2015: Access to care the use of telemedicine across the healthcare continuum-Broder

2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

ACCESS TO CARETHE USE OF TELEMEDICINE ACROSS THE

HEALTHCARE CONTINUUM

Kevin Broder, MDTelehealth Director, Department of SurgerySection of Plastic SurgeryVA Medical Center – San Diego, CA

October 24, 2015


RUBE GOLDBERG (1883-1970)

HIGHLY RURAL, RURAL AND CENSUS DEFINED URBAN AREAS

Map generated by VHA Planning Systems Support Group2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

ELDERLY TRANSPORT

• Costly Travel

• Special Assistance Personnel

• Special Equipment (Gurneys, Wheelchairs, Vehicles)

• Long Clinic Wait Times

• Family Inconvenience


TELEMEDICINE4 MODALITIES

• Store and Forward Telehealth– Images/Data obtained by remote site and uploaded Imaging Database

for later review by provider

• Home Telehealth– Home monitoring devices

• Clinical Video Telehealth (CVT)– Real Time ‘Live’ Videoconferencing

• Specialty Care Access Network (SCAN)– Consultation, Care Planning and Education with Tele-video conferencing


• Establish Conditions of Participation and Service Agreements

• Formation of Telehealth Team• Identify Patients• IT Collaboration/Equipment Allocation• Informatics Collaboration• Integration into Continuum of Care• Ongoing Provider/Patient Support

STEPS FOR PROGRAM DEVELOPMENT

TelehealthCoordinator

Facility Leadership

Providers(Central ‘Hub’)

Informatics

Administrative Staff

TechnicalStaff (IT/BioMed)

PCPRN

Patient/Family(Remote ‘Spokes’)

Case Manager

TELEHEALTH TEAM


IDENTIFY THE PATIENTSVISIT TYPES

• Wound Care/Skin Assessment• Specialty Consultation• Medical Optimization• Post-Op Evaluation• Medication Reconciliation• Psychology• Nutrition• Education


MORE VISIT TYPESVETERAN AFFAIRS EXAMPLES

• TeleCardiology• TeleGenomics• TeleICU• TeleNeurology• TeleNutrition• TelePrimary Care• TelePulmonology (Sleep Services)• TeleRehabilitation• TeleAmputation Clinics• TeleKinesiology• TeleOccupational Therapy• TeleSpinal Cord Injury/Disorder• TeleMOVE! (Weight Loss)

• Broadband Network• Tele-video Conferencing

Equipment• Peripherals

IT SUPPORT/EQUIPMENT

PERIPHERALS

Digital Stethoscope

Exam Camera

12 Lead ECG

UltrasoundSpirometer

Vital Signs Monitor

• Customized automated Consult Requests for SCAN-ECHO and CVT

• Software based query of remote site patient data

• Template for guiding remote provider input

INFORMATICS COLLABORATION



CONTINUUM OF CARE

InterdisciplinaryTeam

SCAN

TelehealthModalities

Spoke Clinics

HubClinics

Specialists

Geriatrician/PCP

NursingNutrition

Physical Therapy

Psychology/Social Work

Multi-Specialty

Consultation

Inpatient Rounds

Home Care

• Telehealth Coordinator - RN• Telehealth Clinical Technician (TCT) – Health Tech/LPN• IT Support• Vendor Support• Routine Education and Training• Administrative Oversight


ONGOING TELEHEALTH SUPPORT

CLINICAL VIDEO TELEHEALTHCVT

Patient/PCP at SpokeProvider at Hub

‘Consult/Post -op/Follow-up/Pre-op’

Patient/Provider at HubPCP/Family/Home RN at Spoke

‘D/C Planning’


USE OF TELEHEALTH REDUCES ADMISSION BED DAYS

CVT TO HOMEPROCESS

• Schedulers Create Appointments in Custom Web App

• Email Confirmation Sent to Patient for Secure Login

• HIPAA Compliant Software– Virtual waiting room


CVT TO HOMEPROCESS

• Patients Connect to Enterprise Video Network from Home– Desktop– Laptop– Tablet

• Connect to Hospital Provider for Encounter

• Electronic Health Record Documentation


CVT TO HOMEEQUIPMENT

Patient/Home RN at HomeProvider at Hub

‘Real Time Home Visit’


CVT TO HOMEMEDICAL PROBLEMS ADDRESSED

• Wound Care• Nutrition• Smoking Cessation• Pressure Relief• Medication Reconciliation• Compliance• Disposition (Remain home vs Urgent Care vs ED)


SAFETY NET


SCANSPECIALTY CARE ACCESS NETWORK

• An innovative model utilizing clinical tele-video conferencing equipment to allow healthcare specialists from an inter-professional care team to provide expert advice to remote providers in rural/underserved healthcare settings

• A ‘Grand Rounds/Tumor Board’ style multipoint tele-video consultation

• Consent - verbal• Inter-Facility Consultation Request Placed• SCAN-ECHO Tele-Video Session

– Case Presentation– Case Discussion– Didactic Lecture

• Documentation

SCAN PROCESS


• Formation of an Interdisciplinary Team of Consultants• Identify Hub and Spokes• IT Collaboration• Informatics Collaboration• Develop Didactic CME/CEU Accredited Lectures

STEPS FOR PROGRAM DEVELOPMENT


• Plastic Surgeons• Rehabilitation Physician• Clinical Nurse Specialist/ Rehab Case Manager• Physical Therapist• Dietitian• Telehealth Nurse Coordinator

INTER-PROFESSIONAL TEAM EXAMPLESCI PRESSURE ULCERS AND COMPLEX WOUNDS

HUBS AND SPOKESVA SCI EXAMPLE


• Wound Debridement• Pressure Ulcer Reconstruction• Adjuncts to Wound Healing• Comprehensive Assessment of Pressure Ulcer Patients• Topical Wound Care• Nutrition for Wound Healing• Pressure Relief Surfaces• Specialty Mattresses & Beds• Prevention of Amputation & Foot Screening• Bioethics Roundtable: Autonomy and Other Issues• Pre-Op Optimization Part I – The Surgical Checklist• Pre-Op Optimization Part II – Nutritional Optimization for Wound

Prevention and Healing

DIDACTIC LECTURES


BENEFITS FOR PATIENTS AND PROVIDERS

• No-cost continuing education credits (CME/CEU)• Opportunity to translate new knowledge into practice to

improve outcomes• Professional networking with colleagues of similar interests• Avoid costly and time consuming travel to distant medical

centers that puts patients at risk


SCANFAR REACHING


TELEHEALTHCONTINUUM OF CARE

HIGH PATIENT SATISFACTION

Veteran TeleWound Care: Initial VA San Diego Experience Utilizing Real-time Clinical Video Telehealth, Store and Forward Telehealth and

Home Telehealth Technology in Comprehensive Wound Management.

Broder KW 1,2, Li A 3, Tesfamicael R 1, Bodor R 1,2

1 Section of Plastic Surgery, VA San Diego Medical Center, San Diego, CA 2 Division of Plastic Surgery, UCSD Healthcare, San Diego, CA

3 Department of Surgery, Harbor UCLA Medical Center, Torrance, CA

2010 Fall Symposium on Advanced Wound Care and Wound Healing Society Meeting, Anaheim, CA


CVT TO HOMETRANSPORT COST SAVINGS & INCREASED ADOPTION

SCI CENTER – SAN DIEGO

2011 2012 2013 2014 20150

50

100

150

200

250

Projected

Encounters

CONTINUUM OF CAREWHERE TELEMEDICINE FITS IN

• SCAN-ECHO• Spoke Telehealth Consultation• Home Telehealth Monitoring• Face to Face Consultation• Clinic Visit• Admission• Inpatient Rounds• Education• Telehealth D/C Planning• Telehealth Follow-up


NO MORE WAITING FOR THE DOCTOR TO ARRIVE

THANK YOUKEVIN BRODER, MD

2015: Access to care the use of telemedicine across the healthcare continuum-Broder

Health & Medicine

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