Healthcare IT News: The world’s smallest and most fragile people need all the help they can get.
Two recent reports concerning the use of telemedicine in hospitals or hospital departments catering to children paints a promising picture for the technology’s deployment in NICUs and other areas. One report from Children’s Hospital Los Angeles found that a remote telemedicine hookup to specialists located off-site helped improve the quality of care given to newborns in the neonatal intensive care unit. The other report, from the University of Minnesota Amplatz Children’s Hospital, found value in video links between hospitalized children and their parents, their caregivers and other hospitalized children.
Results of the CHLA study, recently published in the Journal of Perinatology, targeted 304 patient encounters on 46 pre-term and term infants at Hollywood Presbyterian Medical Center’s NICU and compared the care given by an on-site neonatologist with that offered by off-site specialists using remote robotic medicine technology.
“Telemedicine technology can provide the off-site neonatologist with direct visual and auditory information about the patient and the clinical scenario in real-time, and may facilitate the decision-making process for the neonatologist,” said the report.
The study comes at a crucial time, with telemedicine technology becoming more sophisticated and looking to gain a foothold in critical care settings and hospitals looking to improve care while dealing with limited staff and access to specialist care. A telemedicine setup in the NICU, proponents say, could allow hospitals – especially those in remote locations or with limited budgets and resources – to link directly and immediately to better-equipped NICUs and neonatologists.
“Aside from proving that the system is safe in the NICU, for the first time ever, the visual and audio accuracy and the ease of use of the system was an interesting finding,” said Istvan Seri, head of the USC Division of Neonatal Medicine at CHLA and co-author of the report, in a news story published by InformationWeek Healthcare. “In addition, the acceptance of the robot in the unit by the faculty, trainees, nursing and respiratory staff as well as, apparently, by the parents was truly remarkable.”
The CHLA study pointed out that the telemedicine system included a control station and remote-controlled robot, linked via the Internet over a secure broadband connection. Other features included bio-directional audio and video communications with real-time video, rapid-response cameras with zoom and auto-focus, a panoramic visualization system, a digital camera, audio microphones, amplification circuitry and custom software.
Researchers cautioned that the study shouldn’t been seen as substitute for on-site care. “As a robotic telemedicine exam cannot replace a bedside exam, robotic telemedicine technology should not be conceived as a replacement for the provision of on-site intensive care, but rather a way to ensure that prompt attention and early intervention based on direct and accurate information can be provided” to infants housed in a hospital’s NICU, the report said.
At the University of Minnesota Amplatz Children’s Hospital in Minneapolis, meanwhile, officials used a video communications system developed by Bloomington, Minn.-based Video Guidance to connect the newly opened hospital’s young patients with their parents, caregivers, even other patients.
“Families of hospitalized children are not always able to be at their sides,” said Jason Albrecht, the hospital’s pediatric palliative care coordinator and a child-family life specialist, in a press release.
“Some children remain in the hospital for long periods of time and some parents live many miles away, including out of the country. The desired result of the new video conference systems is to lessen emotional suffering caused by that separation.”
The health system currently has 21 in-room systems dispersed in the children’s hospital, along with three mobile video conferencing carts that float between the NICU and pediatric intensive care unit, as well as other parts of the hospital. The system can also connect to video conferencing services outside the hospital, such as a family with a PC or Mac and a video hookup at home.
Albrecht said the system offers several uses. It can be used by hospital doctors and staff to communicate with parents or caregivers who are at home, at work or elsewhere, and it can link doctors and patients at the different facilities of Fairview Health Services scattered around Minneapolis.
“This gives us the ability to visually connect a parent admitted to University of Minnesota Medical Center to a child admitted to University of Minnesota Amplatz Children’s Hospital when both are patients,” said Albrecht. “For example, a parent donating an organ may be a patient at the medical center and a child receiving the transplanted organ is at the children’s hospital. Now they can communicate via video to see, share and support one another. This also enables a parent/family caregiver serving at one bedside to remain connected with what is happening at the other.”
“Long-term separation from school and peers adds another layer of stress to patients hospitalized for extended periods,” Albrecht added. “We will soon have the ability to loan affordable video conferencing equipment to schools that do not yet have this capability in order to connect patients with their class rooms.”
Monday, July 18, 2011
Thursday, July 7, 2011
Hospitals turn to telemedicine for remote care of patients
USA Today: Tired and lethargic, Kristopher Lee Taylor knew the moment he got out of bed one recent Monday morning that he wasn't going to work.
Taylor, 32 and a Phoenix resident, instead went to Banner Estrella Medical Center, where he was diagnosed with a potentially life-threatening diabetic reaction.
At the Phoenix hospital's intensive-care unit, Taylor was treated remotely by a doctor in Tel Aviv, Israel, via a two-way camera installed in the patient's room.
Health-care companies such as Banner have turned increasingly to remote doctors to monitor their patients because of a shortage of critical-care specialists.
Dr. Baruch Goldstein assessed Taylor, monitored his vital signs and regularly communicated with him and his nurses, who provided hands-on care. Taylor received insulin, potassium, magnesium and fluid to treat diabetic acidosis, a condition in which a lack of insulin caused his blood levels to rise. He was out of the hospital's intensive-care unit within 48 hours and returned home that Thursday.
Taylor was satisfied that Goldstein, located half a world away, checked him several times during the day and night, even navigating a scare when Taylor's heart rate slowed in reaction to multiple needle injections. Not only could the doctor see the patient, but the patient could see the doctor.
"This was better because there was always a doctor on hand," said Taylor, comparing last month's hospital stay favorably to a previous trip.
"This one was a little more instantaneous. I felt he (Goldstein) could respond faster, rather than having to waiting for a doctor to come to your room or call a nurse back."
Banner Health is among more than three dozen hospital systems nationwide with "eICUs," which provide remote care for the most critically ill patients.
Banner's system, which began about five years ago, includes a command center at Banner Desert Medical Center in Mesa that links doctors and nurses to 15 hospitals and about 450 beds in Arizona, Colorado and Nebraska. Starting this year, doctors in Tel Aviv and Southern California also joined the system that remotely transmits critical patient information such as heart and breathing rates. The information allows the remote critical-care doctors to guide and work with doctors and nurses who actually provide the hands-on treatment.
The system, which Banner calls iCare, is available to every patient in intensive care, but patients are offered a chance to opt out when they are admitted.
By now, Banner doctors and nurses have become accustomed to working with virtual counterparts; Banner started iCare in early 2006. Medical specialists have said in the past, though, that while they welcome the help and ability for remote doctors to quickly detect problems, they worry about turning patients over to doctors they don't know.
The concept is that such remote telemedicine centers staffed by critical-care physicians and nurses can better handle the growing number of patients who require intense monitoring. There is a nationwide shortage of such critical-care specialists, known as "intensivists," so the idea is that these doctors can monitor more patients remotely than if they were on-site at a single hospital.
Banner Health's system is among the nation's largest remote telemedicine systems used for critical care.
Over the past four years, Banner said that patients have spent 26,000 fewer days in critical care and nearly 100,000 fewer days in hospital rooms. Last year, Banner estimates that the remote system saved more than 600 lives by providing more attentive care from critical-care specialists.
Banner's estimates are based on a hospital-industry measurement called Apache (Acute Physiology and Chronic Health Evaluation), which predicts outcomes of patients under similar circumstances.
Banner, based in Phoenix, has invested $11.3.million in equipment to establish its telemedicine system, and it is testing a plan to expand the program to areas of the hospital beyond the ICU. Banner is now conducting a pilot program at Banner Gateway Medical Center in Gilbert to assess whether it's feasible to use the telemedicine for medical and surgical units, too.
Banner Health CEO Peter Fine said the technology had proved its worth in the ICU because it had saved lives and reduced the time patients stay in the hospital.
"It's a more effective, efficient outcome for patient care," Fine said. "It is representative of the type of organization we want to be from a clinical-quality perspective."
Fewer fatalities
The idea of using telemedicine to bolster care at even established urban hospitals has gained momentum based on recent research.
In a May article published in the Journal of the American Medical Association, researchers found that patients at a Massachusetts hospital that operated an eICU system suffered fewer infections and fatalities. The death rate at UMass Memorial Medical Center in Worcester, Mass., dropped to 8.6% after the telemedicine program opened at the hospital, compared with the previous 10.7%.
Dr. Craig Lilly, who is director of the Massachusetts hospital's eICU program and the lead author of the study, said that the evidence showed that the telemedicine program saved lives.
Lilly said the biggest barrier to more widespread use of eICUs was capital costs for smaller hospital systems and convincing hospital staff that it was the best way to care for patients.
"Some people call it culture," Lilly said. "The hardest thing is routine, getting people to do things a little differently than they did before."
Robert Groves, Banner Health's director of critical care, said that establishing such a telemedicine program initially required a "leap of faith" for Banner.
Past studies of the benefits of telemedicine program for intensive-care units have produced mixed results. And hospital systems must grapple with not only the up-front equipment costs, but also the training costs associated with establishing such an intricate process and convincing hospital employees that it's the best way to deliver care.
Groves, however, said Banner's ICU units consistently have delivered better results in saving lives and reducing the length of hospital stays for patients.
"The most important outcome is, do you keep your patients alive, and do you provide quality care," Groves said.
Remote monitoring
Goldstein, the Tel Aviv-based critical-care physician, said he became interested in the concept of telemedicine while he was completing his medical training at a New York hospital.
At the time, he planned to move to Israel, but he also wanted to practice medicine in the United States. He investigated several hospitals' telemedicine systems before he landed a position at Banner Health.
Goldstein, who holds dual citizenship in the United States and Israel, works from a small office in Tel Aviv that includes all the remote-monitoring equipment he requires as a doctor. It also operates with redundant T1 data lines to ensure a reliable, high-speed connection.
In a typical day, Goldstein cares for dozens of patients in emergency rooms in Arizona, Colorado and Nebraska. He estimates that he receives 15 to 20 calls from nurses and doctors at Banner facilities during each shift. Otherwise, he keeps tabs remotely on the patients.
Goldstein, a New York City native, typically works during the day in Israel, which is the overnight shift at Arizona hospitals. Two doctors who are also board-certified in critical-care medicine work with Goldstein in Tel Aviv.
Goldstein, who works occasional shifts at hospitals in Israel to keep his bedside skills sharp, said he may add one more physician to the Tel Aviv office as Banner's eICU program grows.
"As long as Banner keeps growing, it is easy to find doctors willing to work with me," Goldstein said.
Monday, June 27, 2011
Space Research Yields New Ultrasound Tools
HOUSTON – Scientists with the National Space Biomedical Research Institute (NSBRI) have developed tools that expand the use of ultrasound during spaceflight and on Earth, especially in rural and underserved locations.
The tools include techniques that streamline training and help remote experts guide non-physician astronauts to perform ultrasound exams. Ultrasound can be used to assess numerous conditions – fractured bones, collapsed lungs, kidney stones, organ damage and other ailments,
With an NSBRI grant, scientists also created a catalog, or atlas, of "space-normal" imagery of the human body, setting the stage for astronauts to provide care without consulting a physician on Earth.
The atlas was handed over to NASA earlier this year.
Scott A. Dulchavsky, the Roy D. McClure, MD, chairman of surgery and surgeon-in-chief at the Henry Ford Hospital in Detroit, is the principal investigator of these projects and is a member of the NSBRI Smart Medical Systems and Technology Team.
"The ultrasound imagery techniques came from space program constraints of not having a trained radiologist on orbit or having a CAT scan or an MRI available, forcing us to use ultrasound for things in which we would not normally use it," he said. "Also, time limitations forced us to put some tight brackets around what is absolutely required for training to be able to obtain a high-quality ultrasound image and to make some sense out of the image."
Dulchavsky and his colleagues from NSBRI, NASA, Henry Ford and Wyle Integrated Science and Engineering Group began their first ultrasound experiment – Advanced Diagnostic Ultrasound in Microgravity (ADUM) – by developing exam techniques for use on the International Space Station (ISS). The goal was for ISS crewmembers to collect high-quality ultrasound images to send to the Mission Control Center for analysis. The ADUM research was split into two projects: NSBRI funded the ground portion of the research, while NASA supported the flight portion.
The researchers conducted 80 hours of ultrasound examinations on the ISS and then sifted through approximately 20,000 images and many hours of video collected during ISS Expeditions 8 through 12 to create the "space-normal" atlas.
The researchers developed the intuitive ultrasound guide to give astronauts broader use of ultrasound in additional organ systems and medical problems that were not part of the ISS experiment. Dulchavsky said, "ADUM initially utilized telemedicine and tele-ultrasound operations in which the astronauts were interacting with researchers and flight controllers on the ground during the examinations. The ultrasound intuitive guide allows astronauts to conduct exams when quick communication with an expert is not available due to distance from Earth or other reasons."
One of the first to be trained and to conduct an ultrasound exam in space was former NASA Astronaut and ISS Expedition 10 Commander Leroy Chiao,
"We demonstrated on the International Space Station that even non-physicians can produce diagnostic-quality ultrasound images using remote guidance," said Chiao who is chairman of the NSBRI User Panel and a member of Baylor College of Medicine's Center for Space Medicine. "These ultrasound exam techniques and atlas will be increasingly important as we venture farther and longer into space. Telemedicine using ultrasound will be an invaluable medical diagnostic tool."
As in space, low costs and reduced-resource consumption make ultrasound an attractive option on Earth, but until recently, the lack of trained personnel has been an issue. Based on their research for NSBRI, Dulchavsky and his colleagues have spun off the techniques for terrestrial use and published "The ICU Ultrasound Pocket Book" – a reference guide for conducting examinations.
The ultrasound imaging techniques are also being used by athletic trainers for some professional sports teams and the United States Olympic Committee to get point-of-care rapid information about athletes' injuries.
However, it is rural locations, both inside and outside the United States, that stand to gain the most from the diagnostic ultrasound capabilities and telemedicine. Dulchavsky has been collaborating with the World Interactive Network Focused on Critical UltraSound (WINFOCUS) to train individuals to use ultrasound techniques in under-served regions.
Healthcare IT News
http://www.healthcareitnews.com/news/space-research-yields-new-ultrasound-tools
The tools include techniques that streamline training and help remote experts guide non-physician astronauts to perform ultrasound exams. Ultrasound can be used to assess numerous conditions – fractured bones, collapsed lungs, kidney stones, organ damage and other ailments,
With an NSBRI grant, scientists also created a catalog, or atlas, of "space-normal" imagery of the human body, setting the stage for astronauts to provide care without consulting a physician on Earth.
The atlas was handed over to NASA earlier this year.
Scott A. Dulchavsky, the Roy D. McClure, MD, chairman of surgery and surgeon-in-chief at the Henry Ford Hospital in Detroit, is the principal investigator of these projects and is a member of the NSBRI Smart Medical Systems and Technology Team.
"The ultrasound imagery techniques came from space program constraints of not having a trained radiologist on orbit or having a CAT scan or an MRI available, forcing us to use ultrasound for things in which we would not normally use it," he said. "Also, time limitations forced us to put some tight brackets around what is absolutely required for training to be able to obtain a high-quality ultrasound image and to make some sense out of the image."
Dulchavsky and his colleagues from NSBRI, NASA, Henry Ford and Wyle Integrated Science and Engineering Group began their first ultrasound experiment – Advanced Diagnostic Ultrasound in Microgravity (ADUM) – by developing exam techniques for use on the International Space Station (ISS). The goal was for ISS crewmembers to collect high-quality ultrasound images to send to the Mission Control Center for analysis. The ADUM research was split into two projects: NSBRI funded the ground portion of the research, while NASA supported the flight portion.
The researchers conducted 80 hours of ultrasound examinations on the ISS and then sifted through approximately 20,000 images and many hours of video collected during ISS Expeditions 8 through 12 to create the "space-normal" atlas.
The researchers developed the intuitive ultrasound guide to give astronauts broader use of ultrasound in additional organ systems and medical problems that were not part of the ISS experiment. Dulchavsky said, "ADUM initially utilized telemedicine and tele-ultrasound operations in which the astronauts were interacting with researchers and flight controllers on the ground during the examinations. The ultrasound intuitive guide allows astronauts to conduct exams when quick communication with an expert is not available due to distance from Earth or other reasons."
One of the first to be trained and to conduct an ultrasound exam in space was former NASA Astronaut and ISS Expedition 10 Commander Leroy Chiao,
"We demonstrated on the International Space Station that even non-physicians can produce diagnostic-quality ultrasound images using remote guidance," said Chiao who is chairman of the NSBRI User Panel and a member of Baylor College of Medicine's Center for Space Medicine. "These ultrasound exam techniques and atlas will be increasingly important as we venture farther and longer into space. Telemedicine using ultrasound will be an invaluable medical diagnostic tool."
As in space, low costs and reduced-resource consumption make ultrasound an attractive option on Earth, but until recently, the lack of trained personnel has been an issue. Based on their research for NSBRI, Dulchavsky and his colleagues have spun off the techniques for terrestrial use and published "The ICU Ultrasound Pocket Book" – a reference guide for conducting examinations.
The ultrasound imaging techniques are also being used by athletic trainers for some professional sports teams and the United States Olympic Committee to get point-of-care rapid information about athletes' injuries.
However, it is rural locations, both inside and outside the United States, that stand to gain the most from the diagnostic ultrasound capabilities and telemedicine. Dulchavsky has been collaborating with the World Interactive Network Focused on Critical UltraSound (WINFOCUS) to train individuals to use ultrasound techniques in under-served regions.
Healthcare IT News
http://www.healthcareitnews.com/news/space-research-yields-new-ultrasound-tools
Friday, June 24, 2011
Telemedicine, midlevel practitioners start to fill physician gap
Aboard a semi-truck refashioned to serve as a mobile clinic in Shakopee, Kai Hjermstad takes the temperature and blood pressure of a patient named Jose, who's come in to have his blood sugar tested. Hjermstad asks about Jose's history. Who told him he was diabetic? Does he take medication? Does he have pain in his legs or feet?
This is the sort of questioning usually done by a public health nurse or primary care physician. But Hjermstad is neither of these. He's among Minnesota's first crop of "community paramedics," a new designation for those who have received special training, and can perform an expanded range of services. A medic for 20 years, Hjermstad provides free care to Scott County residents — many without insurance — via the mobile clinic, owned by the Shakopee Mdewakanton Sioux.
When the consultation is over, Hjermstad reviews Jose's case with his on-site supervising physician, Dr. Michael Wilcox, the county's medical director who oversaw the community paramedic pilot training program at Hennepin Technical College. Hjermstad orders a blood sugar test and recommends a referral to a dentist for a bad tooth.
Welcome to the future of rural medicine in Minnesota, where a lack of physicians has opened the door for midlevel practitioners to take on a greater role in providing health care. Community paramedics target underserved rural areas in particular, and efforts are under way to have dental therapists do work once reserved for dentists. At the same time, telemedicine is attacking the shortage from another angle.
The paucity of doctors in outstate Minnesota has become critical. While about 12 percent of the population lives in the state's most rural areas, the Department of Health estimates that fewer than 5 percent of doctors practice there. The primary care doctor-to-patient ratio in Hennepin County is one for every 508 people, according to a recent tally of health rankings. In some rural counties, however, the ratio is closer to one for every 2,000 people. Five rural counties have no primary care providers at all.
TELEMEDICINE A PRACTICAL SOLUTION
Telemedicine is in some ways the most practical solution. It can bring such services as dermatology, endocrinology, pharmacology and even psychology to the far reaches of the state via camera and monitor. Rural hospitals use the technology to fill out their physician rosters and provide specialty care to populations too sparse to support full-time specialists. Patients tend to see remote doctors from the comfort of their regular clinics or hospitals.
Some have wondered whether telemedicine and the use of midlevel practitioners to perform duties previously left to higher-paid doctors, nurses and dentists might lead to degraded care system in rural Minnesota. But at least when it comes to telemental health, patients seem to like it. One recent survey found that 86 percent of patients counseled remotely through a program at the University of Minnesota-Duluth were "very satisfied." In addition, 91 percent of primary care providers called the service "definitely useful."
In fact, telehealth seems to work especially well for mental health care, since counseling doesn't require a physical examination. Often, when a patient in greater Minnesota sits before a camera for a session, the doctor they're talking to is Jane Hovland, a nurse, licensed psychologist, University of Minnesota associate professor and native of north Minnesota. Rural people, says Hovland, "are such a self-reliant bunch." When it comes to mental health, "We expect people to figure it out on their own."
But the fact is, some can't. The most common diagnosis Hovland makes is of major depression, followed by anxiety disorders.
Hovland notes that Minnesota has more psychologists than the national average. But they tend to practice in the city. "There are 13 counties without a single licensed psychologist," she says. "It's a matter of distribution." That's why doctors with the university's telemental health program have seen 2,300 patients over the past five years.
"I had a client who would ride a bicycle in from the woods for telemental health appointments," Hovland says, noting that because the university sees patients quickly, the no-show rate is very low. "We're trying to show that this is a sustainable model," she says.
MIDLEVEL PRACTITIONERS: FILLING THE GAP
Similarly, advocates have high hopes for midlevel practitioners.
The public has largely grown accustomed to treatment by nurse practitioners, specially-trained nurses who can perform physical exams and prescribe medications. But the idea of using midlevel practitioners to fill health care gaps is spreading to other areas of treatment as well.
Minnesota is the first state in the nation to license "dental therapists," who perform duties that fall between those of a dental assistant or hygienist and those of a full-fledged dentist. They can fill cavities and even pull baby teeth, under the supervision of a licensed dentist. Two groups of students are making their way through the state's education systems, one at Metropolitan State University and the other at the University of Minnesota.
"We have a class of nine who will graduate in December," says Karl Self, who directs the University of Minnesota's 28-month dental therapy program. "We believe in one standard of care. For the scope of practice that a dental therapist has that overlaps with that of a dentist, we train our dental and dental therapy students the same. They take the same classes together and take the same competency examinations. We feel this is important to assure the public of the quality of care being delivered."
By design, the students will be deployed to underserved areas, Self says, including rural parts of the state. "We are targeting areas where there is need, where oral health care providers are interested in another option or tool for increasing access." One student, formally a dental assistant in Montevideo, will go back to that practice.
A MINNESOTA EXCLUSIVE: COMMUNITY PARAMEDICS
Minnesota was also the first state to pass a law establishing certification for community paramedics like Hjermstad. The legislation, signed by Gov. Mark Dayton in April, affords these paramedics expanded responsibilities as long as they are supervised by a physician.
A community paramedic might suture a wound, adjust a medication, or address an asthma attack or allergic reaction. They might help a diabetic stay on an even keel or talk through a mental health issue. And here's the greatest divergence from their traditional role: They'll attempt to do it all on the spot, without automatically driving a patient to an emergency room. A community paramedic might even make regular, preventive home visits to "frequent flyers" — those patients who call 911 the most and cost the system dearly.
Driving this new approach, besides a lack of doctors in rural areas, are changes to federal health care law. In the future, Medicare will penalize hospitals for some emergency room re-admissions on the theory that they should be coordinating better outpatient care.
Community paramedicine is a concept that's been popular for years in other countries, such as Canada and Australia, but has only recently made its foray into the United States. "Minnesota is the first state to recognize this with law," says Wilcox. "When you look at the resources in a rural area, there are not enough nurses. Expanding the role of the paramedic in a rural setting, where they can do patient care between 911 dispatch calls, makes sense."
Wilcox and others argue the new law improves care, saves money and preserves rural ambulance services by increasing paramedic fees. Community paramedics could be reimbursed under the state's medical assistance program, though only after study by the state human services commissioner, who must submit a fee schedule to the legislature by January.
"I think the community paramedic legislation is a great opportunity, especially in rural Minnesota," says Mark Schoenbaum, director of the Minnesota Department of Health's Office of Rural Health and Primary Care. "It's an opportunity to use the skills of our rural paramedics who, because they work in isolated and sparsely populated areas, often have time available, to go and perform a variety of services they are qualified and supervised to do."
PUSHBACK BY PROFESSIONAL ORGANIZATIONS, UNIONS
Not everyone supports the increasing use of midlevel practitioners. The Minnesota Dental Association expressed reservations about the state's dental therapy program and insisted on legislative language ensuring monitoring by dentists and other restrictions, though Self says the organization has come around.
And the Minnesota Nurses Association actively opposed the new community paramedic law. While agreeing that healthcare services need to be expanded in rural areas, Carrie Mortrud, the MNA's government affairs and public policy specialist, says, "Creating a brand-new provider is not the answer."
Mortrud is concerned that community paramedics merely replace nurses with cheaper, lesser-trained personnel, at the expense of patient health. "If they would refer and get people into the right system and right care," the MNA would see the benefit, says Mortrud. "If they are going to go in and take over public health nursing, we are not okay with that."
"Paramedics are trained in algorithms," Mortrud adds. "They are trained to respond to what they find on the scene. Nursing is completely different. Nursing is about building a relationship with your patient so you can help them take care of themselves."
Will the use of midlevel practitioners create a second-class health system in rural Minnesota? Not according to Walt Gregg, a senior research fellow at the University of Minnesota's Rural Health Research Center. "It would only be second tier if they were practicing outside a practice scope they are capable of," he says.
Gary Wingrove, program manager of St. Cloud's North Central EMS Institute and chair of the International Roundtable on Community Paramedicine, helped establish the training curriculum. He hopes community paramedics will be just one more member of a patient's healthcare team. "If they find something adverse," Wingrove says, "they will do the assessment such that they can call the primary care provider and talk about the care plan."
"What's kind of happened over time, as medicine has evolved," says Wingrove, "is we've identified gaps in a community that need to be filled. EMS workers already have a skill set that's common in primary care. When there is a hole in the community and the community searches out a way to fill that gap, the best thing they can do is look to existing providers."
"I could easily see 100 paramedics in the state in three to five years," adds Wilcox. "We start a training program at the end of May. We're going to select 24 candidates this time around."
Young paramedics, says Wilcox, "go into it because they like the street work and the adrenaline rush. But that gets old after a while. If you talk to them as they move along in their careers, they want to do more for a patient than load them up and move them along. This is a career path they haven't had available before."
Source: MPRNEWS
http://minnesota.publicradio.org/display/web/2011/06/20/ground-level-rural-health-care-midlevel-practitioners-telemedicine/
Tuesday, June 21, 2011
Telemedicine put HCV care in hands of PCPs
Primary care physicians with telemedicine support can manage hepatitis C virus (HCV) infection as effectively as specialty clinics, researchers found.
Viral suppression outcomes for rural and prison system primary care clinicians were similar to those achieved by their academic medical center colleagues who provided consultation and video- or teleconferencing support in a prospective cohort study led by Sanjeev Arora, MD, of the University of New Mexico in Albuquerque.
Sustained viral response rates were 58.2% and 57.5%, respectively (P=0.89), Arora's group reported online in the New England Journal of Medicine.
These rates matched those in the pivotal clinical trials for HCV treatments and represented a huge turnaround for the rural and underserved population treated, they noted.
Before the program, rural patients in New Mexico had to wait up to six months for an HCV clinic appointment and then travel up to 250 miles 18 times on average during the course of treatment.
"Barriers to treatment are so formidable and concerns for safety so great that in 2004 almost no patients with HCV infection in rural and frontier areas of New Mexico were receiving treatment," Arora's group wrote in the paper.
Safety concerns center on the serious side effects of pegylated interferon and ribavirin (Copegus, Rebetol), which require aggressive management by multidisciplinary experts, they explained.
Hesitancy on the part of primary care physicians to provide complex treatment for HCV is understandable, Thomas D. Sequist, MD, MPH, of Brigham and Women's Hospital and Harvard in Boston, commented in an accompanying editorial.
Encouraging primary care physicians to treat HCV without any training or assistance wouldn't be ethical, the researchers cautioned.
Sequist agreed with them that the type of program used in the study, with health information technology plus strong commitment to support on the part of academic medical centers, is needed to extend the model to other areas and for other chronic health issues.
Improved access to specialty care in a program like that could do much to address disparities in healthcare, Sequist pointed out.
Minorities -- predominantly Hispanics -- accounted for two-thirds of those treated at the 16 rural community sites and five prisons in the study but less than half of those at the University of New Mexico HCV clinic. Virologic response to treatment didn't differ between Hispanic and non-Hispanic patients in the study.
Community clinicians at the sites connected to weekly discussions via video- or teleconferencing through the Extension for Community Healthcare Outcomes (ECHO) program to ask questions and plan patient care according to evidence-based protocols.
Among the total of 407 patients with previously untreated chronic HCV infection, about 56% treated at both the HCV clinic and at the primary care sites were infected with HCV genotype 1.
Again, sustained viral response rates among the genotype 1 patients didn't show a significant difference by treatment site type either (45.8% for those at the HCV clinic and 49.7% treated by primary care providers, P=0.57).
Serious adverse events were actually less common at community or prison sites compared with the HCV clinic (6.9% versus 13.7%, P=0.02).
After adjustment for patient characteristics, the primary endpoint of sustained virologic response rates remained similar between site types (odds ratio 1.04 for primary care versus HCV clinic, 95% CI 0.67 to 1.60).
The researchers cautioned about the lack of a community group without telemedicine support for comparison, the possibility of residual confounding, and the broad confidence intervals that couldn't rule out a substantial difference in outcome of care between groups in the study.
But given the success in HCV treatment, the ECHO program has been expanded to 255 sites addressing a variety of complex health problems, including substance abuse, chronic pain, asthma, and rheumatologic conditions, they noted.
"The ECHO model has the potential for being replicated elsewhere in the U.S. and abroad, with community providers and academic specialists collaborating to respond to an increasingly diverse range of chronic health issues," they concluded in the paper.
MedPage Today
http://www.medpagetoday.com/InfectiousDisease/Hepatitis/26806
Viral suppression outcomes for rural and prison system primary care clinicians were similar to those achieved by their academic medical center colleagues who provided consultation and video- or teleconferencing support in a prospective cohort study led by Sanjeev Arora, MD, of the University of New Mexico in Albuquerque.
Sustained viral response rates were 58.2% and 57.5%, respectively (P=0.89), Arora's group reported online in the New England Journal of Medicine.
These rates matched those in the pivotal clinical trials for HCV treatments and represented a huge turnaround for the rural and underserved population treated, they noted.
Before the program, rural patients in New Mexico had to wait up to six months for an HCV clinic appointment and then travel up to 250 miles 18 times on average during the course of treatment.
"Barriers to treatment are so formidable and concerns for safety so great that in 2004 almost no patients with HCV infection in rural and frontier areas of New Mexico were receiving treatment," Arora's group wrote in the paper.
Safety concerns center on the serious side effects of pegylated interferon and ribavirin (Copegus, Rebetol), which require aggressive management by multidisciplinary experts, they explained.
Hesitancy on the part of primary care physicians to provide complex treatment for HCV is understandable, Thomas D. Sequist, MD, MPH, of Brigham and Women's Hospital and Harvard in Boston, commented in an accompanying editorial.
Encouraging primary care physicians to treat HCV without any training or assistance wouldn't be ethical, the researchers cautioned.
Sequist agreed with them that the type of program used in the study, with health information technology plus strong commitment to support on the part of academic medical centers, is needed to extend the model to other areas and for other chronic health issues.
Improved access to specialty care in a program like that could do much to address disparities in healthcare, Sequist pointed out.
Minorities -- predominantly Hispanics -- accounted for two-thirds of those treated at the 16 rural community sites and five prisons in the study but less than half of those at the University of New Mexico HCV clinic. Virologic response to treatment didn't differ between Hispanic and non-Hispanic patients in the study.
Community clinicians at the sites connected to weekly discussions via video- or teleconferencing through the Extension for Community Healthcare Outcomes (ECHO) program to ask questions and plan patient care according to evidence-based protocols.
Among the total of 407 patients with previously untreated chronic HCV infection, about 56% treated at both the HCV clinic and at the primary care sites were infected with HCV genotype 1.
Again, sustained viral response rates among the genotype 1 patients didn't show a significant difference by treatment site type either (45.8% for those at the HCV clinic and 49.7% treated by primary care providers, P=0.57).
Serious adverse events were actually less common at community or prison sites compared with the HCV clinic (6.9% versus 13.7%, P=0.02).
After adjustment for patient characteristics, the primary endpoint of sustained virologic response rates remained similar between site types (odds ratio 1.04 for primary care versus HCV clinic, 95% CI 0.67 to 1.60).
The researchers cautioned about the lack of a community group without telemedicine support for comparison, the possibility of residual confounding, and the broad confidence intervals that couldn't rule out a substantial difference in outcome of care between groups in the study.
But given the success in HCV treatment, the ECHO program has been expanded to 255 sites addressing a variety of complex health problems, including substance abuse, chronic pain, asthma, and rheumatologic conditions, they noted.
"The ECHO model has the potential for being replicated elsewhere in the U.S. and abroad, with community providers and academic specialists collaborating to respond to an increasingly diverse range of chronic health issues," they concluded in the paper.
MedPage Today
http://www.medpagetoday.com/InfectiousDisease/Hepatitis/26806
Thursday, June 9, 2011
Cutting the Red Tape: Defense Bill Rider Encourages Telemedicine
A quiet rider on the Defense authorization bill passed by the House on Thursday should make it easier for veterans to get mental health treatment--and perhaps other types of medical care as well, its sponsor says.
The amendment sponsored by Rep. Glenn Thompson, R-Pa., cuts through some of the red tape that hampers military doctors, psychologists, and contractors who treat service members using telemedicine, such as Skype, video link, or even simple telephone calls.
The Servicemembers’ Telemedicine and E-Health Portability Act helps bypass individual state licensing requirements so that a licensed medical professional in one state can treat a patient in another, without having to get a medical license in the patient’s state. All the professionals must be licensed by the Defense Department.
”We have seen a significant increase in posttraumatic stress disorder,” Thompson said in a telephone interview. “What sparked my specific interest in this was the alarming rate of suicides that occur both on post and at home.”
According to the Defense Health Board, 1,100 servicemen and women committed suicide from 2005 to 2009--one suicide every day and a half. The Army's suicide rate doubled in that time. About 1.9 million U.S. service memebrs have served in Iraq and Afghanistan, many on repeated deployments with less than a year in between to rest.
The U.S. military, which once ignored the mental toll that war can take, is actively trying to treat these men and women. Among the many barriers are licensing requirements and a lack of professionals. People may also be embarrassed to seek treatment.
Thompson hopes this bill can get around those problems.
“It was really designed around mental health but, frankly, once it is in place there is not a reason in world that if a service member needs access to another type of specialty medicine … telemedicine could not be used,” Thompson said.
Active-duty service members are treated at Defense Department facilities by DOD-licensed professionals. The problem comes when they come back from deployment--especially National Guard and reservists. “When it comes to behavioral health, the Guard and Reserve have been hit especially hard,” Thompson said in comments on the House floor.
“This will allow our National Guard, Reserve, veterans, and retirees quicker and more-efficient access to care, and open the door to allow for modernization of DOD health care delivery,” Thompson said.
“This amendment will allow for new technologies in telephone and Internet communications to expand into the Department of Defense, which will greatly expand access, especially in rural America. It will also allow more specialists to be involved in providing care.”
Thompson said that most service members were used to using Skype, an Internet-based service that allows users to speak by telephone or webcam, and other Internet technologies to stay in touch with friends and family, and they should adapt well to telemedicine.
Studies have shown that telemedicine can be an effective way to manage a number of diseases, from psychological problems to multiple sclerosis.
Source: NationalJournal
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