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“Advances in Telemedicine & Telehealth:
New Models of Healthcare Delivery”
Ronald S. Weinstein, MD, FCAP, FATA
Director, Arizona Telemedicine ProgramProfessor, Colleges of Medicine, Pharmacy
and Public HealthThe University of ArizonaTucson, Arizona
Corabi International Telemetric, Inc. Apollo Telemedicine, Inc. DMetrix, Inc. GlobalMed (Medical Advisory Committee) AmericanWell (IP- expert advisor)
Disclosures
© 2013, Arizona Telemedicine Program
Innovations in Medicine
© 2013, Arizona Telemedicine Program
Technical
Societal Organizational
Direct-to-Consumer Telehealth
https://www.youtube.com/watch?v=gnVmHZRSOnQ
United HealthCare Virtual Visits
(Single Click on the link)
Direct-to-Consumer Telemedicine
https://www.youtube.com/watch?v=sBryMAxi5tE
American Well
© 2013, Arizona Telemedicine ProgramRandall Moore, M.D.
Mercy Virtual
Mercy VirtualChesterville, MO - 2017
© 2013, Arizona Telemedicine Program
Mercy Virtual
© 2013, Arizona Telemedicine Program
Brief History of Early Telemedicine1. telepsychiatry, teleradiology (1959)
2. prototype telemedicine service (1968)
Aggregation of Enabling Technologies
> Television
> Videoconferencing (bi-directional)
> Teleradiology
> Television microscopy (precursor of telepathology)
> Electronic stethoscopes, etc.
© 2013, Arizona Telemedicine Program
1952
1955
1956-2015Center of Excellence
(1960-1962)
Woods Hole Marine Biology Laboratory
1968-1977Massachusetts General
Hospital; Harvard(1962-1975)
Origins of Television Microscopy(remote clinical microscopy)
Diffusion of Innovations in Medicine--Example: Telemedicine microscopy--
© 2013, Arizona Telemedicine Program
MGH
Logan International Airport *
Television microscopy Massachusetts General Hospital
Boston, Massachusetts, USA
Blood smears Urines
© 2013, Arizona Telemedicine Program
Boston Logan Airport Medical Station – Connecting to the Massachusetts General Hospital
1968
A
B C
The Press Takes NoteMedical World News
July 26, 19681968
R.S. Weinstein et al, Clinical Examination Component of Telemedicine, Telehealth, mHealth, and Connected Health Medical Practices.
Medical Clinics of North America, 102; 533-544. 2018
History of Telemedicine
History of Telemedicine
R.S. Weinstein et al, Clinical Examination Component of Telemedicine, Telehealth, mHealth, and Connected Health Medical Practices.
Medical Clinics of North America, 102; 533-544. 2018
Telemedicine Peripheral Devices
Tele‐ophthalmoscope
Video‐otoscope
Multi‐lead ECGGeneral patient exam camera
Electronic stethoscope
Teleradiology
Legacy Appliances (1968-1980)
Television microscopy
Telemedicine Peripheral Devices
Tele‐ophthalmoscope
Video‐otoscope
Multi‐lead ECGGeneral patient exam camera
Electronic stethoscope
Teleradiology
Video‐endoscope
Electronic scale
Smartphone
Wearables
Video dermatoscope
Video‐colposcope
Blood pressure monitor
Innovations (1995-present)
Television microscopy
Telepathology
• Proof-of-Concept
• High user and provider satisfaction
• Multi-specialty services
• Innovations in “peripheral devices”
MGH-Logan International Airport Telemedicine
© 2013, Arizona Telemedicine Program
1972-1975
Space Technology Applied to Rural Papago Health Care Program(Lockheed Missile Space Company)
Arizona Story
STARPAHC Project: Sells, Tucson & Phoenix, AZ
NASAIHS
Lockheed(1972-1975)
Regional Telemedicine Program
STARPAHC Mobile Telemedicine Vehicle -1975
© 2018, Arizona Telemedicine Program
Dozens of Telemedicine
Programsby 1978
© 2018, Arizona Telemedicine Program
President Lyndon Johnson -- “Great Society”
President Ronald Reagan -- “Reaganomics”
© 2018, Arizona Telemedicine Program
Telemedicine Issues (1986)• Legal
• Regulatory
• Reimbursement
• Quality-of-care
• Standards-of-care
“Telemedicine is a technical as well as an organizational
and social innovation.” --Bashshur et al, 2000
© 2018, Arizona Telemedicine Program
Western Governor’s AssociationReport on Telemedicine
Telemedicine Issues (1993-1994)• Legal
• Regulatory
• Reimbursement
• Quality-of-care
• Standards-of-care
1996
Arizona Rural Telemedicine Network
• > Rural and urban hospitals• > Native American healthcare• > Prisons & jails• > Community health centers• > Schools• > Distance learning affiliates
250+ Sites in Arizona
© 2013, Arizona Telemedicine Program
Telecardiology
Mayo Clinic -Telestroke
Yuma NICU Tele-echocardiology
Tele-infectious diseaseAIDS tele-nursing
Banner eICU program
Diabetes retinal screening
Breast Cancer “Virtual” Survivor Groups
Flagstaff –Navajo/CHF Program
Telemedicine/Telehealth Services (61 total at U of A)
Teleradiology1,400,000 cases
Teledermatology
Teleophthalmology
Telerheumatology
Teleneurology
Dr. Conrad Clemens uses real-time video conferencing and digital stethoscope technology to evaluate a child's asthma.
Tele-pediatrics
Telepsychiatry
“The talk is the treatment”• Psychiatry/psychology• Genetic Counseling• Pain Management• Nutrition• Support group• Hospice care
Cancer Genetic Counseling
Support Groups
Home Health Care Applications• Wound care• Post-operative care• Pre-organ
transplantation• Physical therapy
Wound Management
Telemedicine & Telehealth Services
1. Gap Services2. Urgent Services3. Mobile Telehealth4. Direct-to-Consumer Telehealth5. Cloud Computing Applications
Gap Service and Tele-urgent Services
1. Gap Services
2. Urgent Services
© 2013, Arizona Telemedicine Program
Gap Services - Teleradiology
Urgent Service – TeleStroke
Telestroke
Telemedicine & Telehealth Services
1. Gap Services2. Urgent Services
3. Mobile Telehealth4. Direct-to-Consumer Telehealth
5. Cloud Computing Applications
“Care Beyond Walls and Wires is the
best thing ever for me, and the best thing for my dad.”
Rita Yazzie
Case StudyMobile Telehealth
Telemedicine & Telehealth Services
1. Gap Services2. Urgent Services
3. Mobile Telehealth4. Direct-to-Consumer Telehealth
5. Cloud Computing Applications
(Single Click on the link)
Doctor On Demand
Direct-to-Consumer Telehealth
(Single Click on the link)
MDLive
Direct-to-Consumer Telehealth
1850
0
500
1,000
2,000
2,500
3,000
3,500
4,000
1,500
1880 1910 1940 1970 2000
Managers
Technicians
Therapists
Aides
LPNs
RNs
Pharmacists
Dentists
NPCs
Physicians
Physicians, Non‐physician Clinicians,and other Health Workers
1850‐2010
Health
Employmen
t per
100,000of
Popu
latio
n
Adapted from Kendix and Getzen, and the Bureau of Labor Statistics
FlexnerReport
HillBurton
Medicare
Telemedicine & Telehealth Services
A. Gap ServicesB. Urgent Servicesc. Mobile TelehealthD. Direct-to-Consumer Telehealth
E. Cloud Computing Applications
Cloud Computing: zoom.us
Cloud Computing
© 2013, Arizona Telemedicine Program
Project ECHO Programs(Extension for Community Healthcare Outcomes)
• Project ECHO (Extension for Community Healthcare Outcomes) is a collaborative model of medical education and care management that empowers clinicians everywhere to provide better care to more people, right where they live.
• The ECHO model™ does not actually “provide” care to patients. Instead, it dramatically increases access to specialty treatment in rural and underserved areas by providing front-line clinicians with the knowledge and support they need to manage patients with complex conditions such as: hepatitis C, HIV, tuberculosis, chronic pain, endocrinology, behavioral health disorders, and many others.
• It does this by engaging clinicians in a continuous learning system and partnering them with specialist mentors at an academic medical center or hub.
About Project ECHO
© 2013, Arizona Telemedicine Program
Why Project ECHO?
121,697 square miles
Sanjeev Arora, M.D.
Arizona TelemedicineProgram
ATP Rheumatology TeleECHO Clinic
ECHO TeleRheumatology Clinic
ECHO TeleRheumatology Clinic
Physicians in Bisbee, AZ Attending from a rural hospital conference room
PCORI Programs(PCORI - Patient-Centered Outcomes Research Institute)
“Ostomy Telehealth for Cancer Survivors: A Program of Collaborative Research”
Robert Krouse, M.D., FACS, Principal InvestigatorRonald S. Weinstein, M.D., Co-P.I.
Ostomy Surgery
Session/Content• Session 1: Self-management & immediate
concerns• Nutrition• Pouching System• Goals/Resources
• Session 2: Social well-being and body image
• Social/Interpersonal relationship
• Sexuality/Intimacy
• Psychological Health
• Session 3: Caregiver/Support Person only
• Ostomy review
• Concerns regarding ostomates
• Caregiver/Support person well-being
• Session 4: Healthy Lifestyle
• Interpersonal Relationships
• Travel Concerns
• Physical Activity
• Improving Attitudes
• Psychological Health
• Session 5: Booster session for ostomateand support person
• Content Review
• Available Resources
• Goal Progress
PCORI Funding
Ostomy Self-Management Clinical Research Sites
City of HopeUniversity of Arizona & Arizona Telemedicine Program
Penn MedicineYale New Haven
Steven Moore: Las Vegas Review-Journal 2/15/2005
In-Person Support Group Setting
In-Person Support Group Setting
https://www.reviewjournal.com/life/health/ostmate-support-groups-filled-with-stories-of-past-successes-hopes-for-future/
Ostomy Telehealth Patient Group Session
“Social reinforcement by peers”
Panel of Peer Ostomates• Nurse Educators• Engineer
4-6 New Ostomates
In-Person Model
Telehealth Model
• “Ostomate Peers”
© 2013, Arizona Telemedicine Program
Photo – Ostomate Peer at Home
Take Home Lessons
• Telemedicine/telehealth is focused on patients
Take Home Lessons
• Telemedicine/telehealth is focused on patients
• Regulatory uncertainty is no longer slowing momentum
Take Home Lessons
• Telemedicine/telehealth is focused on patients
• Regulatory uncertainty is no longer slowing momentum
• Top-challenges are related to reimbursement
Take Home Lessons
• Telemedicine/telehealth is focused on patients
• Regulatory uncertainty is no longer slowing momentum
• Top-challenges are related to reimbursement
• EHR is frequently inadequate for telemedicine
Take Home Lessons
• Identifying, selecting, contracting with, and establishing long term working relationships with, telehealth service providers
• Creating realistic outcome expectations
Significant Challenges
© 2013, Arizona Telemedicine Program
© 2013, Arizona Telemedicine Program
Resources
> Arizona Telemedicine Program -- In-state
> Southwest Telehealth Resources Center – Out-of-state
www.telemedicine.arizona.edu
© 2013, Arizona Telemedicine Program
Resources
> Arizona Telemedicine Program -- In-state
Federally - Funded Telehealth Resources Centers – Out-of-state
www.telemedicine.arizona.edu
4th National Service Provider SummitGlendale, Arizona October 2-3, 2018
Arizona Telemedicine Council, Quarterly meetingsAZ State Capitol Campus
April 8, 1968-April 8, 2018
50th Anniversary of Telemedicine Systems
96th Arizona Osteopathic Medical Association Conference
Lecture
Thank you
rweinstein@telemedicine.arizona.edu
Ronald S. Weinstein, MD
© 2013, Arizona Telemedicine Program
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