November/December 2012

Telemedicine Facilitates
‘House Calls’

By Jessica Girdwain
Aging Well
Vol. 5 No. 6 P. 10

For older adults who don’t have the means to visit a doctor, the University of Rochester Medical Center (URMC) in New York may have a novel solution: telemedicine. It’s conducting a research project with 250 participating elders, evaluating the effectiveness of using technology that’s similar to Skype or videoconferencing to conduct medical evaluations—and it’s paying off.

“This technology is patient centered and completely revolutionary,” says Manish N. Shah, MD, MPH, an associate professor of emergency medicine, community and preventive medicine, and geriatrics/aging at URMC.

The technology is especially important in the geriatrics field. The shortage of geriatricians and the large number of aging baby boomers who will need care in the coming years will put a strain on doctors. Technology that streamlines the appointment process allows more patients to be cared for in a shorter period of time.

URMC is certainly in the top tier in telemedicine practice. The technology has been around for decades. In the 1960s, it was done via telephone lines in some cases. The technology wasn’t efficient and was very expensive. But the program has developed it into a viable tool that mimics a traditional office visit but is conducted from 20 or 30 miles away.

“It’s tough to go to an office if you’re an older adult. Maybe you have to arrange transportation to go to the doctor, or maybe you have functional limitations or can’t navigate a massive medical center. With this technology, elders don’t have to worry about those things,” Shah says.

Coordinating Personnel and Equipment
So how does it work? A telemedicine technician (typically a nurse practitioner, physician’s assistant, or EMT) travels to the patient’s home or elder care facility with equipment that will facilitate conducting a typical office visit. Equipment used may include an electronic stethoscope, high-definition video camera, and an otoscope, among other instruments. They all connect to the computer via USB ports. The technician asks the patient basic health questions, takes vital signs, and photographs the patient’s medical complaint, if necessary. Healthcare workers can provide access to other indicators too. For example, they can record lung sounds and upload data onto software for the physician to evaluate. They are also trained in drawing blood and taking X-rays.

The doctor then logs on to the computer from his or her office or hospital and reads through the patient’s history, looks at the photos, and considers any other pertinent information that may contribute to arriving at a diagnosis. If a prescription is needed, computer software allows the physician to send one to the appropriate pharmacy.

“The technology is so simple,” Shah says. “You can essentially do all of the things you normally do during an office visit, but this is via the Internet.”

The time required for the doctor to “see” the patient is five to 10 minutes. Because appointments don’t need to be live, physicians can review the information at a later time. The technician may spend 30 to 60 minutes per case, depending on the care needed.

“This is certainly more efficient for the physician because it gives the doctor all of the information that’s needed in a nice neat package,” Shah says. Most importantly, it benefits elderly patients by making them more receptive to care when they don’t have to leave their homes.

Expanding Medical Coverage
“For many elders, [they] would not get any care at all if it weren’t for telemedicine,” says Terry Rabinowitz, MD, DDS, director of psychiatric consultation and telemedicine services at the University of Vermont College of Medicine and Fletcher Allen Health Care in Burlington, Vermont. He provides necessary psychiatric care for patients in two nursing homes via telemedicine in both Burlington and upstate New York.

“Over 25% of the elderly population have psychiatric conditions that need to be addressed, like depression, dementia, and delirium. Without telemedicine, they may not get the help they need. Many of these patients live in rural areas, and a doctor is not able to drive hours to see them,” he says. For example, for Rabinowitz to see patients in upstate New York, he’d have to travel two hours one way for a one-hour consultation. Of course, allotting five hours per patient isn’t sustainable for any practice.

Another benefit Rabinowitz finds is that older patients simply enjoy the technology and are happy and touched that a doctor takes special pains to see them. “What it comes down to is that telemedicine is exactly like being there face to face. If the practitioner behaves as if the patient is in the room with them, the patient will behave that way too. It takes very little time to adapt to the videoconferencing approach. In fact, if I had to, I could conduct a consultation on my iPhone,” he says, although most of his consultations are done through traditional telemedicine methods.

Successful Strategy
Physicians interested in bringing this type of telemedicine to their practices should be aware of a few points, according to Shah. First, the ideal situation for telemedicine is based on a strong geriatrics practice. URMC’s program has enrolled 250 patients in their telemedicine project, resulting in about 10 visits per week, which provides insufficient volume to keep full-time technicians and practitioners employed. The model best caters to geriatricians who are partners in a practice because they can take care of patients in an assisted-living facility together.

Also, health practitioners should be aware that telemedicine equipment can range from inexpensive—for example, a $30 webcam—to as much as $30,000 for state-of-the-art high-definition equipment. The more expensive versions would transmit with a quality and resolution equivalent to watching a high-definition television show. But the cost largely depends on what functionality is required. For Rabinowtiz, the equipment he uses falls around $4,000 because with psychiatry, he needs a good-quality camera and video monitor. “I need to see facial expressions, but I might not need to see every wrinkle in the skin,” he says.

Start-up costs include buying equipment and paying a technician’s salary. It’s worth checking with insurance providers on potential coverage of related costs, according to Shah. It’s also important to build in time for technicians to train on the equipment. URMC provides a training program that teaches technicians to use new equipment and pairs them with a geriatrician to learn how to communicate with older adults. The full training process takes about one month.

— Jessica Girdwain is a Chicago-based freelance writer who has contributed health-related articles to several national magazines.