Telemedicine Transforms Notions of Integrated Delivery Networks

1/1/99

Providers are electronically linking up with others to share continuing medical education, consultations and community outreach and home care programs. In the process, they are redefining the industry’s understanding of what exactly constitutes an IDN. The much-heralded picture phone that resided in "House of the Future" museum exhibits 30 years ago has not yet materialized — at least not in our homes. But advances in video technology and digital imaging are breaking down the geographical barriers that have defined IDNs and are transforming medicine. Because of this technology, IDN members no longer need to be geographically close to each other. Today, and probably more so in the future, hospitals virtually anywhere can be linked together. Integris Health in Oklahoma City, as one example, has demonstrated that telemedicine can bring together hospitals on a statewide basis and even across the world. IDNs in traffic-clogged metropolitan areas are discovering that telemedicine can decrease travel time, increase committee participation and extend their reach into the underserved corners of inner cities. And even though there’s no history of success, marketers of medical products may find that videoconferencing can strengthen the power of IDN-wide product evaluation committees. Indeed, some IDNs have already discovered that because videoconferencing reduces time demands on clinicians, they are more inclined to participate on committees. "They [IDNs] may still be regional, but the boundaries just grew," says David Balch, telemedicine director for East Carolina University (ECU) and Telemedicine Technologies Co. LLC, both in Greenville, North Carolina. One of the strongest driving forces behind telemedicine is the need to extend the reach of clinical expertise to underserved areas as well as to the home. "Telemedicine is seen as an attractive feature in affiliation agreements, for referring hospitals to tertiary care centers," says Balch. ECU is a pioneer in telemedicine and created Telemedicine Technologies as a business spin-off to transfer telemedicine, informatics and instrument technology from research to production projects. Each month the company holds a weeklong telemedicine course for administrators, technologists and clinicians. More recently, ECU demonstrated its telemedicine prowess when Dr. Randolph Chitwood, chief of the medical center’s division of cardiothoracic surgery, performed a heart valve procedure via videoconference for 1000 cardiovascular specialists at the recent Cardiothoracic Surgery Symposium in San Diego. Kettering’s Cardiac Cath Lab Consults Via Video Together, managed care and telemedicine are dismantling some of the traditional hub-and-spoke relationships between outlying hospitals and centrally-located tertiary care facilities, says Balch. As managed care and competition among providers become stronger, many smaller hospitals are being acquired — not necessarily by traditional tertiary partners — which means that referrals can wind up anywhere. Telemedicine can serve as a way to keep those smaller hospitals in the loop. Kettering Medical Center (Ohio) hopes that is the case. The facility, located in a suburb of Dayton, opened a cardiac cath lab in March. In addition to traditional cath lab equipment, the hospital purchased, in conjunction with Middletown Hospital about 30 miles away, a digital archiving and communications network from Siemens Medical Systems (Iselin, New Jersey). Middletown has coronary diagnostic, but not interventional, capabilities, explains Bilal Ezzeddine, Kettering’s imaging project director. Middletown patients needing angioplasty or bypass previously were transferred to another facility in the Dayton or Cincinnati area. The new system allows physicians at Middletown to transmit patient cine images, in real time via fiber optic links, for consultation with surgeons and cardiologists at Kettering. "We believe we’re saving lives and reducing pre- and post-operative length-of-stays," says Ezzeddine. Why? Because Middletown patients no longer have to wait a day or more to find out whether they need interventional work. What’s more, studies show that prompt responses to cardiac events improve outcomes. Integris’ Network Eases Continuing Education Another model for telemedicine is Integris Health (Oklahoma City). Comprising 18 hospitals, Integris has joined together 10 facilities with a digital visual communication system from VTEL (Austin). Integris began planning video hookup four years ago, during the IDN’s formative stage, says CIO George Conklin. Back in 1993, the budding IDN envisioned a network to facilitate clinical interaction, improve medical education and facilitate administrative meetings. Today, the Integris Health Telemedicine Network is used most extensively for medical and nursing continuing education; its curriculum includes 10 courses delivered via video. Integris has three other telemedicine projects in the works, says Conklin. The first will connect the ER at Integris’ flagship, Baptist Medical Center (Oklahoma City), with its Hugo facility, allowing remote ER consultations that will enable physicians to quickly determine whether an ER patient should be transported via helicopter or other means. The system will use mobile video units equipped with electronic instrumentation such as stethoscopes, as well as what Conklin calls a tablet viewer, which enables Hugo staff to place a hard-copy document (lab report, medical record or X-ray) in front of the camera for Baptist’s review. In the second, Integris’ mobile clinic regularly visits remote communities with videoconferencing equipment that plugs into existing phone lines and transmits images to the Hugo facility. A second van is planned for the northern part of the state. Third, in March, Integris signed a telemedicine agreement with the University of Cairo. The agreement, spurred by Dr. Nazih Zuhdi, Baptist’s chairman of transplantation, was born out of necessity, says Conklin. Zuhdi has brought many Middle Eastern patients to Oklahoma for organ transplants, but given the distance, follow-ups are difficult. Out of that practical need came the electronic linkup solution. Metropolitan IDNs Connect for Convenience North Shore-Long Island Jewish Health System (Great Neck, New York) turned on its videoconferencing switch three years ago, allowing a physician on Staten Island to consult with the chief of staff of pediatric cardiology at the Manhasset facility, as one example, while both view a child’s ultrasound images. The IDN hopes to videoconferencing will extend its medical reach into the underserved areas, in this case, parts of metropolitan New York. Reducing Technical and Political Glitches Although technology has improved over the years, there is still some jerkiness or delays in movement over video transmissions. Fiber optic and T1 lines can accelerate data transmission, but conventional phone lines can hold images up. For that reason, Integris is reluctant to use the technology for actual remote surgeries, says Conklin. "In a minimally invasive procedure, a delay of a second or even a fraction of a second can be very meaningful," he says. This means that the role of the surgeon at the receiving end will be that of a consultant, at least for the foreseeable future. If technical glitches are being cleared up, political ones aren’t. Says one telemedicine director a remote hospital might prefer to consult with and transfer patients to a hospital other than the one with the videoconferencing capabilities, thus wasting the video equipment. What’s more, ego and turf battles can stand in the way of physicians at one hospital sharing CT or MRI images with those at another. Money’s a problem too. Although the USDA has its grant program, Medicare doesn’t reimburse for the technology. And few institutions have figured out how to collect reimbursement for remote consultations — a potentially big problem if the two networked hospitals lack a common owner. Still, favorable economics make telemedicine look like a sure thing.