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Will video telemedicine become as pervasive (and as essential) in the ED as phone, fax and email? A few EPs and consultants who have tried the technology say it’s only a matter of time. 
 
The ills facing on-call coverage can seem insurmountable. First, there is the basic problem of securing on-call coverage, a chasm that is widening. An ACEP survey of ED Directors noted that in 2005, 73% of respondents claimed to have inadequate specialty coverage, up from 67% the year before. But even when on-call specialists are available, they can present a difficult catch 22 for emergency physicians. “When you send the patient to a (specialist),” says Marc Finder, MD, an emergency physician in rural Pennsylvania, “he either thinks you’re an idiot because you didn’t show how horrible it really it was, or you’re an idiot because it really isn’t as bad as he thought you were implying it was.”

But what would happen to on-call coverage, and this rocky relationship, if specialists could not only stay within the comfort of their homes, but could also work alongside their EP counterparts on the same clinical data at the same time?

It’s called telemedicine, and on many levels, it’s nothing new. We already send films, echocardiograms and ultrasounds to remote radiologists. At Norwalk Hospital in Connecticut, neurosurgions view head CT’s remotely and perform more than 50% of their consults by phone only. But what if we could go beyond the phone and the films? What if a specialist was in the room, observing the same patient at the same time, detecting the same myriad nuanced movements and actions that lead to a diagnosis.

Meet RP-7. This “remote presence” robot stands 5 feet 6 inches tall and takes video consults to a new level. At a moments notice, an on-call specialist at a ControlStation™ can connect via the internet to an RP-7 robot within a hospital. Through the robot, the doctor can interact with a patient or nurse. Live, two-way audio and video means that the RP-7 can see, hear and speak. A simple joystick allows the on-call specialist to maneuver the robot through the hospital to a patient’s bedside and move the Robot’s head to view vital signs on monitors and charts.

If the idea of robo-specialists doesn’t sit well with you, you aren’t alone. For some EPs, the concern is liability. “If video is incorporated into the medical record,” says John Frey, MD, “who will have access to it? Do we want plaintiff’s attorneys and juries scrutinizing every nuance of an encounter, every inflection of our speech? Do we want entities who have invested serious effort into payment denial having access to the ‘raw data’?” Others, like Dan Bledsoe, MD, an EP in York, Penn., are more concerned that telemedicine technology could become a crutch for EPs.

“Our neurosurgical and orthopedic colleagues can view films at home while providing advice on management. Though this increases efficiency and decreases miscommunications, I do see a loss of the skill of describing an X-ray over the phone to an orthopedist. In the long run, if our residents go to hospitals not so technologically empowered, they may find themselves in a bit of trouble, having been spoiled by the technology.”

Luckily, we don’t have to look very far to see how this technology could play out. UC Davis in California, an early entrant into video telemedicine, provides pediatric intensivist consults via video to remote EDs. And although most of the EDs affiliated with the Davis program have between 5,000 and 12,000 annual visits, a few larger EDs are joining as well. “One ED, 30,000 to 35,000 annual visits, (is) using us for pediatric subspecialty consults,” says Jim Marcin, a pediatric intensivist at UC Davis. “They may not need us for pediatric ICU, but I’ve called in pediatric burn specialists, pediatric cardiologists, etc.”

Comparing telephone and video consults, Dr. Marcin says the difference is huge. “It’s like the difference between a curbside consult and a bedside consult. I’m more involved in the care: I ask more questions, I spend more time. I ask the family more questions.”
“It is an in-person consult. It literally is,” agreed Kourosh Parsapour, a fellow intensivist at UC Davis. “We don’t usually need to know ‘is the liver big, what are the heart tones?’ etc. Inspection is 90% of the decision tree.”

Ron Elfenbein, an EP in Maryland, became a fervent believer on the consultant end while doing a brief stint 35 miles above the Artic Circle in Alaska. “They had the absolute most advanced telemedicine system in the world. It was a big cost saver. We walked people at the ‘outlying’ facilities through childbirth, chest tube insertion and laceration repair.”

Vermont is another pioneer in the field. The state’s inclement weather means helicopter transport is often impossible, leading to long transport times and delayed care. The result: rural trauma patients suffer nearly twice the mortality rate of their urban counterparts. The solution was a trauma telemedicine network, with a video link to Fletcher Allen Hospital, Vermont’s sole trauma center. The program has installed video equipment not only at the hospital and medical school, but also in the homes of the participating trauma surgeons.

In Michigan, thanks to the Stroke Network established in 2006, neurologists from St. Joseph Mercy Oakland Hospital need only a laptop and net connection to link up to one of the state’s many RP-7 robots. Smaller hospitals with no neurologist on staff rely on these trusty robots to bring a neurologist’s exam into the ED for stroke patients.

For EPs like Marc Finder in rural Pennsylvania, a real-time video specialist would be an answer to prayers. Dr. Finder, who works in a 20-bed hospital with a 5-bed ED, has only one internist and two FPs on staff. When he needs specialty services for a patient, he has only one option: “Pray that I can find someone to accept the patient, and that I can get the patient transferred.” His consultations are phoned to a hospital about 30 miles away.

On its face, it would seem that cost would be a major barrier for video telemedicine and remote presence robots. That might not be the case, however. Not only is the price for video telemedicine dropping, but some rural networks have found grant money to help afford the equipment. According to Dr. Finder, rural hospitals like his “would be willing to purchase the hardware—that would be the smallest of the costs. Even if I would only speak to a senior resident or fellow [in a particular specialty], that would be a lot better than being abandoned on my island.” And if no telemedicine network exists in the region? Dr. Finder suggests that the federal government require federally funded teaching hospitals to provide the video consultations.

While the equipment fees on the consultant end would be nominal, there are reimbursement issues that create a barrier, although the situation is improving. Medicare reimburses telemedicine consultations, but Medicaid policies vary by state. Some states are “telemedicine-friendly”—as of the 2004 American Telemedicine Association survey, California, Louisiana, Texas, Oklahoma, and Kentucky were the only five states in the U.S. that mandated private payer reimbursement for telemedicine. Although the laws in many other states are lacking or confusing, private payers often do reimburse telemedicine services when not state-mandated.

If money continues to be a barrier for your ED, think about ways to get creative with the resources at hand. Just as the fax machine meant a remote cardiologist could see the EKG within minutes after the EP saw it, so cell phone cameras are becoming part of our armamentarium. William Sullivan, an EP in central Illinois, has relied on his to “photoconsult” a dermatologist, and to identify mushrooms in poisoning cases. “The mycologist at the Illinois Poison Control Center has a dedicated e-mail address where docs can send pictures and has helped me out several times in determining the management of patients with mushroom poisoning.” On the consultant end, Dr. James Chao, plastic surgeon and Associate Professor at UCSD,  encourages rural EPs to use cell phone cameras or separate digital cameras.

“We have a lot of EPs in the desert with no plastic surgeon, and a photo speaks volumes.”
Does it Really Help?

The data to date indicates that telemedicine improves care, although many studies still lack sufficient patient numbers. Dr. Marcin of UC Davis presented interim conclusions last month at the American Telemedicine Association convention in Nashville. The Davis study has 2 EPs reviewing charts, blinded to which were telemedicine consults and which were more traditional care. They found overall quality of care was higher in the telemedicine charts.
 

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