Flexible Usage of Space for Telemedicine

Roopa Makena

Industrial & Systems Engineering Program University of Minnesota

Minneapolis, USA

Caroline Clarke Hayes

Department of Mechanical Engineering Program in Human Factors & Ergonomics

University of Minnesota Minneapolis, USA

Abstract – Time and space have always been constrains in providing health care. Telemedicine is changing the face of health care by increasing access to health care for patients in remote and underserved areas, which in turn enables them to manage their health better. This translates to cost savings for providers. However, clinics and hospitals often find it challenging to introduce telemedicine into their organizations for many reasons, one of which is the perception that large infrastructure investments must be made at the onset. This paper presents a brief history of telemedicine, followed by several examples telemedicine health care deliver approaches used in a major U.S. health provider, and several approaches for making flexible use of clinic space to support both distance and in-person patients. We provide these examples to help health care organizations find ways to enter into telemedicine in small ways before making large scale investments. Flexible systems revolutionized the manufacturing industry; we feel that similar approaches can revolutionize telemedicine.

Keywords – telemedicine, Flexibility, health care, space

I. INTRODUCTION Telemedicine is the practice of delivering health care

services across distances by means of telecommunications. With a growing and aging population, providing efficient and timely health care services remains a major challenge, and telemedicine holds great promise for reaching patients who live far from major population centers, or are homebound. The sophistication and pervasiveness of electronic information technologies has reached a point where more, and more types of telemedicine are becoming not only feasible, but practical and cost effective.

Telemedicine is not a new concept. Communicating electronically across long distances started with the advent of telegraphy, and was first used for sending casualty reports and ordering medical supplies during American Civil war. More recently, interest in telemedicine has greatly increased along with the technological advances telecommunication, information systems, robotics, imaging and multimedia. From 1950’s telemedicine was discussed as a way to provide medical access in remote places; today telemedicine

has reached the stage where it is actually used to provide care in remote villages [1]. The increase in the use of telemedicine has grown rapid in recent years. Over the 10 year period between 1993 and 2002, telemedicine appointments at U.S. institutions have increased by a factor of 44 [7]. Additionally, the specialties in which telemedicine is applied have grown. Teleradiology is one of the first areas in which it telemedicine achieved prevalence; more than 50% of all radiology practice in the U.S. was teleradiology as of 1997 [24]. However, the total volume of tele-mental health appointments now far exceeds the use of teleradiology; as of 2001, mental health consultation was the most common application for telemedicine, followed by cardiology and dermatology [7].

The demand for telemedicine has continued to grow both with patients and clinics. Patients like it because of the increased access and convenience. Clinics like it because it can often achieve better monitoring of chronic conditions, or deliver earlier treatment (because of the added convenience to patients) which results in better health outcomes and reduced costs due if problems can be treated before they grow into large crises.

However, barriers that may deter some clinics and originations from adding telemedicine to their set of services include concerns about the infrastructure and training costs necessary to buy and house telemedicine equipment, to train staff and educate patients to use it, and maintaining sufficient space in the clinic to continue to see patients in-person at the clinic and provide other existing services.

It should be noted that adding telemedicine services to a clinic does not necessarily imply that the number of patients seen at a given clinic will increase; it usually means that some existing patients will be seen in a different way: remotely from a satellite clinic, or in their own home. Typically, when a clinic is just entering into telemedicine, the percentage of patients seen through telemedicine will be very small, but will likely grow over time. However, clinics may be unwilling or unable to dedicate specific rooms to telemedicine all the time to serve a small number of patients, when they need that space to see local patients.

Space is at a premium in most clinics; it is difficult to get, and expensive to renovate for new purposes. Therefore, it is highly desirable for clinics to find ways to make dual

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use of existing facilities so that they may to add telemedicine services while continuing to serve patients face-to-face. However, there is relatively little work reported on flexible use of space for telemedicine [25][26][27]. We will present several approaches for flexible use of space for both telemedicine and local patients that are already in use at a major U.S. health care provider. We hope that these examples will be useful in helping other providers to think about how they might begin to add telemedicine services to their clinics without requiring major infrastructure changes. Later, when the clinic has some experience with telemedicine and they better understand the needs of their particular patient population, they can make better decisions about larger and longer term infrastructure investments.

II. HISTORY OF TELEMEDICINE

Care providers have been providing medical advice

across distance for many centuries; even before electronic media, doctors provided medical advice through the mail. Figure 1 briefly describes the history of telemedicine with respect to time.

With the advent of telegraphy, telegraph messages were used to send casualty lists and order medical and other supplies during the American Civil war [3]. The telegraphy was soon replaced by radio which was used for long distance international communication. Radio Morse code messages were used in assisting seafarers with medical advice [2]. The Italian International Radio medicine assisted 42,000 patients in a span of 1935-1996 [14].

During the early 1950’s early telemedicine programs were based mainly on interactive television and telephone. During the same period the U.S. Public Health and the National Aeronautics and Space Administration (NASA) started the project “Space Technology Applied to Rural Papago Advanced Health Care” (STARPAHC) to provide medical care to rural communities of Papago Indians in Arizona. Electrocardiographs and X-Rays were taken at rural locations and sent electronically to medical specialists.

In the 1970s and 1980s there were significant advancements in telemedicine owing to the research and development of manned space flight program undertaken by NASA. Many current telemedicine systems originated from the telemetry research and development of the space program [14-21].

The transition from analog to digital communications has greatly influenced the telemedicine research and accelerated the progress. Since the 1990s, growth of internet and low cost of personal computers (PC) have revolutionized the health sector in reaching the major portion of the patient pool because of its easy accessibility and also providing unlimited storage and access of information. Early applications of telemedicine using Internet have been for store-and-forward applications, e.g. take an x-ray, store a digital version, then forward it electronically to a specialist who can analyze it. Continued advances in high speed computing, data security, and internet bandwidth have contributed to increased feasibility and interest in telemedicine.

Time Scale Technology used Examples/Description

Mid 19th century Postal Prescriptions and diagnosis exchanged between patient and physician by posts.

1835 Telegraphy Used during American Civil War to send casualty lists and order supplies

1906 Telephone Electrocardiograms sent using telephone networks

1920 Radio Seaman's Church Institute of New York - first organization to provide medical care using radio

1950’s onwards Television and Space Technologies Two way closed circuit television correspondence between Nebraska Psychiatric institute and Mental hospital in Norfolk

1967 Video conferencing Station established at Massachusetts General Hospital/Logan International Airport to provide emergency medical care to

airport employees and travelers

1990’s onwards Internet Used in remote patient monitoring, store and forward modes using web for transfer of data

2000’s onwards Mobile phones n Satellite communication Web enabled mobile devices are used to transmit patient information from moving ambulances to hospitals

Figure 1. Phases of Telemedicine development (adapted from Conrick, 2006 [16])

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III. METHODS

To better understand the ways in which telemedicine is currently practices at a major U.S. health care provider, and the associated issues and challenges, we interviewed telemedicine stakeholders at 3 regional offices, each covering a multi-state area. We used a structured set of interview questions to gather information on how telemedicine is used, what equipment, staff and infrastructure is required, and what are the strengths and weakness of each approach.

IV. EXAMPLES OF USES OF TELEMEDICINE

In order to provide context for the examples of flexible space usage for telemedicine, we will first describe some of the typical telemedicine approaches currently used in a major U.S. health care provider. These approaches vary in terms of parameters such as: do they provide synchronous or asynchronous interaction? Do they support individual or group therapy? What type of medical specialties do they support? And do they deliver care at home in a clinic setting? These parameters are shown in Figure 2.

Figure 2: Parameters characterizing telemedicine.

o Store-Forward Telehealth. Images are taken and electronically and forwarded via a secure network to care providers at other sites for examination, or they are stored for later use. Examples of images include x-rays, retinal images, photographs, etc. for use in dentistry, osteopathy, diagnosis and monitoring of diabetic conditions, and dermatology and many other specialties.

o Clinical Video Telehealth. Care provider and patient communicate via teleconference transmitted over a secure network. The monitor used for teleconferencing is a special unit dedicated for the purpose; on the care-provider’s end the unit is usually placed in his or her office, although it may sometimes be located in a

shared public space such as a conference room or staff break-room. On the patient’s side, the monitor may be located in a private examining room, a conference room at a satellite clinic, or the patient’s home, although the latter is not typical at this point in time.

o Care Coordination Home Telehealth (CCHT): Equipment is placed in the patient’s home to allow him or her to communicate daily to care providers so that they may closely monitor chronic conditions on a daily basis. Patients may be given different combinations of equipment. Sometimes they have only a unit for sending text messages via phone lines to a secure website; other times they additionally have devices with which they can monitor their vitals (blood pressure, weight, etc.) and automatically send the data to their care provider. However, some measurements, such as blood glucose, may also be taken with traditional equipment and typed in manually.

o Mixed Models (A variant on Clinical Video Telehealth). In this setup, both the provider and the patient are linked by video teleconference. For the provider, the monitor is typically placed in their office; for the patient, the monitor is typically placed in an examining room. Additionally, at the patient’s end, there may be a nurse or health technician to help the patient connect by video teleconference, or to make observations (as instructed by the care provider), take vitals (blood pressure, heart rate, etc.) and otherwise be the “remote” eyes, ears and hands for the care provider.

For each medical specialty, the degree of back-and-forth interaction required between care provider and patient, and the nature and complexity of the information exchanged, have had a major impact on when and how telemedicine was adopted for that specialty. For example, radiology typically requires relatively little interactive interaction with the care provider and patient once x-rays and other images have been taken. One needs only a secure way to transmit the images to the specialist who will remotely interpret them. Hence, telemedicine was adopted quite early in radiology.

More recently, clinical video telehealth therapies that can be delivered primarily through interactive discussions via teleconferencing, but do not require additional types of medical data (such as blood pressure, etc.) have become quite popular applications for telemedicine. Examples include psychological counseling (and associated tele-pharmacy), weight management, and diabetes counseling and education, and exercise motivational programs. Even group therapy can be delivered through telemedicine; a group of patients may interact with a remote care provider/moderator through teleconferencing, or two patient groups in conference rooms at two different locations may interact with each other through teleconferencing.

Unlike Store and Forward technologies (like radiology) in clinical video telehealth the care provider and patient

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engage in a highly interactive exchange, but the information exchanged can all be delivered through well-developed videoconferencing technologies. Furthermore, as patients are becoming more familiar and comfortable with Skype,1 and medical teleconferencing software has become more user friendly, more patients are willing and able to use such applications with little or no staff assistance – which increases their cost effectiveness.

In contrast to clinical video telehealth, (care coordination) home telehealth may require the patient to take readings with multiple medical instruments of various types in his or her own home without the physical presence of a medical aid. Thus, it requires more types of data than clinical video health, and it requires the patient to have a higher level of training in order to use the telehealth equipment. Consequently, it is far less common than either store-and-forward or clinical video telehealth, and is just beginning to grow. However, it allows patients with chronic conditions, such as diabetes, to be monitored on a daily basis because the monitoring can be done conveniently in their own homes. Even those who live in urban areas near major care centers would be unlikely to participate in this level of monitoring if they had to visit their clinic every day. Consequently, care coordination home telehealth allows patients to take control of their health and achieve better management and outcomes than they could through traditional methods.

Yet other applications of telemedicine, such as tele-surgery or tele-anestheology require very high degrees of interaction with the patient though many channels and instruments, with dire consequences for mistakes. Thus, while possible, such applications of telemedicine may never achieve the prevalence of the approaches described above. While the differing interaction and data needs of various medical specialties has had an impact on whether or not that specialty has yet delved into telemedicine, the successes in the applications described above have encouraged more specialties, such as dentistry, cardiology, audiology, prosthetic amputees, and more to start thinking about initiating a telemedicine program as an addition to their existing services. The next section will describe various approaches through which clinics can add telemedicine, by retrofitting their existing infrastructure for dual telemedicine and face-to-face appointments. While clinics may need to shift different approaches involving more spaces dedicated to telemedicine as patient demand for telemedicine increases, these flexible approaches offer ways for clinics to get started.

V. FLEXIBLE USE OF SPACE FOR TELEMEDICINE

1 While one should not use Skype for exchange of medical information because it is not secure, comfort and familiarity with such applications has encouraged more people to be comfortable using such and application with little assistance from the care provider to work the equipment and software.

The adoption of telemedicine practices has been slow

compared with the rapid pace at which it started. The reasons include legal, liability, and interstate license issues; reimbursement issues, cost factors [7]. Though telemedicine has been very effective in providing health care to a geographically wider patient pools, the initial startup costs for setting up facilities, procuring equipment and establishing high broadband internet connectivity can be costly and intimidating, requiring providers to redesign their current infrastructure and processes. Training staff can also be a major issue.

Understanding the options available for flexibly using space to serve both distance and face-to-face patients is important for encouraging clinics to add telemedicine to the services which they offer. Clinics cannot typically afford to allow telemedicine take away from space needed to manage the existing in-person patient load. They may be more willing to consider telemedicine if it can be incorporated into the existing space infrastructure by making dual use of it. Furthermore, space needs for telemedicine may evolve over time; initially relatively few of the patients may be served through telemedicine, but the demand may rapidly grow. Flexibility is also needed to expand telemedicine infrastructure over time.

A. Telemedicine Carts

Unlike the centralized workstations with fixed connections to computers, decentralized carts which are mobile have been used for telemedicine sessions. A mobile telemedicine system that uses existing infrastructure, could remove many hurdles, dramatically expanding the reach of telemedicine as a clinical tool. Telemedicine carts have been used extensively for reaching rural communities in Alaska and are also referred to as AFHCAN (Alaska Federal Health Care Access Network) Telemedicine carts [12]. The movable carts are also famous in developing regions where the telemedicine practices are starting. The mobile carts are specially designed and have various peripherals depending on the requirement. The peripherals can include but are not limited to digital camera, electrocardiogram, electronic otoscope, scanners. Audiology and otolaryngology services along with primary care have been using these carts.

For clinics just starting to invest in telemedicine, which may have only one or two sets of the equipment needed, it can be put on a cart and wheeled from to the examining or conference room where it is presently needed. This equipment might be only a unit for video teleconferencing, or it might additionally include blood pressure cuffs and other devices for taking and transmitting vital signs. This provides not only flexibility in use of the rooms, but also provides flexibility in the location of the equipment. Furthermore, it does not require any change in the layout of the existing rooms, nor does it compromise their utility as in-patient examining rooms. However, secure network connections need to be available in all rooms where the telemedicine equipment cart would be used. Set up would also require somewhat more work than permanently mounted equipment. Other forms of mobile telemedicine are

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also possible, for example in an ambulance, or in a health van that could reach homebound patients and patients in remote areas where even satellite clinics may be few and far.

B. Virtual Clinics

With the increase in ageing population and rise in chronic disease cases, home telecare looks a viable option in creating virtual clinics. Home Telehealth involves two way interactive audio-visual communications between the provider and patient at patient’s residence. Devices are placed in the patient’s home to allow him or her to engage in daily, secure communications with care providers. This approach is used to more closely monitor chronic conditions such as hypertension and diabetes on a daily basis, with the goal of identifying problems or changes in the patient’s condition early, with the goal of reducing the number of emergency visits and other interventions that may be required if the problems go undetected for a longer time: until the next clinic visit, or until the patient is in crisis. Apart from significant cost benefits, lesser hospitalizations have been reported as the benefits from implementing home telecare [14]. With respect to space, this approach creates a virtual space in which patients can interact with care providers from their own home, and is thus increasing the “virtual” examining space for the clinic.

However, home telecare does not necessarily eliminate the space needed at the patient’s clinic; patients still need to come to their clinic for regular appointments. Instead, this creates a new a new interaction space in the patient’s home for daily patient-care provider interactions which would not otherwise happen. It provides greater access for patients, and encourages patients to take more ownership and interest in their own health. The end result is better monitoring of the patient’s health, earlier intervention, and fewer emergency and in-person clinic visits. This also translates to lower costs and better health for the patient. Additionally, one also finds that patients are more compliant with diet and overall attention to health. This approach can also be termed as smart homes where the patients are educated about their health conditions for self management of chronic conditions.

C. Flexible examining rooms

It is a general misconception among health providers that telemedicine needs independent rooms for functional requirements. However with proper scheduling plan, the same examining room can be used for both out patients and patients from remote communities. As an alternative to locating video-conferencing equipment in a multi-purpose space such as a conference room, break room, or shared office, video-teleconferencing equipment can also be installed in private examining rooms on a wall or desk. For some specialties additional equipment may be needed in the room on the patient’s side. For example, physical examinations, devices to measure the patient’s temperature, blood pressure, and pulse may be needed. For tele-dentistry, mouth cameras to view mouth lesions or check on the progress of post-surgical healing. Such equipment would be operated at the patient’s site by a health technician or other staff, under the direction of the doctor.

While telehealth equipment takes up space needed for supplies and other equipment in the examining room, video-teleconferencing equipment is continually becoming more compact, making it increasingly feasible to create dual-purpose examining rooms that can serve either local patients in-person, or distant patients.

D. Multi-functional Rooms Since space is at a premium in many clinics, it is not

always an option to dedicate one or more examining rooms solely for telemedicine purposes, especially when first introducing it to the clinic. Care providers most frequently interact with distant patients using video-teleconferencing equipment located in their offices. On the patient side, some clinics located telemedicine equipment and meeting space in multipurpose rooms, such as conference rooms and staff break rooms.

Conference rooms which are used for group and staff meetings can also be used for delivering distance group therapy or group education to a group of patients gathered in a conference room. In other words, several groups of patients can participate in a single group therapy session. Use of the conference rooms for telemedicine required careful scheduling to avoid conflicts between patient groups, staff meetings, and other uses of the conference rooms.

In some cases, video-teleconferencing equipment and the patients using it had to be squeezed into staff break rooms because of lack of other places to put them. While this worked to an extent and represented a flexible and creative use of the space, it was suboptimal in other ways. Use of the space was often difficult to manage since staff would sometimes wander into the break room unaware that a private video consultation was in-progress. A short-term solution is to put a sign on the door to let staff know when a session is in progress. However, as the popularity and demand for telemedicine increases, it may begin to render the break room less useful for its original function. At some point, it may become necessary to re-think the location of the video-teleconferencing equipment, perhaps by creating flexible examining rooms as described below, or by relocating the break room.

On the care provider side, teleconferencing equipment was often placed in the care provider’s office, thus converting their offices, which might otherwise be used primarily for paper work and email, into spaces where patients were virtually “seen.”

In addition to thinking about space usage needs, care providers must also support space usage with more sophisticated scheduling applications. When patients or care providers are scheduled in multi-functional rooms, such as conferences rooms that house shared teleconferencing equipment, the scheduling system must also include non-patient uses of the conference room. For example the scheduling system must also keep track of staff meetings in that conference room to avoid scheduling conflicts; one does not want staff do not accidentally walk in on a patient engaged in a private tele-consultation. Similarly, when a care provider from one clinic “sees” a distant patient who is

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physically located at a satellite clinic, it creates a need for the two clinics to coordinate their scheduling more closely. Examining rooms and telehealth equipment may need to be reserved at both locations.

It is also worth noting that in different specialties, care providers use their offices and examining spaces in different ways. For example, in mental health the care provider’s office is not only for paper work, it is often the place in which patients are seen; in other specialties, such as dentistry, care providers may have shared offices, or no offices. Shared offices may be used for filing, email and as break rooms. Such spaces are not private nor are they necessarily quiet, and thus such spaces may not be conducive for private and confidential conversations via video-teleconference between patient and care provider. One site which we interviewed was planning to move group offices for care providers so as to make space for additional examining rooms. Offices have to be moved to a smaller space shared with a lab in which prosthetic models were made which can be somewhat noisy. This particular site is in the stage of considering telemedicine; however it is clear that locating video-teleconferencing equipment in care provider offices will not be appropriate. In this, and similar clinics, it may be more appropriate to locate video-teleconferencing equipment for providers in flexible examining rooms, as described below.

VI. CONCLUSION

Telemedicine has is already used extensively in medical

specialties such as radiology, mental health care, and diabetes management, and health education. In these areas, telemedicine has been beneficial to both patients and health care providers alike. It is can greatly increase the convenience for patients, especially those in rural and remote regions, additionally it can help patients to achieve better monitoring and management of their health. It is can reduce the cost of providing care by reducing the number of emergency visits and crisis intervention required. These benefits have made telemedicine attractive to both care providers and patients [2, 7]. Additional clinics and specialties have become interested in adding telemedicine to their services.

However, many organizations and clinics are hesitant to adopt telemedicine because of the perceived infrastructure investments required to house telemedicine equipment and patients. In order to encourage organizations and clinics to consider earlier adoption of telemedicine, we have described several common approaches used in a major U. S. medical provider for flexibly using existing clinic space to serve the needs of both in-person and distance patients. There are many ways in which existing clinic space may be used to flexibly support both traditional in-person appointments and telemedicine appointments for distant patients. By providing these examples we hope to encourage more specialties and more clinics try adapting telemedicine to their patients needs, therefore allowing patients and health care providers alike to sooner achieve the convenience, improved health management and cost savings.

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