Telehealth's promise for the nation's long-term care residents

Physician Executive, March-April, 2004 by Eric I. Mitchell, Linda M. Rhodes, Kurt Grossman

Innovation and change are two of the hardest things for people to accept and doctors are no exception.

Every day the medical industry is forced to change because of the technological advances that science continues to give us. It may come in the form of a new instrument, a new scanning device, a new diagnostic tool or even an entirely new infrastructure for how medicine is practiced.

Telecommunication is such an innovation: far beyond the computer, it will dramatically alter how we practice medicine. In fact, we're not even talking about adding a new tool to the workbench. The workbench itself will morph into bandwidth allowing the "Star Trek" imaginings of "Beam Me Up, Scottie" to become reality as an 85-year-old Mrs. Jones living in North Dakota is "seen" by one of the best geriatricians in the nation, specializing in adult onset diabetes in Philadelphia.

And therein lies the technological gift of telehealth. Mrs. Jones never leaves her bed yet she finds one of the best specialists in the nation at her bedside.

The demographic tidal wave of aging baby boomers and the current aging World War II generation populating rural long-term care facilities across the country call for a quick and steep learning curve among our physicians and long-term care providers.

The promise of better care and better quality of life to the hundreds of thousands of residents living in long-term care facilities from the application of telehealth shouldn't be viewed as some sort of slippery slope from which to steer clear. Rather, we must ready ourselves with the training, skills and standards of practice for the bunny slopes of telehealth lying directly in front of us--and soon enough we will be ready for the Olympic downhill.

Long-term care demand is high

The current environment of the nearly 17,000 long-term care facilities in the country cries out for innovative solutions: the demand for chronic, specialized long-term care services is rising rapidly while the supply of staffing to provide those services is shrinking.

More residents need heavy care (e.g. ventilator, dialysis, tracheotomy, IV antibiotics) that requires the expertise of specialists. Many nursing facilities report the high demand for psychiatric and mental health care, however, they lack access to professional psychiatric support.

The lack of access to specialty services is, of course, more severe in rural nursing homes. In excess of one-third (35 percent) of the nation's nursing homes are located in non-metropolitan counties accounting for 500,000 certified beds, or about 29 percent of the total supply of long-term care beds in the United States of which over half are certified for Medicare participation.

Many of them now qualify for reimbursement of telehealth medical provider services under the Benefits Improvement and Protection Act of 2000. Yet, despite the new availability of funds, only a few employ telehealth in their facilities.

Nursing homes that have taken advantage of Medicare payment for telehealth consults report a number of substantial benefits: (1)

* On-site primary care is enhanced as a complement to existing primary physicians and nursing staff.

* On-site specialty care is enhanced.

* Ambulance transportation for off-site care is reduced, decreasing risk of injuries and stress among dementia patients during transport.

* Transport costs are significantly reduced.

* Unnecessary emergency room visits and hospitalizations are reduced due to enhanced specialty and preventive primary care.

* Loss of revenue due to bed vacancies caused by hospitalizations is reduced.

* Opportunity to add new services such as psychiatric consults, oral health, dermatology and orthopedic care is increased.

* Social and counseling services for family and caregivers through video conferencing is a telehealth spin-off that creates a team approach to care.

* Family visits with residents through teleconferencing increases morale for both the resident and family member.

* Professional staff training that offers CME by the best practice experts in the field can readily be provided on site.

These benefits have been realized by--not only a few pilot studies--but by other providers who have long been in the forefront of using telecommunications to enhance health care in remote or difficult environments: the United States military, prisons, and hospitals that connect to rural clinics. They provide over 20 years of experience. The testing is done; we just need to apply the protocol.

Debunking the myths of telehealth

Telehealth has been moving at a snail's pace into the mainstream of medical practice. Hopefully, we will be following the U. S. Army's lead in telehealth just like we did when they introduced the intranet that quickly evolved into the Internet.

Soon enough we'll find ourselves catapulted from "I don't need it" to "I can't live without it." But in the meantime, let's take a look at why we think "we don't need it."

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Christopher J. Caryl in his article, "Malpractice and other legal issues preventing the development of telemedicine" argues that there are four obstacles telehealth must overcome before we can't live without it. (2)