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Telemedicine and Telemonitoring: Its Role in Care Management

Marybeth Regan, Ph.D., for HealthLeaders News, May 21, 2007
For years, patients and physicians have sought solutions for several dilemmas in the healthcare delivery systems:
  • How can patients in underserved areas, both rural and urban, access primary care and specialty physicians, as well as other healthcare professionals when no physician is in their immediate area?
  • How can treatment and medication compliance be improved for reduction of disease, risk factors, and management of chronically ill patients?
  • Are there ways other than a visit to the physician’s office or the emergency department for patients to receive health information, education, and decision support regarding care?
  • Can homebound patients--such as the chronically ill, disabled, and hospice patients--be monitored and treated in ways that do not require as many visits to the physician’s office, thereby improving convenience and reducing costs?
  • Can quality of life be enhanced for patients with chronic conditions?
  • Can telemedicine supplant traditional care?


Telemedicine is part of the enabling strategy that can answer these questions. Until now, there has not been feasible and cost-effective solutions to these problems. With the advent of the Internet, Web-enabled applications, and advances in telecommunications technology, a solution now exists: Connectivity--or some phase of telemedicine--can exist in the home and almost anywhere.

With part of its roots in medical research for military and space applications, telemedicine is expected to make it possible to link medical expertise with patients, regardless of location—providing clinicians with valuable new tools for remote monitoring, diagnosis, and intervention.

It is widely claimed and often assumed that innovation in healthcare technologies can contribute to increased access, improved quality of care, and reduced costs. Although telehealth technologies currently account for a small segment of all healthcare technologies, innovation in this area is stimulating significant improvements in productivity and quality of life. Today, after more than 30 years, the potential of telehealth has still not been fully realized due to costs, effectiveness, reimbursement and resistance to change. Telemedicine continues to expand, and pressure for policy development increases in the context of Federal Budget cuts and major changes in health services financing.

Rationale for Telemedicine
Despite these obstacles, the needs to overcome distance challenges, improve care management, and tackle chronic diseases have spurred telemedicine.

Overcoming the distance factor was an early driver of telemedicine. Initially, the technology was defined as the use of telecommunications technology to provide healthcare services to persons who were at some distance from the provider. This typically occurs in two ways. Real-time examinations bear the closest resemblance to the typical face-to-face provider/patient interaction--both patient and physician are present at the same time and can provide instantaneous feedback to one another through video screens and audio. The second method used to transmit information in telemedicine, “store and forward,” is less synchronized. Data such as images and vital sign readings are stored and then transmitted to the medical expert for later examination. Image-oriented areas such as radiology and dermatology are especially suited for store-and-forward transmission, as are data for home telehealth care.

Care management is another driver of remote patient monitoring. Telemedicine has been utilized as an extension of the acute care setting for patient follow-up. Brigham and Women’s Hospital in in Boston, MA, discharges their mastectomy patients home with a laptop and camera. . The first call with the physician is scheduled for the next day to review the incision and answer questions. The hospital determined that this was easier for the patient and provided the follow-up visit quickly after surgeryI This solution provided benefits for both the physician and the patient. .

In addition to addressing issues of distance and care management, telemedicine can be a disease management tool. Telehealth technology is now known to be effective for improving patient outcomes in many disease states, particularly chronic diseases such as diabetes and congestive heart failure. For some time, the general medical populace considered it too experimental.
Disease management companies that are paid by insurers to manage chronic care have managed patients telephonically for over 10 years. In their quest to use the newest technology, many created websites where patients can manage their own diseases. For example, an enrollee can submit clinical information using tools such as glucose monitoring logs to generate dosing and physician monitoring components. In addition, there are online courses and links to other relevant sites. Unfortunately, many patients do not have access to the technology. There are even remote monitoring devices that are used for weight (important for congestive heart failure), blood pressure and even daily vital signs.
Telemedicine’s great potential
In a context of tightened budgets, and increasing costs, telemedicine is emerging rapidly. It has the potential to affect health services delivery in many ways with rapid technological change and a volatile and changing healthcare system.
People with chronic diseases at home, for example, can take their multiple readings more frequently. Either the patient or the care support team can intervene when justified.
In addition, telemedicine, also known as telehealth or e-health, presents a chance to recognize and possibly prevent chronic conditions from worsening in patients, cutting healthcare costs through a reduction in hospital stays and outpatient clinic visits and providing better quality outcomes.
“That doesn’t mean that people don’t need to go into hospital,” says Adam Darkins, MD , chief consultant for care coordination at the U.S. Department of Veterans Affairs, which has spent $20 million for a program to install telehealth monitors in the homes of more than 16,000 patients across the country. “But if you get someone in for two days, stabilize them and get them home, rather than two weeks in an intensive care unit, it’s a win on both sides, “ says Benjamin Nagy, in Managed Healthcare Executive, Sept. 1, 2006.

Telemedicine can also foster collaborative decision making with patients. When patients access health information and obtain health education, they become informed participants in their own health decisions. The supported self-service tools of telemedicine empower patients with knowledge for the decision-making process. This sharing of accountability between providers and patients is a departure from the traditional relationship, in which accountability has resided primarily with the provider. As patients become more accountable, compliance often increases and outcomes are improved, according to Parmod Baur, PhD, president and CEO of Viterion TeleHealthcare, a telemedicine provider.
For example, home telemedicine applications for heart patients include condition monitoring, nutrition education, and meal planning. In some applications, patients are monitored on a 24-hour basis from their homes. A device worn by the patient detects potential cardiac events by tracking irregular heartbeats. The patient uses the telephone to transmit these data to a physician for evaluation and recommendations. The payoffs for monitoring cardiac patients this way are obvious: More accurate and expeditious diagnoses, fewer visits to the emergency department or the intensive care unit, and decreased costs.

In addition to interacting with a physician, patients can interact with others by participating in a home-based, on-line cardiac recovery program. Having to leave home can be highly problematic for many cardiac patients in rehabilitation. Sharing experiences in an on-line support group results in reduced anxiety and increased confidence, and often promotes physical activity. The program has resulted in an added benefit: many of these patients become friends.”
The new generation of telemedicine also brings “space age” technology into the fold. At the high-tech end of telemedicine, a robot that acts as a live-in nurse. The robot collects blood pressure, electrocardiogram, pulse, and temperature information, then transmits it back over the telephone line to a home nursing station. Nurses at the nursing station there monitor the patient’s condition and intervene when the data show that the patients needs to schedule an appointment or change the medication. One question remains: How much and what do you compromise by high tech versus high touch?



Telemedicine saves money, lives
Such difficult questions aside, what if the cost to treat patients--whether your organization is a health plan, employer, hospital or clinic--could be reduced without sacrificing care or patient satisfaction? What is the volume of clinic visits, hospital admissions, and emergency department visits could be reduced while maintaining or even improving clinical and human outcomes? Each of these is possible using advanced telephonic and web-enabled technology. Here are the examples of the financial impact of the financial impact of telemedicine on healthcare costs:
  • Reduces hospitals days per thousand and physician visits for chronically ill patients. Using telephones to remind patients to take their medication or using a Web-based application to monitor glucose readings are two ways telemedicine keeps chronically ill patients healthier.
  • Decreases costs of managing patients with chronic diseases. Continuous monitoring and education--which can be automated with telemedicine--reduce costs. Providers of integrated healthcare, disease management and Internet services, for example, demonstrated an average savings of $7.83 per patient for every dollar spent on one asthma management program. The program--which incorporates patient self-reports, medical records, and claims data--resulted in 52 percent fewer urgent physician visits, a 67 percent decrease in visits and a 36 percent reduction in healthcare costs compared with patient data from before the as noted in a 1998 press release by disease management company Patient Infosystems.
  • Expands service area for providers using telecommunications technologies. Providers can efficiently and effectively manage more patients at lower cost per unit of care. This is important in fee-for service, discounted fee-for-service, and capitated environments

A telemedicine cyber-revolution is providing solutions to many longstanding problems. Imagine an Internet-based technology that provides both transactional and analytical functions for receiving, transmitting, and managing clinical as well as financial data for patients. Increasingly, healthcare executives and providers are realizing the need to expand information management--one of the core competencies for success in the emerging healthcare delivery system. The transition to managing disease and promoting wellness using a new philosophy is clearly the wave of the future.




Marybeth Regan, PhD, is an expert in disease and care management. She has written numerous articles on strategies for care and disease management. She may be reached at Drmarybethregan@aol.com.