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From Sydney, Australia, Emory Healthcare Leverages Tele-ICU to Address Specialist Shortages

December 27, 2016
by Heather Landi
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Emory Healthcare intensivist clinicians based at workstations in Sydney are able to turn "night into day" to provide 24/7 patient monitoring
credit: Jack Kearse, Emory University

Healthcare executive leaders are faced with an ongoing nationwide shortage of critical care physicians and nurses, otherwise known as intensivist clinicians, and many healthcare leaders project that the workforce gap will only intensify as acuity of illness, complexity of care and healthcare costs continue to rise.

With an increase in the number of critically ill patients, the challenge of meeting this need for comprehensive critical care medicine is being felt at Atlanta-based Emory Healthcare as it is as most major hospitals and health systems across the country.

“The environment in which critical care is delivered is highly technical, IT-rich, and the people who deliver critical care, that would be intensivists physicians and critical care nurses, and also allied health personnel, such as respiratory therapists, critical care pharmacists, nutrition support specialists, they all have had much additional training and are technically very advanced,” Timothy Buchman, Ph.D., M.D., founding director of the Emory Critical Care Center, says.

However, there are a number of forces at work creating challenges for critical care, Buchman notes. “We are running out of experienced professionals. The experienced critical care nurse at the bedside is no longer 30 or 40 years old, and many are now approaching retirement age as are the physicians,” he says. “To make matters worse, those experienced people are mal-distributed and tend to congregate in major cities and it leaves the smaller hospitals in suburban and rural areas relatively thin on that level of experience. If you go 50 miles outside of Atlanta, there are plenty of hospitals that have ICUs, but zero to one ICU physician and the majority of the nurses who work in the ICU may not have specialist critical care training.”

Healthcare leaders at Emory Healthcare, the largest health system in Georgia with six hospitals and 16,000 employees, launched its eICU Center in March 2013 at Emory University Hospital to provide round-the-clock ICU monitoring, and the eICU service has since expanded to all hospitals in the health system. Seeing the success of tele-ICU technology, Cheryl Hiddleson, MSN, R.N., director of the Emory eICU Center and Buchman decided to take this program a step further, about 9,000 miles further. This past July, Emory Healthcare, through its Emory eICU Center, collaborated with Sydney-based Macquarie University’s MQ Health program and technology vendor Philips to roll out a project that delivers remote intensive care services from critical care specialists stationed in Sydney, Australia.

Timothy Buchman, M.D., and Cheryl Hiddleson, R.N.

Referred to as the “Turning Night into Day” program, it’s a three-way partnership using remote monitoring to bring 24/7 eICU care to Emory Healthcare patients in Atlanta. Emory Healthcare critical care physicians and nurses based at workstations at Macquarie University’s MQ Health in Sydney use Philips’ eICU technology to provide additional patient monitoring in the ICU.

The pilot program aims to improve the outcomes of high-risk patients in greatest need of constant observation. Combining daytime critical care coverage in Atlanta with night-time coverage from Sydney provides focused, 24-hour-a-day management of ICU patients by critical care specialists, potentially decreasing the risk of complications and shortening patients’ length of stay, according to Buchman.

By using providers in a complementary time zone –– in this case, Sydney –– to cover the Atlanta eICU night shift, it reverses two of the largest drawbacks of critical care night staffing: a shortage of senior clinicians willing to cover night shifts, and the toll that working nights takes on caretakers and their attention levels, Buchman and Hiddleson contend.

“The senior nurses prefer weekday day shifts. You’re just not as sharp at 3 a.m. as you are at 3 p.m. And at nighttime, it’s usually the newest graduates, the least experienced nurses, the ones who need the most guidance and mentorship,” Buchman says.

He adds, “In any healthcare organization, the most valuable resource that we have is our people. If you look at the medical specialties that are out there, the top of the burnout list is critical care. So, we believe that the efforts we’re making in improving the work-life balance and work-life integration of our caregivers will pay the greatest dividends for our patients.”

Citing the success of Emory Healthcare’s eICU Center, Buchman says, “At one point, we said, ‘What if we were to take our entire eICU operation, the hardware, software, the physical environment, and create a copy of it in Sydney Australia, and then rotate for a period of six to nine weeks, a physician and a nurse down to Sydney, and literally allow them to turn night into day, to deliver care back into the Georgia nighttime from the Sydney daytime?,” Buchman says.

The program is set up to have one physician and one nurse working remotely from the Sydney workstations three or four days a week and working concurrently with two nurses on staff in the ICU in the Atlanta hospitals.

“Thanks to our eICU program we can continuously monitor Atlanta-based patients from MQ Health in Sydney and support the bedside team by recognizing adverse physiology, making critical diagnoses and intervening before those issues become significant problems,” Hiddleson says.

According to Buchman, the cross-global remote monitoring program enables healthcare providers to deliver care to critically ill patients that is more timely as well as more effective, accurate and precise.

While Emory Healthcare’s eICU Center has been in operation for three years, for this particular project, there were considerable logistical challenges had to be overcome, primarily technical and legal challenges, Hiddleson says. “Basically we went through a six month process—concerns about our staff practicing medicine in another country, and whether that involves licensure and credentialing. And, there were concerns about the various liabilities, the health insurance, the liability coverage for practice, all those sorts of legal considerations because it’s an international project, and there are different laws and rules that govern each country.”

She continues, “There were also considerable IT concerns, primarily around security and HIPAA [Health Information Portability and Accountability Act], and protecting PHI [protected health information] for patients, and how we could best make that happen. We wanted to make sure data wasn’t transmitting from here to Australia and somehow living in Australia, or being transferred to some document repository there.”

According to Hiddleson, the solution to that particular challenge was creating a multiprotocol label switching (MPLS) circuit that is end-to-end for a high-performance telecommunications network. “Emory configured both of the circuits, their sort of like routers, so they configured both of them, and the routers are both ours. So the program in Australia is on the existing Emory network to ensure the privacy of all the patients and their information,” she says. “There were logistics challenges about getting that circuit up and built. It took four months to make that happen. This is not something that’s done every day, to get all the parties in the same place, to understand this is the goal and what we’re doing. It took a lot of coordinating, persistently saying, yes, we’re going to do it.”

Hiddleson says she is confident that the remote monitoring and consulting from Sydney is as secure and effective as the remote monitoring system in the eICU Center in Atlanta.

“The providers at the eICU workstations have what I call population level views where they are seeing high-level abstractions of 100 or so patients that they are caring for at a time,” Buchman says. “Those abstractions include alerts, such as out of range lab values, and new admissions coming into the various units. They can drill down, through these population level views, to get very detailed information about each patient that they are caring for. And, literally, at the touch of a button, they can go into high resolution audio and visual communication with the patient and whatever family and caregivers are in the room. We have immediate access to the EMRs and to the PACs systems. If there is an electronic system active at a hospital, then we have it.”

The physicians and nurses on staff in Atlanta have reported seamless interaction with the specialists in Sydney, Hiddleson says. And, she adds, “The primary responsibility still falls on the team members at the patient’s bedside. We’re there as a second set of eyes, with the added benefit of being able to speak directly to the bedside staff, patient and family.”

Project leaders are testing the efficiency of Emory clinicians practicing in Australia as well as the program’s impact on patient well-being. Project leaders also want to evaluate how the initiative improves the lives of the senior personnel, the critical care specialists, who are working remotely in Sydney so there are ongoing efforts to track sleep cycles, mood changes as well as clinician stress as measured by cortisol levels, and overall quality of life, says Hiddleson.

While program leaders do not yet have the results of those studies, Hiddleson says she is receiving positive feedback from the critical care specialists who have worked from Sydney and she has observed improvements in critical care clinicians’ quality of life.

Additionally, program leaders have received positive feedback from hospital staff at the bedside in the Atlanta hospitals. “We’ve gotten feedback such as ‘This physician in Australia had the time to talk to us and gave us an education on a particular drug and how a patient would respond,’” she says.

Future plans may include expanding outreach coverage, and possibly extending the international options for Emory clinicians working in the eICU, Buchman says.

“The notion of a global eICU network is an interesting one,” Buchman says. “I am having some ‘what if’ conversations with colleagues on what it would take to put critical care professionals shoulder to shoulder around the world, local and “visiting expatriates,” so that everyone’s home night-time care could be delivered from somewhere that is daylight. And, when you have critical care professionals working shoulder to shoulder with one another, they tend to exchange information, approaches and ideas, and help to spread the ideas around best practices. In our view, this project is not just about delivering nighttime ICU care during the day, it’s also about some pioneering efforts toward globalizing information exchange around best care for critically ill patients.”

He adds, “To be able to move senior personnel to a bedside anywhere more or less at the touch of a button is really remarkable. When you are thin on personnel, this is a very efficient way to deliver care. And, when you have experienced staff who are approaching retirement and they are saying, ‘We can’t do this anymore,’ even preserving three, four or five years of work productivity has an enormous impact on the nation’s ability to care for this rapidly growing group of patients.”






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Senate Passes Opioid Response Bill with Substantial Health IT Elements

September 18, 2018
by Rajiv Leventhal, Managing Editor
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The U.S. Senate yesterday passed The Opioid Crisis Response Act of 2018, which includes numerous important health IT provisions, by a vote of 99-1.

The bill was originally sponsored by Senate Health, Education, Labor and Pensions (HELP) Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.), and includes proposals from five Senate committees and over 70 senators. The House passed its version of the legislation in June and now it’s expected that a committee will be convened to reconcile the differences between the two.

The legislation’s core purpose is to improve the ability of various health departments and agencies—such as the Department of Health and Human Services (HHS), including the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Health Resources and Services Administration (HRSA), and the Departments of Education and Labor—to address the opioid crisis, including the ripple effects of the crisis on children, families, and communities, help states implement updates to their plans of safe care, and improve data sharing between states.

There are several key health IT provisions in the legislation, including: enabling the Centers for Medicare & Medicaid Services (CMS) to test various models that provide incentive payments to behavioral health providers for the adoption and use of certified electronic health record (EHR) technology to improve the quality and coordination of care through the electronic documentation and exchange of health information; requiring the use of electronic prescribing for controlled substances within Medicare Part D; facilitating the use of electronic prior authorization within Medicare Part D; and expanding access to telehealth services for substance use disorders.

Regarding telehealth specifically, the Senate version of the bill will allow for payment for substance use disorder treatment services, via telehealth, to Medicare beneficiaries at originating sites, including a beneficiary’s home, regardless of geographic location. It also requires guidance to cover state options for federal reimbursement for substance use disorder services and treatment using telehealth including, services addressing high-risk individuals, provider education through a hub-and-spoke model, and options for providing telehealth services to students in school-based health centers.

Health IT Now's Opioid Safety Alliance—a working group of prescribers, health systems, technology companies, pharmacies and pharmacists, professional societies, and patients advocating for the use of technology to fight illegitimate opioid use—supported the Senate’s passing of the bill. Said Joel White, HITN Opioid Safety Alliance executive director, “We are especially encouraged by the inclusion of commonsense Opioid Safety Alliance-endorsed language in this bill that will remove bureaucratic barriers to vital telehealth services for those suffering from addiction, modernize prescribing practices for controlled substances, and streamline prior authorization claims to improve efficiency while bolstering patient safety. These solutions can make a world of difference both in dollars saved and, more importantly, lives spared."

White did add, however, as Congress convenes a committee to reconcile the differences in the House and Senate-passed bills, lawmakers ought to include the House-passed OPPS Act (H.R. 6082) as part of any final conference agreement, “thereby ensuring that addiction treatment records are no longer needlessly isolated from the rest of a patient's medical history—a practice that has hindered informed decision making and threatened patient safety for too long.”

Indeed, the Senate version of the bill requires HHS “to develop best practices for prominently displaying substance use treatment information in electronic health records, when requested by the patient.”

White also noted, “Additionally, OSA remains concerned about the lack of real-time, actionable data provided to clinicians by states' prescription drug monitoring programs (PDMPs). With lawmakers poised to devote additional resources toward these programs, we should know if taxpayers are getting a return on their investment. We support the inclusion of language that would require an objective study and report on states' use of PDMP technology." 

As stated in the bill, states and localities would be provided with support to improve their PDMPs and "implement other evidence-based prevention strategies.” The bill also “encourages data sharing between states, and supports other prevention and research activities related to controlled substances."

What’s more, another section of the bill reauthorizes an HHS grant program “to allow states to develop, maintain, or improve PDMPs and improve the interoperability of PDMPs with other states and with other health information technology.”

Sen. Alexander, meanwhile, said yesterday he is “already working to combine the Senate and House-passed bills into an even stronger law to fight the nation’s worst public health crisis, and there is a bipartisan sense of urgency to send the bill to the President quickly.”

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Survey: Healthcare Organizations Report Gaps in Disaster Preparedness Plans

September 12, 2018
by Heather Landi, Associate Editor
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As Hurricane Florence churns toward the East Coast this week, disaster preparedness is a timely topic, yet a new survey finds that only 72 percent of healthcare providers believe their organization’s disaster plan is comprehensive enough to cover a variety of disaster scenarios both inside the organization and across the community.

The findings are even more troubling among specialty care providers, such as cardiologists and endocrinologists, who provide critical treatment to individuals with chronic diseases, with just 29 percent reporting that they have a comprehensive disaster plan in place. More than two-thirds (68 percent) of survey respondents were affected by two or more disasters in last five years, according to the survey, yet most respondents doubt their organization’s disaster plans are up to the task.

DrFirst, a provider of e-prescribing and medication management solutions, surveyed 109 healthcare professionals across acute, ambulatory, hospice and home care about disaster preparedness. According to the DrFirst, the results are critical for addressing potential safety issues that affect the health and lives of millions of Americans who are increasingly subject to hurricanes, wildfires, and floods as well as other man-made disasters like digital and criminal attacks.

“The fact that almost 70 percent of the surveyed healthcare providers have been affected by more than two disasters in the last 5 years should be a major wake-up call for the healthcare industry,” G. Cameron Deemer, president of DrFirst, said in a statement. “As we learned in the aftermath of major disasters such as hurricanes Maria and Harvey, natural disasters lead to surging demands for acute and emergency care, especially from the most vulnerable patients who may have been displaced from their homes without medications or critical medical supplies, like oxygen or diabetic testing equipment. We must take measures now to address the critical gaps impacting patient care and safety, such as communication challenges and ready-access to medical records and specialty care providers.”

The survey revealed another key vulnerability—the widespread dependence on disaster communications methods that fail to meet legal requirements for secure communications between medical teams, pharmacies, and patients, according to the survey. Under the federal law known as the Health Insurance Portability and Accountability Act (HIPAA), a patient’s private health information can only be shared with the patient or other providers via secure methods such as password-protected portals and secure messaging.

One-third or more of clinicians surveyed across acute, ambulatory and hospice/home health state that calling by phone is their top method for communicating with pharmacies, EMS units, patients and families, local authorities, and community health providers in times of disaster. Secure messaging and email complete the top three modes of communication.

A striking number of clinicians use regular unsecured text messaging to reach hospitals: more than one-quarter of respondents use this mode to communicate with hospitals during and immediately after a disaster strikes, and 22 percent report using unsecured texting to communicate with patients or their family members. According to the Centers for Medicare and Medicaid Services (CMS), the use of phones for texting of patient health information is only permissible through a secure messaging platform that provides message encryption. Encryption is also required when emailing patient health information.

Healthcare professionals working in hospitals were more aware of the need for secure messaging tools than individuals working in other settings, including specialty care providers. Forty-four percent of hospital-based respondents said that secure, HIPAA-compliant medical messaging is a key requirement of a disaster preparedness plan.

In fact, hospital-based respondents indicated that the only requirements more important than secure messaging were the installation of backup generators in case of power outages (56 percent) and the ordering and maintaining of extra inventory of supplies and medications (52 percent). Yet, specialty providers place the need for including secure messaging at the very bottom of their disaster planning requirements.

Survey respondents also see telehealth is a viable disaster solution, as 45 percent cited telehealth as an effective option to provide care to patients across the community during or immediately after disasters or emergencies. However, more than half expressed concerns that connectivity and other technical issues could impact the reliability of telehealth, and only 27 percent believe their organization has deployed adequate telehealth capabilities.

Another key finding from the survey is that many organizations preparing for an impending disaster still rely heavily on paper, with most advising patients to keep copies of their medical records. Just 40 percent of respondents believe their electronic health record (EHR) has sufficient information available to take care of all patients during a disaster.


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CPT Codes Updated to Reflect HIT Advancements

September 6, 2018
by Rajiv Leventhal, Managing Editor
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The American Medical Association (AMA) announced the release of the 2019 Current Procedural Terminology (CPT) code set, with changes reflecting new technological shifts in the industry.

According to the AMA, there are 335 code changes in the new CPT edition reflecting the CPT Editorial Panel and the healthcare community’s “combined annual effort to capture and describe the latest scientific and technological advances in medical, surgical and diagnostic services.”

Among this year’s changes to CPT include three new remote patient monitoring codes that reflect how healthcare professionals can more effectively and efficiently use technology to connect with their patients at home and gather data for care management and coordination. Also, two new interprofessional internet consultation codes have been added to reflect the increasing importance of using non-verbal communication technology to coordinate patient care between a consulting physician and a treating physician, according to AMA.

“The CPT code set is the foundation upon which every element of the medical community—doctors, hospitals, allied health professionals, laboratories and payers—can efficiently share accurate information about medical services,” AMA President Barbara L. McAneny, M.D., said in a statement. “The latest annual changes to the CPT code set reflect new technological and scientific advancements available to mainstream clinical practice, and ensure the code set can fulfill its trusted role as the health system’s common language for reporting contemporary medical procedures. That’s why we believe CPT serves both as the language of medicine today and the code to its future.”

McAneny added that the AMA has urged the Centers for Medicare and Medicaid Services (CMS) to adopt the new codes for remote patient monitoring and internet consulting and designate the related services for payment under federal health programs in 2019. “Medicare’s acceptance of the new codes would signal a landmark shift to better support physicians participating in patient population health and care coordination services that can be a significant part of a digital solution for improving the overall quality of medical care,” she said.

In July, as part of CMS’ proposed Physician Fee Schedule and Quality Payment Program rule, the agency recommended various provisions that would aim to support access to care using telecommunications technology, such as: paying clinicians for virtual check-ins, paying clinicians for evaluation of patient-submitted photos; and expanding Medicare-covered telehealth services to include prolonged preventive services.

New CPT category I codes are effective for reporting as of Jan. 1, 2019. Additional CPT changes for 2019 include new and revised codes for skin biopsy, fine needle aspiration biopsy, adaptive behavior analysis, and central nervous system assessments including psychological and neuropsychological testing.

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