1. Kaiser Permanente + HealthSpot Pilot: Onsite Telehealth Provides Quality Care for San Diego County with Convenience & Ease

The HealthSpot pilot program showed outstanding results in providing San Diego County Kaiser Permanente employees with remote care at their workplace.  The program increased quality of care in many cases and also increased the efficiency and convenience of seeking medical attention for participants.

Goals & Objectives

To bridge the gap between employee health, productivity, and care, Kaiser Permanente was looking for ways to bolster health and wellness for San Diego County employees. They turned to HealthSpot to partner in delivering a pilot station for County employees who were part of the Kaiser Permanente healthcare network.

A key Kaiser Permanente customer, the County has an employee base of 17,000 with around 25% working in or near the County Operations Center. The goal of the pilot program was to increase access of care for employees while lowering time constraints and productivity loss when employees went offsite for medical care.

The HealthSpot station is a private, walk-in kiosk located in the County Operations Center that allows patients to receive remote care from Kaiser Permanente providers via high-definition video conferencing and interactive, digital medical devices. Member employees are able to use the station in their workplace for basic primary and urgent care needs without sacrificing quality or privacy. 

By the numbers

Number of patient visits - 451
Number of Kaiser Permanente providers - 17
Length of pilot 12 months
Percentage need for follow-up visit after HealthSpot station appointment 4%
Average patient satisfaction rating for overall experience 9.86 out of 10
Percentage of patients who would recommend a HealthSpot station appointment to a friend 100%

Results & Feedback

Employee and Kaiser Permanente member Ciara Webb visited the HealthSpot station when a persistent cough wouldnt go away. I wasnt sure at first if it would be beneficial to me versus going into an actual doctors office, said Ms. Webb, But I found it was a clean, private environment with an attentive doctor and it gave me a more convenient way to take care of the health issue I was experiencing.
Close to 500 patients used the HealthSpot station during the trial period from November 2013 to November 2014 and participated in a survey at the end of their appointment. Patients were asked questions about their satisfaction with the visit, if they had any problems, and if they were likely to return. The average rating for these questions was a 9 out of 10.
Patients rated their ability to get an appointment when they needed one at a 9.86 out of 10, and many cited the convenience and ease of use as huge benefits of the HealthSpot service. As part of an overall health and wellness push for San Diego County employees who were Kaiser Permanente members, the HealthSpot station allowed the County and Kaiser Permanente to incentivize members to seek care while decreasing absenteeism and time loss.

Employee Benefits

HealthSpot also proved to be a catalyst for some patients who otherwise would not have sought care from their regular provider. About two-thirds of our patients reported that they would not have gone to see the doctor if they hadnt been able to make an appointment at the HealthSpot kiosk, said Dr. Paul Bernstein, Medical Director for Kaiser Permanente San Diego. On top of that, less than 5% needed to be seen as a follow-up in another setting. The majority of patients have their problem taken care of at the HealthSpot location.

Having a central telehealth kiosk in their County Operations Center allowed San Diego County and Kaiser Permanente to access a large number of employees easily and give them in-network care with little to no hassle. They dont have to miss work, take half a day to drive to a doctors office and worry about running around. With HealthSpot, the onsite nurse, virtual provider and the biometric measuring devices in the station allow for a complete exam and make accurate diagnoses and get patients on their way, said Dr. Bernstein.

The right place, right time mentality is one that drives the HealthSpot mission and made the pilot a success. Employees that took advantage of the new benefit offered to them often reported feeling like their visits were more personal than in-person physician visits. The dedicated, face-to-face 20-minute appointment left patients satisfied with the amount of attention and time the provider spent with them on their concerns.

Employees really like how much time they get with the doctor. Many actually felt that their in-person doctor appointments werent as personal as their HealthSpot appointment and they felt that they got more attention from the provider, reported Pitpit.

Provider Response

Dr. Heidi Meyer, a primary care physician at Kaiser Permanente in San Diego, is one of the doctors participating in the HealthSpot pilot program. The HealthSpot kiosk is an incredibly easy way for patients to be seen by a Kaiser Permanente provider right in their place of employment, said Dr. Meyer, Ive found the kiosk provides an intimate setting that has allowed me to efficiently and effectively diagnose my patients. Its an important step in healthcare delivery innovation.

Future Opportunities

The HealthSpot and Kaiser Permanente pilot used innovative telehealth technology to explore a new way to meet the increased demand for access to health services without sacrificing quality, service and efficiency. By creating points of care where employees found it most convenient, the HealthSpot station saw high patient satisfaction and favorable outcomes for both San Diego County and Kaiser Permanente.
The pilot has enabled Kaiser Permanente to increase access to service and growth while taking advantage of new technology. It allowed the County of San Diego to increase employee wellness and decrease absenteeism. HealthSpot will continue to partner with Kaiser Permanente and other healthcare providers around the country to increase access to quality care while focusing on efficiency and convenience. Together with Kaiser Permanente, HealthSpot is providing solutions to the biggest problem with the healthcare system today by making access to care a reality and allowing patients to access the highest quality care in convenient locations, such as their place of work, said Steve Cashman, HealthSpot CEO.

Kaiser Permanente/ HealthSpot

For more information about this case study, please contact:

Kalyn Schieffer, HealthSpot PR Agency, 401-792-7080, 155 Main Street, Wakefield, RI 02840 

2. The Roar of the LionNet: Penn State Hershey Medical Centers State-of-the-Art Telestroke Network

Penn State Hershey Medical Centers (PSHMC) LionNet program leverages telehealth technology to get critical and time-sensitive telestroke consultations from the experts at the PSHMC stroke center to a network of regional hospitals to greatly increase their efficacy in treating stroke patients.

Penn State Hershey Medical Center (PSHMC) is a 563-bed academic hospital and one of the premier comprehensive stroke centers in the state. The hospital averages hundreds of stroke patients per year, with many of those transferred in from rural hospitals where stroke-based expertise is limited or unavailable. The primary issue with transferring stroke patients is that tPA (Tissue Plasminogen Activator), a life-saving stroke treatment, must be administered to ischemic stroke patients within three hours from the onset of symptoms. By the time many patients were transferred, that critical treatment window had often closed.

Having some of the leading stroke specialists in the country, PSHMC saw the opportunity to create a comprehensive telestroke program, LionNet, which could treat stroke patients faster and reduce transfer rates from small and rural hospitals.

A Closer Look at LionNet
 
In July 2012, PSHMC worked closely with REACH Health, its telemedicine technology partner, to design a sophisticated hub-and-spoke network for the South Central region of Pennsylvania. Through a single, scalable platform with audio/visual capabilities, PSHMC provides real-time neurological consults for stroke patients at a network of regional hospitals. What makes LionNet even more unique is that it includes only dedicated stroke-care specialists not fellows, general surgeons or attendees to ensure the best patient care possible.  

Today, the program includes 11 regional hospitals (with at least three more sites scheduled to go live in 2015), and PSHMC has completed approximately 1,000 remote stroke consults. LionNet has dramatically improved patient care for stroke victims, and it has become one of the most often-mimicked telestroke networks in the country. 

The focal point for LionNet was always to improve acute-stroke care, and PSHMC wanted to achieve that by creating mutually beneficial partnerships with regional hospitals. As the hub, PSHMC made a commitment to its spoke hospitals to help with any type of stroke-related care (from pre-hospital and acute care to rehab and preventative care).

Three Years In: Major Successes to Date

In approximately three years, PSHMC and its spoke hospitals have realized impressive results, including:

Improved acute ischemic stroke treatment rates: The national tPA administration rate for hospitals averages below 10 percent. The LionNet program has treated 29 percent of acute ischemic stroke patients with tPA far above the national average.   At some spoke sites, tPA administration grew by 500 percent. Many of the hospitals that had never before treated stroke patients are now doing so and are increasingly comfortable with onsite care.
Decreased transfer rates: LionNet has decreased transfer rates from 40 percent to 25 percent due to spoke sites becoming more comfortable with treating stroke patients.
Decreased door-to-consult and door-to-needle times: National guidelines state that tPA-eligible patients should be treated within 60 minutes of arrival. Keeping this in mind, PSHMC has established a door-to-registration rate (arrival-to-cart activation) of 10 minutes. The registration-to-consult time is no longer than 20 minutes, and the decision to treat with tPA is made in less than an hour. Some spoke hospitals have even been able to take off 20 minutes from their door-to-needle time.
Spokes becoming primary stroke centers: PSHMC has worked closely with two spokes sites to help them become Primary Stroke Centers of their own. 

What the Future Holds

Studies show that a stroke patient fares best when he or she receives regular exams within the first few months following a stroke. But as with acute-stroke care, many small or rural hospitals lack the resources or expertise to provide the appropriate follow up. Due to this, PSHMC plans to extend stroke follow-up care to multiple treating sites through stroke teleclinic and stroke telerehab programs.

For more information about this case study, please contact: Andrew Saluke, marketing program manager, REACH Health; 678.436.8224; andrew.saluke@reachhealth.com

Penn State Hershey Medical Center and REACH Health

For more information about this case study, please contact:

Andrew Saluke, Marketing Program Manager, REACH Health; 678.436.8224; andrew.saluke@reachhealth.com 

3. Georgia Partnership Uses Telemedicine and Centering Pregnancy Model to Significantly Decrease Preterm Labor Birth Rate in High Risk Areas

Georgia Partnership Uses Telemedicine and Centering Pregnancy Model to Significantly Decrease Preterm Labor Birth Rate in High Risk Areas

 Southwest Health Districts CenteringPregnancy program and Womens Telehealth in Atlanta have teamed up to deliver effective, efficient, high-quality access to prenatal care that significantly improves health outcomes among African Americans and Hispanics in an underserved corner of Georgia. Following the launch of the first-of-its-kind partnership between group prenatal care and maternal-fetal telemedicine, the percentage of pre-term deliveries and low birth-weight babies continues to be well below baseline rates in target populations.

 The model is transferable to other areas that lack sufficient OB providers, and can greatly enhance care by providing maternal fetal monitoring and consulting to patients who otherwise lack access to such special services, say the principals behind the partnership. Both principals Southwest Health District Health Director Dr. Jacqueline Grant, an obstetrician, and Women's Telehealth founder Dr. Anne Patterson, a maternal fetal medicine specialists use alternative practice models to improve women's access to prenatal care.

 Southwest Health District's program is the first Centering program in the nation to include telemedicine, said Program Manager VaLenia Milling. It is also the first accredited Public Health-based Centering program in Georgia. The district received a March of Dimes grant to implement the Centering program in 2009 to combat a glaring healthcare disparity gap and access to healthcare issues in the predominantly rural 14-county Southwest Health District. The program remains funded through grant sources today.

 The Centering program initially focused on low-income African-American birth outcomes in Dougherty County, Milling said. In 2011, it expanded into Colquitt County's Ellenton Clinic, where it began addressing prenatal care needs of often undocumented low-income Hispanic farm worker women.

  CenteringPregnancy is a national model of group prenatal care with groups of women whose due dates are in the same month," Milling said. "The groups meet for individual assessments and facilitated discussions in nine two-hour sessions monthly until 28 weeks gestation, then every two weeks until 36 weeks gestation. Afterwards we partner with private practices who continue to provide care through delivery."

 When the group "circles up" for their monthly group meeting, Dr. Patterson periodically participates on-camera from her office in Atlanta. "We start with discussing antenatal testing," she said. "On subsequent visits, we educate patients on fetal growth, gestational diabetes and potential complications such as hypertension and preterm labor.  If they have no problems, then they only see me those times. But if they do develop a high risk problem requiring intervention, they already know me. They are comfortable having a consultation and I think this format also promotes improved compliance."

 The arrangement is much more efficient and effective for low-income patients who must make childcare or travel arrangements, or who lack convenient access to telephones, Milling said. "It also eliminates barriers of insurance status for the patients, so we are seeing them earlier," added Dr. Grant. "There is also an ease of scheduling. Patients are consulting earlier and are more compliant."

 The public-private partnership serves the patients well. The baseline (2004-2008) African-American preterm birth rate for Southwest Health District is 18.2%. The Dougherty site (the county has an 86% African-American population) is 8.1%. Preterm birthrates in the Ellenton Clinic in Colquitt (100% Hispanic population served) reflect similar promise. Centering rates of 6.7% there compare favorably to the baseline Hispanic district rate of 12.1%. 

 "The success of this pilot is evidence the model can be replicated in other areas with high-risk populations, Dr. Patterson said.

The program's efforts are part of an overarching initiative using telemedicine to reach Georgias 159 counties, with hopes of bringing specialized care to underserved areas of Georgia, saving time and money for patients, providers and public health staff, says Suleima Salgado, director of Telehealth and Telemedicine for the Georgia Department of Public Health.

For more information about this case study, please contact:

Southwest Health District Centering Contact: VaLenia Milling 229-430-6332. Womens Telehealth Contact: Tanya Mack 404-702-2055 

4. Increasing Medication Compliance in High Risk Patients by Utilizing Electronic Medication Dispensers

Approximately 1 in 10 hospital admissions of seniors is related to medication non-adherence and while a multitude of factors contribute to hospitalizations and readmission, improved medication management can help to reduce them. While the issue of non-adherence spans age groups, managing medications can be particularly challenging for those 65 and over. Seniors take more prescription and over the counter medications than any other age group, as they have more chronic conditions. Over half of the individuals in this age group take at least three prescription medications. Approximately one-third take eight or more medications (prescriptions, non-prescriptions, and/or supplements).

For seniors with complex medication regimens and trouble remembering to take medications, self-management or simple pillboxes frequently do not suffice. In fact, in an independent pilot study, researchers found that the group using a pillbox averaged 30% missed doses per month versus less than 3% in the automated dispenser with voice-activated message group. In addition, while those who self-administered had no change in physician visits and a significant increase in number of hospitalizations over the course of the six month study, the automated dispenser group had a decrease in physician visits and in number of hospitalizations.

Being able to successfully improve compliance rates requires a detailed understanding of the causes of non-compliance, and a focused operational and clinical strategy to address each of those root causes. The Henry Ford Health System has employed a multidisciplinary model involving Home Health Care nurse case managers, telehealth nurses, ambulatory case managers, nurse practitioners, pharmacists, physicians and occupational therapists in a collaborative, system wide approach to solving the problem of medication non adherence. Creative solutions have also been implemented to address reimbursement which has allowed the hospital to offer this option to an increasing number of seniors at risk for and with a history of medication mismanagement. To date, Henry Ford has managed over 230 patients using telehealth medication dispensers, and has achieved a 96% compliance rate in this high-risk population.

New avenues to impact high risk populations utilizing telehealth medication dispensers are being explored every day. For example, patients with cognitive impairment have been identified as one of the highest risk populations at risk for readmission. Henry Ford Hospital estimates that there are 2500 patients discharged each year who suffer from cognitive impairment. Henry Ford Hospital plans to study this patient population to determine if medication dispensers can improve medication adherence and reduce readmission rates.

For more information about this case study, please contact:

Mary Hagen, Associate Degree Nursing, e Home Care Supervisor; 313-874-3291; mhagen1@hfhs.org

5. Video Recording Doctor-Patient Visits to Remember What the Doctor Said

Patients considering surgery often have difficulty remembering all of the information presented to them in the consultation and follow-up appointments with their doctors. Critical information may be forgotten or misremembered in the days or weeks after a visit which can adversely affect both the patients decision-making capabilities and their post-surgical care. Barrow Neurological Associates conducted a study using a proprietary video recording system to improve patient-doctor communication and help patients remember all of their doctors instructions after leaving the office.

The Medical Memory video recording system was offered to patients of a single neurosurgeon at Barrow Neurosurgical Associates between November, 2009 and July, 2013. Patients were given the opportunity to have their consultation or follow-up visit with the physician recorded on a video camera and then uploaded to a secure website (some early patients were given DVD copies of their visit instead of having it uploaded to the website). The patient was then provided with a login name and password for the website and was able to access the video to watch and listen to the consultation. Recordings included the physicians verbal instructions, explanations of surgical options, radiographic images, and visual use of models and graphic images. Surveys were collected of patient experiences with their videos and their ability to remember the information discussed in the visit after having watched the video.

Between November 21, 2009 and July 21, 2013, 1,078 videos were recorded and made available to patients. An electronic survey was sent to 346 patients asking about both their impression of the service and how they felt after watching their video. 143 responses were collected (a 41.3% response rate), with results showing: over 90% of patients watched the video at least once; 69% of patients shared their video with a friend, family member, or different physician; 48% felt more at ease after viewing the video; 35% reported reduced anxiety; and 65% of patients reported that they remembered more of what their doctor told them. Overall, 90% of respondents felt that the video was helpful.

Patients who cannot or do not remember their doctors instructions fully after leaving their visit are at risk for not following all instructions, which can greatly impact their quality of care and ultimately, their physical health. Video recording doctor-patient conversations provides a new tool for improving patient recall of physician instructions in consultation and follow-up appointments with their doctors. 

For more information about this case study, please contact:

Dr. Randall W. Porter, Neurosurgeon; randall.porter@bnaneuro.net; 602-406-48560

6. Reducing CHF Readmission Using Telehealth

Since 2004, University of Arkansas for Medical Sciences (UAMS) ANGELS has operated a robust statewide telemedicine infrastructure with a 24/7 call center staffed with high-risk obstetrical registered nurses to provide guidance to rural, high-risk pregnant women seeking answers to questions, pregnancy advice, and triage. To provide telephone triage to a patient, the call center nurse utilizes computer software that requires the nurse to ask a series of algorithmic questions to uncover the patients symptoms and medical history, which will offer recommendations toward the most appropriate level of care.

Beginning in January 2013 ANGELS partnered with the UAMS Medical Center Congestive Heart Failure (CHF) Bundled Payment Committee to begin efforts towards incorporating the CHF patient population into the patients they serve. The Committee had been charged with reducing 30 day all cause readmissions in this population starting in July of 2012 when the Arkansas Bundled Payment Initiative officially began. At that time the 30-day all cause readmission rate was 24.99% compared to a national benchmark of 23.99%. Efforts of the interdisciplinary Committee resulted in reducing the 30-day all cause readmission rates to 18.69% (20/107) during the February-April 2013 timeframe compared to a national benchmark of 19.56%.

In May 2013 the ANGELS call center began contacting CHF patients on the day after their discharge and providing telephone triage using a CHF triage algorithm. During this time, ANGELS followed up with 80 post discharge phone calls, 11 triage calls and 1 informational call to 80/86 patients discharged with CHF from the May-July timeframe. During this time, no patients who were triaged were readmitted. After 3 months of implementation the 30-day all cause readmission rate decreased to 12.79% (11/86) compared to a national benchmark which remained steady at 19.17%.

The cost of a CHF admission to UAMS Medical Center from July 2012 to July 2013 averaged $12,000. Had the rates of 30 day all cause readmissions remained the same for the May-July 2013 timeframe, 16 patients would have been readmitted. Instead, 11 patients were readmitted which was a 31% decline representing a savings of $60,000 to the organization which would not have been reimbursed under the Arkansas Bundled Payment Initiative.

For more information about this case study, please contact:

Donna J. Ussery RN, Project Manager, UAMS Centers for Distance Health; djussery@uams.edu Amy Hester BSN, RN, BC, UAMS Director of Clinical Informatics and Innovation; hesteramyl@uams.edu

6. Carolinas HealthCare System: Successfully Reducing Hospital Readmissions for Advanced Heart Failure Patients

Heart failure (HF) is the second most common inpatient diagnosis at hospitals across the US. HF patients who have frequent hospitalizations are at risk for poor outcomes. Those with multiple chronic medical problems have the highest rate of readmission. In 2012, Carolinas HealthCare System (CHS) piloted The Heart Success (HS) Transition Clinic at Carolinas Medical Center (CMC) Main and CMC NorthEast for patients with a primary diagnosis of HF. These clinics were designed to address the potential gap in care between the acute and ambulatory care settings. Patients enrolled in the program meet weekly for 4 to 6 weeks with a multidisciplinary team staffed by specialty trained advanced clinical practitioners (ACPs), a social worker, pharmacist, dietitian and registered nurse.

Both pilots have been successful in reducing readmission rates; however, early data also showed that approximately 25% of the patients being discharged from CMC Main were non-captured. The main reason for this was related to the patients home location and the travel distance to CMC Main.

To address these non-capture patients, CHS implemented a virtual model of the Heart Success Transition Clinic as a pilot. The pilot began in June 2013 at a regional facility located 55 miles from CMC Main. Following the same visit schedule, HF patients discharged from this facility meet with the HS team via telemedicine, using basic videoconferencing and a peripheral stethoscope.

The concept of using telemedicine to access specialty care, eliminating the need to travel to the center is innovative and cost effective. It is an efficient way to accomplish management of complex patients with a chronic illness. The plan manages across the patients continuum of care to decrease readmission rates and increase the patients ability to self-manage resulting in improved quality of life.

Early Results:

During the 6 month pilot June through December 2013, 60 new patients have been enrolled in the virtual clinic and 165 virtual encounters. The 30-day all cause readmission rate at CMC-L has decreased from 19.39 % in 2010 to 9.82 % in 2013. Patients have evaluated the experience with top box scores. The home health nurses have observed a new sense of accountability with the patients in the virtual visit. Unintentional variations in care have been addressed by centralizing staff education.

The Virtual Heart Success pilot is proving to be a best practice in chronic disease care at CHS. As outcomes continue with a positive trend, this model will be shared across service lines.

For more information about this case study, please contact:

Dr. Sanjeev Gulati, (704) 373-0212, sanjeev.gulati@carolinashealthcare.org; Debbie Fenner, (704) 355-8102, Debbie.Fenner@carolinashealthcare.org

7. Kansas iCare: mHealth Clinic Appointments Using iPad Minis between Multiple Professionals and Complex Patients in their Homes

Using iPads for information, games or video connections with friends and family is common, but for important appointments with health professionals and peers this is much less routine.  Fortunately, patients with complex, chronic conditions across the United States can now connect with peers across the U.S. and to health professionals in Kansas using these everyday devices. 

Health professionals from the University of Kansas Medical Center (KUMC) School of Nursing and Center for Telemedicine and Telehealth are conducting an NIH-supported project for the use of mobile technologies for patient care in their home settings.  Patient participants have chronic conditions that require an invasive IV catheter for a 12-hour infusion of nutrition, also called Home Parenteral Nutrition (HPN).  Millions of dollars are spent annually on poor health associated with complex home-caregiving and HPN patients are among the most complex to treat, particularly because of IV sepsis, the most costly but preventable complication and a top 25 NIH research priority. 

iPad Mini tablets with interactive, encrypted video conferencing and secure data exchange are used for real-time intervention for HPN patients by health professionals from the medical center. Project goals include health professionals viewing of patients IV catheters and catheter site wounds, engaging families in skilled home caregiving and healthy behaviors, and reducing patient healthcare visit costs associated with the condition.  Patients also complete perception surveys about mHealth usability and its role in their self-management of complex health conditions.  The mobile device functions as a complex tool for synchronous, asynchronous and informatics interventions; video interactions are supported through a secure videoconferencing app and interprofessional consultations with the patient occur using a multi-point control unit, or bridge. The tablets also give patients access to evidence-based interventions, including step-by-step home-caregiving algorithms, video scenes illustrating complex home-care IV procedures and infection control procedures. 

The video sessions often include 3-4 patients from different locations around the U.S., along with 2-3 of the health professionals from KUMC.  To date, patients have reported that the video sessions are very convenient and robust, with no difficulty seeing or hearing health professionals or peers during the multipoint sessions.  They believe that receiving medical care via the iPad Minis is a good idea and they are able to talk privately and openly.  In a few cases, patients took pictures of their catheter sites with the iPad Minis and sent them to their physicians for identification of infection, which was caught early enough to treat with medication.

Because this is an NIH funded project, more information and results will be available at a future time.  The project is supported by the National Institute Of Biomedical Imaging & Bioengineering of the National Institutes of Health under Award Number R01EB015911. C. Smith, PhD RN, Principal Investigator.  The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health. Clinical Trials.gov Registration # NCT0190028

For more information about this case study, please contact:

Ryan Spaulding, PhD, Director, KUMC Center for Telemedicine and Telehealth, 913.588.2251, rspaulding@kumc.edu

8. Using Telemedicine in Rural Georgia to Provide Children with Access to Child Abuse Physicians

Every year, thousands of children in Georgia who are sexually or physically abused need specialized medical evaluation. Yet this service is typically available only in urban centers. Much of Georgia, like much of the country as a whole, is rural, so many children are either unable to obtain needed care or they must travel great distances to reach a specialty clinic. To address this need, the Childrens Healthcare of Atlanta Center for Safe and Healthy Children (CSHC) started using telemedicine in January 2009.

The CSHC has two outpatient clinics in metro Atlanta to provide forensic interviews and medical evaluations to children and adolescents who are suspected victims of abuse or neglect. The CSHC collaborated with the Georgia Partnership for Telehealth and several child advocacy centers throughout the state to create the ability to provide children in rural communities access to child abuse physicians.

Child advocacy centers provide prevention, intervention and treatment services to victims of abuse and are ideal partners for bringing telemedicine evaluations to local children. In the case of suspected abuse, the police contact a local child advocacy center associated with the telemedicine network. They immediately call the Childrens Telemedicine Program to schedule a consultation. At the appointed time, the child and parent come to the local child advocacy center where they are greeted by a social worker and a medical provider, usually a nurse. They enter an exam room equipped for teleconferencing. The nurse explains the procedure and introduces the specialist to the family. From a desk in Atlanta, the specialist greets and engages the family in conversation to help them relax. The interaction takes place through high-resolution screens that allow the patient, family and doctors to communicate in real time. Together, the nurse and specialist obtain information about the abuse event and the childs general health. The nurse performs a head-to-toe physical exam on the child with the specialist guiding the process utilizing telemedicine equipment.

According to Jordan Greenbaum, M.D., Medical Director of Childrens CSHC, telemedicine has several tangible benefits. An evaluation utilizing telemedicine reduces parental anxiety and stress by providing prompt access to expert care and support. It also saves time and resources for authorities, who can lose a workday driving to and from Atlanta. And for rural medical providers, telemedicine relieves some of the burden of accurately identifying abuse and interpreting physical findings.

For more information about this case study, please contact:

Kelley Kesler, MS, Director of Special Projects; kelley.kesler@gatelehealth.org

9. Telepsychiatry in North Carolina: A Hospital Initiative Evolves into a Statewide Telepsychiatry Program

Hospitals across the United States struggle with providing specialized psychiatric care for patients presenting to the emergency department. In a 2008, nationwide survey of 328 emergency department Medical Directors, 79.2% reported routine psychiatric patient boarding with 35.1% boarding more than 1 psychiatric patient per day. This same survey found the average length of stay for psychiatric patients in the emergency department was significantly longer (average 1089 minutes) than the length of stay for non-psychiatric patients (average 340 minutes). The challenge of providing quality, cost effective psychiatric care to patients in the emergency department, amidst psychiatric provider shortages and high costs associated with psychiatric provider coverage where available, has been a significant issue for hospitals in North Carolina.

In 2010, a study of North Carolina hospitals revealed that over 3,000 patients spent more than 2.6 days in emergency departments waiting for specialized psychiatric care or inpatient placement. This study also found that 200 of those patients waited in excess of seven days. Lengthy patient stays in the emergency department present quality of care issues for patients and significant financial burdens for hospitals.

To address these challenges the Albemarle Hospital Foundation developed a telepsychiatry program in 2011, funded by the Duke Endowment, with the goals of reducing patient lengths of stay, improving timely access to specialized psychiatric care and reducing patient recidivism by improving the coordination of aftercare services. Between 2011 and 2012, ten hospitals throughout northeastern North Carolina began participating in the Albemarle Hospital/Duke Endowment Telepsychiatry Network. The early results of the project found a 47% reduction in length of stay and a 35% reduction in 30 day recidivism rates.  Following these favorable initial outcomes, the Duke Endowment provided an additional year of funding to expand the telepsychiatry network in 2013. Currently, 18 hospitals participate in the telepsychiatry network with a geographical span from as far east as Nags Head, NC to as far west as Lexington, NC.

The positive impact this program has generated for patients, providers, and hospitals drew attention from a number of key North Carolina political leaders in late 2012 to early 2013. During the 2013 session, the NC General Assembly approved and funded a plan for the creation of a state wide telepsychiatry program for hospital emergency departments. Section 12A.2B of the North Carolina Law 2013-360 calls for the implementation of a statewide telepsychiatry program, modeled substantially after the successful Albemarle Hospital Foundation telepsychiatry program. The North Carolina Statewide Telepsychiatry Program (NC STeP) will potentially serve between 65 and 85 hospitals in North Carolina which do not have access to psychiatrists. This Figure shows the hospitals that are already participating in the NC STeP program (green) and the ones that are expected to join the program by June 2015 (pink). The use of telepsychiatry in hospital emergency departments is being embraced in North Carolina. While its use is not expected to solve all of the issues related to providing emergency psychiatric care, telepsychiatry has proven to be effective in improving patient care and is being heralded as a valuable tool for hospital emergency departments.

For more information about this case study, please contact:

Sheila Davies, MPA, NC STeP Coordinator: sdavies@medaccesspartners.com

10. Expanding Access with Video-Based and Online Consultations

For over 10 years, the Center for Connected Health and Partners Online Specialty Consultations (POSC) has provided thousands of patients and their providers virtual access to specialty care at Partners-affiliated hospitals. Secure online and video-based consultations provide unprecedented access to specialists at Brigham and Women's and Massachusetts General Hospitals, Dana Farber/Brigham and Women's Cancer Center, and Massachusetts Eye and Ear Infirmary.

A recent review of POSC consultations found that in only 5% of the cases, the specialist opinion was in complete agreement with the patients' current recommended treatment plans. In more than half of the cases, the consulting specialist recommended a complete change in treatment plan, suggesting profound implications for clinical care.

 "This program works really well and, as a consulting physician, we have all of the information available to quickly make an informed recommendation," said Arnold S. Freedman, MD, Associate Professor of Medicine, Harvard Medical School, and Clinical Director of the Lymphoma Program at Dana-Farber Cancer Institute.

 When diagnosed with non-hodgkins lymphoma, a businesswoman and expatriot living in Asia turned to POSC for help to determine the most effective treatment plan. Dr. Freedman was the consulting physician on her case.

 "My local physician is head of hematology at a major hospital in Asia. He had previously met Dr. Freedman and was delighted to have the opportunity to collaborate with him," she said. Within just two days, the patient and her local physician received a comprehensive report and treatment recommendations. "The completeness of the report, and the experience of Dr. Freedman and the Cancer Center, gave us great confidence that we were making the right decisions," she added.

In addition to online consultations, POSC also offers video-based consultations using PC- based webcams and off-the-shelf video services.

For more information about this case study, please contact:

Gina Cella, Cella Communications; 781-334-4692; ginacella@comcast.net 

11. mHealth Program Provides Improved Prenatal Care for At-Risk Pregnant Women

The Center for Connected Health at Partners HealthCare is employing mobile health programs to reach more diverse patient populations, leveraging technology that is already a part of everyday life -- cell phones and texting. The Center's Message Connect platform allows clinicians and their practices to send customized message to their patients, reaching individuals in their daily lives.

At the Lynn Community Health Center, one of the most medically underserved communities in Massachusetts, the Center and Partners HealthCare launched a text messaging program for young, at-risk pregnant patients. 25 women participated in this program, which offered informational and supportive text messages throughout their pregnancies and two months post-partum. The goal was to offer the program to younger women who have limited support systems in place and would truly benefit from additional reminders about healthy pregnancy. 

The women participating in the program, age 22 on average, received between one and four text messages per week. Results of patient surveys and review of the data showed women who got text messages from their clinical team received the recommended level of pre-natal care 9% more than other pregnant women who did not get text messages. 

 The text messages were one-way, and designed to encourage patients with positive reminders and educational messages.  Text messages were offered in English or Spanish, and each message included a phone number to reach the OB clinical team.  
Some of the messages patients received were: Hi, its your OB team reminding you to count your babys kicks.  Call us if there is a change in frequency, or Your OB team is checking in.  Have you scheduled your ultrasound?  Its baby picture time! Let us know if we can help. 

 This text messaging program provides another opportunity for healthcare providers to reach out, providing additional support and education that will help to ensure that our patients and their babies will get the right amount of pre-natal care," said Leanne McDermott RN, Lynn Community Health Center. "Through this text messaging program, we saw an improvement in the level of appointments the women had, and it also gave patients a constant reminder of the fact that we care and are only a phone call away. 

 As a result of this successful program, the Center is expanding its messaging program for pregnancy and prenatal care, and is developing text messaging campaigns for chronic disease management and health and wellness, including programs to promote activity, better nutrition and healthier living. 

For more information about this case study, please contact:

Gina Cella, Cella Communications; 781-334-4692; ginacella@comcast.net  

12. Avera eCARE Supports 675 Rural Clinicians in the Delivery of Highest-Quality Care

Avera eCARE supports 675 rural clinicians in the delivery of highest-quality care, resulting in earlier interventions, improved use of evidence-based medicine, reduced unnecessary transfers, fewer complications and lives saved. 

eEmergency provides rural clinicians immediate access to board-certified emergency-medicine physicians and experienced emergency nurses to aid in the diagnosis and treatment of stroke, heart attack, trauma and other critical conditions. Since its inception in 2009, eEmergency has served more than 15,000 patients at 70 locations through two-way video interaction or transfer assistance. More than 850 eEmergency encounters (18 percent) have resulted in an estimated $6.8 million in costs saved through avoided transfers. In a recent survey, 100 percent of rural clinicians and administrators agreed that eEmergency services are an important part of the delivery of emergency care in rural communities and have demonstrated significant impact on the quality of clinical services provided in rural hospitals.

For patients presenting to the emergency department with chest pain, collaboration with eEmergency has demonstrated the following improvements in quality measures:

• overall median time to ECG of six minutes; a decrease of as much as 50 percent

• A 100-percent compliance with American Heart Association aspirin administration guidelines; an improvement of more than 44 percent

• 100 percent of eligible patients receiving fibrinolytic (clot-busting) medication

• A decrease in median time to transfer by as much as 60 minutes

Avera eICU CARE provides around-the-clock monitoring of critically ill patients by an intensivist-led team of experienced critical care nurses. Using Avera eICU CAREs advanced monitoring software and integrated electronic medical record systems to identify negative trends in patient status has resulted in reductions in length of stay and cost of care for more than 42,500 patients. Additionally, Avera eICU CARE support has saved more than 850 patients lives according to APACHE predicted versus observed mortality. Avera eICU CARE provides intensivist oversight to more than 60 percent of the critical care patients in the region, compared to only 13 percent nationally. This oversight has led to:

• A total of 28,500 ICU days saved, an estimated cost savings of more than $44 million

• A 100-percent compliance with stress ulcer prophylaxis

• 100-percent compliance with venous thromboembolism prophylaxis

ePharmacy has improved medication safety for more than 73,700 patients in 40 hospitals across the region. Hospital-trained pharmacists have reviewed more than 880,000 medication orders and identified and prevented more than 11,450 serious safety events, including drug-drug interactions, allergic reactions and duplicative therapies. Each month, pharmacists review more than 35,000 orders and complete more than 750 interventions to promote medication safety and cost-effectiveness in rural communities. 

eConsult connects rural patients in clinics and hospitals to specialists in urban communities. Currently, eConsult links 65 rural sites with 27 different specialties, facilitating more than 5,700 clinic visits per year. In fiscal year 2012, eConsult saved patients more than 1.3 million miles of travel. This equates to saving $304,000 in travel expenses and more than 15,300 hours in travel time. More than one-third of patients reported that they would not have received specialist care without eConsult, and more than two-thirds of patients reported that they received equal or better care through eConsult than in person.

         2013

For more information about this case study, please contact:

Jay Weems, Executive Director, Avera eCARE; 605-322-4669; jay.weems@avera.org  

13. Creating Change through Remote Patient Care Management Addressing Cost-Quality-Access with Innovative Telehealth Technology

Profile:

Humana Cares, a national division of Humana, provides support and customized coaching for more than 160,000 older adults with chronic illnesses, their families, and caregivers across the country.

Need:

Humana, like most health insurance companies, searched for the best way to reduce hospital readmission rates and the associated costs for congestive heart failure (CHF) patients. Humana needed to increase member self-management of CHF in order to improve health, reduce catastrophic events, and lower costs

Solution:

Humana Cares developed an extensive support program for CHF patients in 33 states, which included daily biometric monitoring and education with the Intel-GE Care Innovations Guide platform. The program was designed to affect behavior change and create lifelong habits among CHF patients who have had recent hospitalizations or ER visits.

Short-Term Impact:

In less than a year, preliminary results indicate the Care Innovations Guide platform is an effective and valuable element of the Humana Cares CHF care management program:

•        80% adherence rate by members who opted to have daily biometric monitoring

•        94% of members said the Guide was easy to use, 90% said they felt more connected to their nurse, and 93% would recommend it to their friends

•        Positive anecdotal feedback from members that the Guide has helped them develop positive lifelong habits and better manage their chronic conditions

•        Enabled Humana to reach CHF patients in remote areas that may have otherwise gone unmonitored for long periods of time

The Future:

Humana Cares plans to evaluate the success of the program by measuring ROI, admission and readmission rates for members with CHF, as well as ER visits for members with CHF.

Lowering Health Care Costs through Technology-Enabled Disease Management and Behavior Change

Humana recognized the potential to dramatically improve the health status of members with congestive heart failure (CHF). Based on lessons learned from other programs, Humana focused on facilitating long-term behavior change through more personalized care. If the company could achieve this, Humana knew their members would experience fewer readmissions and lower complication rates, ultimately improving quality of life and reducing overall health care costs.

Humana Cares developed an extensive support program for 2,000 CHF patients. In addition to benefiting from a comprehensive disease management program and social services support that addressed an array of challenges, CHF patients participated in daily biometric monitoring and education with the Guide. Daily weight and blood pressure measurements were automatically sent to a Humana Cares nurse who could easily assess the health status of all patients through the Intel-GE Care Innovations Guide - Virtual Care Suite and identify any abnormalities, such as a patient gaining three pounds in one day. The nurse could then contact the patient, set up a videoconference using the Guide, and discuss why the change may have occurred. Did the patient run out of medication, or fail to recognize the sodium content was high in his last meal? Moments like these encourage what Humana Cares calls just in time learning opportunities, which are extremely effective in producing long-term behavioral change. Because Humana Cares nurses intervene at the first sign of trouble, patients gain a personal understanding of which habits exacerbate CHF symptoms and how they can overcome these obstacles.

The Guide is customized to meet the individual needs of the patients and their treatment plans. Humana Cares coordinates and shares data with each patients physician, allowing clinicians to view measurement reports. This is a vital link in the information chain that has the potential to lead to better long-term health and lower long-term health care costs.

Members typically participate in the program for six to nine months, at which point they meet criteria for better managing their condition and living a healthier lifestyle. Once Humana sees evidence that patients have learned how to manage their conditions, patients graduate from the program and Humana personalizes the Guide for another CHF patient.

Recognizing the Potential to Reach More Patients

During the six month deployment period, 1,000 Guide units were deployed in 33 states. Now, CHF patients, even those living in remote areas, can receive personalized care and support in their homes, making it easier for these patients to comply with their treatment plan and manage their chronic condition. 

The overall goal of the program is to increase patient self-management to improve health, reduce hospitalizations and ER visits, and lower health care costs. While its too early to quantitatively measure these results, Humana Cares is optimistic about the programs effectiveness. High patient adherence and satisfaction rates indicate patients like the Guide and find it easy to use. Equally important, Humana Cares nurses report that the valuable, real-time information provided by the Guide enhances the effectiveness of their patient interactions.

Humana will fully evaluate the success of the program including ROI, admission and readmission rates for CHF patients, as well as ER visits for CHF patients. In addition, they will measure post-participation weight monitoring, member adherence, member satisfaction, device and peripheral replacement rates, and staff satisfaction, as well as overall program design. If the program proves to be successful, the company may launch similar programs for patients with other chronic conditions.

The Guide platform is designed to help address the many challenges that accompany chronic conditions. It is a comprehensive, remote health monitoring and management solution to help health care organizations and insurance providers more efficiently extend their services into homes, while engaging patients to create lasting lifestyle changes.

For more information about this case study, please contact:

http://www.careinnovations.com/guide

14. Bon Secours Hampton Roads: Teleneurology Brings Better Outcomes, More Profitability

Like all health systems, Bon Secours Hampton Roads (BSHR) continually seeks ways to improve its competitive advantage. However, developing a growth and differentiation strategy is challenged by the fact that its southeastern Virginia and northeastern North Carolina catchment area is right in the backyard of a large, $3.5 billion, fully-integrated, non-profit health system.

BSHRs flagship hospital, Bon Secours Maryview Medical Center, is a 346-bed acute care hospital located in Portsmouth, VA. Its the largest hospital within the Bon Secours Hampton Roads health system, which also includes Bon Secours DePaul Medical Center, Bon Secours Health Center at Harbour View, Bon Secours Mary Immaculate Hospital and Bon Secours Health Center at Virginia Beach. With a patient population that suffers a high incidence of cerebrovascular disease, Maryview Medical Center was the best choice for initial rollout of a new neurosciences service line that the health system decided to launch. The first step: making Maryview a Joint Commission-certified primary stroke center.

Finding the Best Coverage Option

To obtain primary stroke certification, Maryview needed to provide 24/7/365 emergency neurology coverage. Although fortunate to have one local neurologist taking call, providing round-the-clock on-call coverage was becoming an overwhelming burden for one neurologist to sustain. Like many hospital administrators around the country, Smith found few local neurologists willing to take call. And those that did required that the hospital pay them $800 a day, or approximately $300,000 annually. This extra line item made the service line pro forma less compelling, especially in the start-up phase.

Looking at the traditional alternatives of recruiting neurologists or hiring locum tenens, Smith quickly dismissed the latter since it was not optimal. The recruitment process was not immediately fruitful either and Maryview required a minimum of one or two additional neurologists to provide 24/7 emergency neurology coverage to achieve primary stroke center certification. Conversely, while $300,000 for stroke stipends seemed exorbitant, locum tenens would actually have been more expensive and only a temporary solution, not the foundation of a new stroke center.

Selecting Teleneurology

Fortunately, another hospital in the Bon Secours network previously overcame these challenges as it sought stroke center certification. After extensive due diligence, Richmond Community Hospital (RCH) had selected the Specialists On Call teleneurology solution to solve its coverage challenges.

RCH reported that even in the first year, Specialists On Call decreased costs and improved care quality. Satisfaction among RCH physicians, staff, and patients was high. With a ringing endorsement from RCH, Maryview also implemented Specialists On Calls emergency teleneurology consultation service.

Raising Care Quality, Creating a Bottom Line Impact

Before partnering with Specialists On Call, ambulance services handling stroke patients routinely bypassed Maryview. Since implementation, the hospitals stroke volume has steadily increased. Within the first 12 months of go-live, Maryview experienced numerous benefits, including the following:

•        39 percent growth in admissions

•        $486,000 increase in contribution profitnot factoring any cost savings from the elimination of $300,000 annual stipends

•        0.5 day decrease in the average length of stroke patient stay

•        $200-plus decline in cost per case

•        More than triple the number of cases in which tPA was administered

Setting the Stage for Future Growth

When using the teleneurology service, the hospitals emergency department physicians are now guaranteed a 15-minute response by Specialists On Calls top-quality neurologists. Patients and staff alike appreciate their quick response, evidence-based treatment recommendations and quality service.

Maryviews hospitalists no longer need to cover the ED for neurology patients, and they can contact Specialists On Call with any followup questions. Local neurologists, too, are relieved of the disruption of emergency calls, which gave Maryview the ability to more easily recruit and employ three additional neurologists to support the growth in
the neuroscience program. 

Within the first year of partnership, Specialists On Call helped the stroke program at Maryview grow volume and profit by 35 to 40 percent, along with an across-the-board improvement in quality outcomes.

Specialists On Call delivered on everything I expected. And the physicians feel that way too, which is even better yet, explains Smith. We were a little concerned about patient perception, but it turns out they love it! Its new and modern healthcare.

As a result of the benefits Specialists On Call has brought to Maryview, Smith is now implementing the service in other BSHR facilities.

For more information about this case study, please contact:

Kathleen M. Plath, SVP, Sales and Marketing, Specialists On Call; 866-805-1513, info@soctelemed.com

15. Telemedicine Brings Travel Relief to Pediatric Patients in Montana with Head Injuries

Pediatric patients and their families are breathing a sigh of relief.  St. Vincent Healthcare has launched a pediatric tele-neurosurgery consultation project which allows some pediatric patients who have received a head injury to stay in Montana without transport to a metro area for care.
 
The American Academy of Pediatrics mandates that all head injuries be evaluated by a pediatric neurosurgeon.  The standard of care for pediatric head injuries requires the patient to receive a computerized tomography scan (CT Scan), be observed for 24 hours and then to repeat the CT scan.  For Billings Montana, that means that the nearest Pediatric Neurosurgeon is at a minimum 500 miles away.  We found that in the majority of the cases the child never has to have an intervention done.  Therefore these pediatric patients get evaluated in our emergency department, the CT Scan is done and the patient is transported to the Childrens Hospital of Colorado in Denver for observation.  By the time the parents go there (about a 9 hour drive), the patient isready for discharge.
 
Prior to the implementation of this program, one to two children a month were being transported to Denver and discharged in less than 24 hours.  Cost analysis for this type of transport is valued at $15,000 or more per transport.  With the advent of this program, the child gets the CT Scan,the neurosurgeon reviews the CT and conducts a video assessment of the child.  The Pediatric Neurosurgeon, who is providing oversight for this patient, in conjunction with the local traumasurgeon determines that the children at low risk for emergent complications and are able tosafely stay in their home community; or in Billings if they are from a regional rural community.
 
For those pediatric patients requiring transport to the Childrens Hospital of Colorado, once the child is discharged, follow up visits can be conducted via telemedicine.  The telemedicine services provided is more convenient for our Montana pediatric patients, and saves travel costs for them without compromising the quality of care.  

For more information about this case study, please contact:

Doris T. Barta, Director Telehealth Services; 406-237-8651, Doris.barta@svh-mt.org

16. Patient Profile: Teleneurology Provides Swift, Lifesaving Treatment

As a long time nursing director with Christus St. Michael Health System and a member of its stroke team, Sandra Bowden realized the debilitating impact stroke was having on her community of Texarkana, TX.

Not unlike the national figures, stroke was the fourth leading cause of death for adults and the number one cause of disability in her community hospital serving four states in a 25 mile radius. Sandra was committed to making a difference and took a leadership position on the hospitals stroke planning team, spearheading their campaign to become a certified stroke center.

When she began to experience stroke symptoms at work, however, her interest in stroke became extremely personal.

Sandra's Experience

Shortly after an early morning meeting with the Christus stroke team, Sandra began to feel a tingling sensation around her ear and toward her face. By the time it spread down her left arm, a colleague noticed the left side of her face was drooping and she quickly escorted Sandra to the emergency room.

Once there, the Christus St. Michael Health System emergency department initiated stroke protocol and after the emergency room physician had checked her condition, she was immediately sent for a CT scan.

Top-Notch Treatment

By the time Sandra returned to the emergency room from her CT scan, Specialists On Call had been notified and their neurologist was already speaking with her attending physician.

It was just a short time before the television monitor was brought in and the neurologist introduced himself. By the time he was doing the neurological exam, however, I felt like he was right there in the room, Sandra explains.

Sandra was treated by Specialists On Calls neurologist, Dr. Todd Samuels. A board certified neurologist who has been in private practice for
more than 22 years, Dr. Samuels has worked with Specialists On Call for over three years. He chose to work with Specialists on Call because of its proven clinical effectiveness.

Ive been on both sides of the situation, Dr. Samuels says. Ive been a community neurologist and I know for emergency situations I can provide much more timely care as a teleneurologist than I can as a bedside neurologist.

Quick, Lifesaving Care

Via telemedicine, Dr. Samuels conducted a complete neurologic assessment of Sandra with the help of the attending nurse.

During my consultation with Dr. Samuels, I was the center of his attention, Sandra says. He did his examination. He asked me questions. He addressed me by my name and did the same with my husband. We were his entire focus and he answered all my questions and made us feel comfortable during a very difficult time.

Dr. Samuels explained to Sandra that he believed she was suffering a stroke and was eligible for the clot busting drug, tPA. He then went through the benefits and risks associated with that particular therapy and gave Sandra and her husband time to make a decision. Once they had decided to pursue treatment, Dr. Samuels oversaw the administration of tPA and was able to check in on her periodically.

I dont know what I thought he was going to do...I assumed he would order the drug and that was that, but he stayed and checked in on me, Sandra recalls. In a short time, I started to have resolution of symptoms and you could see Dr. Samuels was very pleased with the outcome.

A Successful Outcome

Shortly thereafter, Sandra was transferred to the ICU where her condition continued to improve. The left side of her face continued to droop for the next couple of days and she experienced a minor issue with her gait and balance, but physical therapy resolved those conditions and today she lives a normal life with no deficits.

By the time I got down to the ED and everything had been done, Specialists On Call was involved, Dr. Samuels was there, and all the proper things had been done with his guidancethe care I received was the highest quality, Sandra recalls.

I could not have asked for any better care. Dr. Samuels guided the treatment and the assessment, and the decision making included me and my husband. I couldnt have asked for higher quality care, says Sandra.
 

For more information about this case study, please contact:

Kathleen M. Plath, SVP, Sales and Marketing, Specialists On Call; 866-805-1513, info@soctelemed.com

17. Pediatric Teledermatology: Improving Access in an Academic Childrens Hospital

Childrens Hospital of Pittsburgh of UPMC is a 296-bed facility that is distinguished nationally by its ranking in the top ten childrens hospitals in 2012-13 by US News and World Report.  As cited in the same US News and World Report, it was the fastest pediatric hospital in the U.S. to achieve Stage 7 recognition from HIMSS Analytics for its electronic medical record and has also been recognized by KLAS as the number one pediatric hospital in its use of health care information technology. 

In accordance with the national shortage of pediatric dermatologists, Pittsburgh has only two board-certified pediatric dermatologists located within a 125-mile radius of the city.  In order to improve access to care and decrease wait time for urgent pediatric dermatology consultations in the emergency room and inpatient floors, a formal telemedicine program was established in January 2011.  A grant was obtained by Highmark Blue Cross Blue Shield to support a pilot of this program.

Between January 2011 and November 2012 a total of 492 consultations were seen by store and forward teledermatology at Childrens Hospital of Pittsburgh of UPMC.  Of these, 305 (62%) were seen in the emergency department, 152 (31%) on the inpatient medical floors, 12 (2%) in the neonatal ICUs and 23 (5%) in the pediatric ICUs.  The response time was less than 1 hour in all emergency room consultations and less than 12 hours (the majority, however, were less than 1 hour) on the inpatient floor and ICU consults.  While this list is not all-inclusive, several examples of some of the most common reasons for teleconsultation included:  urticaria, drug eruptions (DRESS and Stevens Johnsons syndrome), atopic dermatitis, skin infections (Staphylococcal scalded skin syndrome and eczema herpeticum), contact dermatitis, neonatal dermatoses, and atypical viral exanthems. 

The process was implemented as follows:  digital cameras were placed in locked safes in the emergency department and every inpatient floor and ICU so that they were readily available to the busy hospital teams.  A consultation could then be initiated by a member of the emergency department or hospital team by downloading at least 3 high-quality, clear digital images directly into the patients electronic medical record in Cerner Powerchart along with a full note explaining the chief complaint, medical history and physical examination.  The hospital team then paged the dermatology resident on-call, who together with the pediatric dermatology attending remotely accessed the electronic record with a secure remote login and provided recommendations to the team both by phone as well as in the patients electronic record.  The primary in-house team then carried out the treatment as they saw fit based on these recommendations.  For the majority of patients an in-person follow up with pediatric dermatology was performed later in the hospital or as an outpatient to ensure that the recommendations were effective and that the patient was improving.  All interactions were HIPPA-secure and remain permanently archived in each patients electronic medical record.

Our experience has demonstrated that an organized store and forward teledermatology program can enhance patient access to an underserved pediatric subspecialty, such as pediatric dermatology.  It provides more time-efficient, precise care, decreasing patient travel and expense, and even in many cases decreasing prolonged hospital stays which previously may have occurred while patients waited in-house for a subspecialty in-person consult.  This translates into cost savings to both the healthcare system and the patient.  Our pediatric teledermatology program has been met with tremendous patient and provider satisfaction.  The first months pilot in 2011 also won a Best of Blue Clinical Distinction Award within Blue Cross Blue Shield.  While the initial pilot grant has now been exhausted, a bridging grant was just provided by the Childrens Hospital of Pittsburgh Foundation.  The challenge moving forward will be to secure a more lasting and widespread insurance reimbursement pattern for these valuable store and forward interactions in order to continue to expand patient care.

For more information about this case study, please contact:

Robin P. Gehris, MD, FAAD, FAAP; 724-933-9190