Telemedicine: Connecting Care to Communities

At a time when more people need health care, the shortage of physicians across the country is growing.
That dynamic is making telemedicine, or telehealth—the use of electronic telecommunications technology to diagnose or treat a patient in need of care, service or monitoring—even more important.
State leaders increasingly are recognizing that importance. Twenty states and the District of Columbia have telemedicine parity laws, which require private insurance providers to cover telemedicine the same as they cover in-person services. Fourteen states considered telehealth parity bills during the 2014 legislative session, according to Latoya Thomas, director of state telehealth policy for the American Telemedicine Association. In addition, 35 are considering 50 other bills that would improve telemedicine policies or introduce new ones this year. 
Missouri is one state looking at the benefits of telemedicine.
Rep. Diane Franklin, the wife and mother of physicians, believes telemedicine ultimately can save money for the Show-Me State and others across the country. That’s because patients become more engaged in their health care, according to research Thomas cites.
“Patients who don’t move forward—noncompliant patients—are one of the things that cost our medical system so much money,” Franklin said. “So the compliance piece of this is so important.” 
Thomas said research indicates telemedicine can do just that.
“When you provide (patients) access and you give them choice as to how they would like to communicate with their provider or who they’d like their provider to be, … patients have a tendency to be more engaged and willing to adhere to the course of treatment that has been prescribed by their health care providers,” she said. 

An Evolving Field

Telemedicine began nearly four decades ago with the primary goal of connecting medical specialists with primary care providers in remote areas. Today, telemedicine practices are being used to deliver patient monitoring and care services to clients regardless of their location—rural or urban, near or far—to improve access and quality of care. 
“There are still many places that do not necessarily have rural populations but still have health disparities, still have access issues in which telemedicine can be the catalyst to help improve those things,” said Thomas. 
Across the country, there are 200 telemedicine networks, with 3,500 service sites, according to American Telemedicine Association statistics. More than half of all U.S. hospitals now use some form of telemedicine. 
As quickly as technology is evolving, so, too, are the ways in which technology can be used to deliver and manage health care. 
Originally used to connect health care providers by phone or email, telemedicine now allows home health care providers to remotely monitor the vital signs of patients. Neurologists, working with attending physicians and nurses, can conduct a neurological assessment of a stroke victim in an emergency room hundreds of miles away. It is now even possible for surgeons to conduct remote surgery via robotics. 
Through a new text-messaging program in Massachusetts, the clinical team at the Lynn Community Health Center is able to reach young, at-risk pregnant women, providing both informational and supportive text messages throughout their pregnancies and up to two months after their deliveries. The goal of the program is to encourage patient choices that promote a healthy pregnancy among younger women with limited support systems. Women who participate receive an average of one to four texts per week, including educational messages about pregnancy and fetal development, as well as reminders of upcoming appointments.
According to the Center for Connected Health at Partners HealthCare, which helps run the program, initial results of the program are encouraging. Women who participated were 9 percent more likely to receive the recommended level of prenatal care than pregnant women who did not.
In Georgia, students who need health care can receive it at school through secured telecommunications with physicians and therapists working with a school-based nurse or other care provider. This arrangement provides services such as mental and behavioral health, speech language pathology, autism treatment and even teledental treatment.

Telehealth as Economic Development

While the direct provision of telemedicine is an important factor in solving the growing health care needs across the country, Dr. Sanjeev Arora, a gastroenterologist specializing in hepatitis C disease management at the University of New Mexico, argues that is not enough. 
Arora has developed a new model called Project ECHO, which integrates telemedicine into a larger capacity-building effort to train primary care physicians and other health care providers to diagnose and treat complex health conditions in rural and underserved areas.
According to Arora, the Project ECHO model serves as a force multiplier that enables a network of specialized health care providers to build the capacity of primary care physicians, nurse practitioners, community health workers and others providing care to underserved populations through case consultation and continuing education. 
The ultimate goal, he said, is to “demonopolize the knowledge of specialists,” to improve access to health care in rural and underserved areas, enhance the quality of care and increase cost-effectiveness of the health care system, while at the same time providing primary care providers with the knowledge to provide specialty care.
“What ECHO does is serve as a workforce training tool and force multiplication. It’s like we’re not giving people fish, we’re teaching them to fish,” said Arora. 
With ECHO, primary care providers participate in regular teleclinics through which multidisciplinary teams of specialists provide continuing education at no cost. The specialist teams also provide case consultation, which empowers primary care providers to treat complex diseases and conditions in their communities using evidence-based best practices and building their capacity to provide specialty care. 
To distinguish it from traditional telemedicine, Arora refers to the Project ECHO model as “telementoring.”
Evaluations of the program demonstrate positive outcomes for patients. A recent study of the use of the Project ECHO model with hepatitis C patients indicated that patients receiving care by primary care clinicians at Project ECHO partner sites in rural New Mexico had equal, and in some cases slightly higher, cure rates when compared to individuals who received care at university specialty clinics. 
Project ECHO has expanded to dozens of sites across the country and is being used to provide treatment for psychiatric disorders, chronic diseases and addiction, among other conditions. 
Franklin hopes to bring this model to Missouri. She was among several representatives who traveled to New Mexico to learn about the Project ECHO model. She was impressed with the model’s ability to improve access to and quality of care while reducing costs, while also providing physicians with an opportunity to increase their knowledge base, all using basic technologies. 
“You’ve got a laptop and a (Web) camera and then, with that, you can connect in with a specialist team. That’s pretty simple technology to put that wealth of knowledge through,” she said.
Since her site visit to New Mexico last year, Franklin has worked to replicate the model in Missouri. At press time, $1.5 million in funding is included in the proposed budget that takes effect July 1. 
“We’re really thrilled,” she said.