In Washington, D.C., George Washington Medical Faculty Associates (GW MFA)—affiliated with the George Washington University Hospital—has been providing telehealth services for the maritime industry since 1989. So when the organization decided to extend those services for the GW University Hospital emergency department follow-up visits, the infrastructure was already in place.
According to Neal Sikka, M.D., Associate Professor in the Department of Emergency Medicine and a Board Certified Emergency Physician at The George Washington University Hospital, and Director of the Innovative Practice Section at GW Medical Faculty Associates, as the healthcare environment continues to change, those learnings from the maritime industry could prove critical in developing a telehealth ED follow-up program locally in Washington, D.C. Dr. Sikka, who also oversees the telemedicine communication center at GW MFA, gave a presentation on the program, ConnectER, on Nov. 10 at the Gaylord National Resort in National Harbor, Md. (the HIMSS Connected Conference combines the mHealth Summit from previous years with the new Cybersecurity and Population Health Summits, all under the HIMSS umbrella).
In his presentation, Sikka noted the 136.3 million ER visits nationwide annually, per 2011 data, which means the number is likely larger today. He also noted the 1.2 billion outpatient discharges in the U.S. each year. What's more, in Washington, D.C., the average time from discharge to the patient's follow-up primary care practice visit is approximately 15-30 days; in other cities, it's even longer than that, said Sikka. Put all together, the writing was on the wall for an ED follow-up telehealth program that would be convenient for patients and hopefully keep them from being readmitted to the hospital, a far too frequent occurrence in U.S. healthcare.
The potential benefits of using IT in the ED were clear, said Sikka—those who return to the emergency department for follow-up care contribute to congestion, hindering the ability of the ED to serve as an effective gateway for inpatient care. "When patients don't have access to follow-up care for whatever reason, they come back to the ED," Sikka said. "It's [often] an access gap that we needed to bridge."
As part of the ConnectER program, the telehealth consultations consist of 15-minute online visits, from Monday to Friday during normal work hours, for a flat fee of $35 for a range of minor illness, minor injuries, and skin conditions. The consultation uses existing technology and platforms such as Microsoft Lync/Skype and FaceTime to connect patients to providers, Sikka said, noting that the fee is affordable and less then most patients' normal ED co-pays. To be eligible for the program patients must: have been discharged from the George Washington University Hospital ED within the past 15 days; or be a current patient of GW Medical Faculty Associates; and live in District of Columbia, Maryland, or Virginia.
When patients are discharged from the GWU Hospital emergency room they are given paperwork explaining ConnectER. A nurse also discusses the program with the patient to make sure they understand that it could be an option for them, Sikka said. For patients to consent in the program, there is a laborious process which includes a PDF document of consent being sent to the patient in addition to having a YouTube video recorded that has the provider going through the consent process verbally, and the patient acknowledging the process and signing the document electronically.
Key to the ConnectER program is a telehealth call center, called the WECC (Worldwide Emergency Communication Canter) directed by a paramedic and staffed by EMT operators, Sikka said. Patients also consent via this call center, and once connected, the consulting doctor comes in to do the consultation—at which point the call center operator signs off and goes on mute so he or she doesn't hear anything, Sikka explained. He noted that the EMTs are a logical fit for the 24/7 call centers, as they understand medical terminology, have plenty of experience with patients, and are tech savvy.
So far, about 100 patients have been referred to the program, although the emergency department at GWU Hospital sees about 6,000 to 7,000 patients per month. Sikka estimated that at least 2,000 of those patients could benefit from those program. A challenge, however, has been marketing the program to providers and getting them on board; the hospital currently has 45 ER doctors, and there have been struggles in getting them to see the value, Sikka said.
There is also a financial challenge, as is the case with nearly all telehealth consultations. Sikka said that after a year of discussing how these visits should be billed, the organization settled on a flat $35 fee—though he said this is not a sustainable model going forward.
What's more, Sikka noted that while GW MFA is part of an accountable care organization (ACO), it is still "completely operating in a fee-for-service model." However, he said, the hope is that as the program expands, and as GW MFA patients who are further away from the Virginia/D.C./Maryland area continue to seek care at the facility, the way in which care is delivered will shift towards a more value-based model. "The way we provide care in the emergency department hasn't changed yet, but we think this program will help with that. We're certainly waiting for it," Sikka said.