What are Telehealth and Telemedicine?

According to The New England Journal of Medicine, telehealth is defined as the use of medical information that is exchanged from one site to another through electronic communication to improve a patient’s health (Tuckson). Telehealth and telemedicine are terms that are used interchangeably; however, there are slight differences. Telehealth is the broad term for the use of electronics and other technologies to provide clinical care and telemedicine is the use of those technologies to deliver that care. There are many institutes and clinics that are using telehealth services right now. In fact more than 60% of health care institutes and between 40%-50% of hospitals in the united states use some form of telehealth (Tuckson). Telehealth is used more commonly in rural areas as their are many implications for patients being able to get access to their healthcare needs. Rural is defined as sparsely populated areas with low density housing and are far from urban areas. With this definition, 97% of the United States is considered rural. However, only 19.3% of the entire population live in these rural areas (Nasser, 2019). A new study put out by NPR suggests that one in four people that live in rural areas could not get the healthcare service they needed (Siegler, 2019).

 

telemedicine

There are three main types of technology in telehealth. The first one is remote patient monitoring and it offers range of self-monitoring and self-testing that can be done in the convenience of one’s home. It is mainly used for the management of chronic illnesses such as diabetes and cardiovascular disease. A patient with diabetes may have a device that includes voice apps to remind them to record their blood pressure or take their insulin. This telehealth service can save a patient from spending several hundreds of dollars for a hospital visit that could have been prevented. In fact, a study by The University of Pittsburgh Medical Center, shows that RPM reduced the risk of hospital readmissions by 76% (Dolan, 2019).

idkk

The second type of technology type is called store-and-forward systems. It is the transmission of images or information from one provider to another. The medical information is sent through a secure electronic communication system. An example of the type of medical information that can be sent amongst physicians is an X-ray. One physician may send out an X-ray to a specialist to ask for their opinion. This communication saves the physician’s time as they don’t have to meet with each other face-to-face. It also increases the quality of the care the patient is receiving because they are getting another physician’s medical evaluation.

The last type of technology is audio/visual communication. This type of service can be performed between physicians or between a physician and a patient. Virtual visits are taking over the healthcare industry as it cuts down the costs of standard care visits and lessens the amount of traveling the patient has to do.

telehealth visit

There are many purposes of telehealth in healthcare, including: filling in the gaps of provider shortages, reducing patient travel burdens, refilling prescriptions without a doctor’s visit, meetings over the community and many more. Each different sector of healthcare has specific problems that telehealth can help fix. The use of telehealth in obstetrics and telepractice will be talked about in the upcoming paragraphs.

 

Future of Telehealth

There are trends in telehealth that we are going to see in the future. The innovation of technology in the consumer market will continue to attract capital for product development. Such as the da Vinci, which is a surgical robot that can perform a surgery while the doctor is operating it sitting a couple feet away from the actual patient. The advancement in electronic health records and clinical support systems will integrate telehealth services into care-delivery, which will alleviate stress for clinicians and make health care more efficient. There is a nation-wide shortage for healthcare professionals, so telehealth services will need to be provided to rural areas that only have access to primary care. The spread of telehealth services will create access to specialty care that these areas may not have access to as of right now (Heinzelmann, 2015). As a result of the ACA, healthcare is heading towards a value-based care approach for reimbursement methods. We will see bundled payments including telehealth services in the future. Lastly, the growth of the consumption of healthcare is rapidly increasing because of the aging population. Alongside the shortage of physicians, it is detrimental that telehealth services be adapted to serve the aging community.

 

 

Obstetrics

Telehealth being used in obstetrics is new and upcoming, especially in rural areas. According to the Centers for Disease Control and Prevention, rural American’s are at higher risk for preterm births and infant mortality. In 2014, infant mortality rates increased as urbanization decreased. In rural counties, there were 6.55 infant deaths per 1,000 births, which is 6% higher than in small urban counties and 20% higher than in large urban counties (Infant, 2017).

graph

 

 

 

 

 

 

 

A normal, healthy, pregnant woman will visit their OB/GYN once every month from 4 to 28 weeks, then one visit every two weeks from 28 to 36 weeks and then one prenatal visit every week until they deliver. That is a significant amount of time a low-risk pregnant patient is spending their time travelling to the doctor’s office. Telehealth services such as virtual visits are beneficial to these pregnant patients. Some clinics are offering these virtual visits to cut down on visit-related costs and time spent travelling. These women are given supplies to bring home and are also educated on how to use them. When it is time to have the virtual visit, the woman will be instructed to track the fetal heart rate, maternal blood pressure and fundal height.

The situation for high-risk pregnant patients is a little different. Those mothers with other health conditions such as high blood pressure, substance abuse, gestational diabetes or a family history of a genetic disorder are at higher risk for something to happen to the mother or the baby. These telehealth visits may occur, but not as often. However, rural physicians have the ability to communicate with specialists via telemedicine consultations. Information pertaining the health of the mother and baby can be shared amongst these providers, even if they are miles apart. According to The Medical University of South Carolina Center for Telehealth, “maternal fetal telemedicine enables a partnership between the specialist and local providers to co-manage the care and screening of patients with high-risk pregnancies and support all the necessary steps to achieve the best possible outcomes (Lowry, 2018).” Healthcare organizations are taking on programs to help connect these Maternal Fetal Monitoring Specialists to rural providers. In Arkansas, a group called the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS) are doing just that. ANGELS is supported by a 24/7 nurse-staffed call center to provide triage to patients at their home if needed. This program has been credited with cost savings, reduced infant mortality, and reduced maternal complications (Lowry, 2018).

A study performed in June 2017 used eHealth during prenatal, perinatal and postnatal care (Van den Heuvel). This study was conducted with 800 patients and could help close the gap of intimacy that is made when using telecommunication services. eHealth is a system that provides solutions for value-based healthcare that these patients are looking for. Women that are pregnant this day and age are frequent users of the internet and know how to navigate different phone applications. With the use of eHealth and pregancy apps, the medical information  that was obtained varied from 50% to 98%. Seeking information is common with pregnant women and it is shown to reduce maternal anxiety and hospital visits if they had these online resources. The study also included a smartphone-facilitated remote blood glucose monitoring system for those with gestational diabietes. The use of this service decreased planned and unplanned visits by 50% to 66% for these patients. Overall, the patients reported less concerns and anxiety and are comfortable with having fewer standard delivery care visits. The satisfaction rates among the maternal patients was between 86% and 95% (Van den Heuvel).

 

Telepractice.   See video links at top of page

Computer-based clinical applications are increasing in use in audiology today.  Telepractitioners use computer peripherals, including audiometers, hearing aid systems, and auditory brainstem response (ABR), otoacoustic emissions (OAEs), and immittance testing equipment (middle ear function, tympanometry, reflex testing)—that is interfaced to existing telepractice networks. Manufacturers are now producing equipment with synchronous or asynchronous capabilities. 

Research on telehealth has been ongoing for over a century, if we consider telephone usage (Rushbrooke & Houston, 2016). Technology needs might be categorized into: the areas of communication (input devices, software, output devices, transmission characteristics, reception devices); diagnostic and assessment instruments; treatments; therapies. (Rushbrooke and Houston, 2016), Pagiolonga, 2018, Preminger et al (2018). 

Telepractice services are used in schools, medical centers, corporate settings. “Exceptional settings” include prisons, ships, and spacecraft (!) ( Cason& Cohn).In order to change the perception that the telecommunications model of care denotes only health care or medical settings the American Speech Language Hearing Association adopted in 2014 the term telepractice. The term teleaudiology may be used for audiology and  telespeech for speech-language pathologist  (SLP) services. The American Telemedecine Association uses the term telerehabilitation for both SLP and audiology services as well as for those of physical and occupational therapists.  The term teleaudiology was first used in 1999 by Dr. GreggGivens in reference to a system being developed at East Carolina University in Greenville, North Carolina. (Rushbrooke & Houston, 2016)  The first audiologic test via the Internet was performed in 2000 by Givens, Balch, and Keller (Abrams, n.d.; Nemes, 2010). In 2009 Dr. James Hall successfully performed the first transatlantic teleaudiology test from Dallas, Texas, to South Africa. (Preminger, 2018). A survey of audiologists in 2014 suggested that51.9% had used some teleaudiology. (ASHA SIG 18).                                                                                                                             

                                                                                                                      pediatric

 

 

 

Technology applications:
Audiology and hearing aids. It is estimated that 80% of the people who could significantly benefit from hearing aids do not have access to hearing health professionals. (Rushbrooke & Houston). Online diagnosis and prescription is slowly coming into the mainstream. One area where the situation is about to undergo a major change is in hearing aid dispensing. In the 1980’s audiologists gained the right to dispense hearing aids and their price to the consumer has increased greatly since the advent of digital hearing aids in the 1990s. All hearing aids have been available only as sold by licensed audiologists or hearing aid specialists. However, in 2017 the Over the Counter Hearing Aid Act was signed into law. The bill amends the Federal Food, Drug, and Cosmetic Act to require the Food and Drug Administration (FDA) to categorize certain hearing aids for mild and moderate hearing losses as over-the counter hearing aids and to issue regulations regarding them. It will go into effect this year. The January-February 2020 issue of the ASHA Leader reports that the FDA has now designated the Bose self-fitting hearing aid as a Class II medical device (special controls). 
The Global Foundation for Hearing Loss has been instrumental in bringing hearing technology and aural rehabilitation and training to Vietnam. Telepractice will be playing an important role in follow-up of hearing aid fittings and in auditory training (personal communication). 
Audiologic assessment:(Rushbrooke & Houston, 2016). 
Pure-tone audiometry: Custom devices exist for remote testing. Tympanometry: a trained technical assistant needed.
Otoacoustic Emissions and reflex audiometry also require trained technicians. 
Speech audiometry requires higher fidelity sound transmission. Pediatric audiology: schools are responsible for the provision and maintenance of wireless amplification systems for students with hearing or auditory processing impairments. HAT=hearing assistive technology (Schauer, 2019). Cochlear implants (CI): mappings are being done online.       

Speech  and Language Pathology:  Assessment and Evaluation; Treatment: Telepractice is applicable in the areas of articulation, voice, resonance, fluency, and prosody. Related are the treatment for swallowing disorders (dysphagia). assistive and augmentative devices.(AAC) (Schauer, 2019). 
Language therapies for developmental and acquired problems (aphasia) lend themselves to telepractice, as does the cognitive therapy that is widely delivered in the United States by SLPs.  (Coleman et al, 2015). 

When providing telepractice to a person who lives in another country it is necessary for the provider to consult the regulations of that country, not least to protect the person who lives in our country. ASHA maintains a registry of associations around the world for that purpose. When working with interpreters, transliterator, or translators, a provider is responsible for planning the session and making sure that materials are culturally appropriate.        
 In the selection of a web conferencing option it is necessary to consider the ease of use. It may be a good idea to request a trial.. for new equipment a consideration is the sociability which is the number of hosts and attendees permitted. Privacy features and HIPAA compliance must be considered (Towe, 2012). This HIPAA compliance was a strong theme at he Waldo General Hospital training. An upload download speed of at least three megabytes is needed for a good connection. Also, if adding a shared video source you should have at least five megabytes. An alternative connection such as telephone or email is necessary or at least highly recommended.

Ethical Concerns

Telepractice:

The American Speech Language and Hearing Association (ASHA) has emphasized that outcomes should be as effective for a given condition as if the patient and therapist or audiologist were physically together. This requires careful consideration of the condition, etiology, goals and objectives of treatment and frequency of treatment. Numerous specific situations where a provider would need to consider whether or not telepractice was indicated need to be anticipated. For instance, in a situation where a patient presents with a phonologic or motor speech disorder, a clinician who relies heavily on hands-on Prompt methodology for therapy would perhaps disqualify herself from treating  that patient via  telepractice. One could imagine an assistant being trained to use some of the Prompt paradigm for a limited number of phonetic realizations, but in the vast majority of cases that would not be feasible.  There is currently a multi-participant discussion occurring in the ASHA Special Interest Group on Telepractice (SIG 18) that concerns  teletherapy in a school district where the company employing the SLP has evidently had a practice of specifying how long students will be seen in therapy sessions, a decision that clearly needs to be made by the student’s Individual Education Plan (IEP) team.   

Obstetrics:

 

There are many ethical concerns that arise with the use of telemedicine and technologies. The number one concern is the spread of personal health information. Without the use of headphones in a virtual visit or a secure electronic system, healthcare information could be leaked which would break HIPAA violations. In the aspect of Obstetrics, a patient may not want to spread the information about their pregnancy amongst family members. If a virtual visit was to take place in a patient’s home, there is risk that any information may be heard by others. OB/GYNs must meet any licensure requirements and crudentials before providing these services. Crudentials depend on the facility the physicians works at and the source of reimbursement. Also, the Joint Commission requires physicians to have credientials in order to be eligible for Medicare reimbursement (Brauer, 2016). There is need to set ethical rules and regulations that are followed by clinicians and healthcare workers. Another issue is that the intimate relationship between a physician and patient will be disconnected. In obstetrics, sometimes the touch of a physician is needed in order to diagnose. An example would be a breech-positioned fetus, the mother would not know how to diagnose this herself (Greiner).  A provider also needs to be able to effectively relay information to a patient via telecommunication. Video conferences can allow for verbal and nonverbal cues to be seen. This can enhance the physician-patient relationship without having the face-to-face contact.

 

 

Reimbursement 

 Reimbursement patterns in the United States vary by state. A February, 2020  communication from Alyssa Stephenson at  Conduent, the firm that is contracted for Medicaid reimbursement in New Hampshire, contained  the following information regarding Medicaid Coverage for Telehealth Services RSA 167:4-d. “Must comply with Medicare regulations 42 CFR 410.78 except that Medicaid telehealth services may be provided statewide (Medicare restricts to rural areas only and excludes Strafford, Rockingham and Hillsborough counties.” 
Eligible Providers:
  Physicians/PA except for delivery of primary care 
  APRN/Clinical Nurse Specialist/Nurse Midwife except for delivery of primary care
  Clinical Psychologist
  Clinical social Worker
  Registered Dietitian or nutritional professional
Eligible Originating Sites:
  Practitioner’s office
  Hospitals, including Critical Access Hospitals and those with renal dialysis centers
  Skilled Nursing Facility
  Community Mental Health Center
  FQHC/RHC
Medicaid pays the same as if the service were provided face to face.  We see that telepractice is not yet covered in New Hampshire. Medicare does not appear to cover telepractice.

 

Conclusions

The use of telehealth, telemedicine, and technology in the healthcare field is rapidly growing. As physicians get more equipt with the new technology, the obstetric  field and telepractice will see new telemedicine services. Licensure must be present through the state in order for a physician to practice with these services. Physicians who provide telemedicine must comply with the HIPAA privacy and security rules and should be aware of the risks that are involved with using these healthcare technologies.

 

  Telepractice: Teleaudiology is being used, according to ASHA, in the following practice areas (Preminger et al, 2018), Rushbrooke & Houston, 2016). Aural rehabilitation 
Cochlear implant fitting
Hearing aid fitting 
Infant and pediatric hearing screenings 
Pure-tone audiometry 
Speech-in-noise testing 
Video otoscopy 

Speech-Language Pathology
Aphasia 
Articulation disorders 
Autism 
Dysarthria 
Dysphagia 
Fluency disorders
Language and cognitive disorders 
Neurodevelopmental
Voice disorders