Medical Device Daily Washington Editor

The need to ease disease while also cutting costs is ever-present, but who knew at the dawn of the Information Age that the old, hopefully trusty, dial-up connection might one day provide an improved link between patient and doctor?

The case for telemedicine is gaining ground, and the Advanced Medical Technology Association (AdvaMed; Washington) hosted a conference call yesterday to present more evidence for this new medical modus operandi.

But getting such a paradigm equipped and into place will cost plenty up front, and the fate of a recent bill in support of telemedicine does not look good for the first year of the 110th Congress.

Max Stachura, MD, professor of telemedicine at the Medical College of Georgia (Augusta), said that up to now, telemedicine has been mostly used for “distant diagnosis and acute management,” and that it also can involve videoconferencing. “This is traditional telemedicine,” a tool of great importance for patients living in rural settings.

Telemedicine also can be deployed for chronic disease management, especially promising for cutting the nation’s healthcare costs, Stachura said, and that chronic diseases “must be managed if the patient is to continue with his or her life.”

Prior to the advent of remote monitoring, diseases such as congestive heart failure (CHF), diabetes and hypertension “were managed by episodic visits to a clinician’s office,” which Stachura termed “not a normal environment.”

Stachura said that the white-coat effect was one reason — and a compelling one — for getting out of the mindset that patients have to be in a doctor’s office to receive proper care. The white-coat effect is the phenomenon of abnormal physiological response, such as raised blood pressure, when a patient comes to the doctor’s office.

By some accounts, this phenomenon can induce hypertension — sometimes great enough to produce significantly higher mortality — and frequently making it difficult for physicians to adequately manage chronic diseases.

Telemonitoring thus “becomes an important behavior modification tool” for both doctor and patient, according to Stachura, since not requiring a doctor’s office visit. Via remote monitoring, doctors can see the real-time health effect of the patient’s day-to-day behavior.

“All the influences in the living environment” can be measured with telemonitoring, he said, the resultant stream of data giving the doctor some perspective on “how the condition varies [which] is of enormous value in selecting and modifying a disease management plan.”

Telemedicine “does not replace the patient visit,” Stachura said, but is “a tool used to enhance and make more valuable the in-person encounter,” in part by aiding the efficiency of office visits and reducing the need for in-person visits.

In the report, titled “Telehomecare and Remote Monitoring: An Outcomes Review,” Stachura and co-authors cited a number of sources that indicate that this use of information technology can reduce costs.

According to a by Schiller, et al, in the September/October 2007 Remington Report, telemonitoring of CHF patients “saved approximately $8,000 per patient because telehomecare reduced the need for conventional visits.” Stachura puts the office visit at about $100 versus a “tele-visit” of between $15 and $40.

Stachura’s report also referred to an article appearing in the journal Telemedicine and e-Health in 2001 that studied the impact of remote monitoring of diabetics. The randomized study led to the conclusion that controls generated more than $230,000 in hospitalization costs, whereas those participating in the study arm contributed only about $87,000 in hospitalization costs. Ongoing physician care costs also favored the electronic monitoring group, which generated costs of $1,668 compared to controls, whose care triggered $2,365 in costs.

During the conference call, Steve Morse, director of marketing for the Latitude patient monitoring system made by Boston Scientific (Natick, Massachusetts), said that one example for its cardiovascular application is use of electrophysiology (EP) equipment.

“There is immense possibility in this technology to improve outcomes and reduce costs,” he said. Latitude offers remote follow-up to remind patient of routine activities prescribed by their doctors and sends the doctor an alert when pre-specified physiological parameters go out of spec.

Too much data can be as problematic as too little, but Morse said that the engineers at Boston Scientific have worked around this. “The system collects a tremendous amount of data,” but “only sends the data the physician wants, when they want it.”

Latitude notifies doctors of critical changes, such as cardiac events, and also alerts doctors to abrupt weight changes, which may single fluid build-up in CHF patients. This then enables patient management “by exception,” enabling most focus “on the sickest patients [and allowing] physicians to treat a greater number of at-risk patients” than their caseloads might otherwise permit.

The physical range of the Latitude is somewhat limited, however.

Morse said the Latitude “generally communicates anywhere from four to six feet” from the patient, but the company’s EP equipment can store data throughout the day and then, “on a daily basis, download that data.”

He promised that the technology eventually “will go cellular” for real-time monitoring.

Julie Cohen, AdvaMed’s VP for government affairs, briefly reviewed the prospects for reimbursement of remote monitoring, saying that “despite the promise of these technologies, Medicare does not reimburse” because “reluctant to pay for non-face-to-face” events.

She noted, however, that Sen. Norm Coleman (R-Minnesota) has sponsored S. 631 to provide Medicare coverage for remote monitoring for apnea, diabetes, heart failure and other diseases.

S. 631, the Remote Monitoring Access Act of 2007, was introduced in February, however, and has not yet had a hearing in committee. A lack of co-sponsors also suggests that this bill’s prospects for this first year of the 110th Congress are dim.

Cohen said that budget scoring for the initial draft of the bill was about $300 million over five years but that its provision of telemonitoring could save Medicare a net of about $90 million over that period.