Wired to Save Lives: A Virtual Hospital Experience Donald J. Kosiak, MD, MBA, FACEP, CPE Vice President for Medical Development Thursday, March 3 rd -- 11:30am
Conflict of Interest Donald Kosiak, MD Has no real or apparent conflicts of interest to report.
Agenda Objectives Identification of needs Developing telemedicine model Challenges/barriers faced Outcomes achieved Assess key processes and challenges STEPS
Learning Objectives Demonstrate how a virtual hospital model provides value and expertise to hospitals, health systems, and payers Discuss examples of how collaboration among the various service lines saves lives, improves patient care, and positively impacts the financials of the healthcare ecosystem
Learning Objectives Assess the key processes and challenges when serving remote communities, specifically addressing change management practices to build a successful program Explain the importance of developing an administrative support system for the virtual hospital model
Rural
South Dakota - USA
The Headlines Small, rural hospitals show poorer results on measures of quality of care, patient outcomes Science Daily Healthcare access lagging in rural U.S. Reuters
Rural residents are more likely to suffer from: Chronic Health Conditions Heart Problems Cancer Limited Access to Specialists Rural Healthy People 2010 "Healthy People 2010: A Companion Document for Rural Areas 9
Challenges for Healthcare Workforce shortages Geographic isolation Diminishing community economics Increasing reliance on specialists and expensive technologies Demand for quality Access Patient Volumes Workforce Economics
14,000 Diagnoses 6,000 Medications 4,000 Procedures 25% 50% of the time On Call Physician 2016 Job Description Know It All, No Mistakes 11
Challenges for Urban Medicine Large volume of people for few specialists Primary care needs not met Lack of timely, adequate follow-up Long wait times in primary ED Inpatient bed shortages --- full beds but with the wrong patients
Telemedicine for Sick People? Can it work when people are sick? Let s do it in ICU!
What is tele-icu or eicu? New model of care focuses on collaboration The purpose of the tele-icu is not to replace bedside clinicians or bedside care, but to provide improved safety and to enhance outcomes through standardization. The tele-icu is a second set of eyes that provides additional clinical surveillance and support. Goran, S. Critical Care Nurse, AUG 2010; 30 (4), 46-55 eicu is a registered trademark of VISICU, Inc.
Telemedicine for Sick People? Thomas and the Gang: University of Texas Health Science Center at Houston Remote monitoring of ICU patients was not associated with an overall improvement in mortality or LOS Only 31.1% of patients were treated by doctors that allowed the eicu to intervene Thomas, EJ et al. JAMA. 2009 Dec23:302(24):2671-8
New England Healthcare Institute Study Overview Independent study of clinical and financial performance of UMMMC s Tele-ICU program Results independently validated by Price Waterhouse Coopers Published December 2010 Key findings / recommendations Mortality rates decreased 20% LOS decreased 30% Significant gains in ICU volume Improved best practice compliance $1,000 - $4,000 improvement in margin per case Recommended Adoption for Hospitals with 10 + ICU Beds
Does Telemedicine Work? Telemedicine Improves Outcomes In the Heartland Pre-Post Community hospital 17 bed, open ICU 52.5% Level 1 vs. 47.5% full intervention allowed Pre (630 pts 6 months) and Post (2,193 pts 15 months) Mortality decreased from 7.9% to 3.8% LOS decrease from 2.7 days to 2.2 days Sadaka, F. et al. Critical Care Research and Practice; Vol. 2013, Article ID 456389
What About in the ED? Dr. Robert Galli and team: Department of EM, University of Mississippi Medical Center; Jackson, Mississippi 40,000 patients seen High satisfaction rates; good overall adoption Galli, R. et al. Annals of Emergency Medicine; 2008 MAR; 51 (3) 275-284
What About in the ED? Tele-Stroke Programs Virtual stroke care appears cost-effective Cost of tele-stroke over a person s lifetime is less than $2,500 per quality-adjusted life year Threshold of $50,000 is commonly cited as the cutoff for cost-effectiveness Nelson, RE et al. Neurology, 2011, OCT 25; 77(17): 1590-1598
What About in the ED? Children in rural ED s 5 ED s connected to pediatric emergency medicine 226 patients Referring ED physicians reported when consultations were provided using telemedicine rather than phone Changing their diagnosis (47.8% vs. 13.3%) Therapeutic interventions (55.2% vs. 7.1%) Dharmar M. et al, Critical Care Medicine; 2013 OCT; 41(10) 2388-95
Telemedicine Applications Regional prehospital ECG network ECG s sent to a centralized hub with cardiologist on duty 24/7/365 233,657 patients who activated 9-1-1 Interpretation of ECG and instructions to crew PCI vs. fibrinolysis directed from hub Reduced door to treatment times and treatment protocol variation Brunetti, N. et al; Telemedicine and e-health; Vol 17, No 9, Nov 2011 Pg 727-733
Telemedicine Applications Teledermatology via social networking Providers posted non-protected, non-identifiable photos to social media site Specialist can review and post additional questions and treatment plans 75% needed no additional referral or travel, and improved with one-time treatment recommendations Garcia-Romero, M. et al; Telemedicine and e-health Vol 17, No. 8, October 2011. pg 652-655
What Are Others Doing In EM? Romania SMURD Network 150+ ambulances equipped with telemedicine Virtually connected into ED service centers with MD s waiting for the call Nearly 90 rural facilities also monitored with this network 3 hub sites throughout the country
SMURD Critical Care Doctor
SMURD Hub Site - Romania
A Virtual Hospital Experience
S T E P S Introduction to HIMSS IT Value STEPS Satisfaction Patient and provider prospective surveys Treatment/Clinical Provide specialty care to remote and underserved patients Electronic Secure Data Data helps to improve adherence with evidence based medicine Patient Engagement and Population Management Manage difficult conditions Savings Savings of more than $180 million by avoiding transfers, preventing adverse drug events, and decreased ICU days
Virtual Hospital Providers: Physicians Boarded in Critical Care, Emergency Medicine and Geriatrics Advanced Practice Providers Pharmacists Nurses 24/7 immediate, personalized response Advanced Telemedicine Technology Administrative Support
600,000 Square Miles 10 States
elongterm Care 34 sites 2012 ecare for Correctional Facilities 4 sites 2012 eemergency 107 sites 2009 Avera ecare econsult 157 sites 1993 epharmacy 70 sites 2008 Avera eicu ecare 28 sites 2004
Approach To Develop Unique Telemedicine Model 1. Customer need 2. Philanthropic support 3. Visionary team working to change healthcare delivery
Innovation Cycle Sensing & Envisioning Operations Ideas & Intake Realization Evaluation Development
Triple Aim Better Access to Care Better Care & Better Outcomes Lower Costs
What to assess? Culture Geography Resources and gaps before developing a solution Reach out to possible partners to gain efficiency, experience and support
Scheduled Specialty Consults 157 Total Sites 33 Specialty Sites 34 Long Term Care Sites 4 Prison Sites
Immediate access to board certified Emergency Physicians and Nurses 107 Hospital Customers 3,300 Avoided Transfers Physician consultation Nursing documentation support Transfer support Continuing education
Encounters by Chief Complaint (Last 12 Months) Weakness/Lethargy 2% Overdose Behavioral Health 3% 3% Musculoskeletal 4% GI/ABD Pain 4% Other 3% Cardiac/Full Arrest 6% Burns 2% Dermatologic 1% Cardiac Non Arrest/Arrhythmia 27% Neurological/AMS 12% SOB/Respiratory Distress 7% Minor Trauma 10% Major Trauma 11%
Real time pharmacist review of all new hospital medication orders. 70 Hospital customers Improving Safety Required regulatory support Change adoption of Evidence based medicine
Avoidance of Serious Safety Events Kinetics Evaluation 7% Pain Consult 1% Renal Dose Evaluation 27% Interaction/ Review/ Clarification 37% Antithrombotic Therapy - Anticoagulatio n 28% 2,600,000 Orders Reviewed 28,000 Avoided Serious Safety Events $74,000,000 Saved
Geriatric Specialty care for long term care residents. 34 Sites Live 55% of Video Calls Result in Avoided Transfer
24 hour monitoring of critically ill patients by an Intensivist and Critical Care Nurses
Meets Leapfrog Requirements Immediate Physician Consultant Allows for new scheduling of in house coverage Throughput Reduce LOS/Mortality Reduce ED wait for admit Triage support Shares the cost of adding additional critical care team Quality Ensures compliance with P4P bundle APACHE comparison for admission/ discharge management Documentation support increases ICU CMI
Challenges Reimbursement Multi-state licensure Funding Cultural Adaptation Privacy/Security
Conclusion to HIMSS IT Value STEPS S Satisfaction Patient and provider overwhelmingly support unique model http://www.himss.org/valuesuite
Conclusion to HIMSS IT Value STEPS T Treatment/Clinical Overall Improvements: -Mortality -ICU and hospital length of stay -Ventilator days and associated complications -Medication safety -Avoidance of unnecessary transfers -Timeliness of emergency care http://www.himss.org/valuesuite
Conclusion to HIMSS IT Value STEPS E Electronic Secure Data Adherence of evidence based medicine in the following areas: Glucose control DVT prophylaxis Stress ulcer prophylaxis Sepsis screening and treatment Antibiotic selection and monitoring Anticoagulant monitoring Kinetic dosing AMI care Stroke care Emergency airway management http://www.himss.org/valuesuite
Conclusion to HIMSS IT Value STEPS P Patient Engagement and Population Management Manage patients with key metrics: 1. Patient survey data 2. Use of discharge readiness assessments 3. Use of readmission prediction algorithms http://www.himss.org/valuesuite
Conclusion to HIMSS IT Value STEPS S Healthcare Savings Savings of more than $180 million from avoided transfers, prevented adverse drug events and decreased ICU days Key metrics include: - Reduce ICU/hospital length of stay and associated savings http://www.himss.org/valuesuite
Outcomes Achieved Saves $33 Million Health Care Dollars each Year Benefits 16,500 Patients each Month Saved 1,400 Lives Eliminated 49,000 ICU Days (134 years) Reviews 2,000 Orders Daily Avoided 28,000 Adverse Drug Events Saves 1,000 Unnecessary Ambulance Transfers each Year Patients see a doctor 19 minutes sooner on average
Questions? Donald J. Kosiak, MD, MBA, FACEP, CPE Vice President for Medical Development Avera ecare don.kosiak@avera.org