Transcript Joe Flores - Houston Area Nurse Practitioners

Telemedicine is the ability to provide medical advice
and treatment remotely
Joe A. Flores RN,MSN,JD
APRN ENTREPRENEUR FOR TELEMEDICINE
 Joe Flores is an attorney, nurse practitioner, health consultant ,
entrepreneur, former medical ethics professor, author and television
host and producer. Mr. Flores has practiced health law in both state and
federal court in Texas. His practice includes representing health care
companies and has established and administered two multi-million
dollar healthcare entities including home health and hospice
companies. In his health care career he has provided services to
patients throughout the lifespan, military personnel and has worked at
the world-renowned Texas Medical Center. Joe is a board certified
Family Nurse Practitioner who can diagnose and prescribe in
collaboration with physicians in Texas. Mr. Flores is a nationwide
lecturer and author of articles including topics such as health care fraud
and the field of medical legal consulting. Mr. Flores has also authored
articles on topics as diverse as international trade and energy in Brazil as
well as the ethics of human cloning. Joe is currently focusing his efforts
on bringing telemedicine to rural and medically underserved areas
throughout the world and is working US and LATIN AMERICAN
COUNTRIES in joining engineers, technology, doctors and patients
together . Joe can be reached any time by e-mail at
[email protected] or at 361.887.8670.
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JOE A. FLORES, JD, MSN, RN
Attorney and Healthcare Provider
361-887-8670
[email protected]
NOTICE
 The following educational opportunity does not constitute medical or
legal advice nor does it constitute solicitation for business. The
following presentation is to provide increased knowledge to those who
seek to bring medical care to individuals who are geographically distant
or medically underserved throughout the world . This presentation is
also for those who desire the convenience of modern technology to aid
in providing quality medical services to the masses.
-Joe Flores JD, MSN, RN
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GOALS AND OBJECTIVES
In This Teaching Session The APRN Learner Will:
Gain Knowledge on the TELEMEDICINE AND TELEHEALTH
 Gain Increased Knowledge Regarding the uses of telemedicine
and its applications throughout the world
 Review Traditional Medical Delivery and Compare to
Telemedicine
 Learn Strategies To Implement Telemedicine
 Increase Knowledge of Methods to Create a Telemedicine Model
for All Human Beings Worldwide
 Learn About the present and future of telemedicine for civilian,
military and institutional applications
 How APRN’s can gain financially from telemedicine while
helping the underprivileged and preventing unnecessary
emergency room and hospital visits
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“Telemedicine is the Future”
 Why is Telemedicine Not the Present?
 Why are more patients not asking for telemedicine
everyday from their doctor?
 Why are doctors not using telemedicine to increase
efficiency in their clinical practice?
 Why is telemedicine not being used as a cost-effective
method to follow up with patients after an initial face
to fact visit?
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Technology is Here and
Has Been Here All Along
 Historically Telemedicine has been around through
the use of messengers that would bring medicine,
notification of how to treat a person medically and
through the use of various modes
 Military Applications: Signals, drums, horns, flashing
lights, banners, and flaming arrows gave warnings of
plague, diseases and of medicine that was on the way
to treat injured or diseased soldiers
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Telegraph, Phone and Fax
 With the invention of the telegraph much information
could be shared to many people including medical
information about plague, disease and the coming of
physicians and other medical personnel
 Through the invention of the telephone, doctors and
nurses realized they could communicate vital data to
their patients
 For decades the fax was the way to communicate large
amounts of medical data
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Engineers
Work with Doctors
 Many Engineers have seen the advantage of creating
computer programs to aid doctors and nurses through
questions that the patient could answer on the computer
 The technology then could be used to create an interview
process with answers to many common medical provider
questions along with video or pictures attached to the
communication
 The doctor could use the information to accurately
diagnosis the patient
 This technology in the 1980’s was way before its time and
was not widely accepted by the medical community
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Engineers Have Simplified the
Process for Doctors and the
Medical Team
 The technologies surrounding telemedicine have been
solidly formed
 Many of today’s engineers see the medical technology
as very simple
 A program can put up data on a screen such as pictures
or use a video camera and use online forms
 The challenge is to streamline the telemedicine
deployment
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United States and Telemedicine
One Example
 Telemedicine is expected to grow quickly through 2020
 High deductible insurance plans are one reason
 Risk-based contracts and reimbursement cuts
 Increased reimbursement and licensing for
telemedicine
 The switch to electronic medical records and the high
cost of overhead for medical providers
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Telemedicine Advantages for
Physicians
 Decrease Cost and Decrease Waste of Physician Time
 The explosion of the EMR (Electronic Medical Record)
has paved the way for additional technologies
 With the EMR physicians can access medical records
anywhere in the world with a secure internet
connection
 Patient data is then easily obtained at the same time by
many medical professionals to provide positive
outcomes to patients and increase efficiency
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Examples of How Telemedicine
Connects People
 Telediagnosis-connect physician with patient
 Telepresence-connect physician, optional
telepresenter, and patient
 Teleconsult-connect physician with another physician
 Telemonitoring-connect physician or nurse with
patient
 Telesurgery-connect surgeon with patient during
surgery
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Telemedicine Uses in the Past and
Present
 Providing medical care in a warzone
 Providing medical care to remote scientific stations
and work areas such as oil rigs
 Providing care in correctional facilities to prisoners
 Providing care to military personnel through mass
screenings using pictures and video as well as remote
patient monitoring of vital signs
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Telemedicine and the Internet
 Patient education through texts, video, images
 Medical images such as x-rays and scans
 Real –time audio and video consultation
 Vital signs and other measurements (ECG,
temperature, blood sugar, weight, pulse oximetry,
blood pressure
 Engineers created increased data storage capabilities
for large files and data
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Present and Future Engineering
Contributions
 Increasing internet communication speed (bandwidth and
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latency)
Information storage (databases, object storage for large
files such as images and video)
Back up servers for availability of data
Standard format transmission (MP4, PNG, etc)
Security (encryption, password protection)
The Cloud-using virtual servers
Digitizing information (digital cameras, scanners, etc)
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Computers are Everywhere
 Average industrialized citizen has access to a computer or
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handheld device
Telemedicine 2.0 is here
Telemedicine 2.0 uses computing devices belonging to
patients and physicians
Communicating over the internet
Using inexpensive equipment for gathering clinical data
Easy to use by the patient or physician without specialized
training
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Telemedicine 2.0 Devices
 Smartphone cameras
 Digital stethoscopes
 Opthalmoscopes (for eye exams)
 Otoscopes (for ear exams)
 Vital sign monitoring devices
 Wearable biosensors
 Many doctors are becoming “hybrid providers”- allowing
patients to see them in person followed by or
contemporary with the use of various devices
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Main Categories of Telemedicine
 Store-and-Forward, also known as asynchronous
(patients fill out forms on the internet, take pictures of
a growth on their skin)
 Real-time, also known as live or interacting
 Remote Patient Monitoring (RPM)
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Store and Forward Telemedicine
 Everyone is familiar with e-mail: You send a message and someone
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reads it later
In this method the doctor does not have to be present
The patient sends images, medical history, and other necessary clinical
information
At a later time the physician or nurse practitioner reviews the data and
creates an assessment, plan and diagnosis and sends back a response
including prescriptions and instructions on follow-up care
Example: Dermatologists, using pictures and forms obtained from a
patient can reach a diagnosis and plan of care with follow-up
interventions as needed
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Real Time or Interactive
Telemedicine
 Most people think of this category when they think of
telemedicine
 Speaking over the phone with your doctor or nurse
practitioner is an example
 Doctors can also do a secured line face to face
encounter and be reimbursed for the visit online
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Remote Patient Monitoring
 Biosensors that can be used to monitor a patient’s biological signs
 Currently being used for chronic diseases or specific medical
conditions while recovering from surgery
 Examples are blood pressure monitoring and blood sugar (glucose)
 Heart rate, pedometer, sleep monitors and wearable respiration,
brain activity and other sensor types are increasingly being used
 Mental health screening
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Advantage of Telemedicine
 Can be convenient for the patient and doctor
 Asynchronous communications including video and
remote patient monitoring can evaluate a patient 24
hours a day
 Education is key for the patient to understand that the
doctor will be able to evaluate the various illnesses or
conditions without having to be present even on an
internet camera and that the patient privacy will be
protected
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Teleradiology-Where It All Began
 Rise of technology of the 1990’s created a need for
radiologists world-wide to be available to interpret xrays in distant places around the globe
 The market for imaging has been growing 15%
annually with only a 2% growth in new radiologists
 Store-and-forward technology has helped increase
productivity and allowed the industry to grow
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Convenience and Access
 From a patient’s perspective, convenience and access is
very important
 Telemedicine cuts down on office visits, wait time, and
cuts the cost of travel for the patient and family
member or other caregiver
 Through technology patients can log in to a portal and
visit their doctor while being monitoring remotely 24
hours 7 days a week
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Time Saved by Medical Providers
 The short time for a store-and-forward visit is a cost saver
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for a physician or nurse practitioner
An in-person visit is generally 10-30 minutes
Asynchronous telemedicine takes 2 minutes to review,
evaluate and act
Maximize practice efficiency and see more patients
Doctors can see the patient initially and then follow-up
using telemedicine
Telemedicine can send reminders for the patient to visit on
the internet, fill their prescription and for follow-up and
discharge instructions in case of complications in order to
decrease risk to the physician and more importantly harm
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Other Advantages of Telemedicine
for Doctors
 Detailed documentation using secured e-mail and video
and audio with stored vital signs that can be reviewed any
time and retained on large data bases
 Educational Opportunities- Telemedicine can store the
visit and information and medical students can review all
the data and learn from the assessment, diagnosis and
treatment without having to see that patient themselves .
This can create greater learning opportunities without the
time or cost involved for many learning institutions.
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Barriers in Telemedicine
 Patients becoming accustomed to telemedicine and
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physician response time
The cost of training staff and learning the technology
Medical Insurance Coverage
Potential conflict with being “on-call”
Integration with existing systems
Cost
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Other Issues with Telemedicine
 Insufficient Patient Information either by patient not
entering the information or “skipping over it” on an
online format
 Solution: Follow-up. Telemedicine is only a tool and
does not replace the patient being able to call the
physician and see them face to face (through the use of
internet secured communication) to ensure that the
patient is still on the same medication and was
satisfied with the telemedicine experience
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REMOTE PATIENT MONITORING
 Equipment to measure vital signs, blood sugar, weight,
oxygenation and other critical measurements
 Behavior monitoring can be used in mental health
delivery to monitor movement, wandering, lack of
exercise, or used to remind patients of an interaction
or to prevent falls in the home
 Personal fitness monitoring (how much someone
walks per day and the effect on blood sugar, blood
pressure or oxygenation)
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Advantages of Remote Patient
Monitoring
 Patient and Physician Convenience
 Decreased illness and death
 Decrease hospital stays
 Decreased cost of care
 Early alerts to increased blood pressure, an elderly
person about to fall out of bed, or lack of movement
 Monitor heart rate, blood sugar, weight and
oxygenation before a person becomes very ill
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Remote Patient History for Analysis
 The devices can track information digitally for years so
that physicians can analyze the persons’ health and
trends over time
 How medicines effect the person over time
 Which medical interventions worked and which did
not
 RPM allows doctors to see trends across different
diagnoses and use this data to adjust their approach in
an evidence-based manner to improve patient
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Hidden Benefits of Remote Patient
Monitoring
 Family and Patient’s Peace of Mind
 Digital Audit Trail-reduced liability to the doctor due
to stored information and ease to educate and consult
with the patient
 Allows the patient to become an active participant in
their own care and to train to use devices that help
make them feel in control
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Negatives of Remote Patient
Monitoring
 Many devices to choose from
 Patient inconvenience and feeling like “Big Brother” or the
Government can watch their every move
 Sensors may interfere with clothing or mobility
 Much of the need for devices may be the decision of the children of
the patient and loss of independence may be perceived by the patient
 Monitoring device must be accurate and correlated to verify that
measurements such as glucose, weight, oxygen levels and blood
pressure are accurate (nurse visit to the home periodically to verify
use and accuracy)
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Selecting a Vendor of Telemedicine
 As in electronic medical records the move from paper
to computer was slow and arduous and so is the move
from the clinic to the home monitoring setting
 Integration of systems must be present including the
use of devices and the transfer of data to a cloud that
the physician, or other health professional, and the
patient can then access through a secured portal
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Use a Vendor with Solid
Technology
 Use a company that stands by their product and has a
solid technological foundation
 Many organizations are not technologically based but
are marketing based and do not really understand the
product and thus concentrate on branding rather than
efficacy
 Engineers and doctors in a solid company work
together for continuous quality improvement and
belief in the product
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Things to Look for in a Vendor
 What is their performance record on fixing
technological “glitches” ?
 Customer Service Record
 Is the product communicated clearly through all levels
of management?
 Does the engineer have a deep and varied technology
background and can he get things fixed quickly from
device to cloud to portal?
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Customer Vendor Relationship
 The relationship between vendor and customer is
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more important than the technology
Even with the best technology it is relationships and trust
that matter
The vendor must understand the health care providers
business and patient goals
The vendor must be dedicated to put the patient first over
profits
“Take care of the patient and the money and profit
follows” philosophy
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Questions to Ask a Vendor
 What is your experience with similar telemedicine
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deployments?
Do you have references from other customers?
How do you handle security and privacy?
Will you be able to handle the volume of my patients?
What other technology is on the horizon?
Customer support and warranty guarantees?
Does the vendor have qualified health care team members
with experience to validate efficacy and patient and
physician satisfaction?
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Future of Telemedicine 3.0 and
Beyond
 In 1924 in an article in “Radio News” a picture of a patient looking
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into a television with a stethoscope, real time heart beat and
temperature sensors was shown with a boy looking at a doctor on
television
Today this type of service is done regularly and has become a reality
Remote monitoring world-wide is the goal
Monitoring for post-operative care, pediatric care, chronic disease
and care of the elderly is essential as the population ages in
countries around the globe
In the future patients may choose to monitor their health from
birth to death and profiles could be reviewed by your physician to
optimize your life expectancy
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Future Policies
 Electronic Medical Records (EMR) must be secure and
technologies must prevent “hacking” of records for
destructive purposes
 Additional Laws and Procedures May Have to Be Put
in Place To Protect Citizens From Too Much Intrusion
 People may need to be given the option of opting-in to
monitoring or choosing not to participate
 Public buildings are already monitoring biosensors
and security
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Future Medical Exams from Home
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Head and Neck Exam
Abdominal Exam
Neurological Exam
Cardiovascular Exam
Pulmonary Exam
Psychiatric Exam
Dermatological Exam
Exam of the Extremities
Male or Female-specific exams
Laboratory tests
X-rays and Vital Signs
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Future of Telesurgery
 Haptic technologies provide physical feedback to the user by trying
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to recreate the sense of touch, motion, vibration, and other tactile
senses
Haptic technologies are being used in today’s telesurgery systems
The use of Haptic technologies will increase in the Telemedicine 3.0
are 2017 and beyond
Example: A surgery patient in California with a physician
controlling a surgery robot in Houston, Texas.
Patients would be able to receive surgery from surgeons that are the
top experts in the world without enduring unnecessary travel or
time delays while receiving telemedicine monitoring as discussed in
this presentation
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Conclusion
 Most medical practices will be using telemedicine 2.0 by
the year 2017 and most have already begun to transition to
electronic medical records and some form of remote
patient monitoring
 Nurses, hospitals, home health agencies and other entities
can assist the doctor to monitor this wide array of
telemedicine services including engineers to enhance ease
of use
 AT FLORESLAWFIRM.COM we are striving to have
engineers and technology meet physicians and patients in
a positive manner and to get the job done right with
positive patient outcomes and prevent disease and preserve
the quality of life for all human beings on the planet
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References
 American Telemedicine Association. (2015, Aug) What is
Telemedicine? [Online]. http://www.americantelemed.org./abouttelemedicine/what-is-telemedicine
 Gunther Eysenbach, “Medicine 2.0: Social Networking, Collaboration,
Participation, Apomediation, and Openness,” J Med Internet Res, vol.
10, no. 3, p. e22, Aug. 2008, http://www.jmir.org/2008/3/e22/.
 Justin Caba. (2014, Jan.) Doctor’s Appointment Average Wait Time 18.5
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