HP

The business of healthcare is changing. IT should have the confidence and ready state strategy to meet the needs of their population health and community outreach departments.

Fueled by three converging trends – increasing government support and reimbursement for telehealth services; purpose-built, integrated hardware-software solutions; and the “consumerization of medical devices” – telemedicine is poised to make major gains in the coming year. An October 2017 survey from KLAS and the College of Healthcare Information Management Executives asked 104 healthcare organizations about their plans for telemedicine deployments. Nearly 60 percent said that they planned to expand an existing program or launch a telemedicine initiative in a new service line. Respondents also reported that the primary driver for telemedicine expansion is the patient – providing patients with easier access to healthcare services (59 percent), or improving patient experience because of telemedicine (68 percent). “Telehealth offers a great opportunity to enhance the lives of patients,” said Russell P. Branzell, CEO and president of CHIME. “But it needs to be carefully implemented to meet its potential, and we still face headwinds with reimbursement and integration issues.” A paradigm shift While reimbursement has historically been an obstacle to telemedicine, in November the Centers for Medicare and Medicaid Services signaled a shift for broader payments for e-visits, remote patient monitoring and other teleservices for chronic care management. “Telemedicine has gotten a big boost from CMS, and the rules for reimbursement are likely to change,” said Janet Rushing, systems director for the Center for Telehealth and eICU at Geisinger Health System in Danville, Pennsylvania. “And third-party payers tend to follow Medicare.” The federal government seems inclined to relax regulatory barriers as well. This fall, a bill permitting interstate treatment for VA patients won broad support in Congress. Rules that prohibit cross-border treatment seem likely to change in many states. Geisinger is all-in on telemedicine. Beginning in the early 1990s with remote asynchronous services such as cardiology and EKG reads, the system has expanded its offerings to include telestroke services, both inpatient and outpatient consultative telehealth across dozens of specialties, remote patient monitoring, and a nationally known eICU service that it provides to other hospitals. Its latest initiatives are focused on direct-to-patient programs – home telepsychiatry and e-visits, for instance. “We’re in the middle of a paradigm shift,” Rushing said. “In my lifetime, only the sickest of the sick will be hospitalized. Telemedicine will enable more patients to be seen, diagnosed and cared for in the home, and we need to optimize our systems for those patients who are good candidates for telemedicine. If you can be seen and treated at home, why shouldn’t you be?” Integration considerations Even as reimbursement and rules are addressed, providers need to think even more carefully about their investments in telemedicine technology. Will software solutions integrate with the provider’s electronic health record? Will workstation PC peripherals work together to provide a seamless and uninterrupted patient-clinician interaction, even when they are separated by hundreds of miles? After all, ambient noise, bandwidth issues and poorly designed speakers and microphones on computers can detract from a good telemedicine experience and end up inflating the total cost of ownership. At Geisinger, ensuring that a virtual examination is equivalent in every way to a face-to-face encounter has been paramount. Service interruptions and downtime are not options. James Rafel, IT program director, says the system is constantly monitoring its workstations, telemedicine-specific devices and networks to ensure the highest-quality experience for both patients and providers. But serving patients in rural Pennsylvania, Geisinger can’t control every aspect of the telemedicine network – some endpoints can only connect via low-bandwidth connections. “We try to mitigate that when we look at the products we acquire,” Rafel said. “We want to work with vendors who specialize in services that can operate over cell or other low-bandwidth environments. That’s a ‘must-have.’” On the software side, Rushing says that all of Geisinger’s telemedicine applications integrate with the system’s EHR. And since the EHR has been integrated with Geisinger’s PACS system, physicians are able to take real-time data from a telemedicine encounter and contextualize it with the longitudinal data in the patient record. That means hardware acquisitions have to be qualified against standards and meet medical-grade criteria. “And that means we work closely with our vendors,” Rushing said. “We just can’t have any old camera on the (workstation) cart. We want to make sure it will enhance the encounter. We have to be aware and ask the right questions before we invest.” But even when you get the software and hardware integrations right, the success of most telemedicine initiatives will ultimately depend on how patients and providers respond to the new paradigm of care. “It’s a cultural change,” Rushing says. “Services like remote patient monitoring represent a commitment, a partnership between providers and patients. You have to bring the patient and the family into it – they are now part of the care team.” jQuery(function() {jQuery('#parallax-ad-container').hide();});

More than a decade ago, healthcare information technology leaders – concerned about electromagnetic interference (EMI) from mobile electronics – banned cellphones in patient care areas. While there was little empirical evidence documenting such interference with medical devices, apocryphal anecdotes and a precautionary attitude led to the bans. Today, following studies by the Mayo Clinic and other researchers that showed almost no harmful effects from interference, those bans have largely disappeared. Cellphones have become ubiquitous, and they now share the patient room with a host of healthcare IT devices: Computers, monitors, peripherals, smartphones and tablets are all frequently operating within 6 feet of the bedside and exam table, according to a recent study by HIMSS Media1. As IT devices in the hands of patients and providers crowd the point of care, the question of EMI and its potential impacts on nearby medical devices – and patients – is being raised once again. There are new concerns about the impact of wireless technologies such as Wi-Fi and Bluetooth. And experts are also resurrecting worries about the risks of leakage currents when non-FDA-approved equipment is not properly grounded. Consumer-grade concerns Unlike medical devices that undergo rigorous electronics instrumentation testing to meet the International Electrotechnical Commission’s 60601 and, more specifically, 60601-1-2 standards, commercially produced desktops, laptops and tablets are not required to meet similar emissions standards. “These products are designed for consumers and office environments, not clinical settings,” explained Raja Bhadury, head of HP’s care delivery portfolio. “The risk of electrical shock, burns and even cardiac arrhythmias due to leakage current from improperly grounded IT products is not fully understood.” As such, these IT devices are usually not rigorously tested for clinical environments. “Besides, considerable investment is needed to design products to meet these higher emissions standards, and it takes time to go through the certification testing.” Juuso Leinonen, project engineer at the nonprofit ECRI Institute, said the patient safety-focused organization is aware of only isolated incidents in which high-powered radio transmitters (namely, two-way radios) interfered with the function of some fluid warmers operated in close proximity. “Overall, most consumer-grade equipment is low-powered, which seems to mitigate the concern with EMI,” Leinonen said. “At least at present, we do not have reports to support this being a significant issue in the healthcare setting.” But leakage current, on the other hand, poses a threat for certain types of patients, as it has for decades. In 2004, authors Leonard Eisner, Robert M. Brown and Dan Modi provided a primer on leakage current standards for Medical Device + Diagnostic Industry readers. “Leakage current is one of the most stringent, yet telling, parameters of possible danger to patients or caregivers,” they wrote more than a decade ago. “This is especially true for patients with weakened immune systems.” Proactively weighing the risks Good data on any negative impacts caused by leakage current have been hard to come by. One reason for the lack of empirical evidence is patients’ vulnerable state at the onset. It can be difficult to determine whether leakage current or an already weakened organ causes problems with immune-compromised or cardiac patients. Despite the lack of firm research in this area, healthcare providers would be wise to proactively weigh the risks of EMI in their current IT equipment infrastructure, especially with a growing fleet of consumer IT equipment residing in patient rooms, edging ever closer to patient beds. That review includes assessing purchasing plans and guidelines, scrutinizing potential equipment and working with vendors to ensure patient safety at all times.  Specifying a “minimum separation distance” (MSD) between IT devices with radio transmitters and sensitive medical devices can also help reduce risk. Researchers from Concordia University in Montreal found that when hospital staff comply fully with a MSD policy of even one meter, they can operate devices in the same room as the patient and medical equipment without posing a danger2.                              “The reality is, there’s always some risk,” Bhadury concluded. “PC vendors must work with their healthcare customers and regulatory agencies to assess the risk and make thoughtful design choices to address the risk.” References HIMSS Media, Creating a Patient-Safe Technology Environment: a HIMSS Custom Research Report. Prepared for HP. October 2017. “Can personal devices interfere with hospital care?” Science Daily, June 16, 2015, https://www.sciencedaily.com/releases/2015/06/150616123921.htm jQuery(function() {jQuery('#parallax-ad-container').hide();});

But more than half of respondents underestimate the risks of improperly sanitized devices.