The broadband cure
As an emergency-room physician for more than 25 years, Dr. Debra Lister has seen it all — from broken bones to life-threatening medical emergencies. Yet it wasn’t until five years ago that Lister saw an unexpected change in her practice at the Coffee Regional Walk In Clinic in Douglas, Ga., when telemedicine technologies were introduced that virtually connected rural residents to out-of-town medical specialists.
Instead of driving to the nearest city that offers a specific medical specialty, Douglas-based patients now can meet virtually with medical specialists via the telemedicine program Lister oversees at Coffee Regional. She no longer is forced to turn away patients and send them sometimes hundreds of miles away to get examined. Instead, the clinic uses a live video conferencing system to interact in real time with off-site specialists in order to diagnose a patient’s condition and prescribe a treatment regimen.
Specifically, Lister uses a mobile telemedicine cart that consists of a fixed camera installed above a flat-screen monitor, a laptop computer and a basket of peripherals used to capture patient data, such as a digital stethoscope. Off-site medical specialists use a laptop computer to view the patient and instruct the on-site doctor by verbally guiding them through the exam. Patient health data and video are transmitted through a broadband connection, she said.
Once the exam is completed, the off-site doctor analyzes the captured data and submits a report to the local physician. “The information comes to me within a few hours to at most a few days and is much quicker than going out of town to see a specialist,” Lister said.
Lister wouldn’t be able to provide telemedicine services without a dedicated T-1 line. Luckily, the American Recovery and Reinvestment Act provided the Department of Commerce’s National Telecommunications and Information Administration (NTIA) and the Department of Agriculture’s Rural Utilities Service with $7.2 billion to expand access to broadband services nationwide. Of those funds, $4.7 billion was to be doled out by the NTIA to support the deployment of broadband infrastructure through the Broadband Technology Opportunities Program (BTOP).
Georgia Partnership for Tele-health in Waycross, Ga., won a 2010 BTOP award worth nearly $2.5 million for its TeleConnect Georgia for Better Health (TCGBH) program, which builds out broadband networks to support telemedicine applications in underserved and rural areas. The partnership will match a portion of the award in order to connect, via broadband, 1,575 primary-care physicians, 6,000 nurses and 700 non-physician practitioners that serve Georgia’s 91 counties that experience persistent poverty, said Lloyd Sirmons, TCGBH’s BTOP project director. Georgia ranks near the bottom in the U.S. in terms of overall health, according to a 2008 University of Georgia, Atlanta study. To serve the population, TCGBH has been building, for the last five years, a broadband network throughout Georgia’s rural areas to carry telemedicine applications, as well as health education campaigns, to the state’s underserved population.
“Doctors — including Dr. Lister — located in rural areas already have partnered into our network,” Sirmons said. “So that means these patients can go into their local doctor’s office, in the comfort of their primary-care physicians, and access all of the specialists connected to our network. The recent winter award of the BTOP grant helps us to continue to build out this network.”
In the past, rural patients may have had to drive hours to be seen by a specialist, Sirmons said. The buildout of a broadband network means that doctors operating on the network and patients visiting connected clinics can interact and be examined virtually via live video conferencing — saving both time and money.
“Via telemedicine, rural Georgians have access to modern medicine right at their fingertips,” Sirmons said. “A patient needing to see a cardiologist in a small rural town, who may not have had the access unless they drove hours away, can go to a local doctor’s office that has one of our telemedicine units and be examined by a specialist located in a nearby city, like Atlanta.”
Reliable bandwidth for running high-definition video is needed for telemedicine applications, Sirmons said. And while wireless may be an option for some healthcare campuses, it would take robust internal networks to support applications, IT personnel to manage them and commercial carriers to evolve before wireless trumps wired telemedicine connectivity.
“Wireless technology in the past has not been strong enough to support live video conferencing,” he said. “But things are changing. Right now, Verizon offers 3G. But in December it will be going to 4G, like Sprint. So what we are finding is that wireless technology is beginning to catch up.”
The BTOP grant will let the organization continue to build out T-1 lines to service telemedicine applications, including an expansion of its current telehealth broadband network from 133 access points to 197 access points. Jerad Johnson, TCGBH’s BTOP IT administrator, explained that it is an open-access network built using dedicated T-1 lines leased from regulated telecommunications carriers in the state of Georgia.
“It is a private dedicated network that uses point-to-point dedicated T-1 lines,” Johnson said. “The line is used for its security and reliability, with a guaranteed bandwidth that is always available.”
Johnson’s team is in the process of upgrading the network by adding a broadband Internet pipe. He hopes to move away from private, dedicated connectivity and towards using the Internet as the backbone in order to save money. For example, a facility would use existing Internet infrastructure, but it also must have quality-of-service controls installed at the gateway.
“They would need to slice off dedicated bandwidth that would be used for telemedicine services, because the real-time video portion requires guaranteed bandwidth,” he said. “They can’t be sharing with network traffic, like e-mail, or competing with the video portion.”
The video-conferencing aspects of telemedicine require broadband for guaranteed throughput, minimum latency and controlled jitter, Johnson added. As a result, most systems are hardwired, not wireless.
“On a hardwire install, you have more of an opportunity to guarantee 10 Mbps [capacity] and each device has that true connectivity. But in a 54 Mbps wireless network, you are sharing that amount of bandwidth between all of the devices,” he said. “So a hardwired Ethernet connection would always be preferred.”
Sirmons said that the network’s continued expansion will lead to additional clinical applications. For example, one BTOP grant partner — the Georgia Department of Community Health — is leading the charge to establish a statewide health information exchange with the help of the Morehouse School of Medicine. The Atlanta-based college recently received a grant from the Georgia Health Information Technology Regional Extension Center (HITREC), which is charged with providing outreach and support to assist rural physicians in achieving an electronic health record, which is a stated goal of the Recovery Act. With the help of grant funding, 8,275 rural health-care providers will be educated on accessing and sharing electronic health information securely using the network, he said.
“The program focuses on improving the health status through the meaningful use of electronic health records and the exchange of health information via their highly secure, private telehealth networks,” Sirmons said.
In fact, the Morehouse School of Medicine received additional grant monies to address EHR, about $19.5 million, under the Health and Information Technology for Economic and Clinical Health (HITECH) Act, which was enacted in February 2001, as part of the Recovery Act. Dr. Dominic Mack, project director for the state’s HITREC program, said that the monies will fund outreach, education and technical assistance to healthcare providers so that they can implement EHR systems.
Under the program, Mack’s team helps providers choose a clinical records software system. The team will analyze the health system’s needs, compare federally approved clinical record systems and choose one that matches those needs. If an EHR system already is in place, they will advise on software upgrades that meet meaningful-use standards.
“It must meet ‘meaningful use,’” Mack said. “If it’s not user-friendly, people won’t use it.”
In fact, it is essential that software developers ensure that their specific EHR application is user-centered, said Svetlana Lowry, project lead for the National Institute of Standards and Technology‘s Health IT usability group. Lowry and her colleagues at NIST recently completed two reports on the topic to provide guidance to developers of software and computer systems for doctors’ offices, clinics and hospitals in their pursuit of this goal. The publications were developed as part of a federal effort led by the Department of Health and Human Services’ Office of the National Coordinator for Health Information Technology “to help providers adopt and use EHRs that can bring about broad quality improvements and cost savings in the healthcare system,” Lowry said.
The first report discusses a standard reporting format adopted and customized for testing EHR systems. The second provides guidance on employing user-centered-design processes throughout an EHR product lifecycle. User-centered design focuses on understanding user needs; designing user interfaces on the basis of known human behavior principles; conducting usability tests; and enhancing designs and features until usability objectives are met, Lowry said.
“Our hope and objectives are to provide the guidance to industry and to health IT software developers, system architects and executives at companies,” Lowry said. “The guidance focuses on incorporating user-centered design into their processes and practices.”
Efforts to improve the usability of EHRs are widely recognized as key to achieving widespread adoption, Lowry said. In fact, a recent report prepared by the HHS’s Agency for Healthcare Research and Quality identified gaps in the processes and practices used by EHR vendors. It found a lack of standard approaches and formats for testing and reporting usability of EHR products across the industry.
“Usability is extremely important for the end user and is needed to encourage the widespread adoption of EHR technologies nationwide,” she said.
In addition, Mack recommends that electronic medical record systems include evidence-based quality measures and clinical protocols that can guide providers as they practice medicine. It also must have clinical decision-making support applications.
“It means a provider sees a patient, such as a diabetic, and the record will prompt the physician to ask the proper questions as it is related to evidence-based medicine,” he said.
Telemedicine and new software applications will soon let doctors work remotely and address patients’ needs from anywhere in the U.S., using various forms of handheld and mobile technologies, Mack said.
“Doctors won’t have to be in the office,” he said. “They hopefully can get to the point where they use the cell phone to view X-rays. That’s the future of the technology.”
However, Mack said the cost of software suites concerns health-care providers and may hinder future widespread adoption.
“Cost is the No. 1 barrier to electronic health-care record implementation,” he said.
For telemedicine to work seamlessly nationwide, the country also must change the way physicians are allowed to practice, Mack said. Currently, a physician must be licensed in each state in which they practice. Eliminating such restrictions would mean that a specialty practitioner could use telemedicine to treat patients outside of his or her home state, he said.
“I’ve done some work with telemedicine on the Gulf Coast after Katrina. The No. 1 issue was that visiting physicians couldn’t provide services across state lines without having a license within that state,” Mack said. “I think with telemedicine, that’s a big issue that we have to overcome so people can receive services.”
In addition, telemedicine currently targets a specific type of doctor. Lister believes it often is a seasoned practitioner who is confident in his abilities, comfortable using technology and focused on reducing overhead costs associated with brick-and-mortar offices.
“They don’t even need a private office set up to see patients, which opens up myriad possibilities,” she said. “They can be at their home office or anywhere with an Internet connection.”
The market for telemedicine is endless, Lister added. Nursing homes are investing in such systems to reduce the need to transfer frail patients from facilities to a doctor’s office. Even jails are testing telemedicine applications to reduce flight risks, she said.
“Think about every time an inmate goes to have an exam and the security issues involved with transporting them. There are security risks,” Lister said. “I also see it happening in schools with some kids that can’t get the care they need. So, all those different telemedicine applications are starting to be looked at, and applications will continue to grow.”