The Age of Telemedicine

With aging baby boomers, increased numbers of patients due to the Affordable Care Act and a shrinking pool of doctors, there is a fear there won’t be enough healthcare providers for the care that is needed. Enter telemedicine, which has endless applications for the healthcare industry. Telemedicine is a rapidly developing practice of clinical medicine where medical information is transferred through the phone or the Internet, and sometimes other networks, for the purpose of consulting and, increasingly, remote medical procedures and examinations.¹ Today, patients are able to remotely connect with doctors, have their gallbladders removed from an ocean away and receive help, reminders and guidance by a friendly face, even if that face is just on a screen.

Care at a Distance

Telehealth visits seek to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician or practitioner at a distant site. Many insurance companies have contracted with a host of telehealth providers that provide access to a doctor or nurse practitioner who is able to diagnose and prescribe — all at a price of about $50.

And, the trend is growing, with more than 400,000 doctor-patient televisits in 2013, which is more than double that in 2011.² Indeed, by 2017, it is predicted that 1.8 million patients will be treated via televisits worldwide, a sign of the growing acceptance of remote medical services.3 Doctors who provide services through televisits must be licensed in the patient’s state, must obtain informed consent and must document the patient’s visit. On the patient end, they either set up a time for a “visit” or just make a cold call and get in queue for one. The American Telemedicine Association is even developing a specific accreditation program for telehealth visits.

From a patient standpoint, the convenience of meeting with a doctor from the comfort of their home for routine questions is making the lack of in-person attention an acceptable trade for many. However, there are some concerns. Namely, because the patient and doctor don’t meet in person, it’s possible that a diagnosis may be incorrect or inconclusive, or that a patient could be overprescribed or underprescribed a medication. Because of these concerns, the Federation of State Medical Boards is establishing guidelines that will hold virtual visits to the same standards as an office visit, including a full medical history and informed consent, and will allow patients to choose among participating doctors. The group also is finalizing a plan to make it easier for doctors to practice across state lines.⁴

Taking telemedicine a step further, telepresence robots are being used in some hospitals and are another growing trend in hospital medicine — especially in rural areas where there is a shortage of doctors. The videoconferencing robots have a large video monitor, camera, speakers, microphone and wheels and are able to travel through the halls of a hospital and check on resident patients.

One such robot is RP-VITA, developed by InTouch Health and iRobot Corp., which is approved for hospital use by the U.S. Food and Drug Administration (FDA) and is helping doctors remotely care for patients in about 1,000 hospitals internationally.⁵ With the help of a nursing assistant who is in the room with the patient, a doctor from a remote location can log into the RP-VITA by using a computer, laptop or iPad, and he or she can see, hear and speak to the patient, as well as have access to clinical data and medical images. This allows doctors to make assessments and provide instructions from miles, if not thousands of miles, away.

Robotic-Assisted Surgeries

Since FDA’s approval of robotic-assisted (RA) devices for laparoscopic surgeries of cardiac, colorectal, gynecologic, urologic, head and neck and thoracic general procedures, much has been said about their benefits, challenges and costs. RA surgeries, during which a surgeon performs minimally invasive procedures through robotic or mechanical arms affixed to a cart next to the patient’s bed, are praised by many for shorter pre- and post-operative recovery times, as well as the ability to facilitate minimally invasive surgeries — particularly in areas of the body that are difficult to reach. In a 2009 study at Stanford University of the da Vinci Surgical System (developed by Intuitive Surgical), researchers compared RA laparoscopic hysterectomy with a matched control group of standard laparoscopic hysterectomy. They found that the RA surgery had a similar outcome to the standard therapy, and they concluded that the device held exciting promise, particularly in the area of telesurgery.⁶

Today, surgeries are being performed across state lines and even countries. The first transoceanic telesurgery was performed in 2001 in Strasbourg, France. The surgeon was at an office in New York manipulating robotic arms of a device called the ZEUS System (manufactured by Computer Motion) using dedicated asynchronous transfer mode (ATM) telecommunication technology. The patient’s gallbladder removal was carried out in 54 minutes, without complications and with a constant time delay of 155 milliseconds throughout the procedure. All surgeons involved rated the safety of the procedure a “10.”⁷

Yet, some criticize the idea of RA surgical devices due to errors in surgery or even malfunctions of the machines. In fact, every person involved in the administration of an RA surgery has the potential to introduce error, which is why the training and education from setup of the machine through breakdown and maintenance is so critical. Machines like da Vinci and the ZEUS System are approved by FDA; however, training, education and accreditation of surgeons and medical staff using the equipment are not regulated by FDA, as it says the training is the responsibility of the manufacturer, physicians and the healthcare facilities.

FDA did conduct a post-market evaluation survey through the Medical Product Safety Network of experienced physicians who use the da Vinci Surgical System after receiving increased medical device reports related to computer-assisted surgical systems.⁸ In the survey, surgeons reported no serious issues with using the device even though the depth of their training requirements varied.

Impact of Robots on Nursing

Nurses also face new challenges with RA surgeries. A spring 2011 summary report of the McKee Medical Center on the use of robotics technology in gynecologic surgery stated that nurses and nurse circulators are becoming as specialized as the surgeons with use of robotic technology. According to Dr. John Crane, a gynecologist who performed McKee’s first robotic surgery, “At no time has the nurse’s role been more prominent and necessary than now as we take a robotics program to a higher level of efficiency.”⁹

RA surgeries require more nursing and surgical tech staff to assist in setting up the robot prior to surgery, a unique anticipation of surgeon needs during surgery, the skill to undock the robot from the patient post-surgery, as well as the knowledge of how to inventory and complete medical charts.

Nurses must also be trained in the area of post-operative education, including instructions and the timing of those instructions. With patient stays shortened, nurses have to make sure patients and their caregivers understand the tools they need to manage the first days at home. And, they must be in tune with the patients’ and caregivers’ readiness to hear and understand the instructions post-surgery, when they may be overwhelmed by the amount of information and responsibility bestowed on them. They also must assess patients’ and caregivers’ capabilities of working through the transition back to pre-operative lives.¹⁰

Nursebots

Nursebots, personal robotic assistants, are designed to supplement, though not replace, nursing care. Pearl, a four-foot nursebot, was conceived back in 1998 and is being developed by scientists at the University of Michigan, University of Pittsburgh and Carnegie Mellon University as an option to help improve the quality of life of patients, as well as help them maintain their independence.¹¹ Pearl was tested at the Longwood Retirement Community in Oakmont, Pa., as a way of helping the elderly with routine activity reminders such as eating and drinking, using the bathroom and taking medications, as well as providing walking assistance (the slow pace of patients makes assisting them while walking one of the most labor-intensive requirements of nursing home staff). Pearl can also interact with clients through a touch-screen interface that allows for direct communication.12

Researchers view Pearl as a way to augment, rather than replace, human interaction with services that a robot would be able to provide. “Robotic technology can be a way to augment nursing care — high-tech devices taking care of low-tech jobs (delivering trays, linens, lab specimens, etc.),” says Linda Hollinger-Smith, RN, PhD, vice president of the Mather Lifeways Institute on Aging in Evanston, Ill. “It allows nurses to get back to high-touch care.”¹¹

Additional nursebot prototypes are being tested. Japan is seeing huge challenges to its healthcare industry as its aging population far outnumbers those who are able to care for them, and the country is at the forefront of nursebot production. In 2010, Japan’s Ministry of Health, Labor and Welfare estimated two million healthcare workers would be needed for nursing homes and hospitals, and by 2025, it is estimated four million will be needed.¹³ Researchers there have also been testing robot nurse prototypes to assist with everyday tasks such as lifting patients out of beds, taking vital signs and interfacing between doctors and patients, an idea that could save Japan $2.1 billion in healthcare costs.¹⁴

What the Future Holds

When healthcare providers interact with patients, they ask questions and formulate recommendations based on patient feedback. If patients are not compliant with instructions, healthcare providers can ask why and perhaps formulate a new plan based on the patients’ responses. As exciting as robots are, today’s technology doesn’t autonomously allow robots to do this. However, when robots are able to process right from wrong, use “computational meta-ethics” and algorithms to determine what information is missing from their decision-making tree, as well as how best to get that information, technology will be that much closer.¹³

One research center working to help robots make that transition is Memorial Sloan-Kettering Cancer Center in New York, which is working with Watson, IBM’s supercomputer, to develop complex decision-making skills. Watson is learning to make sense of dictated and written notes in medical records, articles published in medical journals and raw data published by public health departments. When making a diagnosis, Watson lists not only strong possibilities, but its own level of confidence in each possibility. It is even theorized that Watson will be able to help with complex issues such as cancer, as well as everyday primary care diagnoses, where a mistake can be equally costly.

Dr. Marty Kohn, an emergency room physician and a clinical leader of the IBM team training Watson, says that about one-third of medical mistakes come from focusing too much on just a few bits of information that he calls “anchoring bias.” A doctor may inadvertently focus on this information at the exclusion of other information and miss a crucial detail, or he or she may have the right diagnosis but not realize it is incomplete and not treat the whole condition. Dr. Kohn says Watson can help. As scientists learn more about medicine, biomarkers and how technology can help to aggregate and filter information, robots like Watson will become more and more invaluable because the complexity of the information and the decision making will become overwhelming. In an example of the high hopes for robots in medicine, WellPoint, the insurance company, has already begun testing Watson as a support tool for nurses who make treatment-approval decisions.¹⁵

Cost Challenges

Cost is always an issue when developing new technology. Developers have to balance the costs of development, the purchase of equipment, training (not only the surgeons but other healthcare workers) and the price charged to the patient.

Today, robots and RA surgical equipment are quite expensive. Da Vinci, for example, costs between $1.5 million and $2 million per machine, and the average cost of a hysterectomy is $8,868 using da Vinci compared with $6,679 to perform a laparoscopic hysterectomy. Medicare and private insurers reimburse the same amount no matter which type of surgery a patient has.¹⁶

With telesurgery, another significant cost challenge is the telecommunications system. Each end of the surgical system must have the ATM communication lines required for this type of surgery. Yet, at present, most hospitals are not equipped to handle ATM communications. It is estimated that a one-year cost of ATM technology availability could be $100,000 to $200,000. So, for those looking at RA surgery from purely a cost standpoint, it may be prohibitive. That’s why others suggest looking at this type of surgery from the standpoint of bringing improved surgical capabilities to all corners of the world.⁷

Telemedicine Is Moving Forward

Costs aside, the momentum toward robotic-enhanced healthcare and technology in general is moving forward. Since 2000, more than 1,370 hospitals have purchased a da Vinci Surgical System,16 and half of physicians surveyed plan to add a robotic system in the next two years. In addition, there was a 60 percent jump in the total number of RA surgeries performed between 2010 and 2013.17 And, the American Medical Association reports that the number of RA hysterectomies has jumped from 0.5 percent to 10 percent in three years.¹⁸

One clear sign that the medical establishment is transforming toward telemedicine is the demand for IT workers. The Bureau of Labor and Statistics reports that IT healthcare industry job advertisements tripled between 2009 and 2010, and it estimates that healthcare IT jobs will grow by 20 percent in the next decade, though even that may not be enough to meet demand.¹⁵

As our healthcare systems continue to evolve and become more autonomous, there appears to be significant potential for improved medical care enabled by the new emerging technology, even if the care is not performed by (or entirely by) a human. However, it remains to be seen how the transition will be implemented, the costs absorbed and what health improvements would result, especially in answer to the growing physician shortage, not only in the U.S. but worldwide.