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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

 

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

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

The DigiPsych Revolution

The term “telepsychiatry” makes you think of those days when a movie star filming in New York would call a Beverly Hills shrink for a long-distance session.

Today, a land-line telephone is seldom used in remote mental health, so perhaps we should start using the expression “DigiPsychiatric” treatment. That term encompasses not just the traditional provider/patient session, but the enormous amount of data that can be collected (both actively and passively) to aid in diagnoses.

Here are some of the pressing problems that DigiPsych is helping to address:

  • Mental health is the third costliest health condition in America
  • Nearly 60 million Americans have a behavioral health condition, far more than can be treated in conventional brick-and-mortar locations
  • Patients who have a behavioral condition in tandem with a chronic disease cost the U.S. healthcare system 75 percent more than those with physical illnesses alone

There’s a lot of innovative work being done at the crossroads of telehealth and mobile mental health apps. For instance, Centerstone Research in Nashville gave smartphones and the Ginger.io app to patients in a recent pilot. The app was used to gather both active (patient-provided) and passive data gathered on sleep patterns, activity levels and communication trends (e.g., a patient who normally sends 20 texts per day is now sending none). The Centerstone program reduced the participants’ ER days by 23 percent and hospital days by 51 percent.

And we’re just beginning to tap the full potential of wearables like FitBit. In a recent study, a specially designed wearable was able to remotely detect patients’ use of opioids and cocaine in real-time.

In the past, a behavioral care provider had to guess whether a patient was abusing drugs or not sticking to treatment protocol. Now it’s possible to gather meaningful data 24/7 to eliminate the guesswork and greatly improve the quality of care. The DigiPsych revolution has just begun.

TeleBehavioral Session

TeleBehavioral Session

“Discharge” Is An Illusion

Health systems and regulatory agencies compile mountains of hospital discharge data – and too often they consider a discharge to be a one-and-done event worthy of a marching band. But some health systems have realized that many patients are never fully discharged. They often move quickly – and invisibly – between inpatient, outpatient and post-acute settings.

Telehealth technology is proving to be a game-changer in this new world where hospital discharge is just a recovery phase, not a grand finale.

According to Modern Healthcare, the Hospital for Special Surgery in New York has developed a telehealth app that allows the staff to easily monitor patients after discharge. For example, clinicians can see how well patients are walking – and that visual confirmation is much more effective than a phone-based check-in.

Telehealth is also the ideal technology for connecting the dots. There are a lot of simple reasons why many patients boomerang back into acute care: not having a primary care physician, not sticking to a medication regimen, etc. A 30-year-old might be able to get away with that, but for seniors it can be a one-way ticket to readmission.

Telehealth technology ensures that physicians, case managers. pharmacists and patients are on the same page (or home page as the case may be).

For a patient recuperating from a stroke, pneumonia or heart attack, discharge isn’t a red-letter day like a college graduation. In the days and weeks following discharge, the care team has to share information every bit as effectively as a coaching staff in the Super Bowl. Every coach wears a headset – and every care coordination team should be using telehealth.

 

Hospital Discharge

Hospital Discharge

 

 

New Mission For CMIOs

The Advisory Board recently released a report on the changing roles and responsibilities of Chief Medical Information Officers – and it predicted that these folks will play a vital role in the rollout and maturation of telehealth systems.

For the past five years, CMIOs have primarily dealt with the herculean task of implementing and fine-tuning EHRs. As more organizations enter Meaningful Use Stage 3, CMIOs can now turn their attention to things like telehealth, population health management and analytics (all of which are intertwined).

The report concludes that CMIOs are ideal candidates for overseeing the design and implementation of innovative projects like telehealth networks. Most CMIOs are seasoned practitioners, not computer nerds. They have the clinical, operational and strategic experience to ensure that telehealth systems will be easy for physicians to use – and will complement what’s being done in population health management and predictive analytics.

In the Advisory Board study, none of the CMIOs interviewed were computer scientists – and almost all of them had backgrounds in physician leadership. They shared a passion for process design and improvement, which means that we’ll see steady yet significant enhancements in the telehealth networks they oversee.

There are three things that every organization should do to help their CMIOs succeed:

  • Offload some of their current EHR work (especially optimization) to other members of their team so they have more time to focus on telehealth.
  • Send them to clinical informatics conferences – Most CMIOs are self-taught and relish opportunities for ongoing education.
  • Give them a greater voice in strategic planning for telehealth, population health management and predictive analytics.

Fortunately, tomorrow’s telehealth networks will be shaped in large part by CMIOs who have years of clinical and operational experience, not by techies who don’t understand that world.

CMIO Telehealth

CMIO Telehealth

Mixed Signals In Texas

The Texas Two-Step is a popular dance, but when it comes to telehealth, Texans are taking one step forward, one step back.

Let’s start with the backward step: last month the Texas Medical Board voted to ban doctors from doing even the basics (making routine diagnoses, prescribing medications) for patients they’ve never physically seen before.

The ruling marked the end of a long battle between the state board and Teladoc, which is based in Dallas but does nationwide teleconsults for routine things like sore throats, flu, etc. The board was acting on behalf of the many Texas physicians who feel that telehealth “takes work away” from them.

But a recent study by the Rand Corporation refutes that argument. Their researchers found that Teladoc availability in California had actually struck a chord with many people who don’t like going to brick-and-mortar physician offices. In fact, 20 percent of those who used Teladoc in California hadn’t physically visited a doctor in the previous year.

Now for the step forward: the Texas business community was highly critical of the board’s decision on telehealth. In their view, the convenience of telehealth increases the likelihood that people will seek treatment faster, which reduces lost work time and increases business productivity.

While the Texas board voted to go back to business-as-usual, the Texas House of Representatives moved forward on three new telehealth bills aimed at improving care for children covered by Medicaid. The bills are sponsored by legislators who normally wouldn’t agree on anything: two liberal Democrats and two conservative Republicans (including a former neurosurgeon).

Is the Texas Medical Board’s decision an attempt to protect doctors’ financial interests while posing as a high-minded effort to prevent “second class” care via telehealth? Legislators on both sides of the aisle are taking matters into their own hands. The bottom line is that Texans of all ages deserve to enjoy the many benefits of telehealth – especially the children.

Texas and telehealth

Telehealth

 

 

Retooling Primary Care

For decades, the entry point in healthcare was the primary care physician’s office. That’s changing rapidly as retailers like Walgreens and Walmart ramp up their efforts. The first wave of retail medicine has been described as a “nurse practitioner in a closet.” But in 2015, we’ll be seeing many retail locations that offer everything a traditional PCP does…and often a whole lot more.

This trend is great news for telehealth providers. Most retail medicine operations are just barely beginning to make a profit. They can become more successful by partnering with telehealth companies that don’t have a comparable investment in brick-and-mortar offices and can leverage scalable, cloud-based technologies.

For example, if nurse practitioners at a retail site wants a quick second opinion, they can get one via telehealth without having to send the patient to a nearby primary care doctor. That keeps more money in the system, both for the retail provider and the telehealth partner.

The rapid growth in both retail medicine and telemedicine is fueled by patients’ desire for greater convenience and faster access to care. A recent Advisory Board story highlighted some of the reasons why Americans have so quickly warmed to retail medicine:

Easy online scheduling – The appointment portals at places like CVS and Walgreens are simple to use – and provide far greater convenience than what most urgent care clinics and EDs currently offer.

Extended hours – Unlike most PCPs, the caregivers at retail clinics work evenings and weekends.

Monitoring chronic conditions – Retail clinics are already adept at helping patients manage and monitor ongoing health problems like diabetes and hypertension.

Deep pockets for clinic upgrades – Retail giants have far more cash than your local PCP for things like the newest medical devices and EMR enhancements.

This will be the year when the synergy between retail medicine and telehealth becomes mutually profitable. The public has made it very clear: give us greater access and more convenience beyond the 9-to-5 limitations of traditional medicine.

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An eBola Solution

In sci-fi movies, people infected with intergalactic viruses are usually treated by contagion-free robots. In similar fashion, technology is playing a role in the battle to prevent the spread of Ebola…but it needs to be deployed in a more robust way.

Currently, some of the CDC’s special biocontainment units across the country are using technology to connect Ebola patients and caregivers inside with consulting physicians and family members at remote locations. The most recent example is that of Dr. Richard Sacra, a U.S. doctor who contracted Ebola in Liberia and was taken to a biocontainment unit in Nebraska.

That’s a smart – but fairly limited – use of technology. Telemedicine would be immensely more effective if used in the danger zone. Imagine, if you will, that the government of Liberia has just built a special Ebola clinic equipped with telemedicine robots and supporting technologies. The robots could allow a remote clinician to watch the attending physician put on and take off protective apparel, reducing the risk of accidental exposure.

Robots can glide right into harm’s way, and obviously don’t require any of the fancy air filtration and ultraviolet light environments that are standard in U.S. biocontainment units.

Using robotic helpers would be an incredible “force multiplier” for the courageous doctors and nurses helping to contain the outbreak. It’s likely that fewer of them would be needed on the front lines, which would mean fewer quarantines for returning caregivers.

The prefix “e” (for electronic) is used everywhere these days: e-commerce, eBay, and so on. Maybe it’s time to thwart a deadly disease with an eBola strategy using telemedicine.

 

 

New Apps for House Calls

You could call it a “tipping point.” A recent study by the Affiliated Workers Association found that more than 36 million Americans have already used telemedicine in some fashion. And now a tech entrepreneur is helping to make telemedicine downright trendy.

Oscar Salazar, a former engineer at on-demand car service Uber, has introduced a new iPhone app called Pager that’s available now in New York City and soon in Boston. The app lets users search for the nearest available doctor, just like Uber looks for cars. The screen display shows the doctors’ photos and specialties. Phone consultations cost $50 and house calls are $300 (which is only slightly higher than the cost of an urgent care clinic visit). And best of all, these on-call docs are available from 8 a.m. to 10 p.m. every day of the week.

The Pager app isn’t meant to put hospital EDs out of business. It’s primarily designed to relieve wait times at walk-in clinics (which can be quite lengthy in Manhattan).

Pager is already getting some serious competition. The Medicast app does pretty much the same thing for people in South Florida, Los Angeles and San Diego. Then there’s the new Virtual Visits platform from Verizon, which is selling the technology to providers and employers who then offer the apps to their patients and employees. This allows any smartphone user (not just Verizon customers) to conveniently consult with doctors and get prescriptions and referrals.

A century ago, roughly half of all doctor visits were house calls. But by the advent of Medicare, the house call had all but vanished (just like pay phones have disappeared in U.S. cities). But Pager reminds us that it’s refreshing to interact with a physician in a non-clinical setting. It’s a whole lot better than reading magazines in a cramped waiting room.