Telehealth access to patient images, via technology that supports secure, fast, diagnostic-quality image access without moving image data, significantly improves patient outcomes for both acute care and non-acute care.
Telehealth combines communications tools and health IT, thus enabling healthcare delivery to bridge distance and time and provide high quality care irrespective of where the patient is located. Through anytime, anywhere provider-to-patient and provider-to-provider connections, telehealth improves outcomes, lowers costs and supports care coordination.
These benefits, which are spurring adoption of telehealth across the globe, are magnified when images are added to telehealth encounters. This article looks at how imaging increases the value of telehealth for both non-acute and acute care situations. In case of the former, including patient images allows providers to share the full patient picture improving care. In acute care situations, such as stroke, images provide critical information that saves lives.
Worldwide adoption of telehealth as a method of delivering care is growing. While North America accounts for about 41 per cent of the global telehealth market, the market in Asia is expected to grow at a CAGR of 12 per cent through 2020, according to a report from US-based analyst firm Frost & Sullivan.
In Asia, telehealth modalities being used include real-time telemedicine encounters, remote patient monitoring and mobile health. While adoption is not moving as quickly as expected, Asia-Pacific governments are building the foundation to drive its adoption by investing in infrastructure, such as nation-wide 3G and 4G access, developing telehealth and eHealth roadmaps, and creating policies that directly or indirectly attract investment in health technology, reports Frost & Sullivan.
Like the North American market, telehealth is an important tool for delivering care to the increasing global incidence of non-communicable diseases, including cardiovascular and metabolic disorders, cancer, diabetes, Alzheimer's disease and other neurological disorders.
The appeal of telehealth to providers is that it improves access to care and supports communications and collaboration without changing the actual care. “We are not changing the clinical service, but rather how, when and where such service is conveyed,” explains Alexis Slagle Gilroy, a partner at the law firm Jones Day and American Telemedicine Association board member.
As telehealth adoption grows, it is also projected to save money. An analysis of recently introduced telehealth legislation targeted at expanding reimbursement showed that some of its provisions could save the U.S. government US$1.8 billion.
“Telehealth is the future of healthcare. It expands access to care, lowers costs, and helps more people stay healthy,” U.S. Senator Brian Schatz said in a statement in May 2017.
Like virtually every aspect of modern healthcare, the foundation of telehealth is digital. As a digital tool, telehealth enables providers to harness digital health data and share itto overcome barriers and break down communications silos. In fact, at large hospital and health system campuses telehealth is sometimes used to facilitate cross departmental communications.
Whether telehealth transactions span a hospital campus, city, state, country, or globe, one key to their optimisation is the integration of digital patient images. Telehealth delivers care through real-time (synchronous) connections and through store-and-forward (asynchronous) connections. Integrating diagnostic quality image sharing into both synchronous and asynchronous connections optimises the benefits of telehealth for both non-acute and acute patient care.
In non-acute care situations, enabling providers to share patient images during telehealth transactions improves coordination between providers and significantly increases patient access to care. For acute care situations combining provider access to images with telehealth saves lives. In all cases, imaging rounds out the picture of patient needs, providing critical information for diagnosis and treatment.
Imaging is expensive and made more so by redundant, repeat imaging. According to a recent joint Healthcare Information and Management Systems Society (HIMSS) and Society for Imaging Informatics (SIIM) white paper, diagnostic imaging accounts for 10 per cent, or US$100 billion, of annual healthcare spending in the US Almost 9 per cent of this imaging is repeat imaging, which often happens when a patient has been referred to a specialist who cannot access the images at the referring provider’s location. As a result, specialists often have to reorder image studies creating an unnecessary cost.
In non-acute care situations, telehealth solves this problem by enabling referring providers to share images with a specialist along with a referral for a consult. This telehealth method of connecting specialists with providers, called e-consult, uses web-based, electronic communications to enable a primary care provider to contact a specialist regarding a patient issue. Related patient images are forwarded with the communication, enabling the specialist to determine if an in-person visit is required and then to have the images on hand for the in-person consult if one is called for.
By providing both critical information and a communications link between primary care providers and specialists, e-consult also solves the problem of so-called “referral silence” between primary care providers and specialists. In a study published in the Archives of Internal Medicine, 69 per cent of primary care physicians said they send specialists notification of a patient's history and the reason for the consultation all or most of the time and just 34.8 per cent of specialists said they routinely receive such information. E-consult, helps to minimise this issue by enabling referring providers to share as much information as they can, including images, in the communication.
Telehealth and imaging also form a powerful tool for addressing management of chronic disease. The leading cause of blindness in the U.S. is diabetic retinopathy. While early detection of retinal complications can decrease the risk of blindness by 95 per cent, long waits for access to specialists has resulted in an high rate of diabetic retinopathy among uninsured patients, shows a study in JAMA Network Internal Medicine.
To solve this problem among the uninsured safety net population in Los Angeles County, primary care providers take images of patient retinas using retinal cameras and then share those images with optometrists via e-consult. After reading the images, optometrists would make recommendations for the patient to see a specialist or not. This process decreased the wait times for screenings by 90 per cent, which before the implementation of the telehealth process was five months. The results of the study show that this integration of imaging with telehealth delivers patient-centred, coordinated care.
Image sharing via telehealth in acute care situations not only delivers the same benefits provided in non-acute settings, but also provides critical life-saving benefits. When faced with urgent, severe and complicated conditions such as stroke or head trauma, emergency care providers need real-time access to neurologists and other specialists. Telehealth provides the real-time access for patients in remote or rural settings and images provide the key patient data that enable neurologists to make timely diagnoses.
When a patient with head trauma arrives in an emergency department the first step is a CT scan. The next step is to get those images to a neuroradiologist for reading and diagnosis. If the patient is in a rural location or it’s 2 a.m. in an urban setting, access to a neuroradiologist typically happens via a telehealth connection. Once the connection is made, the remote neuroradiologist must access the images to make a care decision, such as whether or not to transfer the patient to a trauma centre.
If specialists have access to patient images during a real-time connection with the emergency providers, they can make decisions about transferring the patient or not, saving the costs of unnecessary transfers. In addition, if a patient transfer is required real-time image access allows the receiving trauma team to view the images before the patient arrives to prepare and saving the costs and time required for repeat imaging.
Stroke is the leading cause of death and the third leading cause of disability worldwide,making time critical to its treatment. Telestroke, which combines real-time access to images and video communications, is a truly revolutionary method of delivering care that impacts global population health. For the 15 million people who suffer a stroke annually in across the globe, today their chances of surviving are significantly improved thanks to the use of telestroke and advanced medications.
As stated in a recent study on the state of telestroke published in Journal of NeuroInterventional Surgery, “The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care. Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care.”
In the US, about 20 per cent of the population live in rural areas without access to either primary or specialist care. When a patient with stroke symptoms arrives in an emergency room or clinic in one of these rural areas, there’s a good chance the doctor who saves their life will be located hundreds of miles away and providing diagnosis and treatment via telestroke.
The likelihood is strong that their life will be saved and often they’ll walk out of the hospital virtually intact thanks to the enabling capabilities of telestroke technology, which has at its heart image sharing between emergency room providers and remotely located stroke neurologists. By sharing images with remotely located stroke specialists,emergency room providers are able to get a diagnosis without having to transfer a patient over long distances. Stroke specialists will also give orders, when appropriate, to administer tissue plasminogen activator, or tPA, to break up stroke-causing clots.
Patients must be given tPA within a three-hour window of a stroke’s onset. Patients that receive tPA often have very limited physical impact from the stroke, leading to both less time in the hospital as well as much less time in rehabilitation facilities, if they require rehab at all.
Follow up care is also made easier when images can be shared with primary care physicians, allowing them to collaborate and communicate clearly with the care providers after a stroke. Telestroke has proven so effective that during 2015 its use grew 38 per cent among hospitals in the United States.
A 2016 study conducted by US healthcare firm Kaiser Permanente examined the outcomes for 2,500 patients diagnosed with acute ischemic stroke. The results of the study showed a 75 per cent increase in timely use of the clot-dissolving drug tPA following telestroke consultation. Patients treated via telestroke also received their diagnostic imaging test 12 minutes sooner, and the drug was administered 11 minutes sooner, decreasing the so-called door-to-needle time, or time from arrival to administration of tPA, to less than an hour.
“Particularly in hospitals with limited local resources and/or limited access to neurologic expertise, telestroke is an important tool to aid in the evaluation and treatment of potential stroke,” reports the study. The study also found that telestroke reduced variability in stroke care, enabling consistent outcomes.
For stroke neurologists, the imaging is key to their ability to make the right diagnosis for the patient. Working without the images and the real-time video links of telestroke is like “flying in the dark,” says Andrew D. Barreto, MD, associate professor of neurology of UTHealth in Houston.
Telestroke networks are structured around a hub and spoke system, with urban or academic medical centres providing the hub of expertise to spokes of rural and remote care centres. While telestroke systems can be expensive to implement they deliver significant ROI for both the hub and spoke locations.
As reported by HIMSS, timely access to tPA enabled by telestroke been shown to be economically beneficial, saving millions of dollars each year. Patients treated with tPA experience lower healthcare costs, reduced disability, and fewer long-term care needs. With the direct costs of stroke reaching US$30 billion a year, the improved outcomes and long-term cost savings of telestroke offset its upfront costs.
The other value telestroke brings to hospital networks and healthcare systems is that it can provide a model for other applications of telehealth that incorporate patient images. The close collaboration between a spoke hospital and the hub provider builds a partnership and workflow that can be applied to other types of care, such as head trauma or cardiac care, which increasingly uses cardiac CT for diagnosis.
Image viewing technology used in telehealth systems needs to support several critical features. First, image viewing tools must provide anytime access from any device, including desktop, laptops, tablets and smartphones, so that no matter where patients are located providers can use the device at hand to view images.
In addition, the image viewer must have appropriate accreditations for diagnostic use. In acute patient care settings, diagnostic clearance is particularly critical because providers have neither the time nor expertise to interrupt their workflow to determine whether the the tools they are using are safe for diagnosis, notes Ryan Minarovich, a lawyer and consultant with the Tenzing Group which specialises in regulatory compliance for digital and mobile health products.
"Today's physicians have so many tools and so much information at their fingertips that it’s important to guard both doctors and patients from inappropriate use,” explains Minarovich.
Most importantly, image viewing technology must provide diagnostic quality image access on any device without requiring the transfer of image data from one system to another. Keeping image data on its originating site is critical to modern healthcare for several reasons. Modern patient images are very large and providing access to image data without moving it saves time. In addition, this approach allows maintains the protection and safety of patient data by ensuring it stays on the secured originating system and isn’t transferred to less secure mobile devices.
Imaging is a critical component of patient care. As a tool for bridging both time and distance, telehealth solutions need to include access to images from any place on any device, whether desktop, laptop or mobile. Without image access, the ability of telehealth to lower costs, improve care and save lives is cut short. To provide quality care, providers need access to a full patient picture, images included.