Deborah Kiel lives in Centreville, the county seat of Queen Anne’s County on Maryland’s Eastern Shore. It’s a lovely town, with a population of just under 2,000 people, but not necessarily a hotbed of specialized medical care.
Living in such a remote locale might have been a problem for Kiel, who suffers from ulcerative colitis, a chronic intestinal disease that requires constant attention and care. But in fact, she’s under the close supervision and treatment of Dr. Raymond Cross of the University of Maryland Medical Center (UMMC), some 90 minutes away.
The arrangement is possible thanks to the emerging world of telemedicine.
As part of a recently completed 12-month trial of a new telemedicine program with UMMC’s gastroenterology department—the first such study in the country—Kiel logged onto a laptop in her home once a week, submitted info about her condition and any symptoms she had been showing. She stood on a scale that transmitted her weight to UMMC through the computer’s USB port, and received info about her treatment and any changes to her medications, followed by an educational quiz to help her understand her condition.
“It kept me constantly in touch with the staff at the hospital,” says Kiel, adding that to get such care in person would require a long drive to UMMC in downtown Baltimore. “I really loved it.”
The program Kiel participated in is just one application of telemedicine, a broad term that includes any dimension of patient care that uses technology to bridge the long distances that often prevent doctors from reaching some patients—and each other.
UMMC is at the forefront of a national movement to integrate telemedicine into as many aspects of patient care as possible, both in direct contact with patients and in consultations with physicians and health-care providers in more remote areas. The hospital recently created an official department of telemedicine, coordinating efforts in specialties as diverse as obstetrics, oncology, psychiatry, and critical care medicine.
“Essentially, it extends the availability of our sub-specialists to patients and providers who would otherwise have to get in a car and drive to downtown Baltimore to meet with us in an exam room or conference room,” says Alison Brown, UMMC’s senior vice president for business development and marketing.
The ways in which various departments use telemedicine vary broadly. Some of the most common uses are physician-to-physician, as when specialists at UMMC’s Greenebaum Cancer Center hold teleconferences with physicians at UMMC-affiliated Upper Chesapeake Health in Bel Air, going over specific cases and reviewing pathology slides, bringing together a spectrum of experts to determine the best course of action.
Also among the most common uses of telemedicine at UMMC is in perinatology, or high-risk obstetrics. As part of a state-funded program, perinatologists at UMMC in Baltimore consult directly with expecting mothers from all around the state who may have had pregnancy complications in the past, or who have diabetes, high blood pressure, HIV, or a thyroid condition—anything that could pose a threat to the mother or child.
“St. Mary’s and Cecil counties are the biggest sources of our patients, and Garrett is starting to participate more,” says Dr. Michelle Kush, a specialist in maternal medicine who has seen many of the 210 patients in the programs.
The specialists talk to the patients about their histories, conditions, and pregnancies, ultimately detailing a suggested management plan that is sent both to the patient and to the local physician. In this case, the consultation could theoretically have been done over the phone, but Dr. Kush says the teleconference is much more effective.
“It adds a level of comfort that they can see the person who’s giving the advice and they can talk to you and know who they’re speaking to,” says Dr. Kush, adding that many of the women she consults with wouldn’t be able to travel the long distance to Baltimore for in-person consultations and would rely exclusively on local physicians, many of whom have little or no experience with high-risk pregnancies. “Even though it’s through a screen, once the consult starts and you start speaking, the screen really does go away, and it’s almost as if you were right next to each other.”
Other applications of telemedicine are more interactive. One program, still in development, allows UMMC stroke specialists to evaluate stroke victims from around the state, using a teleconference monitor. The UMMC doctors direct local clinicians in the completion of a physical exam and feed data back to the physician.
Interaction with doctors treating stroke victims is particularly time-sensitive since, in such cases, a decision has to be made fairly quickly whether or not to administer the clot-busting drug TPA. With the new telemedicine capability, doctors all over the state will be able to consult with the region’s best experts in making that decision.
In another segment of Maryland’s telemedicine program, doctors at UMMC’s world-renowned R Adams Cowley Shock Trauma Center monitor patients at Kernan Hospital in Northwest Baltimore, using a robot that has a teleconference screen with the doctor’s face on top. As the robot goes from room to room, the doctor talks to patients and gives instructions for care to nurses on-site.
Dr. Cross, who led the gastroenterology trials in telemedicine, is looking at other possible uses for the technology in monitoring people with chronic illness, in particular. “For chronic illness, you have to have your patient engaged in the process and willing to take part in their care, and self-management is part of that,” he says. “In diabetes, in asthma, in congestive heart failure, patients are very much involved in disease management.”
Besides the direct benefits of the at-home care, he says, patients in his trial maintained better health generally.
As an example, he cites the case of a woman with ulcerative colitis who reported having a fever during her weekly telemedicine session. The hospital called her as a result, and after hearing more symptoms, instructed her to come to the emergency room. It turns out she had a rare infection near her spine, totally unrelated to her colitis, called an epidural abscess. If not treated early, the infection can lead to permanent paralysis or death.
“You could argue that she would have come in for medical attention at some time anyway, but it’s hard to say,” says Dr. Cross. “We got her evaluated quickly and treated.”
There is a building consensus that telemedicine improves patient care while also reducing costs, by preventing more extreme medical interventions. But two significant barriers have so far prevented its widespread adoption.
The biggest barrier to expanding the use of telemedicine is that national insurers, stuck in old-world ways, have been slow to pay doctors who consult with patients without seeing them.
“Reimbursement for a physician to patient consultation is just beginning to emerge on a national basis,” says UMMC administrator Brown. “This landscape is changing because major payers, including the Medicare federal program, all recognize that this is a service that ought to be able to be reimbursed for the professional services provided by the physician. And, as reimbursement increases for the use of telemedicine, we can expect the use of it will increase as well.”
Brown says that UMMC and The Johns Hopkins Hospital have been able to integrate telemedicine into patient care (although only UMMC has a stand-alone telemedicine department) largely as a result of securing grants for research into various applications. But few community hospitals have been able to do the same.
The other significant barriers are technological. In order to confidently offer telemedicine service, UMMC has to ensure that all of the data connections are both secure and have enough bandwidth to transmit detailed MRI images or other test results.
As part of its maternal health program, UMMC has secure, dedicated T-1 connections either through the state Department of Health or through designated community hospitals. For his GI trials, Dr. Cross had to use phone lines rather than wireless Internet to make sure all transmitted data was secure.
“It’s good because it’s not subject to Internet-related security threats, but it’s a little clunky—you have to go to the patient’s home and install it, and the telephone connection doesn’t really give you the capability for instant communication,” says Dr. Cross. “In the future, we’ll move into a web-based system.”
He predicts that, fairly quickly, telemedicine will spread, mostly because patients react so positively to it.
“In our studies, patients feel that the ability to communicate easily with their doctors decreases barriers and improves communication,” he says. “Over and over, they say they feel safer, like someone’s watching out for them.”
Deborah Kiel, recalling her time in the home-based telemedicine program, echoes the sentiment.
“As a patient, I thought more about what was going on with my body,” she says. “It really kept me in touch with the staff at the hospital. It kept me healthy.”
