Reducing referrals and re-admissions by improving the ability of providers to get things right first time through easier access to specialist expertise and advice.
Telemedicine services remove geographical barriers between underserved patients and their medical specialist, improving quality, access and, potentially, reducing cost of care. Patients can now connect to clinicians via mobile devices, secure email or via web portal platforms. While some systems have created supply-induced demand, others have shown a reduction in the medical specialists’ workload through the effective use of email to reduce the number of unnecessary face-to-face consultations and clinical tests.1 Some centers have introduced ‘hotlines’ or email addresses for GPs to seek specialist advice. Using ‘hunt group’ technology means a single gateway can direct the GP to multiple specialists, locating one that is available with the right expertise. Video conferencing, sharing of the patient record or using pre-defined, bookable appointments might improve interactions further. Such approaches have the potential to reduce referrals, and in the long term educate GPs to improve their care. More radically, in the US, a range of developers are attempting to disrupt traditional geographical patterns of healthcare delivery. Services such as Spruce, HealthTap and Doctor on Demand offer instant, 24-hour access to remote appointments through smartphones, while apps like MedZed and Heal are enabling house calls to be requested via mobile devices. Telehealth applications can be particularly helpful in large sparsely populated areas by enabling a small number of clinicians to cover a large geography. In the future, it might even allow teams of healthcare professionals to act internationally on a larger scale, although patient safety, legal protection and information confidentiality present significant regulatory barriers to this expansion.
In many hospitals 60 percent of the real estate and at least as much of the car parking requirement is for outpatient visits. Why put the patient, the carer, the payer and the planet to so much trouble?
— Malcolm Lowe-Lauri, KPMG in Australia
e-ICUs or tele-ICUs are intensive care units that receive clinical support from a remote critical care team through patient surveillance and monitoring, as well as remote video collaboration. Tele-ICUs are generally associated with a number of benefits including reduced mortality and ICU length of stay and reduced staff turnover (a 56 percent reduction in one center, saving over US$1 million per year).2 3 4 Onsite clinical staff reluctance to engage with the remote e-ICU consultants is likely to have a significant negative impact on clinical benefit and cost-effectiveness, however. One study found that hospital costs increased with an e-ICU.5 This may be because healthcare professionals find the remote team threatening, or do not feel they need additional clinical input.
Patient-to-professional telehealth can cost more than it saves: There is mixed evidence on the cost-effectiveness of patient-to-professional telehealth.6 7 To realize the value of these systems, close attention should be paid to patient selection, duplication of services and referral procedures, staff engagement and training, and reassuring patients about safety and appropriate use.
Identify appropriate cases for professional-to-professional telehealth: One study found “failed teleconsults”, whereby a face-to-face consultation is required despite the teleconsultation, could increase costs by US$709 million nationally across the US, although this was offset when email and real-time interactions were both used.8 This means it is important for generalists to try to identify cases for professional-toprofessional telehealth, which are likely to be resolved without specialist follow up.
Kaiser Permanente (KP), the largest not-for-profit health provider in the US, have developed a number of different telehealth systems for remote consultations. These include integrated video appointments and CDU-to-CDU telemedicine across different hospitals to spread demand during busy periods. In 2012, nearly 50 percent of contacts between KP’s patients and primary care providers took place over the phone or secure email, and they estimate that as many as 30 percent of full consultations could soon happen digitally. Certain programs have seen rapid quality improvements, such as their telestroke service, which through rapid assessment of patients via video conference has increased the proportion of people receiving thrombolysis from 14 percent to 84 percent, and those given it within 60 minutes from 16 percent to 52 percent.9
In Ondo state in Nigeria, mobile phones are used to remotely monitor pregnant women and link them to specialist advice. Community health workers (CHWs) were appointed to act as intermediaries between pregnant women and Abiye maternity health centers. To facilitate quick and effective communication between the women and CHWs, mobile phones were distributed free of charge to pregnant women across the state for them to call for advice if needed. The project showed a 47 percent reduction in maternal mortality and 26 percent reduction in child mortality, and is subsequently being scaled up.
1Caffery L J, Smith A C. (2010) A literature review of email-based telemedicine. Stud Health Technol Inform. 2010;161:20–34
2Goran, S., (2010) A Second Set of Eyes: An Introduction to Tele-ICU Crit Care Nurse August 2010 vol. 30 no. 4 46–55
3Kumar et al., (2013) Tele-ICU: Efficacy and Cost-effectiveness approach of remotely managing the critical care. The Open Medical Informatics Journal, 6, 24–29
4Lilly CM, Cody S, Zhao H, Landry K, Baker SP, McIlwaine J, Chandler MW, Irwin RS (2011) Hospital mortality, length of stay, and preventable complications among critically ill patients before and after tele-ICU reengineering of critical care processes. JAMA. 2011 Jun 1;305(21): 2175–83
5Morrison JL, et al. (2010) Clinical and economic outcomes of the electronic intensive care unit: results from two community hospitals Crit Care Med. 2010; 38(1):2–8
6Torre-Díez I, et al (2014) Cost-Utility and Cost-Effectiveness Studies of Telemedicine, Electronic, and Mobile Health Systems in the Literature: A Systematic Review. Telemed J E Health 21(2):81–5
7Mistry, H (2012) Systematic review of studies of the cost-effectiveness of telemedicine and telecare: changes in the economic evidence over twenty years. Journal of Telemedicine and Telecare 2012; 18 (1): 1–6
8Cusack, C.M., Pan, E., Hook, J.M., et al., (2007) The Value of Provider-to-Provider Telehealth Technologies. Charlestown: Centre for Information Technology Leadership
9Zhou YY, Kanter MH, Wang JJ and Garrido T (2013) ‘Improved quality at Kaiser Permanente through e-mail between physicians and patients’, Health Affairs 29(7), 1370–5.
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