4 Healthcare Leaders Explain How Telehealth is Impacting Care Delivery: An HCE Original Report

by webadmin on April 14, 2016

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Recently, HCE spoke with four healthcare leaders about the impact telehealth is having on their delivery of care.

Here’s what they had to say.


Martha Whitecotton, Senior Vice President of Behavioral Health Services at Carolinas HealthCare System in Charlotte, N.C.

Although telepsychiatry is common to many for-profit companies and healthcare systems, Martha Whitecotton, senior vice president of behavioral-health services at Carolinas HealthCare System in Charlotte, N.C., said her organization is taking it to another level.

For the past 15 years, the system’s approach to telepsychiatry has been pretty standard.

“When a patient comes into the ER and their primary diagnosis is a behavioral-health illness or psychiatric illness, they can be medically cleared by an ER physician, but they really need a psychiatrist to clear them for discharge or determine that they need admission if they have a psychiatric illness. Even in very urban areas, it’s very difficult to get a psychiatrist into an acute-care hospital emergency room because there’s such a manpower shortage.

“Telepsychiatry allows you to get a psychiatrist into an acute-care emergency room to provide a diagnostic opinion about a psychiatric patient to see if that patient is safe to discharge or needs to be admitted to a psychiatric inpatient hospital.”

Carolinas HealthCare’s EMR has only improved this process, she said, as the psychiatrist can now enter the prescribed medication into the record and the patient can begin on their medication immediately.

“Often these patients have gone off their medications and that’s what has created the exacerbation of illness and brings them to the emergency room,” Whitecotton said.

Because Carolinas HealthCare’s telepsychiatry program is so refined and advanced, Whitecotton said she and her team have been able to focus on other gaps in care within the program. As an expansive health system, many of the emergency departments in the system were often vying for the same beds for psychiatric patients in need of admission.

Whitecotton said the creation of a centralized inpatient placement team has resolved this quandary. Because the placement team deals with every ER and hospital in the system, they intuitively know how to transfer patients in terms of acuity, removing the most disruptive or the sickest from the ER immediately.

“They know the psychiatric hospital, they know the beds, they know which patients fit in which hospital, they know the patient coordinators at each hospital, so they move the patients much more quickly.”

Furthermore, most emergency rooms are dependent on law enforcement to transport behavioral-health patients, Whitecotton said. “And that becomes problematic, not because law enforcement is not good at it. They are. But they will almost always only transport patients on involuntary commitment. So that means even if the patient is willing to go on a voluntary status, the emergency room is required to convert the patient to an involuntary commitment in order to have them committed.”

An involuntary commitment on their record can have ramifications down the road for the patient as they progress through their treatment. Also, law enforcement must place a secondary priority on transporting patients, since criminal matters are most important. This can lead to a patient languishing in the ER.

For this reason, Carolinas HealthCare contracted with G4S, a company that has built a niche service in the United States on transporting behavioral-health patients.

North Carolina also suffers from a bed shortage, but thanks to the placement team and G4S, Whitecotton said the system has been able to reduce the hours of ED psych hold by 50 percent in some cases.

“We’re accomplishing the Triple Aim,” she said. “We’re impacting the patient’s experience of care, improving the clinical effectiveness of care, and decreasing the cost of care, and that’s really because of telemedicine. That’s what value-based care is all about.”

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Ken Krakaur, President of Third Core and Vice President of Sentara Healthcare, Norfolk, Virginia

In the fall of 2012, Sentara Healthcare partnered with telehealth company MDLIVE to offer telehealth to its patient population. This was the culmination of a strategic plan launched by the system in 2006, which directly addressed the inevitable shortage of providers as the population aged and more consumers sought out healthcare, Ken Krakaur, president of Third Core and vice president of Sentara, said.

After conducting extensive research into venue disruptions over the last several decades, the executive leadership concluded the virtual consult held solutions for this shortage and the funding challenges that would come with it.

“What we were trying to accomplish with MDLIVE was to increase the access to our patients to get our costs down, because virtual consults cost less than a physical consult,” Krakaur said. “We wanted to increase the clinicians’ productivity, and we needed to really increase our digital footprint. We needed to move away from bricks and mortar to clicks and mortar, the idea being that there’s way too much investment in buildings, which just raises the costs and requires you to be into an economic model with physician practices that is not sustainable. We also thought we could generate some new revenue for our medical group.”

MDLIVE was an ideal partner for Sentara, he added, because the company’s energetic, progressive vision meshed well with the system’s approach to customer service and the patient experience.

With approximately 700 providers in Sentara’s physician group, Krakaur could easily see virtual consults being conducted across the entire state of Virginia, especially when a new physician didn’t have a full panel yet. The team also considered the modern penchant to seek an app for every aspect of life.

“Connecting with the physician through that type of a product and that type of a tool we thought would be a real crowd-pleaser,” Krakaur said.

To test reception to telehealth, Sentara rolled the option out to its 20,000 employees, initially making it voluntary. When only 3,000 signed up in the first year, the system began offering incentives, which led to more enrollees and positive word-of-mouth among the employee population.

“You have to explain to your employees when you roll this product out: first, it will save you money; second, it will help you with presenteeism at work; and third, it will be a convenience for you,” Krakaur said. “But in retrospect, I don’t think it’s good to make this voluntary.”

By paying a per-employee-per-month fee to MDLIVE, Sentara is able to provide lower-cost care to its employees through telehealth. For example, the aggregate average for all employee low-acuity claims is $115 for visits to the emergency department, urgent care, and physician offices versus $40 using the MDLIVE virtual consult.

“If I go to the doctor, my office visit co-pay is $40; if I go to the urgent care, it’s $70; if I go to the ED, it’s $250; and if I go virtual, it’s $15,” Krakaur said. “If you can deliver virtual care to our patients in remote areas, even if they’re paying out of pocket $40, it is going to be a much better value proposition, because you don’t have to build a building, you don’t have to employ the staff, you don’t have to do anything. They just go online for low-acuity needs, and they can reach a board-certified physician 24/7.”

In the future, telehealth will also play a role in surgical follow-ups, he believes. “With a good camera smartphone, you can easily photograph your wound and email it to your physician or do a secure video of the wound and prevent having to drive to your physician’s office. They already are using this for behavioral health primarily in the primary-care arena.”

He advises his colleagues to “focus on adoption. The technology is very good, but it’s not any good if it’s sitting on the shelf. Educating people on the benefits of virtual care, and both the value that it brings you in terms of time saved and convenience are all good reasons to promote this, but it’s a big education piece. Don’t underestimate that.”

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Dr. Theodora Ross, Director of Genetics, UT Southwestern Medical Center in Dallas, Texas

UT Southwestern Medical Center, along with the Harold C. Simmons Cancer Center, launched the first and only telemedicine genetics screening program in 2012. Recently, they received a three-year CPRIT grant to expand this program from underserved populations in six counties to 22 counties. This will enable UT Southwestern to reach a patient population that is twice the size of the state of Massachusetts.

According Dr. Theodora Ross, director of the cancer genetics program at UT Southwestern Medical Center, patients are remotely interviewed on their family history. Those who qualify undergo genetic testing for Hereditary Breast-Ovarian Cancer (HBOC) and Lynch syndrome, two of the most commonly inherited cancer predisposition syndromes. For those carrying these mutations, the lifetime risk for breast, ovarian, colorectal, and uterine cancer is as high as 85 percent.

Although only four telemedicine sites are available to these counties, the sites are strategically positioned to be no farther than an hour away for patients. She said they’ve also partnered with UT Southwestern’s Moncrief Cancer Institute in Fort Worth, Texas, to augment the research the medical center is doing.

“They focus on community health services,” Ross said. “We’re into research here.”

Education is a major part of the program’s mission, and Ross said her team plans to accomplish their educational goals by expanding the involvement of genetic navigators in the virtual end of the program. Genetic navigators pre-screen patients, talk with them prior to their visit, and examine the family history of cancer to determine if the patients need counseling before the first pre-screen. The genetic counselors then guide the patients through the telehealth process from consent to testing.

“The navigator is integral to the whole program and will form a relationship with the person,” Ross said.

With the goal being to increase adherence rates to achieve the standard-of-care guidelines outlined by the NCCN, the compliance outcomes have been mixed.

On one hand, the patients with Lynch syndrome who are insured have a compliance  rate with the NCCN guidelines of 90  percent compared to 81 percent in uninsured patients seen at a safety-net hospital. The disparity of HBOC patients’ compliance with management recommendations is more striking, with 74 percent of insured patients following the national guidelines compared to only 39 percent of uninsured patients, Ross said.

The team is using a portion of the grant money to specifically target this less compliant group of patients through various educational means.

“Genetic counseling through telemedicine is very important,” Ross said. “The counseling takes 45 minutes to an hour. Genetics is complex. Having the counselor and patient not only hear, but also see each other’s expressions is key for both accurate communication and good compliance.”

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David Cattell-Gordon, Director of the University of Virginia Health System Office of Telemedicine, Charlottesville, Virginia

The University of Virginia Health System Center for Telehealth will be celebrating its 20th anniversary next year on the same day that Alexander Graham Bell made his first call on the telephone.

Bell’s first call was to his assistant for help after Bell spilled sulphuric acid on himself. David Cattell-Gordon, director of the UVA Health System Office of Telemedicine, said this reminds him that telecommunication has always been used to provide help, improve patient care, and increase efficiencies.

“In this environment in which we have to find greater and greater efficiency and where we’re trying to shift the paradigm from expensive upstream care to keeping people home and healthy in their community, telehealth becomes one more resource with which to do this.”

Over the course of its 20 years, the Center for Telehealth has impacted the entire spectrum of care, from high-risk OB to chronic disease management to mental health, palliative care, and stroke.

“The provider-patient relationship is the key to successful telemedicine,” said Cattell-Gordon. “And so, we are only limited by our imagination on the things we can do to enhance that relationship.”

“This is our drumroll: we have now saved Virginians 15.1 million miles of travel to see a doctor,” he added.

Currently, the Center is emphasizing home monitoring, rural-care access, and 30-day readmission prevention.

“My vision is that the day should come when there’s not an emergency bay out there that doesn’t have a mobile camera in it,” he said. “The technology is there and getting cheaper all the time. Our requirement in the health industry is to, in an evidence-based manner, apply these processes, learn from them, improve them, ensure that they are secure, that they meet HIPAA compliance standards, and we know the clinical outcomes they provide. Let’s use it well.”

The Center has benefitted largely from location, Cattell-Gordon explained. Early on, Virginia granted Medicaid coverage for telemedicine, later expanding that to Medicare. Incidentally, these legislative votes were bipartisan.

“So we have parity in this state,” he said.

The state also has a strong broadband network, which positions the Center nicely for the future.

“I believe the day is coming soon when you look at a community and you measure their health metrics–whether that’s their blood pressure, weight, or blood sugar–that there will be a new measure and that measure is broadband and that broadband will be shown to have a correlative relationship to how healthy a community can be.”

As the Center looks to the future, Cattell-Gordon said he and his team are working with Google Glass to train medical residents to give neurological exams while wearing the device. The attending physician can then see what the resident is seeing and talk to them over the glasses and guide them along, improving the overall instruction and education of the resident.

The Center has also earned approval for a research project to provide iPads to EMS professionals. This will enable them to conduct the NIH stroke scale on suspected stroke patients while they’re in the back of the ambulance. By doing this, the patient will immediately be transported to a CT scan if necessary as soon as they arrive at the hospital, saving precious seconds and salvaging their quality of life. Results from this study will be presented at the 2015 International Stroke Conference.

“My strongest recommendation for leaders in healthcare,” Cattell-Gordon concluded, “is to move on these strategic plans for the use of this tool quickly and see it not as a utility, but as an upfront tool for an entire health system.”

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As healthcare leaders, how are you using telehealth in your organization and how is it impacting your delivery of care? How do you plan to further incorporate telehealth into your strategic planning for the future?

-by Pete Fernbaugh

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