Telemedicine in remote areas

An interesting telemedicine story from Brazil told in Israel

Here's how providers at the Hospital Israelita Albert Einstein in Brazil take care of workers on an oil platform away from the continent. 

 

 

Photo: Roy Habani

 

Telemedicine as a technology is gaining ground all over the world. How it is being used on an oil platform in Brazil provides a fascinating look at how effective it can be both as a means to deliver care and in lowering costs.

The story was shared by Dr. Eduardo Cordioli, general telemedicine manager at the Hospital Israelita Albert Einstein in Sao Paolo, Brazil. Cordiolo was a speaker at the recently-concluded MedinIsrael digital health conference in Tel Aviv, which aimed to highlight how Israel has adopted digital health as a national strategy and where the technology is globally.

Hospital Israelita Albert Einstein is a teaching hospital, with a medical school and separate nursing school. The main hospital, which is a private hospital, has 650 beds but executives also manages two public Brazilian hospitals together with the city where they are located and the Brazilian ministry of health. They also have locations for clinics and ambulatory care. It employs 14,000 people.

Caring for oil platform workers far from the mainland is tricky and in virtually all instances prior to the launch of the telemedicine program required urgent, immediate evacuations from the platform via a helicopter to a hospital on the mainland with the necessary resources.

But in 2017, the hospital conducted 965 telemedicine visits between urgent care nurses on the oil platform and physicians at the hospital on the continent. Here’s the type of connected devices – shown in the presentation – that the telemedicine program relied on for diagnosis.

Photo: Roy Habani

Of those 965 appointments, a whopping 93.2 percent let to patient discharge. Only 6.8 percent of the visits therefore needed evacuations –  that’s a 50 percent reduction from when the telemedicine program was not in place, Dr. Cordioli said. And there appears to be an even better statistic. Of those 6.8 percent requiring evacuations, the majority — 71.4 percent —required non-urgent flights.

Previously, the evacuations were a 100 percent urgent evacuations as the urgent care nurses on the oil platform would not have been able to judge the acuity of the problem. Urgent helicopter evacuations are far more expensive than planned ones, Dr. Cordioli explained.

Later, in an interview Dr. Sidney Klajner, president of the Hospital Israelita Albert Einstein, said that through the telemedicine program, even myocardial infarctions or heart attacks, were able to be diagnosed.

Since the telemedicine program was launched in 2012, the number of video visits have seen an exponential increase. Just in the last three years, the number of appointments went from 7,000 in 2016 to 45,000 in 2017 to 80,000 video visits in 2018.

“We have a huge country and there is a lot of differences between the states. We have rich states like Sao Paolo, Sao Paolo city and the southeast of the country but we have very poor regions also with people who have no access to medicine to care and specialists for example,” Klajner said.

Telemedicine attempts to bridge this very gap. For instance in the northeast portion of Brazil, there is a shortage of specialists and so in ICUs, the telemedicine program is aimed to connect “generalists” with specialists like neurologists and cardiologists. These specialists are now responsible for a certain number of “virtual beds,” he explained.

Aside from this, the hospital has also created a proprietary dermatology app to help in diagnosing skin problems remotely.

“The team can suggest diagnosis or urgent biopsy based on the picture [through the app] and the patient history,” Klajner explained.

He noted that the focus on telemedicine is only part of the digital transformation that is underway at the hospital. Another big change was the removal of an innovation center from the hospital’s research institute about four or five years ago. The innovation center was created to rapidly innovate, prototype and validate ideas within the hospital ecosystem. This is both meant to encourage innovative thinking among hospital employees including physicians and encourage external collaboration.

For instance, a year and a half ago an incubator was created, he said. More than 1,000 Brazilian startups have been able to submit their ideas. The hospital has also acquired a health IT startup that has developed a next-generation sequencing software.

So, it’s not just telemedicine that the health system that serves nearly 1.5 million people is looking at for a digital transformation. But the telemedicine story on the oil platform is certainly compelling.

Inovação em Neurocirurgia

Médicos da USP usam smartphones para cirurgias no cérebro

Em artigo científico, pesquisadores demonstraram a integração entre celulares e endoscópios em 42 neurocirurgias realizadas no Hospital das Clínicas; recurso facilita manipulação do equipamento, tornando procedimento mais intuitivo e seguro

Fábio de Castro

Uma equipe de médicos brasileiros demonstrou que smartphones podem facilitar e baratear as neurocirurgias. Os pesquisadores, do Hospital das Clínicas (HC) da Universidade de São Paulo (USP) adaptaram smartphones ao endoscópio - o instrumento utilizado para observar o interior do organismo. O novo recurso foi descrito em um artigo publicado nesta terça-feira, 13 na principal revista científica internacional de neurocirurgia, Journal of Neurosurgery.

A neuroendoscopia é um procedimento neurocirúrgico pouco invasivo utilizado em alguns casos para corrigir hidrocefalia, remover tumores, tratar doenças vasculares e outros problemas no cérebro. No novo estudo, os cientistas demonstraram a aplicação do novo recurso em neurocirurgias realizadas em 42 pacientes no HC.

De acordo com o autor principal do estudo, Maurício Mandel, do HC-USP e do Hospital Israelita Albert Einstein, a ideia inicial era apenas baratear os procedimentos de neuroendoscopia, mas o recurso acabou mostrando diversas vantagens em relação aos métodos convencionais.  

Segundo ele, um sistema de neuroendoscopia custa de R$ 200 mil a R$ 300 mil. A nova opção os custos são reduzidos ao preço de um iPhone - a marca de smartphone utilizada no estudo - e do adaptador que integra o endoscópio ao celular, que custa cerca de R$ 1 mil. 

Parte inferior do form"Com essa redução de custos, é muito provável que esse recurso possa ser utilizado no SUS, em várias escalas, com aplicação em outros tipos de cirurgia. Mas ao desenvolver o novo sistema, descobrimos que o trabalho do cirurgião também se torna mais seguro e mais simples", disse Mandel ao Estado. 

 

"Com o smartphone, o cirurgião não precisa virar a cabeça para olhar o monitor. Em vez disso, ele utiliza o celular como uma tela de alta definição bem na frente do endoscópio", disse Maurício Mandel, um dos autores do artigo publicado na revista Journal of Neurosurgery. Foto: Journal of Neurosurgery / Maurício Mandel

De acordo com Mandel, com o método convencional, o cirurgião introduz um neuroendoscópio em uma pequena incisão no crânio, no nariz ou no céu da boca do paciente. O neuroendoscópio inclui uma fonte de luz para iluminar o campo de cirurgia, lentes de aumento e uma câmera, que envia as imagens a um monitor na sala de operação, além de canais para inserção de instrumentos cirúrgicos.

"Com o smartphone, o cirurgião não precisa virar a cabeça para olhar o monitor. Em vez disso, ele utiliza o celular como uma tela de alta definição bem na frente do endoscópio. Com isso, ganhamos a enorme vantagem de podermos olhar para o campo cirúrgico enquanto trabalhamos. Isso facilita a manobra do equipamento, porque a tela se move junto com o endoscópio, tornando o procedimento muito mais intuitivo e seguro", explicou Mandel. 

Além disso, segundo Mandel, o método permite gravar e transmitir em tempo real - por wi-fi ou bluetooth - todas as imagens da neurocirurgia. Elas podem ser enviadas, por exemplo, a um monitor onde outros cirurgiões podem acompanhar o procedimento. "Com o celular acoplado, temos a possibilidade de transmitir a cirurgia ao vivo para um colega em qualquer parte do mundo."

"O recurso abre portas para algumas possibilidades que nem imaginamos ainda. Às vezes, na medicina, há casos difíceis ou raros que mesmo um cirurgião muito experiente pode nunca ter encontrado em sua carreira. Se temos a oportunidade de compartilhar a cirurgia ao vivo com um colega mais experiente, isso pode ser muito bom para os pacientes", disse Mandel.

Recurso pedagógico. Segundo Mandel, o estudo descreve o uso do smartphone adaptado ao neuroendoscópio em cirurgias realizadas em 42 pacientes, mas a equipe do HC já utilizou o recurso em mais de 150 casos - incluindo tratamento para hidrocefalia, aneurismas e a retirada de hematomas provocados por trauma. De acordo com ele, como todos os passos da cirurgia são gravados, o conteúdo está sendo utilizado também para fins pedagógicos.

"Mostramos também no estudo que a integração de smartphone e neuroendoscópio proporcionou que nossos residentes aprendessem muito mais rápido a realizar neurocirurgias." 

O acoplador utilizado pelos pesquisadores para integrar smartphone e neuroendoscópio já existia no mercado e era utilizado especialmente para facilitar a entubação de pacientes. "Tivemos a ideia de utilizar o acoplador para a neurocirurgia. Foi preciso fazer algumas adaptações", contou Mandel.

Durante as cirurgias descritas no estudo, os pesquisadores utilizaram iPhones modelos 4, 5 e 6, combinados com diversos tipos de neuroendoscópios. As imagens foram enviadas por wi-fi diretamente a um monitor de vídeo que permaneceu na sala de operação, para o caso de ser necessário utilizar o procedimento convencional. Mas não foi preciso recorrer ao monitor externo nenhuma vez. 

Todas as cirurgias foram bem sucedidas e não houve nenhum tipo de complicação relacionada ao uso do smartphone, de acordo com o estudo. Uma das conclusões do artigo é que o baixo custo do novo recurso permite sua utilização em áreas onde a infraestrutura médica não é suficiente para a aquisição e manutenção de equipamentos caros.

Além de Mandel, os demais autores do artigo são  Carlo Emanuel Petito e Rafael Tutihashi, também do HC-USP e do Hospital Albert Einstein, Wellingson Paiva, Fernando Gomes Pinto, Almir Ferreira de Andrade, Manoel Jacobsen Teixeira e Eberval Gadelha Figueiredo - todos do HC-USP - e Suzana Abramovicz Mandel, do Hospital Albert Einstein.

 

Information Technology

Problems with health information technology and their effects on care delivery and patient outcomes: a systematic review

Mi Ok Kim Enrico Coiera Farah Magrabi

Journal of the American Medical Informatics Association, Volume 24, Issue 2, 1 March 2017, Pages 246–250, https://doi.org/10.1093/jamia/ocw154

Objective: To systematically review studies reporting problems with information technology (IT) in health care and their effects on care delivery and patient outcomes.

Materials and methods: We searched bibliographic databases including Scopus, PubMed, and Science Citation Index Expanded from January 2004 to December 2015 for studies reporting problems with IT and their effects. A framework called the information value chain, which connects technology use to final outcome, was used to assess how IT problems affect user interaction, information receipt, decision-making, care processes, and patient outcomes. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results: Of the 34 studies identified, the majority (n = 14, 41%) were analyses of incidents reported from 6 countries. There were 7 descriptive studies, 9 ethnographic studies, and 4 case reports. The types of IT problems were similar to those described in earlier classifications of safety problems associated with health IT. The frequency, scale, and severity of IT problems were not adequately captured within these studies. Use errors and poor user interfaces interfered with the receipt of information and led to errors of commission when making decisions. Clinical errors involving medications were well characterized. Issues with system functionality, including poor user interfaces and fragmented displays, delayed care delivery. Issues with system access, system configuration, and software updates also delayed care. In 18 studies (53%), IT problems were linked to patient harm and death. Near-miss events were reported in 10 studies (29%).

Discussion and conclusion: The research evidence describing problems with health IT remains largely qualitative, and many opportunities remain to systematically study and quantify risks and benefits with regard to patient safety. The information value chain, when used in conjunction with existing classifications for health IT safety problems, can enhance measurement and should facilitate identification of the most significant risks to patient safety.

Keywords: health information technology, patient safety, adverse events, systematic review, unintended consequences

Medical virtualists

Is It Time for a New Medical Specialty?The Medical Virtualist

Michael Nochomovitz, MD¹; Rahul Sharma, MD, MBA²

   

¹New York Presbyterian, New York, New York    ²New York Presbyterian, Weill Cornell Medicine, New York, New York

JAMA. Published online November 27, 2017.     doi:10.1001/jama.2017.17094

Medicine has seen a proliferation of specialties over the last 50 years, as scientific discovery and care delivery advanced. Diagnoses and treatments have become more complex, so the need for formal training for specialty competence in cognitive and surgical disciplines has become clear. There are currently 860 000 physicians with active certifications through the American Board of Medical Specialties and 34 000 through the American Osteopathic Association.¹

Drivers of Specialty Expansion

Specialty development has been driven by advances in technology and expansion of knowledge in care delivery. Physician-led teams leverage technology and new knowledge into a structured approach for a medical discipline, which gains a momentum of its own with adoption. For instance, critical care was not a unique specialty until 30 years ago. The refinement in ventilator techniques, cardiac monitoring and intervention, anesthesia, and surgical advancements drove the development of the specialty and certification, with subsequent subspecialization (eg, neurological intensive care). The development of laparoscopic and robotic surgical equipment, with advanced imaging, spawned new specialty and subspecialty categories including colon and rectal surgery, general surgical oncology, interventional radiology, and electrophysiology.

In nonprocedural areas, unique certification was established for geriatrics and palliative care. Additional new specialties include hospitalists, laborists, and extensivists, to name a few. These clinical areas do not yet have formal training programs or certification but are specific disciplines with core competencies and measures of performance that might be likely recognized in the future.

Telemedicine and Medical Care

Telemedicine is the delivery of health care services remotely by the use of various telecommunications modalities. The expansion of web-based services, use of videoconferencing in daily communication, and social media coupled with the demand for convenience by consumers of health care are all factors driving exponential growth in telehealth.²

According to one estimate, the global telehealth market is projected to increase at an annual compounded rate of 30% between 2017 and 2022, achieving an estimated value of $12.1 billion.² Some recent market surveys show that more than 70% of consumers would consider a virtual health care service.³ A preponderance of higher income and privately insured consumers indicate a preference for telehealth, particularly when reassured of the quality of the care and the appropriate scope of the virtual visit.³ Telemedicine is being used to provide health care to some traditionally underserved and rural areas across the United States and increased shortages of primary care and specialty physicians are anticipated in those areas.⁴

A New Specialty

Digital advances within health care and patients acting more like consumers have resulted in more physicians and other clinicians delivering virtual care in almost every medical discipline. Second-opinion services, emergency department express care, virtual intensive care units (ICUs), telestroke with mobile stroke units, telepsychiatry, and remote services for postacute care are some examples.

In the traditional physician office, answering services and web-based portals focused on telephone and email communication. The advent of telehealth has resulted in incremental growth of video face-to-face communication with patients by mobile phone, tablet, or other computer devices.^2,3,5 In larger enterprises or commercial ventures, the scale is sufficient to “make or buy” centralized telehealth command centers to service functions across broad geographic areas including international.

Early telehealth focused on minor ailments such as coughs, colds, and rashes, but now telehealth is being used in broader applications, such as communicating imaging and laboratory results, changing medication, and most significantly managing more complex chronic disease.

The coordination of virtual care with home visits, remote monitoring, and simultaneous family engagement is changing the perception and reality of virtual health care. Commercialization is well under way with numerous start-ups and more established companies. These services are provided by the companies alone or in collaboration with physician groups.

The Medical Virtualist

We propose the concept of a new specialty representing the medical virtualist. This term could be used to describe physicians who will spend the majority or all of their time caring for patients using a virtual medium. A professional consensus will be needed on a set of core competencies to be further developed over time.

Physicians now spend variable amounts of time delivering care through a virtual medium without formal training. Training should include techniques in achieving good webside manner.⁵ Some components of a physical examination can be conducted virtually via patient or caregiver. Some commercial insurance carriers and institutional groups have developed training courses.⁵ These are neither associated with a medical specialty board or society consensus or oversight nor with an associated certification.

Contemporary care is multidisciplinary, including nurses, medical students, nurse practitioners, physician assistants, pharmacists, social workers, nutritionists, counselors, and educators. All require formal training in virtual encounters to ensure a similar quality outcome as is expected for in-person care.

It is possible that there could be a need for physicians across multiple disciplines to become full-time medical virtualists with subspecialty differentiation. Examples could be urgent care virtualists, intensive care virtualists, neurological virtualists, and psychiatric or behavioral virtualists. This shift would not preclude virtual visits from becoming a totally integrated component of all practices to varying extents.

Based on early experience in primary care, one estimate suggests that 30% to 50% of visits could possibly be eligible for a virtual encounter.⁴ This could be amplified when coupled with home care and remote monitoring devices. There are varying data on the influence of telehealth on total health care services utilization and that will be determined with greater adoption. In addition, as the number of emergency department visits continues to increase nationally, health care systems must develop innovative ways to maximize efficiency and maintain high-quality standards.⁶

However, complete replacement of the traditional clinical encounter will not occur. “Bricks and clicks” will prevail for patients’ convenience and value. Physicians will lead teams with both in-office and remote monitoring resources at their disposal to deliver care. This model could be enhanced in the future with digital assistants or avatars.

In the surgical specialties, remote surgery has been more focused on telementoring and guiding surgeons in remote locations. There have been examples of true virtual surgeons who have operated robotically on patients hundreds of miles away.⁷ This approach can be expected to develop further in the coming years.

Critical Success Factors

The success of technology-based services is not determined by hardware and software alone but by ease of use, perceived value, and workflow optimization.

Medical virtualists will need specific core competencies and curricula that are beginning to develop at some institutions. In addition to the medical training for a specific discipline, the curriculum for certification should include knowledge of legal and clinical limitations of virtual care, competencies in virtual examination using the patient or families, “virtual visit presence training,” inclusion of on-site clinical measurements, as well as continuing education.

It will be necessary for early adopters, thought leaders, medical specialty societies, and medical trade associations to work with the certifying organizations to formalize curriculum, training, and certification for medical virtualists. If advances in technology continue and if rigorous evidence demonstrates that this technology improves care and outcomes and reduces cost, medical virtualists could be involved in a substantial proportion of health care delivery for the next generation.

Article Information

Corresponding Author: Michael Nochomovitz, MD, Physician Services Division, New York Presbyterian, 525 E 68th St, PO Box 182, New York, NY 10021 (mnochomovitz@nyp.org).

Published Online: November 27, 2017. doi:10.1001/jama.2017.17094

Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contributions: We thank Risa Oliveto, Jonathon Monteiro, Shauna Coyne, and Laura Forese, MD, MPH, New York Presbyterian; Jane Torres, Weill Cornell Medicine; and Peter Fleishut, MD, New York Presbyterian-Weill Cornell Medicine, for providing input on the manuscript, none of whom were compensated for their help.

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American Osteopathic Academy of Orthopedics website. http://www.aoao.org/. Accessed August 23, 2017.

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Vaidya A. Global telehealth market to rapidly rise to $12.13B by 2022: 7 key trends. Becker’s Hospital Review. July 19, 2017. https://www.beckershospitalreview.com/telehealth/global-telehealth-market-to-rapidly-rise-to-12-13b-by-2022-7-key-trends.html. Accessed August 23, 2017.

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Dare  F. Voting for virtual health. https://www.accenture.com/t20170216T205948__w__/us-en/_acnmedia/PDF-43/Accenture-Health-Voting-for-Virtual-Health.pdf. Accessed August 23, 2017.

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Ripton  JT, Winkler  CS. How telemedicine is transforming treatment in rural communities. Becker’s Hospital Review. April 8, 2016. http://www.beckershospitalreview.com/healthcare-information-technology/how-telemedicine-is-transforming-treatment-in-rural-communities.html. Accessed August 23, 2017.

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There's a growing need to train physicians on how to handle virtual visits with patients. Modern Healthcare. August 27, 2016. http://www.modernhealthcare.com/article/20160827/MAGAZINE/308279981. Accessed September 11, 2017.

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Reddy  S. Can tech speed up emergency room care? Wall Street Journal; March 27, 2017. https://www.wsj.com/articles/can-tech-speed-up-emergency-room-care-1490629118. Accessed August 23, 2017.

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Eveleth  R. The surgeon who operates from 400km away. BBC. May 16, 2014. http://www.bbc.com/future/story/20140516-i-operate-on-people-400km-away. Accessed August 23, 2017.

Hospital of the Future

The hospital of the future will find you

By Anders Wold

 Illustration: nicescene, Getty Images

Digital disruption is the new normal. We use video conferencing in global business meetings, summon car rides through our phones using GPS, and snap or tweet our lives to friends and followers.

For its part, healthcare is breaking down traditional hospital walls, and it’s not just the developed world leading this disruption. Indeed, the healthcare model for billions of people in the developing world has always been different. Lacking the massive and complicated hospital infrastructure of other regions, medical care in many parts of the world travels to the patient in the form of a visit from a local doctor or a stop at a rural clinic.

This “last mile of care” – where the hospital finds the patient, not the other way around – is made possible as medical innovation across the globe becomes increasingly mobile, digital, personal and accessible.

Healthcare solutions are becoming more digitally connected, affordable and convenient for both the patient and caregiver. A Journal of Hospital Librarianship study found that 85 percent of health care providers were already using smartphones and/or tablets in their daily work. One-third of health information exchange data is already in the cloud, according to a white paper from Cisco.

Digital health, in other words, is here. Data from remote monitoring devices, such as smart scales and blood pressure cuffs, are being transmitted to doctors around the world to improve patient outcomes. In remote areas across Latin America, cloud technology allows doctors to share ultrasound images with their patients and distant colleagues with the simple click of a button. Similarly, pocket-sized ultrasound technology is helping midwives in Africa determine if expectant mothers can deliver babies safely or need to go to the nearest hospital.

Big data, analytics and artificial intelligence enable health care to be more personalized and precise – a fact with which patients appear increasingly comfortable. Virtual assistants on our phones or kitchen counters are dispensing medical advice from WebMD, and a recent global PwC survey across 12 countries showed that nearly 40 percent of people trusted AI and robotics to administer a heart rhythm test and then make clinical recommendations. That hypothetical is already becoming a reality. A new algorithm server is helping medical professionals read patients’ ECGs remotely and AI is helping doctors diagnose lung cancer in China.

In emergency rooms and operating rooms across the world, machines are generating millions of data points, but only a small fraction are harvested and saved in hospitals’ electronic medical record systems. Gathering, analyzing and acting on this deluge of data is the next step. For instance, clinicians can now use cloud-based, algorithm-powered apps to pull hundreds of data points directly from anesthesia machines with every patient breath. These apps unlock actionable insights that can help clinicians with clinical, operational and economic improvements.

Mobile digital health is revolutionizing not just how and what care people get, but where they can receive it. Already, 70 percent of U.S. employers offer telehealth services, and a World Health Organization survey found that 87 percent of countries worldwide had at least one massive mobile health program underway.

While most acute care will continue to take place inside brick-and-mortar medical facilities, future generations will likely receive care virtually, and participate in their own care to greater degrees. For instance, subtle stick-on monitors that look like digital Band-Aids are being developed right now to help doctors remotely monitor key vital signs, from heart rate and blood pressure to sweat and oxygen levels.

Disruption is indeed the new normal for healthcare. By pairing new thinking with new technology in new clinical areas, we can make sure that future healthcare solutions are at once more personal, more digital and more globally connected. In a future where hospitals are everywhere and nowhere, and data is ubiquitous, care must and will come to the patient.