Telemedicine Evolution:

Transcription

1 Telemedicine Evolution: Expansion and Quality Improvement Lemuel Shattuck Hospital / UMass Correctional Health Ken Freedman, MD, MS, MBA, CMO, LSH Pat Herald, RN, BSN, CNN, LSH Paul Romary, CEO, LSH Tom Groblewski, DO, SWMD, UMCH Helene Murphy, MEd, LSW, UMCH

2 Learning Objectives A well-designed telemedicine program offers many advantages such as reduced security risks, timely care, lower operating costs and enhanced continuity of care. Elements of a comprehensive program include necessary equipment and connectivity, consensus criteria for appropriate encounters, credentialing solutions, staff training and scheduling, and timely access to and entry of clinical documentation. Managers, clinicians and correctional staff must pro-actively engage in their roles and commit to continuous quality assurance and quality improvement efforts. March 23, 2012 Correctional Health Care Conference 2

3 Telehealth Options Different modalities are available for the real time exchange of health information and direct care Telemedicine, teleconferencing, and telemonitoring (telemetry) Telehealth options overcome impediments such as: Time, geography, staffing levels, transportation, mobility, finances and safety March 23, 2012 Correctional Health Care Conference 3

4 Rationale For Telemedicine Decrease costs, improve efficiency and increase access Improve timeliness & continuity of care by coordinating the logistics of clinical & correctional staff scheduling and inmate availability Narrows the gap between PCP Patient Specialist Facilitate inmate access to care that reduces appointment wait times, the potential for grievances and inmate discomfort levels Diminish the chance of prison-based health emergencies Reduce ED visits and hospitalizations Reduce correctional system transport costs and community safety risks March 23, 2012 Correctional Health Care Conference 4

5 Background: Trilateral Relationship DOC-UMCH-LSH relationship overview Contractual obligations among three state agencies Specialty clinics compatible with telemedicine encounters: Dermatology, Gastroenterology, Orthopedics, Co-infection (HCV/HIV), Rheumatology, and Urology. Coming soon: Nephrology, Endocrinology, Hematology/Oncology Demand for health services that sustain symbiotic interagency relationships March 23, 2012 Correctional Health Care Conference 5

6 Number of Encounters Telemedicine Growth Chart Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 March 23, 2012 Correctional Health Care Conference 6

7 Milestone #1: IT Standardization / Connectivity / Equipment Lessons learned: Standardize IT equipment Acquire the latest proven technology Assure training and technical support is available Determine ideal setup at remote and HUB locations Know your bandwidth capabilities How did we apply the lessons: Technical / training service contract / support Dedicated telemedicine suites ISDN lines Dedicated DOC & LSH IT staff March 23, 2012 Correctional Health Care Conference 7

8 Milestone #2: Medical Standardization Lessons learned: Provider support critical to sustaining and growing the program Positive clinical outcomes are essential to reinforcing telemedicine s promise Clinician authority is key to defining appropriate telemedicine versus face-to-face encounters Pre-encounter planning and post-encounter follow-up Multi-site commitment to best practices CMS telemedicine credentialing standards March 23, 2012 Correctional Health Care Conference 8

9 Inclusion Criteria (examples) SPECIALTY EXCLUSION (NO) INCLUSION (YES) CLINICAL DATA NEEDED Gastroenterology Complex medical problems Acute medical problems Review of pathology Initial Hepatitis C consult Initial, non-acute GERD Initial, non-acute constipation Intake sheet Problem list MAR/allergies Studies Referenced SOAP note Referral Co-infection (HIV/HCV) (HIV/HBV) Hepatitis B monoinfection Hepatitis B & HIV Hepatitis C monoinfection Hepatitis C & HIV Intake sheet Problem list MAR/allergies Studies Referenced SOAP note Referral Orthopedic Surgery Dislocation Acute fractures Infection K-wire recipients post-op Consults for surgical or treatment options MRI follow-ups Some post-operative follow-ups (dependant upon institution), as allowed by MD/ PA Intake sheet Problem list MAR/allergies Studies Referenced SOAP note Referral March 23, 2012 Correctional Health Care Conference 9

10 Milestone #3: Scheduling / Logistics Lessons learned: Define timelines/schedules for clinical, inmate and support staff Pre-register all approved telemedicine patients Prepare medical records/correspondence Medical record updated and shared Coordinate inmate movement/transport at prisons Make special arrangements as needed (e.g., high-security) Engage other disciplines as necessary (eg. PT telephone callin) March 23, 2012 Correctional Health Care Conference 10

11 Effective Teleconferencing Preparedness: know the patient and the problem ahead of time Patient-Clinician Communication: optimize AV connection to promote confidence and trust Scheduling: limit encounters to 7 minutes Flexibility: facilitate follow-up as needed Care Coordination & Collaboration March 23, 2012 Correctional Health Care Conference 11

12 Operationalizing Teleconferencing Inmate/Patient LSH Specialty DOC Site/Transportation UMCH IT Support March 23, 2012 Correctional Health Care Conference 12

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14 Continuous Quality Improvement Activities Data used for quality assurance and performance improvement Satisfaction surveys Inmates UMCH Providers LSH Providers Utilization metrics Results reporting to DOC and management oversight committees March 23, 2012 Correctional Health Care Conference 14

15 Inmate Satisfaction Survey Q1 Able to hear Doctor clearly? YES = 277 (96.2%) NO = 11 (3.8%) Q2 Able to ask questions that you needed to? YES = 277 (96.5%) NO = 10 (3.5%) Q3 Were all questions answered? YES = 265 (93.9%) NO = 19 (6.7%) Q4 Were next steps of care explained? YES = 228 (98.7%) NO = 3 (1.3%) Q5 Were you satisfied with visit? YES = 261 (91.6%) NO = 24 (8.4%) March 23, 2012 Correctional Health Care Conference 15

16 Inmate Satisfaction Survey Comments: Just because it s not hands on - how can you tell if I am okay if you can't physically examine me I would prefer hands on as doctor cannot examine current problem from older MRI and medical documents Would like to be face to face with the person Would have liked to talk with Doctor alone Went well and saved trip to LSH I like this better instead of going out handcuffed all day for this to be explained to you I just feel like I can't get the proper attention through a screen especially when the major part of being a doctor involves HANDS ON experience March 23, 2012 Correctional Health Care Conference 16

17 UMCH Provider Satisfaction Q1 Telemed visits improve communication with site staff and specialist? YES = 23 (88.5%) NO = 3 (11.5%) Q2 Effective in managing difficult patients? YES = 24 (92.3%) NO = 2 (7.7%) Q3 Was Telemed visit organized well? YES = 23 (88.5%) NO = 3 (11.5%) Q4 Was equipment, reception and connectivity satisfactory? YES = 22 (84.6%) NO = 4 (15.4%) Q5 Was Telehealth session effective? YES = 25 (96.2%) NO = 1 (3.8%) March 23, 2012 Correctional Health Care Conference 17

18 UMCH Provider Satisfaction Comments: LSH were not aware patient had been added to schedule Inmate argumentative, had to redirect him several times Unfortunately, this was my first telemedicine session with the equipment and it took me a while and some help to get all the correct cables connected, as well as the scopes put together. Now that I have done it for myself, this should go smoother next time. The patient was from an outside institution and took a while to process through the trap to get into the facility. Perhaps we should tell DOC 10 minutes arrival time prior to the session so that the session can start on time. I don t think it is a good way of interacting with a challenging patient one-on-one with the Shattuck, but within the context of a group meeting (with a UMCH provider present), it could be very effective. The Shattuck can hear both the patient and the provider, and the provider can educate the LSH provider on what can and cannot be done/provided at the site. Appropriate selection of patients and less wait time Having a little more updated information about the patient such as recent labs and medications March 23, 2012 Correctional Health Care Conference 18

19 LSH Provider Satisfaction Strongly Agree or Agree Neutral Disagree or Strongly Disagree Q1 The Telemed doctorpatient relationship is equivalent to an inperson encounter Q2 I am able to provide appropriate disposition through Telemedicine Q3 Telemedicine offers me an improved daily work experience 51% 14% 35% 86% 14% 0% 57% 29% 14% March 23, 2012 Correctional Health Care Conference 19

20 LSH Provider Satisfaction Comments: Clinic very well organized. No wait time. Paperwork prepared. All greatly improved! Patients more appropriate now that we have worked out details for which patients can be seen without any physical exam as far as palpating and maneuvers. Noticed some lag in communication process (a fraction of a second delay in relay of our voice) I am not certain that it will ever be as good as seeing a pt. English speaking patients only. No hearing impaired patients This helps to decrease DOC visit for screening colonoscopies and liver biopsies Very helpful to have clinic administrator available to retrieve info and manage follow-up recommendations I think this continues to be a positive and helpful program that allows for both follow-up and initiation of treatment and evaluation New benefit: able to communicate with the physical therapist via Polycom to get their perspective regarding patient progress. 20

21 Telemedicine Visits by Month GI, Ortho, ENT, Dermatology, Rheumatology & Co-Infection Total # of Visits 10-Jan 10-Feb 10-Mar 10-Apr 10-May 10-Jun 10-Jul 10-Aug 10-Sep 10-Oct 10-Nov 10-Dec 11-Jan 11-Feb 11-Mar 11-Apr 11-May 11-Jun 11-Jul 11-Aug 11-Sep 11-Oct 11-Nov 11-Dec Growth from the addition of specialties and tele-health sessions over time March 23, 2012 Correctional Health Care Conference 21

22 Future Vision Deploy store-and-forward approaches to managing clinical interpretations and treatment communications Acquire more bandwidth to enable the use of peripherals for advanced diagnostic purposes, e.g., cardiology and ENT Grow encounter volume as more opportunities to avoid inmate trips are identified; expand number of suitably equipped prison sites Evolve satisfaction survey and other QA data to ensure achievement of desired outcomes and implement PI Use telemed to expand training opportunities for prison-site providers and clinical support staff March 23, 2012 Correctional Health Care Conference 22

23 References Anogianakis, G., Ilonidis, G., Spyros, M., Anogeianaki, A., Vlachakis-Milliava, E., Developing Prism Telemedicine Systems: The Greek Experience, J. Telemedicine and Telecare 2003; 9(Suppl. 2):S2:4-7. Bashshur, R.L., Reardon, T.G., Shannon, G.W., Telemedicine: A New Health Care Delivery System Annual Review Public Health 2000; 21: Bradley, J., Telemedicine, Today s Caregiver, Broens, T., Determinants of Successful Telemedicine Implementations: A Literature Study J. Telemedicine and Telecare 2007; 13: Broens, T., Grealish, A., Hunter, A., Glaze, R., Potter, L., Telemedicine in a child and adolescent mental health service: participants acceptance and utilization, J. Telemedicine and Telecare, 2005: 11(Suppl. 1):53-6. Fox, K.C., et. al., Journal of Adolescent Health 41, 2007; NCCHC Position Statements: Use of Telemedicine Technology in Correctional Facilities, Russell et al., Internet-Based Outpatient Telerehabilitation for Patients Following Total Knee Arthroplasty, J Bone Joint Surg Am. 2011;93: Wade, V., Karnon, J., Elshaug, A.G., Hiller, J.E., A systematic review of economic analyses of telehealth services using real time video communication. BMC Health Services Research 2010; 10:233. Yellowlee, P., Shore, J., Roberts, L., Practice Guidelines or Videoconferencing-Based Telemental Health, October Telemedicine and e-health 2010; 16(10): March 23, 2012 Correctional Health Care Conference 23