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Expanding Telemedicine to medical homes for comprehensive care delivery. Roshni Kulkarni, Colleen Vallad–Hix, Laura Carlson and Rebecca MalouinMichigan State University ,

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Telemedicine Definition

The use of medical information exchanged from

one site to another via electronic communications

to improve patients’ health status.

American Telemedicine Association www.ata.org

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Telemedicine and TelehealthTelemedicine: Billable Interactive

Clinical Services• Telehealth: Includes• Telemedicine + other services: Tele-education Disaster and terrorism response Regional health information

sharing Research and administration

TeTelemedicine(Billable)

Telehealth

Homeland Security

Public Health

Consumer Education

Administration

Research

Health Professional

Education

Regional Health Information

Sharing

http://www.caltrc.org/general-information/what-difference-between-telemedicine-and-telehealthBurke B. M.D U of Arkansas; umtrc.org

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Background Information

Patients with hemophilia live an average of 58 miles from their Hemophilia Treatment Center (HTC) ~20% live >90 miles from their HTC making comprehensive care delivery a challenge. CDC

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The Need for Telemedicine • Augments services, improves access• Reduces travel time &costs • Alleviate Physician shortage

• Provide specialist access to rural populations• Increase physician utilization • Widen pool of available physicians• Deliver Comprehensive care• Types of Telemedicine:

• Store and forward • Real Time

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Synchronous/Real-Time Interactive Telemedicine• Requires presence of both parties at the

same time and a communications link to allow a real-time interaction.

• Uses HIPAA secure Video Conferencing + teledevices

• (HIPAA = Health Insurance Portability and Accountability Act. Privacy act to protect individuals health information)

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Tele-Comprehensive Care Delivery

1990 Marquette outreach clinics 1998 Telemedicine (TM) Marquette, 2011 Traverse City Telemedicine2013: Combined outreach and Telemedicine Services for a patient with severe hemophilia in a hospital 2014: TM follow up of above patient at a PCP office

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Tele-comprehensive Care Follow up

8

2 weeks

4 months

5 months

1 month

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• Upper Great Lakes Family health Center (UGLFHC) Portage located in Houghton/Hancock in Keweenaw Peninsula

• Population: 53,461• Home to MI

Technological University ( Michigan Tech)

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MSU/NHPCC grant • Goals

–Increase access to family-centered and culturally competent specialty care

–Increase the number of patients with bleeding disorders that are timely and accurately diagnosed and referred for specialty care

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MSU/NHPCC Grant: Objectives • Objectives

– To understand the feasibility of telemedicine between specialists and medical home for children with bleeding disorders by specialists, medical homes, and families

– To assess the acceptability by patients, families, primary care physicians, primary care staff, specialist physicians, and specialist staff

– To assess the cost of telemedicine visits versus traditional visits from the societal perspective

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Measures addressed : HP2020 and NHPCC • Enhancing comprehensive care services

• Increasing coordination with medical homes• Improving access to comprehensive care services, including

telemedicine and assisting patients in obtaining insurance coverage

• Referral to genetic services as needed • Enhancing access and services to underserved populations• BDBS-15: Increasing the number of people with severe VWD

who are diagnosed before age 21

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Measurable Objectives • Objective I: To understand the feasibility of telemedicine between

specialists and medical home for children with bleeding disorders by specialists, medical homes, and families.

• Objective 2: To assess the acceptability of telemedicine between specialists and medical home for children with bleeding disorders by patients, families, primary care physicians, primary care staff, specialist physicians, and specialist staff.

• Objective 3: To assess the cost of telemedicine visits versus traditional visits from the societal perspective

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Outcomes • Understanding of feasibility of implementing TM between specialists

and medical homes for patients with bleeding and clotting disorders• Understanding of patient/family, physician, and staff acceptance of TM

for care for patients with bleeding and clotting disorders• Cost estimates for relative cost of TM versus traditional visits to

specialist for patients with bleeding and clotting disorders• Improved access to comprehensive and coordinated care for patients

with bleeding and clotting disorders in medical homes• Improve access to comprehensive services for patients with bleeding

and clotting disorders from specialists• Increased number of families involved in planning, evaluation, and

implementation activities• Improved data tracking in the ATHN database 

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Evaluation Plan: Rebecca Malouin Background: -PhD and MPH in public health from Johns Hopkins University and a MS in epidemiology from MSU-Assistant professor: Family medicine and pediatrics and Human Development-Associate Chair for research in family medicine-Expert in evaluation of health services interventions using mixed methods, focusing on new models of care in primary care-Previous to position at MSU, first newborn screening/genetics epidemiologist at MI state health department (MDCH)-Published two recent monographs for AAP on evaluation of pediatric medical home initiatives as well as best practices in family-centered care 

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Telemedicine

*Standardized using SNOMED CT, LOINC and First DataBank’s NDDF, Core data element

Telemedicine Clinics

Time period June 2014- Oct 2014Clinic Dates June 10th, July 8th, Aug 5th, Sept. 23, Oct 21No. of patients 9Telemedicine visits 10Age range 2 weeks -16 years Frequency of TM Clinics 1 per monthNo of patients seen/clinic 1-2 Videoconferencing system Vidyo

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Telemedicine Stats

*Standardized using SNOMED CT, LOINC and First DataBank’s NDDF, Core data element

Telemedicine Clinics Portage Clinic

Types of disorders Others tested Epistaxis/possible Ehlers Danlos Von Willebrand disease (VWD*) Parents and 2 sibsCervical lymphadenopathySpherocytosisIron def anemia/ hemoglobinopathy Family members (thal intermedia)VWD* * Same patientMenorrhagia, anemia, abn coag profileMenorrhagia, abn coag profileVWD Mother, sibling and maternal uncle

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Costs of Telemedicine at Portage Demographic Parameters Portage

Average distance that patients travelled 33.4 (2.4 -42.3 ) miles

Distance patients lived from local center. N=7 patients with 8 visits

30-50 miles : 2 patients10-15 miles ; 2 patients<10 miles ; 3 patients

Distance for Patients to MSU (RT) 960 -1000 miles RT (460-503 miles OW)

Commercial airline ticket cost $1142 to $1184

Driving time 9 hrs OW or 18 hrs RT

Time lost from work 20 hrs ( 9 hrs travel time OW)

Physician cost saving $3850

One Way= OW, Round Trip = RT

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Patient Cost Items

Portage Clinic Houghton

Patient comes to MSU, East Lansing

Patient to attend clinic at MSU- Driving costs (Driving, meals and lodging)

$615

Time lost from work (RT) hours @ $33/hr wage 20 hr x$33=$660Total with driving $1275If patient flies ( $1184 airline costs + travel time = 16 hours @$33/hr = 528

$1712

Meals and Lodging $175 /night S175Total with flying $1887

Patient attends clinic locally at Portage

Patient to attend clinic at local facility (Driving) $18.7

Time lost from work (RT) @$33/hr wage 3 hrs x$33= $99Total- attending local clinic $117

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Physician /Comp care team costs

Physician/team location Costs

Physician costs to do clinic at Portage

Physician cost for outreach clinic $2266Time lost from work 14 hrs @ $150/hour

14 hrs X $150 =$2100

Total cost to conduct clinic at Portage

$4366

Comprehensive care team Cost for 3 team members ~$12,000Physician/comp team cost of Telemedicine (TM) clinic at MSU

Physician cost for TM clinics $00.00Time lost from work 0hrs

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Site visit to Portage MI : Sept 25th 2014 • MSU staff: Physician, Nurse and Social worker

• Dr. Rebecca Malouin joined by Teleconference using Vidyo• Transportation: MDOT plane • Combined with drive to Iron River to see a sever hemophilia baby,

and a clinic next day at Marquette General Hospital. • Portage staff met: Dr. Vallad-Hix, Adult hematologist, pediatrician,

nurses, IT staff, Lab specialist• Meeting to inform about NHPCC grant aims/methodology• Discussed barriers, needs• Educational material distributed• Local pediatric patient with cancer in follow up phase seen

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Happy Family!!

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Nursing Roles1. Grant coordinator

2. Clinic Nurse

3. Clinic coordinator

4. Follow up with

billing

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Grant CoordinatorAssisted with pieces of the grant

• Budget/ Justification• Monitoring Grant Budget and Account• Writing Standard Operating Procedures for clinical and

office staff• Site Visit• Staff Education• Coordination

• Outreach staff – Scheduling, Lab templates• Physicians – Both Portage Health and MSU• Information Technology (IT) – Both Portage Health and

MSU

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Clinic Nurse Role• Gather all referral information from outreach location, review

with Dr. Kulkarni, order any other testing desired prior to visit• Nursing assessments with telemedicine patients• Patient teaching and education• Clinic follow up needs:

• Further patient and family testing desired after evaluation• Coordination with Portage staff for follow up• Assist in scheduling return visits if needed• Documentation and data- making sure both institutions have

visit documentationwww.google.com

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Practical considerations: Key Points• Pre Clinic Visit: Communication and

Coordination • Scheduling telemedicine clinic visit dates and times• Exchange of information for billing and review prior to visit• Obtain further testing prior to visit if desired • Inform IT on both ends for testing if needed

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Day of Visit:• Send the link for the telemedicine visit to IT, physicians

and other staff necessary for visit• Open up the telemedicine room 15 minutes prior to the

scheduled visit• Obtain all signed forms, Release of information,

Consents, Etc.• Conduct the visit

• Hematologist, PCP, nurse & staff, HTC Nurse ,Social worker

• History, Physical examination with PCP and discussion and education with patient about possible diagnosis and treatment

• Nursing and Social Work visit with patient and familyPCP= Primary Care PhysicianHTC= Hemophilia Treatment Center

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Post Visit: Follow-up• PCP and HTC exchange office visit notes and test

results• Place in ATHN Clinical Manager• HTC nurse will follow up with PCP office for further test

results• Order Stimate® for Stimate® trials – sent directly to

PCP along with protocol, Stimate® information, fluid restrictions and education materials. • PCP office will schedule and carry out trials and patient

education

PCP= Primary Care PhysicianHTC= Hemophilia Treatment Center

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Nursing Obstacles • Portage Health restructuring –

• Difficult communication and coordination due to staffing changes in the PCP office and management group

• Difficulty in finding time for

• Nursing assessment• Having the appropriate staff present for needed portions of the

visit. Finding the right mix to allow the PCP to continue to carry out clinic while CBCD staff are seeing the consultation

• Follow up: what office does what?

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Social Work: Responsibilities •Review referral information from UGLFHC•Ensure patient has sufficient insurance•Contact patient, parent/guardian, UGLFHC for clarification•Participate in telemedicine sessions•Provide follow-up to all entities for local & state referrals•Provide educational materials to staff, patient, families•Consult on coordination plans with health department, schools and primary care physician office

Upper Great Lakes Family health Center (UGLFHC)

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Early Obstacles•Incomplete referral packets received from UGLFHC•Patients, parent(s) & guardian(s) expressed concerns about medical care and provider coordination•Lack of UGLFHC Staff knowledge of social work availability•Lack of UGLFHC Staff knowledge of telemedicine process•Technology barriers at both sites for staff•Duplication of services to patients

-Example: Patient had both HTC and UGLFHC providing referrals to health department and completed two CSHCS Diagnostic Evaluation requestsUpper Great Lakes Family health Center (UGLFHC)

Children's Special Health Care Services (CSHCS)

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Coordination•Understood need to not duplicate patient services and put a procedure in place for referrals (i.e. CSHCS/Health Dept.)•Participated in Houghton meeting for CBCD & UGLFHC staff•Toured Portage Hospital and UGLFHC facility•Attended formal presentation & conducted informal discussions with medical, technical and laboratory staff•Provided educational resources for UGLFC staff and patients regarding bleeding disorders, school plans & insurance •Followed up with UGLFHC staff to continue improved coordination of social work support and patient care

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Evaluation

Rebecca Malouin PhDDept. of Pediatrics and Family Practice MSU

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Measurable Objectives• To understand the feasibility of telemedicine between

specialists and medical home for children with bleeding disorders by specialists, medical homes, and families

• To assess the acceptability by patients, families, primary care physicians, primary care staff, specialist physicians, and specialist staff

• To assess the cost of telemedicine visits versus traditional visits from the societal perspective

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Feasibility Questions• Is medical home based on TM feasible?• What types of services are appropriately delivered via TM at

various sites?• What serendipitous applications emerge?• How many patients can be seen? Unable to be seen?• What kinds of technical issues arose?• What kinds of new patients were seen?• How many and what types of laboratory diagnostic tests were

performed?

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Feasibility Methods• Measures extracted from the EMR, ATHN dataset

and surveys

• List of measures tracked• Phone calls tracked from patients and

providers• Patients enrolled through project will be

documented in ATHN dataset, HDS and CDC surveillance project

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Acceptability Questions• How do providers (hematologists, primary care

physicians, center staff, medical home staff) perceive this application in regard to satisfaction and perceived quality of care?

• How do patients and/or caregivers perceive this application in regard to satisfaction and perceived quality of care?

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Acceptability Methods

• Key informant interviews with physician and staff during first and last period of the project

• Key informant interviews with families within one month of first telemedicine visit

• Interviews audio recorded, transcribed, coded by multiple coders, analyzed etc.

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Acceptability by Staff at Primary Care Site• Accustomed to protocols; would benefit from telemedicine

protocol for hematology consults• Protocol would assist with better organization for family

participation in visit as well• Would be helpful to have information for families as to what to

expect from the consult• Importance of planned visits and keeping to the calendar due

to difficulty in scheduling in a busy pediatric practice• Stressed demand for telemedicine consults by specialist in

rural areas – becoming more common and so much more convenient for families

 

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Acceptability by Families• Would be helpful to be given written information

about what to expect from the consult and specific information on why the consult is necessary

• Would be helpful to have primary care physician in room at all times to help explain what the consulting physician is sawing (due to both accent and content)

• Having so many of the team members on the video on the specialist side is confusing to the families, especially if multiple people are talking at once.  Would be preferable to speak to each one at a time, if necessary.

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Acceptability by Families contd…..

• The roles of each of the people on the specialist side were not clear.  It was not clear to the family why a social worker was present.

• Would be helpful to be given clear options (multiple) at the end of the visit with potential outcomes if each option is not followed.

• Family had extensive experience with telemedicine consults with other specialists and appreciated the availability to see a specialist in this format.