Looking at the ‘Big Picture’: DHMC Making ‘Telehealth’ a Routine Part of Care
Dr. Daniel Albert asks patient Myrna Centers, of Littleton, N.H., about her prescriptions via a computer. Dartmouth-Hitchcock Medical Center is working with other hospitals on telemedicine to work with patients remotely. (Valley News - Jennifer Hauck) Purchase photo reprints »
Dr. Daniel Albert and Registered Nurse Krista Merrihew speak with a patient on a computer screen at Dartmouth-Hitchcock Medical Center. (Valley News - Jennifer Hauck) Purchase photo reprints »
Lebanon — One recent Tuesday afternoon, Dr. Daniel Albert was scheduled to see a succession of patients who live in the northern reaches of the Twin States.
Albert, a rheumatologist at Dartmouth-Hitchcock Medical Center, walked into a modest conference room and took his seat in front of a flat-paneled computer screen. Next to him was Krista Merrihew, a registered nurse at DHMC.
They both flipped open their laptops, on which they could view patients’ medical histories, and waited for the first appointment to arrive. Minutes later, the image of a 30-something woman appeared on the computer screen. She was 90 miles north of Lebanon, sitting in front of a video camera in a doctor’s office at Weeks Medical Center in Lancaster, N.H.
“Have things gotten worse, better or remained the same?” Albert said into the camera set on top of the screen.
For the next 25 minutes, the conversation carried on the same as it might have if the three were sitting in the same room. The patient said she was feeling worse, dealing with severe pain and depression. She couldn’t sleep. The list of her medications took Merrihew a minute to read through. They reviewed lab work together, talked about her family situation and daily routine. At the end, the patient left with Albert’s recommendation to have a sleep study done and see a psychiatrist. The doctor also prescribed a new medication.
Albert would like to see patients in person, but when distance or time make such visits impossible, he can overcome those obstacles with the telehealth technology Dartmouth-Hitchcock has been making an increasingly regular part of care.
Last year, Dartmouth-Hitchcock established its first office of telehealth, a broad term used to describe all the ways in which technology can be deployed to provide remote care. It could be as simple as sending a text message to remind a patient to take her medicine, or as sophisticated as using robots to perform surgery. A specialist at one hospital could look over the shoulder of an emergency department doctor across the state as they consult together on how to save the life of a car accident victim.
Or, as in Albert’s case, a secure application similar to the Internet phone service Skype can be used to reach out to patients who might otherwise not get treatment.
“We really are looking at the big picture, which is why we are advancing all of those tools and platforms,” said Sarah Pletcher, medical director for Dartmouth-Hitchcock’s Office of Telehealth. “We’re ultimately trying to get the best care to the patient as close to their home environment as possible.”
Doctors have been consulting remotely with each other and patients over the telephone for decades. But technological advances such as mobile devices and the addition of high-definition cameras and screens, which enable doctors to examine patients closely, have opened exciting new avenues for remote care.
In the past, telehealth has been something of a novelty among health care providers and the frequency of use has largely been determined by the interest — and resources — of doctors and their institutions. But health industry experts believe that the time for this burgeoning field has come, particularly as hospitals look for new ways to cut health care spending while providing better access for patients.
Plenty of questions remain. With a profusion of new technology coming on the market, health care providers must be careful to sift through the sales pitches and determine which devices make the most sense for them, Pletcher said. Regulatory issues have become an obstacle for some telehealth initiatives, and smaller hospitals are still figuring out whether they can afford the investment.
There are also reservations about how some of these new technologies will change the personal relationship between doctors and their patients. The late U.S. Surgeon General and Hanover resident C. Everett Koop thought telehealth was useful in practicing medicine, but firmly believed that doctors should rely on their hands, ears and noses instead of only using the latest high-tech equipment to examine a patient, said Joe O’Donnell, a senior scholar at the C. Everett Koop Institute at Dartmouth.
“He was a fan of telehealth,” O’Donnell said. “But he felt when you’re with technology, you can’t let that get in the way of doing diagnostics that you would do at the bedside or with the patient in your office.”
The potential for improving access and saving patients the time and money of long travel, however, make telehealth well worth exploring, physicians and patients said.
There will always be a place for in-person meetings with a doctor, Albert said, but there is a lot that can be done without being in the same room as a patient. Most promising, offering remote care could mean reaching people who have been tolerating pain or suffering from a disease simply because they could not see a doctor with the expertise they need.
“It does reduce health care costs and increase access,” Albert said in an interview. “It’s not perfect, but it’s better than nothing. And that’s sometimes what we have, is nothing.”
More ‘Touches,’ Not Fewer
Just as digital technology has connected family and friends through email, mobile phones and social media, so it is taking the next logical step by opening doors for doctors to communicate with patients.
Dartmouth-Hitchcock dermatologists and psychiatrists have been seeing patients at distant clinics, just like Albert in rheumatology has been doing since last June.
But DHMC’s telehealth initiatives go far beyond that, Pletcher said. The hospital is exploring “consults on demand,” in which a specialist at DHMC sits at a monitor and talks with a trauma surgeon who is working to save a patient’s life an hour or more away. Telehealth could be used to gather second opinions from doctors outside the area, or to facilitate education and outreach between providers.
“There’s all sorts of ways we can use technology to collect providers and patients in care teams in collaborative ways to try to extend out expertise and best practices and protocols and guidelines all the way out as close to the patient in their home environment as we can,” Pletcher said.
The idea behind telehealth is not to supplant in-person visits to the doctor, Pletcher said, but rather to supplement them. Particularly in a rural area, technology allows DHMC doctors to see patients who because of life factors — job, lack of a car, family considerations — can’t take the time to drive to the medical center and be seen in person.
“A lot of these patients would not come here,” said Merrihew, the DHMC nurse. “They might get primary care and suffer along.”
Doctors at smaller rural facilities say telehealth gives them access to specialists they can’t afford to have on staff. And nurses in the room with a patient can sometimes conduct a physical exam as the doctor supervises remotely via camera.
To be sure, there are times when consulting with a patient via a screen, even a high definition one, just doesn’t yield the kind of information that a doctor needs, Albert said. Sometimes, a doctor needs to physically examine a patient to get a better understanding of his condition. No high-tech consultation, for example, can replace the advantage of a doctor using his hands to check for a swollen lymph glands or detecting an enlarged prostate.
Nonetheless, there are frequently times when Albert said he can learn quite a bit from simply talking with patients, and often that’s all that is required. When that’s the case, patients shouldn’t have to drive all the way to Lebanon, he said.
Neal Morehouse, 53, who lives in North Stratford, N.H., is one of Albert’s patients. Morehouse has a rare blood disease, and the medication he’s received has deteriorated cartilage in his joints. He has undergone total hip, shoulder and knee replacements since 2006.
Before Albert began doing remote consultations less than a year ago, Morehouse would have to travel 31/2 hours each way to DHMC. A 45-minute visit to his doctor meant that Morehouse would have to clear his schedule for an entire day and spend around $50 just to fuel his gas tank. Now, he drives 25 miles to Lancaster, where he sits at a computer terminal at Weeks and talks to Albert remotely.
At first, Morehouse was skeptical when Albert suggested a virtual visit. His fears were put to rest after the first session.
“It’s just like if I went in with a regular appointment with him,” Morehouse said. “We talk face to face.”
The cameras and equipment DHMC uses are high definition and the conversations between patients and doctors are encrypted to protect privacy. Otherwise, the telehealth tools are often off-the-shelf hardware sold in most retail electronics stores.
And the technology works well enough that it can be used to do some partial exams, Albert said. When Morehouse was developing sores in his mouth, he didn’t need to make a trip to Lebanon so that Albert could have a look.
“I go right up to the camera, open my mouth and he can see right into it,” Morehouse said.
Everyday consumer electronics have a big role to play in telehealth. Smartphones can be used for everything from text messaging with patients about medication reminders or smoking cessation strategies, to using various “bio monitor” applications that can measure respiratory rates, skin temperature and other indicators, which can then be sent to clinicians.
“Smartphones now are capable of managing very sophisticated medical monitoring data,” Pletcher said. “So the applications for these is just going to exponentially increase.”
Beyond giving patients greater access to doctors, much of telehealth is aimed at caring for patients in their homes.
Home monitoring equipment runs the gamut, from simple scales that patients use to measure their weight, to blood glucose meters and wireless cardiovascular monitoring. The information is then sent back to caregivers as they check in on a patient’s condition. These monitors offer far more opportunities to check in on a patient’s condition without burdening that person with frequent visits to an exam room, physicians say.
Personal interaction between patient and physician remains crucial, Pletcher said. People like Morehouse still have to visit a nurse in a clinic or even drive to Lebanon on occasion for treatment. But in the meantime, physicians have more information at their disposal.
“(Patients are) still being touched,” Pletcher said. “They’re still somewhere with someone in most of these cases. So this is more touches and not fewer touches.”
Regulatory and Organizational Challenges
Technical problems posed by limited broadband access is only one of the many challenges facing health care providers. (See related story)
Another one is meeting regulatory requirements.
Though based in New Hampshire, DHMC still works with many Vermont providers, including Mt. Ascutney Hospital in Windsor and Gifford Medical Center in Randolph. But if a Dartmouth physician wanted to offer telehealth services to patients in Vermont, the doctor might need to get licensed in that state as well. Many DHMC doctors are not licensed in both states.
“It’s a barrier,” Pletcher said. “It’s not an insurmountable barrier. … We may have to make difficult decisions to say, well, this specialist is in a really obscure specialty and he’s going to be needed once a month only. Do we go through the very costly and lengthy process to get him licensed, or is that just a resource that patients in Vermont aren’t going to have?”
The Food and Drug Administration, which has regulatory authority over medical devices, has given increased attention to telehealth, including the apps that would turn a patient’s mobile device into a virtual doctor’s office. As the FDA considers whether to regulate certain devices, hospital officials are left with questions about what to buy.
“You sort of have to take your best guess and come up with equipment that will deliver high quality health care and be secure and compliant and privacy safe and hope that it all works itself out,” Pletcher said.
There are also issues of cost.
Insurers are still figuring out what they will pay for, and the equipment can be prohibitively expensive for small hospitals.
One way DHMC is trying to address the cost question is with federal grant money.
Martin Johns, director of the hospital division at Gifford, has worked with DHMC to apply for federal grant funds to support telehealth initiatives. Johns said Gifford has been eager to work with DHMC on telehealth, particularly as pressures grow on hospitals to control costs and still keep providing high quality care to patients.
“The plight of the rural hospital, the critical access hospital, is that you want to be able to provide services for the members of your community and provide excellence,” he said. “But there are occasions and diagnosis where you really would like the input of some specialists in a particular area.”
Trauma, stroke and psychiatry are three of those specialty areas of care where Gifford would like to tap DHMC resources, he said.
DHMC has been providing limited psychiatric consults for a few years, Pletcher said, and this month will launch a program where its stroke specialists will consult with emergency departments at other hospitals. Eventually, that program will include other specialties as well.
Not every initiative will prove worthwhile, physicians said, and there will always be times when providing the right care means an in-person visit with a doctor.
But in a rural region, that’s not always possible. Cost pressures are forcing hospitals to make careful decisions about how they are using their resources. Not every small hospital can afford to have a stroke expert on staff. Nor should they be expected to, Pletcher said.
“It never really made sense, honestly, to have every service available at every health care facility,” she said. “I think with telehealth, you have the ability to be smart about regionalization of resources.”
Chris Fleisher can be reached at 603-727-3229 or firstname.lastname@example.org.