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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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The Role of Health IT in Caring for Rural America

January 23, 2019
by Betty Rabinowitz, M.D., chief medical officer, NextGen Healthcare, Industry Voice
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According to the US Census Bureau, approximately 60 million, or one in five Americans, live in rural areas. Rural areas are sparsely populated, have low housing density, and are far from urban centers, and these factors create unique and complex challenges when providing healthcare to this population.

After completing their training, physicians and nurses often gravitate to urban areas. The patient-to-primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas, according to data from the U.S. Department of Health and Human Services (HHS). This discrepancy makes access to care more difficult, and data collected by the Rural Health Information Hub indicates that this negatively impacts care outcomes and even life expectancy in rural areas. Due to the scarcity of specialists such as mental health providers, dentists, and oncologists, patients must often travel significant distances to seek these types of care.

Compounding the impact of the shortage of primary care physicians and in parallel to it, access to care has further been impacted by an increase in closures of rural community hospitals.  According to the Government Accountability Office’s (GAO) analysis, 64 rural hospitals closed from 2013 through 2017. This represented approximately 3 percent of all the rural hospitals in 2013 and more than twice the number of closures of the prior 5-year period. The GAO's analysis further shows that rural hospital closures were more prevalent in the South, among for-profit hospitals, and among hospitals that received the Medicare Dependent Hospital payment designation, one of the special Medicare payment designations for rural hospitals. The national shift to ambulatory care, which resulted in reduced hospital occupancies, worsened the financial burdens of these rural hospitals, resulting ultimately in their closure. These closures often inevitably portended the decline in other medical services that depended on these hospitals for their livelihood, for example ambulance services, home health services and outpatient laboratories. 

The opioid epidemic has had a significant, disproportionate impact on rural America as well. The rate of opioid overdose deaths is 45 percent higher in rural than in metro areas, according to data from the National Rural Health Association. This is likely multifactorial: a combination of socioeconomic factors and reduced access to mental health providers, pain treatment, and addiction treatment centers and specialists. Because of the geographical realities in rural areas, access to emergency services is not as readily available and many more overdose cases result in death due to unavoidable delays in arrival of emergency teams capable of pharmacologically reversing an impending lethal drug overdose. 

Rural healthcare providers face significant challenges, and the resulting provider burnout and health outcome disparities are real. Developments in health information technology (HIT) offer some needed hope.

Widely available telemedicine capabilities enable rural health systems to overcome the impact of geographic distance and resource scarcity. Patients meeting virtually with their providers can significantly decrease the burden of travel and consequent poor access. Mental health services are well suited for virtual visits, as are follow-up visits after surgical procedures or monitoring patients with stable chronic conditions.

Rural health providers often practice solo or in small groups and, at times, are professionally isolated. Health IT tools offer great promise in reducing this isolation by providing video consults with specialists. Rural providers can even do live consults with colleagues in real time—an empowering and helpful option. 

As an example, the University of Washington Division of Pain Medicine offers weekly TelePain sessions, a videoconference with specialists with expertise in the management of challenging chronic pain problems. The UW TelePain program significantly increases access to experts who provide real-time support in the care and treatment of the most challenging chronic pain patients.

Mounting evidence shows that poverty and other social determinants of health significantly and negatively impact health outcomes. According to the Rural Health Information Hub, rural residents tend to be poorer, with about 25 percent of rural children living in poverty. On average, per capita income in rural areas is lower, and the disparity in income is even greater for minorities in these areas. The negative health impact of poverty is often mediated through lack of health insurance or under-insurance, which may deter these individuals from seeking medical care and from adhering to care recommendations.

Smoking rates are also higher in rural areas, as are deaths from motor vehicle accidents and youth suicide. Chronic conditions such as diabetes and COPD (chronic obstructive pulmonary disease) are more prevalent, and when present, less well controlled, adding further burden to rural providers’ already thinly stretched resources.

Contributing to this complex healthcare landscape, higher percentages of older adults also live in rural areas. Many of the healthcare challenges faced by residents of rural areas are amplified significantly in the elderly.  Geographical distance, access to care, poverty, isolation, the scarcity of food programs such as Meals on Wheels, elder day care and long-term care programs, all impact healthcare complexity and outcomes in this vulnerable population. 

Healthcare provider organizational are increasingly leveraging technology to address the social factors that impact rural patients’ health. As example of one innovative approach to reducing disparities in access to care is the effort by the Patient Access to Pharmacists’ Care Coalition which is working to enact federal legislation to enhance access to care for Medicare beneficiaries in underserved communities. The coalition is proposing an amendment to Medicare rules that would increase medically underserved seniors’ access to health care through pharmacist-provided care. Since nearly 95 percent of the U.S. population lives within 5 miles of a pharmacy, according to data from the National Association of Chain Drug Stores, and improving access to pharmacist’s services by creating appropriate Medicare reimbursement rules holds significant promise. 

Dr. Betty Rabinowitz is the chief medical officer of NextGen Healthcare. She has more than 25 years of extensive clinical experience and expansive knowledge of population health and value-based practice transformation.


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Stanford Children’s Health Expanding Telehealth Services

January 22, 2019
by David Raths, Contributing Editor
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Pediatric health system launches service that offers digital second opinion consultations

Telehealth specialty services continue to increase in pediatrics, especially in neurology, psychiatry, cardiology, neonatology and critical care, according to a 2018 report by SPROUT (Supporting Pediatric Research on Outcomes and Utilization of Telehealth), a telehealth research network. Some health systems are expanding the types of telehealth services they offer. For instance, in a January 2019 story on its website, Stanford Children’s Health described its plans to more than double its number of telehealth appointments — from 1,100 visits in 2018 to 2,500 visits in 2019. 

Until this year, Stanford Children’s telehealth visits have largely been offered to patients for follow-up appointments. The report noted that some of those are clinic-to-clinic visits, in which a nurse practitioner at a primary-care office connects with a physician at a specialty clinic. The nurse practitioner at the remote clinic examines the child while a high-resolution camera and microphone let the physician at the specialty clinic see and hear exactly what the nurse practitioner does.

Through the Stanford Children’s Health MyChart patient portal, patients and families can connect with their physicians remotely using phones and tablets. Vandna Mittal, director of digital health services at Stanford Children’s Health, is quoted as saying such virtual visits are popular among teen behavioral health patients who go away to college but want to maintain a close relationship with their mental health provider at Stanford.

Stanford Children’s Health also offers clinic-to-school visits, in which physicians can connect remotely with a patient in a school nurse’s office. For instance, a physician caring for a child with Type 1 diabetes can communicate directly with the school nurse and the patient’s parent through a telehealth visit at the nurse’s office, minimizing the need for the parents and the child to travel to the doctor’s office and enabling the doctor and the school nurse to interact.

Telehealth is also being used within Packard Children’s Hospital. From inpatient units, on-call doctors are evaluating patients in the emergency department via telehealth before they are admitted; in some cases, specialists are able to advise ED care teams on the most appropriate transfer methods for patients, according to the Stanford Children’s report.

In November 2018, Stanford Children’s Health launched a new service in conjunction with Stanford Health Care that offers digital second opinion consultations from Stanford physicians. Through the program, called Grand Rounds, patients don’t have to visit the hospitals or clinics for this service. Rather, people can create an account through the Stanford Children’s website and pay a $700 fee; Stanford will collect all of their medical records for them (if the records are in the United States). An expert from Stanford will then review the medical information and send a written second opinion, usually within two weeks.




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Key Questions Before Partnering With Telehealth Specialty Providers

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For primary care clinics, especially those in rural areas, establishing solid relationships with organizations that provide specialty telehealth services can vastly improve the number of services they can offer their patients. But building and maintaining those relationships so that they make sense financially and in terms of quality and patient satisfaction takes a lot of work.

I hadn’t realized how complex that relationship-building could be until yesterday, when I got a chance to hear an online presentation by the California Telehealth Resource Center (CTRC) detailing 20 questions clinics should ask specialty telehealth providers when vetting different offerings. The speaker was Kathy Chorba, CTRC’s executive director, who has 20 years of telehealth program development experience, beginning with establishing and growing the UC Davis Telemedicine program, incorporating 80 sites and 35 specialties, and directing the Telemedicine Learning Center. 

Chorba began by noting that the work of assessing these partnerships should begin only after you have done a needs assessment, identified the kinds of specialties you want to engage (dermatology, psychiatry, etc.), and the volume you expect to generate. You should also have established physician buy-in and identified your telehealth team. Once you have done these things, then you are ready to start establishing partner relationships, she said.

I won’t go through all the questions Chorba suggested clinics ask of specialty provider groups, but just the following sampling of them might help those of us who are not in the telehealth trenches everyday better understand some of the logistical issues involved.

• What specialties are available through this provider group? Chorba noted that some specialty provider groups offer one specialty only (such as behavioral health) while others offer a wide variety of specialties.  She added that some clinics prefer the “one-stop shop” for all their specialty needs, because it simplifies the contracting, credentialing, referral process and workflow, while other clinics prefer to shop around and find the best price for each specialty.

• Does the provider group contract with your payer(s), bill you by the hour or block of time or patient seen? Specialty provider groups use different payment mechanisms, and you have to find one that is mutually beneficial. Chorba added that before you negotiate, you should know how many referrals you think you will have for each specialty and how soon you will be able start. “This will help determine the financial model that fits your program,” she said.  The speciality provider will know if they have capacity.”

• What are the rates for live video and store and forward and are they the same for adult and pediatric? Rates will vary depending on the specialty services needed, as well as volume and modality. Rates for store-and-forward specialties such as dermatology will typically be lower than live video specialties, and new patient appointments may be more expensive than follow-up appointments, Chorba said. Also, rates may vary according to the volume of patient referrals you anticipate sending to the specialty group. Each specialty also tends to have a different timeframe for visits. Dermatology visits may take 20 minutes, while psychiatric visits take an hour. “One rule of thumb is 40 minutes for new visits and 20 minutes for followup visits,” she said. Clinics have to structure their appointment strategy to afford the specialists’ time. “When does a $250-per-hour specialist cost less than a $200-per-hour specialist? When the $250 specialist can fit more patient visits into that hour,” she said.

CTRC offers clinics a sustainability worksheet to help them understand all their costs involved in purchasing blocks of time from telehealth specialists. Initially they may expect to lose some money because all the patients are new and the visits are longer, but as you move into the growth phase, and the specialists are seeing more follow-up patients, you can fit more patients into an 8-hour day. “The bottom line is you are not losing money anymore,” Chorba said. About seven months into the program, you should hit the maintenance phase, where you are keeping your patient no-show rate down and overall costs down.  

• Does the specialty provider group have referral guidelines for each specialty? Besides specifying the time required for new and follow-up patients, these guidelines also state what information or tests are needed prior to the consult (labs, chart notes, etc.). Chorba added that the tests required could be unavailable or too expensive for your patients or not covered by their health plan. “Just knowing the referral guidelines and tests rquired prior to a consult,” she said, “may help you decide that is a provider you don’t want to work with.”

• What level of technical support will the specialty provider group provide? While most primary-care clinic sites have some technical support staff available, few clinics have staff that are able to troubleshoot telemedicine video and peripheral equipment and/or broadband connectivity issues. Some specialty provider groups provide a basic level of technical support or troubleshooting assistance in order to make sure services are provided as scheduled. Chorba said clinics should make clear what type of support it can provide.

This is just a subset of all the questions Chorba raised with webinar attendees. It helps explain why Federally Qualified Health Centers and other small clinics need consulting help to get their telehealth programs up and running. In closing she mentioned that the CTRC is now working on its next set of guidance on how to keep that relationship with specialty providers healthy once you have chosen a group to work with. With so much emphasis on the potential for telehealth these days, it is important for all of us to remember that the transition to telehealth and the hand-offs between providers involves a lot of complexity!




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