Advances in telemedicine hold great promise throughout the world.
by Vijay Govindarajan
If you’ve not yet heard of telemedicine or think that it’s not a great way to deliver quality health care, you may want to read this. Telemedicine, made possible by the availability of mobile networks, is revolutionizing health care. But not in the U.S.
You have to look to India, where telemedicine is already widely used in the delivery of health care — and is saving lives even in the most rural corners of the country. It is especially used in peritoneal dialysis (PD), a key treatment option for patients with severe and chronic kidney disease, so-called end-stage renal disease (ESRD). Under this procedure, fluid is introduced through a permanent tube in the abdomen, and flushed out either every night while the patient sleeps, or via regular exchanges throughout the day. It is home-based care. The alternative treatment is hemodialysis (HD). Compared to HD, the primary advantage of PD is the ability to deliver treatment without visiting a hospital; it is thus more cost-effective. The primary disadvantage is that it can cause complications due to infections, since PD permanently attaches a tube to the abdomen.
The major barrier in the acceptance of PD is concern that patients won’t have proper access to a doctor — especially in geographically dispersed countries such as the United States. As a result, less than one in twelve ESRD patients are treated with PD. The net result? It costs over $170,000 to treat patients with ESRD in the U.S., using the more expensive HD.
Dr. K. S. Nayak, Chief Nephrologist at the Lazarus Hospital in Hyderabad, India, and his team are able to treat ESRD patients using PD with excellent results at a remarkable one-fifteenth of the cost, about $12,000.
How is this possible?
Lazarus Hospital uses mobile phone short messaging service (SMS), inexpensive digital cameras, and the internet to address patient accessibility issues. Those technologies — coupled with a dedicated PD team (comprising medical and paramedical staff) have enabled the hospital to develop a unique PD remote monitoring system. The innovation is in the software that provides the connectivity. (U.S. patent pending for the PD-SOFTWARE).
Patients are constantly in touch with kidney specialists, communicating in real time, around the clock. To monitor complications from infection, patients and their caregivers are trained during their initial PD period to use their own mobile phone cameras or digital cameras to take photographs of the PD effluent bag.
After signing into the (secure) hospital website, patients and caregivers are directed to a personalized home page from which they can use the site to enter and share information. Health complaints made by patients receive immediate response. Remote monitoring is augmented by a home visit protocol that ensures that each PD patient’s progress is followed up by a well-trained clinical coordinator (CC) on a regular basis. The CCs are trained to follow a set protocol and are equipped with a standardized checklist for a step-by-step assessment of patient well-being during each visit. All this information, together with a brief summary of the patient’s most current laboratory results, is conveyed to the nephrologist by SMS from the patient’s home. The CC is instructed to wait until the nephrologist responds (usually within 15 minutes), and then to counsel the patient accordingly. CCs also assess and advise patients on nutrition, psycho-social well-being, and physical fitness and rehabilitation levels.
The hospital retrospectively analyzed 115 rural patients who had started PD using this remote monitoring technology. Amazingly, rural patients performed well on PD and had significantly better survival rates than did their urban counterparts.
But in the U.S. it’s a different story. Over 90% of patients in the U.S. with ESRD use HD as their treatment. However, that is a procedure that requires the patient to go to the hospital three times a week. This is more cumbersome, more expensive, and hampers the patient’s lifestyle and work/family obligations. What is the primary driver of this system-wide inefficiency and cost? Most health care providers would agree that it is physician “mindset:” higher physician reimbursement for HD than PD, and concerns about accessibility in a geographically vast country contribute to historically low use of PD in the U.S.
It doesn’t have to be this way. The “distance” between the patient and the PD unit can be overcome, at a dramatically low cost, by efficient use of the internet, mobile phones, and a strong home visit protocol. To quote Dr. Nayak: “Our success can easily be replicated in the U.S. Conservatively, even if 15% of ESRD patients choose PD over HD, cost savings for Medicare and Medicaid will run into many millions of dollars every year.”
Why can’t we adopt this in the U.S.?