WESLEY VALDES D.O.
Telemedicine and Remote Monitoring
Wesley Valdes D.O.
University of Illinois at Chicago
Acting Medical Director Office of Telehealth Research and Innovation
Assistant Professor of Clinical SurgerySection of Wound Healing and Tissue Repair
Clinical Assistant ProfessorBiomedical and Health Information Sciences
Wesley Valdes D.O.
Take care of Patients
Improve Patient’s Health (when possible)
Perform professionally and responsibly
Opportunity
Health Care Reform in Kuwait By reorganizing the way data is collected and
managed, chronic diseases outcomes can be greatly affected Healthier population Reduction in cost of care (i.e. less complications) More efficient care Manage resources more appropriately Increase quality
What to remember!
Centralization of clinical data in monitored centers can significantly improve patient care
Government or non-profit supported data centers can enhance adoption of physician participation
Remote patient monitoring is a proven process than can help physicians manage patients, improve quality of care, and significantly reduce cost of care.
Fact
Advances in information technology have surpassed the current business model of medicine
The Business Model of Medicine
Ambulatory Patient Care
Designed for Acute Care
You saw a doctor when you were sick
Chronic Disease
Diabetes
Obesity
Hypertension
Hyperlipidemia
Asthma
Coronary Artery Disease
Hospital Medicine
Chronic Diseases
Telemedicine
Arizona Telemedicine Program $2,600,000 savings over 6 month study
Department of Corrections $1,000,000 annual cost savings
Chronic Care
Efficiency ≠ Quality
Quality + Efficiency = Efficient Quality
Care-Giver Focused
Department Focused
Progression from Back Office to Bedside:
Accounting
Billing
Registration
Order Processing
Operational Support
Clinical Support
Laboratory, Radiology, Pharmacy, Etc.
Care Plans, Nursing Documentation, Physician Order Entry, Etc.
Healthcare and Advances in Technology
1960s Enactment of Medicaid and
Medicare Cost-based reimbursement Focus on financial needs
1970s Still focused on financial and
accounting systems Technology focused on
mainframes 1980s
PPS introduces focus on cost containment
PCs coming into vogue Ancillary support expanding
1990s More pressures on cost
reduction Technology begins to gain focus
as a quality improvement vehicle
Integration becomes the key, how to service clinicians with disparate systems
2000s Patient safety becomes a focus CPOE becomes huge Mobility and universal
connectivity opens new opportunities and challenges
PROFESSIONAL ISSUES
EMRs don't guarantee quality care, a review of 50,000 patient records shows on 14 of 17 measures, physicians using paper records did equally well as those using EMRs. They even outperformed electronic record users in one area.
By Kevin B. O'Reilly, AMNews staff. Aug. 13, 2007.
Electronic Health Record Use and the Quality of Ambulatory Care in the United StatesJeffrey A. Linder; Jun Ma; David W. Bates; Blackford Middleton; Randall S. StaffordArch Intern Med. 2007;167:1400-1405.
EMRs don't guarantee quality care!
Quality indicator EMR No EMR
Antithrombotic therapy for atrial fibrillation 54% 60%
Aspirin use for coronary artery disease 45% 40%
Beta-blocker use for coronary artery disease 40% 38%
Diuretic and beta-blocker use for hypertension 64% 60%
Statin use* 33% 47%
Inhaled corticosteroid use for asthma 44% 44%
Treatment of depression 82% 86%
No benzodiazepine use for depression* 91% 84%
Selected antibiotic use for acute otitis media 68% 67%
Smoking cessation counseling 30% 23%
Diet counseling for high-risk adults 28% 33%
Exercise counseling for high-risk adults 20% 21%
Blood pressure check 68% 71%
No routine electrocardiogram 97% 96%
No routine urinalysis* 94% 91%
No routine hemoglobin/hematocrit 86% 86%
Avoiding potentially inappropriate prescribing in elderly patients 93% 93%
Quality indicator EMR No EMR
Antithrombotic therapy for atrial fibrillation 54% 60%
Aspirin use for coronary artery disease 45% 40%
Beta-blocker use for coronary artery disease 40% 38%
Diuretic and beta-blocker use for hypertension 64% 60%
Statin use* 33% 47%
Inhaled corticosteroid use for asthma 44% 44%
Treatment of depression 82% 86%
No benzodiazepine use for depression* 91% 84%
Selected antibiotic use for acute otitis media 68% 67%
Smoking cessation counseling 30% 23%
Diet counseling for high-risk adults 28% 33%
Exercise counseling for high-risk adults 20% 21%
Blood pressure check 68% 71%
No routine electrocardiogram 97% 96%
No routine urinalysis* 94% 91%
No routine hemoglobin/hematocrit 86% 86%
Avoiding potentially inappropriate prescribing in elderly patients 93% 93%
Quality indicator EMR No EMR
Antithrombotic therapy for atrial fibrillation 54% 60%
Aspirin use for coronary artery disease 45% 40%
Beta-blocker use for coronary artery disease 40% 38%
Diuretic and beta-blocker use for hypertension 64% 60%
Statin use* 33% 47%
Inhaled corticosteroid use for asthma 44% 44%
Treatment of depression 82% 86%
No benzodiazepine use for depression* 91% 84%
Selected antibiotic use for acute otitis media 68% 67%
Smoking cessation counseling 30% 23%
Diet counseling for high-risk adults 28% 33%
Exercise counseling for high-risk adults 20% 21%
Blood pressure check 68% 71%
No routine electrocardiogram 97% 96%
No routine urinalysis* 94% 91%
No routine hemoglobin/hematocrit 86% 86%
Avoiding potentially inappropriate prescribing in elderly patients 93% 93%
Abnormal Finding
Action by Healthcare professional
TIME
Abnormal Finding
Action by Healthcare professional
TIME
Abnormal Finding
Action by Healthcare professional
TIME TIME
Patient
follows plan
Communication
Evidence based decisions
Enhanced measurement
Compliance
Clinical Integration Chronic Disease Management
Members of a health care team working in concert to implement a plan of care.
Members of a healthcare team including the patient working in concert to implement a plan of care.
Communication
Evidence based decisions
Enhanced measurement
Compliance
Behavior Change Management
Key Points
Technology has made a lot of data almost instantaneously available
Traditional physician offices are not set up to manage large amounts of clinical data
Clinical outcomes can be significantly improved with better data management
Technology is available that can assist and enhance physician performance
Telemedicine vs. Telehealth
Medical care provided via telecommunications technologies
Delivery of health-related services and information via telecommunications technologies
TELE - HEALTH
TELE - MEDICINE
Tele-health
Home monitoring – patient safety Gas leaks Alzheimer patient alarms Bed wetting Water overflow (sinks and baths) Fall alarms Telecom activated Key boxes 911 / Healthcare interoperability
Tele – health / medicine
Home patient educationPatient data monitors
Real Time Technology
Utilization of cellular networks
Diabetes – helping change
Real time availability of data allows – Utilization of resources Early identification of poor control Rapid response to non-compliance Increased compliance Improved communication between patients and
providers Better clinical control
A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus Steven Shea, MD, Ruth S. Weinstock, MD, PhD, Justin Starren, MD, PhD, Jeanne Teresi, EdD, PhD, Walter Palmas, MD, Lesley Field, RN, MSN, Philip Morin, MS, Robin Goland, MD, Roberto E. Izquierdo, MD, L. Thomas Wolff, MD, Mohammed Ashraf, BA, Charlyn Hilliman, MPA, Stephanie Silver, MPH, Suzanne Meyer, RN, Douglas Holmes, PhD, Eva Petkova, PhD, Linnea Capps, MD, Rafael A. Lantigua, MD for the IDEATel Consortium
J Am Med Inform Assoc. 2006;13:40-51. DOI 10.1197/jamia.M1917
8.35% to 7.42% in the subgroup with baseline HgbA1c 7% (n = 353).
Shea study on telemedicine
For test patients with HgbA1c above 7% 0.93 reduction in HgbA1c (353 patients) 0.25 for control group (831 patients)
Reduction in blood pressure and cholesterol levels seen as well
Remote Patient Monitoring
One component gathering medical data
One telecommunication component
One evaluation component
Remote Patient Monitoring
One component gathering medical data
One telecommunication component
One evaluation component
Next Steps
Remote Monitoring Clinical Data Center
SecureConnection
Kuwait Health Reform(at least as far as chronic disease is concerned)
48
Recognize the financial and quality impact of poorly controlled chronic diseases.
Collect and manage the data for these diseases.
Invest in (or participate in existing) clinical data centers to provide real time management of chronic disease states in affected individuals.
Invest in aggressive patient education and community outreach for disease management.
Repurposing the investment
Data-intensive diseases
Diabetes Hypertension Congestive Heart
Failure Asthma
Data-intensive situations
Emergency ResponseMass Casualty Renal Dialysis Infusion Centers Intensive Care Units Stroke Heart Attack
49
Care Bundles
ICU intensivist staffing is associated with a reduction of 40% in ICU mortality and 30% in overall hospital mortality.
Clinical decision support systems reduce adverse drug reactions - 86% reduction in 4 years post-implementation.
Use of “bundles” significantly improve clinical outcomes
Raising the bar with bundles: Treating patients with an all-or-nothing standard. Joint Commission Perspectives on Patient Safety. 2006 Apr;6(4):5-6.
54
eICU Operational SolutioneICU Operational SolutioneICU Operational SolutioneICU Operational Solution
eICU®
Video AssessmentVideo Assessment
Hospital
Network
eCareManager &The Source
Real-TimeWave Forms
PBX‘Hot Phone’
Smart Alerts
Video Assessment &Video Conference
BedsideMonitor
Camera Ceiling/WallMount Speaker
MicrophoneICUPatient Room
Audio/VideoServer
Healthcare Data StandardsMany Applications with Different Message and Coding
Standards
Radiology
Hospital Pharmacy
Knowledgebases
Physiological Monitors
Medical Devices
Bedside Computer
Laboratories
Admission
Transfer Discharge (ADT)
Billing
Payers
Community
Pharmacies
Orders & Results
Patient Patient Medical Medical Record Record
Information Information (PMRI)(PMRI)
Pharmacy Benefits
ManagersClinical Content
HL7DICOM
HL7
HL7
HL7ASTM
HL7ASTM
HL7 &proprietary
HL7 &
HL7
HL7ASTM
HL7ASTM
HL7
ASC X12NNCPDP
ASC X12NNCPDP
X12NNCPDP
Protocolsproprietary
LOINC
Where’s the EHR – Challenges with Information Sharing
Hospitals
Laboratory andDiagnostic Centers
Ambulatory CareClinics
Physician Offices
Long Term Care
Medical Suppliers
RehabilitationCenters Payer
Organizations
Pharmacies
Home Health CareElectronic
Health Record
Patient RoomsNurse's Station
**Central Monitor
X-ray Scanner
Patient Monitoring
Telephone
Bedside Monitors
Video Voice
Bedside Monitors
Video VoiceHot Phone
Laser printer
Video Conferencing
eCareManager/The Source
Remote ViewingGateway
Patient RoomsNurse's Station
**Central Monitor
X-ray Scanner
Patient Monitoring
Telephone
Bedside Monitors
Video Voice
Bedside Monitors
Video VoiceHot Phone
Laser printer
Video Conferencing
eCareManager/The Source
Remote ViewingGateway
Patient RoomsNurse's Station
**Central Monitor
Patient Monitoring
Telephone
Bedside Monitors
Video Voice
Bedside Monitors
Video VoiceHot Phone
Laser printer
Video Conferencing
eCareManager/The Source
Remote ViewingGateway
Patient RoomsNurse's Station
**Central Monitor
X-ray ScannerX-ray Scanner
Patient Monitoring
Telephone
Bedside Monitors
Video Voice
Bedside Monitors
Video VoiceHot Phone
Laser printer
Video Conferencing
eCareManager/The Source
Remote ViewingGateway
Technical ArchitectureTechnical Architecture
Data CentereICU®
Clinical Workstation
HCA Workstation
/
eVantageServer RackeCareManag
erSmart Alerts
Interface Engine
HA Database (2)
Domain Controllers
(2)
HIS SystemADT SystemLab SystemPACS System
MICU (10)
GICU (10)Hospital Network
Patient RoomsNurse's Station
**Central Monitor
X-ray Scanner
Patient Monitoring
Telephone
Bedside Monitors
Video Voice
Bedside Monitors
Video VoiceHot Phone
Laser printer
Video Conferencing
eCareManager/The Source
Remote ViewingGateway
Patient RoomsNurse's Station
**Central Monitor
X-ray Scanner
Patient Monitoring
Telephone
Bedside Monitors
Video Voice
Bedside Monitors
Video VoiceHot Phone
Laser printer
Video Conferencing
eCareManager/The Source
Remote ViewingGateway
Patient Rooms
**Central Monitor
Patient Monitoring
Bedside Monitors
Video Voice
Bedside Monitors
Video Voice
Remote ViewingGateway
Patient Rooms
**Central Monitor
Patient Monitoring
Bedside Monitors
Video Voice
Bedside Monitors
Video Voice
Nurse's Station
Telephone
Hot Phone
Laser printer
Video Conferencing
eCareManager/The Source
Nurse's Station
Telephone
Hot Phone
Laser printer
Video Conferencing
eCareManager/The Source
Remote ViewingGateway
Internet
The SourceASP Hosted
X-ray ScannerX-ray Scanner
eCareManagerHIS/PACS
CICU (10)
SICU (14)
ICU Bedside Monitor ‘A’Network
Hospital A
HIS ‘A’InterfaceEngine ‘A’
HL7 InterfacesDigitized Vital Signs
ADT (IN)
Lab Results (IN)
Med Orders (IN)
Flowsheet (IN)
Notes (OUT)
eCareManager
Near Real-TimeVital Signs
Hot Phone
Smart Alerts
Video Assessment &Video Conference
eICU®
Audio & VideoAudio/Video
Switch
Monitor ‘A’Network Gateway
Audio & VideoNurse Videoconference
In-room Video Assessment
Hospital B
HIS ‘B’InterfaceEngine ‘B’
Audio/VideoSwitch
Monitor ‘B’Network Gateway
Audio & Video
ICU Bedside Monitor ‘B’Network
HL7 AcceleratorSQL Server
Windows 2000
Rack MountedApplication & DB Servers
ICU-to-eICU Interfaces
eCareManager Smart Alerts HA Database
Interface Server
Near Real-Time Vitals (waveforms)
Sentara Healthcare: eICU® Case Study1
Critical Care Medicine 32:31-38;2004
(1) Severity Adjusted
0
200
400
600
800
1,000
1,200
1,400
Hospital Mortality ICU Length of Stay Hospital Length of Stay
(27)%
(17)%
(13)%
Baseline eICU
0
1
2
3
4
5
6
7
VA
P in
fec
tio
ns
/ 1
00
0 d
ev
ice
da
ys
0
20
40
60
80
100
120
% V
en
t B
un
dle
co
mp
lian
ce
VAP infections / 1000 device days % Compliance
95% Goal
Ventilator Bundle Compliance
1.491.36
0.8
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Pre-Intensivists Intensivist Program eICU Program &Intensivist
Ob
serv
ed /
Pre
dic
ted
IC
U M
ort
alit
y*(8.6%)
(36%)
*Ohio Hospital Association
(18 months) (12 months)(12 months)
Ohio Health, DH – Care Model Comparison
Overall Program Performance - Q3 2006
0%
20%
40%
60%
80%
100%DVT Prophylaxis
Ventilator Days (100% = 0 Days)
Stress Ulcer Prophylaxis (Vent at risk)
Low Tidal VolumeBlood Transfusion Threshold
Beta-blockers
Glycemic Control
All eICU Centers AICU ICUs
Cost Analysis
6-Hospital System Outcomes
70
0.6
0.8
1
1.2
1.4
Q1 06 Q2 06 Q3 06 Q4 06 Q1 07
ICU Mortality
Hospital Mortality
ICU LOS
Hospital LOS
Sev
erity
– A
djus
ted
Res
ults
N = 3800 patients
*
*
*P< 0.001
P< 0.001
P< 0.02
*P<0.001
Cost Reduction in U.S. eICUs
71
$100K in Routine Cost/bed/yr/day of stay
$170K in Ancillary Cost/bed/yr/day of stay
$5K per patient not admitted to ICU
30 Bed eICU with 70% occupancy = $4.5M cost reduction/year net of eICU cost, or $150K /bed/year
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