Clinical Applications Using Telehealth

1
Clinical Applications Using Telehealth
Stephanie Laws, RN, BSN Project Associate,
Richard G. Lugar Center for Rural Health, Union
Hospital, Inc., Terre Haute, IN
2
Background

• Telemedicine and telehealth both describe the
  use of medical information exchanged from one
  site to another via electronic communications to
  improve patients health status

3
Background Continued

• Telehealth
• The delivery of health care from a distance
• Can include any type of care, teaching, or
  information exchange
• Telemedicine a subset of Telehealth
• Involves clinical care (billable services)
• 2 types
• Store and Forward e.g., tele-radiology Rural
  Consults
• Live clinical services via videoconferencing

4
Introduction

• Rural communities share in the responsibility for
  a healthy nation and the nation shares in
  responsibility for a healthy rural America (Rural
  Health A Vision for 2010, 1998).
• Recruitment and retention are two critical issues
  related to the maintenance of a strong rural
  hospital clinical workforce.
• Innovative technology is one way to reduce the
  sense of isolation felt by rural providers.
  Innovative technologyand innovative integration
  of technologycan facilitate a full continuum of
  care that is affordable, accessible, and
  available, while promoting accountable and
  technologically advanced partnerships among rural
  communities.

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Overview of Presentation

• What are the challenges with regard to
  recruitment and retention in rural areas?
• What do these challenges mean to community and
  rural hospitals?
• Behavioral Health example of how technology can
  be integrated to facilitate overcoming these
  challenges.
• Additional ways to meet the challenges (e.g.,
  targeted recruitment, curriculum, training,
  hands-on experience, multidisciplinary team).

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Recruitment and Retention Challenges Nationally

• Physician Shortages
• In January 2005, the 16th Report of the Council
  on Graduate Medical Education (COGME) concluded
  that due to a variety of factors, the US is
  expected to face a severe shortage of physicians,
  ranging from 85,000 to 96,000 by the year 2020.
• Slower physician growth due to retirements
• Greater demand for services due to aging
  population
• Changing physician lifestyles resulting in
  reduced working hours

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Recruitment and Retention Challenges in Rural
Communities Mal-Distribution
Although 21 percent of the U.S. population
lives in rural areas, only 10 percent of
physicians practice there. (Brooks RG, et al.
Acad Med 2002 77790-8) Few problems have been
as enduring as the inadequate numbers of
physicians practicing in rural and inner-city
areas. Council on Graduate Medical Education
(COGME). (www.cogme.gov/2002 summary.htm)
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Retention Challenges in Rural Communities

• Aging physician population
• Lack of access to up-to-date resources locally,
  e.g. (burnout)
• Lack of adequate coverage for time away
  (lifestyle and burnout)

• Specialty consults
• Continuing Medical Education
• Medical informatics

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Recruitment Challenges in Rural Communities

• Physician Shortages
• Students not specifically selected for rural
  practice
• Students not specifically trained for rural
  practice
• Change in the way medicine is practiced
• Financial Considerations

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Example Area of High-Need Behavioral Medicine

• A recent study of 422 Critical Access Hospitals
  (CAH) across 44 states, completed by the Maine
  Rural Health Research Center, found that nearly
  10 of all CAH Emergency Department (ED) visits
  are mental health related.
• The study concluded that patients presenting with
  suicidal symptoms represent 2 of all CAH ED
  visits.
• The study revealed that, due to the lack of
  availability for mental health consultation
  services in rural settings, poor outcomes were
  the result, such as higher rates of homicide and
  suicide. An increased use of emergency services,
  hospitalizations, and unnecessary placement in
  mental health institutions was also noted.

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Behavioral Medicine (continued)

• In a study featured in Psychosomatics
  (March-April 2006), primary-care providers in
  rural areas reported having inadequate skills to
  manage mental-health issues.
• The Psychosomatics study indicated new models of
  psychiatric intervention are needed to improve
  the accessibility of mental health in the
  primary-care setting, particularly in rural areas
  of the United States.
• Maine Study Recommendations Telemedicine
  technology is one strategy to improve the
  accessibility to mental health care, particularly
  in areas underserved by physicians.

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Addressing the Challenges Through Innovative
Approaches

• Community and rural hospitals across the country
  are addressing these challenges
• Through use of innovative and appropriate
  technologies
• By providing opportunities for students to
  experience solutions first-hand

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What does this mean for Community and Rural
Hospitals?

• Inadequate supply of physician
• Providers not equipped to handle variety and
  amount of need
• More educated consumers seeking specialty
  services out of community
• Market share eroded by transfers that could
  easily be handled on site

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How Do We Meet the Challenges?

• Retention Provide current physicians with tools
  and resources needed to be successful in a rural
  environment
• Recruitment Multipronged approach important
• Pick the right students
• Train students to be successful in rural
  communities
• Provide hands-on rural experiences that
  demonstrate innovative, best-practices on site

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Telehealth Applications

• Web-based telemedicine applications that allow
  for the secure transfer of
• - Patient medical records - Vital Signs
• - Pictures - Blood Sugars
• - Video footage - EEGs
• - EKGs
• Example Radiology applications
• Extensive and detailed studies can be sent
  quickly to a specialist for reading
• Patients can stay in their local community and
  receive results within a short time frame
• Live and Interactive Telemedicine
• - Utilizing videoconferencing technology to
  provide real time medical consultation between
  provider and patient or provider and provider

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Quality Images
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Strategic Planning at WCCH
High priority behavioral health
needs Recognition of Need -Significant number
of problematic mental health cases
(multidisciplinary involvement) -Mental health
cases often involve thorny questions (legal
advice/consultation) -Many cases present after
hours (8-5/M-F) -Payor source of patients
(uninsured/underinsured) -Hospitalized for safety
reasons -Overcrowding in ER -Extended
LOS -Mental Health Professionals not wanting to
travel -Staff not equipped to handle acute
M.H. -Concern regarding same standard of care
evenings and weekends
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Baseline Data - WCCH

• Year prior to integration of Telemental Health
  Program
• ED logged gt195 Mental Health-related encounters
  in 1 year
• 15 received MH consults ( 7.7)
• 3 Outpatient F/U
• 1 Emergency Transfer
• 24 came in M-F 8-5
• 76 presented after hours

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Collaborating to Meet the Need

• In 2006 the Richard G. Lugar Center for Rural
  Health began researching the need for a
  telemedicine-based system to allow improved
  access for patients seeking mental-health
  services in the rural setting.
• That same year, a generous grant from the State
  Office of Rural Health was awarded to facilitate
  connectivity between West Central Community
  Hospital and Hamilton Center to provide real-time
  mental health evaluations in the Emergency
  Department.

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Meeting the Challenges Innovative Approaches

• With the assistance of the Richard G. Lugar
  Center for Rural Health, Hamilton Center, and
  West Central Community Hospital Administration,
  the process to integrate behavioral-telemedicine
  began.

• Policy formation
• Education
• Integration of Technology

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A New Beginning

• The program went live September 12, 2007.
• Mental health coverage immediately expanded from
  Monday thru Friday during the hours of 800 am to
  500 pm, no weekends or holidays, to 7 days per
  week from 700am to 1100 pm.
• To date 35 telemental health consults have been
  completed at WCCH.

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Data Analysis
First 6 months results post-implementation -24
telemental health consults completed -78 of
consults were found to have a prior mental health
history -Chief Complaint at ED
Overdose 56 Suicidal gesture 8
Intoxication 16 Acute Mental
Health 16 -14 patients were successfully and
safely discharged home with a follow-up
appointment made with mental health
provider. -Remainder of patients transferred to
inpatient mental health unit OR admitted for
medical reasons.
Stephanie
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Impact
A mid-40s woman was brought to the Emergency
Department (ED) by police for erratic behavior in
public and a possible overdose of multiple
medications. She was unknown to ED staff. She
spoke very fast, gave multiple physical and
psychiatric complaints, related an epic medical
history and listed 20 current medications. She
admitted to taking large doses of multiple
medications (Vicodin, Valium, Tylenol) in the
past 2 days, but denied suicidal ideation and any
need for care. A telemental health consult
revealed she was known to Hamilton Center staff,
who determined she was safe to leave and follow
up with her scheduled psychiatric appointment in
2 days.
Stephanie
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Collaborative Approach
Patient
Hamilton Center
WCCH
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Collaborative Approach

• Upon Patient Presentation
• Medical Screening Examination and Triage
• Based upon assessment findings, E.D. physician
  orders Behavioral Health Consult
• Hamilton Center staff made aware of consult
• E.D. staff complete a screening questionnaire,
  complete basic laboratory tests (including a
  rapid toxicology), have patient sign consent for
  Behavioral Telemedicine Consult, and fax
  completed packet to Hamilton Center staff
• Upon receipt of required information,
  telemedicine consult is performed
• Written results of consultation are faxed to the
  E.D. within 90 minutes for physician to make
  appropriate disposition plan

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Benefits from the Telemedicine Program

• Fewer unnecessary hospitalizations- physicians
  able to make appropriate disposition plan based
  upon real-time behavioral health consult results
• Reduced length of stay for patients hospitalized
  with mental health needs
• Less defensive medicine being practiced out of
  fear of uncertainty of how to handle mental
  health patients
• Enhanced throughput in the E.D.
• Enhanced continuity of care among providers
• Patients able to stay in community close to loved
  ones
• Retained market share
• Ability to expand to other specialty areas
  (cardiology, neurology, ortho.)

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Benefits Directly Related to Recruitment and
Retention

• Supports providers
• Mitigates risk for providers
• Providers have the tools needed to be successful
• Patients have the ability to remain in their
  local communities as appropriate

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A Collaborative Approach - Expanded

• Multiple Uses for System Vigo County
  Correctional Facility
• Larger clinical impact
• Cost effectiveness
• WCCH to Hamilton Center AND Vigo County Jail to
  Hamilton Center
• New inmates frequently
• Acutely anxious
• Depressed
• Overwhelmed
• Drug seeking
• Unpredictable
• Inmates frequently placed on and taken off
  suicide watch without mental health evaluation
• Providing assistance at jail lessens burden to
  Emergency Department
• In first 6 months 5 Emergent and 102 Routine
  Consults
• Most evaluations and routine sessions completed
  during regular business hours but afterhours also
  available
• Reduced travel and transport time
• Enhanced safety

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Impact

• A family physician was providing coverage for
  the jail clinic on a Sunday morning. He was
  contacted about a female inmate who had just been
  arrested and placed on suicide watch, obviously
  very distraught. The physician saw her and found
  she had prior MH treatment history. Rather than
  prescribe a tranquilizer, he requested a video
  consult. She was seen by a HC clinician within
  the hour. After completing the consult, the
  woman showed significantly decreased agitation,
  reduced fear, and improved functioning. An
  appropriate treatment plan was developed and
  implemented. The physician noted, how else
  could she have gotten such care on a Sunday
  morning?

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WCCH Specialty Needs

• Top 4 specialty related transfers were
  cardiology, neurology, orthopedics, pulmonology.

Average monthly transfers from ED 47.5
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Taking it Broader at WCCH

• As a result of these findings, WCCH now expanding
  to telecardiology
• Chest Pain Rule-In/Rule-Out
• Monitored beds commodity/enhanced bed utilization
  at tertiary care centers
• Target Low Risk ACS Patients
• Retained outpatient services (stress tests, etc.)

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Mental Health
Cardiology
WCCH
Recruitment/Retention
Market share
Successful Implementation
Neurology Telestroke?
Orthopedics?
Pulmonology?
Additional Specialty Services
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Taking it Broader Across Indiana

• Geographically limitless care - Expanding to
  additional CAHs in Indiana
• Model easily replicated
• Fully interactive
• Can support any conversation-based appointment
  and many exams
• Many clinical instruments (stethoscope, etc.)?
• Allows for market aggregation
• Barriers
• - Technical - Must have connection
• - Legal/Political - must be licensed to
  practice in the patients state

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Recruitment A Holistic, Long-Term Approach

• Rural Health Innovation Collaborative (RHIC)
• Partners Union Hospital (WCCH and Lugar Center
  for Rural Health), Indiana State University,
  Terre Haute Economic Development Corporation,
  Indiana University School of Medicine
• School of Medicine Expanding Rural Focus
• Selecting the right students
• Rural Curriculum
• Includes hands-on, experiential,
  multidisciplinary training rotations
• Comfort with rural locations
• Comfort with multitude of players and their roles
• Understanding of connectivity from remote
  locations (not isolated) access to specialists,
  information (e.g., via handhelds to libraries,
  store-and-forward CME, etc.)
• Demonstration of innovative, cutting-edge
  opportunities

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Billing/Reimbursement

• To date, reimbursement for telemedicine services,
  particularly private reimbursement, has been a
  confusing and often times difficult proposition
  for people providing telemedicine services.
• As of January 1, 2009, skilled nursing
  facilities, in-hospital dialysis centers and
  community mental health centers will be added to
  originating sites for Medicare reimbursement.
  Current list includes Critical access hospitals-
  nominal fee.
• G/T modifier added to billing codes

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Conclusion
Why not go out on a limbisnt that where the
fruit is? Frank Scully
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Contact Information

• Stephanie Laws, RN, BSN
• Richard G. Lugar Center for Rural Health
• 1433 N. 6 ½ Street
• Terre Haute, IN 47807
• 812-238-7479
• slaws_at_uhhg.org
• Check out our website at www.lugarcenter.org