Advances in Health Care Bring Remote Expertise Close
By KATE GREENE
July 12, 2013
Dr. Chad M. Miller operates the RP-VITA robot at the Ohio State University Hospital in Columbus, Ohio.
Leroy Chiao remembers well doing his first ultrasonic eye exam. The test, which looks for a buildup of pressure inside the skull and changes in the optic nerve that cause persistent blurred vision, involves pressing the ultrasound wand against a person’s closed eye and manipulating it to get a glimpse of all the various parts. The medical team that guided Chiao when he practiced his first test in 2004 was working inHouston. Chiao, then the commander of the International Space Station, was orbiting some 220 miles above Earth.
“NASA invented telemedicine,” says Bobby Satcher, a former astronaut who flew on the shuttle’s 31st trip to the space station and is now a surgeon and assistant professor of orthopedic oncology at MD Andersonin Houston, which has recently announced a big push into teleheath. As long ago as the 1960s, mission control received updates from sensors worn by the astronauts about their heart rates, body temperature and respiration from as far away as the moon. Chiao and his fellow astronauts had previously been trained to observe their crewmates for certain other damaging effects of prolonged minimal gravity, such as degradation of the bones and teeth. Today, he notes, every ISS crewmember receives regular ultrasonic eye exams guided by specialists on the ground.
Americans are increasingly flooding the path broken by the astronauts. Patients around the country can now teleconsult with distant doctors about everything from nausea and fever to cancer treatments. In January, the Federal Communications Commission announced up to $400 million in annual funding for the development of broadband networks to link rural areas and urban medical hubs. Experienced surgeons are mentoring younger practitioners miles away, watching the action on camera and carrying on conversations. And, if you find yourself desperately in need of a specialist in the ICU, don’t be surprised if a robot rolls up to your bedside with a doctor working elsewhere speaking to you on a screen. All told, the telehealth market is expected to more than double in just five years, from $11.6 billion in 2011 to $27.3 billion in 2016, according to a 2012 report from BCC Research.
“Within a minute, I got a call from a patient service representative,” marvels Ken Krakaur, 60, of Williamsburg, Va., who was recently so incapacitated with flu-like symptoms when his wife was out of town that he opted to try a virtual doctor visit. As senior vice president of Sentara Healthcare, a hospital system in Virginia and North Carolina, he took advantage of a new health-plan feature, one that will be rolled out to members of selected Optima Health insurance plans this year: an immediate consultation through MDLive, a telehealth provider based in Sunrise, Fla. In just 10 minutes, he was on the phone with a physician, who asked a lot of questions and recommended over-the-counter medication. Sentara calculated that teleconsulting would save money as well as aggravation for patients, Krakaur says. For simple conditions like a cold, the flu, sunburn, joint pain and nausea, for instance, the average cost of care for an office or urgent care visit is $119 versus $39 for virtual care. Plus, “I didn’t need to spread my disease to other people in the office,” he adds.
Increasingly, patients with serious or complex illnesses get to tap otherwise tough-to-access expertise. “Anything I want to show him, he can see,” says Richard Riggs, 67, a tire salesman from Hays, Kans.,who underwent surgery at the University of Kansas Medical Center for melanoma in 2009. The cancer returned a number of times between 2009 and 2012. Though KU Medical Center in Kansas City is nearly four hours by car from Riggs’ home, a video link at a local cancer center in Hays puts him in regular touch with his oncologist there, Gary Doolittle, who gets help from an oncology-trained nurse in Hays with the physical exams and ongoing care.
After repeated surgeries, Riggs began oral chemotherapy, administered by doctors locally, followed when his cancer progressed by a regimen of ipilimumab, a new agent that stimulates the immune system to fight cancer and has shown great promise in a subset of people with advanced melanoma. Now, Doolittle says, scans show no evidence of disease. At first, remote visits were “a little different,” Riggs recalls. But the process has “really worked out well.”
On hospital floors, robots now bring distant expertise right to the bedside. Chad Miller, an associate professor of neurology and neurosurgery at the Wexner Medical Center at Ohio State University, tells of an intensive care patient he “saw” three years ago when he was working in Los Angeles as a neurointensivist for a provider of telemedical services. The patient had arrived at Fountain Valley Regional Medical Centershowing signs of stroke: His language was impaired, and he was slow to respond.
Thanks to a human-size stand-in made jointly by iRobot, manufacturer of the Roomba robotic vacuum, and InTouch Health, a remote health and telepresence company, Miller was able to examine the patient and ask questions. His face appeared on a screen atop the console, and he could zoom in with a camera. He also had access to the patient’s scans and history. Miller was able to determine that the man actually was suffering from acute meningitis and quickly prescribed antibiotics.
“Getting the right specialist there can be a life-and-death situation,” says Yulun Wang, CEO of InTouch Health, whose latest venture with iRobot, the RP-VITA robot, was announced in May and is now presiding at a handful of hospitals including those at Ohio State and UCLA. For Miller and other doctors operating it remotely, it’s a huge improvement. Unlike older versions that had to be rolled in by staff, the RP-VITA can get around by itself, locating itself using sensors, GPS and internal maps, and avoiding obstacles and people. The remote doctor need only tap a patient’s location on a laptop or tablet, and the robot will roll to the bedside. Even late at night from home, says Miller, he will be able to see how his patients are progressing. As many as three doctors at once can tap in for a real-time huddle.
Given that there are about 10,000 intensive-care units in the country and only slightly more intensivists – the specialists familiar with multiple systems in the body and how they interrelate during trauma – it should come as no surprise that many health care systems are exploring robots and other variations of the tele-ICU. Sentara has pioneered a central mission-control model, monitoring ICU beds in five of its acute-care hospitals from one place. An intensivist on duty has access to the records and vital signs of patients in more than 100 beds, all of them able to be assessed by a camera in the room if needed. The vital signs and lab results of each patient are fed into a system that processes minute-by-minute data and provides alerts when heart rate or blood pressure, for instance, reaches a threshold or a new trend is emerging as a red flag. “It gives a doctor specially trained to treat critically ill patients the opportunity to see more patients and take care of more critical issues,” says Steve Fuhrman, Sentara’s eICU medical director.
Data collected on the Sentara system show that “we’re saving one life per monitored bed per year,” says Fuhrman. One independent study of Sentara Norfolk General Hospital published in 2004, for example, revealed a 25 percent drop in mortality rates of ICU patients compared to before the system went online. Patients’ length of stay also dropped by 17 percent. Fuhrman says that since then, the teleICUs have maintained 20 percent lower mortality rates than predicted for intensive care units.
One of the most exciting developments in telemedicine, experts say, is the potential for discharged hospital patients to be monitored from home, and for everybody to stay healthier through ongoing self-surveillance. Smartphones and tablets, now used by more than 50 percent of the U.S. population, are already outfitted with the camera and microphone needed to monitor heart rate, cough and lung function, and with a few extra components, they can take electrocardiograms and blood-pressure readings. MD Anderson, which recently announced $1 million in funding from AT&T to jumpstart a program to remotely manage surgical patients, is piloting an initiative to send some people who have just undergone a pancreas removal home with a computer and a wireless stethoscope and thermometer. Such patients are at high risk for readmittance, says Surena Matin, a urologist and surgeon who is leading the initiative. This way, they can check in with a nurse and share their vital signs and avoid panicked trips to the ER.
The Cleveland Clinic‘s Heart Care at Home program discharges heart patients with a small telehealth unit that monitors vital signs such as blood pressure and weight fluctuations, which might indicate fluid buildup, and transmits the data through a phone line to a support team at the hospital – no Internet or smartphone needed. Nurses stop by as often as is necessary during the 40 days after discharge. Presbyterian Healthcare Services in Albuquerque, N.M., similarly refers patients with congestive heart failure or chronic obstructive pulmonary disease to their homes with equipment capable of video and of analyzing measurements taken by the patient. The program has a 96 percent patient satisfaction rate, and readmissions are down to 1 percent from 6 percent at the start of the program in 2001. One prevented hospital visit saves $5,500, about the cost of one patient’s home equipment.
“I can manage things myself instead of every six months going to the doctor,” says Heidi Dohse, 49, who suffered a dangerous heart arrhythmia at 18, underwent then-experimental ablation to effectively rewire her heart, and is on her seventh pacemaker. That’s a good thing, because now that she is a program manager for Google in Somerville, N.J., her cardiologist at the University of California, San Francisco Medical Centeris a continent away.
An athlete who has competed in 100-mile bicycle races and wants to continue to ride longer distances, Dohse is helping to test out a type of self-guided telemedicine called mobile health that enables patients to collect their own stats, from heart rate and blood pressure to weight and food consumed, on an ongoing basis and share it with their doctors. She wears a watch that keeps track of her ticker, letting her know whether she’s cycling within a healthy heart rate range; an EKG device attaches to her smartphone when she experiences an episode of tachycardia, or quickened heart rate. Her doctors can access the EKG results, and consider them over time to make decisions about medications or pacemaker settings. Dohse can also use an app to correlate her cardiac data with her diet and see, for instance, what the effects of drinking caffeine have been on her heart rate.
The UCSF Medical Center study, launched in March, aims to collect heart data from a million people worldwide over the next 10 years and to find trends that will lead to a better understanding of heart function and ways to predict disease. The Health eHeart program, as it is called, also is already helping people like Dohse manage their conditions. What’s great about it, she says, is “having trend data to make good decisions” about what to eat and how hard to train.
In the no-so-distant future, experts say, these streams of patient data that allow a minute-by-minute picture of health status will regularly help with predictions, early interventions, diagnosis and treatment planning. Imagine that your doctor, instead of viewing you just as a snapshot, can watch a feature-length film of your vitals over weeks or months. “All of these devices are making it possible for us to collect information about people’s behavior that we haven’t been able to see before, to look at metrics that we may not have thought of before,” says Satcher. Artificial intelligence programs will sift through the numbers and spot problems and suggest solutions faster, and potentially more effectively, than any single doctor could today.
Perhaps the most exotic application of telemedicine would be to perform a surgery remotely, a long-term goal of the MD Anderson effort. The technology exists: A surgeon using the da Vinci surgical robot today to perform minimally invasive operations sits at a console across the room from the patient, manipulating controls that move robotic arms and the surgical instruments. Other surgeons and nurses stand by at the table. Remote robotic surgery has even happened; in 2001, surgeons in New York removed the gall bladder of a woman in France (with the assistance of a team at the patient’s bedside). But Matin suspects that commonplace remote surgery is a few years away, since the necessary high-speed communication lines still aren’t reliable or cost-efficient enough. Moreover, there are legal barriers. It would be illegal for a surgeon licensed in Texas, for instance, to operate on someone in California. (There is legislation in Congress currently addressing this obstacle.)
Meanwhile, he’s working on sharing MD Anderson’s surgical expertise from afar. With the use of a specialized webcam, software and a microphone in the distant OR, an MD Anderson surgeon can sit in on a surgery in real-time from her office, reaching across the distance and into the future.