International Telemedicine: Developing a Model for a Global Pediatric Practice

Molly Reyna, BA, Oussama El-Baba, MHA, Gerard Martin, MD, Philip Hopkins, Craig Sable, MD

Children’s National Medical Center, Washington, DC

International Health Partnership Models for Patient Care

• Patients travel to United States• Medical teams travel internationally– Consultation– Patient Care– Education– Advance state of care

• Physicians provide consultation for international physicians after record review

Goals of International Outreach

• Improve health care• Increase educational opportunities– Didactic– Hands on patient care

• Build sustainable business model– Patient care– Education

Our Experience

• Over view of international program at Children’s National Medical Center

• Utilization of telemedicine to complement and enhance our international program

International Referrals to DC: 2006

Service Line• Cardiovascular surgery – 46 • Cardiology – 17 • Orthopedic surgery – 7 • Gastroenterology – 4 • General surgery – 4 • Pediatric medicine – 2 • Urology – 2 • Oncology – 1 • Physical medicine – 1 • Neurosurgery – 1 • Otolaryngology – 1

Country• Kuwait – 43• Saudi Arabia – 11 • Uganda – 8• United Arab Emirates – 6 • Qatar – 4 • Brazil – 3 • Netherlands – 1• Barbados – 1• Greece – 1• Chile – 1• Afghanistan – 1 • Honduras – 1• Argentina – 1

Countries Visited: 2006

• Middle East– Saudi Arabia– Kuwait– United Arab Emirates– Qatar

• Europe– Belarus– Ukraine– Russia

• Africa– Uganda– Morocco

• Latin America– Dominican Republic

• Asia– China– Sri Lanka

Financial Impact: Direct Patient Care

• Inpatient admissions– N = 67– Hospital charges: $6,280,000

• Outpatient encounters– N = 286 – Hospital charges: $372,000

• Same day surgery/cardiac catheterization– N = 12– Hospital charges: $195,000

• Total charges (hospital and professional) – $9,020,000

Telemedicine/Distance Education

• Telemedicine– Germany– Saudi Arabia– Iraq– Morocco– Qatar

• Distance Education: Live Lectures– Bosnia– Iraq– Morocco– Ukraine

• Potential sites for 2007 – 08– Egypt– Eritrea– Uganda– Kuwait– United Arab Emirates– Belarus

Telemedicine

• Specialties– Cardiology– Nephrology– Pulmonary medicine– Infectious disease– Gastroenterology– Emergency medicine

• Models– Electronic data transfer– Live case presentation– Discussion of transferred data

Cardiology Case Study 1

• 24 hour old baby born at Landstuhl Regional Army Medical Center in Germany

• Trisomy 21/mild cyanosis• Referring army cardiologist suspected

coarctation of the aorta• Initial plan– Start prostaglandin E– Arrange for medical transport to Washington, DC– Plan for expedited discharge of father from Army

Cardiology Case Study 1

• Referral call received at 9 AM EDT (3 PM GMT +1)• Three way telemedicine call to view live echocardiogram

established within 1 hour – Physician home (IP to hospital/bridged via Gateway to Germany)– Our hospital in DC (ISDN – 384 kbps to Germany)– Patient and physician in Germany

• Telemedicine diagnoses– Patent ductus arteriosus/normal transitional circulation– No coarctation of aorta

• Recommendations/outcome– Oxygen therapy for 24 hours– Normal newborn care– Repeat echocardiogram (also by telemedicine) at DOL #3 was normal– No disruption of service for father

Cardiology Case Study 2

• 1 month old blue baby in Saudi Arabia• CNMC cardiologist in Saudi Arabia with local

physicians: 6 AM EDT (2 PM GMT + 3)• Live videoconference (ISDN – 384 kbps): 8 AM EDT• Cardiologist and cardiac surgeon in Washington

reviewed and discussed case with Saudi team• Outcome

– Complex congenital heart disease– Surgical plan agreed upon– Patient transferred to Washington for surgery

Nephrology Case Study

• 5 year old boy in Iraq with severe hypertension, headaches, stroke, and hyperpigmented lesions

• Data sent in advance via email (PowerPoint) and reviewed by nephrologist

• Live case discussion (IP – 256 kbps)– Satellite from Baghdad to New York– IP from New York to Washington

• Recommendations– Medication– Renal artery angioplasty

Telemedicine Business Model

• Sustainability is critical• Direct reimbursement/contractual agreement

– Telemedicine installation/maintenance– Lectures– Patient consultation– Direct revenue from test interpretation– Customization from menu of services

• Downstream revenue• Grant/external funding• Support poorer countries with revenue from wealthier

countries

Outcome measures

• Patient care outcomes: – Direct patient care statistics: mortality, morbidity,

length of stay– Public health initiatives

• Physician satisfaction• Academic productivity• Public relations/media coverage• Financial

Challenges

• Language barriers• Time zone difference• Computer technology compatibility• IT staff communication• Band width availability• Medical practice variability • Ongoing funding• Sustainability• Travel time/insurance/safety

Lessons Learned

• Strong incentive to move forward with international telemedicine– Good business in wealthy countries– Can fill critical need in poor countries

• Need to be very cognizant of each country’s needs, resources, customs, and politics

• Relationship building is vital– Multiple visits necessary for success– Ongoing communication with technical, medical,

administrative and political staff

• Involvement of embassy’s on both ends is very helpful

Next Steps

• Continue to build international program– Open up CNMC office in United Arab Emirates– Partner with adult hospitals– Schedule routine international visits

• Expand telemedicine reach– Build networks in existing countries– Look for new partners

• Advance the concept of combined international programs/telemedicine service line