Creating a Telecardiology Network

Technology allows remote patients to connect with doctors for better care and less travel time.
By: 
Dave Fornell

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April 21, 2010

Telecardiology networks help improve care by connecting patients with doctors and specialists, regardless of their location. This has greatly improved access to cardiologists for patients in remote, rural areas. These networks also allow immediate consultations with pediatric congenital heart specialists at top hospitals without the need for travel.

In addition to offering better patient care and saving time, these systems also offer a platform to host continuing medical education (CME) programs, decrease professional isolation and help enhance existing business relationships.

Connecting Rural Patients to Cardiologists

Hamot Medical Center, a 341-bed tertiary care center located in Erie, Pa., began its telemedicine program more than three years ago. It expands collaboration between four rural hospital systems and improves patient care in remote areas of northwestern Pennsylvania, western New York and eastern Ohio. The system also provides cardiology services for 14 prisons in the state.

The program concentrates on cardiology and cardiovascular services, but is also used for neurology, nephrology and trauma, said Valarie Jackson, MS, Hamot’s telemedicine program director and assistant director of regional business development. The system uses high-definition video conferencing primarily to conduct clinical consultations and patient follow-ups. It also connects rural, solo cardiologists to Hamot to enable real-time evaluation and review of diagnostic catheterizations.

For many years, Jackson said cardiologists and neurologists from Hamot traveled to rural clinics up to 150 miles away a couple times a week. For some patients, this was their only opportunity to be seen and treated by specialists. This program has been very successful, but no matter how many times the physicians visited, demand continued to increase. Hamot was unable to accommodate all of these patients without long waits for appointments.

“We wanted to provide increased access to specialty care but were limited by physician manpower,” said Robert L. Maholic, DO, FACC, interventional cardiologist, Medicor Associates Inc., Hamot Medical Center. “The distances involved also puts a large burden on the patients if they need to travel for office visits.”

Remote Consultations

He said the telemedicine system is used for new patient evaluations, examining nonemergent conditions such as atrial fibrillation, stable angina and shortness of breath. It also is used for patient follow-ups to review test results and interventional and surgical procedures. A physician assistant or nurse practitioner usually facilitates these consultations. They “present” the patients from the remote facility and create a seamless interface with the speciality physicians to help examine the patient during a video consultation.

“When considering the telemedicine concept, we could not envision a patient looking at a video monitor to visit with a physician the same way as an in-person visit,” Jackson told Diagnostic & Invasive Cardiology. “But, it takes only a few minutes before the monitor disappears and they interact with the physician as if he/she was in the same room.”

Rural physicians also use the system to immediately transfer images for collaboration with colleagues. “This connectivity really helps allow them to reduce their isolation,” Jackson said.

Since the system allows consulting physicians to see each other, it offers a much better interface than the phone or e-mail. Dr. Maholic said the video has greatly improved communication because visual cues, such as body language, are not lost. “It has really revolutionized how we review patients,” Dr. Maholic said. “I think we have been able to provide better care. We are still doing the same amount of driving, but we are able to provide care for more patients.”

Instead of patients waiting a month or more to see a cardiologist, they can now schedule a telecardiology appointment in a more timely fashion – from 24 hours to a week depending on the acuity. When at Hamot, cardiologists can visit with patients from numerous locations in a single day without hours of travel.

Learning From Other Hospitals

Dr. Maholic and Jackson suggest any facility interested in creating a telecardiology network should visit a hospital that already has one. These facilities already have done the homework and worked through the technical bugs. “Take advantage of the facilities that already have these programs in place,” Jackson said.

Networking in Virginia

Hamot visited the University of Virginia to examine its telemedicine network prior to creating its own. Established in the 1990s, it is one of the oldest telemedicine networks, created to deliver medical care to rural providers and patients in Virginia’s prisons. It encompasses 37 specialties, including cardiology, thoracic cardiovascular surgery, pediatric cardiology and stroke care. The program also is used for video-based CME.

“It allows the patients to get state-of-the-art care from specialists,” said Karen S. Rheuban M.D., FACC, professor of pediatric cardiology, medical director, office of telemedicine, senior associate dean for CME and external affairs, University of Virginia Health System.

Today, the system is used for about 3,000 remote consultations annually. Adult cardiac patients use the system for follow-ups after surgery. It also improves triage before a patient is referred or transported to a larger hospital.

“We do a fair amount of pediatric cardiology, but only a small amount of adult cardiology,” Dr. Rheuban said. Much of the use is for pediatric echo studies to evaluate congenital heart conditions.

“We used to drive all over the state to treat patients,” said Dr. Rheuban. “We have traveled to some really rural areas of the state, some that are as far west as Detroit is.” She said telemedicine made sense to cut travel time, expenses and allow more time with patients.

Technical Considerations

In order to conduct real-time, interactive video consultation, sufficient bandwidth is required. Jackson said low bandwidth sometimes causes unsynchronized video and audio. At the onset of their program, Hamot decided to use dedicated T-1 lines for the greatest amount of bandwidth, to assure encryption and to enable Health Insurance Portability and Accountability Act (HIPAA) compliance. The network is being converted this summer to a fiber-optic system to further improve bandwidth capabilities. Jackson said this will allow greater use of the network as consultations, diagnostic images, continuing education and business meetings increase in frequency.

Before Hamot purchased equipment, its staff attended the annual meeting of the American Telemedicine Association to see what vendors offer. Jackson said they chose video conferencing equipment from Tandberg because of its ease of use and interoperability.

Electronic stethoscopes allow heart and lung sounds to be electronically sent in real-time to the consulting site. Other interfaces allow diagnostic images to be transferred over the system.

The Virginia program started with simple video conferencing, including replaying videotaped echo studies. Today the University of Virginia uses a Web-based picture archiving and communication system (PACS), Agfa Impax, to transfer high-quality images.

The network uses teleconferencing equipment from Tandberg and Polycom. It also uses one Remote Presence RP-7 robot. Dr. Rheuban said the key is that all the equipment must connect with the telemedicine system. “We will never acquire any equipment if it is not interoperable with our system,” she said.

When the program was created, Dr. Rheuban said the cost of equipment was high and there was no telemedicine reimbursement. However, the cost of equipment and T-1 lines have dropped, federal grants are available to expand rural health care access, and some reimbursement is available. She said expanded use of Web-based PACS is also making creation of telemedicine networks much easier and cost-effective.

Return on Investment

Hamot Medical Center initially invested $250,000 to start the program. On average, Jackson said a base unit costs about $10,000, and with peripheral devices the setup cost may be around $20,000.

The program has expanded collaboration with Hamot’s rural community hospital partners to improve patient care, enhance access to care and share resources, such as CME programs. It also has helped build collegiality among physicians, nurses, allied health professionals and administrators.

For clinical consultations, Jackson said the reimbursement is no different than a regular office visit for those insurances that cover telemedicine.

However, telemedicine is not universally embraced across the country, and a big barrier is that reimbursements vary from state to state. This is one thing Jackson said hospitals need to research prior to beginning a program, as it may impact the program’s sustainability. Hamot had to petition insurance companies to justify the coverage of telemedicine consultations.

“It has been a real labor of love for us in creating this program,” Dr. Rheuban said of the University of Virginia network. “We are not a big revenue center. More than 90 percent of the patients we see through the program never even come into our facilities.”

Grants for Telemedicine

The federal government is in favor of expanding telemedicine to underserved rural areas and provides some funding. Hamot received funding for its program through the Federal Communications Commission’s Rural Healthcare Pilot Program, which encourages use of technology to offer top care in rural areas.

Hamot applied for and received a grant from the Rural Utilities Service (RUS) Distance Learning and Telemedicine Program. The grant is administered through the U.S. Department of Agriculture (USDA). The Distance Learning and Telemedicine Program provides access to education, training and healthcare resources for people in rural America. Hamot also received a matching rural community facilities grant through the USDA.

Network Contracts

The University of Virginia has extensive legal agreements with its client clinics and hospitals. Patient consent is also required for their information to be transferred through the telemedicine system.

Hamot Medical Center has agreements with its participating hospitals listing the responsibilities of each. Hamot owns the systems and peripheral devices (except those from grant funding) and the regional/rural hospitals assume the responsibility for connectivity. In many cases, there are clinical affiliations in place and the connectivity supports more than telemedicine.

Sidebar

Legislation, Reimbursement for Telemedicine Telemedicine’s boundaries are defined not by technology, but along state borders and by bureaucratic government designations, said Karen S. Rheuban, M.D., professor of pediatric cardiology, medical director, office of telemedicine, University of Virginia Health System. She is also the president of the American Telemedicine Association, an organization that strongly advocates expansion of telemedicine and its reimbursement. She has presented Congressional testimony and works with Medicaid and Medicare to support telehealth. While telemedicine networks can aid rural clinics and hospitals with fast access to specialists, laws, regulations and reimbursement vary from state to state. Many times a doctor from one state may be prevented from consulting and treating a patient in another. Medicare only reimburses telemedicine costs for rural consultations. Those performed in designated urban areas are not reimbursed. However, Dr. Rheuban said the federal government designates some towns as “urban” if the majority of its population commutes to an urban center for work. She said this is the case with one Virginia town in the mountains, where many drive 50 miles into Tennessee for jobs. The University of Virginia conducts telemedicine consultations there, but is not reimbursed because of the federal urban designation. Despite this issue, Dr. Rheuban worked with Virginia Medicaid to help change coverage of telehealth services. Today it covers all eligible Virginia children, regardless of geographic location. More recently, Dr. Rheuban worked with the commonwealth of Virginia to create a new law mandating private insurance companies reimburse the costs for telemedicine. “Unfortunately, doctors cannot be everywhere, and for a long time geography proved to be one of the greatest impediments to proper care,” she said. “With this legislation to expand access to telemedicine, we are helping more Virginians to get the treatment they need, and to live the healthy lives we all deserve.”