Validating Virtual Coma Care

A new study was recently released showing that doctors can assess coma patients via telehealth just as effectively as those at the bedside.

The 15-month study involved about 100 patients in varying levels of coma. Two neurologists (one remote, one at the bedside) assessed the patients using two leading metrics: the Glasgow Coma Scale (GCS) and the Full Outline of UnResponsiveness (FOUR) score. Both scales measure things like eye and verbal response – and the FOUR score also assesses brain stem reflexes and respiration. In both assessments, the differences between the bedside and remote scoring were minuscule.

Full results of the study were published earlier this year in Telemedicine and e-Health journal. In the abstract, Dr. Bart Demaerschalk concludes that “by establishing a telemedicine platform in the ICU, patients with a decreased level of consciousness or those in a coma can be triaged and assigned a care management plan more quickly.” Demaerschalk’s team is now planning to study telehealth’s efficacy in assessing brain death – a diagnosis that must adhere to strict guidelines.

Many patients enter a coma following high-severity traumatic brain injuries (TBIs). According to the Centers for Disease Control and Prevention, the cost of TBIs requiring hospitalization account for about 90% of total TBI medical costs.

“This study suggests yet another way telehealth can enhance patient care,” says Amelia Adcock, MD, a co-author of the study. “There is a shortage of intensive care unit providers and facilities with round-the-clock patient coverage. Telehealth can provide a way to ameliorate this shortage and improve early evaluation of critically ill patients.”

Telehealth Safeguards Newborns

Some precious lives start out in jeopardy, like the 10% of newborns with an Apgar respiration score of one (irregular breathing) or zero (no breathing at all). Most of these babies can be resuscitated easily, even in a small community hospital, but about one case in a thousand requires advanced intervention that only a highly trained neonatologist can provide.

Telehealth is helping deliver that expertise, as documented recently in Mayo Clinic Proceedings. For twenty months, Mayo’s division of neonatal medicine worked with six health systems to provide 84 newborn consultations using telehealth technology.

Dr. Jennifer Fang, a fellow in Mayo’s neonatal program, said, “Following a complicated delivery, a newborn’s outcome is associated with the quality of care provided during the first minutes of life. In Mayo’s telehealth study, the enhanced access to neonatologists – who could guide the local care team through the resuscitation – allowed one-third of the babies to stay with their families in the local hospital.”

Providers at the community hospitals gave the telehealth consultations high scores for clinical teamwork and quality of care. “These results speak to the acceptability and clinical impact of this type of telehealth project in community hospitals,” added Fang.

We’ll never know how many of these small town, one-in-a-thousand babies will grow up to become adults who change our world. But now newborns around the globe – in both rural and underserved urban locations – can get a better start thanks to telehealth. And their parents can breathe a little easier, too.

Want To Cut Your Hospital’s Door-To-Needle Time By 13 Minutes?

There are times when 13 minutes can seem like an eternity, like when you’re sitting through movie previews in a theater. But in the world of stroke treatment, shaving 13 minutes off door-to-needle time is more like a heart-pounding Olympic event where every second matters.

Overlook Medical Center and Atlantic Health System in suburban New Jersey recently published a study in the journal, Stroke, which found that patients evaluated for stroke through the use of telehealth while in the ambulance en route to the hospital could be treated with the brain-saving drug alteplase 13 minutes faster than patients who were not evaluated in transit.

“Each passing minute of lost blood supply translates to more brain damage,” said John J. Halperin, lead study investigator and chair of the neurosciences department at Overlook. “Our observations suggest that in-transit telestroke services may provide a scalable, inexpensive way to expedite stroke treatment.”

In New Jersey, in-transit telestroke evaluations require close coordination between Basic Life Support (BLS) ambulances and Advanced Life Support (ALS) units. In Overlook’s service area, four ALS units were equipped with an InTouch Xpress telehealth device, which could be clamped onto BLS ambulance stretchers, allowing images to be transmitted by 4G wireless during patient transport. The stroke neurologist was able to instantly perform an evaluation in collaboration with the attending paramedics.

13 minutes may not sound like much, unless you ask a professional athlete or a stroke patient. For Great Britain’s Mo Farah, 13 well-planned minutes produced a gold medal in the men’s 5000-meter run in Rio. And 15 of the stroke patients in the Overlook/Atlantic study were also winners. They avoided possible death or disability by getting alteplase treatment 13 minutes faster than usual.

Telehealth Enterprise Evolution

The 10th InTouch Telehealth Innovation Forum was a showcase for many health systems that are moving beyond telestroke to an enterprise vision for virtual health.

That was the primary focus of a presentation by Chad Miller, MD, the system medical chief for neurocritical care at OhioHealth, where the telestroke program was being underutilized. Most incoming calls did not involve tPA decision-making, but were non-stroke neurological problems like seizures and hypertensive emergencies.

Under Dr. Miller’s leadership, OhioHealth restructured the program to become a round-the-clock virtual health network, spanning 12 hospitals and 20 spoke facilities. This gave doctors the ability to do remote workups and assess a wide range of neurological conditions.

In the OhioHealth network, a neurologist can now provide coverage at a hospital 70 miles away, rather than having to drive, losing valuable time. For cases involving carotid revascularization, a patient can be promptly seen by a vascular neurologist both before and after the procedure.

Miller then turned the podium over to Stephen Klasko, MD, President and CEO of Thomas Jefferson University and Jefferson Health. In a high-energy keynote address, Klasko sang the praises of enterprise virtual networks, noting that enterprise-wide virtual rounds and patient self-scheduling are starting to be utilized. His organization is also rolling out an innovative direct-to-employer model that uses telehealth technology to create strong partnerships with Philadelphia area employers.

At the InTouch Telehealth Innovation Forum, speakers from HCA, The Cleveland Clinic, and Mayo Clinic also discussed how their organizations have successfully transitioned from a telestroke-centric perspective to comprehensive virtual care networks.

Telehealth’s future can perhaps best be described in the title of the Mayo Clinic presentation: An Enterprise Connected Care Strategy. Connected care is the key to a better future for healthcare and must be designed by those who are experts in the telehealth space.

Telehealth Enterprise

Telehealth Enterprise

 

Solutions To ED Boarding

Telebehavioral or telemental health care took center stage at the 10th InTouch Telehealth Innovation Forum. Presenters demonstrated how telemental health programs are improving outcomes and lowering costs – from Critical Access Hospitals all the way to the nationwide HCA network.

A recent study by The Commonwealth Fund found that about 80 percent of mental health or psych patients present at EDs and primary care offices, where providers often lack the training to effectively treat them. And a study by the IAHSS Foundation revealed that many Emergency Departments board mental health patients for 24 hours or more. Some rural hospitals have wait times as high as 18 days.

At the InTouch Telehealth Innovation Forum, three providers outlined their solutions to this growing problem:

  • The 25-bed Illini Community Hospital in Illinois showed how telemental health technology is linking its community with a tertiary center 50 miles away – and with mental health practitioners as far away as Kansas City. Illini has already achieved a Press Ganey patient satisfaction score of 99 percent.
  • At the other end of the scale, HCA annually conducts 17,000 telemental health or behavioral care consultations across its vast network. The hospital giant has already dramatically reduced the ED backlogs of mental health patients.
  • The PeaceHealth system in Oregon now provides telemental health care to four hospitals – bringing pediatric services to one facility that had never offered them. PeaceHealth plans to widen its program to provide behavioral telecrisis consultations for two other Oregon hospitals.

Studies show that outcomes improve significantly when a behavioral care patient is seen within four hours. These three programs are providing much-needed guidance to other hospitals that are currently overloaded with mental health ED patients and are looking for both clinical and financial solutions.

TeleBehavioral Session

TeleBehavioral Session

Thumbs-Up for TeleICUs

The American Association of Critical Care Nurses (AACN) is an influential organization with just under half a million members. Its teleICU nursing practice guidelines provide a very thorough blueprint for how health systems can join the ranks of the 45 teleICUs currently connecting more than 200 hospitals.

In the American Journal of Critical Care, the AACN recently published the results of a survey that affirmed the teleICU’s effectiveness to date. Here are some of the highlights from that study:

  • Nearly 80 percent of the nurses who took part in the survey indicated that teleICU systems improve patient care
  • About 75 percent of respondents felt that teleICU technology improves their job performance
  • 63 percent found that the teleICU enables faster work performance
  • 66 percent saw improvement in clinical collaboration
  • Nearly 50 percent of the respondents felt that telehealth allows more time for patient care

Survey respondents felt that telehealth’s three top benefits were the ability to monitor vital signs, provide medical management and improve patient safety.

The study also revealed some obstacles to teleICU adoption, including the lingering belief among some clinicians that telehealth interferes with care. The overall findings were quite positive – and reflect the prevailing views of America’s largest specialty nursing association.

It’s estimated that up to 1,000 nurses work in American teleICUs, and an additional 16,000 nurses interface with them every day. It’s clearly a nursing career path that has just begun to blossom.

TeleICU

TeleICU

Telehealth Lessons from Space

Providing telehealth services to the International Space Station, 250 miles above the earth, circling the globe every 90 minutes, is about as “remote” as it can get –. That’s why the World Health Organization is using the lessons learned from telehealth in space to improve remote care in some of the world’s most underserved areas.

In a recent WHO bulletin, Dr. Alfred Papali concludes that medium-tech works nicely when high-tech isn’t available. The first responder in space is typically a crew member whose training is comparable to that of a paramedic – and there’s no advanced diagnostic equipment on board. Astronauts use a point-of-care ultrasound device to diagnose ailments, then seek the counsel of earth-bound physicians. Data transmission from space, however, isn’t continuous.

Papali notes that those same constraints are common in many impoverished places on earth. The WHO is already using the equivalent of paramedics to provide antiretroviral medications in sub-Saharan Africa. Plus it’s easy to get portable ultrasound devices into remote areas where it’s impossible to lug a CAT scan machine.

NASA has begun to address data transmission lagtime by providing astronauts with “virtual remote guidance” – a fancy name for pre-recorded instructional videos.

The WHO will soon use the same approach in Haiti, where caregivers will receive just-in-time instructions on how to perform endotracheal intubation and other difficult procedures.

Whether in space or Himalayas, some patients don’t have the luxury of getting transported to a fully equipped medical center. It would take 24 hours and millions of dollars to get a sick astronaut back to earth. Likewise, it’s usually impossible to airlift a patient from rural Nepal to a hospital in New Delhi. Providing the best available care on-site – aided by telehealth technology – can still be a lifesaving option.

Telehealth in spcae

Telehealth in space

Five Encouraging Trends

In certain fields, things seem to continuously trend upwards. That’s true with smartphones, where device ownership increased 30% in just the last four years. It’s also true for the Golden State Warriors basketball team, which saw its win totals increase from 51 to 67 to a record-setting 73 over the past three seasons.

We can now add telehealth to that list, where usage has increased by an astonishing 50 percent since 2013. Nearly 15 million people used telehealth services last year.

The ATA recently identified five trends that are creating favorable tailwinds for our industry:

  • More telehealth legislation – To date, 29 states and the District of Columbia have passed laws requiring commercial payers to cover telehealth. Eight more states are considering legislation this year.
  • Employers jump on the bandwagon – Telehealth is rapidly gaining popularity with employers like Nissan and Google that offer onsite health clinics. By 2018, many of these companies will use telehealth.
  • Older adults see the value of telehealth – People approaching Medicare age are quite comfortable with web surfing and smartphone apps. More than half of older adults say that “health information” is one of their primary reasons for digital engagement.
  • App adoption has doubled in the last three years – In 2013, only 16 percent of Americans had a health app on their smartphone. Now that number has doubled to 32 percent.
  • Medicaid is loosening distance requirements – 86 percent of states now cover Medicaid telehealth services statewide rather than imposing distance restrictions.

Many industries are envious of these positive trends. Fax machine manufacturers are no doubt having a lousy year. But things are definitely looking upbeat for the telehealth sector.

Five Telehealth Trends

Five Trends

Embracing The Network

There have been dozens of books published on how to “fix” healthcare, but probably one of the best is “Where Does It Hurt?: An Entrepreneur’s Guide To Fixing Healthcare” by Jonathan Bush (who also happens to be CEO and co-founder of healthcare software giant athenahealth).

In a recent article, Bush proclaimed that the “future of the hospital is the network.” He praised Mt. Sinai Hospital in New York for its marketing campaign headlined “If Our Beds Are Filled, It Means We’ve Failed.” Those ads show that Mt. Sinai is serious about moving away from isolated, intermittent care to continuous, coordinated care – a shift that Bush feels all hospitals should make.

Bush believes that successful hospitals are rapidly moving from the EHR-centric model, to the patient-centric world of cross-continuum connectedness, a/k/a the network. Telehealth is an integral part of that brave new world.

Telehealth is the arterial system that can connect acute care specialists, home health providers, Ambulatory Surgery Centers, imaging centers, and all points between. Bush foresees a day (coming soon) when a patient can get an immunization at a retail clinic, an outpatient surgery at an ASC, and a telehealth consultation at home all in a single week.

That’s the “right care, right time” mantra that has long been the guiding principle of telehealth.

Bush sees a bright future for telehealth because relying on a robust network is the only way to “unbreak” our healthcare system.

 

Telehealth Network

Telehealth Network

 

 

Oasis In The Desert

In a recent MarketWatch report, Phil Miller, from the physician search firm Merritt Hawkins, said that 65 million people in the U.S. live in what’s “essentially a primary care desert.” According to the latest Kaiser Family Foundation research, it’s not just a rural phenomenon. Rhode Island and Connecticut are struggling to find primary care physicians just as much as North Dakota and Nebraska.

 Telehealth technology and osteopathy may soon be providing an oasis in that desert. Telehealth can help improve primary care access in struggling states like Missouri, by leveraging the expertise of first-line physicians in states like Delaware, which are amply supplied. Meanwhile, osteopathic schools are starting to create long-distance alliances to solve the primary care shortage.

The educational requirements for an osteopath are nearly identical to an M.D. program – and more than half of young osteopaths go into primary care. That’s one of the reasons why the New York Institute of Technology recently created an osteopathic medical campus at Arkansas State University in Jonesboro. The first group of 115 students will begin classes this fall.

Innovative programs like these can go a long way toward reducing the projected primary care shortfall. The Association of American Medical Colleges estimates this could be as high as 31,000 physicians by 2025.

Telehealth technology is already helping to improve access to specialty care nationwide, which may encourage more medical students to consider a career in primary care. There’s still significant pressure on medical students to forsake primary care for the higher paying specialties in order to pay back six-figure college loans.

Until there are more incentives to enter primary care (perhaps government funded), telehealth can bring “water to the desert” by connecting patients with physician assistants, nurse practitioners and osteopaths who are ready to help.

 

Telehealth

Oasis in the Desert