Wednesday, January 12, 2011

Telemedicine Faces Challenges

The New York State Health Foundation (NYSHealth) mostly supports grants to expand health insurance coverage, improve the management and prevention of diabetes, and encourage the integration of substance use and mental health services. NYSHealth is interested in opportunities that fit their mission but are also interested in opportunities that are perhaps outside of their priority areas.

Bassett Healthcare and affiliates is a system of physicians, providers, hospitals, and community health centers in 8 counties in New York, covering 5,000 square miles. The Mary Imogene Bassett Hospital, the foundation for the Bassett network is a 180 bed acute care inpatient teaching facility located in Cooperstown N.Y.

In their 2007 response to the NYSHealth grant program, Bassett Healthcare received funding for the grant “Expanding Access to Specialty Care in Rural Hospitals through Telemedicine” for $977,586 that ran from 2007to 2009. The goal for the grant funding was to use telemedicine to deliver healthcare in central upstate New York and provide telemedicine availability across Bassett healthcare’s system of care.

The project’s history began with a central hospital and four affiliated hospitals with 250 salaried physicians, 23, regional clinic sites, and 13 school-based pediatric clinics. This hospital system appeared to be the ideal place to implement a telemedicine system aimed at expanding access to care. Bassett initially foresaw a hub and spoke arrangement with its main hospital in Cooperstown being able to provide specialty teleconsulting services for patients at their affiliates.

Originally, in partnership with the New York State Department of Health, Bassett in 2000 put a Telestroke initiative modeled after the REACH program in Georgia in place to help treat patients in rural areas. The original plan was to use the grant funding to build upon their Telestroke initiative but at the same time explore treatment for other acute emergencies using telemedicine.

Portable video conferencing carts supplied by Polycom were placed at several locations in Bassett’s Cooperstown facility and at each of the affiliates to make it possible for consulting physicians in the emergency room, inpatient areas, and the outpatient clinic to treat patients. Subsequently Tandberg equipment was added to enhance equipment compatibility so that Bassett would be able to expand beyond treating strokes for remote patients.

Eventually, the telemedicine technology proved to be workable only for stroke patients but the physicians could see that the intended additional uses for remote technology for acute emergency care included in the plan were not going to work using telemedicine.

Challenges resulted in setting up the project. First of all, the technology from the start of the project was not always up to current standards. The project eventually explored and purchased alternative and more suitable telemedicine systems.

Secondly, because the initial plan was to use telemedicine to manage remote patients presenting with acute emergencies and strokes, using the REACH system, it might have worked in NY State as it does in Georgia, but the REACH technology only works for strokes and Bassett’s plans were more far reaching.

Thirdly, Bassett had invested in expensive technology but the technology would not work with cardiac patients or others presenting with acute emergencies. Groups of specialists were sending patients with acute emergencies immediately to the hospital rather than interact with the hub hospital remotely.

Also, additional state regulations introduced another challenge. New York State does not allow a hospital to transfer its credentialing approval to any of its affiliates so each physician delivering teleservices has to submit to a separate credentialing process as required at each of the affiliate sites.

The credentialing process not only includes a review of educational degrees and completed training, but also requires a separate assessment of the individual’s performance at that site which must be approved by the hospital board and renewed on a regular basis. These requirements severely constrain the possibilities for remote consultations on severe acute conditions. So if there is no neurologist available to assess a stroke patient and no cardiologist available to assess a heart patient, treating these patients at the smaller hospitals can be a potential violation of the state’s regulations.

To, meet the challenges and to look for new directions, focus groups were held, discussions with individuals and at conferences took place, and individual interviews with doctors and nurses were held to look for other ways that telemedicine could best address their needs. The need to manage home care patients with chronic conditions was discussed and a plan of action was initiated. Presently, 17 Phillips home monitoring units were placed with Bassett’s affiliated home care service “AHCare” to help patients with heart failure, chronic obstructive pulmonary disease, diabetes, and hypo/hypertension.

Bassett is also exploring other uses for telemedicine as for skin and wound care services, to provide remote sleep apnea for evaluations and other pulmonary services, to provide diabetes support, provide plastic surgery and dermatology teleconsultations, link to a dialysis center, use telemedicine for psychiatry, for post-operative interactions, and to treat pediatric asthma. Plans are to serve other migrant health clinics elsewhere in upstate New York.

NYSHealth still has an active grant program and has just issued their RFP in December 2010 for their “2011 Special Projects Fund” grant program. Funding requests range from $50,000 to $1,000,000 with grants typically in the $250,000 range. Organizations can apply for these grants at any time through May 5, 2011. Organizations nonprofit (501) (c) (3) and for profit organizations with a significant presence in New York state will be accepted.

For more information, go to NYSHealth web site at and click on Funding Opportunities. Projects that involve the purchase, installation, or upgrade of HIT systems including EMRs will not be accepted. To view the Bassett Healthcare Summary go to