What is Telemedicine?

Telemedicine, Telehealth and Teleradiology are terms that refer to the process of providing medical information over electronic communication equipment. Telemedicine uses a range of technologies including standard telephone service, high-speed internet, wide-bandwidth transmission  in conjunction with computers, fiber optics, satellites, and other sophisticated peripheral equipment and software.

There are three models of Telemedicine: Real Time, Store and Forward and Home Health Medicine. Real time telemedicine allows doctors or doctors and patients to communicate together to assess or contribute to the patient’s health care. This can be done by telephone, internet web conferencing, video conferencing or even posting to a private internet discussion board.

The store and forward model of Telemedicine refers to the transmission of medical data from one device to a recipient who reviews the data on another device. For example, when a patient is scanned on a bone density scanner, the resulting scan, analysis and quantitative data can be electronically transmitted via dicom format to a storage device. Cardea Technology’s BoneStation system is an example of a store and forward system used for teleradiology. The scans from the bone density machine are transmitted to the BoneStation central database where a physician can retrieve and view them through the BoneStation web application.

Home health telemedicine refers to measurements or treatments that are given to patients in their home and the results are transmitted back to a medical center, usually some distance away. Home health equipment consists of capturing vital signs, video conferencing capabilities, and the gathering of patient information from a remote monitoring device that can be reviewed and alarms can be set from the hospital nurse’s station, depending on the specific device.

For more in depth information on telemedicine, please refer to these professional telemedicine organizations and web sites:

Telemedicine Information Exchange

American Telemedicine Association

International Society of Telemedicine and eHealth

Great Plains Telehealth Resource & Assistance Center

Canadian Society of Telehealth

California Telemedicine and Ehealth Center (CTEC)

Medicare Makes No Bones About It

The Federal government has made no bones about it. With current Medicare policies, they simply are not taking the issue of bone health seriously. At least that is the position that Congress and Medicare has taken through the summer of 2008. Surprisingly, the public is by-and-large unaware of the situation. The result will likely be a degradation in the quality of life for many elderly, particularly women, as they experience hip fractures that could have been prevented in many cases with the support of adequate levels of Medicare DXA exam reimbursement.

We are talking about Osteoporosis. It is a disease that causes a weakening of the bones. About 10 million Americans have the disease, with women at four times the risk. Another 34 million are at risk. For more information about Osteoporosis see the National Osteoporosis Foundation’s web site.

Osteoporosis is known as the “silent disease”. It often shows no visible effects – until it is too late. The result is usually a fractured bone, the worst of which is usually the hip. A fractured hip in the elderly can be a life altering event. Almost one in four patients age fifty and older die within a year of a hip fracture. Many of those that survive require long term care. The good news is that drugs are available to prevent fractures.

In the United States, a DXA exam is the most common test to measure bone strength – or bone density – and Medicare reimburses for the test. It is typically performed on an outpatient basis and usually takes less than thirty minutes. A DXA machine utilizes x-rays to determine bone density. Typically the hip and spine are measured and sometimes the arm.

A DXA machine

Figure 1 – A typical DXA machine.

Sample hip scan

Figure 2 – A sample DXA hip scan.

Starting in 2006, Congress and Medicare, in two separate and unrelated actions, began processes to reduce reimbursement to physicians for performing DXA tests. The cuts were gradual through 2010. By 2010, the reimbursement rates would be far below the cost to perform the tests. In 2006, Medicare paid approximately $139 for the test. By 2010 the rate was reduced to under $40.

What does that mean for the elderly patient who is at risk. Most (about 70%) of these tests are performed in physician’s offices. Those physicians will be hit especially hard, because the DXA reimbursement cuts are a little more drastic for them. They will simply stop offering the tests. It will become more difficult to schedule an exam and patients will have to travel further. It is unclear how large institutions, such as hospitals, will react. Some may continue offering DXA testing. For these large health centers, the 2010 reimbursement rates are below their costs.

The affects are just beginning to ripple through the industry. Some physicians have already stopped offering DXA tests. According to a study by the Lewin Group, 93% of physicians will stop offering at the 2010 reimbursement rates. Technologists, who perform the exams, have sought other positions or have been let go. Training of technologists has seen a significant decrease.

The public seems to be largely unaware of the state of affairs regarding DXA testing. However, physicians and other industry groups have been fighting to save DXA testing in the U.S. There is legislation before Congress that could help. At this point, it is unclear whether DXA will remain a viable option in the U.S.

Cardea Technology is the maker of BoneStation, a software tool that assists physicians with the review of bone density exams.

Additional links:

International Society For Clinical Densitometry Advocacy

Perfrect Storm Brewing in Women’s Bone Health

Bill to Save DXA

Recent Study of Bone Health Across the Globe

Integration of medical systems and devices

Much of medical technology has now become digital. Medical devices integrate through special languages and formats that are understood by a wide variety of machines allowing data to be transmitted and used by multiple medical departments or practices.

Before the digital era began, medical personnel would take a measurement on a medical device and display or print out the results. For example, x-ray machines provided a method for scanning a patient and producing the resulting image on film. The film would then have to find its way, usually by human hands, to a reviewing radiologist in order to be interpreted. With the evolution of technology, devices are becoming less dependent on humans and more on electronic transmission. That is to say, the results from medical imaging devices are stored electronically and require less dependability of human input to accomplish a task. In the case of the x-ray, digital images of x-rays are transmitted across computer networks, stored remotely, and displayed for medical personnel.

At the heart of the digital world is the computer network. Digital equipment within an office or small geographic area is connected with a local area network, or LAN. For organizations that are spread out geographically, a wide area network, or WAN, may be used to connect LANs. Computers, medical devices, and information systems communicate via the network.

There are a wide variety of devices used for diagnostic purposes. They take measurements and/or images and transmit them, via computer network, to medical information systems. Most people are familiar with the common types of medical devices, such as CT, MRI, digital x-ray machines (x-ray machines which no longer use film) and other imaging devices.

Other types of information systems act as repositories for medical data. Some of the common types of systems include: HIS (Hospital Information System), RIS (Radiology information System), reporting systems, and PACS (Picture Archiving and Communications System). HIS and RIS provide a wide variety of capabilities that encompass both administrative and clinical functions, including scheduling, billing, and storage and viewing of results. RIS tend to be geared more towards radiology departments. PACS are typically used for storage of large numbers of images and support almost instant recall of any image for viewing.

So how do the medical devices and information systems integrate? The computer network provides the physical connection through which systems communicate. Beyond that there are two standards that allow devices to interact via a common language – HL7 and DICOM. HL7 is generally used to transmit textual information, such as patient data, exam data, and results. DICOM was devised largely for radiology and includes the ability to transmit images.

Let’s take a look at how the process works and how the various systems and technologies fit together. A typical situation is one where a primary care physician orders a test for a patient. The patient is referred to a specialist – say a radiologist – for an x-ray. The radiologist will then read the image and provide results in the form of a report.

The steps in the process might go like this:

1) An appointment is made with the medical specialist, typically by the patient or primary care physician’s staff.

2) If the primary care physician’s staff makes the appointment, they might create an “order” in the HIS/RIS for the appointment.

3) On the scheduled appointment date, the patient arrives. A technologist performs the x-ray and transmits the images to the PACS via DICOM. Newly received images will remain in a queue within the PACS. This queue is often referred to as a worklist.

4) The radiologist logs into the PACS. It is common for radiologists to utilize multiple computers and monitors when reviewing images. A special monitor connected to the PACS offers high fidelity images, allowing the radiologist to see details in the image. A second monitor typically runs standalone reporting software, such as a dictation package. The radiologist, while looking at the image on one monitor, will dictate results into the other.

5) When the review of images and patient data is complete, the radiologist saves the interpretation on the computer with the reporting software. To get the results to the primary care physicians, the radiologist transmits the report to the HIS/RIS where the primary care physician has access to the report.

6) The primary care physician logs in to the HIS/RIS and view the results. Note that primary care typically does not have access to the tools of the specialist. PACS and the reporting software are tools used by the specialists to create reports.

This scenario represents one way in which medical systems may be integrated. This is a common case and most other situations are variations of this.

Electronic Health Records in Practice

Administrators of today’s medical practices are facing rapid changes in the management of patient health information as advances in technology occur and government initiatives influence the direction of healthcare information systems. Understanding the evolving terminology and concepts used to describe this vast array of technology is fast becoming a pivotal part of the needs of a medical practice. Here is a look at some of the key concepts.

A Document Management System (DMS) is an early form of a record management system. A DMD is a system used to track and store electronic documents or images of paper documents in a physician’s office. It does not generally assume the interconnectivity capabilities of an electronic medical records system, although more recent systems offer the option of an integrated platform. Examples include voice recognition software, a desktop database, or a template-driven document production system.

An Electronic Medical Record (EMR) offers increasing sophistication over a document management system. An EMR is the creation of a medical document within a physician’s office with the added capability of the import of information from a variety of external sources such as laboratories, radiology centers and pharmacies. Often, this record can also be exported to offices outside the physician’s practice, including the patient, pharmacist, referring physician or specialist. An electronic medical record usually offers full interoperability within an enterprise.

An Electronic Health Record (EHR) is a more universal health care record than an EMR and it’s management is not centralized by one physician, but rather contains a longitudinal record of a patient’s health from multiple health care offices. For example, the content of an EHR may come from a primary care physician, a bone density practitioner, a laboratory, a pharmacy and an insurance carrier. Each of these sources of information can both receive and give new information. Since the information flow of an EHR is “bi-directional” (giving and receiving) and the content includes the total experiences of the patient, it is distinguishable from an EMR. The EHR also supports the collection of data for uses “other than clinical care, such as billing, quality management, outcomes reporting, and public health surveillance and reporting”. (HIMSS, 2002)

A Continuity of Care Record (CCR) is an electronic health record that meets certain standards of portability and data exchange. ASTM International, the Massachusetts Medical Society, HIMSS, the American Academy of Family Physicians, the American Academy of Pediatrics and health informatics vendors jointly developed the standards describing a CCR. The goal was to create a CCR that will enable each healthcare provider to access and transport historical health information in order to support the safety, quality, and continuity of patient care. The CCR may be used as a vehicle to exchange clinical information among providers, institutions, or other entities. Because the CCR is an XML standard document, it will be both machine and human readable, and the data content may be displayed or printed in a variety of formats, including by web browser, PDF reader, and word processor.

Benefits of the CCR

The CCR is expected to have a significant impact on the quality of care by reducing medical errors and limiting costs:

  • A healthcare provider will not have to search for or guess about a patient’s allergies, medications, or current and recent past treatments.
  • A healthcare provider will be informed about the patient’s most recent healthcare assessment and services.
  • Patient demographic information can be quickly and easily verified.
  • A patient’s insurance status will be more easily identified and established.
  • Costs associated with the patient’s care may be reduced, such as avoiding redundant tests.
  • The effort required to update the patient’s essential information will be minimized.

Investing in Healthcare Technology

A successful software investment should noticeably enrich a medical practice. Improvements can include a decrease in work time, a decrease in the costs of certain resources, a reduction in data errors, a minimization of losses of healthcare information, HIPAA compliance and an increase in employee job satisfaction. The ultimate benefit of a new system can be measured as either tangible or intangible but whichever is most important to an organization, it is important for the buyer to know the specific returns before a purchase agreement is signed.

One of the first things to look for when acquiring a new technology is the reduction in time for performing a particular routine task. For example, the average time to review a patient exam with Cardea Technology’s BoneStation is approximately two thirds shorter than without using an automated review function. In a bone density office where the average patient visit volume is high – approximately 6600 exams per year – a practice gains more than an hour and a half per day when using BoneStation to review patient exams.

A second benefit to look for is a decrease in the costs of tangible resources, an important result of the change to electronic data management. Some of these reductions include elimination of printing costs for paper copies of reports for practices that use email and electronic report transmission, an increase in the life and availability of printing resources and a reduction in the cost of envelopes and postage to mail reports to recipients. Additionally the physical storage space for filing cabinets is reduced and the time needed to pull patient medical charts is eliminated. For high volume practices, the savings add up to more than $20/day when 100% of reports are distributed electronically.

An inevitable factor of acquiring new technology is a reduction in the number of specialists needed to perform routine tasks. For example, a reporting solution like BoneStation replaces the need for an outsourced specialist to transcribe patient reports. This savings can amount to anywhere from $20K to $60K per year, depending on the length of dictated reports and the type of service used. Eliminating the need to locate and re-file patient charts provides more time for other tasks.

A last tangible benefit is the decrease in data errors that reduces the time and cost of resolving medical errors and possible malpractice claims. The Institute of Medicine estimates that medical errors cost the United States approximately $37.6 billion each year and about $17 billion of those costs are associated with preventable errors. A decrease in costs due to data loss can amount to thousands of dollars each year. BoneStation’s data is saved and backed up on a secure server regularly, greatly reducing the risk of lost data typically stored on CDs and other degradable, non-stationary media.

In addition to purely financial returns, there are also several intangible, yet important benefits to keep in mind when deciding to purchase a new technology. Due to better availability of patient health information, physicians and practices are able to make better decisions about patient health care. Increased staff morale is created from using state of the art tools that make it easier to do their jobs. Physicians gain greater autonomy by being able to work remotely. Faster production and delivery of exam results to recipients facilitates faster turnaround time for reimbursement and the commencement of medical treatment. Conveniently organized access to patient reports may also result in a reduction of unpaid Medicare and Medicaid claims.