Technology expands reach of special care


Dr. Ray Dorsey from the National Parkinson Foundation's Center of Excellence at Johns Hopkins Parkinson's Disease and Movement Disorder Center, is featured in this article about telemedicine from Delaware Online.

Betty Leebel walked back and forth across a 20-foot stretch of her Lewes home while her doctor watched her gait. At this house call, he reviewed her medications, went over her medical history, tested her hand movements and made sure her memory was sharp.

But Dr. Ray Dorsey wasn’t in the room during the exam. In fact, he wasn’t even in Delaware.

Dorsey, associate professor of neurology and director of The Johns Hopkins Parkinson’s Disease and Movement Disorders Center in Baltimore, is one of a growing number of physicians making house and clinic calls across the country and across the globe. The American Telemedicine Association estimates more than 10 million Americans are taking advantage of telemedicine each year and Delawareans are increasingly adding to that number.

Telemedicine is a broad term used to describe health care with an electronic twist, and most of us – whether we realize it or not – are familiar with the concept. Any time a radiologist sends an electronic version of a scan or a doctor pulls lab results off of a computer, they are engaging in telemedicine.

But what may be less familiar is the use of video- and teleconferencing between doctor and patient for everything from mental health screening to dermatology to trauma management. Or, telemedicine can stand in for a visiting nurse and allow a remotely-located nurse to monitor a patient’s vital signs, without them having to leave home.

Betty was diagnosed with Parkinson’s Disease in 2002. A neurological disorder that affects a specific set of motor neurons in the brain, Parkinson’s causes tremors, rigid muscles and slow movements. Over time, people with Parkinson’s – roughly 1 percent of people over age 60 – can lose muscle function, become severely disabled and suffer impaired speech.

Dennis Leebel, Betty’s 74-year-old husband, cares for her and brings her to a specialist a couple of times a year, which he said is important for properly managing the disease. Though Parkinson’s cannot be cured, medications control disease symptoms well. Unfortuantely, Leebel said, most non-specialized neurologists unwittingly under-medicate their Parkinson’s patients, so he believes specialists are important for quality of life.

But there are no Parkinson’s specialists in Delaware. Patients are forced to travel to Philadelphia, the Washington, D.C. area or Baltimore, and since they can’t drive, they must rely on others to get them there. Nearly all patients, and most of their caregivers, are over age 65, Leebel said, but getting a loved one to a specialist can mean a long haul. Some, he said, just aren’t up for it.

“It’s a grueling trip for us,” Leebel, who is in good health, said. “It’s 12 hours, round-trip, by the time we find parking and get something to eat.”

Leebel described his wife as “pretty well twisted up,” with scoliosis – an abnormal curvature of the spine – caused by muscle loss in her core brought on by Parkinson’s. Her disease is well-managed by medication, but he said it’s a continuing challenge and her symptoms worsen throughout the day.

The “visit” the Leebels had with Dorsey was a first for the couple, and was the first time Dorsey consulted a Delaware Parkinson’s patient in their home, while sitting in his office in Maryland. Leebel, in part, has himself to thank for that. He is part of a movement to get more telemedicine streaming in Delaware.

Telemedicine is not new to the state. Nearly seven years ago, Christiana Care Health System began a tele-ICU for Christiana and Wilmington Hospitals. During the day, intensive care unit patients are seen by intensivists, doctor specialized to treat the needs of critical patients. But at night, rather than having an on-call doctor, an intensivist off-site monitors patients through video cameras at patient bedsides.

Just over three years ago, Christiana Care moved beyond their walls and began remotely monitoring patients 24/7 in smaller units at several Maryland hospitals. Dr. Al Rizzo, director of eCare at Christiana Care and a pulmonary and critical care physician, said it allows them to help out these smaller hospitals, which don’t have the staff to care for their ICU patients around the clock.

“The purpose is to extend the ability to provide critical care,” Rizzo said. “When there are shortages, or in these smaller hospitals, we can respond to come to the bedside.”

Though the Christiana Care doctors on the other end of the video monitor can’t touch the patient, they can help direct nurses and other staff at the on-site hospital on what to do, whether it’s responding to a collapsed lung or cardiac event, or altering the medications a patient receives. Or, a local physician can be called in. Christiana Care is now tele-monitoring 70 ICU beds, only 26 of which are actually at Christiana.

Rizzo hopes Christiana can also get an e-stroke program up and running in the next year or so, too. He said stroke patients need to be treated fairly quickly, to preserve brain function, and telemedicine may provide a better opportunity to do so.

As of this summer, the state’s largest hospital system is now also working with Beebe Medical Center to provide e-trauma, or as Paul Minnick, registered nurse and vice president of patient care services at Beebe called it, tele-trauma, and Beebe may get in on the e-ICU at Christiana Care, too.

Cameras and television monitors are used by Christiana Care doctors in Newark to examine trauma patients in Lewes, for triage and care management. Having a Christiana Care doctor evaluate a patient in Lewes may help prevent the need to move a patient up to New Castle County.

“They can evaluate all the way down to their pupil reactions; the equipment is able to zoom in very closely,” said Loretta Ostroski, nurse manager in Beebe’s emergency department. “They are also credentialed to have full access to the electronic medical records and see the tests results of patients.”

The state, under the auspices of Delaware Health and Social Services and centers like La Red Health Center, has embraced telemedicine as a way to provide more care to people in need, especially downstate, where physician shortages limit access to care, and also as a way to drive down health care costs and manage chronic diseases.

Several federal innovation grants, part of the Affordable Care Act, have been awarded to telemedicine programs nationwide to test their ability to reduce hospitalizations and help patients manage their health. Rizzo said telemedicine studies in the ICU have shown patients spend less time on ventilators and have fewer infections.

In 2011, the 50+-member Delaware Telehealth Coalition formed to help move the telemedicine quest forward and Leebel has been involved. But, he thinks more people need to come to the table, particularly those who stand to be impacted most: big hospitals and patients. His commitment is helping bring Parkinson’s telemedicine to Delaware, through collaboration between Dorsey at Hopkins and La Red in Georgetwon, by the end of this summer.

Betty will be their first patient.

Despite the benefits, there are numerous hurdles to leap in bringing more telemedicine to Delaware, and they are not unique to the First State. In an address to the Institutes of Medicine earlier this year, Health and Social Services secretary Rita Landgraf outlined some of these issues.

For one, physicians on the other end of the telemedicine receiver must be licensed to practice medicine in Delaware, but licensure is paperwork-heavy and can be time-consuming and costly for doctors. The technology itself has not been widely adopted, so equipment must be purchased, installed and the processes worked out. People must also be trained.

And then there is the trepidation.

“The human factor – fear of technology, changing the way we do things – is a bigger barrier than we thought,” said Carolyn Morris, a planner with the Delaware Division of Services for Aging and Adults with Physical Disabilities and member of the telehealth coalition. “... patients are much more agreeable to it, but it’s more providers. They don’t see how it can work for them.”

Some hospitals and doctors see it as a threat; they are concerned they will be out of a job, replaced by doctors from other states, other health systems, other countries. But in Delaware, this is not the case.

Beebe began offering telepsychiatry this February, after the last psychiatrist on contract left and they couldn’t find replacements. Minnick said they wanted to continue offering quality behavioral health to Sussex County, 24 hours a day, with only a one-hour turn-around when help was needed.

Through a New Jersey-based provider, Insight Telepsychiatry, the hospital is offering patients access to mental health care, free of charge. While Medicare and Medicaid cover telemedicine provided at approved health centers, not all insurers in the state will reimburse for it, so the hospital is eating the cost.

“If we can’t hire and bring in these types of physicians, we can certainly do it through telemedicine,” Minnick, who helped introduce telemedicine at Beebe, said. “In this situation, it’s not like we’re saying ‘we no longer need you.’ We’re saying, we don’t have psychiatrists in the community, we don’t have what we need. Our patients need this.”

La Red recently received a federal rural health care services outreach grant to provide more telepsychiatry in Sussex County. Nemours/Alfred I. duPont Hospital has for a while been using telemedicine for pediatric cardiology consultation, according to Morris, and they will soon also be providing telemedicine to miltary families at Dover Air Force Base.

The VA has long been a leader in telemedicine, said Charlie Quesenberry, and they provide it in their outpatient clinics, in dermatology, for mental health, and can help veterans whether they are in Dover or New Jersey.

And a Newark-based group, Affinity Health and Medical Systems, Inc., is bringing telemedicine into three predominantly black and hispanic charter schools in Wilmington, to eliminate the health care access barriers known to impact minority populations, and have hired local and mostly-minority physicians to provide care, said Shane Lewis, vice president of Affinity.

The “home visit” Betty had with Hopkins’ Dorsey last week was something he is doing as a free, first-time consult to aquaint seniors with telemedicine. Medicare and Medicaid will not cover telemedicine received at home but they will at health centers like La Red, only 18 miles from the Leebel home, and close to the 200-other members of the Leebels’ Parksinson’s support groups in Lewes/Rehoboth and in Seaford.

Leebel is hopeful more physicians will adopt telemedicine, and more become licensed in Delaware, if they are not already. He thinks many people stand to benefit from it.

“It’s something that needs to happen,” Leebel said. “What’s so nice is that we did it ... without 12 hours of agony.”