JAMDA xxx (2015) 1e2
JAMDA journal homepage: www.jamda.com
Editorial
Telehealth Can Bridge the Gap for Rural, Disabled, and Elderly Patients Aung Zaw Win MD, MA, MPH * Notre Dame de Namur University, Belmont, CA
The goal of all clinical care is to provide the right care, at the right time and place, while ensuring patient safety and quality outcomes. We have come a long way since traditional face-to-face health care. A new trend in medicine has been developing around the world. Telehealth is defined as the use of telehealth technologies to provide clinical care in circumstances in which distance separates those receiving services and those providing services. Access to appropriate health care services continues to be a major challenge in rural America.1 Telehealth is becoming an important means of providing specialty medical services in rural areas.2 Telehealth care by a hospital specialist through videoconferencing is comparable to face-to-face care.3 The quality of patient care is not compromised by telemedicine, according to panelists at a recent forum hosted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.4 The global telemedicine market is poised to increase to $36.3 billion in 2020.5 A hospital is not always the best place to care for people with chronic conditions like diabetes, heart failure, pulmonary disease, and posttraumatic stress disorder. Rural Americans are more likely to suffer from chronic health conditions such as diabetes, heart disease, and cancer.6 Hersh et al7 reviewed 25 research studies on the efficacy of telehealth and concluded that chronic disease management is one of the areas in which there is the strongest support for its use. The benefits of telemedicine include reductions in hospital admissions/ readmissions, length of hospital stay, and emergency department visits and mortality.8 The Department of Health has similarly suggested that millions of people with social care needs and long-term conditions could benefit from telehealth. Telehealth is gaining popularity, and 3 of 4 Americans surveyed said they would use telemedicine.9 However, most clinicians have not been trained in telehealth. Telehealth is very important for America. There are 50 million Americans who live in rural areas.6 There are only 65 primary care physicians per 100,000 rural Americans, approximately 40 less than the 105 per 100,000 urban or suburban Americans. Moreover, the number of specialists per 100,000 people is 40 in rural areas,
The author declares no conflicts of interest. This work was performed at the San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA 94121. * Address correspondence to Aung Zaw Win, MD, MA, MPH, San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA 94121. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jamda.2015.01.077 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
compared with 134 in urban areas.10 The higher the degree of rurality of rural areas, the higher the decrease in the supply of doctors.11 One recent study estimated that some 4.17 million individuals older than 50 years could potentially use telehealth. The proportion of people older than 65 years is higher in rural areas than in urban areas, and their numbers are expected to increase in the next decade.12 More than half of rural Americans must travel more than 20 miles for specialty care, with an average reported distance of 60 miles.6 Cancer survivors in rural areas were 66% more likely to forgo medical care than their urban counterparts because of travel costs.13 Telehealth allows patients and doctors in isolated communities to engage in long-distance consults with experts. It might be used by a patient at a Navajo health clinic to communicate with a doctor at a large hospital in another state, or a patient in a rural North Dakota town can get medical care from a doctor at a medical center. It is estimated that in 2012, a telehealth program saved Alaska $8.5 million in travel costs for Medicaid patients alone.14 A multicenter study conducted in the United Kingdom found that telehealth is associated with lower mortality rates in patients.15 The Telehealth Promotion Act of 2012 was designed to promote and expand the application of telehealth under Medicare and other federal health care programs.16 Telemedicine for the Medicare Act of 2013 was designed to permit Medicare providers licensed in a state to provide telemedicine services to Medicare beneficiaries in a different state.17 The anticipated entry of 32 million previously uninsured US citizens into health insurance plans because of the Affordable Care Act, along with the general aging of the population, is contributing to shortages of primary care physicians nationwide and exacerbating shortages of specialists in rural areas. At current rates of graduation and retirement, there could be a gap of 150,000 physicians in 5 years, according to the Association of American Medical Colleges.18 Difficulties in recruiting and retaining health care providers have resulted in long-standing disparities in rural and urban physician supply.10 Moreover, there are subpopulations within rural populations that are even more acutely vulnerable. Three such subpopulations are children, military veterans, and older adults.19 In rural areas, the number of elderly will increase dramatically from 35 million in 2000 to 54.6 million in 2020. Without access to care, the rural health disparity, especially for the elderly, will continue to grow.20 In telehealth, the recipient is actively involved in transmitting and, in many cases, receiving information. If the patient cannot provide an accurate history, then it is important for a reliable historian, such as a spouse or caregiver, to accompany the patient to the telehealth visit.
2
Editorial / JAMDA xxx (2015) 1e2
The equipment used for telemedicine can vary from facility to facility. The patient and provider sides usually have the same type of equipment. Clinical Video Telehealth (CVT) is defined as the use of real-time interactive videoconferencing, sometimes with supportive peripheral technologies, to assess, treat, and provide care to a patient remotely. This is similar to Skype and other real-time videoconferencing platforms. Typically, CVT links the patient(s) at a clinic to the provider(s) at another location. Currently, health care organizations and companies are looking into wireless technologies involving the tablet and the more familiar iPad. However, at the beginning of 2012, fewer than 1% of hospitals in the United States had fully functional tablet systems.21 In 2013, 84.2% of Americans used the Internet.22 However, for patients who do not have Internet access at home, the new technologies offer an opportunity to provide virtual care. Wherever there is a “fourthgeneration” (4G) mobile telephone signal, patients will be able to access his or her provider using the wireless technology. The smartphone has opened up the potential for improving health outcomes.23 According to the Pew Research Center, as of January 2014, 58% of American adults had a smartphone and 42% of American adults owned a tablet.24 Previously, Americans were limited to using a personal computer to access the Internet. The new technology is still in the pilot phase. At the predetermined time, the clinician can “call” the patient’s tablet. The patient can accept or reject the videoconference call. Once again, it is noteworthy that the tablets are programmed to accept a videoconference call from the clinician but the patient is unable to call the clinician. Interventional app tools available on smart devices can be provided in an “always-on” setting and apps for appointment reminders are also available. Education that is typically provided to the patient as written handouts can be reviewed in apps as audiovisual movie clips. Thus, advances in telehealth can be adapted to address a greater range of health care needs among populations in hard-to-reach settings. References 1. Alverson DC, Shannon S, Sullivan E, et al. Telehealth in the trenches: reporting back from the frontlines in rural America. Telemed J E Health 2004;10:S95eS109. 2. Hassol A, Gaumer G, Grigsby J, et al. Rural telemedicine: a national snapshot. Telemed J 1996;2:43e48. 3. Ferrer-Roca O, Garcia-Nogales A, Pelaez C. The Impact of Telemedicine on Quality of Life in Rural Areas: The Extremadura Model of Specialized Care Delivery. Telemed J E Health 2010;16:233e243. 4. Telemedicine can build bridge to expanded health care, say panelists. Available at: http://www.aafp.org/news/practice-professional-issues/20140205rgctele medicineforum.html. Accessed December 15, 2014.
5. Global telemedicine market expected to reach USD 36.3billion by 2020: transparency market research. Available at: http://www.broadwayworld.com/ bwwgeeks/article/Global-Telemedicine-Market-Expected-to-Reach-USD-363Billion-by-2020-Transparency-Market-Research-20140905. Accessed December 15, 2014. 6. HIT must “go rural.” Available at: http://www.healthitoutcomes.com/doc/hitmust-go-rural-0001. Accessed December 15, 2014. 7. Hersh WR, Helfand M, Wallace J, et al. Clinical outcomes resulting from telemedicine interventions: A systematic review. BMC Med Inform Decis Mak 2001;1:5. 8. Bashshur RL, Shannon GW, Smith BR, et al. The empirical foundations of telemedicine interventions for chronic disease management. Telemed J E Health 2014;20:769e800. 9. Anderson H. Survey: Consumers keen on telemedicine. Available at: http:// www.aota.org/practice/rehabilitation-disability/emerging-niche/telehealth.aspx. Accessed November 25, 2014. 10. National Conference of State Legislatures. Telehealth and rural health care delivery. Available at: http://www.ncsl.org/research/health/telehealth-andrural-health-care-delivery.aspx. Accessed December 15, 2014. 11. Lee JH, Chung K, Yang DH. Changes in the supply of primary care physicians in rural areas in the USA, 1990e2000. Int J Public Pol 2010;6:190e203. 12. Baernholdt M, Yan G, Hinton I, et al. Quality of life in rural and urban adults 65 years and older: Findings from the National Health and Nutrition Examination survey. J Rural Health 2012;28:339e347. 13. Palmer NR, Geiger AM, Lu L, et al. Impact of rural residence on forgoing healthcare after cancer because of cost. Cancer Epidemiol Biomarkers Prev 2013;22:1668e1676. 14. Agency for Healthcare Research and Quality. Telehealth improves access and quality care for Alaska Natives. Available at: https://innovations.ahrq. gov/perspectives/telehealth-improves-access-and-quality-care-alaska-natives. Accessed December 15, 2014. 15. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on use of secondary care and mortality: Findings from the Whole System Demonstrator cluster randomised trial. BMJ 2012;344:e3874. 16. US Government Printing Office. Bills 112th Congress. HR 6719. Available at: http://www.gpo.gov/fdsys/pkg/BILLS-112hr6719ih/html/BILLS-112hr6719ih.htm. Accessed December 15, 2014. 17. GovTrack.us. Tracking the United States Congress. Available at: https://www. govtrack.us. Accessed December 15, 2014. 18. FCW. VA sets the telehealth table. Available at: http://fcw.com/Articles/2010/ 05/24/FEAT-telehealth.aspx?Page¼2. Accessed December 15, 2014. 19. Lutfiyya MN, Bianco JA, Quinlan SK, et al. Mental health and mental health care in rural America: The hope of redesigned primary care. Dis Mon 2012;58: 629e638. 20. Kuehn BM. Veterans health system cited by experts as a model for patientcentered care. JAMA 2012;307:442e443. 21. NPR. For hospitals there’s no app for adopting tablet computers. Available at: http://www.npr.org/blogs/health/2011/12/23/144193091/for-hospitals-theresno-app-for-adopting-tablet-computers. Accessed December 15, 2014. 22. The World Bank. Internet users (per 100 people). Available at: http://data. worldbank.org/indicator/IT.NET.USER.P2. Accessed December 15, 2014. 23. Poropatich R, Lai E, McVeigh F, Bashshur R. The U.S. Army Telemedicine and mHealth Program: making a difference at home and abroad. Telemed J E Health 2013;19:380e386. 24. Pew Research Internet Project. Mobile technology fact sheet. Available at: http:// www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. Accessed December 15, 2014.
JAMDA journal homepage: www.jamda.com
Editorial
Telehealth Can Bridge the Gap for Rural, Disabled, and Elderly Patients Aung Zaw Win MD, MA, MPH * Notre Dame de Namur University, Belmont, CA
The goal of all clinical care is to provide the right care, at the right time and place, while ensuring patient safety and quality outcomes. We have come a long way since traditional face-to-face health care. A new trend in medicine has been developing around the world. Telehealth is defined as the use of telehealth technologies to provide clinical care in circumstances in which distance separates those receiving services and those providing services. Access to appropriate health care services continues to be a major challenge in rural America.1 Telehealth is becoming an important means of providing specialty medical services in rural areas.2 Telehealth care by a hospital specialist through videoconferencing is comparable to face-to-face care.3 The quality of patient care is not compromised by telemedicine, according to panelists at a recent forum hosted by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care.4 The global telemedicine market is poised to increase to $36.3 billion in 2020.5 A hospital is not always the best place to care for people with chronic conditions like diabetes, heart failure, pulmonary disease, and posttraumatic stress disorder. Rural Americans are more likely to suffer from chronic health conditions such as diabetes, heart disease, and cancer.6 Hersh et al7 reviewed 25 research studies on the efficacy of telehealth and concluded that chronic disease management is one of the areas in which there is the strongest support for its use. The benefits of telemedicine include reductions in hospital admissions/ readmissions, length of hospital stay, and emergency department visits and mortality.8 The Department of Health has similarly suggested that millions of people with social care needs and long-term conditions could benefit from telehealth. Telehealth is gaining popularity, and 3 of 4 Americans surveyed said they would use telemedicine.9 However, most clinicians have not been trained in telehealth. Telehealth is very important for America. There are 50 million Americans who live in rural areas.6 There are only 65 primary care physicians per 100,000 rural Americans, approximately 40 less than the 105 per 100,000 urban or suburban Americans. Moreover, the number of specialists per 100,000 people is 40 in rural areas,
The author declares no conflicts of interest. This work was performed at the San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA 94121. * Address correspondence to Aung Zaw Win, MD, MA, MPH, San Francisco VA Medical Center, 4150 Clement Street, San Francisco, CA 94121. E-mail address: [email protected]. http://dx.doi.org/10.1016/j.jamda.2015.01.077 1525-8610/Ó 2015 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
compared with 134 in urban areas.10 The higher the degree of rurality of rural areas, the higher the decrease in the supply of doctors.11 One recent study estimated that some 4.17 million individuals older than 50 years could potentially use telehealth. The proportion of people older than 65 years is higher in rural areas than in urban areas, and their numbers are expected to increase in the next decade.12 More than half of rural Americans must travel more than 20 miles for specialty care, with an average reported distance of 60 miles.6 Cancer survivors in rural areas were 66% more likely to forgo medical care than their urban counterparts because of travel costs.13 Telehealth allows patients and doctors in isolated communities to engage in long-distance consults with experts. It might be used by a patient at a Navajo health clinic to communicate with a doctor at a large hospital in another state, or a patient in a rural North Dakota town can get medical care from a doctor at a medical center. It is estimated that in 2012, a telehealth program saved Alaska $8.5 million in travel costs for Medicaid patients alone.14 A multicenter study conducted in the United Kingdom found that telehealth is associated with lower mortality rates in patients.15 The Telehealth Promotion Act of 2012 was designed to promote and expand the application of telehealth under Medicare and other federal health care programs.16 Telemedicine for the Medicare Act of 2013 was designed to permit Medicare providers licensed in a state to provide telemedicine services to Medicare beneficiaries in a different state.17 The anticipated entry of 32 million previously uninsured US citizens into health insurance plans because of the Affordable Care Act, along with the general aging of the population, is contributing to shortages of primary care physicians nationwide and exacerbating shortages of specialists in rural areas. At current rates of graduation and retirement, there could be a gap of 150,000 physicians in 5 years, according to the Association of American Medical Colleges.18 Difficulties in recruiting and retaining health care providers have resulted in long-standing disparities in rural and urban physician supply.10 Moreover, there are subpopulations within rural populations that are even more acutely vulnerable. Three such subpopulations are children, military veterans, and older adults.19 In rural areas, the number of elderly will increase dramatically from 35 million in 2000 to 54.6 million in 2020. Without access to care, the rural health disparity, especially for the elderly, will continue to grow.20 In telehealth, the recipient is actively involved in transmitting and, in many cases, receiving information. If the patient cannot provide an accurate history, then it is important for a reliable historian, such as a spouse or caregiver, to accompany the patient to the telehealth visit.
2
Editorial / JAMDA xxx (2015) 1e2
The equipment used for telemedicine can vary from facility to facility. The patient and provider sides usually have the same type of equipment. Clinical Video Telehealth (CVT) is defined as the use of real-time interactive videoconferencing, sometimes with supportive peripheral technologies, to assess, treat, and provide care to a patient remotely. This is similar to Skype and other real-time videoconferencing platforms. Typically, CVT links the patient(s) at a clinic to the provider(s) at another location. Currently, health care organizations and companies are looking into wireless technologies involving the tablet and the more familiar iPad. However, at the beginning of 2012, fewer than 1% of hospitals in the United States had fully functional tablet systems.21 In 2013, 84.2% of Americans used the Internet.22 However, for patients who do not have Internet access at home, the new technologies offer an opportunity to provide virtual care. Wherever there is a “fourthgeneration” (4G) mobile telephone signal, patients will be able to access his or her provider using the wireless technology. The smartphone has opened up the potential for improving health outcomes.23 According to the Pew Research Center, as of January 2014, 58% of American adults had a smartphone and 42% of American adults owned a tablet.24 Previously, Americans were limited to using a personal computer to access the Internet. The new technology is still in the pilot phase. At the predetermined time, the clinician can “call” the patient’s tablet. The patient can accept or reject the videoconference call. Once again, it is noteworthy that the tablets are programmed to accept a videoconference call from the clinician but the patient is unable to call the clinician. Interventional app tools available on smart devices can be provided in an “always-on” setting and apps for appointment reminders are also available. Education that is typically provided to the patient as written handouts can be reviewed in apps as audiovisual movie clips. Thus, advances in telehealth can be adapted to address a greater range of health care needs among populations in hard-to-reach settings. References 1. Alverson DC, Shannon S, Sullivan E, et al. Telehealth in the trenches: reporting back from the frontlines in rural America. Telemed J E Health 2004;10:S95eS109. 2. Hassol A, Gaumer G, Grigsby J, et al. Rural telemedicine: a national snapshot. Telemed J 1996;2:43e48. 3. Ferrer-Roca O, Garcia-Nogales A, Pelaez C. The Impact of Telemedicine on Quality of Life in Rural Areas: The Extremadura Model of Specialized Care Delivery. Telemed J E Health 2010;16:233e243. 4. Telemedicine can build bridge to expanded health care, say panelists. Available at: http://www.aafp.org/news/practice-professional-issues/20140205rgctele medicineforum.html. Accessed December 15, 2014.
5. Global telemedicine market expected to reach USD 36.3billion by 2020: transparency market research. Available at: http://www.broadwayworld.com/ bwwgeeks/article/Global-Telemedicine-Market-Expected-to-Reach-USD-363Billion-by-2020-Transparency-Market-Research-20140905. Accessed December 15, 2014. 6. HIT must “go rural.” Available at: http://www.healthitoutcomes.com/doc/hitmust-go-rural-0001. Accessed December 15, 2014. 7. Hersh WR, Helfand M, Wallace J, et al. Clinical outcomes resulting from telemedicine interventions: A systematic review. BMC Med Inform Decis Mak 2001;1:5. 8. Bashshur RL, Shannon GW, Smith BR, et al. The empirical foundations of telemedicine interventions for chronic disease management. Telemed J E Health 2014;20:769e800. 9. Anderson H. Survey: Consumers keen on telemedicine. Available at: http:// www.aota.org/practice/rehabilitation-disability/emerging-niche/telehealth.aspx. Accessed November 25, 2014. 10. National Conference of State Legislatures. Telehealth and rural health care delivery. Available at: http://www.ncsl.org/research/health/telehealth-andrural-health-care-delivery.aspx. Accessed December 15, 2014. 11. Lee JH, Chung K, Yang DH. Changes in the supply of primary care physicians in rural areas in the USA, 1990e2000. Int J Public Pol 2010;6:190e203. 12. Baernholdt M, Yan G, Hinton I, et al. Quality of life in rural and urban adults 65 years and older: Findings from the National Health and Nutrition Examination survey. J Rural Health 2012;28:339e347. 13. Palmer NR, Geiger AM, Lu L, et al. Impact of rural residence on forgoing healthcare after cancer because of cost. Cancer Epidemiol Biomarkers Prev 2013;22:1668e1676. 14. Agency for Healthcare Research and Quality. Telehealth improves access and quality care for Alaska Natives. Available at: https://innovations.ahrq. gov/perspectives/telehealth-improves-access-and-quality-care-alaska-natives. Accessed December 15, 2014. 15. Steventon A, Bardsley M, Billings J, et al. Effect of telehealth on use of secondary care and mortality: Findings from the Whole System Demonstrator cluster randomised trial. BMJ 2012;344:e3874. 16. US Government Printing Office. Bills 112th Congress. HR 6719. Available at: http://www.gpo.gov/fdsys/pkg/BILLS-112hr6719ih/html/BILLS-112hr6719ih.htm. Accessed December 15, 2014. 17. GovTrack.us. Tracking the United States Congress. Available at: https://www. govtrack.us. Accessed December 15, 2014. 18. FCW. VA sets the telehealth table. Available at: http://fcw.com/Articles/2010/ 05/24/FEAT-telehealth.aspx?Page¼2. Accessed December 15, 2014. 19. Lutfiyya MN, Bianco JA, Quinlan SK, et al. Mental health and mental health care in rural America: The hope of redesigned primary care. Dis Mon 2012;58: 629e638. 20. Kuehn BM. Veterans health system cited by experts as a model for patientcentered care. JAMA 2012;307:442e443. 21. NPR. For hospitals there’s no app for adopting tablet computers. Available at: http://www.npr.org/blogs/health/2011/12/23/144193091/for-hospitals-theresno-app-for-adopting-tablet-computers. Accessed December 15, 2014. 22. The World Bank. Internet users (per 100 people). Available at: http://data. worldbank.org/indicator/IT.NET.USER.P2. Accessed December 15, 2014. 23. Poropatich R, Lai E, McVeigh F, Bashshur R. The U.S. Army Telemedicine and mHealth Program: making a difference at home and abroad. Telemed J E Health 2013;19:380e386. 24. Pew Research Internet Project. Mobile technology fact sheet. Available at: http:// www.pewinternet.org/fact-sheets/mobile-technology-fact-sheet/. Accessed December 15, 2014.
