Genetic Telemedicine from the Medical College of Georgia/ Georgia Health

Sciences University1995 to the Present

David Flannery, MD

Department of Pediatrics

Medical College of Georgia of GHSU

Disclosure

• I am an uncompensated member of the Board of Directors of the Georgia Partnership for Telehealth, a not-for-profit 501c3 corporation

Medical Geneticists

• Physicians trained to diagnose and treat genetic disorders such as Neurofibromatosis, Marfan Syndrome, Down Syndrome, and PKU, – and provide genetic counseling to patients and families

• There are only 1400 MD Clinical Medical Geneticists in the US

• There is a geographic misdistribution of Clinical Medical Geneticists in all states

• As a result, almost all Clinical Genetics programs in the US provide services to patients in distant sites by conducting outreach clinics where they travel by auto to distant sites and see patients and families– This is very time-consuming, expensive, inefficient , and creates

delays in access to care

Georgia, is the largest state in land area east of the Mississippi. We have few concentrated areas of specialty medical care

Original State Telemedicine System was called GSAMS

Medical College of Georgia Telemedicine Genetic Services – The Early Years

• In 1995 we offered acute or urgent consults on the GSAMS telemedicine network

• First telemedicine consult was on July 4, to Albany,GA on a baby who we diagnosed with Pfeiffer syndrome, a severe dwarfism. We were able to send orders for DNA testing for the disorder, and then were able to test the parents and determine that the disorder was not inherited, and would not recur in future children

• Despite our offering availability there was little uptake

Time for a New Idea

• We then tried a new model - regularly-scheduled “virtual clinic” using Telemedicine, with Children’s Medical Services in Waycross, GA, in December 1995, which was successful for several years– The Telemedicine Clinic was supplemental to our

Bi-monthly in-person Outreach clinic in Waycross

This was successful - many patients were seen on telemedicine, and we freed up appointment slots for our on-site outreach clinic, decreasing the time to next appointment at our outreach clinic to 2 months

Challenges with GSAMS Telemedicine

• High start-up costs for facilities• High monthly line maintenance fees (~$2600/mo)• Distant sites began dropping out in the late 90’s

GSAMS’ decline and Waycross’ response

• The Southeast Health Unit (Health Department) in Waycross was committed to continue Telemedicine services, and set up a dedicated system between one of their Health Department offices and MCG in 2000– Here is one lesson about “sustainability” of

Telemedicine programs• This internet-based point-to-point system is still in

active use• The nurse who was tasked with developing this

system is now well-known to you all:

Paula Guy

The rest of Georgia languished without telemedicine genetics

Then came the Creation of a New Statewide Georgia Telemedicine Program in 2005

The result of Negotiations by Insurance Commissioner Oxendine regarding Anthem and WellPoint Merger

Result – Oxendine’s Rural Health Initiative• $100 million over the next 20 years in rural capital

bonds• Statewide Telemedicine Program

$11.5 Million over 3 years

Transitioned to Not for Profit 501 (3) c -Georgia Partnership for TeleHealth, December, 2007

13

GPT – “Open Access” Network Model

• Creates a web of access points• Any Presentation Site can connect to any other site

Specialty Center

Specialty Center

Specialty Center

Presentation Site

Presentation Site

Presentation Site

Presentation Site

Transition to Not for Profit 501 (3) cGeorgia Partnership for TeleHealth, Inc December, 2007

Mission • Improve and promote the availability and provisioning of

specialized healthcare services in rural and underserved areas of Georgia.

• Educate and provide training to hospitals and healthcare facilities that furnish, administer and finance Telemedicine programs and facilities.

• Reduce the service barriers that exist for patients who live in rural areas of Georgia at a distance from hospital and other medical facilities.

15

Georgia TeleHealth Infrastructure

Georgia Telemedicine Centralized Scheduling Dedicated 800 phone # and staffing to support Program

Scheduling capabilities for Presentation Sites and Specialty Sites

Field-Based TM Liaisons Regionalized coverage with specific targeted areas

Division of responsibilities between presentation and specialty sites

Expanded Reimbursement

16

17

Current GHSU Genetic Telemedicine Activity

• Using GPT network– Expanded to 2 Half-day scheduled clinics per month

• Using Waycross telemedicine hook-up– 1 half-day per month

Current GHSU Genetic Telemedicine Activity – GaPartnership Network Clinics

– Typically averaging 5 patients seen per session• No-show rate 0 – 33%

– Multiple distant sites• i.e., I encounter a patient in a TM room in

Douglas,GA, then switch to a TM site in Valdosta, and then switch to a site in Hazelhurst, and then back to Valdosta

– Most patients have developmental delay plus something else – dysmorphic features, growth problems, family history

– 75% are New Consultations– History, Family History, Exam, fax orders for testing– Diagnosis rate same as on-campus consults

Current GHSU Genetic Telemedicine Activity – Proprietary Waycross Telemedicine Clinic

– Typically 4-6 patients scheduled• Typically 25 -50% no-show rate

– Most patients are follow-up patients• Recent clinic:

– Down syndrome +FAS, – Tuberous sclerosis, – Beckwith-Wiedemann, – Dysmorphic unknown syndrome

GHSU Genetic Telemedicine – Revenue Metrics

Summary of Activity for Telemedicine Services

FY11 Financial Activity through May for the Population Defined by Telemedicine List

Zero balance accounts only

All Locations

Date of Service Charges Payments Contractual Bad Debt Collections Bad Debt Other NCR II

FYTD 2011 through May $XXXXXXX $XXXXXX $XXXXXX $0.00 $0.00 100.0%

NCR = “Net Collection Rate” – i.e., what percent of the allowablePayment did you receiveCollections average $125.34 per encounter

Lessons from More than a Decade of Telemedicine Genetics

• Genetics can be done by telemedicine– Quality of the interaction with patients and families is

good– Image quality is good for dysmorphology

• Patients are satisfied– Formally assessed several years ago

• Show rates vary– seem to correlate with the enthusiasm of the

nurse/coordinator at the distant site with regard to their interaction with the patient being scheduled

http://medgen.genetics.utah.edu/index.html

Up-slanting Palpebral FissuresAble to see minor physical variations

(Dysmorphic Features)

Other Lessons from More than a Decade of Telemedicine Genetics

• Most patients/families take to TM like ducks to water,

–BUT• Some people DO NOT

– And it can be painful and cringe-worthy• The Consultant can’t know this, but the Physician

and Coordinator at the remote end need to look at the patient/family and reflect on their suitability before making the referral for TM

Why has this worked so well for so long?

• Local “champions” for telemedicine in distant site communities

• Availability of Centralized Scheduling into our “virtual clinic” sessions

• Open architecture of the network, which allows hopping from site to site during the “virtual clinic” session

Other Opportunities for Genetic Telemedicine

• Follow-up of patients with Inborn errors of Metabolism, like PKU and other disorders detected by Newborn Screening– We have experience with this

• TM works fine– Physician component would be reimbursable– Would need a waiver for Dieticians to bill for services

Genetic Counseling by Telemedicine: Tremendous Opportunity

• Telemedicine would be good for counseling for:– Cancer Genetics – Breast, Colon, etc.– Patients with already diagnosed Mendelian Disorders– Already diagnosed Multi-factorial disorders

• But, Genetic Counselors are not licensed in the vast majority of States, and are not recognized by payers

Untapped Opportunities

• “Store-and-Forward “ Telemedicine Consultations– A great “fit” for Dysmorphology consultations– Could easily go across State boundaries

• Informally already occurs, even across national boundaries:

– Skeletal dysplasias listserv– Every Geneticist who has “expertise” with a particular

syndrome frequently receives inquiries from other physicians regarding patients

– Probably needs to be formally structured to be able to meet a definition of “practice of medicine” that would be recognized by State Medical Boards

There are challenges,BUT - It’s Worth the Effort!

• Improved Access– Connecting Patients and Families with Genetic

services that they would otherwise not receive• Decreasing cost of care

– Patient/families’ travel– Genetic consultants’ travel– “Green” service – how to calculate?

• Enhanced revenue– Geneticist avoids lost opportunity encounters at

home institution that would occur while they are on the road to do outreach clinics

– BECAUSE

With Telemedicine,You Can Be In Two Places At The Same Time !