EMS Stroke Conference—June 2014 TeleHealth Overview EMS Stroke Conference—June 2014

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Describe applications of telemedicine Objectives Describe applications of telemedicine Learn about future applications of telemedicine Learn how about performance metrics See a demo of telemedicine Understand challenges of telemedicine

Interactive Healthcare over Distance What Is Telemedicine? Interactive Healthcare over Distance Using telecommunication technology (aka video-conferencing equipment) Improves Access to Care Quality of Care Provider & Patient Satisfaction Reduces Cost So what is telemedicine - strictly defined its “…..” Here is a photo of me providing Dr. Tom Roe of Eugene a consult (there I am on the v-c equipment) on this critically ill stuffed animal - whose name and condition I can’t disclose due to HIPAA - Privacy concerns - I hope you’ll understand - this was for a media piece that ran in the Eugene Register and on the local TV stations. Historically when physicians need to a consult they’ve picked up a telephone and call. They then describe to the best of their ability what they’re seeing. Telemedicine adds live streaming video so that both are seeing the same thing.

Triage Decisions Consult calls received 24/7 The Dilemma for ER Providers & OHSU Providers Whether to Transport based on a verbal report plus institutional, provider, & parental comfort levels Who is impacted by the Decision? Patient Family Transport Team Financial Impacts to Healthcare System, Family, & Local Economy PANDA to Eugene (by ground ambulance): $6,322 PANDA to Medford (fixed wing plane): $21,572 Now I’d like to briefly explain the role that we play as Pediatric Intensivists in the care of these kids. We receive phone calls throughout the day & night from community hospital ER’s seeking advice on management of these critically ill children. Now it’s important to recognize that many of the smaller hospitals throughout the state only see a small handful of really sick kids a year and when they so show up it can create a great deal of anxiety, which you can often hear in their voices on the other end of these calls. The dilemma we face is to make a decision with the referring provider of whether or not to transport the child to Portland. We’re counting on the ability of the remote team to both properly assess the child and to then communicate that assessment verbally over the phone. And while we know from the data, that many of these kid could be safely cared for in their community, if there is any question on either side of the call, we often default to transporting the child – either by ground ambulance, fixed wing planes from greater distances, or in emergent conditions, by helicopter. Unfortunately at times, the child is unnecessarily transported at great expense to many. The impact of this decision is widespread. Obviously & most importantly, the child’s care could be dramatically affected. Transporting the child also places a significant hardship on Parents who are removed from their community, it’s support, their other children, their jobs, etc. An in the winter, when the wind is blowing or the roads are icy, both the patient and our PANDA transport team is put at risk. Additionally, the financial impacts are great with hits to the healthcare system, the payors, the family, and the local economy from the loss of healthcare dollars and other associated spending. An example is the cost of just the medical transport which is in excess of $6000 by ground from Eugene for example to a shocking $21,000 for a plane ride from Klamath Falls. SO is there a way to help with this dilemma, that could provide not only an improvement in the quality of care, but also reduce potentially dangerous and often times unnecessary transports with cost savings to all?

Telemedicine Becoming Mainstream

TeleHealth Across the Continuum of Care Ambulatory Care ED, Nursery, Acute Care Inpatient Transitions SNF LTAC Hospice In Home Monitoring “Smartphone” Apps Continuum of Care Prehospital care—Where is it?

Acute Care Telemedicine Program began 2007 PICU to Sacred Heart, Eugene Motivations Improve care pre-transport Better Triage Avoidance of unnecessary, expensive, & risky transports Expansion – Service lines Stroke, PICU, NICU, Trauma, Neurosx Genetics, Psychiatry Expansion – 16 sites based on local needs

Emergency/Nursery Consults by Month Since May 2010: 734 emergent consults 418 Transfers to OHSU (57%) 315 remained in home community (43%)

Telemedicine Consults by Service Line As of 8/9/12-340 consults consults stayed in local community (30% of total) Total Consults (May 2010-June 2014): 734 Averted transport savings: > $4,700,000

OHSU: TeleStroke Program Local OHSU Stroke Neurologist activates the robot- if transferred they are involved in the patients care. 24/7/365 Neuro- interventionalist coverage- > 300 cases of stroke thrombectomy experience. 23 year track record of “Tele”-phone stroke coverage which we are making even better with video.

TeleStroke Experience…

Quality Review – TeleStroke Results 501 telestroke consults since May 2010 24% of patients received tPA vs. national average 2-3% “Drip & Ship” vs. “Drip and Keep” 54% of pts stayed in the community

OHSU Connection…

TeleStroke Consult to Mercy MC, Roseburg Telestroke Demo

Rogue Regional Tele-Stroke Stats 109 Total Tele-Stroke Consults 75% of those patients stayed in their home community Estimated Transport Savings: $1,929,500 Demo Time!

Telestroke: Use in Stroke Tx Stroke onset 8:15; OSH 70 miles from OHSU 1. Patient examined 10:15 via telestroke; TPA given 2. INR TX explained and consent obtained from his wife 10:45. 4. Arrived OHSU 11:40; exam repeated Stentriever 11:50 (3’35” post onset) 3. Case and ETA reviewed with Lifeflight- left 10:55

Ambulatory TeleHealth Delivering Value to Patients and Payers Access to appropriate follow-up care improves compliance & outcomes Cost containment Multiple applications Post-op checks Chronic disease mgmt Less mobile populations OHSU Pt home including prisons

TeleStroke: Use in Clinical Care Yearly F/U visit La Grande 225 miles from OHSU

Ambulatory Outreach

Ambulatory Outreach New Tools 3M Littman Stethoscope Total ExamCamHD

SNF/LTACH Discharges TeleHealth Readmissions can be reduced by more effective discharge transitions 167 readmissions from SNF/LTACH (30 day all cause) in FY 2013 Linked to strategically important continuum sites Vibra - Prestige – Avamere “Warm” Video-enabled nurse-to-nurse Handoffs Educational “Brown Bags” Telemedicine consults

In Home Monitoring – Congestive Heart Failure 79 patients enrolled since December, 2012 80% of patients completed the program Some patients dropped out, couldn’t connect, etc Average number patients monitored per day ranges from 2 to 6 ,with a high of 9 Average Telephone Encounters per patient is 7 calls per month versus 11 - 14 encounters prior to program Average call length is shorter in duration and more focused Reported ED visits in the interim of 30 days with 65 patients Self efficacy scores improving Expanding to diabetes via Internal Medicine primary care practice

Telemedicine and EMS: Started in the 70’s with ECG telemetry On-site decision support Routine and disaster triage Exchange of information Voice, data, images Information (12-lead reports, treatment protocols) Transport decision support (acuity based) Language interpretation Transport support

Special Rolling Stroke Response Unit Germany Includes: Mobile 8-slice CT scanner w/ ability for angiography and perfusion POC laboratory Data transmitted over encrypted 3G, 4G and satellite Rural application for Oregon?

Mobile CT…In an Ambulance

Clinical Service Pilots & in Development Oregon Perinatal & Neonatal Network (OPNN) CCO Cardiology demonstration with HealthShare ED Virtual Bunker as Triage Center Tele-Psychiatry Expansion Tele-Retinopathy of Prematurity Exams Pediatric Hospice Tele-Genetics Expansion Tele-Trauma Tele-EEG, Echo, Ultrasound

Telemedicine Challenges Starting a Program Takes Time & Money Infrastructure (staff, equipment, connectivity, time) Adoption (administrative, providers, patients) Roadblocks - Legislative, Rules, Tech, etc. Credentials & Licenses Equipment re Stark Implications Connectivity Reimbursement Senate Bill 24 passed by ‘09 Oregon Legislature Medicare billing limitations (urban vs. rural)

Resources OHSU Telemedicine Telehealth Alliance of Oregon ohsu.edu/telemedicine Telehealth Alliance of Oregon ortelehealth.org Northwest Regional Telehealth Resource Center, Spokane, WA nrtrc.org American Telemedicine Association americantelemed.org Center for Telehealth & E-Health Law ctel.org Office for the Advancement of Telehealth telehealth.hrsa.gov

OHSU TeleHealth Services Thank You OHSU TeleHealth Services 503-418-3625