetes, cancer, psychiatric disorders, and trauma
> Improve access to services such as radiology, pathology, and rehabilitation
> Promote patient-centered care at lower cost and in local environments
> Enhance efficiency in clinical decision-making, prescription ordering, and mentoring
> Increase effectiveness of chronic disease management in both long-term care facilities and in the home
> Promote individual adoption of healthy lifestyles and self-care.1
Telemedicine has been particularly effective in providing care for rural patients who might find it difficult to travel farther than their local hospital. In Louisiana, for example, 28 rural hospitals are using video teleconferencing to bring patients together with specialists at the Louisiana State University Health Sciences Center (LSUHSC) in Shreveport. Without this option, some patients would face a 5-hour drive to see an LSUHSC specialist in person.
The ability to send large volumes of data such as high-definition video over the Internet enables specialists to “examine” patients and view diagnostic images remotely. In some programs, the patient’s electronic health records are transmitted over the Web to aid in diagnosis and treatment.2
Military and prison telemedicine programs
The Department of Defense and the Veterans Health Administration (VHA) have used telemedicine extensively in caring for combat veterans with traumatic brain injuries.3 Telemedicine is employed for neurological assessment, acute medical and neurosurgical treatment, psychiatric intervention, behavioral therapies, and occupational and physical rehabilitation.
According to one description of the VHA program:
“Veterans once at risk of being left untreated can now be monitored and cared for in their homes and communities. VHA home telehealth programs are reducing
hospitalizations, emergency room visits, and length of hospital stays, while improving the quality of life for veterans.”3
Some state prisons rely on telemedicine to reduce the travel and security expenses associated with inmate care. New Jersey, Georgia, and Texas have incorporated university-based care into their telemedicine programs for prisoners, and California will soon be adding similar telemedicine programs.4 Texas has saved $215 million by using this approach, and telemedicine has been linked to improvements in inmates’ blood glucose levels, cholesterol levels, and hypertension.4
Studies of telemedicine use in acute and chronic care
Telemedicine can play a role in acute care situations. A 2009 scientific statement from the American Heart Association/American Stroke Association recommends the use of telemedicine for stroke in the absence of specialist care. The consensus statement found that a neurological exam conducted via videoconferencing can be as effective as a bedside exam for nonacute stroke patients. Also recommended are specialist use of teleradiology for computed tomography brain scans in suspected stroke patients, and in thrombolysis and IV tissue plasminogen activator decision-making for stroke patients in collaboration with on-site medical care.5
In an prospective evaluation of pediatric patients in emergency departments in Vermont and upstate New York, telemedicine was used to provide specialist consultations and to support transport teams. Providers found it to be superior to telephone consultations and to improve patient care.6
A 2009 randomized study compared telemedicine case management with usual care in older, ethnically diverse, medically underserved patients who had diabetes mellitus. Over a 5-year follow-up period, the study group achieved net overall reductions in hemoglobin A1c, systolic and diastolic blood pressure, and low-density lipoprotein cholesterol. Despite these improvements, however, mortality rates were about the same in the interventional and usual-care groups.7
In the area of pain management, a 2010 randomized trial involving cancer patients with pain and depression saw positive results from the use of case management by telephone and automated symptom monitoring. Of the 274 patients with pain, those in the intervention group had greater improvements in pain severity over the 12 months of the trial than did those in the usual-care group.8