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David Kernek looks at the whys and wherefores of telemedicine

Remote access to doctors for those living and working off-shore or in remote or dangerous areas has seen a real boom in recent years. David Kernek looks into the whys and wherefores

Here are two accounts, told to ITIJ by Europ Assistance (EA) in France and World Travel Protection (WTP) in Canada, which demonstrate the different but commonplace uses of telemedicine, which can shrink time and distance to save lives, improving the health of people in remote communities and cutting costs for assistance companies and insurers. One is dramatic – a story of life or death – while the other, though never front page news, underlines the value of telemedicine in delivering everyday healthcare in far-flung settings.

On a Saturday evening in October this year, a 42-year-old man working on an oil rig off the coast of West Africa told the onboard paramedic that he felt unwell. The man, said Dr Mathias Kalina, group medical director at EA, was overweight, ‘as many are in this industry where Body Mass Index is a challenge, and the work entails demanding physical tasks’. Although the oil rig worker had been having regular anti-hypertensive treatment, he did not report chest pain. The paramedic, having recorded an abnormally high blood pressure, did an electrocardiogram (ECG) as part of the routine assessment and sent the data electronically to EA’s emergency doctors in charge of topside support. The paramedic initiated treatment to reduce blood pressure and supervised the patient’s clinical status, expecting to be able to keep the patient onboard the rig until the regular helicopter shuttle on Monday morning.

On receiving the ECG data, EA’s on-call medical doctor diagnosed myocardial ischaemia – lack of blood flow and oxygen to the heart – and requested a much more intensive treatment with bedrest, oxygen, IV fluid access, and medication for overnight observation. On the Sunday, the man was evacuated by helicopter to an on-shore hospital where he was treated for myocardial infarction (a heart attack).

“This story highlights the remote medical expertise that gives an additional layer of quality to on-site medical coverage,” said Jean Florence, chief marketing officer, group health global business line, at EA. “The evolution of telemedicine will soon add many innovative sensors, including biochemical ones, which will allow the measurement of extra variables and improve the quality and accuracy of diagnoses at a distance.”

She emphasised the value of telemedicine in maritime and aviation emergencies, but said that for Europ Assistance, there are other key applications: access to international standards for expatriates; chronic diabetes and cardiac disease management; and, in occupational health, standard procedures for international companies with centralised medical data management and fitness-to-work validation.

In Toronto, Abasse Asgaraly, business development director at WTP Assist in Canada, flagged up the role of telemedicine in territories where Canada meets the Arctic Circle. “Before the deployment of telemedicine networks and medical facilities where patients could access telemedicine consultations, they were evacuated by air to cities where medical professionals were available. We had hundreds of minor medical issues such as otitis (ear infection) or insect bites, with patients being transported across vast distances, and with costs being paid by the Canadian government. A medical evacuation from the far north, almost at the border of the Arctic Circle, to the territory capital, Iqaluit, would cost on average CA$6,000 – for an ear infection!”

These costs have now been cut significantly, said Asgaraly, who had a role in establishing these telemedicine networks. “We have telemedicine in many remote areas of northern Canada. They have small clinics where nurses or paramedics can connect patients via technology – tablets and mobile phones – for consultations with major healthcare centres in cities hundreds of miles away. They can check ears and throats and so on and get a very accurate diagnosis. If it’s an ear infection, there’s clearly no need for an expensive evacuation; it can be treated locally with antibiotics.”

There is about to be a revolution in the way medical care is provided, and that revolution is what we’re talking about here

And, he added, in the big cities of North America and Europe, miniaturisation and image compression technologies help to keep tabs on the health of ageing populations. “Mobile phones, tablets and wearable devices offer health and wellbeing monitoring apps. They can monitor daily physical activities – calories burned, heartbeats, blood pressure, blood sugar levels, and so forth. Many chronic patients have access to small devices at their home that can check their medical conditions and send immediate alerts to their healthcare providers in case a set level of criteria is exceeded. This is extremely valuable for cardiac patients.”

Talking about a revolution

For Dr Sneh Khemka, senior vice-president, population health, at Aetna International, though, telemedicine is ‘the wrong term’. “Telemedicine has been around for a very long time, and people have made very restricted use of it. It was often little more than one doctor talking to another on the telephone. There is about to be a revolution in the way medical care is provided, and that revolution is what we’re talking about here. Some 20 years ago you’d never have imagined people doing their banking solely online, or doing most of their shopping online. That has become the norm in a very short space of time, and that is what is going to happen in the medical sector.”

The main area of healthcare that’s going to be utilising the benefits of telemedicine is the primary care sector, said Dr Khemka. “Let’s split healthcare into primary and secondary levels, with secondary meaning you need someone to lay hands on you, you need to go into hospital, you need to have an intervention, you need surgery. That’s all going to stay traditional. But about 50 per cent of primary care – what we call GP work – can be done without actually visiting the GP. Think about what you see your GP for. They need to ask you some questions, but not necessarily do an examination or do any tests. Or you see them because you’ve got a long-term condition and you need regular check-ups, or because you need mental health advice, or for more basic things such as coughs and colds, and repeat prescriptions. The vast bulk of that work can be done by telemedicine, or v-health as we call it. I think there’s a revolution about to happen because we have access to so many things via our mobile devices – why not access to doctors? That’s why I think we’re on the cusp of a revolution when it comes to the provision of mobile services.”

The main area of healthcare that’s going to be utilising the benefits of telemedicine is the primary care sector

This is big, he continued, for travel and international private medical insurance. “When you’re an expatriate or when you’re travelling, you don’t have your GP to hand. You find yourself in Hong Kong or Singapore or India or wherever, and you don’t know where to turn. If something goes wrong, or you need some medication advice, or your kid’s coughing and you don’t know what to do, if you could have access at any time to a virtual doctor at very low cost, what would you want to do? You can speak to a doctor from your own country, who speaks your own language, and you can get really good medical advice. And if you need to see somebody where you are, they can help direct you to the right person.”

Such a service is convenient, provides almost instant access to medical care, is reliable, and is low-cost, he said. “For me, that’s a winning combination, especially for those who are travelling to places they don’t know or living in places that do not have the primary care infrastructure that you find in the West. I think that for this market, v-health could be the replacement for primary care, particularly for expatriate workers and travellers. Some of this is already happening. There are lots of companies around the world doing this: for example, there’s Babylon in the UK, Mobile Doctors 24/7 in Dubai, Medgate in Switzerland, Teledoc in the US – they’re all over the place.”

Making it work

The technology is in place to make better access to telemedicine or v-health a real possibility for a much wider segment of the population, and steps in that direction are progressing rapidly. So, how does it work, and how will technology allow progression in this field? Dr Khemka gave the following example: “I’ve got what I think is a viral infection and I’ve got a rash. I’m in my office, and I can’t take the afternoon off, but I need to see somebody. I book the appointment on my phone, and I usually get to see somebody within 20 minutes because it’s a virtual consultation. Using the video interface on my smart device, I can show the doctor the rash, and using my phone camera, the doctor would be able to look inside my throat. It would be a video consultation in complete privacy and with complete security of the data transmission. If the doctor needs to give me a prescription, he or she will email or fax it to my local pharmacy, and I’ll collect it. That’s how it works.”

There are regulatory barriers in some jurisdictions, where the technology has outpaced legislation

If a blood sample – or similar – is needed, this should not be a stumbling block. “In the UK, the technology is coming – it’s not fully here yet – whereby a blood sample kit is sent by courier to your home. You prick yourself, you need only a pin prick like a diabetic does, and you send it back with the courier or in the post. For the more traditional stuff, if you do need to go for a blood test or an X-ray, there’s no need to go to your GP, wait for ages and get them to give you a referral letter. The virtual doctor can send a referral letter to your local hospital or clinic, you pitch up there, get it done much quicker and more efficiently, and their electronic systems will allow them to upload the X-rays and blood results to your own mobile devices where you and your virtual doctor can see it.”

Looking ahead, Dr Khemka said apps will play a crucial part in the world of v-health. “They are definitely the way forward. There are some really good developments on the way. You’ll keep a record of your virtual consultations on the app, along with your medical records and insurance details. Your Apple watch can take your heart rate, and there will be smart devices that will do rudimentary ECGs and even check lung functions, and in five years, we’ll probably have devices that can take blood and urine samples and have them analysed immediately and transmit the result to a virtual doctor. We’re not a million miles away from it, but we’re not there quite yet.” (for more on wearable devices and eHealth, see ITIJ 172, May 2015, The eHealth revolution.)

Aetna is using v-health technology internationally, for people who are travelling or on expat assignments, and has plans to extend the service to new markets. But Dr Khemka highlights three key safeguards. “For us, it’s very important that we don’t compromise patient confidentiality in any way. There are regulatory barriers in some jurisdictions, where the technology has outpaced legislation and where, for example, doctors are not permitted to give advice without seeing the patient. Responsible companies such as ours ensure they work well within regulatory barriers. And we ensure our doctors, who go through rigorous testing, are of the highest quality.”

For Dr Stuart Scott, medical director at Iqarus, which provides offshore medical support and occupational health in the energy sector – from the North Sea to the Gulf of Mexico – there are roles for both the 20th Century telephone and 21st Century video technology. “We currently provide top-side [oil and gas industry jargon for anyone or anything above the sea] services to more than 200 different sites – a mix of fixed off-shore installations, drilling rigs, support vessels of various kinds, and major construction sites, predominantly at this time up in Shetland (off Scotland). We normally have a medic in place, who would be either a nurse or a paramedic, or sometimes an ex-military combat medic. They have a large amount of equipment, but a lot of what they can do requires authorisation by a doctor, which is where the top-side doctors come in.”

telehealth solutions are not only a great way for a client to keep their workforce protected, they also optimise costs and maximise productivity

These doctors increasingly provide their expertise via telemedicine, even if the telephone still plays a vital role. “We support these sites remotely, and the traditional way of doing that is by telephone, which obviously we still use because it’s safe and it works. We have lots of experience with telephone triage and giving advice by telephone. But increasingly, we are providing remote video access. We have a telemedicine solution that we put off-shore. It enables us to carry out remote consultations using high-definition cameras, and it allows the doctor on call, who has an iPad, to take over the desktop of the off-shore medic to look at the patient’s blood pressure, ECG and other vital signs. We can also have actual consultations with patients; sometimes in stress or psychiatric cases, being able to see the individual rather than just speaking to them over the telephone gives you much more information and allows you to make a much safer clinical judgement as to whether someone is fit to stay at the site or whether they have to travel home.”

Iqarus also provides medical cover for sites that have no qualified medics in place. “These are normally vessels that have a designated officer who has a responsibility for medical provision, but with no medical training other than a two-week course every five years. When we can, we’ll quite often do the remote consultation with the actual patient, and that can be done by video quite easily. In a lot of cases, that’s how crew members on ships are communicating with their families. They’ll have either an iPhone or a computer and do it with Skype. A lot of the vessels and sites we’re looking after will have very good satellite links and therefore good bandwidth back to the beach.”

Privacy in remote consultations is a concern, however, said Dr Scott. “We do ours using fully-encrypted WebEx, so the clinical information and video consultation is recorded and held on a safe server. If you’re using FaceTime or just ordinary Skype, from a patient-doctor confidentiality aspect you have to be very careful, because there is the opportunity for people to access the information. Setting up a secure WebEx is very simple: the medic emails the link, the doctor clicks on it, puts in the password, and you’re connected. “The main advantage – the enormous benefit – is that it allows you to get much more information much faster about the patient, and therefore make the best decision as to what action is needed.”

International SOS uses the term telehealth when referring to remote medical assistance and cites the definition given by the International Organisation for Standardisation (ISO): ‘Information and communications technologies to deliver healthcare and transmit health information over both long and short distances’.
Said Dr Neil Nerwich, the group’s medical director of assistance: “Telehealth services – which we have provided since 1985 – have become popular as employers look to reduce costs and improve productivity while delivering an enhanced quality of care. As a result, the number of companies trying to enter the telehealth space has increased dramatically.”

Telehealth, he added, has enabled a ‘great step forward’ in healthcare delivery, but he said: “It’s important to remember that any form of telehealth communication is only as good as the professional providing the medical input.”

International SOS, he told ITIJ, was the first – and is the only – company in the world to be certified in accordance with the ISO’s 2014 guidelines on the delivery of telehealth services. “The guidelines are there to ensure providers deliver consistent, quality remote medical assistance and have policies in place to safeguard a client’s private data.”

Dr Marie Van Eck is at the very sharp end of International SOS operations. Formerly with the rapid deployment medical and rescue service RMSI, she’s now the group’s medical director for the Middle East. The working environment in Iraq, where International SOS provides medical cover at 61 sites, is, she said, ‘extreme in all senses’. “These sites are all on-shore, but they are highly challenging, and not just because of the ongoing violence or extreme climate. A site might be only a few miles from a major city, yet it remains ‘remote’. Getting to a clinic can be very difficult. The quality of the roads is poor and there are frequent road blocks. It can take ages to get through checkpoints, and what should be a 30-minute journey can easily take three hours.”

She explained: “Especially helpful when the paramedic and patient are stuck on-site is the Tempus Pro Transport monitor with integrated telehealth. The devices on our sites are linked directly to our assistance centre in Dubai. At the flick of a button, an on-site medic can get immediate advice from a clinical physician or ICU nurse. Further escalation is available if needed, but sometimes the best approach is to watch and wait rather than transport a patient. In this environment that’s an important option.”

Sometimes co-ordination and monitoring is more important than cutting-edge technology

The Tempus Pro function is not needed in all cases, said Dr Van Eck, ‘but it’s great to have this exciting technology available’. “From the client, to our local clinics in Iraq, to the assistance centre in Dubai, everyone is on the same page, physically seeing things in real time,” he said. “It’s the best possible support we can give our staff, our clients and patients. And our telehealth solutions are not only a great way for a client to keep their workforce protected, they also optimise costs and maximise productivity.”

Money matters

A review of telemedicine’s contribution to population health, principally in the US, was made earlier this year by Luis Felipe Arango Pardo in a term paper for the Executive Master of Health Administration programme at the University of Southern California, where Arango Pardo is director of international strategy and business development at the Keck School of Medicine. “Telemedicine today,” he writes, “is able to detect heart failure from thousands of miles or monitor an individual’s health through wearable devices. Both approaches are having a radical impact on the healthcare industry. The range of telemedicine services has expanded very much in the last couple of years. While most healthcare organisations had some telemedicine programmes in place in both 2013 and 2015, of those that didn’t, nearly triple the respondents in 2015 (64 per cent versus 26 per cent) said they would launch a service in the next 12 months.”

He finds many of the recently introduced remote healthcare devices ‘impressive’, but suggests that telemedicine isn’t only about the latest machinery. “We must keep in mind that the relevance of telemedicine resides in the ability to provide healthcare services at a distance. Sometimes co-ordination and monitoring is more important than cutting-edge technology. A well coordinated and monitored programme based on SMS text messages could be very effective in controlling costs and improving outcomes, without any additional fancy equipment.”

A prompt treatment or prescription in many cases will prevent the admission of the patient

Arango Pardo highlights a study made in 30 rural US communities in which 957 teleconsultations were made with 812 patients by 48 general practitioners. “Using telemedicine effectively improved primary care services,” he notes, “and integrated in a better way with secondary care. In 86 per cent of the cases, the service entailed a saving of resources, and in five per cent, it improved the timeliness. Ninety-five per cent of general practitioners considered the overall quality positively.”

His paper emphasises the financial benefits that can come from telemedicine. “Probably, telemonitoring is the greatest money-saver in all telemedicine. The fact that patients’ vital signs and other indicators can be monitored at a distance in a co-ordinated way will not only save lives – the ultimate purpose of the health system – but will also save great amounts of money. A prompt treatment or prescription in many cases will prevent the admission of the patient. Monitoring discharged patients is very effective in preventing readmissions, one of the highest costs for our system.”

He points to an American Telemedicine Association study that ‘suggests that the estimated return on investment associated with the telemonitoring programme was approximately 3.3’. “That is, for every $1 spent to implement the programme, there was, approximately, a $3.3 return on the investment in terms of the cost savings accrued.”

With such savings likely across the broader scope of telemedicine, it’s clear to see why embracing these technological advancements is a key focus for many. Although not without its limitations, telemedicine is certainly the future of healthcare delivery and medical assistance for a growing number of expatriates and travellers.