Telemedicine today, and the future of virtual health care

In parts of the Perelman School of Medicine, new technology-enabled approaches to health care recall a time when practitioners came to patients.

“It used to be that the doctor would go to the patient in their horse and buggy, that the provider would go to the patient,” says Bill Hanson, Penn Medicine’s chief medical information officer, of the history of health care delivery. “Then, increasingly over the last century, patients have come to where the provider is… Now, in situations like Penn Medicine with our Center, we have patients traveling 10 or 100 miles to come for an evaluation, but where appropriate, we’re now able to engage in meaningful interactions with a patient in a way that eliminates that travel, hassle, expense, and barrier with the help of Penn’s Center for Connected Care.”

The means for those meaningful eliminations: telemedicine, using technology to offer remote care that brings that horse-and-buggy concept full circle.

The Center for Connected Care is the latest innovation in telemedicine at Penn, a medical command center launched in 2018 that includes the processes of Penn’s existing E-lert eICU service—a remote electronic intensive care unit, created in 2006 covering 270 ICU beds, as well as home telehealth care and on-demand virtual urgent care. 

The Center, operating with a “hub and spoke model,” Hanson explains, with a suite in Penn Medicine Rittenhouse staffed by doctors, nurse practitioners, and critical care nurses, can diagnose and treat—through audio and video—low-acuity conditions, and, on the other end of the spectrum, critically ill patients in ICUs at four hospitals who need specialist care at night. 

On principle, Hanson says, Penn’s telemedicine offerings are tremendously patient-centered.

“Patient satisfaction is a huge focus for us,” he explains. “This goes along with trends we’re seeing in so many other industries where people are moving to [remote transactions] with banking, and shopping, and other activities. The availability of these real-time connections makes things very convenient and may save patients’ time or facilitate earlier treatment and, in some settings, shorten hospital stays and save lives.”

For example, he says, a stroke specialist neurologist can now evaluate a remote patient through the telestroke service, connected by audio-visual equipment that allows them to engage with patients and doctors in emergency rooms around the region that are suitably equipped. 

New technology, he says, has broadened and deepened the capabilities of telemedicine in the past 10 years: the switch from paper to electronic patient records, access to 4G (and soon 5G) cellular networks, ubiquitous WiFi, and increased computing power within medical systems. Video connections are now smoother, broadcasted at a higher resolution, and generally more reliable—while also allowing interactions with patients who are more likely than ever to have what is essentially a pocket-size computer in the form of a smartphone. 

“A lot of forces have converged to push things to this point,” Hanson says.

The Center for Connected Care is not the only ambitious telemedicine effort at Penn.

Telegenetics

At times, when a patient is considered at-risk for a condition based on personal or family history, it’s recommended by a physician that they receive a test to highlight genetic markers. They receive the test, and come back at a later date for their results with a genetic counselor. 

But the return trip is often the barrier to having the test at all—especially for people in rural communities. That’s where the Telegenetics Counseling program stepped in with a video-conferencing solution. 

“This is an amazing resource for segments of the population [in remote areas], and the patients we see through the program feel they’re getting specialized care in their local community without having to drive,” Angela Bradbury, an associate professor of medicine at the Hospital of the University of Pennsylvania (HUP), says. “Major barriers for them have been dissipated by technology.”

Through a large, randomized study funded by the National Institutes of Health conducted from 2010-12, Bradbury and her team were able to establish that telemedicine is feasible as a way to expand access to care among populations who struggle to get access to counselors. Studies, of which there are several, are ongoing and encouraging.

“In all of the work I do,” she says, “this is probably the most rewarding because of the relative advantage for these populations.”

Regulatory barriers and insurance coverage remain obstacles with the program, she says, with licensure practices varying from state to state. But technology costs have gone way down, thanks to investment from institutions, Bradbury says, and combined with patients feeling more comfortable using video-conferencing software, the potential for telegenetics is growing. 

She’s currently working on research that would allow for web-based interface, addressing the limited number of genetic counselors in the field and increasing indications for testing.

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Skin and oral telemedicine

Since the lining of the mouth is closely related to the skin, diagnosis of a number of dermatologic conditions requires an expertise in oral medicine, a dental specialty most frequently practiced in dental schools and university medical centers. Thus, when Carrie Kovarik, an associate professor of dermatology, managed a remote dermatology telemedicine study as part of the Botswana-UPenn Partnership, she noted that a significant number had oral diseases. 

Kovarik consulted Martin Greenberg, professor emeritus of oral medicine at the School of Dental Medicine, to review the clinical photos that would be sent—along with patient history—as part of the project. 

Greenberg quickly asked to join in the study and saw how telemedicine had potential for early diagnosis of serious oral diseases in remote areas without access to specialists.

The initial pilot study showed that local doctors and Penn doctors agreed on the diagnosis approximately two-thirds of the time, but Greenberg believes that with improved cameras and better training of local doctors and nurses in intra-oral photography, the diagnosis rate will improve considerably. 

Greenberg also notes he was able to train a local dental specialist in Botswana to use this technology, and he believes that oral telemedicine has significant potential to improve diagnosis of oral diseases in remote, underserved areas in the U.S., as well as abroad.

“You’d need a larger study and would need to perfect the technology, but I do believe we can help patients and doctors [in oral care] once it gets perfected,” Greenberg says. “This is an early stab at it.”

Remote psychotherapy for veterans

For the past year, Leah Blain and her team at the Steven A. Cohen Military Family Clinic have provided behavioral health care to veterans and military family members remotely—through Zoom, the growing video-conference platform that’s also HIPAA-approved. 

“We’ve been able to serve veterans and [their] family members who are some distance from the Clinic, and living and working in areas where there’s just not reliable health options,” Blain says. “I’ve worked with an Army veteran out in Lebanon, Pa., and ended up working with his family, son, and wife as well, when there just would not have been easy resources [otherwise] for a military culture.”

Others who use the service are people who simply can’t fit a clinic visit into their schedule. Many patients, she says, will be in a hurry but be able to grab a meal and take a private session in their home, to save time. Others have children and cannot find a sitter, or are stuck in bad weather conditions. 

It’s also just as effective as in-person counseling, she says, based on available evidence.

“The evidence is very strong in psychotherapy outcomes, that there are no significant differences,” she says. “People attending telehealth are having just as solid of outcomes as attending in-person sessions.”

One major value of telemedicine in this scenario, she says, is that it encourages continuity. She compares it to patients being less likely to skip a dose of a medication. 

The Clinic saw about 400 clients in the first half of 2018, she says, and just shy of 10 percent opted for telemedicine. Moving forward, she adds, they hope to improve their uptake, while also strengthening their ability to share clinical materials through telehealth. 

Veterinary medicine

Carlo Siracusa, an associate professor of animal behavior and welfare at the School of Veterinary Medicine, and James Serpell, the Marie A. Moore Professor of Ethics and Animal Welfare at Penn Vet, have found telemedicine success by developing an easier means for consults with veterinary behavior specialists through a web platform created with Connect4Education.

Behavioral care in veterinary medicine is a relatively young field that aims to reduce the number of animals re-homed or euthanized for behavioral issues that can be addressed. There are only 70 board-certified veterinarians with this specialty in the United States, making the field a work in progress, especially with logistics.

“Answering consults by phone or email is what we have done in the recent past, and that’s worked fine. But the problem was that we didn’t have a standard packet of information that the vet provided—each one had different information and sometimes this made it difficult for us to form a clinical opinion based on the information we were provided,” Siracusa says.

Beyond that, lines were blurred as to whether they were offering a free or charged consult, which has now been streamlined. The Penn Vet Behavior App, free to use for a limited time and specifically for dogs, essentially streamlines the consult process, and also makes some functions easier—like sending a video. 

The platform, he says, is significant as a first step toward allowing veterinarians to remotely access standardized questionnaires and make comments on a single frame of an uploaded video.

“As a first attempt, I think our platform is actually pretty sophisticated and it will get better in the coming months,” he says. “We establish a first contact with the primary care veterinarian, who then will be provided a link to his or her client that can access the platform and fill in the information requested.”

He’s clear that telemedicine can’t substitute direct interaction with a client and patient, but is useful for access to specialists in veterinary behavior.

Looking ahead, they plan to offer the service internationally and fix bugs. 

“The main obstacle is cultural,” Siracusa says, “and is represented by the fact that many people, including many veterinarians, do not think pets need behavior care, similar to what happens with human behavior care, which is thought to be only for ‘crazy’ or ‘weak’ people by some parts of the population.”

Monitoring post-pregnancy blood pressure

Adi Hirshberg, an assistant professor of clinical obstetrics and gynecology, is using a form of text messaging to catch more cases of high blood pressure among women who have preeclampsia and are recommended to document their blood pressure for 72 hours after giving birth, and again seven-to-10 days after delivery. While dangerously elevated blood pressures are not common 10 days after delivery, she says, women often have no symptoms but are still at risk for stroke, making it a concern for doctors. 

“Previously, we had a blood pressure clinic where patients could come back for a check-up, and [for new mothers] it’s hard to find time or energy to make this visit,” Hirshberg says. “There are additional needs, like transportation and child care issues. A lot of women weren’t coming in until they were sick, and that was frustrating for us.”

The solution, they thought: Find a way for these at-risk women to test at home.

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The technology is an automated service, Heart Safe Motherhood, that sends patients a text message through a software program. Patients go home with a blood pressure cuff and take the readings themselves. Twice a day, they get reminded, and get feedback based on the blood pressure reading submitted. A provider then contacts the patient about next steps, based on the reading.

“Previously, we had about a 30-percent office show rate, and now we have 90 percent of patients send in at least one blood pressure reading after they go home,” she says. “Closer to 85 percent send at least one blood pressure reading per day for the 10 days we monitor them.”

They are, she says, catching more people with high readings; as many as 10 to 15 percent of patients need some sort of management. 

The program began clinical testing in September 2017—with support from the Penn Center for Health Care Innovation—and has been developed during a four-year period. Today, participation in the program is, she says, “routine care for Penn patients with preeclampsia.” 

Hirshberg and her team, which includes co-founder Sindhu Srinivas, director of obstetrical services at HUP, hope to scale the program across other hospital systems. They are also looking at other uses for automated messaging, such as supporting women with gestational diabetes and postpartum depression. 

Studying sleep disorders in truck drivers

Elizabeth Kneeland-Szanto, an associate director of the innovation program for sleep medicine at the Perelman School of Medicine, is leading a team of four staff members and three providers, covering 14 states, to offer remote sleep screenings to truck drivers who are employees of AmeriGas Propane. Because of the danger a truck driver’s untreated sleep disordered breathing can put other automobile drivers in, sleep disorders are considered a public health issue among truck drivers, making them a prime audience for telemedicine services related to sleep. 

The program, launched four years ago, was the first commercial telemedicine program in the Penn Health System. Kneeland-Szanto’s team conducts sleep assessments that truck drivers need in order to obtain a driving license necessary to do their job; atypical of how these assessments are normally paid for, they are not turned in to an insurance company, creating, Kneeland-Szanto says, fewer inaccurate self-reported pre-screening assessments on the part of truck drivers, and more engagement with the process. 

The process begins with an initial telemedicine visit with a Penn sleep physician, after which a diagnostic home sleep testing device is sent to the drivers to test for the presence of sleep disordered breathing. If they test positive for a sleep disorder, the physician may decide to initiate auto-adjusting positive airway pressure therapy, delivered by way of a small machine and set up by a medical equipment provider, who will also activate the remote monitoring profile to allow for comprehensive, ongoing care management to ensure therapy is being used regularly and is effective. The team receives data from the machine on a daily basis, thanks to wireless modems built inside each device that transmit data to a secure centralized cloud server.

“We’re very proactive in coaching and provide structured outreach and support,” she says. “This is why compliance to therapy in this population can be as high as 80 to 90 percent for drivers who have been on therapy for at least 60 days, which is much better than the 50 percent average identified from a large body of sleep research.”

Looking ahead in the world of sleep, the fundamental need is to train more sleep-boarded clinicians in all countries, to familiarize them with telemedicine, and to increase patient access to easy-to-use technology, particularly quality phones. 

For-profit project gains are used to fund research and develop pathways to deploy the same standard of care to patients with lesser means, and help to improve their waking lives by improving their sleep.
 
“We’re kind of like the Robin Hoods of sleep,” Kneeland-Szanto says. “At least, that’s the goal. Commercial activity is important to generate resources, but ultimately we must never forget what it means to be part of academic medicine and part of the legacy of Penn.”

The future of telemedicine

Time will tell the future of telemedicine, but it’s already grown well beyond the phase of being an idea.

“I think it’s here to stay,” says Hanson, the chief medical information officer. “Ten years ago, it might have been trendy in some ways, but if you look at it closely—really any indicators you might choose to look at, including industry projections and legislative activity, provider interest—[they] point to increasing adoption and demand.

“And I absolutely think it’s going to be a new aspect of the way we provide care for our patients.”

Obstacles to its growth are largely logistical—namely technology and the costs associated with it, and the limited reimbursement providers still receive for remote services—but also include a slew of ethical questions. 

“There’s discussion about the need for discussion, and that’s just getting started,” says Jonathan Moreno, a Penn Integrates Knowledge Professor and the David and Lyn Silfen Professor of Ethics in the Department of Medical Ethics and Health Policy.

Among those topics are how operating from afar affects communication, whether clinicians understand the context in which a patient is living, the patient’s social and physical environments, how privacy standards are managed, and more questions that often apply to cyber-based operations in general. 

“There’s also a justice issue, which is, ‘Will this help people in rural poor [areas], or will it be a hot commodity for first adopters?’ For those who like the idea of not schlepping to the doctor’s office,” Moreno says. “You just don’t know, and it depends on how it gets integrated into systems.

“These are the kinds of questions people are asking.”