Doctor's home visit is back — kind of — as telehealth flourishes nationwide
March 28, 2014
There is nothing futuristic about telehealth, the use of technology to connect patients to doctors without an office visit.
Telehealth is flourishing and growing rapidly in Nebraska, Iowa and nationwide. It uses long-standing technology such as videoconferencing and telephones as well as emerging devices that enable patients to track and deliver their own heart rates and blood sugar levels.
“This is like the tsunami. So much is happening. Technology is changing really rapidly. Legislation is changing,” said Mandi Constantine, who was hired 15 months ago as executive director of telehealth for the Nebraska Medical Center to hasten the hospital's efforts.
Doctors and hospitals are finding many purposes for telehealth and numerous ways to implement it. The Nebraska Med Center alone has at least 13 new test projects or initiatives in telehealth, ranging from stroke exams to cancer care.
The technology allows frail patients to have psychiatric appointments in their nursing homes and women enduring high-risk pregnancies to be seen by specialists without having to drive 100 miles or more. It holds the promise to restore, in a sense, the long-vanished doctor's home visit. Telehealth has special value in vast rural states such as Nebraska and Iowa, where specialists can be thinly distributed. It can reduce costly visits to the emergency room and hospital admissions.
Telehealth proponents say it's a struggle for laws and rules to keep up. The Nebraska Legislature, for instance, is considering an amendment that would require the state Medicaid program to cover remote monitoring of patients by technology.
Among other things, the amendment also would remove the requirement that a patient be at least 30 miles from the doctor in a videoconference consultation for that interaction to be reimbursed by Medicaid.
“We're just trying to eliminate as many barriers to it (telehealth) as possible,” said State Sen. Jeremy Nordquist of Omaha, who introduced the legislation.
Although Constantine said Nebraska has a long way to go before it maximizes telehealth, a former University of Nebraska Medical Center dean and chancellor, Dr. Cecil Wittson, was perhaps the first in the nation to use it.
Wittson did some psychiatric consultations with two-way audio and video about 55 years ago with patients in the regional center in Norfolk, Neb. Max Thacker, associate director of info technology at UNMC, said Wittson used technology similar to closed-circuit television.
This month, Dr. Michael Barsoom, a maternal fetal medicine specialist at Bergan Mercy Medical Center, consulted with 25-year-old Nicole Gronenthal about her pregnancy.
Gronenthal, who had lost a baby near the end of pregnancy a couple of years ago, was in a doctor's office in Norfolk. Barsoom was in a meeting room in the Omaha hospital.
They could see each other by video monitor. Barsoom observed the ultrasound as it proceeded from the office of Dr. Keith Vrbicky, an obstetrician-gynecologist whose office in Norfolk is equipped with the videoconferencing technology. Vrbicky spent about $30,000 for the technology in 2008 so his patients could have easy access to sub-specialists such as Barsoom.
“How you doing, dear?” Barsoom asked.“
Just really uncomfortable,” Gronenthal answered. “A lot of back pain and a lot of difficulty breathing.” She was more than 31 weeks along in her pregnancy.
Barsoom asked Norfolk sonographer Nora Petersen to give him views of specific fetal body parts.
“Can you show me the face and the stomach?” Barsoom asked. “Heart looks good.”
They discussed whether she should come to Omaha to have some fluid drained.
“Everything looks good, Nicole,” Barsoom said. “We're still seeing the baby running on the smaller side.
”Gronenthal said she appreciated getting Barsoom's expertise without having to drive 110 miles to Omaha.
The Nebraska Medical Center's Constantine said the Department of Veterans Affairs has helped lead development and use of telehealth. “Their work is just incredible.”
The VA began using telehealth in the late 1990s and started doing remote patient monitoring in the early 2000s. Last year the VA cared for 608,900 patients through home monitoring, videoconferences and other technology, said Dr. Adam Darkins, the Veterans Health Administration's chief consultant for telehealth.
A home-monitoring device, sometimes called a “health buddy,” records a VA patient's blood sugar, blood pressure and other vital signs and relays them to a secure website for data collection. The device also asks patients questions about shortness of breath, ankle swelling and other problems. A care coordinator may then contact the patient and adjust his medications, give advice or schedule an appointment.
That technology costs $300 to $400 per patient annually, Darkins said. But the VA determined that it saved about $2,000 yearly per patient by keeping them out of the hospital.
The region's VA health system had more than 550 patients in home telehealth in January, up from 300 two years ago. Dr. Ahsan Naseem, associate chief of staff for telehealth in the region, said the remote system helps clinicians keep a “virtual eye” on patients.
“It's like a home visit every day,” Naseem said. “It holds tremendous value.”
Naseem said the Nebraska-Western Iowa VA health system also does video telehealth for specialties as varied as wound care, nutritional counseling, infectious diseases and psychiatry.
Mike Lachance of David City, Neb., used to drive a 130-mile round trip to and from the VA in Omaha twice a week for meditation and group sessions for post-traumatic stress disorder.
Now Lachance, 48, just meets a VA psychiatrist by videoconference through his home computer once a week. Lachance likes it that way.
“I'm a lot more comfortable in my home,” the former Air Force security police officer said. “For myself, it's a major home run.
”Dr. Cliff Robertson, CEO of Alegent Creighton Health and the state network of Catholic Health Initiatives, said the CHI system he came from in Washington state started a fairly simple method of telehealth.
After providing it to employees of the Franciscan Health System since 2009, the system last fall started offering the public a “virtual urgent care” service by phone or by a videoconference with a smartphone or computer. The service costs $35, puts the patient in contact with a doctor and, in most cases, prevents expensive emergency room or urgent care visits for colds, upset stomachs or other manageable health problems.
Robertson, who declined to say if and when virtual urgent care would arrive in the metro area, said technology has changed the way families and friends interact. “It's having the same impact on health care.”
Far from every doctor has developed a passion for telehealth. Dr. Herschel Stoller, an Omaha dermatologist, said he has heard plenty about it and believes it is “an up and coming field.”
But Stoller, 63, said, “I'm old school. I like to see people in person and interact — touch, see, feel — because that's how I was trained.”
Younger practitioners with more experience in computers and technology might feel comfortable with telehealth, he said, but he would need training before he would feel at ease diagnosing a skin condition without an in-person appointment.
In Iowa, distribution of abortion pills through a videoconference appointment with a physician has led to legal, legislative and Iowa Board of Medicine debate. For now, remote dispensing of abortion-inducing pills by a physician to a woman is legal.
Nebraska Dr. Hemant Satpathy, a maternal fetal medicine specialist at Methodist Health System, said he would see every patient in person if he could. In difficult cases, he will hold hands and pray with patients.
But time and money are saved by videoconferencing with women with high-risk pregnancies who are a long way from Omaha, Satpathy said. “I think it's a great thing.”
Satpathy and other maternal fetal specialists at Methodist connect by videoconference with the women through Vrbicky's practice in Norfolk.
Dr. Tom Magnuson, an associate professor of psychiatry at UNMC, said seeing elderly psychiatric patients by videoconference has transformed the service he provides. Some used to have to drive in from rural Nebraska, “and we'd see them once,” Magnuson said.
Now he can see patients by videoconference in nursing homes across the state. He talks with geriatric patients and prescribes medicine for long-standing mental health problems, depression, mild impairments and dementia. He has done it by telehealth for 10 years now and has seen patients that way in about 50 nursing homes.
Eydie Schrad, director of nurses at Cloverlodge Care Center in St. Edward, Neb., said that for a time the staff had to drive patients to Boone County Health Center 12 miles away because the hospital was hooked up for videoconferences and the nursing home wasn't. But UNMC's Thacker helped Cloverlodge get connected, Schrad said, and since then they haven't had to take elderly patients out in the cold or the heat for psychiatric appointments.
Donna Hammack, now of St. Elizabeth Regional Medical Center in Lincoln, helped Good Samaritan Hospital in Kearney acquire a $1.5 million federal grant in 1994 to connect that hospital by videoconference to small central Nebraska hospitals. Hammack said it cost about $60,000 to connect each site, but the cost of the technology has declined to less than $10,000.
By the mid-2000s, Hammack, the Nebraska Hospital Association, the Nebraska Public Service Commission and others collaborated to install videoconference technology in virtually all hospitals and public health departments in the state.
UNMC's Thacker said that system for years was used mainly for meetings and continuing medical education.
Now, he and others said, Nebraska doctors and hospitals are starting to use it extensively to see and treat patients.