Kathy J. Chorba, Director, Specialty Care Safety Net Initiative
Center for Connected Health Policy
Ellen Rothman, MD, Chief Medical Officer
St. John’s Well Child and Family Center
Frank Anderson, RN, BSN, Director of Telehealth Development
Open Door Community Health Centers
Lessons Learned from Designing, Implementing
and Supporting Multi-Site Telemedicine Programs
Overview
Operational lessons learned and tips on how to implement and coordinate a
statewide specialty care network of 44 clinics and five university-based specialty sites
The value of telehealth to an urban, multi-site clinic organization, as well as lessons learned while implementing a telemedicine program in the midst of EHR
implementation.
The value of telehealth and creative visioning from a rural/frontier multi-site clinic organization.
What is Telehealth?
Telehealth is the use of telecommunications, health
information, and videoconferencing technologies to
deliver medical care, health education and public
health services.
Telehealth Technologies
y Live video is used for real-time patient-provider consultations,
provider-to-provider discussions, and language translation services.
y Store & Forward technologies electronically transmit patient information
between primary care providers and medical specialists. Information could include digital images, X-rays, video clips and photos.
y Remote patient monitoring uses telehealth technologies to collect
medical data from patients in one location and electronically transmit that
information to health care providers in a different location, either real-time or store and forward.
Examples of Telehealth Technologies:
Live Video Teleconsultation
Variety of high-speed digital telecom
Outpatient or Inpatient specialty consultation
Live Video is used for real-time patient-provider consultations, provider-to-provider discussions, and language translation services.
Telehealth Technologies: Store & Forward
y Often low bandwidth, still
images, can store video clips
y Best used in Dermatology,
Ophthalmology, Pathology, Radiology
y Exploring new avenues in
Psychiatry, Endocrinology, Hepatology, Orthopedics …
Store & Forward technologies electronically transmit patient information between primary care providers and medical specialists. Information could include digital images, X-rays, video clips and photos.
Center for Connected Health Policy
Strategy and planning body to promote integration of telehealth
within California’s health care system
y Promote a shared vision for telehealth adoption and integration in
the health care delivery system
y Work to assure that California is a national model of telehealth
integration
y Identify and promote practice pattern, policy, regulatory, and
statutory change that will maximize the ability of telehealth to improve health outcomes and care delivery
y Use demonstration projects as a “laboratory” for analyzing needed
system changes
y Manage a specialty care initiative in partnership with UC campuses and
community health centers to develop a sustainable model for telehealth services
What is
the Specialty Care Safety Net Initiative?
Collaborative effort to determine the policy, statutory, and practice pattern barriers that may prevent the UC Schools of Medicine from providing specialty care consults to safety net patients.y Key Partners
y University of California Medical School Specialty Departments y 44 Safety Net Clinics in California
y Endorsed and Programmatically Sponsored by
y University of California Office of the President
y Funded by
y California HealthCare Foundation
y Administered by
SCSNI =“Laboratory Environment” established
to look for policy and practice pattern barriers
y
Provide
access to UC specialty services
for safety net
patients via telemedicine and telehealth technologies
y
Provide
telemedicine equipment and software
necessary to bring each clinic up to the same level for full
participation
y
Provide
user training and technical support
throughout the duration of the project, via
Telemedicine.com
Dermatology Endocrinology Hepatology
SCSNI Timeline
Feb 2010 Clinical Services began with 12 telehealth clinic sites and4 UCs
Clinics had existing equipment, experienced telehealth staffing and referral relationships May-Sept 2010
The 5th UC, and
26 clinics with no telehealth experience were
added
Equipment & training provided by SCSNI &
Telemedicine.com Sept 2010 -Dec 2011 Accepted 6 SCSNI clinic affiliate sites into program 49 clinic and UC partner sites Feb 29, 2012 SCSNI -sponsored clinical services end Clinics seeking partners to continue telehealth services
Program Design
Minimize, Standardize, Consolidate
y
Request for Consult
y Patient Consent y Referral Guidelines y Format y Requirements y Technology y Video units
y Store and forward software y Minimum bandwidth
requirement
y Training
Program Design
Minimize, Standardize, Consolidate
y Request for Consult
y
Patient Consent
y Referral Guidelines y Format y Requirements y Technology y Video unitsy Store and forward software y Minimum bandwidth
requirement
y Training
Program Design
Minimize, Standardize, Consolidate
y Request for Consult y Patient Consent y
Referral Guidelines
y Format y Requirements y Technology y Video unitsy Store and forward software y Minimum bandwidth
requirement
y Training
Program Design
Minimize, Standardize, Consolidate
y Request for Consult y Patient Consent y Referral Guidelines y Format y Requirements y
Technology
y Video unitsy Store and forward software y Minimum bandwidth
requirement
y Training
y Technical Support
Tandberg Edge 95 Tandberg video camera Sony Bravia monitor IV pole Cart
UPS battery backup
Computer &
monitor, Cannon S90 digital camera,
Logitech web camera
Bandwidth Requirement
Dedicated, secure 384 kbps or better
provided by the CTN or via dedicated ISDN
Program Design
Minimize, Standardize, Consolidate
y Request for Consult y Patient Consent y Referral Guidelines y Format y Requirements y Technology y Video units
y Store & forward software y Minimum bandwidth
requirement
y
Training
Program Design
Minimize, Standardize, Consolidate
Technical systems and user support provided throughout
the duration of the project New user, refresher and follow-up training provided
on-demand via: telephone
email webinar
video
y Request for Consult y Patient Consent y Referral Guidelines y Format y Requirements y Technology y Video units
y Store & forward software y Minimum bandwidth
requirement
y Training
Program Implementation and
Ongoing Support
Program Implementation and Support
SCSNI Program Oversight Operations Support Telemedicine.com Equipment Installation Technical Support Site Assessment Installation and TrainingContinuity of Care
Program Support: Evaluate and Revise
y
How are we doing? What’s working and what needs to change?
y
Monthly telemedicine coordinator conference calls and
webinars
y
Quarterly clinician champion conference calls and webinars
yTelemedicine coordinator workshop
Program Support: Evaluate and Revise
Evaluate
: Clinician Champion Feedback:Specialty requirements
for physician
participation results in
a lack of productivity
for the PCP, which in
turn creates a
financial burden for
the clinic.
“It’s not as easy as we thought –
we need coordinator staffing support!
”
y Coordination – who plays the role of “Coordinator”?
y Level of employee? MA, RN, MD y % FTE
y
Job duties = promote, coordinate, follow through
y Follow up expectations and culture change
y Convincing the coordinators to demand customer service
y
Forms, processes, software and order of business
y What? When? How? Huh?
Equipment
Training, technical &
operational support
Specialty Availability Streamlined patient
presentation requirements
Extranet for process flow What else?
Process and culture changes are needed to take your
telehealth program from quagmire to mainstream
Accomplishments
y Needs assessment y Buy-in from the top y Staffing in place
y Systems and processes
are in place
y Equipment and
telecommunications infrastructure in place
y Working relationship with
consultants
Everything is in place, why aren’t we gaining traction?
Culture & Process
Barriers to Integration
y Lack of PCP buy-in y Lack of patient buy-in y Difficulty coordinating
appointments
y Excessive wait time
for appointments
y Managing and
preventing no-shows
y Multiple demands on
Proven Strategies for Overcoming Barriers
y Telehealth implementation requires a commitment to systems
change
y Telehealth integration requires a commitment to education,
It takes 6 months to implement a program….
And Finally,
Never Judge a Book by It’s Cover!
St. John’s Well Child and Family Center,
Compton Clinic
Site Visit Revealed:
y Busy clinic
y No designated place for equipment placement or storage y Total medical director interaction time - 5 minutes
Judgment:
y If any clinic needed telehealth, this one surely did
y But, their ability to designate time and staffing toward telehealth was
questionable at best
Reality:
y After a rocky start, the clinic ended up being one of SCSNI’s most
The St. John’s Well Child and Family Center
Experience
The value of telehealth to an urban, multi-site clinic
organization.
Lessons learned while implementing a telemedicine
program in the midst of EHR implementation.
Ellen Rothman MD, Chief Medical Officer
S T . J O H N ’ S W E L L C H I L D A N D F A M I L Y C E N T E R
E L L E N R O T H M A N , M D
Telemedicine in an Urban
Setting
Flexibility of Telemedicine
y Primary care provider participates in one-on-one
encounters and gains valuable teaching and insight
y Specialist can weigh in before the consult and
provide advice and feedback; sometimes the face-to-face visit is not necessary
Advantages of Telemedicine
• Close proximity to the hospital doesn’t necessarily make it easier to walk through the doors
• Barriers caused by lack of
transportation and poor public transport infrastructure in
Los Angeles
Specialties Available
• Live Consult
– Neurology, adult and pediatric – Psychiatry
– Endocrinology – Orthopedics
• Store and Forward – Hepatology
– Psychiatry – dermatology
Specialties we wish we had…
y Rheumatology y Nephrology
y We were skeptical of how helpful
orthopedics would be, but it turned out to be quite valuable
Framing the Clinical Question
• It’s important to recognize the strengths and limitations of Telemedicine
• This is not ongoing continuity specialty care where the specialist takes primary ownership of the
problem
• This is shared management where the specialist can provide intermittent advice on management and
evaluation
• This elevates the role of the primary care provider in ongoing specialty care health concerns
Clinical Questions Best Addressed
• Medication that is not having desired effect • Input when the diagnosis is uncertain
• Advice on how to best organize a diagnostic evaluation
• Interpretation of test / biopsy / imaging results
• Management of medications, like psychotropics, that might be out of the clinician’s experience range
Dermatology, Store and Forward
y For store and forward, in particular, the specialist
sees the rash at its peak, rather than a few weeks later when it has already improved or resolved
y Challenges: If I don’t recognize the rash at a glance,
the dermatologist likely doesn’t either
y Biopsies can be a challenge to pull together in the
Challenges
y The challenges of getting two clinicians, a patient,
and technology all in the agreed upon place all at the same time cannot be minimized!
y Language barriers
y Multicultural gaps need to be bridged and can be
more challenging in the less personal environment of a telemedicine visit
Challenges
• Nature: High winds in San Diego knocked out the lines
• Technology: Phone lines in South LA have
intermittent gaps in service, and when there is not enough bandwidth, pixelation occurs
• Patients: We struggle with high no-show rates, and despite education and repeated calls, patients don’t always realize that this is a premium opportunity
Challenges
• Time: The visit can take up to 1 hour, and the room must be available on time, which often takes it out of circulation 15-20 minutes before
• Providers: They don’t like to take time out of their day to speak with a specialist
• Clinic Operations: A busy community clinic with high volumes, 30% no-show rates, and substantial walk-in business has a hard time keeping to a
punctual schedule
• Staff Turn-Over: building a consistent team is critical!
The Rewards
y Clinician learning
{ This proved to be the strongest positive reinforcement and
ultimately propelled effective implementation
{ Even when I referred a simple headache that I would have
ordinarily handled alone, I learned some management
Patient Satisfaction
y Patients were uniformly willing to participate
y They were spontaneously quite positive about their
experiences
y We had no complaints
y The consent process was a bit laborious, so we were
pleased to see Assembly Bill 415 pass that relieved
Transition to Electronic Records
• We implemented GE Centricity
electronic health record in July 2011
• We refined the referral process
significantly
• We used the system to guide
providers to preferentially refer to telemedicine
• We now added a computer to the
room in addition to the telemedicine equipment
• It’s all ok–we have figured out how
to accommodate that much technology in one exam room
Financial Sustainability
y Billing continues to be an issue – LA County
programs do not recognize teleconference appointments
y Need to bill for the time on two ends – the specialist
and the primary care
y Continue to struggle to piece together services for the
Direction for the Future
y Telemedicine is a powerful tool y Now there is momentum to
develop E-consult process in Los Angeles
y Marriage of E-Consult and an
active Telemedicine program would be awesome
The Open Door Community Health Center
Experience
The value of telehealth and creative visioning from the
perspective of a rural/frontier multi-site clinic
organization.
Frank Anderson, RN, BSN, Director of Telehealth Development
CPCA 2012
Telehealth and Specialty Care
Frank Anderson, RN,BSN
Why telemedicine helps
• Access to specialist care and specialist
willingness is limited by reimbursement
cuts / high no show rates.
• Remote locations are further hampered by
distance / travel time and gas expense
Why create a specialty center?
Retaining Local Resources
Millions of Healthcare Dollars
Healthcare dollars being exportedSmall retention of healthcare dollars big economic consequences
Retention of local dollars rather than attracting new dollars
HEALTH CARE REFORM
• MAY STIMULATE…OR
SUPPRESS THE NEED
FOR FQHC SPECIALTY
CENTERS
Recruiting specialists
Market analysis of greatest need
Local capacity is a factor
Live Video Telehealth
• Medical consultations.
• Continuing education and
training.
Beyond Specialty Care
• Using videoconference
technology to unify,
standardize, and improve care
in a multi-site health care
Traditional“Store and Forward”
Uses
• Retinal screening-population
management.
• Dermatology- least expensive
startup (digital camera)
.
Future of Store and Forward
• Psychiatry or other “cognitive based”
consults..
• Eminently convenient
• Could have many applications within a
FQHC network or with contracted
Store and Forward Psychiatry
ODCHC-UC Davis program thru SCSNI
Grant supported the specialist time until end
of February 2012.
Started late in 2011.. small case sample size
so far (approx 20 referrals to date)
S & F Psych (cont.)
• Mental health assessment interview done
on video by Psych RN or other provider.
For 20-30 minutes.(can be billed as a visit)
• Video and paper assessment sent to
specialist via encrypted e-mail
Consult notes made available for entry into
Pt’s EMR (options here)
• 1) Raw video(multiple gigabytes)
• 2) saved to software (Second Opinion
V8.0)
• 3) Compressed to approx. 300 Megabytes
•
and sent to specialist
Specialties Available at TVSC /
Telehealth usage
• Allergy and Immunology *
• Behavioral Health / Counseling (LCSW or Psych.D.******
provider)
• Cardiology**
• Dermatology ***
• Diabetes Education/Management***
• Gynecology
• HIV / Hep C Treatment*
• Ophthalmology (Retinal Scan reading)***
• Orthopedics (non acute conditions)*
• Pediatrics(Behavioral Mgmt.)****
• Psychiatry****
Future Just Around The Corner
Technology in every office
The virtual home visit
Constant on line monitoring
Migration into our homes
Virtual home health
Internet support groups
Why not
LEAD
rather than follow
Why not
NOW
rather than later
Progress
Kathy J. Chorba, Director, Specialty Care Safety Net Initiative
Center for Connected Health Policy
Ellen Rothman, MD, Chief Medical Officer
St. John’s Well Child and Family Center
Frank Anderson, RN, BSN, Director of Telehealth Development
Open Door Community Health Centers
