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

2. No disclosures (darn).

3. 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

4. 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.

5. 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?

6. Telemedicine Becoming Mainstream

7. 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?

8. 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

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

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

11. 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.

12. TeleStroke Experience…

13. 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

14. OHSU Connection…

15. TeleStroke Consult to Mercy MC, Roseburg
Telestroke Demo

16. 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!

17. 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

18. 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

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

20. Ambulatory Outreach

21. Ambulatory Outreach
New Tools
3M Littman Stethoscope
Total ExamCamHD

22. 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

23. 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 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

24. 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

25. 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?

26. Mobile CT…In an Ambulance

27. 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

28. 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)

29. 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

30. OHSU TeleHealth Services
Thank You
OHSU TeleHealth Services