Taking the Pulse of Telemedicine

Little “Joey” is very sick and his parents are in a panic. The 2-year-old arrives by ambulance at a suburban hospital an hour outside Boston, where emergency physicians quickly determine that death is imminent. What should the team do next? What’s the best intervention for a child in this state of crisis?

A pediatric intensivist would know. But keeping that kind of specialist on staff is not practical for community hospitals, which typically see only one or two critically ill children each year. 

For youngsters like the hypothetical Joey, such care is available through telemedicine.

Local doctors whisk the boy into a room outfitted for videoconferencing.  The system provides a connection to the Boston-based MGH Hospital for Children, where an on-call pediatric intensivist can consult from afar. The specialist can see the room from four camera angles, monitor readouts from medical equipment, and talk to doctors and nurses.

The recommended course of action – inserting a breathing tube – is a tricky procedure to perform on a small child. Coaching the emergency team, the off-site doctor notices they are pushing the tube down a bit too far. They make the adjustment; Joey starts breathing and his vital signs begin to stabilize.

Better-Practice Promise

Fast and expert care, better outcomes, and reduced costs are the promise of telemedicine.  But the approach comes with complications: issues related to technology, virtual team building and business processes, to name a few.

Three Bentley colleagues have marshaled their complementary areas of expertise to study challenges and best practices in using telemedicine under time pressure. The team is Janis Gogan, professor of information and process management (pictured on right); Monica Garfield, associate professor of computer information systems (center); and Ryan Baxter, assistant professor of accountancy.

So far, the researchers have examined telemedicine services in critical-care pediatrics, trauma care, acute stoke care, geriatric psychiatry, and dermatology. In each area, their work delves into the technical, administrative, organizational and emotional challenges involved. And they are looking at both sides of the arrangement, that is, efforts at several prominent teaching hospitals that serve as telemedicine “hubs” and at community-based “spoke” hospitals, which receive the consultation services.   

An Objective Eye

Pediatric cases pose special challenges. Baxter cites the panic and fear that often accompany a child’s arrival at the emergency room.

“Under stress, people tend to tunnel in on one thing and fail to see the big picture,” he says. “In these cases, the off-site specialist can serve as the ‘eyes above the room,’ noticing things that the on-site team might miss: an intubation tube at the wrong angle, for example, or EKG readings that are becoming unstable.”

The long-distance consultation serves other purposes, too. “Doctors at the community hospital sometimes just need the specialist’s reassurance that they’re doing the right thing,” expains Gogan. “Other times, the specialist helps to stabilize the child for a safe transfer to the teaching hospital.”

Coming of Age

Telemedicine has been around since the 1960s, but its use lagged before the rise of the Internet. Today’s initiatives, says Gogan, allow for providing “better care, faster, by experts at a lower cost.”

But there are tradeoffs. Take technology: Cash-strapped hospitals must invest in the necessary equipment, then train enough staff in its use.

“You can’t just flip a telemedicine ‘switch,’” says Gogan. “Hospital administrators tend to underestimate the amount of training needed for people to get comfortable with the technology. There’s also a lot of advance effort required to change clinical processes and practice those new processes as a team. For example, if a critically ill patient must be seen quickly by the hub hospital specialist, then the patient intake process needs to be revised.”

Another reality is that once community hospitals gain expertise in caring for critical pediatric patients, they become more confident and use telemedicine less. While having that knowledge is a plus for those hospitals and their patients, the consequence is investing significantly in technology that may be used for only a short time.

The business concerns extend to the reimbursement of off-site doctors, which remains an open question. Moreover, telemedicine specialists need practice privileges at the community hospitals – a problematic scenario, particularly when collaborations cross state lines.

“Telemedicine is still largely handled on a state level,” adds Gogan. “So doctors would have to hold licenses in each state and be credentialed at each participating hospital.”

Real Life, Real Practice

The Bentley team hopes that, ultimately, its work will help save more patients like little Joey.

“By identifying both the business and non-business issues of telemedicine, these studies should help hospitals reduce costs, improve the interactions of virtual teams, and improve patient care,” says Gogan, noting that the team has written a working paper and submitted several papers for presentation at conferences. Two papers are under review at journals. 

“A lot of academic research tends to be more theoretical,” adds Baxter. “But this is real life, real practice. I have four children, and if I ever need to take them to a community hospital in an emergency, I would want that hospital to have telemedicine capabilities and to do it well.”