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Issues
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Telehome health care
Another Kind of Tele-Home Health: Medical Call Centers
Robert M. Johnston, M.D., Richard L. Nevins, M.D., and Michael L.
Weaver, M.D.
The authors are co-founders of FONEMED, LLC, a medical call center
service based in Kansas City, MO. 816/968-1300; www.fonemed.com.
Patients today are increasingly proactive about seeking health information
and participating in decisions about their medical care. Much of healthcare,
perhaps 40%, consists of the simple exchange of information between
experts (physicians and nurses) and patients. Until recently, the
surest way to assure this exchange was to see a physician in their
office. This can be a time consuming, expensive, highly inefficient
way to accomplish many of those interactions that don't require hands-on,
face-to-face assessment. This is especially true in the after-hours
setting, when what would have been a simple office visit during the
day becomes a very expensive emergency room visit at night or on the
weekend.
There is a simple, inexpensive way for patients to "see"
a qualified healthcare worker after hours - for reassurance, for advice,
for education, or for triage to a care center as necessary. That is
by establishing a "medical call center" staffed by trained
nurses. A study published in 1993 (see Reference) reported on the
4-year experience of a call center that took after-hours phone calls
for 56 pediatric practices in the Denver metropolitan area. During
the study period over 100,000 calls were managed without any adverse
clinical outcomes. Just over half the patients were managed with home
care advice only, and 28% were given home care advice after-hours
and seen the next day in the primary physician's office. Of all patients
directed by the telephone triage nurses to a care facility be seen
after hours, 78% were determined to have a condition necessitating
after-hours care. Satisfaction among subscribing pediatricians was
100%, and among parents was greater than 96%. Our experience with
a wide complete range of patients (not just pediatric) confirms that
these findings apply also to adults.
Role in managed care
Increasingly, medical call centers are seen as a way of short-circuiting
the expensive, doleful process that sends so many anxious patients
to the emergency room late at night for what turns out to be a trivial
or "delayable" condition. Call centers, coupled with other
low-tech approaches to patient education, has evolved into what is
called "personal healthcare management." This is becoming
an important way for managed-care entities to reduce the cost of covering
lives while maintaining or improving quality of care. Personal Health
Management Programs, an umbrella term that includes medical call centers
as a key constituent, covered about 8 million outsourced lives/year
in 1994. Currently, call centers respond to almost 100 million calls/year
from about 35 million covered lives in the U.S., with virtually no
incidence of litigation. At current growth rates they could cover
100 million lives by 2000. (Source: Merrill Lynch & Co.) (See
Chart)
What happens when the patient dials the call center
Medical Call Centers connect patients by phone, 24 hours/day and 365
days/year, to the health information they seek. When patients in need
of medical assistance call a Medical Call Center, they will typically
hear a custom greeting, designed for the organization to which they
belong. The caller will have the option of being connected to the
audio health library, or speaking immediately with a Registered Nurse.
If the caller selects to talk to a nurse, the nurse works through
the patient's symptoms and recommends an appropriate course of action.
In our system, 90% of all calls are answered by a nurse within 20
seconds of going into the call queue. With proprietary software, the
triage nurses have at their fingertips the patient's recent call history
and their doctor and coverage information. Members will know immediately
if their visit to a provider will be covered by their insurance, because
callers are matched against the system's knowledge base of health
plan requirements. Member satisfaction is increased, and claims adjudication
costs decreased, because the approval process for many visits will
occur up front.
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Teleradiology
Teleradiology is the most widely deployed application of telemedicine.
In use since the late 1950's, Teleradiology is the "granddaddy"
tele-imaging application. Numerous definitive studies (see Twenty
Selected Teleradiology References, Vol. 4, no. 2) have shown that
transmitted radiographic images (with the possible exception of mammograms;
see Telemammography Feasibility, Vol. 4, no. 2) can be displayed on
a remote monitor and interpreted with diagnostic reliability. In the
past year Teleradiology, which refers to the transmission of images
between enterprises, has begun to integrate with PACS (Picture Archive
and Communication Systems), which refers to image acquisition, management,
and transmission within a single enterprise. The lines have been blurring
as health care institutions link together their far-flung affiliate
hospitals and clinics.
History of Teleradiology
In 1959 in Montréal, Quebec, telefluoroscopic examinations
were transmitted using coaxial cable by Jutra [18]. Later, in the
late 1960s, Bird established a microwave video link between Massachusetts
General Hospital and a walk-in clinic at Boston's Logan International
Airport [24]. The system included a teleradiology application.
Other teleradiology projects followed in the 1970s and 1980s in the
USA, usually part of larger telemedicine programs. Although these
were effective at transmitting the information needed and although
users were satisfied, the projects stopped when external sources of
funding were withdrawn. This suggests that they could not justify
themselves on a cost-benefit basis. Limited acceptance by physicians
may also have played a role.
A period of rapid growth started in the early 1990s. Two of the most
important driving factors for this came from outside the medical environment.
First, in the late 1980s and early 1990s a shift towards digital communication
technologies took place, so separate information transmission services,
such as telephone calls, telegrams, image and document transfer, and
television programming became electronically equivalent after conversion
to digital formats. As a result, many telecommunications specialty
markets have merged into a single market in which the single product
provided is digital bandwidth. Telemedicine offers the opportunity
to increase sales in the digital bandwidth market because of its high
demands for bandwidth, due to the need for interactive video imaging
and for the transmission of high-density still images.
Second, there is increasing demand all over the world for equal access
to low cost medical care. Telemedicine enables the provision of medical
care in rural and undeserved areas. Strong competition is taking place
among providers of telemedicine services for winning health care contracts,
for economic and medical risk reduction, and for the provision of
low cost specialty services.
The elements of a teleradiology system
A teleradiology system consists of an image acquisition section and
an image display/interpretation section, connected by a communications
system (i.e., a network). A Picture Archiving and Communications System
(PACS) is a sister technology of teleradiology that also allows storage
and archiving, as well as transmission, of digital images within an
enterprise -- typically a hospital.
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Teledermatology
Since late 1994, Teledermatology has been deployed between Mäntyharju
Municipal Health Center, Mikkeli Central Hospital, and Kuopio University
Hospital. Supported in part by contributions from the Etelä-Savo
Hospital District and the Finnet telephone companies, it is an ISDN-mediated
system running at 128 to 384 Kbps, using PictureTel 2000 equipment
with far-end camera control and autofocus.
User Perceptions of Teledermatology Using Interactive Video
Before deploying a full-blown Teledermatology system, we wanted to
assure that patients and physicians would accept the technology. Using
the same patients -- but different dermatologists -- for both exams,
we compared traditional in-person to 2-way interactive televideo (IATV)
examinations. The study was done "in-house" at the Baltimore
VAMC, where all video visits were transmitted between the examining
room and the physician station at 384 Kbps (1/4 T1) or 1.544 Mbps
(T1), over an internal T1 line. During the two month trial in the
Fall of 1995, 109 consenting clinic patients had their skin problems
evaluated first over the telemedicine system (see callout), then in
person, by four rotating dermatologists. A trained nurse-escort accompanied
the patients for the IATV exams, 61% of which were conducted at full
T1, and 39% at 1/4 T1. Patients and physicians completed a 12-item
questionnaire with responses based on a 4-point Likert scale [strongly
agree; agree; disagree; strongly disagree.
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Peripheral Devices
A key feature of telemedicine systems, which distinguishes them from
simple videoconferencing systems, is the use of peripheral devices.
These enable the clinician to better approximate an on-site physical
examination, and include electronic versions of standard examination
tools (stethoscopes, otoscopes, ophthalmoscopes) as well as other
'sense extending' implements that are almost exclusively electronic:
close-up cameras and document stands, dermascopes, and microscopes.
These are the tools that might be most useful in a multi-specialty
telemedicine practice. There is as well a wide range of electronic
tools specific to various specialties: cardiology (cf. vol. 4, no.
3), ophthalmology (vol. 4, no. 5), radiology (vol. 4, no. 6), etc.
To our knowledge, there has never been a survey soliciting observations
from users about just which peripheral devices they're using, which
they aren't using, and why. We thought it might also be interesting
to fire a few questions at some prominent vendors to see what they're
up to.
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