1. Telehealth Alliance of Oregon
Telemedicine Pilot Project Between Sacred Heart Medical Center and Oregon Health & Science University Doernbecher Children’s Hospital
Telehealth Alliance of Oregon
November 1, 2007

2. Presented by Miles S. Ellenby, M.D., FAAP Thomas Roe, M.D.
Associate Professor, Pediatrics & Anesthesiology
Division of Critical Care Medicine
Doernbecher Children's Hospital
Oregon Health & Science University
Thomas Roe, M.D.
Clinical Professor, Pediatrics, Oregon Health & Science University
Clinical Practice Pediatrics, Eugene, OR
Co-Pediatric Course Director, Oregon Medical Education and Research Collaborative

3. Disclosure
The Accreditation Council for Continuing Medical Education (ACCME) requires all speakers to make a verbal disclosure of all relevant financial relationships with any commercial interest and the nature of the financial interest pertaining to this lecture.

4. Sacred Heart Medical Center and Oregon Health & Science University
Sacred Heart Medical Center RiverBend – open August 2008
OHSU tram – opened January 2007
Sacred Heart Medical Center University District – renovation complete 2010

5. Sacred Heart Medical Center RiverBend

6. Sacred Heart Medical Center
432 beds
Trauma II
Primary Service Area population: 336,811
Secondary Service Area population: 343,464
100 miles from Oregon Health and Science University
Ground and
Panda Air Transport available
Portland
Eugene
OREGON
Map Courtesy of KSA

7. SHMC Current State Tele-PICU technology Computerized Medical Record
PAC System (radiology)
CPOE – Neurology and Rehabilitation units up
Regionalization of healthcare for medical students
32-bed NICU
No pediatric hospitalists – rollout pending
Regional hospital with 30-40% admissions from outside Lane County (primary service area)

8. SHMC Pediatrics Unit Pediatric Care Unit opened Spring, 2002
16 beds, nurse manager, nurse educator
RNs are PALS certified
Levels of care: B to E
B – simple
C – bulk of patients (medical, surgery, trauma)
D – complex – would be in a PICU at another facility
E - stabilize and manage for immediate transport
Patient volume and complexity has increased

9. SHMC Pediatric Unit Transports
Current Transports to OHSU and Legacy
Automatic: ventilator, head trauma, heart, new cancer diagnosis
Potential: Sepsis, hematologic, neurology (unmanageable seizures)
Transports are frequently difficult on the family due to loss of work, expenses and lack of local support system.
CME Children’s Miracle Network Lions Guest House = 14 units

10. Pediatric Task Force on Regionalization of Pediatric Critical Care
Pediatric Task Force on Regionalization of Pediatric Critical Care: Consensus report for regionalization of services for critically ill or injured children.
Crit Care Med 2000;28:
Pediatrics Volume January 2000
Mortality and morbidity of children with serious trauma or illness

11. A PICU at SHMC?
Question was asked again in 2004: Is a PICU the answer to keep clinically appropriate patients at SHMC?
Determined not feasible - SHMC does not have enough volume to justify two intensivists and PICU at this time, however …
Acuity level of patients has increased since unit opened in 2002
Many SHMC physicians interested in exploring options for PICU care
OHSU Critical Care physicians very motivated to start pilot and are technologically focused and skilled
Telemedicine application proven at UC Davis
Telemedicine pilot approved Fall 2006
Pilot project started April 2007

12. Patient Transfer Data
SHMC transported 58 pediatric patients from January 2004 to Feb 2006 (26 months)
2/3 of these patients needed a specialist or more intensive care than was available at SHMC.
1/3 ended up on OHSU general pediatric ward as PICU services were not needed
Cost of transport
Air: $6,378 (fixed wing); $5,486 (rotor wing)
Ground: $5,832

13. Background OHSU interested in pursuing with SHMC SHMC Champions
OHSU Telemedicine champions – Dana Braner, MD; Miles Ellenby, MD
SHMC Champions
Medical/Nursing
Manager/Educator Pediatric Unit
Administrative – Director Marketing and Business Planning
Physician support
Meetings held to increase interest
2005 Telemedicine mini-conference UC Davis
2006 first telemedicine colloquium – October 2006
Grand rounds OHSU - SHMC
Multiple site visits and meetings

14. Barriers Capital and operating costs to SHMC
Capital and operating costs to OHSU
Billing
Reimbursement
Credentialing
Legal and contract issues
Resistance from physicians

15. Capital & Start-up Costs

16. Operating Costs Primarily Nursing Staff Education
$30,000 SHMC Foundation Education Endowment
8 hour critical care core curriculum
4 hour simulation lab experience OHSU
4 hour job shadow OHSU PICU
24 of 27 nurses participated
Post Anesthesia Care Unit job shadows (use of PALS) at SHMC
2 hour didactic training on use of TM equipment
Ongoing teaching with scenarios to encourage MD/Staff use
Plan to follow-up with 4 hour curriculum in 2008, where staff needs indicate

17. Effects of Pediatric Telemedicine on SHMC
Physician shortage
Transportation costs to the patient and facility
Decreased revenue
Safety and quality issues
Recruitment of medical providers

18. Benefits of Pediatric Telemedicine
Increase actual and perceived SHMC quality
Improve mortality
Decrease LOS
Decrease complications
Improve staff morale and expertise
Enhance training opportunities
Economic – increased revenues and margin
Increase collaboration with ED
Translation service
24/7 PICU resource coverage

19. Additional Clinical Applications
Started use in Emergency Department August 2007
Interpretive Services
Medical Education
Intra-campus potential – RiverBend to University District
Expansion to PHMG physician offices

20. Metrics and Tracking – Set goals and measure outcomes
Physician satisfaction
Patient satisfaction
Staff satisfaction
Number of uses relative to number of opportunities
Number of physicians using transports
Mortality
LOS
Financial issues

21. Summary of Pilot Project
Telemedicine consults by Doernbecher intensivists with SHMC pediatricians
Pilot Spring 2007 – Spring 2008; then evaluate for ongoing implementation
Staff Critical Care Core Educational training at OHSU
Credentialing OHSU pediatric critical care physicians
Financial Considerations
Contribution margin increase from reduced transports
Expenses – staff training, minimal capital
Payment for consults during trial – 1st 30 patients N/C, $500 each after 30
Senate Bill 519 and State of Oregon reimbursement for Telemedicine

22. More Telemedicine Benefits

23. Impact of Telemedicine on Two Patients Case Studies
8 mo presented with hypotonia, lethargy, “cross-eyed”, loss of head control and visual tracking.
Workup initiated at SHMC including:
Head CT - normal
Brain MRI - normal
LP - 22 WBC’s, normal glucose, protein
Telemedicine consult performed
early agreement for transport based on worsening mental status & concern for potential loss of airway protection.
OHSU Transport Team dispatched by ground.
Shortly after departure, Transport Team received urgent cell phone call from SHMC RN’s expressing concern over worsening neuro exam. SHMC MD had departed.
RN’s were unable to call out as land lines were down.

24. Impact of Telemedicine on Two Patients Case Studies
Transport Team informed PICU attending, questioning need to dispatch helicopter to expedite transport.
PICU attending was also unable to reach SHMC by phone, but Telemedicine equipment worked.
Led RN’s through repeat neuro exam including pupillary exam.
Neuro exam was unchanged from previous.
What had changed??? The RN’s had changed shift.
Transport continued by ground and was uneventful.
Infant was hospitalized x 16 days at OHSU, ultimately had full recovery from meningo-encephalitis (either viral, post-viral, or partially-treated bacterial).

25. Impact of Telemedicine on Two Patients Case Studies
2 mo hospitalized at SHMC with bronchiolitis.
By hospital day 5, infant was clinically improving but a CXR demonstrated a large pneumothorax.

26. Impact of Telemedicine on Two Patients Case Studies
OHSU Transport Team urgently dispatched based on size of pneumothorax and possible need of emergent intervention.
Telemedicine consult performed.
Infant looked “so good” compared to CXR findings that a repeat film was requested by PICU attending.
Transport was cancelled with the new finding.

27. Demonstration of Telemedicine in ICU setting

28. Telemedicine Parent Testimonial