Going the distance
Access to health care expands when telemedicine is deployed
Judith B. Kosasih, MD ’88, GME ’92, demonstrates the telemedicine interface for the VA Telemedicine Prosthetic Clinic with team members Sue Novak, physical therapist, and Joshua Dezek, certified prosthetist.
Geography can be an unwitting antagonist to a patient seeking quality health services. When access to medical expertise is limited by miles or by physician scarcity in a region, patients may face a choice between burdensome travel and forgoing care.
As the technologies and methodologies necessary to accommodate it have advanced, telemedicine has emerged as a viable and growing solution to some of the obstacles that hinder or prevent the traditional clinic visit. Telemedicine can encompass high-quality, two-way video and audio as well as specialized instrumentation, electronic note-taking and recoding capabilities. Medical College of Wisconsin alumni engaged in telehealth practices are using the approach to directly provide or facilitate health care to remote areas in the U.S. and abroad as well as develop new tools that are both patient- and physician-friendly.
A year spent in rural Appalachia demonstrated to Bettina Cuneo, MD ’83, the discrepancies in health care based on location, and she has begun applying some of the lessons learned to her urban subspecialty practice in the Chicago area. Dr. Cuneo is Director of Perinatal Cardiology at the Heart Institute for Children, affiliated with Advocate Hope Children’s Hospital, and Professor of Pediatrics and Obstetrics at the Rosalind Franklin School of Medicine and Science in Chicago.
Through a sophisticated, real-time telemedicine system, Dr. Cuneo serves pregnant women whose fetuses are at risk for cardiac structural defects, arrhythmias or heart failure. Technology bridges the distance, but success is dependent on the “human software” at both the transmitting and receiving end of the visit. While a sonographer conducts a fetal echocardiogram at the remote location, Dr. Cuneo can see both the patient and the study as it is being done and interact accordingly.
“I can instruct the sonographer if I still have questions when she is doing the scan and then tell the patient if everything is normal or if I suspect a problem,” she said. “If there is a problem, I scan the patient in person that same day. You can’t give bad news over a DSL line.”
Diagnosing fetal cardiac disease is important because it may dictate how a pregnancy is managed. For example, some babies will be so critically ill that they need to be delivered in the catheterization suite to have a life-saving procedure in the first 15 minutes after birth. Through telemedicine, Dr. Cuneo can provide such crucial diagnoses to more women, who might otherwise have to travel great distance or not receive the service at all.
“I can care for many more pregnant moms and fetuses with suspected or confirmed cardiac anomalies, and their care can be triaged,” she said. “A secondary benefit is empowerment of the local obstetrician or maternal fetal medicine specialist because suspected cardiac defects can be confirmed or shown to be normal, thus not all moms will need to be transferred.”
The capability of reaching more women via telemedicine also dovetails with Dr. Cuneo’s research to improve fetal cardiac disease outcomes.
“The problem with a lot of the research in perinatal cardiology is that the conditions are rare, so with the number of affected patients being small, it is difficult to use evidence-based medicine to recommend care,” Dr. Cuneo said. “The more I see, the more I know, the more I can contribute to the literature to advance understanding of disease.”
Helping disabled vets
In Milwaukee, Medical College of Wisconsin physicians at the Clement J. Zablocki VA Medical Center are seasoned practitioners of telemedicine in many different specialties, including nephrology, infectious diseases, pre- and post-operative general surgery, rheumatology, physical medicine & rehabilitation and pulmonology. Telehealth Coordinator Scot Kueper, RN, BSN, said patient satisfaction is very high, and the number of telehealth clinics is growing. VA physicians can connect with patients at four community-based outpatient clinics in Wisconsin, as well as units of VA hospitals in Madison, Wis.; Tomah, Wis.; Iron Mountain, Mich.; and Chicago, Ill.
Judith B. Kosasih, MD ’88, GME ’92, is an early adopter of telemedicine and established the Telemedicine Prosthetic Clinic in conjunction with the Iron Mountain VA in 1998. She is Associate Professor of Physical Medicine and Rehabilitation at the Medical College and Medical Director of Medical Rehabilitation, Director of the Polytrauma Support Clinic Team and Director of the Amputation Clinic Team at the VAMC.
When she began the program, she said the monitor was as big as a bookcase and the delay in the audio relay required long, deliberate pauses in conversation. The speed and digital clarity have advanced greatly, but like Dr. Cuneo, she attributes success to the quality of the teams controlling the experience.
“Behind this valuable technology as a clinical tool, the real driving force for effective application in our telemedicine prosthetic clinic is the dedicated teamwork, communication and care coordination between the local and remote clinic site providers,” Dr. Kosasih said.
Telemedicine enables Dr. Kosasih’s team to provide equal access and timely intervention to veterans who live in remote areas. The majority of clinic patients have either transtibial or transfemoral amputation, though some have bilateral lower limb amputation or upper limb amputation.
Telehealth visits primarily facilitate evaluation and prescription of permanent prosthesis, modification or parts replacement for new or established patients. Follow up for discharged inpatient rehab patients and even initial consults can be performed, due to the videoconferencing abilities. The patient is supported at the remote clinic site by a physical therapist and prosthetist while Dr. Kosasih leads the visit from Milwaukee with her rehabilitation team.
“The veterans clearly benefit from this unique access of prosthetic clinic services, especially those who live in remote areas and can’t tolerate long distance travel,” she said.
Ronald G. Landes,
In nations where paucity of medical resources impedes access to care, telemedicine can improve health and even create jobs. Ronald G. Landes, MD ’73, is on the International Virtual e-Hospital Foundation (IVeH) Board of Directors, where he helps unite global experts to propel new technology applications to health care in the developing world. The IVeH is growing an ambitious telemedicine platform in the Balkans.
The political and ethnic conflict that engulfed Kosovo in the 1990s displaced thousands of medical and health care professionals as well as nearly 75 percent of the population. From a personnel and resources standpoint, the medical system was decimated. Beginning in 2000, through what became IVeH , international partners and sponsors developed a program that now includes six integrated, regional telemedicine centers, extending the reach of care in post-conflict Kosovo.
“This program was designed to provide education to physicians throughout the country without requiring they leave their local area and also enhance health care in a variety of ways,” Dr. Landes said. “It serves as an example of how sophisticated technology can improve health care in the developing world in a way that advances the self-worth of the population.”
Building on its work in Kosovo, the IVeH is establishing a new program in neighboring Albania. Among the initiatives is a retinal imaging program for the diagnosis of vision disorders. Local providers utilize portable technology to capture images of a patient’s eye, and then are able to send the images for interpretation by a certified expert. This distance testing technique is also being introduced for cervical cancer screening, where pap smear images are reviewed via telemedicine technologies.
“We measure success by how much we improve health care and how many jobs we create,” said Dr. Landes, who is President of Landes Bioscience, an Austin, Texas-based publishing company he founded 20 years ago. “I’m pretty sure technology within the telemedicine platform will be an asset. I don’t believe we’ve fully demonstrated that yet, but I think we will.”
Better tools for tomorrow
Creating new technology for telemedicine activities is a focus of Eric Greenman, MD ’90, Fel ’95, who founded the start-up iTel Companies, Inc. after being frustrated with the options available for distance patient communication. Dr. Greenman maintains a full-time psychiatry practice in Scottsdale, Ariz.
“Psychiatry is well-suited to telemedicine since we don’t need to lay hands on patients,” he said. “Psychiatry is a profession where you can talk over the phone, but if you have secure video conferencing, it’s a much better way to communicate with people.”
As Chief Medical Officer at iTel, Dr. Greenman is involved with creating a system that could allow any provider to set up their own telemedicine practice with the advantages of a fully HIPAA-compliant video tool and built-in billing engine. They are also developing the ability to “co-browse” meaning both physician and patient (accessing the platform from their respective computers) can simultaneously view and manipulate a Web page, putting test results or links for instruction at a patient’s fingertips.
The system is still in a pre-launch phase, but Dr. Greenman hopes it will soon help patients avoid time lost from work or spent needlessly commuting to the clinic.
“We’re already doing beta testing with patients, and they love it,” he said. “They like the convenience to stay at home, and this offers some advantages for patients who are homebound or have difficulties accessing transportation.”
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