Telehealth Approaches to Integrated Multiple Sclerosis Care

May 30, 2013CMSC Annual Meeting, Dallas, TX

Mitchell T. Wallin, MD, MPHClinical Associate Director

VA MS Center of Excellence East-Baltimore

Associate Professor of NeurologyGeorgetown University School of MedicineUniversity of Maryland School of Medicine

Disclosures

M. Wallin, MD, MPH has the following disclosures:

Biogen-Idec, Inc. Investigator Initiated Grant Support

Learning Objectives:

Telehealth & MS health care

Using telehealth for remote assessments: Remote neurological examinations (EDSS)

Remote cognitive assessments (ANAM)

MS Surveillance Registry

Discuss optimal models of care for MS

Patient-Centered Medical HomeJoint Principles (Kirschner, 2010)

Personal physician

Whole-person orientation

Integrated care

Quality and Safety

Enhanced Access

Patient-Centered Medical Home Joint Principle Endorsement

18 Specialty Medical Societies: including Am Acad Neurology, Am College Cardiology, Am College Chest Physicians, Am Soc Clin Oncology, Infec Dis Soc America, Soc of Critical Care Medicine

Promise of improved coordination, quality & efficiency

Concerns: Unrealistic expectations

How will new services be reimbursed

Implementation challenges for small practices

Telehealth & Neurology(Agarwal S. J Neurol 2011)

Telestroke: initiated in 1990s for acute stroke thrombolysis consultation, AHA Class I evidence for reliability of remote NIH Stroke Scale exam

Teleneurology Pilots: Parkinson’s Disease

Epilepsy

Neurorehabilitation

Multiple Sclerosis

Telemedicine in Leading US Neurology Departments(George B. Neurohospitalist 2012)

60% of respondents provide limited telemedicine services Stroke

Movement disorders

Neurology critical care

Most programs started 2008-2010

External funding sources

Taking Charge of Your Health CareWhen and Where you Need it

• Telehealth: a means of utilizing technology so that patients and providers can communicate remotely, enabling patients to receive health care through telecommunicationsClinical Video Telehealth

Home Telehealth

Store & Forward

•

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E-Medicine in the VA Health Care System

VHA is largest integrated health care system in US

Common electronic medical record (CPRS) across all sites with links to utilization

My HealtheVet is patient portal for access to their record, make appts, rxs, surveys, secure messaging

Tablets, smart phones being used to access CPRS & Telehealth platforms

https://www.myhealth.va.gov

Integrated MS Care Comprehensive & coordinated care

between health and social sectors Many unmet needs found in review of MS

care delivery in part due to fragmentation and discontinuity of the health care system

Multidisciplinary community team worked with MS specialists

Home-based care interdisciplinary team intervention

Clinical & Demographic Predictors of Progressive Disability in MS

Favorable Risk Factors Unfavorable Risk Factors

Young age at onset Older age at onset

Female Sex Male sex

Race: White Race: African American

Onset sx: optic neuritis, sensory Onset sxs: motor, cerebellar, sphincter

RR disease onset Severe disability after first attack

Short interval between first-second attack

High frequency of attacks in first 5 yrs

Progressive disease from onset

Age and Disability Progression (Confavreux, Brain 2006)

Clinical Features of the GW-Era MS Cohort (n=2,478)

Onset subtype: relapsing (94%), progressive (6%) with no single presenting DSS functional system being significantly different between groups

Significantly more males and AA had progressive onset MS

Optico-spinal MS presentation:

Asian > NA/Alaska native > Hispanic > AA>Whites

NMO confirmed cases: n=6 (AA: 66%, White: 33%)

Visual

BrainstemPyramidal

CerebellarSensory

Bladder/BowelMental

Spinal CordMultiple OTH

Pe

rce

nta

ge

of

Pat

ien

ts

0

10

20

30

40

50

White (n=1,833)Black (n=656)Hispanic (n=153)Asian/Hawaiin/Pacific Islander (n=26)Am In/Alk Nat (n = 7)Unknown (n = 14)

Clinical Features of the GW-Era MS Cohort

DSS Score

0-2 3-4 5-6 7-9

Per

cen

tag

e o

f P

ati

ents

0

10

20

30

40

50

60

Male (n = 1,603)Female (n = 845)Total (N = 2,448)

DSS Score

0-2 3-4 5-6 7-9

Per

cen

tag

e o

f P

ati

ents

0

10

20

30

40

50

60

White (n = 1,684)Black (n = 600)Hispanic (n = 135)Asian/Hawaiin/Pac Isl (n = 20)Am In / Alk Nat (n = 5)Unknown (n = 4)

National MS Society Expert Consensus Statement (2007)

● Initiate therapy as soon as possible following diagnosis of active-relapsing disease with an FDA approved DMT

● Access to medications should not be limited by age, level of disability, or frequency of relapses

● Continue treatment indefinitely unless lack of benefit, intolerant adverse effects, or better treatment becomes available

● Ensure adequate accessibility of all FDA-approved drugs for MS

● Change treatments only for medically appropriate reasons

MS System of Care HandbookVA MS Center or Excellence Network

(www.va.gov/ms)

Access to multidisciplinary MS care, home care, long-term care via hub and spoke system

All FDA approved MS DMTs available

Annual exam and MS Assessment Tool required

Telehealth used to enhance clinical access and follow-up (Clinical Video Telehealth intrafacility, CVT-Home, Store-forward)

Existing approaches of care using telehealth

do not utilize constructs from evidence-based models for chronic care which were shown to successfully improve quality of care;

current technology is not cost-effective;

existing IT tools are not fully integrated into the health information systems

MS Home Automated TelemanagementInformation Infrastructure

MS HATVA Demonstration Project

MSCoE and Johns Hopkins U2011-2014

Home Unit

HAT Server

(Austin Automation Center)CPRS-VISTA

Home Unit

Home Unit

MS HAT: Remote Neuro ExamBackground

Physician care is routinely carried out in doctor’s offices and hospitals.

Patients with MS are often separated from specialty care due to disability or distance.

The value of low-cost webcams as a tool for remote neurological exam has not been systematically evaluated.

MS HAT: Remote Neuro ExamObjective

Develop a videoconferencing application utilizing low-cost webcam to assist in examining patients with MS in the home.

This study evaluated the feasibility of using regular webcam and microphone as a tool to aid in the management of MS.

MS HAT Webcam System Design

The video chat application was developed in Microsoft Visual Studio

MS HAT: Remote Neuro ExamStudy Design

A total of 20 patients with MS were recruited

Trained study asst. played role of patient’s caregiver

Two MS clinicians examined each patient at the clinic using the Kurtzke Expanded Disability Scale (EDSS).

On a single visit, each patient underwent two identical sets of neurological assessment: Traditional in-person evaluation

Remote assessment using portable webcams

MS HAT: Remote Neuro Exam Kurtzke Expanded Disability Scale Scores (EDSS)

MS HAT: Remote Neuro ExamTelemedicine Satisfaction Survey

Overall, the remote assessment system received positive ratings from both patients and providers. 100% - Patients felt comfortable with the equipment used.

85% - Patients were satisfied with the telemedicine parts of this examination.

90% - Providers were able to obtain adequate information interviewing the patients via video chat.

95% - Providers felt confident in the final assessment.

Remote Cognitive Assessments in MS (n=20)

Symbol Digit Modalities TestANAM-ICE Summary Score

Home Telehealth for MS

Home-based teleneurology is just-in-time care

When transportation is a challenge

What our research has shown: The remote neurological & cognitive exam is similar to the

live exam

Patient & provider satisfaction is high

Cost of care is less

Multidisciplinary care is enhanced

MS Assessment Tool & MS Surveillance Registry

CPRS-based annual assessment of all VA-users with MS (MS Policy Handbook-2009)

Core demographic & clinical information captured/stored

Pilot in VISN 5 & 20 (n=500)

Goals: Improved real-time surveillance of

MS population

Efficient monitoring of DMT use & untoward effects

Optimize management of patients

Data for epidemiology and policy decisions

MS Surveillance Registry Development – Big Picture

CPRS template

CPRS template

CPRS template

CPRS template

Corporate Data Warehouse

Project Database

Web Application

MSCoE MS Registry Main Page

• Data updated daily• Main page allows for filtered cohort selection based on individual search preferences

Expanded Diagnosis & DMT Medication Filter Options

Patient DashboardMS Surveillance Registry

Integrated MS Care Conclusions

Integrated MS Care is important to define and use to develop goals within a health care system

Telehealth can improve access to MS specialty care MSCoE MS Principal Care is critical to optimize outcomes

Telehealth (CVT, MS HAT, My HealtheVet) Integrated Neurology Project Demonstration VISN 5, 6 & 20 MS Surveillance Registry for real-time tracking of morbidity &

clinical decisions

MSCoE Telehealth-Informatics Research Group VA MSCoE

Joel Culpepper, PhD Amy Kunce, MA Heidi Maloni, PhD Jodie Haselkorn, MD, MPH Ruth Whitham, MD NW Innovation Center Staff

VACO/Office of Specialty Care Glen Graham, MD Cythnia Sundahl Omar Cardenas Clare Mahan, PhD

Johns Hopkins University/Welch Ct

Joseph Finkelstein, MD, PhD

Amy Cha, MPH

McKenzie Bedra, MPH

Jeff Wood, BS

Georgetown University/DoD Robert Kane, PhD

Funding: VA Merit Review, VA MSCoE, Biogen-Idec

Questions?