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At Children’s Hospital Los Angeles, Scaling Telemedicine to Fill Gaps in Specialized Care

July 13, 2017
by Heather Landi
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Many hospitals and health care systems are leveraging telemedicine to bridge the distance between patients in underserved areas with medical specialists. At Children’s Hospital Los Angeles, a particular group of subspecialists, pediatric ophthalmologists, are using the technology to fill gaps in specialist care in developing countries, with the goal of eliminating preventable infant blindness.

Within Children's Hospital Los Angeles, a large multispecialty medical group, the Vision Center operates as a referral center for children with complex eye diseases and offers expertise in various pediatric ophthalmologic subspecialties. Thomas C. Lee, M.D., a pediatric retina surgeon and director of The Vision Center, is leading an innovative telemedicine project that delivers remote training for eye surgeons in Armenia in partnership with the Armenian EyeCare Project (AECP). The goal is to help reduce rates of a preventable infant blindness, called retinopathy of prematurity (ROP), which occurs three times as often in Armenia as in the United States and other Western countries, according to Lee.

Lee has been working with the AECP organization for eight years, and explains some of the core challenges around the gap in specialists for complex eye diseases in developing countries. While developing countries around the world have improved their neo-natal care services for premature infants, through the establishment of neo-natal intensive care units, an ongoing issue is that many physicians in developing countries have not always been prepared to handle the complications that can happen when babies are born premature and then going on to survive, he explains.

One of those issues is ROP, which is a very preventable but potentially devastating form of childhood blindness that affects both eyes in children. And, many of the sight-saving surgeries for premature infants with certain retinal conditions must take place within 48 hours of birth. In developing countries, such as Armenia, resources are often scarce and there are not enough surgeons available with the specialized knowledge required to provide complicated eye surgeries within the needed timeframe of a premature infant’s birth.

“So, the challenge was, how to school up their educational program and get it launched as quickly as possible so it doesn’t take them the standard learning curve to figure this out,” Lee says. He notes that the first case of ROP in the U.S. occurred in 1942, the first treatment program was established in 1987 and it wasn’t until 1990 that the program was validated. “So, from 1940 to 1990, years went by with children going blind from a preventable form of blindness and it took us 50 years to figure that out. We want to avoid the developing world go through a 50-year protracted learning experience like we did. And that’s where an online training program becomes so meaningful,” he says.

Thomas C. Lee, M.D.

Lee says he was approached in 2009 by the Armenia EyeCare Project to help the doctors in Armenia to diagnosis and treat this form of childhood blindness through a cost-effective, online remote training program, and the program as evolved as advances in health IT have accelerated. “We initially did it online, using store and forward photographs and using something called a RETCAM. That allowed us to review images remotely and then email them back with what we thought the diagnosis was, and then we compared whether their [the Armenian ophthalmologists’] diagnosis and our diagnosis correlated,” he says.

Year to date, through this telemedicine program, 4,437 infants have been screened for ROP, with 309 procedures completed to treat the ROP, and 40 operations performed the address the most severe form of ROP, Lee reports.

While the program was successful, there were still many premature infants with retinal conditions who had to be flown to Russia for surgery as the surgeons in Armenia were not trained to perform the more complex surgeries. Armenian health officials approached Lee and the Vison Center at CHLA with the idea of using video-enabled telemedicine to mentor and monitor the surgeons in Armenia.

“That started a longer conversation about how we could use real-time synchronous telemedicine to do that, where we would actually supervise their doctors remotely. My first initial response was, I can’t do that. But then we identified different platforms that would allow us to stream the signal out of their operating room,” Lee says. After conducting in-person training at CHLA with two Armenian retina surgeons, Lee says the Vision Center began “an evolution of a training platform that would allow us to continue to monitor, mentor and teach these surgeons in their operating rooms, on their patients, in real time.”

Lee says there were initially some limitations to the technology, primarily problems with either latency, because the system had to buffer the signal, or there was compression artifacts (a noticeable distortion of media) from the software compression that was occurring in the operating room.

In 2016, Lee and his team at CHLA began working with L.A.-based IT consulting firm SADA Systems to deploy Microsoft's cloud collaboration and communication platform, Skype for Business Online, to help bridge the 7,000-mile gap between Los Angeles and Armenia. Using Skype and Polycom videoconferencing endpoints, Lee and other pediatric retina surgeons can view the actual surgery in real time and communicate face-to-face with the surgical team. With the Armenian EyeCare Project and through this technology platform, Lee has remotely trained two surgeons and observed four surgeries in Armenia live from his office in California. The retina scan images and related diagnoses hosted by the technology platform make it possible for doctors to collaborate and reference past surgeries as needed.

According to Tony Safoian, president and CEO of SADA Systems, the technology platform is providing a foundation in which healthcare organization can actually crowdsource surgical training, making experts such as Dr. Lee, and others, accessible to healthcare providers around the world.

Lee says his sees the ability to scale this technology from its current capacity in Los Angeles to remote cities in the U.S., as well as other third-world countries such as Armenia and neighboring rural regions.

“I think with this kind of technology, we can crowdsource training for doctors and surgeons in the developing world in a way that is really efficient. And by crowdsourcing it, we’re not relying on a single individual to carry the weight, as we can have multiple people chime in and address the surgery for that day. So, the concept of a medical mission is becoming outdated, and given the technology, there should be better and more effective ways to do it.”

What’s more, he sees the potential for real-time, synchronous telemedicine platforms to be used for mentoring and proctoring in other surgery specialties. “This technology can be used for medically-oriented engagement, such as an evaluation of a skin rash or even a heartbeat, as we can now stream Bluetooth stethoscope audio signals onto the web,” he says.

Lee, who also is an associate professor of ophthalmology at the USC Roski Eye Institute at the Keck School of Medicine of the University of Southern California, has been practicing medicine for 18 years and he contends that health IT innovation, such as telemedicine, will play a transformative role in healthcare delivery moving forward.

“I think there’s some things about healthcare that have stayed the same, the doctor-patient relationship continues to survive despite all the changes to healthcare. I think what’s changed dramatically is that healthcare continues to be more expensive and continues to require more resources, and, in a fashion, that, in the end, is probably not sustainable,” he says, adding, “We need to find ways to become more efficient in how we deliver healthcare, and make it more productive for the doctors who are delivering the care to deliver care to as many patients as possible, whether they are here or whether they are halfway around the world. I think telemedicine will really allow us to leverage the time and effort that physicians spend; it’s really targeted to point of care.”

Lee also provides ophthalmology services, via telemedicine, to 12 hospitals throughout California, and in Phoenix, to help diagnosis and treat ROP. “I can now screen many more children just as effectively, and not have to go out to each NICU all the time. That has made the ability to deliver that level of care much more feasible, which is the direction that I think we need to go.”



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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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