eHealth Evolution

By Anna Lynn Spitzer

Paul Blair With Students

The McDermott family's day-to-day lives improved,
thanks to telemedicine visits with Dr. Ira Lott.
(Photo courtesy of family.)

Twenty-one-year-old Haley McDermott lives in Bakersfield, Calif., about 2-1/2 hours outside of Los Angeles. She has cerebral palsy, severe developmental delays and a seizure disorder. For the past six years, her mother, Debbie, has taken her every 4-6 months to Bakersfield’s Kern Regional Center to consult with Dr. Ira Lott, a UC Irvine pediatric neurologist.
 
Lott does not see Haley in Bakersfield, however; he is 115 miles away at the UCI Medical Center. The physician and head of UCI’s telemedicine program consults with Haley and her mother using high-speed, two-way, interactive audio-video conferencing equipment.

Haley, who lacked head and trunk control, spent much of her time slumped down in her wheelchair, Debbie says. One of her legs was contorted, making it several inches shorter than the other and causing painful pressure wounds on her tailbone.

Last year, during a routine neurological visit, Debbie mentioned the pressure wounds to Lott. He referred Haley to Dr. Sam Rosenfeld at Children’s Hospital of Orange County, who performed life-altering spinal fusion surgery.  Her pressure wounds healed, she has better head and trunk control, and instead of crying, she smiles all the time, her mother says. “Now she’s happy. She can sit and be part of the family instead of lying in her bed on her stomach staring at the mattress.”

Advances in information technology are creating revolutionary healthcare-delivery mechanisms like telemedicine that can improve quality, reduce cost and quite possibly save an over-burdened system from imploding. The wide assortment of eHealth applications includes smart phones, iPads and mobile operating systems, which offer inexpensive monitoring and increased access; online and wireless solutions, which provide independence for seniors and comfort for sick children; and electronic medical records, which smooth information exchange and afford an extra layer of security.

Telemedicine was born in 1906, when the first EKG was transmitted over telephone lines. In 1967, two years before the first message arrived on the Internet, Massachusetts General Hospital and Logan International Airport established a link to allow specialists to provide immediate care for seriously ill travelers.  Today, ongoing improvement in the technology has broadened telemedicine’s reach to include those in rural or underserved areas who otherwise might not have easy access to quality medical care.

Haley is just one of many patients Lott treats via telemedicine. In addition to those at the Kern Regional Center in Bakersfield, he consults with a host of other California clinics participating in a statewide project called the Specialty Care Safety Net Initiative (SCSNI). The two-year pilot, administered by the California Center for Connected Health Policy, is identifying ways to establish permanent telemedicine relationships between medical centers and underserved areas, and to better understand the barriers that slow this effort.
 
All five University of California medical schools participate in SCSNI, which currently links 40 clinics statewide with medical specialists at the UC medical centers. Eventually, the program will use the California Telehealth Network (CTN), a state- and nationwide broadband network that will connect more than 850 healthcare organizations.
 
Lott, the veteran of 1,200-plus telemedicine consults, first explored telemedicine 10 years ago when he recognized the extent of the disparity in rural areas for specialty medical care. “Before [telemedicine] we had to drive out to these areas and hold clinics. That just was not cost-effective and it didn’t result in good continuity,” he says.

After conducting dozens of telemedicine consultations and completing a reliability study, Lott was sold. “I became convinced that it was a reliable vehicle for delivering neurology care.”

Paul Blair and student demonstrating the device
Paul Blair and student demonstrating the device

 

Left: A balance-monitoring insole delievers real-time information on a user's gait. Pictured from left,
Mark Bachman, grad student Peyton Paulick and Dr. Hamid Djalilian. Right: Hector Parra and
Dr. Ira Lott confer between UCI's campus and medical center complex via Telios. (Photos by Paul Kennedy.)

 

Debbie McDermott couldn’t agree more. “I wish more people had this opportunity. I advocate for kids with disabilities and I always tell them about telemedicine,” she says.

“And Dr. Lott, even though he is a neurologist, was looking at the whole child, not just the seizures. A lot of physicians would have looked at Haley and thought, ‘why bother doing a surgery that costly and that massive.’”

UCI’s telemed specialists also include a pediatric endocrinologist, a pediatric psychiatrist and an adult neurologist who conduct live, real-time consultations with patients in the SCSNI clinics. These clinics include the Share Our Selves (SOS) community clinic in Costa Mesa, Calif., which uses the telemedicine consultations for some of the 1,000-plus patients who visit the clinic each month.

SOS Medical Director Dr. Patrick Chen joined the clinic in 2006. In the last five years, he says, there has been nearly a 100 percent increase in those without insurance seeking a primary-care provider. Many of these patients have chronic diseases that require specialty care. “Telemedicine is opening up healthcare to people who otherwise wouldn’t have access to it. When resources are scarce for specialists, telemedicine can really help to fill these gaps ,” he says.

SOS is also testing e-consult in a program funded by Access OC, a nonprofit program that addresses specialty care for the county’s uninsured population. E-consult can fill the bill for the type of referrals that don’t require real-time patient-to-doctor contact, such as neurology, dermatology and cardiology. Currently, 12 specialists participate in the program, assessing cases and returning their recommendations to the SOS doctors within 48-hours.

Chen recently did a neurology e-consult for a 38-year-old pregnant patient with a history of seizures. She was taking two anti-seizure medications, and Chen wanted to be sure they would not adversely affect the pregnancy. He documented her case, sent it via e-consult to a neurologist, and learned that both medications were safe to use during pregnancy.

 “Live telemedicine is great but it requires a lot of coordination,” he says. “E-consult is a cost-effective way to access specialty care without requiring the patient to attend another appointment.”

UCI’s telemed specialists also include a pediatric endocrinologist, a pediatric psychiatrist and an adult neurologist who conduct live, real-time consultations with patients in the SCSNI clinics. These clinics include the Share Our Selves (SOS) community clinic in Costa Mesa, Calif., which uses the telemedicine consultations for some of the 1,000-plus patients who visit the clinic each month.
Paul Blair and student demonstrating the device
Pai Chou designs compact sensor platforms that can monitor children for a variety of conditions.

“Live telemedicine is great but it requires a lot of coordination,” he says. “E-consult is a cost-effective way to access specialty care without requiring the patient to attend another appointment.”

For Dr. Laura Mosqueda, head of UCI’s geriatrics program, telemedicine is a win-win for the elderly. “An office visit can mean 4-6 hours of upset for them,” she says. “If I can have [virtual] office hours in assisted-care living facilities and nursing homes, it’s good for everybody. The facilities don’t have to transport folks, patients don’t have the upset and I can be more efficient. They can get quicker, better care.”

Telemedicine also facilitates home monitoring, which is especially helpful in the first few days after a hospital stay.  “You could send them home with telemedicine equipment and they could have a daily visit with their doctor,” she says, adding, “There aren’t enough geriatricians to take care of all the older adults. This is a better way to utilize resources.”

Nurses are in short supply, too, according to Ellen Olshansky, director of UCI’s Program in Nursing Science. eHealth technologies and telemedicine can extend the reach of nursing care, especially when it comes to monitoring those with chronic illness and keeping patient/provider communication channels open.

Olshansky cautions, however, that the human connection – the importance of which is emphasized in nursing education – must be maintained in the process.

 “The trend towards eHealth is good in many ways; it’s using technology in a positive manner,” she says, citing the trend toward early hospital discharge and home health monitoring. “We just have to balance it with human interactions and making sure we are there for our patients.” 

If telemedicine’s next stop is the home, then Calit2’s Telepresence Interactive Operating System, Telios, could be there too.
 
The software, built on a Web 2.0 platform, allows two-way communication via webcam between medical specialists and individuals in the privacy of their homes. Peripherals – monitors for heart rate, blood pressure or glucose, for example, and devices like stethoscopes, otoscopes, dermascopes and more – can be connected to the system to aid in diagnosis and monitoring.
 
“The [teleconferencing] systems can’t be beat at what they do, but they’re very, very expensive,” says Hector Parra, who coordinated UCI’s participation in the SCSNI and helped develop a Telios prototype that is being used at the SOS clinic. “Telios is completely software-based so it’s free and offers a very low barrier to entry. With a Web browser and a webcam you can get some of the same features.”

Additionally, most teleconferencing systems are cumbersome and difficult to integrate into other products. One of Telios’ strengths, Parra says, “is it’s very modular, so if you need to add different components or integrate something, you can.”

Adds Lott: “Telios is a very promising application because home care is going to become increasingly important in all aspects of medicine in the next decade.

 Telios meshes with current consumer electronics trends too. “Almost every new television will have a Web browser built into it, and since we designed the system around Web 2.0 it will work in every TV,” says co-developer Mark Bachman, assistant professor of electrical engineering and computer science.
 
Web TV is just one in a long list of wireless devices and online applications transforming healthcare research, development and deployment. New technologies are melding with the latest advances in medicine, computer sciences, engineering, biology, chemistry and gaming.

Nowhere will these disciplines merge more seamlessly than in Calit2’s new eHealth Collaboratory, where researchers pool their multidisciplinary expertise to create what Irvine division director G.P. Li calls a “high-touch” approach.

“High-touch goes beyond developing the next new gadget,” Li says. Technology users have different needs and the eHealth Collaboratory seeks to bridge these gaps.
 
“We want to personalize the individual user experience for patients, but also for physicians, nurses and other healthcare providers. We want to offer enough information to the users but not so much that they have information overload. Our approach is not to create universal solutions but to use technology to lower the barriers to individual support.”
 
Located on the building’s third floor, the Collaboratory advances all facets of eHealth, giving researchers a venue to display their breakthroughs and attract additional funding. Telemedicine, mobile operating systems, wireless solutions and even micro- and nano-fluidics are all on the agenda but are just one step on the road to the ultimate destination: user empowerment.
 
“We’re trying to figure out how to use technology to empower people to take care of their health,” says Bachman, who manages the recently opened space. “The fact that telecommunications is such a big part of our lives and consumer electronics are now so cheap opens the door to a great opportunity.”

True to its name, the eHealth Collaboratory is truly collaborative, he says. “We have an opportunity to learn to build things that really work but we’ve got to collaborate with people who are in the trenches, who know exactly what healthcare consumers really want.”

One such collaboration includes a mechanical and aerospace engineer, a neurologist, an electrical engineer and a computer science gaming expert. The four professors joined forces to create “iMove,” a grant-funded endeavor that combines information technology and robotics to improve human mobility.

David Reinkensmeyer, professor of mechanical and aerospace engineering, anatomy and neurobiology, and mechanical engineering, is a principal investigator. “We are particularly interested in whether training in robotic environments can improve motor skill performance outside of the training environment,” he says. “We are trying to understand the computational mechanisms of human motor learning.”
 
In another collaboration, pediatric anesthesiologist Dr. Zeev Kain and engineer Bachman are teaming with psychologist Michelle Fortier to develop a mobile application for children undergoing cancer treatment.  “Pain Buddy,” which is funded by a $450,000 grant from the Hoag Foundation, will prompt kids to report their pain level at regular intervals on a handheld electronic device – a kind of mobile pain diary. The data will be downloaded on a server and made available to the child’s oncology treatment team, which can respond with instructions and recommendations
.
The current iteration features a customizable avatar that can walk children through the process; future versions may include a social networking aspect so kids can communicate with peers experiencing the same conditions.
 
“The literature shows us that children age 8 and up can really use these electronic devices to monitor their health information,” says Fortier. “I thought this would be a great way to provide them with improved pain management, but also with a tool that could be their buddy during the cancer treatment.”

Fortier, who is using $50,000 from her grant money to support the Collaboratory, plans a Spanish-language version of the Pain Buddy, as well as an adaptation for other types of acute and chronic pain.
 
Computer scientist Walt Scacchi collaborates with healthcare professionals to develop online games and virtual world applications that can address a host of chronic health issues like obesity, asthma and diabetes.
 
“These ailments are growing very fast and there are not enough healthcare providers to deal with that,” he says. Low-cost game technology or virtual worlds can provide sustained reinforcement and help those with illnesses interact with others who have similar conditions. “With social networks, people start to know how to help themselves and help each other. And they may find that less intimidating than a face-to-face encounter with a doctor or nurse in a medical setting,” Scacchi adds.
 
Computer science professor Magda el Zarki is working with a physician on two proposals to develop virtual worlds for autistic kids and their caregivers. By incorporating behavioral traits and characteristics demonstrated by autistic children, el Zarki hopes to create realistic venues in which children can hone their social skills and caregivers can learn strategic behavioral strategies.

She believes more health-related functions will begin to evolve online. “The interfaces are getting easier to use and I think people are going to move much more into immersive worlds,” she says. “There is a tremendous amount of possibility in this area.”

Online platforms can offer individualized help for relief of other medical conditions. Dr. Hamid Djalilian, a UCI Medical Center otolaryngologist, created an online treatment program for tinnitus, a ringing, humming or buzzing in the ears that affects approximately 30 million people in the U.S.
 
A state-of-the art treatment device costs about $6,000, but Djalilian created an inexpensive substitute: Beyondtinnitus.com, a subscription Web site that uses algorithms to produce sounds to relieve those heard by the patient.
 
Djalilian says a pitch that is close to the sound of the ringing will help a large majority of patients, but can be annoying to listen to. So the site utilizes a sound-mixing algorithm that creates a variety of more pleasant sounds. When the user has identified the correct tinnitus pitch and loudness, the program delivers a customized sound file that can be downloaded onto an iPod or other device.
 
The sound file also can be mixed with the user’s own MP3 music, working in the background to stimulate the parts of the brain that can reduce the ringing. Djalilian says about 95 percent of the Web site users have found relief.

Pain relief also is the focus of an online tool developed by pediatric anesthesiologist Kain. He used the Web to create a personalized application that helps children prepare for surgery and their parents manage postsurgical pain.
 
The Web-based Tailored Intervention Preparation for Surgery (WebTIPS), a colorful and compelling site created by DMA Animation, allows parents to log on prior to the surgery to enter information specific to themselves and their children. They answer questions about anxiety level, temperament, coping style, belief in pain medication and more.

Data are processed and the site delivers a personalized program that includes information about the surgery, postoperative pain management and tips for coping. “Everything is individualized,” Kain says. “When they go home, if it’s 3 a.m. and the child is crying, parents can go to the site and see what to do.”

The trend toward digital solutions doesn’t stop with innovative products. Digitizing medical records has become a priority for healthcare providers. Not only can electronic medical records raise quality of care while lowering cost, but the federal government is offering incentives – close to $22 billion in American Recovery and Reinvestment Act funds – as well as penalties, which begin in 2015, for failing to adopt the technologies.
 
UCI Medical Center began transitioning to electronic medical records in 2009, implementing phase two last year. “We have taken all of this information that people are used to putting in a paper chart and we’ve moved that into an electronic format. The EMR runs seven days a week, 24 hours a day,” says Adam Gold, director of emerging technologies at UCIMC.
 
The system is available even during maintenance and updates, as users are taken to a read-only system. This seamless process takes place across all 3,000 hospital workstations.

Portability, manageability, oversight and data themselves are improved. “That information is always available now, whereas before, we really only had the chart and what the doctor or nurse had in their head at the time,” Gold says.

EMRs also ensure safety in drug dispensing. Electronic medication management requires healthcare providers to interact with the system at the dispensary and again before they medicate the patients. The system can also sound an alarm to prevent negative drug interactions and alert providers to serious side effects.

Mosqueda says the EMR improves efficiency and quality of care in her geriatric practice by making it easier to track secondary conditions associated with illness or disease. “If someone has diabetes, it’s easier to track things like blood sugar and we can use electronic means to remind us to check renal function, foot care and eye care, and all the other things that go around it.”

Next on the agenda at UCI Medical Center is connecting clinicians to the EMR through their iPhones and iPads, which entails encrypting, password-securing and managing approximately 400 devices.
 
Patient and physician portals will also debut later this year, allowing both groups outside access to pertinent medical records. The patient portal will allow patients to link their medical records to online health resources like Microsoft Health Vault and to decide which parts of the record they want to share with other providers or family members.

Technology in healthcare management will continue to evolve. In five years, Gold says, he wouldn’t be surprised to see iPads mounted in every patient room for interacting with the EMR, Bluetooth barcode scanners for patient identification and medication information, and device-to-device communication that would allow real-time updates to be sent to doctors.

Developing systems to support these devices is critical to achieving total integration. “You can buy every gadget in the world and give it to the clinicians but if we don’t implement it right from a technology and usability perspective, they are not going to use it,” says Gold.

Calit2’s new eHealth Collaboratory strives to deliver healthcare solutions that meet these same criteria. “Our high-touch approach includes involving patients, physicians, nurses and other healthcare providers as we develop new technologies,” says Calit2 director Li.  “In this way, we hope to create technology that can be personalized to a wide range of users and will be valuable to those delivering the healthcare as well as those receiving it.”

In all cases, the focus is on empowerment and personal dignity, says Bachman. “Everybody is doing eHealth right now but they’re all doing the same things. They all want to strap things to you and take data from you. But we don’t want to turn people into laboratory animals. If we do that, we have completely failed,” he insists.
 
 "It's not enough to improve people's health if we do it the wrong way. We want to promote better health through empowerment, with dignity and respect.”

--Anna Lynn Spitzer