Disclosures. Objectives. Telemedicine to Improve Care for the Underserved. I have nothing to disclose

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1 Disclosures Telemedicine to Improve Care for the Underserved March 11, 2016 I have nothing to disclose George Su, MD Medical Director of Telehealth, San Francisco Department of Public Health Associate Professor of Medicine, UCSF San Francisco General Hospital Objectives 1. Basic telemedicine modalities 2. Telemedicine delivery models 3. Design of telemedicine applications and care for the underserved 1

2 Definitions Telemedicine: use of medical information exchanged from one site to another via electronic communications to improve patients health status Telehealth: same as above, but not restricted to clinical services San Antonio Harlingen American Telemedicine Association, 2010 Five types of telemedicine Referring provider Specialist Patient Provider Home monitoring Remote medical education Informational push Telemedicine modalities Synchronous Live video Asynchronous Store-and-forward American Telemedicine Association,

3 Synchronous live Asynchronous Remote monitoring Telemedicine models Rural ( traditional ) Urban Delivery system model 3

4 Telemedicine models Hub and spoke Traditional vs. Urban Hub site Spoke/network member Rural health grant recipients Center for Applied Research and Environmental Systems Office of Rural Health Policy, HRSA, 2011 Spoke and hub Neurosurgery Trauma Alaska Federal Health Care Access Network (AFHCAN) Neurology Psychiatry Oncology 4

5 Virtual Dental Home Courtesy of Frank Anderson IDEA Tel 5

6 Rural telemedicine Urban telemedicine Geographic barriers and access disparities Telehealth carts, video applications Higher workflow burden Higher density of specialists Access to specialty services Health disparities and barriers to care Hub and spoke Maxine Hall Health Center South of Market Health Center Haight Ashbury Free Clinic SF AIDS Foundation Black Coalition on AIDS 6

7 Delivery system model Urban telemedicine PLUS Design of telemedicine applications are contextualized to and aligned with system goals: Quality care Cost-effectiveness Patient-centeredness Annually: 110,000 inpatients 592,000 outpatients 33,000 mental health 3,300 trauma Delivery system Capitation Financial resources Primary care burden Specialty access Fixed workforce Integrated care Delivery system model: design considerations telemedicine Partnership model System-wide context and benefits Population health Chronic care management Patient-centered care principles 7

8 The Partnership Model The Partnership Model Drivers determine outcomes Drivers: Reasons to partner Partnership Components: Joint activities and processes Outcomes: How did we do? Facilitators: Supportive factors Typically a primary care-specialty partnership Technologies must enhance these relationships Ohio State University Global Supply Chain Forum Redrawn: Lambert et al., Harvard Business Review, 2004 The Partnership Model: Telemedicine Drivers align with institutional priorities Drivers: Access Inefficiencies Costs Satisfaction Telemedicine Components: Technology Workflows Outcomes: Better access Efficient care Lower costs Satisfaction Facilitators: Sponsors Incentives Teledermatology Toby Maurer, MD Chief, Dermatology at SFGH 8

9 Teledermatology Teledermatology workflow Referring provider Medical assistant SFGH Dermatology Faculty SFGH Dermatology Scheduler Referring provider Drivers: Access Wait times Force multiplier Telederm Components: Technology Workflows Workflows EMR Facilitators: Prop 1D DSRIP Log onto Medical record Document consult in medical record Create OUTGOING REFERRAL Clear camera Take photos Notification worklist Review and triage Submit report, automated to clinic Appointment as needed Direct provider notification Automated Electronic record notification Results posted to medical record Outcomes: System-wide spread/adoption Access Contact medical assistant for photos Upload and Submits DELETE photos Consults vs. third next available appointment Reports and images Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Apr TNAA 72 days 111 days 65/month 96 days 90/month Consults 16/month 42 days 9

10 Force multiplier Diagnosis n Inflamed seborrheic keratosis 24 Nevus, non-neoplastic 14 Psoriasis vulgaris 13 Actinic keratosis 10 Acne vulgaris 6 Other atopic dermatitis 4 Ganglion, unspecified hand 4 Viral warts 3 Hemangioma unspecified site 3 Atopic dermatitis, unspecified 3 Nummular dermatitis 3 Vitiligo 3 Lichen simplex chronicus 2 Other prurigo 2 Alopecia areata, unspecified 2 Other rosacea 2 Rosacea, unspecified 2 Teleretinopathy Cynthia Chiu, MD Associate Professor of Ophthalmology Program Director Jay Stewart, MD Chief, Ophthalmology at SFGH Jim Larson Lead Technician Teleretinopathy Drivers: Poor screening rates Technical capacity DR screening Components: Technology Data Workflows Model Facilitators: Prop 1D DSRIP Outcomes: Screening program 10

11 Population Diabetic retinopathy screening rates Active Panel Diabetics (per clinic) Active panel patients with DM Active panel patients with DM IMPACT $60,000 camera Demand? Local expertise Capacity Quality assurance Integration FEASIBILITY IMPACT $60,000 camera Demand? Local expertise Capacity Quality assurance Integration FEASIBILITY 11

12 Target need Active Panel Diabetics (per clinic) Home monitoring: positive airway pressure George Su, MD Medical Director Eula Lewis RRT, CTTS Outpatient Director, Respiratory Care Services Program Director 12

13 Effector arm Day 30 Identify at-risk patients Phone interrogation POTS PAP Clinic Enlist DME vendor(s) Follow-up protocol RCS Day 60 Home monitoring pilot: 30 day Days with 4 hr/day use over 30 days (%) Day 30 Day 60 Day 30 Day 60 POTS Usual care 13

14 Patient-centered care for the underserved Patient-centered care for the underserved Welcoming environment, comfort, support Respect for patients values and expressed needs Patient empowerment or activation Socio-cultural competence Coordination and integration of care Access and navigation skills Community outreach Community Health Center Telemedicine Specialty Silow-Carroll, et al., 2006 Community health Center (CHC) Specialty service Which statement regarding the use of telemedicine in community health centers (CHCs) is correct? A. Community health centers that provide telemedicine services are more likely to serve urban rather than rural communities. B. The costs required to implement telemedicine in CHCs are low, and do not pose a significant barrier to adoption. C. Telemedicine in CHCs increases access to specialty-level care and diagnostics, while maintaining a patient-centered focus and attention to needs of underserved communities. D. Community health centers that provide telemedicine services have lower nonphysician staff ratios than CHCs that do not offer telemedicine. C o m m u n i t y h e a l t h c e n t e r s t h.. T h e c o s t s r e q u i r e d t o i m p l e... T e l e m e d i c i n e i n C H C s i n c r e a s.. 100% 0% 0% 0% C o m m u n i t y h e a l t h c e n t e r s t h.. 14

15 Provision of telemedicine by CHCs Increases access to specialty-level care and diagnostics, while maintaining a patient-centered focus Point-of-service specialty services leverages local expertise and resources Telespirometry George Su, MD Medical Director Eula Lewis RRT, CTTS Outpatient Coordinator, Respiratory Care Services Program Director Shin, et al, 2014 Patient Data loops Virtual Coach Telespirometry (pre- & post- comparison) 23% Acceptable 16% FAIL 45% FAIL 25% Caution 59% Acceptable 32% Caution n=985 15

16 Pulmonary function testing lab wait times Wait times (weeks) Community health center telemedicine -survey of 625 CHCs 147 (23.5%) one telemedicine service 82 (13.1%) 2 telemedicine services 2 telemedicine services vs. without: 54.9% vs. 34.8% rural 28.0% vs. 47.0% urban 18.2% vs. 17.1% both 5.2 vs. 3.5 mid-level providers (FTEs per 10,000 patients) 25.9 vs other (FTEs per 10,000 patients) Shin, et al., 2014 Telemedicine at community health centers Limited budgets, low debt tolerance, competing demands for funds Costs: technology, system upgrades, ongoing use, maintenance Alternative funding (grants, group purchasing, open source solutions) Medicare reimbursement: originating site is rural Health Professional Shortage Area (HPSA) located outside of a Metropolitan Statistical Area (MSA) FALSE FALSE CORRECT FALSE Question Which statement regarding the use of telemedicine in community health centers (CHCs) is correct? a. Community health centers that provide telemedicine services are more likely to serve urban rather than rural communities. b. The costs required to implement telemedicine in CHCs are low, and do not pose a significant barrier to adoption. c. Telemedicine in CHCs increases access to specialty-level care and diagnostics, while maintaining a patient-centered focus and attention to needs of underserved communities. d. Community health centers that provide telemedicine services have lower nonphysician staff ratios than CHCs that do not offer telemedicine. Gaylin, et al., 2011; Fortney, et al.,

17 TELE-MED Act of 2015 Amends title XVIII of the Social Security Act to permit certain Medicare providers licensed in a State to provide telemedicine services to certain Medicare beneficiaries in a different State Expands pool of eligible consultants, but doesn t address reimbursement gaps (particularly for non-rural setting) n=985 Telemedicine to improve care for the underserved Rural traditional telemedicine geographic disparities High potential to address disparities and barriers in urban settings Can leverage CHCs to promote patient-centered care Substrate for primary-specialty relationship ( partnership model ) Delivery system model requires multidimensional design Well-designed programs can align with health care reform principles Well-established value proposition (cost/benefit) for rural model Health outcomes/urban models need further evaluation Reimbursement remains barrier Thank you! george.su@ucsf.edu George Su, Medical Director of Telehealth, SFDPH Bruce Occeña, Director of Telehealth, SFDPH 17