Anne E. Burdick, MD, MPHProfessor of Dermatology

Associate Dean for TeleHealthMarch 20, 2014

University of Miami TeleHealth Enhancing Healthcare for Floridians

I have no conflicts of interest to disclose.

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UM TeleHealth is a catalyst forhealthcare transformation in

Florida.

Access

Convenience

Quality

Cost

SynchronousReal-time interactive

AsynchronousStore-and-forward

We use 3 operational telehealth systems

SynchronousReal-time interactive

AsynchronousStore-and-forward

We use 3 operational telehealth systems

Hybrid

University of Miami TeleHealth

•1974: Dr. Jay Sanders, telemedicine in Miami jails

•1994: Fellowship at MCG, ATA Board member

•1994: Teledermatology for migrant workers, JAMA

•1996: Developed American Academy of Dermatology Telemedicine Position Statement

•1999: Founded ATA Teledermatology Interest Group

Approved 2007

2007

Approved 2007

2007

“Based on the history and images

provided, my impression is as

follows.”

Approved 2007

Endorsed by American Academy of Dermatology

2007

“Based on the history and images

provided, my impression is as

follows.”

2008

“Economic Evaluation of Telemedicine: Review of the Literature and Research Guidelines for Benefit–Cost Analysis”

Dávalos ME, French MT, Burdick AE, Simmons SC

Telemedicine and e-Health 15: 933-948, 2009.

2009 Manuscript of the Year Award

Our challenge in Florida: Limited telehealth reimbursement

• Medicaid: only Children’s Medical Services, waiver

• Medicare: Rural and Health Provider Shortage Areas

• No private payers

Our strategy:

• Contracts

• Grants

• Advocate for policy change

Dept of Health Children's Medical Services

• Teledermatology

• Telegenetics• Telenutrition• Telepsychiatry

Miami-Dade School Telehealth Initiative

• 7 North Miami Beach schools: • Elementary, middle and high schools

• Staff in school clinics supported by Children’s Health Fund, John T. MacDonald Foundation, AHEC

• Equipment from a HRSA grant

• UM specialists reimbursed by Verizon Foundation grant

• Dermatology by hybrid telemedicine • Endocrinology, nutrition and psychiatry by VTC

Miami-Dade School Telehealth Initiative

• UM doctor provides primary care onsite and to schools by VTC

• RNs, MAs or medical/nursing students present patients

• UM specialists: scheduled clinics

• Nutrition: onsite + VTC, groups

Miami-Dade School Telehealth Initiative

Expansion• Awarded an Innovation Grant from Centers for Medicare and Medicaid Services

• Booker T. Washington High School added

• New services and partners:• Larkin Hospital for telemental health• NOVA SE University for teledentistry

Eczema herpeticum

Generalized herpes simplex infection + atopic

dermatitis

Eczema herpeticum

Generalized herpes simplex infection + atopic

dermatitis

Sent to ER for hospitalization with IV acyclovir and

antibiotics

Eczema herpeticum

Generalized herpes simplex infection + atopic

dermatitis

Sent to ER for hospitalization with IV acyclovir and

antibiotics

UM pediatric mobile van teleconsultations

• Route: Little Haiti, Sweetwater, Homestead

• Verizon Foundation grant for specialist

reimbursement and 4G network provided

• Nutrition, dermatology, cardiology by VTC

Training in telehealth

• Dermatology residents• Genetics fellows• Medical students• ARNP and DNP nursing students

UM TeleHealth: Educating residents inthe “Core Competencies” required by American College of Graduate Medical

Education

• Interpersonal and communication skills

• Systems-based practice

• Patient care

• Practice-based learning and improvement

Acute teleneurology to hospital emergency departments

• Specialists on Call, Inc.

Discharge planning enhancement

• Patients transfers from UM Hospital to Miami Jewish Home for the Elderly

• Verizon Foundation grant for a Vgo robot

• Interactions between nurses, doctors and patients

• Goal: to decrease readmissions

UM Employee TeleHealth

• Employees at a UM satellite clinic 10 miles away

• 45-60 minute by car or Metrorail

• VTC specialty teleconsults with faculty at the medical campus

• Neurology, dermatology, nutrition, cardiology

Teletrauma: Ryder Jackson Memorial/University of Miami Trauma

Center

• Trauma bay resuscitations• ICU rounds, InTouch robot

• Air ambulance optimization from Lower Keys Medical Center

Teletrauma: Ryder Jackson Memorial/University of Miami Trauma

Center• Brazil Olympic team, London

• U.S. State Department contract for 24/7 teleconsults for personnel in Iraq + Afghanistan

• 16 specialties: • Trauma and orthopedics• Anesthesia, cardiology, dentistry,

dermatology, ENT, gynecology, internal medicine, nephrology, ophthalmology, psychiatry, pulmonology, radiology,

urology

Human assistance and disaster response: UM TeleHealth in Haiti

Aerial view of University of Miami Hospital, Port-au-Prince, Haiti.Arrow A is the location of the operating room in the posterior part of the first tent.

Jaffer A K et al. Ann Intern Med doi:10.1059/0003-4819-153-4-201008170-00266

©2010 by American College of Physicians

• Trauma and critical care

• Teleradiology

• Pediatric subspecialties

Telemedicine for Trauma, Disaster, and Emergency Management Eds: Latifi R,

Poropatich R. Artech House, Boston. 2010

Cutis 88, 213: 2011

Store-and-forward Teledermatology

Nashville Area

Oklahoma Area

Albuquerque Area

MICMACPleasant Point, ME

Oneida, NY

Catawba, SC

4 yo: 3 days itching, sores hands & stomach

4 yo: 3 days itching, sores hands & stomach

………Scabies

UM – Alaska store-forward TeledermatologyAlaska’s healthcare challenge:

• 49% MDs are primary care physicians, U.S. average is 28%

• 59% residents live in medically underserved areas• 48th in doctor : resident ratio

• 65% MDs are in Anchorage• Shortages in many specialties

UM – Alaska store-forward TeledermatologyAlaska’s healthcare challenge:

• 49% MDs are primary care physicians, U.S. average is 28%

• 59% residents live in medically underserved areas• 48th in doctor : resident ratio

• 65% MDs are in Anchorage• Shortages in many specialties

UM Teledermatology service, started 12/13• ARNP at Alaska Native Medical Center, Anchorage• Reviews referrals from 180 community primary care

centers in the Alaska Federal Health Care Access Network

• Sends selected teledermatology cases to UM

UM Cruise Ship Teledermatology

• Provides rapid access to University of Miami dermatologists for crew and occasionally guests on ships all over the world

• Within 72 hours or 24 hours

• Royal Caribbean Cruise Lines since June 2010

• Carnival Cruise Lines since November 2012

Teledermatology at Sea

• Provides dermatology care for an employee population that’s geographically dispersed

• Allows ship’s medical staff to effectively manage their crew’s skin conditions

• Reduces onshore dermatology visits

• Assists in medical evacuation decisions

• Cost avoidance

• UM selected Medweb software

• Cruise IT teams evaluated software

• Username/password assigned to each ship

• Introduced service at RCL/CCL conferences

• Lab and X-Ray capabilities determined

• Additional drugs recommended

• MDs and RNs reviewed UM’s online training

• Test case submitted by each ship before sending consults

Fleetwide Rollout

Ship MD UM DermatologyConsultantPhotos

Consult Form

PC

PC

Internet UM Server

S

Workflow

Dermatology at Sea: Special Issues

• Limited drug formulary• Challenging to access shoreside dermatologists • Diverse occupations• Off work or “dry” work difficult, no redundant

crew• Maximum Medical Improvement • Medical isolation • Medical evacuation

Tinea versicolor

Alopecia areataContact dermatitis

Wart

Candida intertrigoErysepelis

Bullous cellulitisLeishmaniasis

“3 day painful rash with vesicles, left trunk. On Acyclovir 800mg every 4 hours. Correct?”

“3 day painful rash with vesicles, left trunk. On Acyclovir 800mg every 4 hours. Correct?”

Agree with Herpes zoster and treatment

Rare Diseases

Multiple acral reticular histiocytosis

Hidradenitis suppurativa

Relapsing polychondritis

Oral lesions: Torus palatinus

New England Journal of Medicine, April 11, 2013

<5% Consults are referred to a dermatologist

Present x 1 monthWart vs. squamous cell cancer vs

keratoacanthoma

New pigmentation of a single nail Probable melanoma

Growing dark dot x 1 yearProbable melanoma

STAT case: Hand dermatitis, violinist

STAT case: Fever + coryza + rash, R/o Measles

STAT case: Erythema multiforme major

UM TeleHealth is enhancinghealthcare in Florida and

beyond.

Anne E. Burdick, MD, MPHAssociate Dean for TeleHealth

Professor of Dermatology aburdick@med.miami.edu

(305) 243-8252telehealth.med.miami.edu

Thank you