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At Aurora Health Care, Telehealth Use is Improving ER Patient Flow

December 1, 2016
by Heather Landi
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The use of a tele-triage technology platform in the ER at Aurora Sinai Medical Center reduced door-to-doctor times by 75 percent
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It is widely known that long emergency room wait times are a persistent challenge for hospitals and health systems across the country. The median wait time from the point of arrival in the emergency room to the time a patient sees a medical professional, or what’s called door-to-doctor, is about 30 minutes, according to 2014 data from the Centers for Medicare & Medicaid Services (CMS). However, the CMS data tracks average wait times by state and the times vary from 46 minutes in Maryland to 16 minutes in Colorado. Data from the U.S. Centers for Disease Control and Prevention (CDC) published in 2014 indicates that the median treatment time was more than 90 minutes. The CDC data also indicated that 41 percent of patients waited 15 to 59 minutes, 27 percent waited fewer than 15 minutes and 13 percent waited one hour but less than two hours.

Data from ProPublica’s ER Wait Watcher site, which uses Google data, estimates the national average ER wait time as 24 minutes, but the site also estimates the average time, nationwide, that patients spent in the ER before being sent home is 135 minutes, or two hours and 15 minutes. With patient volume in emergency departments expected to increase in the next five years as sicker, more complex patients drive up ED care, it is anticipated this challenge of long ER wait times will only grow.

Physician leaders at Milwaukee, Wis.-based Aurora Health Care are familiar with this challenge and this past year the health system deployed a telemedicine solution with the aim of improving patient flow in its emergency rooms with the overall goal of enhancing patient care and providing a better patient experience. The ED technology solution, a tele-triage approach, was deployed first at Aurora Sinai Medical Center last December and the health system recently expanded the technology to Aurora West Allis Medical Center and Aurora Medical Center in Kenosha.

Aurora Health Care is a health system with 15 hospitals and 159 clinics serving areas of eastern Wisconsin and northern Illinois. Aurora Sinai Medical Center is a 177-bed general medicine and surgical hospital located in downtown Milwaukee, and like many other urban emergency departments, the hospital has seen a steady increase in ED volumes, according to Paul Coogan, M.D., president of Aurora Emergency Services and an emergency department physician at Aurora Sinai.

“We now see over 60,000 patients a year, and just a couple years ago, we were under 50,000 patients a year. So we were seeing a gradual increase in our door-to-provider times, and our overall length of stay, so we needed to come up with a solution to help address our increased demand,” he says.

Paul Coogan, M.D.

Coogan continues,” For a period of time, as they’ve done in other ERs, we put a provider out in triage and had that person interact with the patients in triage, and that was pretty well received. But the problem was, you can only cover one site, and that person was putting in orders, but the idea that we could cover multiple sites through a telemedicine product was exciting.”

Michael Rodgers, director of strategic innovations for Aurora Health Care, says implementing a triage approach in the emergency room served as a springboard for the development of the technology initiative.

“We didn’t start thinking that this was the solution that we would end up with. We started with a provider on triage and we’re getting a lot of benefit from that. We actually just thought, ‘how can we actually replicate that?’” Rodgers says.

Aurora Health Care leaders saw an opportunity to work with a local health IT startup company, EmOpti, Inc., based in Brookfield, Wis., on a technology solution that would replicate the triage approach.

“So we used a Lean startup methodology, just like a startup company would use, to quickly figure out what would work the best and we’re continuing on that path as we go forward, with features, functionalities and a road map that we have set up to even take this initiative to the next level,” Rodgers says. “At the end of the day, this is actually what we came up with. Telehealth wasn’t the goal; it was more the outcome to solve a problem, and the opportunity to enhance the care to our patients.”

Michael Rodgers

And, he adds, “One reason we went with this solution is that, to be honest, we didn’t find anything else out there. I know other healthcare systems are starting to dabble in this area, but there’s not a solution out there that we found that could really help with tele-triage and that would really help to build out a system that would enable us to expand beyond just one site, and really make it effective in multiple different areas.”

EmOpti was founded by Edward Barthell, M.D., an emergency physician, and the company develops acute care optimization solutions that utilize command center, analytics and telemedicine technology to enable physicians in support centers to securely interact with multiple acute care facilities simultaneously.

The tele-triage technology solution allows patients who seek care at an emergency department at Aurora Sinai, Aurora West Allis or Aurora in Kenosha to be seen by an Aurora physician via video when they arrive, with another caregiver right at the patient's side. The offsite physician can serve multiple Aurora emergency departments at once.

“This solution helps us get orders started immediately, obtain results quicker and treat people faster— ultimately, it helps us provide an enhanced patient experience to all who visit the ED. That is critically important for an ED that is as busy as the one at Aurora Sinai,” Coogan says.

According to Coogan, the provider in triage is stationed in a separate support center, “what we refer to as ‘the bunker,’” he says.  “It’s a actually a nice room with multiple screens and when the patient presents to one of our three hospitals, to triage, the nurse gets a brief history, does vital signs, and then the nurse requests a consult. And I’ll get a ping, and I can click on that and open up the files, which opens up the patient’s chart so I’m face-to-face with the patient. The average consult is lasting about a minute and 20 seconds.”

Coogan points out that ER physicians are experienced at developing quick rapport with patients. “They don’t know us and so it’s a natural fit for us to be able to establish rapport, and even though it’s a minute and 20 seconds, we’re able to get the necessary information from the patient,” he says. “Then we’ll sign off with the patient and I’ll explain to him or her, ‘now we’re going to get some testing started on you to help speed up this process.’ At that point, one of our technicians will be there in triage to draw their blood, maybe get an EKG, and our radiology department is notified of any X-rays that we order. The plan is that by the time they get back to the room, that most of their workup is already done.”

Since deploying the tele-triage solution at Aurora Sinai Medical Center, the results and outcomes, so far, have been significant.

“I think one of the biggest things is that we’ve had the opportunity to do is that we’ve been able to reduce our door-to-doctor times by 75 percent. We’ve been able to effectively use that same model across multiple hospitals, which is huge, to provide a benefit for even more patients,” Rodgers says. “The other aspect of that is that length of stay is reduced and our left without being seen (LWBS) rate is reduced as well. And that all goes back to enabling patients to be able to see a doctor quickly, get their orders entered and make sure the patients understand that they are our top priority with getting them treated well.”

According to Rodgers, patient satisfaction, based on survey scores, increased following the technology implementation and anecdotal feedback from doctors and nurses supports the idea that the services are well-received by patients.

Furthermore, Coogan believes improving the patient flow in the ER is not only a patient experience issue, but a quality of care issue as well. “The biggest complaint we face nationally in the ER is overall wait time, so if you can address that, the patient experience scores are going to improve, which is what we saw. And, also just for quality, the faster you can see patients and get their orders in and take care of any abnormal results, not only does it decrease overall length of stay, it’s just an overall patient safety measure. Studies have shown that the longer the patients’ length of stay, the more boarding you do of patients in the ER, the more hospitals are on ambulance diversion, all those things lead to increased patient morbidity and mortality. So, anything you can do to speed your disposition of patients improves not just the patient experience but, more importantly, morbidity and mortality.”

Rodgers also points that hospital reporting measures as required by the Centers for Medicare & Medicaid Services (CMS) includes ER metrics. “This was also a big motivator to spend more resources addressing ED length of stay,” he says.

Initially, hospital leadership anticipated older patients would be hesitant to utilize the tele-triage services. “We thought, ‘well, this is going to be an issue, they are going to think it’s too impersonal.’ But what’s interesting is that our older patients really have been the most satisfied. It’s surprising to us. I think they just enjoy the technology,” Coogan says, also noting that of the tens of thousands of consults that have occurred in the past year, “only a couple of people have declined” the tele-triage services.

“The patients have really enjoyed this, and they really like the fact that they get to talk to a physician right away,” he says.

As part of the technical implementation of the health IT solution, EmOpti worked with another vendor to integrate the technology with the hospital’s Epic electronic health record (EHR) system. “We actually integrated with Epic, so we use Epic and EmOpti together and they are in sync. So it’s not something where it’s built in. I equate it to almost like a Legos set, where you have different pieces that you put together and it naturally fits. It seems to work that way very well then, internally, we have an interface team that’s done an outstanding job with this,” Rodgers says.

While there was some initial resistance from physicians, nurses and staff to using a new, additional technology tool, but ER staff, nurses, technicians and physicians have embraced it, Coogan says. “As long as it’s presented as ‘this is something we’re using to not only improve the patient experience, but it really will improve your work life.’ What we found is that some of the downstream effects are that nightshifts are less busy because you’re not walking into an ED at 11 p.m. with 20 patients waiting to be seen and nothing having been done on them.”

Additionally, older physicians are showing an interest in the possibility that tele-triage shifts, as opposed to physical shifts in the ER, could prolong their careers, Coogan says. He adds, “The nurses like it because being a triage nurse is a pretty lonely job, you’re out there on your own, you have to make all the decisions. They have to decide, ‘Is this 35-year old person with chest pain, is it safe to put them in the waiting room, or do I need to rush them back?’ So by getting a consult, I can talk to the patient, look at their EKG right over the telemedicine, and I can say, ‘let’s just move that person to the back,’ or ‘that EKG looks fine, I think we can get blood work started but until a bed becomes available, that person is fine to wait in the waiting room.’”

Coogan and Rodgers add that executive leadership at the health system increasingly supports the use of technologies, such as the tele-triage solution, to enhance patient care. In addition to the three hospitals previously mentioned, the health system has expanded the use of the tele-triage services to a handful of urgent care clinics.






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MUSC Telehealth Leaders Share Their Roadmap to Success

October 17, 2018
by Heather Landi, Associate Editor
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The Medical University of South Carolina (MUSC), based in Charleston, is widely regarded as an industry leader in telehealth with a robust, high-volume telehealth program that touches not only MUSC’s local community but also impacts patients throughout the state.

In 2017, MUSC was one of two academic health systems recognized by the federal government as a National Telehealth Center of Excellence. The Health Resources and Services Administration (HRSA) gave MUSC this designation in recognition of MUSC’s expansive breadth and depth of telehealth services, most of which are in medically underserved areas of South Carolina, a state with a high burden of chronic disease and health disparities.

The MUSC Health Center for Telehealth brings together resources from across MUSC Health to connect patients and providers across South Carolina. The Center provides 77 unique telehealth services to more than 200 sites in 27 South Carolina counties, which includes hospital-based programs, such as tele-stroke and tele-ICU, as well as outpatient programs, where urgent, primary and specialty care is delivered directly to patients. The Center also operates school-based telehealth and provides telehealth services for skilled nursing facilities and institutional facilities.

Three key leaders of MUSC’s telehealth program will be presenting at the Convege2Xcelerate conference taking place Oct. 22 at Columbia University in New Yok City. The conference is sponsored by Partners in Digital Health, publisher of Blockchain in Healthcare Today and Telehealth and Medicine Today, and will feature sessions on transformational technologies including blockchain, telehealth and artificial intelligence (AI).

The MUSC speakers include James McElligott, M.D., who is the medical director for telehealth at the MUSC and an assistant professor in the division of general pediatrics at MUSC Children’s Hospital. McElligott oversees the Center for Telehealth at MUSC. Kathryn King Cristaldi, M.D., the medical director for School Based Health and an assistant professor in the division of general pediatrics at MUSC Children’s Hospital, also will be presenting, along with Dee Ford, M.D., a professor of medicine in MUSC’s division of pulmonary and critical care medicine.  

Leading up to the conference next week, Healthcare Informatics Associate Editor Heather Landi recently spoke with Drs. McElligott, Ford and Cristaldi about their innovative work in telehealth services, what they plan to share with the Converge2Xcelerate audience and their vision for the future of telehealth delivery and its potential to transform healthcare. Below are excerpts of those interviews.

What do you plan to share with the Converge2Xcelerate audience during your presentation?

McElligott: We’re not doing as much on telehealth 101, but more on innovation and how telehealth leads to innovations in healthcare business models.

Ford: We will focus on two major initiatives within our Center of Telehealth. We will share the structured, guiding framework that MUSC applies to telehealth service development, which includes strategy, development, implementation and continuous quality improvement, and how we were able to develop that. We’ll talk about how you can develop and refine that to help ensure that you are able to successfully deploy a telehealth solution and sustain that solution. And the second part will focus on telehealth finance, and we’ll talk about the value proposition framework for telehealth services, as financial performance is integral to sustaining and scaling telehealth services. How does the value proposition inform how you structure and quantify your different telehealth services when you have a diverse portfolio of telehealth services, such as we do? Those two things, the structured framework for implementation and sustainment and the value analysis strategy for telehealth, will be the bulk of the session.

McElligott: When organizations are developing telehealth programs by using these distance technologies to enhance healthcare, what many folks struggle with is that they are specifically trying to take what they do with in-person care and extend it. Looking at the value proposition means you flip that a little and say, maybe the way we do it now is because it’s practical for what it means for a patient to walk into your office. What you find is that as you develop these services and as they morph a little bit, you have to ask yourself, what I am doing this for again? Some of the services that we have developed are directly to support a need, like another hospital contracts with us for a certain service, such as tele-stroke, because they have a lack of it.

James McElligott, M.D.

The other telehealth services are focused on a population health perspective or trying to solve a problem in another way. If you remain focused on why you set out to do what you do, it keeps you guided towards that value proposition, rather than reinventing the wheel of what in-person care is like. It’s a way of giving yourself a trajectory of what we’re trying to get done and breaking out of the mold of traditional healthcare. You have to give yourself a trajectory and then design your telehealth service from that perspective.

Your organization has been able to scale its telehealth program to a full suite of modalities. What has been your roadmap to success?

Ford: I think it is a couple of things. One is the people—early on, we had physician engagement and strong physician leadership buttressed with an excellent administrative team who were collaborative and recognized that building some small siloed thing would not allow us to achieve scale. We had a really great team of dedicated people, both from a leadership level down to the front line, administrative support team. We also have very strong executive buy-in as far as telehealth being a key strategy. Our most senior leadership were very bought-in to the importance of telehealth and to MUSC using it in order to meet the healthcare needs of our state. That combination of talent and passion and leadership endorsement was integral. And, frankly, we were well-supported financially in terms of pursuing these efforts through a combination of funding sources, including some legislation allocation grant funding. We had the right people, leadership buy-in and enough financial resources to be able to grow and build.

Dee Ford, M.D.

Looking ahead, many people believe “telehealth” will become, simply, health, and a seamless part of healthcare. What is your view of the future of telehealth delivery?

Cristaldi: I think there is that thought that eventually we won’t be telehealth experts and we won’t work within the Center for Telehealth, but rather, we’ll be healthcare experts, and this will just be a part of what we do and part of the healthcare landscape. I think that’s everyone’s goal—how do we integrate this into healthcare as we know it. The thought behind it is—how do we address health, wellness, disease and the whole spectrum and continuum of care, when we can have more access to our patients and/or are patients have more access to us, and in different ways? Looking at how to directly connect to patients, that will be the future.

McElligott: That kind of conversation happens a lot over the past half-decade or so. It still seems to be going in the opposite direction, as the term itself [telehealth] is not going away as quickly as some of us thought it would be. It’s certainly is getting integrated and some of it is getting normalized and absorbed into healthcare.

You can look at it from two perspectives; one, it will be normalized, and just be a part of care. On the other hand, I think that it will be powerful enough that it will really change the way we do care, enough that it will be distinct. What I mean by that is, if you are using your cellphone to access care enough in multiple different ways, the whole healthcare relationship with the population might be enough to change that we will be accessing preventive care in a totally different way than we are now, where we go to a doctor and they tell us all the things to do to be healthy. So, yes, it may very well be absorbed into healthcare over time, but I think it will be different than what people think; it will be patient-driven in a way that’s even hard to predict now. It’ll be absorbed, but it will also transform healthcare at the same time.

Ford: I agree with that perception. The guiding vision for our Center for Telehealth is efficient and effective care. There isn’t another dollar in the healthcare system to pay for add-on services. But, you can clearly use technology to either make it more effective in some way, so more timely access to the right specialist, or, also, to make healthcare more efficient. And, there’s some work that you see in chronic disease management; there’s been good success in those areas to increase efficiencies in the systems. I think those two things combined—using technology to make the health system more effective and/more efficient, from the perspective of the patient, the provider, the payer, and the system—is going to be the thing that drives it forward and transforms the healthcare system.

What are some of the telehealth success stories for patient populations in South Carolina?

Cristaldi: Certainly, one of the most profound example is tele-stroke. In South Carolina, only a handful years ago, the majority of the population did not live within driving distance of a stroke specialist. That meant that, for most patients, if they needed tPA, the clot-busting drug that saves the lives of people who are having ischemic stroke, they didn’t live close enough to a hospital that had a stroke specialist to provide that kind of care. To me, that is so profound. You can’t physically get to lifesaving care, even though it’s well established in the medical community. To me, that was how I felt living in East Africa [where she completed some of her pediatric training].

Kathryn King Cristaldi, M.D.

Through the tele-stroke program, we connect stroke specialists out to the majority of hospitals in South Carolina and every South Carolinian now lives within an hour of expert stroke care. At a large population level, we’ve changed the ability to address a deadly disease. And, in our school-based programs, we’ve been able to increase access to care for children, particularly in counties where residents have no access to pediatricians. We have evidence that our quality metrics in dealing with chronic disease, like asthma, can even be better than those of in-person care, because we are able to see patients more often and really monitor their symptoms.

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Seven Companies, Four Individuals Indicted in Billion-Dollar Telemedicine Fraud Conspiracy

October 16, 2018
by Rajiv Leventhal, Managing Editor
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Four individuals and seven companies have been indicted in a $1 billion telemedicine fraud scheme, the Department of Justice announced this week.

The District Court for the Eastern District of Tennessee unsealed a 32-count indictment on the individuals and companies. The indictment stated that HealthRight LLC, a telemedicine company with locations in Pennsylvania and Florida, and Scott Roix, 52, of Seminole, Fla., and the CEO of HealthRight, pleaded guilty to felony conspiracy for their roles in the telemedicine healthcare fraud scheme in a criminal information. Roix and HealthRight also pleaded guilty to conspiring to commit wire fraud in a separate scheme for fraudulently telemarketing dietary supplements, skin creams, and testosterone, according to DOJ officials.

In addition, three other individuals were indicted along with their compounding pharmacies, Synergy Pharmacy Services, located in Palm Harbor, Fla. and Precision Pharmacy Management, located in Clearwater, Fla.. Another co-conspirator, Larry Everett Smith, of Pinellas Park, Fla. also a pharmacy compounder, and his companies Tanith Enterprises, ULD Wholesale Group, Alpha-Omega Pharmacy, all located in Clearwater, Germaine Pharmacy located in Tampa, Fla., and Zoetic Pharmacy located in Houston, Texas, were all also named as defendants. All the defendants were charged with conspiracy to commit healthcare fraud, mail fraud, and introducing misbranded drugs into interstate commerce, per the indictment.

The indictment alleges that from June 2015 through April 2018, these individuals and companies, together with others, “conspired to deceive tens of thousands of patients and more than 100 doctors” located in Tennessee and elsewhere across the country “for the purpose of defrauding private healthcare benefit programs such as Blue Cross Blue Shield of Tennessee out of approximately $174 million. The indictment further alleges that the defendants submitted not less than $931 million in fraudulent claims for payment,” according to the indictment.

More specifically, according to the indictment, the defendants “set up an elaborate telemedicine scheme in which HealthRight fraudulently solicited insurance coverage information and prescriptions from consumers across the country for prescription pain creams and other similar products.” The indictment states that doctors approved the prescriptions without knowing that the defendants were massively marking up the prices of the invalidly prescribed drugs, which the defendants then billed to private insurance carriers.

In addition to their roles in the healthcare fraud conspiracy, Roix and HealthRight were also charged with conspiring to commit wire fraud as part of a scheme to use HealthRight’s telemarketing facilities to fraudulently sell millions of dollars’ worth of products such as weight loss pills, skin creams, and testosterone supplements through concocted claims of efficacy and intentionally deficient customer service designed to stall consumer complaints, according to the indictment.

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With $6.3M PCORI Contract, UPMC Health Plan to Study Tech-Based Approach to Chronic Disease

September 25, 2018
by Heather Landi, Associate Editor
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The UPMC Center for High-Value Health Care was recently awarded a $6.3 million contract from the Patient-Centered Outcomes Research Institute (PCORI) to study different care delivery models to improve outcomes for patients with chronic disease and a co-existing behavioral health condition.

The multi-year study will highlight payer-provider collaboration to support individuals with both physical and behavioral health conditions. The UPMC Center for High-Value Health Care is housed within the UPMC Insurance Services Division, which includes UPMC Health Plan, and is part of Pittsburgh-based UPMC health system.

The focus of the study is to better understand how to design systems to manage chronic disease and will compare a technology-centric approach with a team-based, high-touch intervention, according to UPMC.

PCORI awarded the UPMC Center for High-Value Health Care support for a five-year study with a long-term objective to enhance the ability of health care systems to better support individuals with chronic diseases like inflammatory bowel disease (IBD) and behavioral health conditions, reduce variations in practice, connect patients with care that is best for them, and improve meaningful, patient-centered health outcomes.

This PCORI study is related to a recently completed one-year pilot study, which showed that participation in an IBD specialty medical home, a care delivery model that is uniquely designed to provide comprehensive and well-coordinated health services, increases patients' quality of life while decreasing levels of disease activity and use of unplanned care. In fact, the pilot study demonstrated a 50 percent decline in emergency room visits and a 30 percent decline in hospitalizations among participants.

“The early successes of the pilot study are encouraging and now this multi-year PCORI study will allow us to further align the payer and provider to develop long-term benefits and applications in a variety of clinical settings," William Shrank, M.D., chief medical officer for UPMC Insurance Services Division, said in a statement. "The use of technology as a key component of the study underscores the role that emerging trends will play in the future of health care."

Participants who enroll in the study will receive IBD specialty medical home care through either a team-based or tech-based approach.

The team-based approach is a personalized service design that includes gastroenterologists, behavioral health specialists, registered nurses, and health coaches who provide intensive, in-person support and resources. The tech-based approach leverages a digital platform using remote monitoring, digital behavioral interventions, and telehealth to deliver team-based care at the patient's convenience, at home and in the community, with the guidance of health coaches.

“By examining the effectiveness of a 'team vs. tech' approach, we expect that this research will provide insight on the most effective methods to provide both physical and behavioral health care to individuals with IBD and most importantly, a better quality of life for patients both now and into the future,"  principal investigator for the study, Dr. Eva Szigethy, professor of psychiatry at the University of Pittsburgh and senior faculty at the UPMC Center for High-Value Health Care, said in a statement.

Co-investigators of the study include clinical experts from the UPMC Center for High-Value Health Care, the University of Pittsburgh, Mount Sinai Health System in New York, and Brigham and Women's Hospital in Boston.

This marks the fifth PCORI contract awarded to the UPMC Center for High-Value Health Care over the past five years.


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