Time is of the essence when treating stroke patients. By using telemedicine, emergency physicians have been able to evaluate a patient for acute stroke and administer tPA treatment within 25 minutes, according to Mark McLean, MD, FACEP, emergency department medical director, Maury Regional Medical Center, Columbia, Tenn, and medical director of TeleHealth for TeamHealth.

“During that time a physician examines the patient, the patient gets a [CT] scan, a teleneurologist reads the results and performs an exam with the National Institutes of Health’s stroke scale, and lab tests are done and reviewed,” Dr. McLean said. “All of this could not be done this quickly if we had to wait for a community neurologist to arrive and assess the patient.”

Approximately 3,500 US medical institutions participate in an estimated 200 telemedicine networks.

Telemedicine is used in a variety of applications and services.In acute care, most telemedicine consultations are done via Internet, phone, or mobile devices such as a tablet or smartphone, said Alan Roga, MD, FACEP, chief executive officer, Stat Health Services, the providers of Stat Doctors, Scottsdale, Ariz.

Approximately 3,500 US medical institutions participate in an estimated 200 telemedicine networks, according to the American Telemedicine Association (ATA). About half of these networks provide patient care services via telemedicine every day. Telemedicine specialists can be located anywhere—their home, an office, or another hospital.

How It’s Used

Jennifer Newton, MD, emergency department stroke director, Saddleback Memorial Medical Center, Laguna Hills and San Clemente, Calif, said the facility started using telemedicine two years ago as a way to improve its acute stroke care. “This has allowed us to improve both our overall tPA rates and door-to-needle times,” she reported.

Treating stroke patients actually tops the list of ways that telemedicine is used. According to Paul Hildebrand, MD, associate director, TeamHealth Patient Safety Organization, Knoxville, Tenn, which provides telemedicine services: “Round-the-clock availability historically has not been a major area of interest for neurologists. Teleneurology fills the need by preventing disruption of office hours with emergency calls, relieving the on-call burden, and providing rapid response to neurological emergencies in places and situations where access would not otherwise exist.” In fact, ATA estimates that, in 2012, close to 100,000 patients went to the emergency department for strokes and were seen by neurologists using telemedicine.

“When a hospital contacts us, we respond within 15 minutes to determine the acuity of the call and then connect a specialist to the emergency room physician,” said Joe Peterson, MD, chief executive officer of telemedicine provider Specialists On Call, Reston, Va. “If a video consultation is required, our mobile telemedicine endpoint is wheeled to the patient’s bedside so our specialist can examine the patient. Within 30 minutes of its conclusion, the hospital receives all written recommendations and documentation for the patient’s medical record.”

Our telemedicine partner provides a callback consultation with the emergency department physician within 15 minutes and bedside exam within 30 minutes—and oftentimes sooner. It allows us to share the job of informed consent, has improved the emergency department physician’s comfort level with administering tPA in appropriate cases, and has allowed us to have face-to-face team discussions about time-sensitive stroke care in real time.—Jennifer Newton, MD

Telepsychiatry is also useful to emergency physicians because the number of patients presenting to emergency departments with mental health issues is growing. “These patients can place an enormous burden on already-busy emergency departments because they are often difficult to manage and observe,” Dr. Hildebrand said. “The shortage of available psychiatric consults or psychiatric beds may cause long waits for appropriate treatment.” Telepsychiatry can expedite the treatment process and improve patient flow by allowing for diagnosis and assessment, medication management, and group therapy by a consulting physician.

According to Jonathan D. Linkous, chief executive officer, ATA, Washington, DC, among telemedicine’s newer uses is having EMS personnel send information, such as an initial diagnosis and vital signs, to emergency physicians prior to a patient’s arrival. And because there are a limited number of burn centers equipped with specialists, this is a growing area for telemedicine, as well. Telemedicine is also increasing in popularity in rural hospitals that do not have access to full-time emergency physicians.

Benefits Abound

For the patient, telemedicine provides access to specialty care that couldn’t be obtained otherwise, resulting in improved patient outcomes and patient satisfaction. In fact, according to a study in Telemedicine Journal, overall patient satisfaction with telemedicine was found to be 98.3 percent.¹

For physicians, telemedicine gives access to all of the resources of a tertiary-care hospital so they can provide better patient care. “This is absolutely critical in emergency rooms when patients need very specialized care,” Linkous said. Clinical effectiveness and efficiency also increases.

Dr. Newton said telemedicine allows the hospital to provide patients with a team approach to time-sensitive stroke care. “Our telemedicine partner provides a callback consultation with the emergency department physician within 15 minutes and bedside exam within 30 minutes—and oftentimes sooner,” she said. “It allows us to share the job of informed consent, has improved the emergency department physician’s comfort level with administering tPA in appropriate cases, and has allowed us to have face-to-face team discussions about time-sensitive stroke care in real time.”

Collegial support offered by the telemedicine physician team has also resulted in improved physician retention and recruitment in rural facilities. “These physicians feel less isolated with ready access to peers for consultation and additional support on difficult or multiple cases,” said Donald J. Kosiak Jr., MD, MBA, FACEP, eCARE executive medical director and emergency medicine physician of telemedicine provider Avera Health, Sioux Falls, SD.

Telemedicine also helps keep medical costs lower. “The convenience and affordability of telemedicine services contribute to increased productivity and reduced absenteeism in the workplace, as well as positive employee morale and less burnout,” Dr. Roga added.

According to Dr. Peterson, other financial benefits include reduced length of patient stay, more accurate care, fewer patient complications, and a competitive advantage in the local market.

Risks, Liabilities, and Other Concerns

As with any medical service, the risk of malpractice always exists. But Linkous said studies have indicated that telemedicine poses no greater risks than employing on-site providers.² “In some ways, you’re better covered because most services are digitized and available for review,” he said.

Telemedicine is regulated by several entities including the US Food and Drug Administration, Centers for Medicare & Medicaid Services, and state health codes and medical boards. “Telemedicine providers must have appropriate licensure to ensure that they are practicing within their scope of regulating entities, as well as have the appropriate medical liability coverage and protections,” Dr. Roga said. “Additionally, privacy standards are governed by HIPAA.”

Despite its benefits, however, sometimes the “remote” factor can pose challenges for either party. They may include:

• Low comfort level. Not every provider feels comfortable asking for and receiving assistance. “As a telemedicine provider, the risk of feeling like ‘Big Brother’ is quite high,” Dr. Kosiak said. “If your direction isn’t taken, it could lead to real-time conflict.”
• Lack of dedicated staff. If a facility is not willing to dedicate staff to care for patients treated with telemedicine or makes them a lower priority, the system won’t provide maximum benefit.
• Inability to physically intervene. When directing from a distance, telemedicine providers can’t physically step in. “It’s best to have a detailed plan before proceeding,” Dr. Kosiak said. “You need to be good at talking through multiple steps of patient care.”

Mitigating Risks

When choosing a telemedicine provider, legal advisers recommend that health care providers negotiate vendor responsibility in their contracts, motivating them to offer a high level of performance, Dr. Hildebrand said.

In order to protect patient information,health care institutions should verify the security of a telemedicine vendor’s systems and operations. Be wary of unencrypted communication platforms, such as Skype or Google Talk, which do not allow for providers to protect against breaches.

As with face-to-face encounters, documentation of telemedicine encounters must be included in the patient’s ongoing medical record. This documentation ensures an accurate and complete patient history that can be referenced by subsequent physicians.

Hospitals should also ensure that telemedicine providers who are credentialed on the staff of a different hospital or whose licenses are from another state or country are legally permitted to provide services to the receiving hospital’s patients.

In addition, patients should be made aware of and consent to the potential benefits and risks associated with telemedicine, including delays that could result from deficiencies or failures of telecommunication equipment and the potential for security breaches.

Proactive risk, quality, and compliance activities are vital to avoiding mishaps related to telemedicine and any negative public exposure that could follow, Dr. Hildebrand maintained. He urged EDs that use telemedicine to develop a risk-management program that includes some of the following tactics:

• Confirm that the performance of telemedicine providers meets compliance, credentialing, and quality-of-care standards as determined through a peer-review process.
• Ensure physicians know informed-consent requirements for telemedicine.
• Confirm that telemedicine providers can point out the difference in the patient-physician relationship via telemedicine and understand the need to remotely establish rapport and trust.
• Create or review existing telemedicine agreements for compliance with CMS’ Conditions of Participation and modify them as needed if the facility decides to rely on the credentialing of the distant-site hospital or telemedicine facility.
• Review insurance provisions of a telemedicine agreement for mutual hold harmless and indemnification provisions and to ensure adequate insurance coverage.
• Ensure that professional liability insurance provides coverage for telemedicine services.

References

1. Gustke SS, Balch DC, West VL, et al. Patient satisfaction with telemedicine. Telemed J. 2000;6:5-13.
2. Telemedicine Case Studies. American Telemedicine Association Web site. Available at: http://www.americantelemed.org/learn/telemedicine-case-studies. Accessed December 24, 2013.

Karen Appold is a medical writer in Pennsylvania.