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Viewpoint: Telemedicine's Lasting Change for Nursing Home Patients (and EDs)

Janiak, Bruce MD

doi: 10.1097/01.EEM.0000405500.69713.87

    The use of audiovisual communications to enhance medical care for patients remote from physicians is not new. Radiologists have been reviewing films this way for many years. Even in the 1980s, I had a telemedicine connection to an island in Lake Erie supported by emergency physicians at a Toledo hospital some 60 miles away. In that application, we used a paramedic on site who helped take care of summer vacationers who experienced a medical emergency. The paramedic had been trained in our department to suture, take simple x-rays, and perform EKGs.

    The electronic connection was via “slow scan” technology. Images were transmitted by plain old telephone service. It took about 90 seconds for them to appear on the screen, and the resolution was imperfect at times. Still, we were able to deliver reasonable service to the ill and injured and to authorize using drugs such as antibiotics.

    Patients with fractures were usually sent by boat to a mainland hospital just a few miles away. Unfortunately, the system failed because the board of trustees on the island wanted us to dispense medications more liberally, which would have violated Ohio's pharmacy laws. The board also wanted us to transport all patients needing hospital treatment by helicopter rather than boat. I was unable to justify this unnecessary expense for injuries such as a fractured wrist.

    One of the earlier experiences in telemedicine health care failed for different reasons. Massachusetts General Hospital had a telemedicine connection to a clinic at Logan Airport. The technology used microwave transmission, making the images much better than mine. The project was funded by a grant, however, and ended when the grant expired. There are many other applications for telemedicine. Inmates in Galveston, TX, jails, for instance, are evaluated by telemedicine, and some schools use telemedicine to fill the gap when nurses are not available.

    But telemedicine could bring lasting change to emergency medicine and nursing homes. Our ED at Georgia Health Sciences University is connected to 10 nursing homes throughout the state using Tandberg equipment and a T1 line. We are attempting to demonstrate that emergency physician intervention prior to transporting the patient to a local emergency department may prevent unnecessary and expensive transports. I have never met an emergency physician who did not feel that some of the transports from nursing homes were medically unnecessary.

    Our process is simple. When nursing home personnel decide that a patient might have an emergency medical condition needing ED evaluation, they first call our communications center. Personnel there turn on the telemedicine unit and notify the attending emergency physician of the consult request. At the same time, nursing home personnel fax the patient's face sheet to our communications center to facilitate billing and identification. Nursing home staff move the patient to the telemedicine room, and the emergency physician evaluates the patient. After the evaluation, the physician makes suggestions and advises a disposition. If it is necessary to listen to the patient's chest or look in his ear, the emergency physician can use electronic peripherals. A medical record is created and distributed to the nursing home, the billing service, and the nursing home primary care physician.

    It has been estimated that an unnecessary transport may generate charges in excess of $2,000 so a significant financial margin exists. Simply put, if we can avoid five transports, we can return $5,000 to the health care system where it can be more appropriately spent. Added to this unnecessary expense is the sad fact that these patients may tie up an emergency bed for many hours waiting to be returned to the nursing home.

    Prior to initiating this process, I met with nursing home directors, nursing home staff, and primary care physicians. Buy-in was universal from the staff but spotty from the physicians. Although we carry malpractice insurance for this endeavor, there are still some primary care physicians who are worried about their exposure. I also encourage the nursing staff to transport patients with potential life-threatening problems immediately without utilizing the telemedicine system.

    So the obvious question is, how is this working? Sometimes political issues may override technological ones, and resistance to utilization may come from concerned primary care physicians, from nurses who are simply afraid of the technology, or from a natural human resistance to change. Constant encouragement from an advocate or from within the nursing home system is necessary. Assuring primary care physicians that they retain total control over system utilization is critical. Although we have had only about 20 consults in the past year, I believe that increasing health care costs will continue the pressure to utilize telemedicine support systems.

    The cost of the Tandberg system is approximately $20,000 for capital equipment per installation and a lease cost of $400 to $450 each month for the T1 landline. Functionally, it is difficult for nurses, especially if they are working alone at night to move a nursing home resident to the telemedicine room. Imagine being a weekend nurse trying to move a 200-pound patient by yourself onto a stretcher. You can understand their reluctance.

    Help is on the way. Encrypted communication via the Internet is now available. I know you're all familiar with Skype and its competitors. Switching over to Internet-based communication will dramatically decrease costs, making it easy for nurses to take a laptop into a patient's room.

    The federal government also has changed some of the rules for telemedicine consultations on reimbursement. Formerly, consultations were not billable if they were within your federally designated metropolitan area. Now local consultations are allowed, increasing our motivation to explore this technology.

    Dr. Janiakis the vice chairman and a professor of emergency medicine at Georgia Health Sciences University. He is also a former president of the American Board of Emergency Medicine, and a former president of the American College of Emergency Physicians.

    In Brief

    New ABEM President Named


    Richard N. Nelson, MD, is the new president of the American Board of Emergency Medicine. He has been a member of its board of directors since 2004, and was elected to the executive finance committee in 2008. Since 1983, Dr. Nelson has served ABEM as an oral examiner, item writer, examination editor, and chief oral examiner, and he serves on a number of ABEM committees. He also is an ABEM delegate to the American Board of Medical Specialties.

    Dr. Nelson received his medical degree in 1978 from the Ohio State University College of Medicine, and completed his emergency medicine residency in 1981 at Akron (OH) City Hospital. He is a professor and the vice chair of emergency medicine at the Ohio State University College of Medicine.

    ABEM also elected officers to the 2011-12 Executive Committee: Mark T. Steel, MD, immediate past president; John C. Moorhead, MD, president-elect; James H. Jones, MD, secretary-treasurer; Francis L. Counselman, MD, as a member-at-large; and Jo Ellen Linder, MD, as a senior member-at-large.

    © 2011 Lippincott Williams & Wilkins, Inc.