Does Technology Keep Patients
Out of Hospitals?
Lee H. Schwamm, MD
Executive Vice Chairman, Department of Neurology, Director of Stroke Services & Mass General TeleHealth
Massachusetts General Hospital
Professor of Neurology, Harvard Medical School, Co-Director, Institute for Heart, Vascular and Stroke Care
The New ‘Complex’ Patient:
Disclosures
• PI of NIH/Gnenetech funded MR WITNESS trial of
extended window thrombolysis in wake-up strokes
• Int’l Steering Committee, DIAS4 trial of IV desmoteplase
3-9 hr after stroke onset
• DSMB, Penumbra 3D trial
• Stroke System consultant to the MA DPH/CDC
• Chair, AHA Get with the Guidelines Stroke CWG
Overview
• To control costs we will need to focus on value
• Avoid costly hospitalizations or prolonged dependency
• Pool risk across the continuum, so that we remove
perverse incentives that prevent increased upfront investment to reduce long-term costs
• Increase access to care and encourage use of low cost
preemptive interventions through remote monitoring,
telehealth visits and adherence to recommended therapy
• Provide access-on-demand for physician-to-specialist
consultation in urgent situations to promote golden hour treatments that are effective
Stroke is a High Incidence, High Cost Condition
• ~800,000 new strokes each year in the US
• The direct cost of stroke in 2010 was $20.6B, with total
costs of $36.5B, with a mean lifetime cost of ischemic stroke in the US estimated at $140,048
• Between 2012 and 2030, total direct medical stroke
related costs are projected to triple, from $71.6 B to $184.1 B, with the majority among 65 to 79 yr-olds
• Severe strokes (NIHSS>20) cost 2x mild strokes
• Data from Sweden show that healthcare costs associated
with stroke survivors with spasticity are 4-fold higher than for stroke survivors without spasticity
Why Act Now?
• Stroke is a common and expensive disease, with both
early mortality as well as lifelong costly disability
• Avoiding disability can reduce long term costs and societal
burden due to stroke
• Risk of stroke doubles every decade after 45, with an
impending avalanche of stroke and dementia, because up to 50% of dementia is caused by cerebrovascular disease
• Proactive discussions about care after an unexpected
catastrophic event (e.g., stroke) must occur during routine primary care and become more publicly accepted
Cycle of Stroke Care: Where are the costs?
Home ED- based
Patient history, vitals, CT scan Triage decision: ED physician/ neurologist EMS transfer Self-present Stroke center Hospital Inpatient Rehab Facility Skilled Nursing Facility Transitional Residential Living PCP followup
Cycle of Stroke Care: Where are the opportunities?
Home EMS transfer Self-present Stroke center Hospital Inpatient Rehab Facility Skilled Nursing Facility Transitional Residential Living PCP followup 2. Cost-effective early Rx: IV tPA and Stroke Units3. Early supported DC to Home
4. Flexible post-acute levels of care 5. Medical Home 6. Remote monitoring Comprehensive or high volume Stroke centers 1. Smarter triage
EMS, Emergency Medical Services; HS, hemorrhagic stroke, IS, ischemic stroke; tPA, tissue plasminogen activator
Acute Stroke Triage: Hospital Setting
Site of
stroke Patient history, vitals, CT scan
Triage decision: ED physician/
neurologist
Negative CT Positive CT ICH
EMS transfer Prehospital triage Self-present Stroke center Hospital
Can Technology Help Solve the Problem?
• Technology can bridge the gaps in time and distance that
separate patients and providers
• Technology can transform data into information and
support more effective decision making
• Technology can offer lower-cost alternatives to in-person
visits
• Technology can’t magically reallocate healthcare providers
from one discipline to another, or one activity to another, so thoughtful planning will be required to realign resources and compensation to demand as trends shift over time
What is Disruptive Innovation?
How Does TeleHealth Change Care?
Achieving Telehealth’s full potential
•
Telehealth is a disruptive technology
•
Telehealth must be integrated into traditional
ambulatory and hospital-based practice
•
Telehealth should address the IOM domains of
quality and therefore be safe, effective,
patient-centered, timely, efficient, and
equitable
Seven Critical Strategies
•
Understanding patients’ and providers’ expectations
•
Untethering telehealth from traditional revenue
expectations
•
Deconstructing the traditional health care encounter
•
Being open to discovery
•
Being mindful of the importance of space
•
Redesigning care to improve value in healthcare
•
Being bold and visionary
Systems of Care (A,B) vs. Alternative Models (C,D)
Active European and US TeleStroke Sites
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Müller-Barna P, Schwamm LH, Haberl RL. Telestroke increases use of acute stroke therapy. Curr Opin Neurol. 2012 Feb;25(1):5-10. Silva GS, Farrell S, Shandra E, Viswanathan A, Schwamm LH. The status of telestroke in the United States: a survey of currently active stroke telemedicine programs. Stroke. 2012 Aug;43(8):2078-85
Telestroke stakeholder representatives at hub and spoke hospitals
…cost-effectiveness
R.E. Nelson, et al. Neurology, 2011
…high NIHSS inter-rater reliability to bedside, on-site evaluation
S. Shafqat, et al. Stroke, 1999
…greater accuracy than telephone
consultation alone in determining rt-PA eligibility
B.C. Meyer, et al. Lancet Neurol, 2008
…higher rates of rt-PA use,
equivalent patient outcomes, and low intracranial hemorrhage rates
P. Müller-Barna, et al, Curr Opin Neurol, 2012
L.H. Schwamm, R.G. Holloway, P. Amarenco et al. A review of the evidence for the use of telemedicine within stroke systems of care: A scientific statement from the American Heart Association/American Stroke Association, Stroke, 40 (2009), pp. 2616–2634
TeleStroke is Cost Effective
•
Payer
– Short term increase in
costs w/ break even at 90 days
•
Healthcare System
– Greater value per
Healthcare $ spent
1 Neurology. 2011 Oct 25;77(17):1590-8. Epub 2011 Sep 14. The cost-
effectiveness of telestroke in the treatment of acute ischemic stroke. Nelson RE, et al.
Cost, Savings and CBO Scoring
• 66% of the 795,000 new strokes per year are in Medicare
beneficiaries. 94% of them live in non-coverage areas. 87% of strokes are ischemic. Therefore
795,000 x 0.66% x 0.94% = 493,218
493,218 x 0.87% = 429,100
• Alternatively, the rate of ischemic stroke hospitalizations
among the 40M beneficiaries was 1134/100,000 for age 65+
40,000,000/100,000 x 1134 = 453,600
Estimating Savings from TeleStroke
• TBD
It’s not about the technology,
it’s about trust
Rethinking Stroke Prevention and Wellness:
Cost-Effective and Safe
Technology MGH Pilots
Email Primary Care Provider reviews patient’s pre-visit
questionnaire to determine treatment options and assess the need for visit or phone appointment.
Videoconferencing Psychiatrist conducts a follow-up Virtual Visit with an
adolescent patient with autism for medication management.
Telephone Psychiatrist provides consults to oncologists regarding
the management of psychiatric conditions for cancer patients.
Text Messaging
Electronic Curbside
Primary Care physician is alerted of ‘alarm symptom’ in a patient who is completing an asynchronous eVisit via web portal.
Specialist reviews referral requests and triages to curbside consult – answers PCP questions by email.
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When was the last time you saw a teller?
Its not just kids Skyping these days…
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Foster Communication • Build Relationships • Improve Access
and Convenience • Enhance Patient Care • Improve Healthcare Value
Mass General TeleHealth Goals
Value = Quality Cost
Expanding from TeleStroke
(hospital-to-hospital) to TeleNeurology (office-to-home)
To Infinity…and Beyond
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Cardiology Cardiology Patient
At Home
Partnerships
Remote
Monitoring,
mHealth
Apps
Clinical
Care
Education
Medical
Simulation
MGH TeleHealth
MGH Learning
Laboratory
MGH Academy
MGH TeleHealth Focus Areas
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•30
Provide specialty consultation to community hospitals, providers, and patients
• Second opinions to providers and patients
• Virtual Staffing for Community Hospitals
• Specialty Consultation to Community Hospitals
Episodic Care Management
Improve quality and decrease expense trend for our “risk” population
• Synchronous Specialist Virtual Visits
• Synchronous Patient Virtual Visits
Population Health Management
Foster collaborative communication and improve quality of care for patients
• Virtual alternatives to in-person attending staffing
The Telehealth Adoption Curve
Is Anticipated Loss of Comfort and Productivity a
Major Barrier to TeleHealth Adoption?
Teleneurology applications: Report of the
Telemedicine Work Group of the AAN
OBJECTIVE:
To review current literature on neurology telemedicine and to discuss its application to patient care, neurology practice, military medicine, and current federal policy.
METHODS:
Review of practice models and published literature on primary studies of the efficacy of neurology telemedicine.
RESULTS:
Teleneurology is of greatest benefit to populations with restricted access to general and subspecialty neurologic care in rural areas, those with limited mobility, and those deployed by the military. Through the use of real-time audio-visual interaction, imaging, and store-and-forward systems, a greater proportion of neurologists are able to meet the demand for specialty care in underserved communities, decrease the response time for acute stroke assessment, and expand the collaboration between primary care physicians, neurologists, and other disciplines. The American Stroke Association has developed a defined policy on teleneurology, and the American Academy of Neurology and federal health care policy are beginning to follow suit.
CONCLUSIONS:
Teleneurology is an effective tool for the rapid evaluation of patients in remote locations requiring neurologic care. These underserved locations include geographically isolated rural areas as well as urban cores with insufficient available
neurology specialists. With this technology, neurologists will be better able to meet the burgeoning demand for access to neurologic care in an era of declining availability. An increase in physician awareness and support at the federal and state level is necessary to facilitate expansion of telemedicine into further areas of neurology.
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Benefits of and Barriers to Telemedicine
Implementation for Neurologic Disease
TeleHealth Challenges
• Reimbursement
• Licensure and Malpractice
• Patient and Provider Adoption
• Technology Platform and Workflow Standardization
• Impact of EPIC on workflow design
• Internal competition from traditional face-to-face
• Finding the clinical balance between traditional vs. virtual
visit balance driven by patient need and medical appropriateness
• Perceived competition from community hospital partners
Summary
• To improve value and manage populations, traditional
healthcare delivery models need to be disrupted
• TeleHealth remains a tremendous opportunity for
improving neurological care when patients are
geographically dispersed, underserved, often of limited mobility and in dire need of treatment
• Aggregating patients in novel ways will increase the
efficiency of the clinical research enterprise and lead to new treatments faster
• We need to train our residents and faculty in the practice
of the future, not of the past
