Medical Consultations With Webcams Extremely Successful

AgaveNectar writes "Doctors are far from being early adopters, so they have just gotten around to publishing a report that webcams help immensely with making the right decision when someone shows up to a rural emergency room suffering from a stroke. Using clot-destroying medications like Alteplase is really risky, and it should only be given in acute cases. In a study of 222 patients, rural ER doctors consulted with faraway stroke specialists. They made the right decision 98 percent of the time when the expert examined the patient with a webcam, and only 82 percent of the time when they just talked to each other on the phone. Perhaps this report will finally convince the medical community that telemedicine is important."

Comments

Next, outsourcing to Bangalore

[Animats]

Now, at last, medical care can be outsourced to low-wage countries.

Re:Next, outsourcing to Bangalore

[ffejie]

They already do this - who do you think reads all those X-Rays?

Re:Next, outsourcing to Bangalore

[ColdWetDog]

I'm not sure that I call transmission of digital information 'telemedicine' but we use remote radiology all the time since we are too rural to afford a full time radiologist.

I'll call them up and tell them that Portland, Oregon is officially considered a "low wage country". I bet they will be surprised!

Re:Next, outsourcing to Bangalore

[shellac]

They already do this - who do you think reads all those X-Rays?

Radiology is the obvious candidate for outsourcing, but there are legal issues with this. The radiologists in India that can look at films do not have an American medical license. If there is a misread, they are not legally responsible. The hospital can get sued, and they will get accused of using unlicensed radiologists.

What a lot of hospitals do now is that only the films done late at night are outsourced. In my hospital, there is a "night hawk" service that reads the films, and who knows where on earth they are actually located. This is considered a preliminary reading.

When the in-house radiologist comes in the morning, they put in the "official" read.

If the doctor has serious reservations about the outsourced prelim read, they can call a radiologist who is on call at home and wake his ass up to read it. The problem is that the doctor on call, who is not a radioloist, has to recognize that there is a misread.

In reality, my personal experience is that the outsourced guys do a great job at the reading.

This outsourcing would decrease medical costs, but first the government would have to put in legal protections for the medical centers. American radiologist would no doubt be quite pissed and up in arms about this.

Re:Next, outsourcing to Bangalore

[AgentSmith]

Next is the big pipe dream. With your webcam you can get Webtouch, the force feedback apparatus,
that allows a doctor or nurse to physically 'contact' you. Doc wears gloves on the other end that control the apparatus and allow for detection of pressure, heat and maybe even surface texture.

The best thing aside from being there.

Of course the pr0n applications for this would be through the roof.

P. S. to prep for this, all you medical folk better play your videogames. I don't want my spleen accidentally ripped out
during a routing colonoscopy!

 

Are they using SSL?

[seanonymous]

Will my privacy be protected, as per HIPAA, when then they stream video of me lying in a hospital bed, being less than articulate, across the interwebs?

I'm convinced telemed is important...

[NIckGorton]

But not because of this.

The problem is that this is not really a good demonstration of the efficacy of telemedicine, because they picked a treatment for which there is a marginal benefit for a very small proportion of people. In order to get thrombolytics for stroke, you have to meet a certain set of criteria that in my experience few meet: no recent trauma or surgery, normal blood pressure, no history of stroke in the past 3 months (or hemorrhagic stroke ever), no current ulcer disease, no diabetic retinopathy, no seizures, deficit is more than minor but not too major, certain onset of symptoms in under 3 hours (and it will take an hour to get you imaged and blood tests done after you get to the ER), and a lot more.

In addition, if we give you thrombolytics for your stroke (and you are an ideal candidate) you get a 13% greater chance to recover with minimal or no deficit, but you have a 7% greater chance of your stroke getting phenomenally worse by becoming a hemorrhagic stroke which more often than not leave you dead or in a permanent vegetative state (in addition to all the other problems you can get from being completely incapable of clotting for a good 24 hours.)

What they should do is demonstrate this where it could be really useful: with a NP or PA way off in the hinterlands or in underdeveloped countries. But that isn't snazzy, doesn't pay well, and drug companies that sell gazillion dollars a pop medicines don't sponsor it.

Re:I'm convinced telemed is important...

[ColdWetDog]

Agreed and arg!

From the FA (no, not the stupid Wired blurb, the one in Lancet):

Correct treatment decisions were made more often in the telemedicine group than in the telephone group (108 [98%] vs 91 [82%], odds ratio [OR] 109, 95% CI 27-446; p=00009)

Not awfully shabby, small study though. No power analysis (how many patients would be needed to validly determine if an 18% difference in 'outcomes' was real). Note the hedging on outcomes - here is the real problem with the study.

Intravenous thrombolytics were used at an overall rate of 25% (31 [28%] telemedicine vs 25 [23%] telephone, 13, 07-25; p=043).

Not all that different here. Note the lousy p-value. So, you do pretty much the same if you got it 'right' or 'wrong'. Interesting.

90-day functional outcomes were not different for BI (95-100) (06, 04-11; p=013) or for mRS score (06, 03-11; p=009). There was no difference in mortality (16, 08-34; p=027) or rates of intracerebral haemorrhage after treatment with thrombolytics (2 [7%] telemedicine vs 2 [8%] telephone, 08, 01-63; p=10).

Blast and damn. No difference no matter what the hell you do.

However, there were more incomplete data in the telephone group than in the telemedicine group (12% vs 3%, 02, 01-03; p=00001).

Whatever that means. Again, no functional difference no matter what you do.

So yeah, not much to see here, move along. Nothing like overruning your data with conclusions. If you're an ER doc (and I am one) you should really be able to describe the neurologic exam of someone having a fairly large, well defined stoke to a neurologist on the other side of the phone. If you can't you can look it up. Not that the webcam is any great technological milestone but the article basically showed that it's use made no difference to the patient

Re:I'm convinced telemed is important...

[edsyc]

If you're an ER doc, what makes you qualified to criticize their statistics?

1) It is impressive that they managed to recruit so many patients for such a complicated study, and I don't think their sample size is that small in the first place.

2) If you do a power analysis, it won't tell you whether the 18% difference is "real" after you've already established statistical significance.

3) Regarding intravenous thrombolytics: So the 28% vs 23% is "not all that different". But could it make a difference to a few patients? The "lousy p-value" (p=.043) indicates a significant difference at alpha=.05, so I have no idea why you call it lousy.

Your post basically showed that ER docs will use the year of stats classes that they took in school to interpret research any damn way they want to.

A more interesting study

[nasor]

I would like to see a study comparing patient's success rates at self-diagnosis with google vs. a doctor's diagnosis success rate. Every time I've had to go to the doctor lately I've successfully diagnosed myself with the internet and known the treatment before I went, only to pay $120 for a doctor to look at me for 5 minutes and say what I had already guessed.

Re:A more interesting study

[ColdWetDog]

I would like to see a study comparing patient's success rates at self-diagnosis with google vs. a doctor's diagnosis success rate. Every time I've had to go to the doctor lately I've successfully diagnosed myself with the internet and known the treatment before I went, only to pay $120 for a doctor to look at me for 5 minutes and say what I had already guessed.

That's a pretty broad brush, but overall my guess is that patients who do a fairly decent search on the Internet AND have some sort of defineable symptom or problem (rather than "I don't feel so good") is about 50-75%.

Most of the time, they end up thinking about the things that have already been dropped from the doc's differential because of previous questioning, testing or just natural history (males typically don't get pregnant). The really useful part that I have found is while wandering around looking for answers, they run into questions that a) I should have asked but didn't b) I asked but they gave an incorrect / noncommittal answer or c) I asked the wrong way. Looking at the problem from several different viewpoints in the (?)privacy of your home can often be useful.

But people come to doctors for a bit more than just to answer the question of "what do I have". There might be a useful conversation about what to do about it. And I have a very hungry Labrador Retriever puppy to feed. Have you seen the price of Purina Dog chow recently?

So, the radiologist is working at 2AM?

[BitterOldGUy]

Below you said: If you're an ER doc (and I am one) you should really be able to describe the neurologic exam of someone having a fairly large, well defined stoke to a neurologist on the other side of the phone.

Then above you said :I'm not sure that I call transmission of digital information 'telemedicine' but we use remote radiology all the time since we are too rural to afford a full time radiologist. I'll call them up and tell them that Portland, Oregon is officially considered a "low wage country". I bet they will be surprised!

It has been reported in the Economist and in other business magazines that there's a trend in electronically sending X-rays and other data via the internet to docs in India for review and diagnosis. They then just email back there answers.

For one; it's much much cheaper. Two, there's time difference. So, when or if you do a night shift in the ER, where do you send those X-Rays? Is that Portland radiologist or another still working at 2:00AM?

I've worked on the technology at McKesson/HBOC - 8 years ago.

Re:So, the radiologist is working at 2AM?

[Anonymous Coward]

It has been reported in the Economist and in other business magazines that there's a trend in electronically sending X-rays and other data via the internet to docs in India for review and diagnosis. They then just email back there answers.

For one; it's much much cheaper. Two, there's time difference. So, when or if you do a night shift in the ER, where do you send those X-Rays? Is that Portland radiologist or another still working at 2:00AM?

Teleradiology has been around for quite some time (as you point out). It's not just for outsourcing overseas & small rural hospitals, but also for radiologists who prefer to work out of their home.

On the other hand, it raises questions:

- Is this practicing medicine without a license in the host jurisdiction?
- Who is liable for errors?
- Is the patient aware their care is outsourced?
- Does the patient share in the savings or does the hospital bill the cost of a local radiologist?
- Is the information transmitted securely with due regard for privacy?

Re:So, the radiologist is working at 2AM?

[ColdWetDog]

It has been reported in the Economist and in other business magazines that there's a trend in electronically sending X-rays and other data via the internet to docs in India for review and diagnosis. They then just email back there answers.

I'm sure that happens. We chose to use a more local group, largely because of the issues you raised.

- Is this practicing medicine without a license in the host jurisdiction?

I think this varies from state to state. In Alaska, you do need a valid Alaska license. You also have to have privileges at the hospital which is another complex step so you would weed out anyone completely unqualified.

- Who is liable for errors?

Well that all depends on the lawyers and the jury. But they the radiologist from Oregon (or wherever) can be a defendant in a malpractice action if it comes to that.

- Is the patient aware their care is outsourced?

Not really up front - patients are rarely aware of who or what the radiologist is - they're typically hidden in dark rooms and not allowed out much (sounds like your typical Slashdotter, doesn't it). If anyone asked, we could tell them. I actually do mention it when appropriate. I will tell the patient that we're sending the data down to Oregon so somebody qualified will look at it and get back to me.

- Does the patient share in the savings or does the hospital bill the cost of a local radiologist?

Not sure exactly how to answer that since there aren't any real "savings". The radiologists bill separately - their fees are pretty much set by the insurance companies. If you're paying cash, well, in the US you're screwed but that is another rant... The hospital pays the radiology group a set fee per study for overhead and storage costs (they have to keep the data for varying times so it's a significant issue). I think we pay about $7.00 per study which we feel is a pretty good deal because then the little rural hospital doesn't have to deal with a huge, complicated IS infrastructure.

- Is the information transmitted securely with due regard for privacy?

Yep, they are very careful with data handling. Everything going out into the Evil Internet is encrypted. Everything coming back goes by secure fax, phone or hopefully sometime in the mysterious future, by secure transmission into our mythical electronic medical record.

It's actually been a significant improvement in patient care. Instead of one or two general radiologists, you can have the study read by someone, for example, that just looks at head CTs. They have a night crew. They have a big IS department that's more or less functional. There were more gliches and setup problems and costs than I had hoped for when we started, but welcome to the real world....

Turing Test?

[belmolis]

Medical Consultations With Webcams Extremely Successful

I'm amazed that nobody has noticed that this means that webcams have passed the Turing test.