PSTX Seal

E-Medicine

Thank you very much for that kind introduction, Dr. Stobo. We wanted to take a little time today and share some of the programs and technologies that we use for electronic health or E-Health.

Now, E-Health has a lot of aspects to it. There's electronic health that refers to the phenomenal advances and devices to test your blood sugar at home. Or if you've been in airports or other public spaces lately, you may have seen things called AEDs, automatic defibrillators. These are the way electronics and technology are improving healthcare.

But one of the other ways that technology is having an impact is in the mechanism by which healthcare is delivered. You've got people exploring ways where people are e-mailing their doctor. You've got hospitals, insurance companies, healthcare organizations putting up portals where you can log in and find out your doctor's schedule and get information. You’ve got cybercondriacs, as were mentioned earlier, and electronic health records and telemedicine.

Telemedicine is an area that we have a special affinity here for at UTMB because of our background in it. Telemedicine is nothing new. One of the most notable first implementations of telemedicine was in Boston at Logan Airport. Not long after it was completed there was concern that being on an island there would not be a way to get healthcare to the airport if there was actually an incident or a problem. So a television system was put in and this was really one of the first seminal implementations of telemedicine.

But telemedicine has not had the best of reputations all the time. It's been around for 15 to 20 years. There are valid criticisms as you go through the discussions about telemedicine. The equipment can be very expensive, originally over $150,000 per location. There's an impression that people don't like it, that the patients don't like it. I don't want to talk to a television set. I want to talk to my doctor.

From the medical establishment approach sometimes there were doubts - a doctor and a television set? How can this be real? And, of course, many policymakers have the concern that this is just going to be another way to bilk the system. They're going to set up shops in India and Bangalore, and you're going to be seeing doctors that you don't understand from thousands of miles away.

But we've had a bit of a different experience. And if you'll bear with me here for a moment we're going to share with you a recent T.V. spot from San Antonio (Playing of T.V. segment). So a little different perspective on how far telemedicine has come. Now, how do we get here? UTMB has always had a special place in the state of Texas. Our slogan is Here for the Health of Texas.

If we take a look at this small graphic the blue-shaded counties are areas where there are unsponsored patients in high numbers. The green dots up there represent areas where there is outreach activity of UTMB across those counties. To cover those kinds of distances UTMB has had to develop technologies that allow this kind of work to be done.

The patient/doctor relationship is vitally important to all of us here at UTMB. One of the things we'll talk about at the end of this little discussion is returning to the digital house call. But the doctor/patient relationship today is based on the idea of bringing doctor and patient together. There are many in national healthcare policy making that are concerned that there's still a lot of energy in healthcare institutions about the next building to be built and parking deck to be designed and skywalks to be navigated.

Technology offers ways, opportunities, to bring doctors and patients together using technologies of telecommunications: satellite, fiberoptic, microwave. And at UTMB we've tried to respond to this challenge by building the technologies next to the patient and building the technologies next to the doctor that allow these telecommunications technologies to play a role in bringing doctor and patient together.

We have here at this end of the room an example of one of these devices, and I'd like to share with you a little bit about it here in just a moment. This is one of our T-carts or telemedicine carts. We operate about 250 of these in various locations across the state of Texas. About half of them are in prison facilities, but there are others in areas like Liberty County, Brazoria County, imaging healthcare programs, construction companies, and insurance companies around the state.

They provide everything that's needed to deliver this type of telemedicine care. It has an electronic medical records workstation. It has medical quality video conferencing. It has additional devices and peripherals that allow us to perform the examinations that you saw in the short video. The basic camera that comes with it is completely and remotely controllable by the doctor from wherever he might be on the network. And that includes zooming out and zooming in and providing a tremendous range of flexibility. The cameras are all automatic focus, automatic brightness control ‑ I guess I should go ahead and focus in on my boss here ‑ and they allow the doctor to provide the perspective into the examination room that he or she feels that they need to provide the examination.

Now, in addition to these types of cameras, we also include an electronic document camera. No matter how hard we try to make the documentation system and healthcare paperless paper always pops up. So we always put in one of these document cameras so that a last-minute EKG, lab results, other studies can be shared to the doctor, regardless of how far away they are, without anyone having to run to a fax machine or run to a scanner and do these types of things. This same device can be used to show x-rays. We have orthopedic specialists that can do this to do preoperative work, postoperative work, and, again, keep the patient where they are instead of having them to travel to see the specialist physician.

We always install one of these handheld medical scopes that is multifunctional. It has a fiber optic light in it. It has halogen illumination, so it's very bright for clinical work. And it has different attachments. This is an attachment for looking in ears and up noses. I'm pretty good with a Q-Tip. I won't leave this up long. And other examination scopes that can go all kinds of places you don't want to talk about at lunch.

In addition to this type of technology there are devices to send stethoscope sounds live from one place to another. And we build every one of these devices with probably their most important feature which is that anywhere they are in the world they can pick up a UT football game. So we're absolutely at a commercial here in the game, and in a few minutes here we'll put it on so people can catch up and maybe catch the kickoff.

Back to reality for a moment. What kind of environment do the doctors work in for this type of telemedicine environment? This is one of several telemedicine studios where we have physicians that do this work exclusively and tell the very bad joke that they don't have to wash their hands between patients. But it does very, very well. This is Dr. Oscar Boultinghouse, who I have the privilege of working with as our chief medical officer for the Electronic Health Network. He plays a very important role in identifying and training the physicians - primary care emergency medicine, cardiology, orthopedics - that work in these environments.

And up here on the screen is the vision into the clinical areas. That's a nurse working in a clinic with one of these carts. And then in front of him he has electronic medical records that allow him to get the information that he needs to examine the patient and understand the case. This is another example of one of these rooms. This is Dr. Michael Davis, a cardiologist that practices exclusively. He crosses over between the correctional environment and the free world non-correctional environment.

About two-thirds of the telemedicine encounters we do are in the correctional environment. They represent a significant amount, but the growth in our non-correctional environment has been significant. We do over 60,000 patient visits a year solely by telemedicine. In the correctional prison care environment there is more specialist medicine delivered by telemedicine than by face-to-face encounters. And you may wonder what this like, so I have another short video (Playing of video).

I'm going to pause here for just a moment. What you're going to see now is one of the things that are very important in telemedicine is moving the information from where the physician's making a decision back to where the patient is so that it can be acted up. It might be prescriptions; it might be consultation reports. To do that and make sure it's done on a timely basis these providers exclusively use voice recognition systems, where as they speak it actually types their clinical notes. That's what's going to be demonstrated now (Playing of video). So you get a sense of what it looks like from the physician's end during one of these telemedicine encounters.

One of things that we're very proud of here at UTMB is the work that many of you are aware of for our role in biodefense. This afternoon you'll be learning more about that from Dr. Lemon. But we feel that the combination of the biodefense resources emerging here at UTMB, with our telemedicine capabilities, is an important combination. The resources again here are important and are unique in many cases to the United States. And using the electronic health technologies that we have to allow those resources to reach out, support folks in the field that are responding to a biodefense emergency, we feel is an important combination.

Telemedicine equipment does not have to look like the shiny white cart. You might not be able to spot the telemedicine equipment in this picture until we open it up and begin using it. We continue development in areas like this. And that has earned us some recognition on a national level from the National Homeland Defense Foundation. I'd like to show you a short video here (Playing of video). So there you are. We're very proud of that recognition from the National Homeland Defense Foundation.

What we really look for in the future from this is a return to maybe a gentler day. One of the things that we think is important as we continue our journey in telemedicine and telehealth is a return to I guess the gentler time of the house call. And we are developing this skill set of connecting doctors to clinics. And we're beginning the journey of understanding the best way to connect doctors to the home.

All of these graphics on the screen are concepts, prototypes. But I guess in our world it is an opportunity to have technology play an important role in what we refer to as the lather, rinse, repeat of healthcare delivery, the importance of chronic care: get some labs, talk to the patient, adjust the medications, see you again in a while. But even specialty medicine is referred to as having a lather, rinse, repeat. I'm going to see you to see what I need to see you for. I'm going to see you to do what we're going to do. And then I'm going to see you again to see if what we did worked.

Telehealth has an important role in many of those steps. And what we are doing now is developing the strategies in the partnerships so that when you purchase that glucometer for your blood sugar at Wal-Mart, when you purchase that scale at Bed, Bath, and Beyond, when you purchase that blood pressure cuff in your drugstore, that they innately have the ability to wake up in your home and identify you and identify your data to a secure system that shares that information to your doctors and to your hospitals.

I have an 80-year-old father who is a cardiobionic man in Detroit. And he still in the dead of a Detroit winter has to go out once a week and get his protein taken. And the idea that he has to do that, go out and risk a slip and fall in icy weather, is always a concern to myself and my family. The idea that this kind of information can be obtained in the home and that video technologies are available so that the physician visit is available on my dad's television set is really part of our future vision for the delivery of healthcare , for chronic healthcare monitoring and, again, really extending this reach.

Part of this reach is work that we're doing with partners across the state of Texas, with our UT System component colleagues in Tyler and in Brownsville. And we are doing this due to some important support through the Office of the Advancement of Telemedicine. And Senator Cornyn was very vital in putting this together and helping us get this important support. And I know all of us here at UTMB thank him for his role in enabling this to happen. This is going to allow us to investigate the role of telemedicine in three very different socioeconomic and demographic areas of Texas.

So, with that, I'm going to close with another short video. And then we'll go to the football game. And while I'm setting up the video I'll be happy to go back to the game. Anybody going to kill me if I go back?

Question and Answer:

Dr. Stobo: I hope you can see how this technology impacts on a lot of things that were discussed this morning, certainly access to healthcare and quality of healthcare, the error issue regarding healthcare, and also the cost of healthcare. We can have various people on either end of the telemedicine linkage. We use nurse practitioners, physician assistant, corpsmen, as well as physicians. And so it does really impact on access, quality, cost, et cetera. Glenn, what does this cost?

Dr. Hammack: We currently build and deploy these for just under $40,000, one-time cost. In some of our research programs and some of our smaller communities we actually lease them for under $8,500 a year.

Audience: What does it cost per patient?

Dr. Hammack: Cost to a patient for a visit in most of our clinics where we bill Medicare or Medicaid or private insurance is really no different. We work very hard to coordinate with standard insurance programs. So to the patient there's no difference than they would have under their regular insurance. They may have a co-pay; they may not. It really works with their regular insurance programs.

Dr. Stobo: We provide healthcare to the thousand employees of Amoco, which is located probably five blocks from here. And we did a study. If the employee at Amoco came up to UTMB to receive their healthcare the average time away from the desk where they worked was over 3.5 hours. The average time if they went to the telemedicine facility in the Amoco building was 30 minutes.

Now, Amoco thought that was so valuable for them that they pay the patient’s co-pay if they go to the telemedicine facility in the building. But they go up to UTMB, the patient has to pay their own co-pay. It made financial sense to Amoco to have the patients seen in the building.

Audience: What's the training effort upon both the doctors and people on the other end?

Dr. Hammack: That's a great question. The training is very straightforward. One of the things we had to do, again because this stuff started out in this very large prison healthcare program, we had 3,500 employees all across the state of Texas that had to be briefed and trained on how to do that. Literally every shift nurse, every physician's assistant had to know how to do this. In fact, we believe training is one of the things that were important to the successes that it had. We wanted that gadget over there to be as simple and easy to understand as a fax machine. And nobody should be scared of it and nobody is off limits to touch it. And if you don't know how to use it it's as big of a clinical sin as not knowing how to use your own EKG machine.

To do that we actually built a separate training team that we call the Clinical Technology School that is an ongoing group of about five or six individuals that run programs all around the state to take skilled, qualified, experienced healthcare practitioners and get them comfortable working in this technology. The other thing that we work very hard at is taking as much mystery out of it as we can. We really took an approach of, if you're walking on the floor of the hospital and the rubber hose pops off your stethoscope you don't throw it down and call for a technician. You understand what needs to happen and you push the rubber hose back on and you go back to work.

We tried to give all the folks involved a basic understanding of the technology so they could continue working. Physicians are trained. Dr. Oscar Boultinghouse does put together a great program. It's kind of like training a pilot. You come and you get your basics and then you're watching somebody do it, and then you swap a place and you do it for a while under supervision, and then you go solo. But the average physician, it does change, varies quite a bit. We've had people jump in and learn it in as quickly as in one or two days. We've had folks take one or two weeks.

Audience: What's the status of performing surgery from remote locations?

Dr. Hammack: Great question. There's tremendous interest and tremendous developments ongoing in the field of robotic surgery. UTMB and many other of our colleagues in the UT System have what's called the Da Vinci robot. It's one of the several types of surgical robots that are there. It is being done. It is still kind of experimental. It's having special value in the area of orthopedics where the robot can actually place implants and things like that with greater accuracy than the hand could. It also has tremendous use in microsurgery because it can actually reduce hand motion down to micromillimeters but still retain the control.

Everybody's doing it. You know, are we going to get to a point where it's available everywhere and you actually go to your corner strip mall to get a surgery done? That's probably not going to happen in the near future. But developments are very impressive and it does have some very important applications in some of the areas that I mentioned.

Audience: Glenn, what is the situation with commercial users, with corporations? I know that Amoco was your original, and for a long time there was nothing else. And now Zachry's doing it. So what did they have to overcome to adopt it that was endemic to them rather than just the learning a new process?

Dr. Hammack: That's a great question. We started out with this group called Amoco. We're now doing Zachry Construction. We're now actually completing some agreements with some other companies. It had a lot to do, at least I believe, with at one time there was a great resistance to have corporations have any kind of onsite medical care. There was fear of medical legal risk; you had people shutting down the idea of the company nurse. You had people shutting down the clinics on the plant.

Because they're all facing the challenges of rising healthcare cost to their employees while trying to retain benefits and preserve benefits to their employees, they're now starting to become much more open to alternatives. And that's why we're seeing development of additional contracts.

Audience: How have patients responded?

Dr. Hammack: Patients overwhelmingly are in favor of it. And I'm not just referring to the prisoners. I'm referring to folks in the counties, the folks that are in these commercial environments. We have been running patient satisfaction surveys for years, and it got to the point that they weren't telling us anything new. Everybody loved it.

To be honest, the perceptions of the healthcare establishment tend to be far more disbelieving in these technologies than the patients do. They're banking online and they're e-mailing pictures of their kids around the country. They get this.

Audience: How do you handle situations where blood work or other lab testing is required?

Dr. Hammack: In our county and other types of programs there's actually a time reserved for that work to be done. The healthcare team that is there staffing one of these sessions is trained and credentialed to do the necessary laboratory work. They might be what are called a physicians' assistants. Of course, a nurses and paramedics are also trained to do this type of stuff. So it is built in to the strategy. It is built in to the strategy, that lab work. Also, where we have remote clinics far away, and we understand that these patients are going to need other types of things - imaging, MRIs, CT scans, things like that - we work very hard to identify resources local to the patient to get that work done.

Audience: And how do you maintain security and privacy and do you keep a permanent video of these things?

Dr. Hammack: The security and privacy is always important. There is a general impression out there that if it's electronic it's more vulnerable. And there are some areas in which that's the case. Everything that we do is either done on a private connection that is ours alone between the two locations or it's done over areas where it might transit the internet, but it does so in a secure fashion called a VPN. We really borrowed heavily from the financial transaction industry, the big banking industry, about moving secure information from point to point to build that into the system so it operates at full compliance with HIPAA and the other regulations.

The other great question you have is about videotaping or recording. Just until recently just until last year Texas for Medicaid reimbursement of telemedicine required a permanent recording to be kept. It made it very complicated in light of the HIPAA regulations. They since have then changed that policy. So we do not now do any videotaping or recording of these sessions.

Audience: A short comment, but when you asked about the response I had to smile, because most of my patients in the last 12 years have been patients in their eighties in nursing homes. I don't think you want to survey them in how well they respond because they usually respond a lot to the personal touch - to someone holding their hand, someone they know, and someone who's the old doc. So I think the older person in a nursing home would not be well served by this. I don't think it would work. They'd be better served by a person, a physician's assistant or a doctor.

Now, the other person who doesn't respond too well is the old doctor. This last week I made a diagnosis by touching a patient, moving his arm, and I wouldn't have done that if I had to see him on the television or the nurse doing the exam for me.

So I think it's a great technology; I think it has a wonderful use. But with great technology, there are always some limitations. And I have to laugh, because I'm in a business where there's a world of limitations.

Dr. Hammack: We would agree with that. This is not the only modality to deliver healthcare, but in certain areas it can be a very useful adjunct.

Audience: People that might not get healthcare otherwise.

Dr. Hammack: No, you're absolutely right.

Dr. Stobo: Let me make a couple of comments because those are some great statements. First, do not get the impression that there's, you know, a dollar bill changer on the front of this and the patient just walks up and gets seen. These are always supported by a credentialed medical professional. It might be a paramedic, it might be a registered nurse, or it might be a physician's assistant.

The experience in the nursing homes, both with employees and with residents, has been very educational. Because there are aspects of what you mentioned earlier and there is an additional factor of transportation. The cost and the risks and the stress of moving an individual out of a supportive care environment and getting him into the hospital things like that. So that's where it has had a role.

Audience: I can see that it would work very well for them.

Dr. Stobo: That is the site of the national laboratory. The only national laboratory in the state of Texas is supposed to be one out of two national laboratories for research and emerging infection and biodefense in the nation. We're not sure what's going to happen with the national laboratory that's supposed to be built in Boston. It's running into some difficulty with its community.

It will be open in 2008. And we are real pleased to be able to have such a facility on our campus and in the state of Texas. The estimated economic impact for the state of Texas for this facility, without counting any downstream effect of start-up companies or products, is $1.4 billion. So it's a tremendous economic stimulator for the state. Thank you all very much for your attention. And, Glenn, thank you very much.