2014 NRTRC Telemedicine Conference Reaching Patients Far and Away: Telemedicine & Telehealth March 24, 2014 Jovanna McKinney Katherine Flynn, RN Yolanda Evans, MD MPH
Disclosures Practice Gap: Lack of awareness on how to provide specialty care services to under-served populations in the region. Desired Outcome: Providers will be able to apply knowledge acquired from the conference to better provide care using telemedicine to patients across the region. Providers will be able to solve problems within their practice using telemedicine. Providers will be able to identify the services available for their patients via telemedicine within their region. Providers will be able to recognize the changes in telemedicine and how best to continue improving their practices during change. Disclosure of relevant financial relationships in the past 12 months: I have no relevant financial relationships with commercial interests that may have a direct bearing on the subject matter of this CME activity.
Overview What is Telemedicine Use at SCH Research FAQ s Future Endeavors
Telemedicine: Definitions Telemedicine: the use of medical information exchanged from one site to another via electronic communications to improve a patient s health status Telehealth: a broader term that does not always include direct patient care; use of information technology to access health assessment, diagnosis, intervention, consultation, supervision, & information across distance Telemedicine Telehealth Videoconferencing Videoconferencing: holding a conference with people at remote locations by means of transmitted audio and visual images
Telemedicine Terms defined As defined by Medicaid Distant Site The physician or licensed practitioner is located here at the time of service Originating Site The patient is located here
Seattle Children s: History of Telemedicine 2001 Goal: to provide enhanced access to pediatric specialty care in the region. Funded through a $3.1 million Federal appropriation and administered by the Office for Advancement of Telehealth. Provided interactive video teleconferencing and diagnostic services at 11 sites in the Pacific Northwest. 2005 Federal funding ended. Children s has implemented telemedicine program into its operational structure.
Telemedicine & Telehealth at SCH Telehealth technology is used in various settings: Outpatient Clinics: enabling access to subspecialty providers and services Teaching: access to pediatric, surgical, and nursing grand rounds; bowel and bladder health; Autism series Inpatient: pediatric and neonatal intensivists and discharge planning coordination
Why We Do It The use of telemedicine has numerous benefits including: Cost savings for travel Access to Specialists Quality care for patients Convenience Building partnerships
Telehealth Challenges and Solutions Challenge Providers based on geography or location Telehealth Solution Access to medical providers at larger hospitals or medical practices Lack of subspecialty services in the community for children with special health care needs Limited learning opportunities for community providers Access to subspecialty clinics without families needing to travel or take extra time off of work Access to CME training and subspecialty training, conferences, and lectures Limited funding to pay for bringing subspecialists into rural communities Savings on travel reimbursement for subspecialists providing outreach services
Telemedicine Volumes Seattle Children's Telemedicine Program 2010 2011 2012 2013 Total Ambulatory Consults 1,672 2,265 2,577 2,677 Echocardiograms Conducted 870 1,028 1,242 1,357 Total Consults - 2001-2013 16,209
Telemedicine use by Specialty Visits by Specialty: Oct 2012 Sept 2013 Echocardiogram 1357 Psychiatry 932 Dermatology 81 Endocrine 188 Nutrition 22 Pulmonary 23 Neurology 15 Rehabilitation 12 GI 25 Other (including Pain, PASS, VAN, Renal) 22 TOTAL 2677
A Patient Story 6 y/o patient seen in GI clinic from a single parent family. Mom has had to decrease her hours at work and change jobs in order to care for her child. Travel to Seattle is a hardship as they live in Elma WA, yet follow up care (including nutrition) is of vital importance. Telemedicine enables this follow up They travel 30 minutes to Olympia for telemedicine visits instead of over 90 minutes to Seattle
Research & Examples
Patient Satisfaction For Telepsychiatry, parents of children and adolescents endorsed high satisfaction Satisfaction increased with return appointments Parents of younger children were more satisfied than those of adolescents Myers K, Valentine J, Melzer S. Child and adolescent telepsychiatry: utilization and satisfaction. Telemedicine and e-health. Mar 2008, 12(2): 131-137
Words From Patients and Families From Families and Providers Using Video conferencing for discharge teaching I felt more comfortable about the team that will be caring for my child in Missoula. I m OK about going home now Montana mother When I have kids get direction from the medical Mecca, we don t always get a clear message from the parents and notes. Care can fragment. VTC discharge makes for better care and outcomes. -Montana Pediatrician Coordination of care for this patient has been difficult for many reasons including location and language barriers. Using VTC you could actually see and meet his care providers. Alaska Dietician
Research: Psychiatry Children s ADHD Telemental Health Treatment Study (CATTS) What was CATTS? CATTS was a study funded by the National Institute of Mental Health to determine whether children with ADHD in underserved communities can be effectively treated through telemental health (TMH) --- over the TV!
Examples in Action: Psychiatry Pediatric Access Line (PAL) Program started in 2008 in WA and 2010 in Wyoming 800-900 phone consults/year About 1 in 10 lead to telemedicine visit Telemedicine patient consultation is a back up to phone consultation During the consultation psychiatrist and patient visit to address concerns of the community provider
Examples in Action: PAL Wyoming Foster Care and Court evaluations are a growing source of consultation For more information: www.palforkids.org and www.wyomingpal.org Wyoming
Heart Center Telemedicine in Cardiology is used for: Teleconferencing: Regional collaboration Educational activities Patient management and planning Tele-consulting: Echocardiography (cardiac ultrasound) Prenatal cardiac consultation
International Cardiac Telemedicine Program Kiev, Ukraine
Cardiac Telemedicine: Implementation Regional echo Results obtained at regional site Transmitted echo image Live interpretation at Seattle Children s
Real-Time vs Store and Forward Of 769 pediatric echos performed via telemedicine over a 2 year period: 0.4% could not be transmitted due to technical difficulties All but one follow up echo (of 67 repeated in person) confirmed the initial diagnosis 655 video recorded studies over 20 months were also examined 32 were repeated real time and 12 of those (38%) had discrepancies Accuracy of video recordings may be less accurate than real time telemedicine Lewin M, Xu C, Jordan M, Borchers H, Ayton C, Wilbert D, Melzer, S. Accuracy of paediatric echocardiographic transmission via telemedicine. J Telemed Telecare, 2006; 12(8):416-21
Telemedicine Facts and Questions
Medicaid Regulations Providers must practice within their scope and must be licensed in the state where the patient is located States can reimburse providers at the distant site and a facility fee at the originating site Telemedicine is viewed by the government as a cost effective alternative to face to face care. If a state decides not to cover telemedicine visits, they must assure access and coverage for face to face visits Providers who cannot bill Medicaid for telemedicine services include RD, MSW, PhD, PsyD
Telemedicine FAQ Why can t I just use Skype or some other video chatting interface to conduct patient visits? Encryption is needed to adhere to the HIPAA federal laws on patient privacy. Using a secure server through an institution such as Seattle Children s ensures you are following Federal privacy regulations.
Telemedicine FAQ Can I use my desktop computer? No, not ideally. In order to perform patient encounters that meet the standards of in-patient encounters, medical providers must be able to clearly see patients (including skin for rashes, work of breathing, etc). The equipment used in videoconferencing is high definition and allows for this.
Telemedicine FAQ How expensive is the equipment? The cost for standard base video conferencing equipment varies based on how it will be used, but ranges from $5,000 - $11,000 total.
Future Endeavors
New and Evolving Technology ipad solution For provider to provider consultation Future uses with inpatient care and transport In Touch Robot Cardiology is trialing for echo reads Has potential uses in multiple disciplines Versatile Connections Blue Jeans Vidyo
Future Changes to Service? Medicaid and the Joint Commission Changes to provider privileges There may now be the possibility of reciprocal privileging (a provider may not have to recredential at the originating site) House Bill 1448 Passed in 2013: a bill that supports the use of telemedicine by more than MDs and ARNPs Will provide support for reimbursement
If You re Interested in Telemedicine Our Telemedicine demonstration video: http://youtu.be/xg8fykt-brq
Additional Information Seattle Children s Telemedicine Program http://www.seattlechildrens.org/contact/telemedicine/ Children s ADHD Telemental Health Treatment Study (CATTS) http://www.tv4adhd.org/videogeneral.php Partnership Access Line for Psychiatry consultative services www.palforkids.org and www.wyomingpal.org
Thank You!