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Telemedicine Primer

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Telemedicine Primer Telemedicine Primer CONTENT Telehealth in Emergency Medicine: A Primer History of Telehealth 2 BY NEAL SIKKA, M.D., FACEP; SARA PARADISE, M.S.I.V.; AND MICHAEL Technology 2 SHU, M.S.I.I., GEORGE WASHINGTON UNIVERSITY SCHOOL OF Modern Applications in Emergency 3 MEDICINE Medicine Telestroke 3 Originally founded in 1998, the telehealth interest section of ACEP Teleradiology 4 brings together emergency medicine practitioners interested in expand- Teletrauma 5 ing patient care into the digital world. While not much has changed Mobile Health & Medical Apps 5 in the ideology behind telehealth since the group’s initial conception, Integration with Quality Drivers 6 improved access to high-speed technology and a greater cultural accep- Security & Risk 7 tance of digital communication is revitalizing the field. The purpose of this paper, therefore, is to re-introduce the concepts of telehealth, e-care, Cost of Telehealth 8 and mobile health in light of recent advances, and give a modern take Reimbursement 8 on its applications within emergency medicine. Challenges & Opportunities 9 This paper will give an overview of the definition of telehealth, its Future Innovation 10 history, current technology, practical uses, cost and reimbursement, quality improvement measures integrated with telehealth, as well as potential risks and opportunities to its use. Definition What exactly is telehealth? Telehealth is a conglomerate of Health I.T. methods used in current medical practice to improve a patient’s health via a two-way communication between a patient and practi- tioner at a distant site.1 This includes practices already prevalent in many emergency med- icine settings, including trauma or stroke neurology consultations via real-time video connections, remote monitoring of patient vitals for ICU patients, and online decision-making aids. Telehealth falls in three basic categories of transmission: Store and forward—or “e-care”—includes ‘asynchronous’ communication, e.g., transmitting patient data and/or digital images which are captured, stored, and sent as files to clinicians who respond with assessment; remote monitoring, which entails a central system that feeds patient information from sensors and monitoring equipment; and real-time patient management—or ‘synchronous’ communication—that uses a telecommunication link enabling instant interaction via video con- ferencing.2 #pricetransparency 1 ACEP Emergency Telemedicine Section Telemedicine Primer • June 2014 In addition to these uses of the term, in 2009, the Technology FCC National Broadband Plan (http://www.broad- Emergency telehealth faces a new frontier with the band.gov/plan/10-healthcare/) defined telehealth to installation of high-speed technologies that allow the encompass newer modalities, such as electronic health transfer of images and videos in an efficient fashion. records and mobile health—or “mHealth”—currently The success of this transfer depends on three essential two rapidly expanding areas of telehealth. components: the speed at which the data can be trans- History of Telehealth ferred; the reliability of the system; and, for patient care purposes, the security of the system. While the concept of telehealth has been around for The speed at which data is transferred is known as more than 40 years, it did not become feasible for use bandwidth or “pipes,” and is measured in multiples or until the 1980’s with the expansion of digital commu- diminutives of Bits/seconds. The bandwidth of a sys- nication. Some of its earliest applications trace back to tem can vary widely based on the type of communica- the 1970’s, including EMS voice-based medical over- tion, e.g., radio vs. cellular vs. wired. (See box on page sight, pre-arrival notifications, and remote transmis- 3 for typical bandwidth speeds.) 3 sion of ECG telemetry. To put this in a telehealth perspective, sending an Unfortunately, the incorporation of telehealth into ECG requires about 1-2 Kbps,4 whereas a complete practice was slow to be adapted by physicians and video telehealth consult requires a higher quality, more hospitals due to concerns regarding cost, privacy, secure network; most complete video-based telehealth reimbursement, as well as logistics of setting up a tele- operations utilize 384 Kbps bandwidth speed, but 1-2 health network. Within the past five years, access to Mbps provides higher definition.5 high-speed, cost-effective technology such as 3G, 4G, With regard to reliability, wired technologies are less and LTE networks, greater definition on reimburse- prone to latency, dropouts, or complete loss of con- ment policies, and successful models demonstrating its nectivity, as they provide a constant connection that effectiveness have increased adoption. allows thorough transmission of voice, text, or images. ACEP surveyed the uses of telehealth in the emer- Wireless, as one could imagine, can be more vulner- gency medicine community to gain a better under- able to such inconsistencies depending on the service standing of how these services are being utilized. connectivity.3 FUNDING ACKNOWLEDGMENT This Primer was produced as a Section Grant Project of the American College of Emergency Physicians. PUBLISHER'S NOTICE The American College of Emergency Physicians (ACEP) makes every effort to ensure that contributors to its publications are knowledgeable subject matter experts. Readers are nevertheless advised that the statements and opinions expressed in this publication are provided as the contributors’ recommendations at the time of publication and should not be construed as official College policy. ACEP recognizes the complexity of emergency medicine and makes no representation that this publication serves as an authoritative resource for the prevention, diagnosis, treatment, or intervention for any medical condition, nor should it be the basis for the definition of or standard of care that should be practiced by all health care providers at any particular time or place. If drugs are mentioned, they generally are referred to by generic names; brand names might be added for easier recognition. Device manufacturer information, if provided, is listed according to style conven- tions of the American Medical Association. To the fullest extent permitted by law, and without limitation, ACEP expressly disclaims all liability for errors or omis- sions contained within this publication, and for damages of any kind or nature, arising out of use, reference to, reliance on, or performance of such information. Copyright 2014, American College of Emergency Physicians, Dallas, Texas. All rights reserved. Except as permitted under the US Copyright Act of 1976, no part of this publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including storage and retrieval systems, without permission in writing from the publisher. Printed in the USA. To contact ACEP, write to PO Box 619911, Dallas TX 75261-9911; or call toll-free 800-798-1822, or 972-550-0911. 2 ACEP Emergency Telemedicine Section Telemedicine Primer • June 2014 Conventional Radios Modern Applications of Telehealth 2 Kbps in Emergency Medicine Cellular 1G 1200 Bps (1981) The ability to interact with patients remotely is appli- Cellular 4G 50 Mbps downstream, cable in many emergency medicine settings. Whether 360 Mbps upstream rural or urban, access to instant, high-quality medical care may be enhanced through advanced communi- Broadband wireless 600 Mbps (2007) cation techniques. As such, many emergency depart- Wired systems ments, urgent care centers, and ICUs across the coun- 10 Gbps (2003) (LAN, Fiberoptics) try have adopted varying degrees of telehealth, rang- (Bashford, 2011) ing from monitoring vitals from afar to large, video- based telehealth consults from miles away. While the Of utmost consideration in medicine is system applications are limitless, we will review applications security. A 3G or 4G public network, such as the Long relevant to emergency medicine. Term Evolution (LTE) initiative in Mississippi, is an example of a public safety system that has high secu- The ability to interact with patients remotely rity without sacrificing quality.3 As with all patient health information (PHI), encryption on telehealth is applicable in many emergency medicine products, following proper HIPAA compliance guide- settings. Whether in rural or urban settings, lines, should be considered a priority. access to instant, high-quality medical Equipment care may be enhanced through advanced In addition to appropriate bandwidth speed, secu- communication techniques. rity, and reliability, equipment to conduct a proper videoteleconferencing (VTC) consult requires either an add-on desktop hardware program or a dedicated system that is sold with remote-controlled camera, Telehealth Consultations control computer, TV monitor, CODEC software/ ED physicians are masters at multi-tasking and triaging hardware (“Coder/Decoder” which converts analog to patients. However, some diagnoses have beneficial but digital technology), and microphone.6 risky treatments that are best administered in conjunc- To ease this process, a number of programs have tion with other medical specialists. The emergency pro- recently been marketed for physician-patient confer- vider’s knowledge and experience, the patient’s acuity of encing. Two of these, VSee and Vydio, are similar to care, and available facilities are all factors that may alter Skype in their functionality, but are advertised as hav- the level of care. We will examine the
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