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"Telemedicine,” one of the latest buzzwords in the medical technology industry, is a concept that represents a paradigm

shift in information management processes. Telemedicine makes it easy to manage patient data across different platforms nationally and quickly. Some of the same technology employed in telemedicine can also enable virtual communication between practices and their patients. The missing link to this point has been the availability of an intelligent medical practice patient communication system that goes far beyond traditional client/server-based “reminder” solutions.

fills this void, allowing even practices that still use older scheduling and patient management systems to upgrade their one-way patient communications to include the functions of automatic routine reminders, recall/recare, wellness communications, and contacting patients who desire earlier appointments following late cancellations. Cellminder takes virtual communications to the next level by reducing the time needed to manage routine one-way conversations, increasing profi tability, enhancing patient

satisfaction, and improving quality and continuity of care.

Most commercial solutions for reminding patients of their appointments are based on telemarketing-type servers that use offi ce phone lines to deliver messages—mostly to home answering machines. They do help to reduce the many hours required for practices to manually call their patients, and they help to reduce revenue losses due to no-show patients. However, these systems are often slow and ineffective, relying on a transactional methodology that is based on communicating with patients one at a time.

To achieve true and complete one-way communication management status, the IT department at Cellminder rethought the entire

methodology and process of patient communication management.

Advanced Methodology and Software Platform

The virtual communications software platform deployed by Cellminder was built based on extensive interviews with practice administrators, front desk personnel, and doctors dissatisfi ed with their current patient communications and desiring

a system that was user-friendly for even the least sophisticated practice staff . The value in using this form of technology stems from the diff erence between “oneway” and “two-way” practice-to-patient communications. Virtual communications technology is far more effective and effi cient for one-way messaging, saving medical practices many thousands of dollars per month, as well as helping to generate revenue when dealing with the roughly 80% of practice-to-patient communications that are one-way in nature.

Clients access the virtual communications management toolset online, similar to other software as a service (SAS) models like 

. Double entry of patient contact and appointment information is eliminated through data integrations that synchronize easily with any practice management system that can export a text-delimited file.

Unlike most “reminder” systems, Cellminder requires little or no end-of-day export activity, as all future appointments, new patients, and changes to existing appointments are automatically updated each day. The virtual communications platform also relies on specific patient preferences to enable practices to communicate more effectively.

Virtual communications eliminates using practices’ phone lines completely, although the Caller ID reveals the practice’s name and phone number. This means that patients are contacted nearly concurrently rather than consecutively, as with manual or even server-based systems, plus, with Cellminder the practice’s phone lines remain available for inbound and outbound two-way communication calls.

Virtual communication technology allows practices to customize their own patient communications based on their patients’ demographics, communications preferences, and personal schedules, plus additional content that can be delivered by various means.

Through synchronization with practice management and EMR software, practices only need to access the virtual communications website directly for less than two hours per month, mostly to view and print reports on all their one-way communications activity or to contact any number of patients immediately for any sudden schedule change. Virtual communication is the perfect partner for practices upgrading their practice management system to an EMR with telemedicine capabilities, and Cellminder is the only communications solution marketing this technology.

Gary Szasz is Founder and Senior Vice President of Cellminder, Inc.

Articles

"Telemedicine," one of the latest buzzwords in the medical technology industry, is a concept that represents a paradigm shift in information management processes.

Virtual Communication Technology Saves Time and Money

Upon hearing news of the proposed merger between satellite radio companies XM and Sirius (for an interesting take on whether this will happen, check out this 

), I couldn’t help but think of my own experience with satellite radio and how much I love it. Before I explain, here’s how I see it…

There are two camps of satellite radio listeners: those who love Howard Stern (Sirius) and those who don’t (XM). I fall into the latter category, and I’m glad I made the choice all those years ago when satellite radio was just as misunderstood as Sanjaya Malakar. Over the years, XM has added a 24-hour hockey station (XM 204 — Home Ice) and Major League Baseball to its channel lineup, giving me something to look forward to besides the great uninterrupted music during my 70-minute ride to and from work every day.

Currently, I have two XM subscriptions/radios: one for my car complete with the sports ticker, 30-minute replay, and the “Favorites” feature that tells me when one of my favorite songs/artists is currently playing on another station. My second unit is hooked up to my home theater system, which allows me to listen to the XM feed outside on my “B” speakers (outdoor speakers and the summer…sounds like a future “Downtime” topic…) and turn on contemporary jazz (Channel 71, “Watercolors”), light pop/romance songs for the lady (Channel 23, “The Heart”), or “later” classic rock (Channel 49, “Big Tracks”) and enjoy a fine cigar and a glass of Rosemount Shiraz on my deck (hmmm…cigars and wine…another “Downtime” column!). And sometimes, when I want to bother my annoying neighbor, I throw on Channel 42 (“Liquid Metal”) and crank up the volume. Good times.

The thing is, I’m a gadget hound who was never interested in satellite radio until my dad got it and told me how awesome it was. Now, you have to know that my dad is not the most technologically savvy individual by any stretch of the imagination, but he’s a damn smart fellow and the best Jeopardy! player I’ve ever seen; so, his advice is usually sound. A day later, I had my fi rst XM radio, and I haven’t looked back since.

Simply put, you don’t know how good satellite radio is until you have it. To test myself, I tried listening to the clowns on New York’s 95.5 WPLJ morning show one Friday, and it was like I was back in 2002: They were doing the exact same shtick (“The Friday Morning Blast Off , complete with in-studio audience!”) as they did back then, with the same musical preludes, the same gags, the

same commercials, the same personalities, the same jokes…everything. Th e formula was identical, and the result was also the same: LAME. Hearing the show just confi rmed what I already knew: never again would I go back to free radio. I will gladly pay 12

bucks a month to keep my ears free from the debacle that is AM/FM.

Which brings me to my next “can’t-live-without-it” gadget: 

. Much like satellite radio, TiVo is only appreciated if you have it. If you don’t, well, I’m sorry.

Anyway, TiVo brings something to the table that other digital video recorders (DVRs) simply can’t: personality. With everything from the little “TiVo guy,” to the ergonomic and perfectly situated “peanut” remote, to the unmistakable audible “boops” (they’re not beeps, they’re boops) that greet every keypress, TiVo is a welcome part of our home, both upstairs as a hacked 120-hour original Series 1 DirecTiVo unit that integrates with my DirecTV satellite television, and downstairs as the HD TiVo unit, which can record HD broadcasts. Nirvana indeed!

With innovative features like the “Season Pass,” “Wishlists,” and “Suggestions,” my TiVo has become the go-to gadget in my home. Honestly, if I could only keep one piece of tech, TiVo would be it. With three kids, television watching comes at a premium, and with top-notch shows (see my list) only a click away, when an hour can be had on my schedule, the TiVo is my life—and time&mdash;saver.

Recoding television through a hard drive is such a simple idea, but I never thought it could be this cool or literally impact my “downtime” as much as it has. When I first brought it home, my wife thought it was just another piece of electronics that I would soon abandon for the next big thing. It wasn’t long before she became even more of a television junkie than she already was, setting up 

Season Passes for our kids or recording stellar programs like 

So even if I have to sort through countless “Oxygen” shows or Noggin entertainment, it’s all been worth it. The power of TiVo, indeed. 

Upon hearing news of the new merger between satellite radio companies XM
and Sirius, I couldnÃ¯Â¿Â½t help but think of my own experience with satellite radio and how much I love it. 

Don't Know What You've Got Till It's Gone (...or You've Never Had It)

During the past 40 years, experts in technology, telecommunications, and medicine have collaborated on numerous demonstration projects that have documented the efficacy and efficiency of telemedicine. Today, this research is paying dividends in the form of a variety of telemedicine projects and applications that are enabling physicians to provide healthcare services to patients located anywhere from 100 feet to 10,000 miles away. Telemedicine has moved beyond the demonstration stage, with many applications starting to be integrated into daily practice in a variety of settings from large hospitals to private physician offices to direct use by consumers.

It’s easy to describe the benefi ts of this new technology in broad, sweeping terms. However, examples of specifi c applications and their results can best demonstrate how telemedicine is beginning to transform the delivery of healthcare.

Teleradiology is a means of electronically transmitting radiographic patient images and consultative text from one location to another. Teleradiology represents, by far, the most widespread use of telemedicine today, and for good reason; due to an ongoing shortage of radiologists and increased use of medical imaging, a critical need exists to use such effi cient applications as teleradiology to meet demand. Once considered merely an interesting demonstration of the technology, today several hundred US hospitals use teleradiology services, allowing radiologists to work from home or the hospital to outsource certain imaging services.

One growing element of remote radiology services is the use of internationally based companies to provide after-hours (sometimes

called “nighthawk”) services. Th e companies employ radiologists in such locations as India, Switzerland, Australia, France, and Israel to provide US hospitals with needed services.

Agency for Health Care Research and Quality and the Harvard School of Public Health

, in 2000, 37% of hospital stays for children across the US were paid by Medicaid, with respiratory conditions the most frequent

diagnosis for one to nine year-olds. Remote monitoring can significantly reduce this problem, as the following example illustrates.

demonstrated that home telemonitoring of children afflicted with asthma can

significantly improve outcomes over traditional offi ce-based care. A group of “virtual patients” recorded vital sign data online (such as pulmonary functions) and submitted it online to their case managers weekly. These were compared to a control group receiving traditional care.

The one-year trial showed that children who accessed care through the Web-based case management system had better MDI/S scores, were more likely to keep a journal of daily asthma symptoms, and demonstrated a greater increase in asthma knowledge. The “virtual patients” achieved excellent asthma care, revealing that store-andforward technology combined with case management can provide an important tool to assist in disease management. The benefits of pediatric telemedicine were also explored by the University of Iowa College of Medicine, which conducted a study of specialized interdisciplinary team consultations for children with health and developmental disorders. 

The study included four groups of children: those with severe behavior disorders, with swallowing disorders, needing assistive technology, and with unmet health needs—primarily traumatic brain injury (TBI). The results indicated a high degree of satisfaction between parents, children, healthcare providers, caregivers, and teachers. The telemedicine network provided access to high-quality healthcare and was a timesaver for both the providers and the family. The cost savings to the local school district equaled $971 per session. Th e travel and time costs to parents for out-of-pocket expenses equaled $125. As a result of the study, the telemedicine clinic for children with special needs was adopted as part of the regular clinical venue at University of Iowa Hospitals and Clinics and participating schools (Harper D, 

Incorporating workplace telemedicine for employer-sponsored health plans can yield a number of benefits, including:

• Increased efficiencies due to less actual patients in waiting room

Several years ago, the University of Texas Medical Branch at Galveston initiated a project with the 

to determine if telemedicine could lower employer costs and increase employee convenience without lowering the quality of care. After the initial 100 visits, it was discovered that telemedicine consultations averaged 27 minutes, compared with 122 minutes for face-to-face visits (includes travel time, waiting time, and time spent with the provider). This translated into an average time savings of 1.6 hours and a direct salary savings of $47.37 per telemedicine encounter. It is clear from this example, and many others, that telemedicine can not only help provide good healthcare for employees but also reduce costs for employers.

Reports on two demonstration projects completed at the 

University of California, Davis and the University of Colorado

 using remote consultations, monitoring of vital signs, and online discussions show how telemedicine can eff ectively help people lose weight and keep the pounds off. The California demonstration focused on children and adolescent patients and concluded that children struggling with weight problems embraced the telemedicine weight management services and that telemedicine could help facilitate the delivery of care to individuals in rural areas lacking access to healthcare services. 

The Colorado demonstration provides a remote option to the University’s traditional weight loss program by providing individuals with home access to self-monitoring software programs, Web-based reporting, and health professionals.

We are seeing a widespread and rapidly growing use of telemedicine in mental health. In fact, telemental health services are one of the three most frequently provided health services using telemedicine technologies. Telemedicine is used to provide many types of mental health services, including pre-admission and discharge planning, pyschotherapy, support groups, case assessments and evaluations, medication management, court commitment hearings, and continuing medical education (CME) for providers.

 in Vermont found that telemental health is actually superior to face-to-face consultations in certain cases. Treatment for cases of paranoia or schizoid states, extreme shyness, comorbid nonpsychiatric illness, terminal illness, and some phobias were found to be more eff ective using a “distance” approach with remote videoconferencing. Additionally, videoconferencing allowed nurse facilitators, family members, or social workers to be present and improved scheduling coordination with diff erent parties. The use of videoconferencing allows providers to tilt or zoom in to observe specific body parts (eyes, mouth, hands, face) or to watch a family member’s or caregiver’s responses to a consultant’s questions or remarks without disturbing the patient, other parties, or both (see our Day in the Life piece in the Pulse section of this issue for more on these findings, provided directly from the lead investigator).

The goals of using telemedicine in eye care include preserving vision, reducing vision loss, and providing better access to medicine. There is no better use of such applications than identifying early onset of diabetic retinopathy (DR), a leading cause of new-onset blindness in the United States and many other industrialized countries.

 develops in nearly all persons with diabetes, aff ecting more than 5.3 million Americans older than age 18 years (2.5% of the US population). The medical, social, and economic ramifi cations of the disease are substantial, making early detection and treatment of the disease absolutely essential.

A University of Pittsburgh study found that using telemedicine for diabetic retinopathy screening enabled the healthcare team to reduce the time for patient screening to approximately 15 minutes. Another study of more than 250 patients in Minnesota found virtually no significant diff erence between in-person DR screenings and those performed remotely. Today, a telemedicine service for diabetic retinopathy screenings has been used to assess more than 25,000 patients. In addition, the 

 has chosen remote DR screenings as one of its priorities in the use of telemedicine for Native Americans and Alaskan Natives. 

A study in Montreal found that 18% of the diabetics who participated in the telescreening of DR went undiagnosed in traditional screening. In comparison, as part of an external endocrinology clinic, 6.2% of diabetic persons were identifi ed in the same way. In addition, researchers consider that with a 

, six out of 10 persons followed by an ophthalmologist could avoid regular screening tests, enhancing the margin of time available to ophthalmologists for follow-up and eventual treatment of those screened at the right time.

Telemedicine has applications in oncology from diagnosis to treatment planning to follow-up care and consultation. A review of telemedicine research at the 

 (NCI) notes that telemedicine “has the potential to facilitate better communication between patients and their providers, help patients take better care of themselves, help their caregivers keep better track of their health condition and their self-care, alert doctors to medical emergencies, and provide reminders when patients are due for cancer screening tests and other appropriate medical services.” 

The NCI notes that telemedicine systems will enable oncologists to remotely view biopsy specimens, MRIs, digital mammography and other imagery, and discuss cases with experts at geographically isolated locations. Other possible applications include remote monitoring of patients who are undergoing chemotherapy or coping with end-of-life issues, online assistance for parents of children with cancer, and applications that promote and encourage cancer screening.

One successful telemedicine program, organized through the 

NCI’s Cancer Disparities Research Partnership

 program, enabled patients and radiation oncologists at New Hanover Regional Medical Center (NHRMC) in North Carolina to connect with University of North Carolina, Chapel Hill (UNC) oncologists using 

 medical consultation workstations. NHRMC physicians examined patients with locally advanced head and neck cancer and initiated intensity modulated radiation therapy planning, “contour[ing] tumor target volumes (TTVs) and adjacent normal organs at risk (OARs).” Using the TELESYNERGY set-up, they shared images (including “contours and dose volume histograms for TTVs and OARs”), isodose distributions, pathology slides, and other data with UNC oncologists for review and consultation.

The examples in this article provide merely a glimpse of the potential uses of telemedicine technologies. Telemedicine can also be usefully applied in obstructive 

, and dozens of other specialties and settings. Even greater capabilities are in store for the future, as the technology continues to advance with faster

data transfer, improved voice and video transmission, and increased interest among both patients and practitioners.

Jonathan D. Linkous is the executive director of the American Telemedicine Association (ATA), the largest membership-based organization in the world focusing exclusively on providing health and medical care through telecommunications technology. Mr. Linkous has spoken and written extensively in the US and in other countries on policy issues, emerging applications, and market trends that impact telemedicine. Mr. Linkous has more than 20 years experience in the nation’s capital working in corporate and public sectors.

During the past 40 years, experts in technology, telecommunications, and medicine have collaborated on numerous demonstration projects that have documented the efficacy and effciency of telemedicine.

Telemedicine: Seeing the Future Today

On November 29, 2006, Th e Brain Tumor Foundation (BTF) launched The Road to Early Detection, an unprecedented

nationwide campaign aimed at broadening public awareness about brain tumors and the urgent need for early detection through brain scans.

Dr. Patrick J. Kelly, MD, FACS, Joseph Ransohoff Professor and Chairman of Neurosurgery, NYU Medical Center, Founder

and President of Th e Brain Tumor Foundation (BTF), is a pioneer of The Road to Early Detection campaign, which provides

free MRI brain scans for fi ve boroughs of NYC—particularly in under-served communities&mdash;and will eventually do so for the entire US.

“Regrettably,” says Dr. Kelly, “by the time brain tumors become symptomatic, most are incurable. With our best modern treatments, all we can off er is a small gift of time. I am firmly convinced that early detection is the best insurance that treatment will be effective and that more lives will be saved.”

With the knowledge that MRI brain scans are the best and only way to detect a brain tumor—or other brain abnormalities&mdash;Dr.

Kelly and others remarked, “We have grown accustomed to routinely checking for breast, colon, prostate, and other cancers; why not brain tumors? By finding and treating a brain tumor early in its development, thousands of lives may be saved.” Sponsored by a $1.5 million grant from the New York City Council, BTF has purchased the fi rst Mobile MRI Unit, manufactured by GE, in an eff ort to provide free brain scans to everyone throughout New York City by bringing the Unit to where they work, study, or live. And, in order to put brain tumors on the national medical agenda, the Foundation has linked up with a prestigious medical research institution where the brain scan data will be analyzed and presented at hearings in city, state, and national arenas, including the US Congress.

How Can an MRI Brain Scan Help in the Battle Against Brain Tumors?

The most obvious advantage of an MRI is that, unlike other types of scans, it emits no radiation. MRIs also get better spatial

resolution than CT or PET scans and are safe, non-invasive, and completely painless. The BTF’s Mobile MRI Unit is housed in a 50-foot trailer and uses today’s most advanced MR technology. The MR system itself (1.5T Signa EXCITE II EchoSpeed+ 4 Channel Vector 200 Mobile MR System) is a high-performance, whole-body MR system that features an actively shielded magnet, detachable patient table, actively shielded high-performance gradients, phased array digital RF electronics, and the Linux operating system. EXCITE II ScanTools 11.0 software is used to deliver a full range of pulse sequences and analysis for whole-body imaging and includes the spin echo, fast spin echo, fast gradient echo, time-of-flight, phase contrast, and echo planar pulse sequences. The MR unit also has a six-element, multi-station coil array that delivers high SNR and spatial resolution over the full range of spine, soft-tissue neck, and carotid studies.

The Mobile MRI has a staff of medical experts and a support staff who will work with patients needing referrals to the appropriate physicians. BTF will be working with these professionals, as well as gathering brain scan data to be analyzed for national health and research institutions on the demographics and epidemiology of brain tumors. 

At the 2004 and 2005 Brain Tumor Awareness Day conventions, 93 people signed up for a brain scan. Six were diagnosed with brain tumors, and eighteen others were diagnosed with other brain abnormalities. These results corroborate recent studies projecting that nearly one million people in the US are walking around with a brain tumor but are undiagnosed, with 25,000 in NYC alone.

Although no cures exist yet, the impact of brain tumors can be vastly reduced with such innovations as the Mobile MRI Unit. By detecting and treating brain tumors early on, thousands of New Yorkers will be saved from almost certain death and human

suffering, as well as signifi cant fi nances, due to job loss, health insurance, hospitalizations, and costly treatments. With The Road to Early Detection campaign, we are steering toward a future in which the pain and anguish suffered by cancer patients and their loved ones may exist no longer, and brain tumors can be completely eradicated. For more on the 

Michael Schreiber is the chairman of Th e Road to Early Detection campaign.

On November 29, 2006, The Brain Tumor Foundation(BTF) launched The Road to Early Detection, an unprecedented nationwide campaign aimed at broadening public awareness about brain tumors ...

The Road to Early Detection: Mobile MRI Unit Leaving Brain Tumor Deaths Trailing Behind

We spoke with Terry Rabinowitz, MD, FAPA, FAPM, Associate Professor of Psychiatry & Family Medicine, Director of Telepsychiatry, University of Vermont Fletcher Allen Health Care hospital, Burlington, VT, to learn more about the use of telemedicine in modern practice.

How do you decide when to employ telemedicine, and what technology is needed on both ends of the consultation?

The decision to use telemedicine is based on many variables. “Does the patient have access in their local area to the needed services?” and “If they have physical access, are the people who would provide those services available in a timely way?” are two questions that have to be asked about any person before a telemedicine consultation.

Our equipment includes a high-resolution, auto-focus video camera that has pan, tilt, and zoom capabilities; we use a high-resolution monitor, as well. The video is transmitted over telephone or Internet lines, and I use a remote control to operate the camera that is filming the patient. Also, we use picture-in-picture capability, so I can see what I look like to the patient, because the video camera sits just above the monitor; if I were to look into their eyes, it would be as if I weren’t looking into their eyes with respect to the camera. I can monitor if they see me close up or far away, and I will vary the image a little. 

I first get a briefing from a nurse facilitator without the patient present, and then I invite the patient in for evaluation. Sometimes, they’re accompanied by one or more family members. I’ve found that for the vast majority of patients, when accompanied by family, the interview is much better. I get much more information.

How does telemedicine compare to face-to-face interaction? What do your patients say?

I haven’t had a single patient who hasn’t liked the technology or the modality. One patient said she preferred it to face-to-face interaction, because she felt less nervous without me in the room. Much to my surprise, I also find it may be superior in a lot of ways to face-to-face interviewing, because I have remote control over the patient’s camera, which is very quiet and unobtrusive. I can move that camera and zoom in and out with virtually no disruption of the interview. I can ask an emotionally charged question and zoom in on the patient’s face or hands. Sometimes, people don’t want to tell you everything they feel, but I can see their immediate response to the question before they have an opportunity to cover up that response. I can also ask a question of the patient but focus on a family member and see what their response is to that question. 

What benefits does telemedicine offer across all medical specialties?

It enables us to treat patients who would otherwise not have access to the particular medical specialty or sub-specialty they require. It will also likely provide a cost savings function, because the video conference itself is not very expensive. The initial outlay for the equipment may be a little high, but that’s a one-time event, and it doesn’t wear out very quickly. We also know that more timely consultation in any area leads to improvement in healthcare and outcomes. Another benefit is that telemedicine makes it easier to consult with an expert from another specialty. For instance, if in the course of performing a telepsychiatry consultation for a patient in New York I realized that he had a rare medical condition—and it turns out that the world’s expert on that condition is in the Netherlands&mdash;through a relatively easy set of steps, we could arrange for a three-way video conference to have this patient evaluated and seen by that expert, enhancing the chances for more optimal treatment.

How much does it cost to set up a telemedicine center?

The initial investment for a high-quality video camera and monitor runs about $7,000, plus the appropriate computer software to interface, and then the phone or Internet line charges.

For telepsychiatry, and I believe this is the case for all other telemedicine services, Medicare is willing to reimburse for services at identical rates to face-to-face services. Many private insurers still are not willing to pay for these services, but I think we will be able to get increased buy-in from private insurers as they see that these consultations are likely to save them money in the long run.

Do you archive the video consultations for later review?

Yes we do. We ask for permission when we are interested in video-taping, and we receive permission from all persons who attend the conference. We also tell them the reasons for taping it could be for student, faculty, and resident education; to help in the review of the case; or for help in getting input from colleagues or experts. 

My goal is to try to get as many people as possible at all different levels educated about telemedicine. That’s the best way to enhance the chances that this technology will be accepted. Most people are a bi technophobic, afraid of new technology. Once they see it in operation, I think virtually all of them are impressed and convinced that this can work.

The Association of Telehealth Service Providers

We spoke with Terry Rabinowitz, MD, FAPA, FAPM, Associate Professor of Psychiatry & Family Medicine, Director of Telepsychiatry, University of Vermont Fletcher Allen Health Care hospital ...

A Day in the Life of...A Virtual Doctor

Information technology plays an important role in many aspects of our society and is an emerging force in the healthcare industry. One area of health IT that shows great promise is remote health monitoring, which during the past 10 years has risen from humble beginnings to become a significant player in healthcare. 

 spoke with Joseph Kvedar, MD, director of the 

 in Boston, MA, who explained that “remote health monitoring involves the use of sensor technologies, primarily to gather physiologic information about patients that allows care providers, as well as patients, to make decisions about the care without actually being in the same room.”

Remote health monitoring is designed to help empower patients in becoming more actively involved with their personal health management. Patients with a chronic illness, such as diabetes, asthma, or chronic heart failure, need to be motivated to follow management plans and make necessary lifestyle modifications in order to minimize the chances that they’ll develop additional complications that could further jeopardize their health, thus requiring expensive treatment. The feedback provided by constant monitoring can help reinforce adherence and good health practices. 

 in remote health monitoring have even found that patients who use the technology make fewer unnecessary doctor visits and are less likely to require hospitalization. Remote health monitoring can also help 

. “If an organization plans patient visits every three days at a cost of $100 per visit, for example, over a 60-day period, the cost is $2,000 for 20 visits." Mark VanderWerf, president of American Medical Development (AMD) Telemedicine, said that incorporating remote health monitoring into such a patient’s care may mean that patient “might only visit [the doctor’s office] seven to nine times in the 60-day period, so for each 60 days, you save in excess of $1,000.” 

Remote health monitoring systems also provide tools for patients that enable them to learn about and understand their illness, so they can walk into a doctor’s office feeling more confident. Companies like 

 have worked hard to incorporate educational modules into their products as a way to encourage self-management. 

 spoke about the advantages of incorporating remote health monitoring tools into patient care with R. William Vandivier, MD, clinical director of the Chronic Obstructive Pulmonary Disease (COPD) Center at the University of Colorado Hospital. “I think ultimately they [the patients] get better care,” he said.

Self-management and education are essential parts of the treatment plan for patients who have a chronic illness, according to Health Hero Network, Inc., which has incorporated tools into its monitoring systems to enable patients to take a more active role in their own care. The Health Buddy System®, a user-friendly four-button device with a large screen, is the company’s flagship program. It “integrates home health monitoring technology with clinical information databases, Internet-enabled decision support tools, health management programs, and content development tools.” With the ability to support 130 programs—10 with 

 certification—that remotely monitor 30 different conditions (eg, cardiovascular, endocrine, psychiatry), the Health Buddy can be used by practitioners in just about any medical specialty. Its educational content “can be combined into programs that address a single disease state or comorbid conditions or even trimorbid conditions,” says Suneel Ratan, Vice President of Business Development at Health Hero. “That’s the first degree of personalization for the patient&mdash;it’s personalized to their condition.” 

The Health Buddy also sends a daily transmission of specified patient data based on a set of rules established by the healthcare professional depending on what illness is being monitored. Patients will spend about 10 minutes with the Health Buddy answering questions (eg, “How are you feeling today?”) and connecting other devices that measure vital signs so the information can be uploaded into the system. “It will assess [the patient’s] behavior and [give them] coaching about their behavior,” said Ratan. “They’ll be assessed about their knowledge of their condition and given feedback and [further] education about their condition.” The device dials into a set 1-800 number overnight and uploads data and results to a physician interface—which can manage up to 200 or 300 patients&mdash;for care managers and care providers to view the following morning. Patients whose vital signs and symptoms show an adverse change will be automatically placed at the top of a contact list, making it easier for a care provider to follow up with those patients at a higher risk, reducing the amount of time spent on the phone. This way, they’re “only managing the 5-7% who are showing up as high-risk for signs and symptoms on a given day,” said Ratan.

Additionally, Health Hero offers monitoring and educational capabilities for cancer patients through its 

. The primary focus of the cancer program is to “address the physical and emotional needs of patients dealing with various types of cancer” such as lung cancer; offer support for patients undergoing chemotherapy, and assist in helping patients maintain a positive mental attitude. Features include educational information and medication reminders, symptom monitoring, and affirmation or fun trivia questions upon completion of each daily session.

With a focus on providing user-friendly capabilities to upload realtime patient data from biometric devices into personal health records (PHR), 

 is “a pioneer in Internet-based remote health monitoring systems [and] serves those managing asthma, diabetes, pulmonary disease, hypertension, cardiovascular disease, congestive heart failure [CHF], and HIV/AIDS.” Although MediCompass Connect®, which “enables the collection of data that can be shared by members with their care team between provider visits,” is iMetrikus’ main focus, it’s the 

 that may be the more interesting health monitoring resource, due to its ability to connect to more than 30 monitoring devices from different companies. MetrikLink transmits information through a telephone line or over the Internet, enabling authorized members of the healthcare team to easily review patients’ data. As part of MediCompass, it serves as a “universal communication gateway that securely transfers data from health monitoring and point-of-care devices.” Robert Murphy, Senior Vice President of Marketing, told 

, that “MetrikLink is really where our core development is and where our unique place in the marketplace is.” 

 is a company whose main focus is to “develop portable and easy-to-use tests” for many markets, including healthcare. The company has devised “low-cost disposable tests that yield quantitative results without the need for costly instruments” for a variety of medical specialties (including oncology). One product, the PortaWBC white blood cell count test, is ideal for the approximately 1.5 million patients nationwide who undergo chemotherapy every year. It is important for each of these patients to have their white blood cell (WBC) levels tested before every chemotherapy treatment; a portable tester is an ideal way to promote timely monitoring and ensure that WBC count is at the appropriate level before each session. The 

 is the “first affordable WBC count test that patients can easily perform in the convenience of their home.” Some of the advantages include in-home convenience, laboratory accuracy, fast results, user-friendly capabilities, and inexpensive cost.

The companies that create and distribute remote health monitoring products are understandably enthusiastic about the technology’s potential to help improve healthcare outcomes in a variety of disease states and patient populations. But what do some of the healthcare professionals who have studied remote health monitoring and incorporated it into practice have to say? 

One benefit of remote health monitoring technology touted by supporters is its ability to increase access to care for geographically underserved areas. Because patients in rural areas often have a much harder time than their urban and suburban counterparts when it comes to accessing medical care, a study is being conducted at the 

, under the direction of Dr. Vandivier, to measure the effectiveness of remote health monitoring in patients with COPD who live in urban and rural regions of Colorado. “Urban medicine is kind of different than rural medicine, so we’ve partnered with 

, and we’re enrolling patients from both of our sites,” Dr. Vandivier told 

. “We’re also doing rural medicine, which we’re maybe even more excited about because a lot of patients out in these counties in Colorado that are rural or even frontier— which have even fewer people&mdash;have a lot harder time getting their medical care.” 

The study, known as the Advanced eHealth for COPD in Colorado Program, is designed to “evaluate the impact of the eHealth approach on reducing healthcare costs and improving quality of life for participants.” The study will provide up to 400 patients with a pulse oximeter, a hand-held spirometer (for exhaled breath monitoring), a pedometer, and an electronic communication device, which they will use to make daily reports of their selfmonitored health information to healthcare

professionals at Kaiser and the University of Colorado, who will in turn provide patients with educational information about COPD and “contact any participant who has a monitored parameter in a questionable range and determine what interventions may be needed.” The study is also looking at the economic impact of remote health monitoring. 

 from a pilot program showed that remote monitoring saved “nearly $3,200 per patient over just a 12-week period, largely by alerting healthcare providers to signs of developing problems before they ballooned into larger complications.”

, “Initially, I actually was skeptical of this sort of mechanism to teach patients about their disease and to administer care to them, but I am a true believer in it now. I think for our patients, it’s really made a huge difference.” 

Another remote health monitoring program, conducted by the 

, is focusing on “extending the care community beyond the traditional walls of healthcare institutions by bringing healthcare to the everyday surrounding of the health consumer and their families.” Dr. Kvedar told 

 that the Center runs many programs and initiatives to measure the effectiveness of remote monitoring of patients with chronic diseases. The Center has analyzed “the latest data on years of patients going through that kind of a process” and found that “the hospitalization rate for patients on the intervention is reduced from a former rate of 22% to 5%.” The 

 is also looking at how “new models of care that extend and enhance the physician—patient relationship are emerging through innovation of technology and process.”

We had a bit to say on the topic of the patient—physician relationship in our 

, “The 21st Century Patient—Physician Relationship.”

With regard to his personal experience with remote health monitoring technology, Dr. Kvedar said, “Remote monitoring means that I can take care of almost all of the aspects that I would normally rely on the physical examination in the office to give me without being in the office with the patient.” 

Even the government has recognized the importance of using remote health monitoring for patients with chronic illnesses. In fact, on February 15, US Senator Norm Coleman (R-MN) introduced the 

, which would “provide for coverage of remote patient management services for chronic healthcare conditions under the Medicare Program.” The text of the bill included nine statements (or “findings”), including: “Remote patient monitoring can make chronic disease management more effective and efficient for patients and the health care system” and “Utilization of these technologies not only improves the quality of care given to patients, it also reduces the need for frequent physician office appointments, costly emergency room visits, and unnecessary hospitalizations.”

 stated that over the next decade, it will become increasingly more difficult for patients to find new oncologists. This gradual decline may be attributed to an ongoing rush of cancer patients, creating an increased demand on the already limited supply of physicians currently available. 

The anticipated shortage is due not only to rising needs, but also to the limited rate at which oncologists are entering the field (approximately 10,400 oncologists are currently employed in the US, with only 500 new ones entering the field each subsequent year). The cause? Nearly half of these physicians are nearing retirement themselves. This accounts for an approximate 27 oncologists for every 100,000 US senior citizens.

Ultimately, it is the cancer patient who will suffer this staggering decline in healthcare accessibility. Because of the difficulty in training new physicians in an adequate and timely fashion, treatment will be unable to keep up. Among the various treatments at risk are cancer vaccines and recent advances in preventative care. 

When asked if remote health monitoring could help to lessen the impact of this particular problem, Kvedar says, “There are several advantages to having a connective health view of the healthcare system. One of those is that individuals that can make informed decisions about patient care, including patients themselves, do not have to be doctors all the time.” Kvedar further discussed how remote health monitoring may make it easier for the physician to “take more of an oversight role in care. The technology allows for a complete physio-logic picture to be in front of a doctor, and perhaps a care provider that’s closer to the action, say a home care nurse, can make decisions about that care much more effectively because of the richness of the information.”

Do You Think Remote Health Monitoring Will Revolutionize the Healthcare Industry?

“I think that it’s more a question of technology has evolved and how it continues to evolve, how people market it to consumers, and individuals becoming more accustomed and acclimated to using the technology in their everyday lives. That’s where it becomes revolutionary.”

Senior Vice President of Marketing, iMetrikus

“We believe it has the power. We believe it’s going to take a lot of work to do it, but that in the next three to five years, you’ll see a significant increase in the number and types of remote monitoring that are occurring in our healthcare system.”

Vice President of Business Development, Health Hero

“I do think it will revolutionize healthcare simply because it will help us get proper care to people in all sorts of situations. People are so much more electronically savvy these days that for the first time, they’re going to be able to actually use these kinds of systems. I definitely think it is important, but I also don’t think remote health monitoring is a substitute for real people.”

Council on Aging — The Health Hero® Technology Platform

 editor, Erin Romanski, also contributed to this article.

Remote health monitoring empowers patients and physicians, increases access to healthcare services, and helps reduce healthcare costs.

Long Distance Dedication: Remote Health Monitoring

As early as November 2001, the increasing popularity of Internet consultations without a previous relationship between physician and patient was well recognized, enough that Swedish researchers conducted a study that lasted through January 2002 to “investigate how an Internet-based 

 service without any preexisting doctor—patient relationship was used and evaluated by the enquirers.” Their findings, published in April 2006, show that such services are appreciated for their convenience and flexibility and the ability for users to reflect upon diagnoses, second opinions, and advice from a physician as opposed to attempting to remember conversations during a face-to-face meeting with a doctor.

Dozens of sites have popped up during the past six or seven years, and even earlier, offering advice (see O

 below), diagnoses, second opinions, and even prescriptions from doctors who never physically meet the person with whom they are consulting. Dale C. Alverson, MD, Medical Director of the Center for Telehealth and Cybermedicine Research at the 

University of New Mexico Health Sciences Center

that the popularity of such sites has risen “because of the gaps in access to services and the limited resources that we have to provide services. The tools of telehealth— the information communication technologies&mdash;offer opportunities to reach out to people who need services they can’t receive easily and also provide a way for healthcare professionals to virtually extend themselves to those people.” Further, the anonymity such sites offer to patients has also spurred their interest. “If you want Viagra or whatever it may be, and you don’t want to go to the doctor, that’s one way to get it. It’s a huge marketplace,” adds Rob Sprang, MD, Center for Telehealth & E-Health Law board of directors, and director of 

, University of Kentucky College of Medicine. 

, where individuals seeking health information provide answers to a comprehensive set of questions regarding weight, diet and other habits (smoking, alcohol intake, exercise, etc), immunizations, current medications and health supplements, current and previous family and personal health issues, presenting symptoms, and other factors. The information provided is aggregated to produce a thorough report that displays all replies entered, suggestions regarding what to do based on them, and the probability of certain diagnoses and their urgency.

Patients can then save their summary and, for $50, obtain comments on all aspects from a physician and ask a medical question to be answered by that physician. Users can also conveniently link right to the sister site 

, where questions can be asked of a general physician for $60. Similarly, 

 “a diagnosis and treatment program that uses medical specialists to accurately diagnose symptoms…with a program created by 1,500 specialist physicians”— and its sister site 

—“a treatment program that uses medical specialists to accurately select the best and newest treatment for each patient, based on individual patient’s characteristics”&mdash;offer their services through a one-year subscription of $9.99.

Without regard to safety, it’s clear why patients would want to take advantage of the services provided by the above sites, but we can only speculate as to why a US oncologist would participate (please e-mail us at 

 if you participate, know someone who does, or have thoughts on the matter). Although Online Medical Diagnosis lists its associated physicians, no contact or affiliation information is provided, and when we searched for the individuals using Google and Yahoo, either no actual physician turned up or the name was so common that it would be difficult to determine who was the physician in question. Further, e-mail messages sent to the only site listing direct contact information for its doctor(s) and other staff were immediately bounced back, and calls to corporate numbers lead to unreturned voice mail messages and/or a bunch of “I don’t know, let me transfer you to…”

Given how difficult it is to actually contact any of the doctors working with these sites or look up the names of those that may be listed, it’s nearly—and likely purposely&mdash;impossible to confirm their legitimacy. “I can’t imagine that they are legitimate physicians,” said Sprang. “I realize there are doctors that may use the Internet for existing patients to help them renew prescriptions or make modifications to prescriptions, but anyone who associates with these blind Internet operations should have their medical license revoked. It’s unquestionably inappropriate.”

So, with a clear negative stigma surrounding them, why would an oncologist get involved with an online consulting or prescribing service? Aside from providing an easy way to make a buck without having to deal with coding, reimbursement, or typical office hours, oncologists who offer consultations and prescriptions online can take as long as they want to provide answers or information to patients, and can do so from the comforts of their own home should they so chose.

However, “Any physician who gets involved with this, I really have to question,” added Sprang. “There are a lot of legitimate physicians who are turning to the Internet to facilitate contact with physicians. It’s a brilliant application of the technology.” Sprang stresses the importance of differentiating between the legitimate practice of telemedicine—treating a patient who is actually viewed and heard via video teleconferencing technology&mdash;and the consultations and prescriptions provided by the services listed in the above sidebar.

Other online physicians and oncologists include those who are using video teleconferencing to establish a relationship with a patient— just as they would with a patient who comes to their office, clinic, or hospital&mdash;and using secure e-mail messaging services and further video conferencing for follow-up (see our feature story from the American Telemedicine Association and our Day in the Life item in the Pulse section for more on this technology). “The premise is that if you use telehealth to provide service,” stated Dr. Alverson, “you should be able to provide that service in the same way you would establish a relationship with the patient face-to-face; that is, you do an adequate history, you make sure that an adequate physical is done&mdash;and that may require a third party. You should perform the examination in a way very similar to how you would if you were seeing the patient physically face-to-face. And that’s actually been a general policy that’s been developed through various national organizations, such as the Center for Telehealth & E-Health Law.”

Sprang feels such practice will “unquestionably” become preferred in the not-too-distant future. “Very few of us are able to live in a community that has access to all of the medical services that you could ever need,” he explained. Telemedicine “is the only way that I can see that we can make sure that you are not penalized for living in a medically underserved area, whether a rural area or in downtown urban areas because of financial constraints.” He notes that the idea of medically underserved populations is often mistakenly only associated with rural areas (see our feature on remote health for more on this). “If you live in downtown Lexington and don’t have a car, you’re medically underserved,” he added. “You’d have to walk all the way across town to get to a doctor’s office; a young mom with a young baby for instance just can’t do that.”

In either case, rural or urban, Dr. Alverson explained to 

that because many people can’t actually make the trip to the office or clinic—regardless of how close it may be&mdash;“many healthcare professionals are beginning to adopt and integrate telehealth, because it allows them to more effectively and consistently provide service to patients.” Primary care providers can now use telehealth to “allow their patients to more easily get oncology services; a primary care provider in a rural community can now offer the ability for the patient to get that service more quickly, more easily when they need it. Oncologists can follow-up with their patients more effectively as well. There’s more and more evidence, particularly in areas of chronic disease and the aging population, that more expedient access to care can be offered through these tools of telehealth, which is improving the health of the people served. There are some good examples of that, even in the home environment, with diseases like cancer and congestive heart failure, in which it’s being shown that problems are being picked up sooner.” He added that because patient management can be rearranged with telehealth, patients are able to remain out of the hospital, improving quality of life and saving the healthcare system money, because the patients aren’t requiring more extensive critical care services.

However convenient and cost-effective providing medical services via telehealth may be, oncologists who do so are faced with additional legal and ethical issues that may hamper their ability to “contend” with the “traditional” oncologist who sees patients only physically, face-to-face. “Modern medical concerns with telemedicine and robotics practiced across national and other jurisdictional boundaries engage the historical, complex area of law called conflict of laws,” wrote Dickens BM and Cook RJ in the July 2005 issue of the 

. Does a practitioner licensed in one jurisdiction and treating a patient in another violate the laws in that other jurisdiction? If that practitioner violates a contract or treats the patient negligently, does the practitioner incur liability in his jurisdiction, the patient’s, or both? What if treatment that is lawful in the practitioner’s jurisdiction isn’t lawful in the patient’s? Is that a crime? These questions have yet to be answered definitively, according to a June 2006 

article. However, the author writes that “it is also the case that health-care professionals who undertake telemedicine in a prudent manner will minimize the possibility of medicolegal complications.”

Although our above-described “pretenders” are a minority in the world of healthcare providers, “there certainly can be the threat that we’ll see more of [them,] because of the difficulty in trying to track these types of people,” explained Dr. Alverson. “There is a legitimate concern about unqualified, unauthorized people creating online services that ask patients to fill out a questionnaire on a Web page and then they send them a prescription. That’s a problem that needs to be monitored. These people and the sites they run can have a fairly large impact because the Internet reaches so many people.” He added that improvements in ways to police such activity and track down what he calls the “Viagra doctors” can help in weeding out the “bad actors.” Dr. Alverson also thinks “we have an obligation to educate the general public about the potential harm that can be done by obtaining your healthcare virtually from someone you don’t know who may not be qualified to provide that service. That gets into the area of authentication who is really on the other end? Are they really qualified to provide this service? That goes for video conferencing as well a person can get on a camera in a live monitor and say he’s a psychiatrist, and patients just have to trust that he is. Now there are some very interesting ways of authentication with biometrics, using fingerprints, retinal scans, and so on. I think we’ll see more of that because of these concerns.” Why haven’t ideas and proposals like Dr. Alverson’s come to fruition? Some states are implementing laws to crack down on care provided across borders via the Internet to patients who are never met by the doctor (see 

 below). Dr. Sprang noted that “Congress has proposed multiple laws, but I don’t know of any that have passed yet.” He added that in the current Kentucky legislative session, Senate bill 88—meant to address these issues&mdash;was introduced and passed in the Senate, sent to the House, amended, and then sent back to the Senate. “I don’t know whether anything is going to happen with this either.”

So, talk to your congressperson, tell him or her about the importance of passing bills like Kentucky’s bill 88. But, when you do, make sure to explain the importance of the bill’s language, warns Sprang. “I’ve been talking to the attorney general of the state, because the attorney general in Kentucky—a very aggressive guy&mdash;decided he had enough and that he was going to push the state legislature to clamp down on this.” In that legislation, “the language said to prescribe medication, you had to have a face-to-face encounter. I’m OK with that, unless you interpret it as we have to be in the same room together, which is possible with a strict interpretation. So, I called him and said ‘look, nobody is more supportive of what you’re trying to do than I am, but you need to make sure you qualify that term as including an interactive videoconference encounter.’ His office said, ‘Oh, we would never want to do anything that would damage telehealth. We value that technology.’ So, they came back and wrote in the legislation also including an encounter as defined in my telehealth legislation. It protected us. That’s my only concern with being too zealous about going after this legislatively. If you don’t carefully craft the language, you could put the telehealth industry out of business. Nobody is more supportive of fighting the Internet pharmacies than the telehealth industry, just be careful when you write the legislation that you don’t throw the baby out with the bathwater.”

When it comes to legitimate telemedicine, unless you plan on retiring anytime soon, it’s certainly worth your while to at least check out the technology. Telemedicine is here to stay and growing in numbers and popularity. After all, if you can’t beat ’em, join ’em.

Sites Offering Cancer-Specific Consultation Services

Dozens of websites have popped up over the past few years offering
advice, diagnoses, second opinions, and even prescriptions from
physicians who never physically meet the patient.

Online Oncologists: Contenders or Pretenders?

What remains less certain, and unquestionably disturbing, is the degree to which this profoundly powerful tool—available to patients, physicians, researchers, and the general public&mdash;may actually be employed in ways that result in genuine harm.

addressed this very topic, as it applies to traditional African medicine. Consider, for instance, the report from investigators at the 

, who queried a group of patients (n= 212) participating in phase I clinical trials on their use of unapproved biologically-based complementary and alternative medicine (CAM). Following their entry into the trials, these patients were scheduled to receive highly experimental 

Few, if any, would argue with the statement that the Internet has revolutionized health-related communication.


April 2007 | Oncology Live®