University Times

“Telemedicine is really an extension of what we do in clinical practice and mirrors a lot of what we do when we see patients in person,” said a Pitt ophthalmologist who heads UPMC’s tele-ophthalmology program.

“The technology has enabled us to evolve, and be able to do things we were never able to do before. It’s really in the last decade that the IT has caught up for us to do the things we want to do,” said Robert J. Noecker, professor of ophthalmology and vice chair of information technology, international services and operations in the School of Medicine, at last week’s Science 2010 symposium. As a clinician, he also directs UPMC’s Glaucoma and Anterior Segment Surgery Service.

Noecker, who has worked in tele-ophthalmology at Pitt for six years, gave examples of different kinds of telemedicine technology capabilities and covered a few specific clinical situations in his Oct. 7 lecture, “Long Distance Relationships: Telemedicine Today.”

“I think we’ve all heard about telemedicine: The president likes it; the federal government is very much into supporting it, and the VA is extremely happy with telemedicine, especially as it serves rural areas that don’t have specialty care. It’s been around for more than 20 years. But where are we today?” Noecker said.

“Telemedicine can be as simple as taking a picture with your phone and transferring it over the Internet. But, that said, in true formalized medicine we’re not allowed to do that. There are underlying IT issues with patient privacy, for example, that represented hurdles for us,” Noecker said. “But we have overcome those hurdles and made telemedicine a big part of our health care delivery in Pittsburgh.”

He and his colleagues in other telemedicine programs now are evaluating outcomes. “We’ve been doing it long enough to ask what’s the impact of all this, instead of just saying let’s try to do this because it’s a good idea,” Noecker said.

Pitt, in partnership with the 20 UPMC hospitals, has a number of programs in the burgeoning field of telemedicine, including dermatology, internal medicine, ophthalmology, psychiatry, radiology, stroke and wounds, among others.

“What we’re using is telecommunication software, much of it developed by UPMC, and equipment. As part of the telemedicine leadership, one of our jobs is to build common platforms that the departments with early telemedicine programs have used, so we’re not building redundant pathways and we can build on the infrastructure that we need as a department,” Noecker said.

The telemedicine initiative uses technologies such as store and forward (where health data are sent to an intermediate station to verify the integrity of the information), videoconferencing and remote-monitoring IT to enhance the diagnosis and treatment of patients in real time, as well as to provide remote consultation capability.

UPMC has been using electronic health records for a decade or so, and that’s the backbone of the system in terms of communicating and storing all the information in a useable, accessible and secure format. The UPMC system also is integrated to provide appropriate information to the patient, the provider and the payer, he noted.

The primary goal of telemedicine is to address unmet clinical needs, for example, providing specialized care to areas where none exists.

“There’s a big push for rural health care. If patients have to come to Oakland, that’s a major undertaking. So if they can be screened closer to home and told they don’t have to come to Pittsburgh, that’s a big win for the patient, for the cost of health care and especially for the providers,” Noecker said.

Two telemedicine specialties that have done well here for some time are teledermatology and telestroke, he said.

There are few stroke specialists in western Pennsylvania outside of Oakland, he said, and treating stroke is very time-sensitive. A physician has to decide within a short timespan whether a stroke victim is an appropriate patient for treatment with tPA (tissue plasminogen activator), a protein that breaks up blood clots.

“There is a window of opportunity to start tPA therapy, then the window closes and the strokes take their course,” he explained. The remote determination regarding therapy is done as a real-time video interaction, using Polycom camera cart technology.

“What the nurse has to do in the emergency room is plug the cart in, establish a network connection and get the neurologist who is on call on the other end. The neurologist remotely can determine what the location of the stroke is, and make a decision based on that and the other information provided by the emergency room whether or not to start tPA therapy,” Noecker explained.

As Pitt and UPMC move into other telemedicine specialties, the Polycom technology serves as the basic infrastructure.

“The bandwidth is adequate, the signal processing is good, you don’t get choppy images, you can have a conversation to instruct the patient to move a certain way, lift up an arm, look left, look right, and so forth,” Noecker said.

Before telemedicine, only about 1.3 percent of patients in the UPMC system got tPA therapy, which means they were prescribed the therapy in the appropriate time window. Since the advent of the telestroke program, that rate has been raised to about 3.1 percent, or about a two and a half fold increase.

“That may not seem like much, but, remember, these are the people likely to suffer severe damage or die [without the therapy]. This clearly demonstrates the time difference has been shortened. In this clinical situation it is often the difference between success and failure.”

Dermatology, similarly, faces a shortage of specialists, particularly in the emergency room setting, where treating certain burns and rashes can be critical, Noecker said.

“This technology is somewhat different in that it uses what’s called store and forward. Basically, a photograph of a patient is taken; it’s transmitted to the dermatologist, who assesses it and sends a report back. It’s really the difference between a robust video-interactive system closing the feedback loop versus: This is just what it is, diagnose it and end of story. This technology also has document feedback: The hospital gets paid for the services, the physician gets paid. It does become part of the permanent patient record, so if necessary follow up is mandated, all the information is there,” he said.

Other examples of telemedicine technology include teleconsults, which basically are team doctor consultations. “It’s being used now in some departments for hospital rounds,” Noecker said. “We’re developing [a remote consultation] to help train doctors in Thailand, so they can ask questions of our teaching faculty members.”

At the health care consumer level, there is a program called Health Trak, which UPMC health insurance is pushing right now, Noecker said. “It’s a multi-layered program. You can make a request for doctor’s appointments, you can make prescription refill requests. You go online and can do it at any time, type in your request, and somebody will get back to you online,” he said.

“At the next level, you can look up your lab test results. So if you  have blood work, you don’t have to wait for the traditional phone call and have to be there when the call comes.”

At the highest level are e-visits. “This is like going to your doctor. It is most effective when problems come up that are relatively minor conditions. If you have a sinus infection, you can get a confirmation online and start therapy, which is basically taking an antibiotic. You don’t need to see the physician,” Noecker said.

Health insurers see the value of e-visits in streamlining evaluations, cutting down on visits and saving time, and they are beginning to cover this interaction, he noted.

“Surprisingly, when you look at who’s using e-visits, it’s not just the college kids, it’s pretty much spread out across all age groups. We found that people who never go to the doctor were not using e-visits,” Noecker said.

On the other hand, the really heavy users also go to the doctor’s once or twice a year, so it’s a way of cutting down the total visits. What the patients like about e-visits is convenience, the faster response time on the computer, no travel, no time off from work, no time waiting in the doctor’s office,” he said.

In his own specialty, outcomes in tele-ophthalmology show improvement in health care delivery, he said. “For us, one of the clinical problems is that every year the compliance rate for diabetics to get an eye exam is stuck at 60 percent. It doesn’t matter if you work at Pitt, whether you live in the Hill or McKeesport, it’s 60 percent. Not just in Pittsburgh, it’s a national issue,” Noecker said, adding that federal standards are pushing for at least a 70 percent compliance rate.

“There seems to be some disconnect between the primary care office saying you need an eye exam and the patient going to the ophthalmologist or the eye care specialist to get it.”

A number of factors contribute to that, including lack of education about the importance of eye exams for diabetics; lack of transportation, and forgetfulness, he said.

Through the tele-ophthalmology program, UPMC now is employing cameras in primary care physician offices. A health care worker can take an image of the retina and the back of the eye of a diabetic or pre-diabetic patient and transmit it directly to Noecker’s clinical practice. “We look at it and we say, ‘You’ll be okay if you control your blood sugar; let’s check again in six months. Or, you have a problem and we need to see you right away,” he said.

“How well does it work? To find out, we’ve looked back over about a three-year period,” Noecker said. They discovered that eight patients among the 285 they treated remotely had serious eye problems that would have led to blindness had they not been detected when they were. But his team also detected cases of macular degeneration, glaucoma and cataracts.

“So we have a very high rate of detection for eye disease,” Noecker said.

Moreover, he said, his practice saw about a 20 percent improvement on the HEDIS (Healthcare Effectiveness Data and Information Set) scale, a set of performance measures and trends widely used in health care.

The tele-ophthalmology program also helps minimize certain overused responses.

“We found that about 25 percent of patients who are helicoptered into Presby for eye trauma don’t have to be there. They might have broken a blood vessel, their eye got all red, and they don’t know this will get all better in two weeks on its own,” Noecker said.

Prior to the implementation of telemedicine technology, the primary communication from a remote patient was by phone, an inadequate way to diagnose eye trauma. “We would always say, ‘Send the person in, because we’re not sure what is going on.’ Now we can serve them instead by using the Polycom software — and there’s a new handheld camera that’s been developed in the last couple years that allows very high magnification with very good detail. We can react in real time,” Noecker said.

In summary, Noecker said that the advantages of telemedicine include: delivering high-quality expert care in areas where it is not otherwise available; reducing travel time and patient visiting time; reducing costs; increasing efficiency; seeing more patients; giving and getting more referrals, and reducing paperwork.

Noecker theorized that uses for telemedicine virtually are limitless. “Based on a lot of these technologies, when imaging is involved you can develop a program in tele-‘any-ology,’” he said.

—Peter Hart