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OUTREACH
Experts Go Global with TelemedicineIn the small farming community of Finley, Ohio, medical oncologist Sharon Cole has a hitching post outside the front door of her office for the horse-drawn buggies of her few Amish patients. Inside, Cole is a model of futuristic medicine when she reviews an online consult from a Harvard medical specialist about diagnosis and treatment recommendations for a patient with a rare cancer.
Joseph Kvedar directs a program that delivers HMS expertise to patients and their physicians around the world via Internet and video links. CME credits are available for doctors who use the service. (Photo by Phil Farnsworth) Cole's patient is one of more than 5,000 cases triaged from around the world since June 2001 by the Partner's Online Specialty Consultations service (econsults.partners.org). Most often, patients use the Internet-based system for second opinions. Sometimes, as with Cole, doctors use it to consult specialist colleagues. Nine out of 10 cases involve cancer. "We're using the power of communications technologies to move medical knowledge," said Joseph Kvedar, HMS associate professor of dermatology at Massachusetts General Hospital and director of Partners Telemedicine. "We connect people across geographies to improve care."
Local, Regional, and National CareCole manages treatment of common cancers of the breast, lung, prostate, and pancreas. She refers leukemia and lymphoma cases to nearby specialists at Cleveland Clinic and Ohio State University. Two years ago, when one of her patients faced a rare and aggressive uterine sarcoma, she arranged for the woman to visit George Demetri, director of the Center for Sarcoma and Bone Oncology at Dana-Farber Cancer Institute and an HMS associate professor of medicine at DFCI and Brigham and Women's Hospital. A general medical oncologist may see only a few sarcomas in her lifetime, Demetri said, but his specialty team at DFCI and BWH receives more than 700 referrals a year.The visit, originally scheduled for one week after the 9/11 terrorist attacks, was postponed when planes were grounded across the country and was canceled when the woman, like many others, refused to fly. Demetri suggested the online consult. "Why fly across the country when this is easier?" asked Demetri, who has consulted on 66 patients through the telemedicine program. "It will never supplant doctors' interaction with patients, but I'm not these patients' doctor. I'm a consultant to their doctor. It's a wonderful tool to leverage our extensive niche expertise in a set of unusual diseases." E-consult BasicsWith the patient's permission, Cole filled out a detailed online case history on a private section of the telemedicine website. Her staff gathered test results together and shipped pathology slides and X-rays to the e-consult coordinating office. Insurance usually does not cover the cost, so the patient pays the telemedicine program $500 to $750 for the opinions, which often include formal reviews by several specialists. In Boston, the case review can include evaluation by the oncology team, including pathologists and radiologists who are up to date about the changing diagnostic markers and different treatment protocols for the 150 kinds of sarcoma. In a week or so, Demetri posts a full report to a secure private section of the telemedicine website for Cole, who then reviews it with her patient to help make treatment decisions.The online consultation can be initiated by the patient, but the Partners online service requires that the main contact be with a physician who has seen and examined the patient, an irreplaceable interaction even in the Internet age, Kvedar said. Ninety percent of the first 79 online consultations resulted in new treatment recommendations, most commonly a new chemotherapeutic regimen, according to an analysis published by Kvedar and his colleagues in the March 29 issue of the British Medical Journal. The diagnosis was changed in five percent of the cases. The average turnaround time was about seven working days compared with 19 working days to see a comparable specialist in person. The preliminary analysis did not measure clinical outcomes. CME Credit AvailableOne drawback is the extra physician and staff time consumed by the online medical history. "A lot of people ask me what technologies we're using," Kvedar said. "I've learned that technology is the last thing you think about. Health care is so complex and stressed that any change or innovation undoubtedly disrupts someone's income or workflow. The biggest obstacles have been workflow and incentives." In an HMS-approved pilot project, Partners Telemedicine will offer continuing medical education credits in 2004 to doctors who use the online service.A big benefit for Demetri is the formal structure the online consulting service provides to respond to some of the many patient and doctor inquiries he receives every day by e-mail. Other projects at Partners Telemedicine move other types of medical information to physicians and their patients. Every week, Kvedar and his colleagues see eight to 10 patients via video conferencing in a weekly dermatology clinic at Nantucket Cottage Hospital. The island has one of the highest rates of skin cancer in the state coupled with a shortage of dermatologists. Farther away, in Aguadilla, Puerto Rico, MGH physicians are providing telemedicine education in pediatrics to physicians at Buen Samaritano Hospital. The program is led by Ernesto Gonzalez, HMS associate professor of dermatology at MGH and supported by Aguadilla native Carlos Delgado, Toronto Blue Jays first baseman. In another hemisphere, a satellite Internet connection links Partners Telemedicine to two clinics in Cambodia. The local pharmacist has no questions about diagnosing and treating malaria, the one available lab test in the clinic, but a traveling nurse welcomes basic medical advice for treating high blood pressure, diabetes, and hyperthyroidism. --Carol Cruzan Morton |
