PediaCast 170 * Telemedicine
- Dr Rachel Brown
Section of Neonatology
Nationwide Children's Hospital
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike!
Dr. Mike Patrick: Hello, everyone, and welcome to PediaCast. It is Episode 170 for July 13th, 2011 and we're calling this one 'Telemedicine'. Again, not necessarily a clinical topic like we've been doing the last few weeks, so we're kind of going back to when we did social media, but I think it's a topic that parents will be interested in.
We're joined in the studio today by Dr. Rachel Brown. She's an neonatologist here at Nationwide Children's but also has an interest in telemedicine, so she's going to talk about how Nationwide Children's uses it and sort of what the future looks like with regard to telemedicine.
Before we get started with that, though, I want to remind you, if there is a topic that you would like us to talk about, it's easy to get a hold of us here at PediaCast. Just go to our website, which is pediacast.org. You can click on the Contact link. You can also email email@example.com or call the voice line, 347-404-KIDS, that's 347-404-5437. Just leave a message that way and we'll get you on PediaCast.
I also want to remind you the information in every episode is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right, let's get right to our studio guest today.
Dr. Rachel Brown is a physician with the section of Neonatology here at Nationwide Children's and an associate professor of pediatrics at the Ohio State University College of Medicine. She is also a principal researcher for the Research Institute at Nationwide Children's where her primary research focus is thrombopoiesis. She also has a special interest in the use of telemedicine in clinical practice, which is why she stopped by the studio today.
Dr. Brown earned her medical degree at Wright State University, completed her pediatric residency at La Bonheur Children's Hospital in Memphis, Tennessee, and her neonatology fellowship at Shands Hospital for Children, which is associated with the University of Florida at Gainesville.
Welcome to PediaCast, Dr. Brown.
Rachel Brown: Thank you.
Dr. Mike Patrick: It is great to have you here.
Now, you've been here at Nationwide Children's since 2006, as I understand it.
Rachel Brown: Yes.
Dr. Mike Patrick: You were in Ohio, went to medical school at Wright State over in Dayton, and then went to Memphis, then to Gainesville, now back here in Columbus. So where is home?
Rachel Brown: I grew up in Dayton, Ohio.
Dr. Mike Patrick: Oh, OK. Sure. So you're a Buckeye at heart.
Rachel Brown: Actually, I went to Michigan.
Dr. Mike Patrick: Oh. [Laughter] You were born a Buckeye.
Rachel Brown: I guess.
Dr. Mike Patrick: All right. So are you still a Michigan fan?
Rachel Brown: Yeah.
Dr. Mike Patrick: See, I didn't know that before I invited you here. [Laughter] It might have made a difference. No, I'm just teasing.
So you were in Gainesville. What did you think of Florida?
Rachel Brown: It's hot.
Dr. Mike Patrick: You know, that is what I tell people. Most of the audience out there knows that we lived in Orlando for a while, I actually did the show down there, well, that's the first thing I say when people ask us, here in Ohio, it's like, 'Oh, cool, you lived in Florida. That must be really great.' But it is very hot, isn't it?
Rachel Brown: Yep. In the winter you spend about four months inside, but in the summer in Florida, you spend about four months inside.
Dr. Mike Patrick: Yeah. Right. Exactly. Instead of being a slave to your furnace, you're a slave to your airconditioner, basically.
Rachel Brown: Exactly.
Dr. Mike Patrick: And Gainesville, it's like Orlando. There's not a lot of breeze, either.
Rachel Brown: No.
Dr. Mike Patrick: So it is very hot. A little more easy to withstand being outside in the summer if you're on the coast, but inland, not so much.
Rachel Brown: Not so much.
Dr. Mike Patrick: But you did enjoy your fellowship there?
Rachel Brown: I did.
Dr. Mike Patrick: And it was a good place to be for three years?
Rachel Brown: Absolutely. Great training.
Dr. Mike Patrick: It's about how long we were in Florida, too.
All right. Before we start talking about telemedicine, I had mentioned that your primary research focus is thrombopoiesis. What in the world is that?
Rachel Brown: When I was a Fellow at University of Florida, one of the concentrations that they were doing was a lot of neonatal developmental hematopathology. Basically it talks about how the neonates clot, so platelets are used for clotting, so that helps you stop bleeding. We looked at the developmental differences between neonates in pediatric patients and adults.
Dr. Mike Patrick: Got you. Are you still doing that kind of research now?
Rachel Brown: Not as much.
Dr. Mike Patrick: Or is your focus on something a little bit different these days?
Rachel Brown: More of my research is on telemedicine now.
Dr. Mike Patrick: Wonderful. Well, why don't we just start, if you could define for our listeners what exactly is meant by the term 'telemedicine'.
Rachel Brown: Well, I think it can mean a lot of different things, but a very basic definition is practicing distance medicine using electronic devices. It can encompass things as simple as a telephone but it can also encompass things like using the intranet and internet. It's quite a broad field.
Dr. Mike Patrick: Sure. Does the doctor have to physically away from the patient?
Rachel Brown: Typically, yeah, because it's practicing at a distance, and they always define the remote site and then the other site.
Dr. Mike Patrick: Right. What about if I'm practicing at an urgent care, let's say, that's affiliated here with Nationwide Children's, and we get an x-ray, it gets zapped to the main campus for the radiologist to look at, and then we can see the picture, get the report. Is that telemedicine as well?
Rachel Brown: Yeah. Absolutely. Because the radiologist is not onsite.
Dr. Mike Patrick: Got you. So lots of different means that this can be accomplished. What about here at Nationwide Children's, what kind of things are we doing here in the world of telemedicine?
Rachel Brown: Well, I think that some of the things that started even before I came have been going on for a long time, obviously telephone consults, but there are also, the cardiology group is doing echoes that they can get sent through telephone lines to review.
And then when I started, we developed a pilot program with one of the hospitals in the area, Adena Regional Medical Center, and what we did was we placed a high-definition camera at both sites, the Adena nursery and the nursery at Nationwide Children's Hospital, so we were able to do consults on babies that were sort of borderline whether they needed to be transported or not. We know this is a group that we would like to decrease the number of transports because when they came to Children's, their stays were often very short, so we were separating them from their moms and their families, and then the families had to come to Columbus.
So basically we were able to view the baby, talk with the physician in Chillicothe while we were in Columbus, and make up a plan for that baby and decide whether the baby did need to be transported or whether we could continue to consult with them throughout the night or throughout the day, and also view x-rays.
That's what the Division of Neonatology has been focusing on, but there are lots of other things that people are doing. They're trying to develop more for the Behavioral Health group at Nationwide Children's Hospital, especially for some of the more rural areas in Ohio that may not have pediatric psychiatry available.
They are trying to develop more for Orthopedics. The Emergency Medicine group at Children's is also trying to do a pilot program with one of the other hospitals in the area basically to try to expedite care when it's necessary but also to prevent the transfers when they don't need to happen.
Dr. Mike Patrick: Right. So basically, the physicians here see a lot more of particular illnesses and things, I mean, it's more normal for them, so if you're a doctor at an outside place and it's something that you're only going to see once a month, or even less often than that, and you just want some reassurance that you're doing the right thing, or 'Is there something else I should be thinking about?' and then it also gives the parents some peace of mind, too. 'Hey, they've talked to a specialist.'
Rachel Brown: Absolutely. In fact, we've even talked with some of the parents face to face on the video camera because they do just sometimes want to speak with someone from Children's.
Dr. Mike Patrick: Right. And then, in terms of neonatology, do they bring the baby over to the screen or is there a portable camera that moves? Do you need to actually see the baby when you…
Rachel Brown: Yep. They have an area in the nursery that they can take the warmer bed or the isolette, and then we're able to zoom in, zoom out, move the camera as we need to from our end at Children's so then we can view the baby. We kind of have them undress the baby. We're able to view their color, their profusion, how they're breathing. Sometimes we've looked at rashes. Sometimes we've looked at any kind of orthopedic anomalies that we might see and try to help them figure out a plan.
Dr. Mike Patrick: Can you hear, is there a stethoscope?
Rachel Brown: We originally had tested a stethoscope. It wasn't as good. Apparently, there's a newer model that's quite good. There used to be a lot of background noise, so we didn't find it very useful. But certainly that's coming. I think as telemedicine becomes more prominent, they're developing tools that are better.
Dr. Mike Patrick: Got you. When you say that you could look at films, for instance, did they just hold those up to the camera or were they digitalized and sent separately?
Rachel Brown: They were digitalized to like our system at Children's. The telemedicine unit at the remote site is remote to us, we're actually considered the remote site, but the remote site is attached to a PC, so they're able to pull up their digitalized films.
Now, if we ran into a site that didn't have that, they could actually hold the film up. But really, what happens is the film comes up just as we would see it at Children's, on a screen. We're not able to adjust it, but we can have them adjust it as we need to.
Dr. Mike Patrick: Sure. What about procedures? Are you watching the other physician and talking them through something? Or let's say they had to put a chest tube in or umbilical lines, although I would think if they're an outside hospital and taking care of newborns, they might already know how to do that? I don't know.
Rachel Brown: Yeah. We've had requests for that. We haven't actually had to do it yet, but we've had requests, 'Would you be able to even come in the delivery room with us if there was a baby that was really premature?' and 'We haven't taken care of a 23-weeker for a really long time. Could we wheel the unit in and you could help run us through intubating,' and things like that, 'just to make sure that we're doing things appropriately?'
When we had one of the hospitals going from a Level 1 to a Level 2, so they were going to be doing more CPAP, they were having us kind of look at their setups and make sure that they were doing the CPAP correctly.
Dr. Mike Patrick: But that's a little different than being there in the midst of a resuscitation where it almost seems like it could be more of a distraction then.
Rachel Brown: Right. I think that some of this might actually come into play when we use it more with the emergency room and with the PICU. If there are certain kids that do need things done more immediate, then that can be helpful, I think.
Dr. Mike Patrick: right. I've read some news stories about actually surgical procedures being done through telemedicine. You have the surgeon at a remote site basically doing a robotic arm, I guess. Have you come across that?
Rachel Brown: Yeah. There are some people that are doing that. I think that is a program that is coming of age. I mean, you certainly still need people there in case there's a complication, but yeah, there are some people who have very specialized skills that are able to do things from afar.
Dr. Mike Patrick: Or if people are in a remote area that weather makes it so that they can't be evacuated out, or something like that, would be sort of a nice system to have there if you needed to.
Rachel Brown: Exactly.
Dr. Mike Patrick: How do you think telemedicine, we talked about how it benefits the outside place by giving them access to the specialist. How does it benefit us here at Nationwide Children's?
Rachel Brown: Well, I think that it benefits us because we're able to teach. What we have found is that this is actually a very good teaching tool for teaching other pediatricians and other practitioners how we would manage children.
But also, it enables us to keep beds available for kids who really need to come, for example a 23-weeker. Not that we would ever not want any child to come, but there are some reasons to keep a child, especially a newborn, at their birth hospital. Basically, certainly being with their parents and with Mom is important, and it's really not always the best thing to put a baby into an ambulance and drive an hour away.
Dr. Mike Patrick: Right, right.
Rachel Brown: So I think that the benefit is extremely good for everyone involved.
Dr. Mike Patrick: Oh, the parents, the referring hospital, the remote hospital.
Rachel Brown: In greater terms, it is a better utilization of health care dollars.
Dr. Mike Patrick: Speaking of dollars, is there a charge, then, for this service, and does that charge go to the patient or to the outside hospital? How does that all work?
Rachel Brown: Well, that is sort of in the development stage. Each hospital actually that we're developing a contract with is different. Some of them would like to be charged by the minute, some by the unit, whether it's an hour or a month, for unlimited service for telemedicine.
Dr. Mike Patrick: Kind of a subscription plan.
Rachel Brown: Uh-hm. Each hospital's been a bit different. It seems like the hospitals are going to probably absorb that cost because then they're able to keep the patients there, and some hospitals may choose to then put that cost on to the family. But I think that we're still working all of that out, as some of the insurance companies are working out what they will and won't pay for.
Dr. Mike Patrick: Right. It really comes down to, I'm sure the charges are expensive, just like all of medicine is, so then who ends up paying for it? And the insurance companies, do they want to or don't want to? That's always such an issue for families, too. But it's got to be cheaper than transporting them and then having care at a tertiary care center everyday.
Rachel Brown: Absolutely. The cost is actually not as high as you would think, because the calls are very short. I think, because we're able to visualize the patient, it makes the communication with the physician so much more efficient.
Our average time on a telemedicine call is about seven minutes, so it's very short, and the cost of a transport from about an hour away can run upwards of $5,000, and then a stay in the ICU, which may not be necessary, is certainly expensive as well.
Dr. Mike Patrick: It's crazy to me that insurance companies would argue it, but anything new that comes out, it seems like they want to argue, and preventative care oftentimes is not reimbursed. It's funny how, 'Sure, we'll pay for the $5,000 transfer, but we're not going to pay for the seven minutes.' It's very frustrating, isn't it?
Rachel Brown: I think it's an unproven entity to them. I think it's becoming more proven especially as more people are utilizing this and showing no consequence.
But it is certainly, I mean, we can't lay hands on a patient. We kind of have to use the physician who's available at the site. But a lot of what we do and a lot of what physicians do in general is just looking at a patient. How they're breathing, what their coloring is, a lot of that can be done just by looking at them, not by even laying hands on them.
So we feel pretty comfortable, and if we don't, we do suggest transporting them. We feel pretty confident, and we always know that if there's a change in their clinical status, they can call us back.
Dr. Mike Patrick: Right.
Rachel Brown: One other thing I would mention that we kind of haven't discussed, just one other benefit, which is not really any kind of monetary benefit, is that if a baby does need to come to the hospital but the mom is unable to, we kind of call this our baby cam, but we'll take our telemedicine unit to the baby's bedside and they'll wheel the mom into the unit at the other site, and we'll basically be able to show her her baby.
Dr. Mike Patrick: Oh, that's really great.
Rachel Brown: And they're able to look at the monitor, they're able to meet the nurse and the physician and kind of get a status update. It's a lot better for them to see the baby kind of moving around and looking more like their baby than when we just send them a picture.
Dr. Mike Patrick: Sure. Absolutely.
Rachel Brown: So that's been actually very, we've gotten a lot of positive reviews from that. It makes the mom just kind of feel at ease. We feel like it probably helps with their anxiety level quite a bit.
Dr. Mike Patrick: Yeah, absolutely. Yeah, that's fantastic.
Rachel Brown: Because inevitably there are going to be some babies that need to come no matter what telemedicine we have available.
Dr. Mike Patrick: And teaching, then, too.
Rachel Brown: Yep. And a lot of the nurses will come and want to see what's going on and to kind of get an update and see, make sure they did things correctly or what they might have done differently.
Dr. Mike Patrick: Sure. Got to figure out a way to breastfeed then over the…
Rachel Brown: I don't know if we can do that.
Dr. Mike Patrick: [Laughter] Telemedicine breastfeeding.
What about sort of the gray area of medicine that we don't like to talk about but it's there, and that's the liability aspect of all this? I'm sure that there's lawyers out there already, 'Oh, telemedicine. This is something that we can…' Are we doing this appropriately? Are there liability risks involved with this?
Rachel Brown: Sure. The risks are similar to as when you talk via telephone, but I think it's slightly more than that because you're actually visualizing the patient. I think it is there, but like I said, I feel like we're pretty conservative. If we feel like there's any concern for a baby to come, they're going to be coming. But we always have to think about the liability of a transport as well. I mean, there's risks involved in all of the things we do.
So it is there. There haven't been any big lawsuits that I know of using telemedicine with video. Yeah, there's always lots of small little things here and there that come up, even with telephone calls and consults. So you do have to be aware.
We have instituted a telemedicine consult sheet in our electronic medical record, the Epic system, so we are documenting it. We are going to videotape them, or at least record them, I guess it's not a videotape but it's a recording system, so that if there's any quality concerns.
Dr. Mike Patrick: Right, right.
Rachel Brown: Kind of like what they do in the emergency department with the traumas and things like that. We're not going to review them unless there's a concern.
And of course, we'll get consent from the parents to review them if necessary, but we're doing that and they'll just be stored for 30 days just to make sure if there's any quality issues, whether it's a quality issue with the camera or a quality issue with the care or discussion with the physicians.
We think we're doing all the things we need to do to make sure that it's a safe way to evaluate patients.
Dr. Mike Patrick: Sure. How does what we're doing here at Nationwide Children's compare to, I mean, are we on the cutting edge and doing things that other hospitals aren't doing? Or is this something that children's hospitals around the country are really picking up on and it's exploding?
Rachel Brown: I think that we're up and coming. There are other areas that are further along than we are.
University of California has a quite extensive program, using it regularly for a lot of different subspecialities including, there's a line to schedule an appointment and you can schedule an appointment for telemedicine for things like endocrinology and other subspecialties. So they may be a bit further than us. But I think we're, at least in the Midwest, quite far along compared to some other places. Arkansas is using it frequently for their fetal medicine program.
Part of the reason I think that people haven't pushed forward is because there wasn't a lot of legislature available for this. I think as people are investing more and realizing that this really is a way to utilize health care dollars, they're making more laws to help us proceed with it.
Dr. Mike Patrick: Is it always physician-to-physician, or could this be in someone's home? Could a specialist then see a child in their home and practice that way, too?
Rachel Brown: Sure. There are a couple places, and again this is in the South where there are very medically fragile children and they'll do some telemedicine with those kids because it's difficult to get them to the hospital, and you want to keep them out of the hospital if you can.
There are times when there is even telemedicine, there's small boxes that on a daily basis they will ask elderly patients, 'How is your breathing today?' and different things like that, and then those responses will go to a physician.
There are lots of different ways this can be used. I always tell people you've got to think out of the box and make sure that telemedicine works for you and what you need. Really, it could be used for any number of things.
I think that you have to keep in mind what is a medically secure connection, like Skype isn't necessarily as secure. But if you're OK with that, you could utilize Skype. But we have other things that we could utilize. Certainly you could try to set things up from home.
Dr. Mike Patrick: Sure. Now from a technical standpoint with Neonatology, how are you connected to that other hospital? Through the internet or private phone lines? How does that work?
Rachel Brown: It's basically internet. It's just a lot bigger connections, I guess, than just your regular home connection.
Dr. Mike Patrick: Is that like an ISDN line?
Rachel Brown: This is where I…
Dr. Mike Patrick: This is the IT people who are involved.
Rachel Brown: This is the IT people.
Dr. Mike Patrick: Got you, OK. But it is secure and private?
Rachel Brown: Absolutely. There's multiple firewalls, so it is a secure line.
Dr. Mike Patrick: Right. No one's going to hack in and figure out what's going on?
Rachel Brown: No.
Dr. Mike Patrick: Because that would be a HIPAA issue if they could.
Rachel Brown: Correct. It's definitely secure.
Dr. Mike Patrick: Great. What do you see for the future of possibilities of telemedicine? We've talked about some of them, with more remote stuff and the surgery type things, but anything else that comes to mind?
Rachel Brown: Every time I talk to a group and they say this is where we kind of have something that we don't have available, I say you should look in using this for telemedicine.
I feel like with the economy the way it is, it's so much better for families to have to take an hour off of work and maybe go to a doctor's office and not have to pay the gas money to come to Columbus or wherever. You could have follow-up appointments for surgical procedures or for wound care or you could meet with a dietician if you're a diabetic via telemedicine. We talk about using it with pharmacy, with respiratory therapy folks. I really feel like there's endless possibilities.
Dr. Mike Patrick: Yep. Because when you think about it, as a physician, there are some situations where you really do want your hands on the kid.
Rachel Brown: Absolutely.
Dr. Mike Patrick: But there are a lot of specialty clinics where, really, it's more how's your medicine working out for you, maybe you do want to check a blood pressure and some vital signs, but that's something people will do, it can be trained to do at home, too.
Rachel Brown: Absolutely.
Dr. Mike Patrick: It's interesting.
Rachel Brown: And we've talked about, 'Well, maybe we should try to get a telemedicine unit in this library,' in this room, not necessarily at the hospital but at the library for things, so they don't have to go to the hospital, they could go to the library for even, for example, a class by a nutritionist to help people with a healthy lifestyle.
Dr. Mike Patrick: Yeah, or a diabetes class.
Rachel Brown: Yeah. Stuff like that so that it could be a group of people that could get taught at once by someone who specializes in that from Nationwide Children's Hospital that may not be available in your community, but a class that would be for a bunch of people in a central location in the city or town.
Dr. Mike Patrick: Now, what does a research project in telemedicine look like?
Rachel Brown: Well, we were actually trying to see if we did decrease the group of patients that we felt like probably were transports that may have been avoided. We were looking to see if telemedicine improved that. Actually, the time period that we used the telemedicine, we did not actually decrease transports, but we did decrease transports of that group of children.
So what we were looking at was the kids that got transported before and after telemedicine, what their length of stay was at Children's, and afterwards, it was a longer length of stay. So we do realize that we did improve that group of kids that was just staying for a short stay, like two to three days. So we did feel like that was an improvement.
We also think that there's a lot of things that we could look at as far as utilization of health care dollars, so we haven't crunched those numbers yet. I think that there is some way, we hope that there is an ability to look at maternal bonding if we do do what we call the baby-cam, whether that can improve anxiety and bonding with the moms that aren't necessarily able to be there. So we think there's a lot of room for telemedicine research.
Dr. Mike Patrick: That's great. That's fantastic. I think it's something we're going to be hearing a lot more about in the future.
Well, I really appreciate you stopping by the PediaCast studio. It's great meeting you.
Rachel Brown: Thank you.
Dr. Mike Patrick: One question before you go, and we ask this of all of our folks who stop by. One of the things that I have a passion about is families spending more time together and more quality time with their kids and away from video games and TV screens, not that there's some benefit and purpose for that as well, but really spending time as a family. And from my own childhood, board games was always fun. So we're asking everyone who stops by, what was your favorite board game or is your favorite board game?
Rachel Brown: I'm a big fan of Sari.
Dr. Mike Patrick: Sari! OK. You know, Kelly, our social media person who stopped by a couple of weeks ago, that was her favorite one as well. I had to look it up because I thought it was Trouble. I get Trouble and Sari confused, but Trouble's the one with the loud popper. We couldn't think of the name of Trouble. So Sari, that's two for Sari now.
All right. Well, again, we appreciate Dr. Rachel Brown stopping by. I also want to thank Nationwide Children's for supporting PediaCast, and of course I want to thank all our listeners out there.
I want to remind you, next time you see your doctor, whether it's for a sick visit or a well checkup, make sure you tell them about PediaCast so they can share it with their other patients because it's great evidence-based information for moms and dads out there. Tell your friends and family as well.
Once again, if you'd like to contact us here at PediaCast, it is easy to do. If you have a question for us, a comment, a topic idea, just head over to pediacast.org. You can click on the Contact link. You can also email firstname.lastname@example.org and the voice line, one more time, is 347-404-KIDS, that's 347, 404, K-I-D-S.
And until next time, this is Dr. Mike saying stay safe, stay healthy, and stay involved with your kids. So long, everyone!
Announcer 2: This program is a production of Nationwide Children's. Thanks for listening! We'll see you next time on PediaCast.