Clinical Telemedicine Blog

Telepsychiatry, The Right Time But Not Yet In Enough Places

By Chris Pick

This week I was reading a January 2012 TRENDWATCH from the American Hospital Association entitled “Bringing Behavioral Health into the Care Continuum:  Opportunities to Improve, Costs and Outcomes.”  While I work with and around the problem every day it makes me pause whenever I see some of the numbers. 

….among children mental health conditions were the 4th most common reason for admission.

….27% of Americans will suffer from a substance abuse disorder in their lifetime.

….in 2009, more than 2 million discharges from community hospitals had a primary mental health diagnosis

….in the past year, 34 million adults had comorbid mental health and medical conditions

Here is what it means:

Patients with comorbid mental health and medical conditions experience higher healthcare costs, with much of it attributable to higher medical, not mental health, expenditures. Individuals with comorbid conditions are at a heightened risk of returning to the hospital after discharge. 

There is a critical shortage of behavioral healthcare treatment capacity. According to the report, 55% of US counties have no practicing psychiatrists, psychologists, or social workers. Only 27% of community hospitals have an organized inpatient psychiatric unit, while state and county hospitals are closing to financial constraints.  Emergency department visits and resulting problems like boarding are on the rise.

With health care parity for mental health, healthcare technology advances, and public and government pressure to reform and recreate healthcare delivery, telepsychiatry is quickly becoming a solution. It allows the too small pool of psychiatrists, who are not evenly geographicly distributed, to meet the growing national mental health challenges.  We see the armed forces, the Veterans Administration, rural counties, managed care and many entities using telepsychiatry to reach no, low or special needs access areas.  Specialists in substance abuse, child psychiatry, mental retardation, and geriatrics can reach dispersed patient populations in need of a higher level of specialization. 

Increasingly we are seeing hospitals, who previously did not have or could not maintain sufficient on demand coverage,  identify and take advantage of the improved quality, cost, and outcomes that telepsychiatry offers.  The new questions become:

-What is the benefit to the care of the co-morbid patient when the hospitalist has a Psychiatrist to consult? 

-What is the benefit to the hospital that has no mental health services but has patients whose primary diagnosis is a mental health condition being brought to the Emergency Department and admitted to the hospital?

-What is the benefit of being able to diagnose, stabilize, manage, and direct to appropriate treatment the patient who is undiagnosed, untreated, or suffering from exacerbated mental health symptoms?

-What is the benefit when a child, elderly person, substance abuser comes to the hospital with an acute mental health problem and a specialist in that field is there to help?

-What is the savings when a psychiatrist is almost instantly available to determine capacity, treat emergent and urgent cases, and provide specialized recommendations?

Increasingly, as telepsychiatry is being used in the hospital setting, outcome studies all show that with early intervention, assessment, and treatment there is reduced cost of care, LOS, readmissions, staff burden and risk; and there is increased quality, services, and satisfaction. 

My work deals with the problems of how to address the mental health challenges that our hospitals and their communities are facing. Every day I show hospitals that telepsychiatry is a tool to decompress ED’s, provide needed specialty treatment, and reduce the costs hospitals bear while trying to meet the needs of the people they serve.  Can we afford not to address this growing problem?  There is still a ways to go in improving the national landscape for telepsychiatry (new prescribing laws and national licensing, reimbursement and medicare coverage, and so on…), but in your community the answer may already be here.

Topics: telemedicine, healthcare, Emergency Medicine, Physicians, telemedicine solutions, Specialists On Call, SOC, hospitals, telepsychiatry, emergency departments, emergency department, On Call Coverage, Telepresence, Specialty Physician Shortage, Patients, Emergency Psychiatry, telehealth, psychiatry

Teleneurology Provides Rapid Response from a Top Level Neurologist

By Jeff Simer

Two weeks ago I had the pleasure of attending the Society of Interventional Radiologist CLOTS training course in Dallas TX. The course is staged as a comprehensive five-day training course is composed of in-depth multidisciplinary lectures emphasizing the entire spectrum of stroke diagnosis and management.

The conference was centered around the minimally invasive approach to advanced ischemic stroke intervention and all of the management considerations, along with this, there was a full suite training course on the various techniques and medical device technology-from imaging to the catheter based solutions to intervention.

There were many presentations at the meeting, presenting many findings from some of the luminary interventional programs in the U.S. and Europe. 

Several presentations focused specifically on the overall process in which acute ischemic stroke is identified, triaged, processed, and managed on a systemic level.  This approach is generally considered a “Hub and Spoke” a model of developing a transfer pattern with in a defined geography where institutions that do not have in-house interventional capabilities can efficiently refer the appropriate cases to the “hub” for the advanced procedure that would not be able to be performed in-house at the originating site.  This model is particularly attractive to the interventional team as the number of in-house cases that present are generally not in sufficient numbers to fully support and justify the cost burden of a full swing interventional program. 

SOC attended this course in order to bring attention to one of the key issues that hinders these programs from realizing their growth potential-Acute Emergency Neurological consultation in the ED.  All interventional programs depend on the neurology staff of any given institution to identify candidates for both IV lytics, medical management, and in most cases, those that would benefit from advanced intervention in a bi-plane suite.  Many community level hospitals do not have 24/7/365 neurology to cover ED stroke call.  Even those that do, do not have the ability to respond to stroke codes within the “window” that stroke cases require to capture the opportunity for either lytics administration or intervention.  Hence the emphasis on how to create a network of hospitals that can feed an interventional practice.  This window is often lost due to the response times from the local specialists.  The lytics window is up to 4.5 hours for IV, and 8-12 for endovascular therapy.  The SOC specialists are guaranteed to respond in 15 minutes or less, thereby shortening the time that is lost waiting for a specialist to give an opinion on the case. 

Many Interventional programs lack the depth of call and expertise to provide such rapid response to neurological emergencies in the community setting.  With that said, many of the institutions that develop partnerships as “hub and spoke” lose momentum as the neurological consulting staff is not deep enough to provide 24/7/365 call coverage in a consistent and rapid fashion-burn out ensues and the network loses its effectiveness.  As a result, many of the partners lose confidence in calling for consultation and revert back to just sending all cases to the tertiary center.  This is neither good for the patient nor the receiving hospital, as the vast majority of cases are ones that can stay at the originating hospital and need not be transferred away from the community.  The receiving hospital is then using resources to manage patients that could have been kept at the partner site and not using the resources for advanced care. 

SOC had Dr. Heather Linn present on the history of SOC, the methods and value that having the availability of rapid response from a top level neurologist.  She articulated to the audience how 15 minute response time, along with the correct information has allowed SOC doctors to deliver more front line acute stroke care than any other neurological practice in the U.S.  Because SOC physicians are all fellowship trained and also well versed on the available interventional treatments available in most tertiary centers, SOC is uniquely able to assist both hubs and partner hospitals in tending to the extremely time sensitive nature of acute ischemic and hemorrhagic strokes.  With that said, there was considerable interest from the interventional field in how SOC can partner in assisting the flow and triage of patients that are appropriate candidates for advanced neuroendovascular procedures.  The body of specialists I spoke to were blown away with the volume of cases that the SOC physician staff has responded to, on average over 10,000 a year.  Further, they were also impressed with the ability to appropriately manage and in many cases recommend treatment for these critically ill patients. 

I very much enjoyed the presentations I attended and want to thank everyone that stopped by the booth and asked questions or for more information.  It is clear that there is high value in utilizing the SOC solution as a key component in an advanced neuro-rapid response outreach program.  I look forward to seeing more partnerships with SOC as an integral part of advanced Neuroscience initiatives.

Topics: telemedicine, Stroke, neurology, teleneurology, emergency neurology, healthcare, Emergency Medicine, Neurologic Emergency, Physicians, Neurologic Emergencies, telemedicine solutions, Specialists On Call, SOC, hospitals, emergency departments, emergency department, On Call Coverage, Telepresence, Patients, telehealth, neurologists, telestroke, Efficiency, CLOTS, Society of Interventional Radiologist

Teleneurology as a Model for Telemedicine Growth: Part 2

By Amy Levitt

Author: Joe Peterson, M.D.

Teleneurology as a Model for Telemedicine Growth
The old lessons that have proven true in this new medium called telemedicine are primarily clinical ones. Quality, as Ford once said, has to be job #1. It has to be built into operating systems and managed as, or more aggressively with, distributed groups of physicians, as it does in traditional bricks and mortar institutions. There should be no reason that providers of physician services at a distance enjoy any holiday from the same accepted quality and privacy standards that traditional institutions are held to: Joint Commission accreditation, HIPAA compliance, etc. Of note, the fact that connecting to physicians remotely requires an electronic flow of information does give telemedicine a leg up in managing quality. As every patient’s case has to be committed to a system in order to be communicated to a distant facility, then that data is by definition accessible for real time review and monitoring. For example, adherence to best practices and accepted protocols are simple to measure in patient care decisions being communicated real-time through a single data system. Similarly, the logging of real-time actions into a single data system allow the review and measurement of the time required or delayed during progress against a diagnostic or clinical plan—it’s a great way to define the actionable inefficiencies in a clinical operation.

Like quality, patient satisfaction remains a prerequisite not only for good care but also for the most efficient care. Investments in telemedicine-based efficiency actually allow telemedicine-based interactions to devote more time to the patient interaction—always a factor in patient satisfaction—simply because local logistical factors have been washed from the physician’s day. This has been a happy and unexpected side effect of telemedicine. A well organized service leaves the physician with more time to speak to patients and a better ability to remain “on schedule” throughout the day, leading to many more “thank yous” than physicians working over this new medium were accustomed to receiving in the course of their traditional practice.

Teleneurology has taught new lessons about the actual role of technology in the patient interaction; enough patients have been seen that there is a body of experience now built directly from thousands of patient care interactions. One is the clear lesson that technology alone is not a solution, it’s a component. Despite the great potential of telemedicine as an adjunct to traditional care strategies, there’s a very large amount of videoconferencing equipment that was purchased with grant money and now sits in a closet covered with a dusty ER blanket. This happens because there’s a great deal more steps required to efficiently connect patients and physicians, in real time, than a couple of videoconferencing endpoints.  Teleneurology has taught us that real people and technology infrastructure—not isolated equipment purchases—are what’s required to capture the efficiencies promised by the concept of telemedicine.

Another lesson learned from these thousands of patients is that they are much faster to accept change than the physician community. As long the quality of the technology ‘connections’ are good and the service is executed with obvious professionalism, patients are accepting this new delivery mechanism and have moved on in their internal review and acceptance of telemedicine as a delivery vehicle for good care.

I was reminded very directly of this earlier this month while interviewing a family about their telemedicine experience. The daughter that was with her father during his acute stroke, was telling the other family members about the experience: “and so the emergency doctor then got the neurologist, who talked to dad and me, and he told us that dad should get this new medicine which he did, and he could move his arm and leg again before I left the hospital.”  At no point did this daughter mention to her family the qualifier that the neurologist appeared by video. She had already accepted the medium and moved on to what was important to her, that her father get better. Tens of thousands of patients have accepted this new medium, and now the traditional care system is charged with catching up.

Teleneurology has reminded us also that change is hard in clinical medicine but that with telemedicine, great speed can be obtained in capturing the numbers of patient and clinical encounters required to prove the case of this new care delivery tool. Clinical results, financial results, subject populations for clinical trials, all can be accumulated faster with 100 hospitals connected through a single telemedicine system than can be through traditional research collaborations between bricks and mortar providers. In this regard, the growth of telemedicine as a delivery mechanism will be fueled more each month by the accumulation of patient experiences.

To date, of these new and old lessons derived from the experience of teleneurology, many will form the basis for the successful expansion of telemedicine into new clinical venues.  From this regard, teleneurology has, and continues to, plow an important path for the growth of telemedicine. At the same time, teleneurology reminds us of the oldest lesson of change: all the hype over gadgets and the newest and greatest doesn’t overcome the reality that financial considerations drive many changes in healthcare. If financial models are developed that incorporate the same obvious wins for hospitals, patients, neurologists and payors that are intrinsic to the teleneurology model, telemedicine will grow. This lesson from teleneurology is perhaps one of the most important legacies that early teleneurology programs will leave in the unfolding story of telemedicine.

Topics: telemedicine, teleneurology, Physicians, Patients, Efficiency, Uncategorized

Teleneurology as a Model for Telemedicine Growth: Part 1

By Amy Levitt

Emergency teleneurology and telestroke care—the importation of stroke and emergency neurology specialists to the patient’s bedside using videoconferencing technologies—is growing steadily in magnitude, impact and validation. Early in the decade some hundreds of patients each year were connected to specialists by video conferencing; in 2010 literally thousands of acute stroke patients will have a distant specialty neurologist involved in the critical phases of their care. The typical associated conclusion is that the evolution of technology has allowed the growth of telemedicine in general, and specifically teleneurology and telestroke. Nothing could be further from the truth, and it’s time the word gets out that the breakthroughs driving the successful growth of this one dimension of telemedicine are financial, not technical.

Today, both university-based and private telemedicine efforts bring good neurology to the bedside of the patients who most need the benefits of evidence-based best practices. Patient acceptance has proven to be high, technology supportive of good clinical results, and distance-based practice capable of great, measureable clinical impact. Increasingly, local physicians are realizing that telemedicine can be used to enhance, and not burden, their practices, and in the case of on-call coverage, can help them focus upon their core practice and prevent burnout while actually expanding their patient population. The successful evolution of teleneurology is providing an operational model for the effective distribution of other specialty services by telemedicine. And it’s all due to the fact that hospitals who lack effective neurology call coverage are financially worse off, and at a competitive disadvantage to those hospitals that have good call coverage.

The model for hospital-supported teleneurology has been relatively easy to define because about 70% of emergency neurology cases referred to expert neurologists by telemedicine are acute strokes and other neurovascular events. In this narrow collection of diagnoses, it’s been possible to build a reasonable predictive model for hospital returns-on-investment against the costs of imported specialty neurologists. And on that basis, telestroke and teleneurology services have grown, and are demonstrating the values that telemedicine has always seemed to promise but never deliver: efficiency, distribution of talent free of geographic restraints, and real benefits for patients and hospitals.

Not all specialties lend themselves to the financial model that supports teleneurology and telestroke care…But all telemedicine strategies that deliver combined efficiency and quality will eventually find support from a party at-risk for the costs of poor care, and this will spark the attention of telemedicine providers ready to deliver clinical care at a distance. And there will, of course, be technology involved; it will be less expensive than today’s technology; and its reliability will be critical to the effective use of the system, but it will not have started the next push in telemedicine. Finances will drive that. As a model for care, teleneurology has explored interesting ground that will serve as a foundation for other telemedicine specialties. It too has lent some new lessons, and reinforced the importance of some that are old.

Topics: Stroke, teleneurology, Physicians, Patients, neurologists, Efficiency