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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.

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.

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].

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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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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AMIA Supports NIST Efforts to Secure Telehealth RPM Ecosystem

January 9, 2019
by Heather Landi, Associate Editor
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Back in November, the National Cybersecurity Center of Excellence at NIST, the National Institute of Standards and Technology, issued a draft paper outlining a project it plans to undertake to provide a reference architecture addressing the security and privacy risks for healthcare delivery organizations leveraging telehealth capabilities, such as remote patient monitoring.

Traditionally, patient monitoring systems have been deployed in healthcare facilities, in controlled environments. Remote patient monitoring (RPM), however, is different in that monitoring equipment is deployed in the patient’s home, according to NIST’s NCCoE. NIST is housed within the Department of Commerce.

These new capabilities, which can involve third-party platform providers utilizing videoconferencing capabilities, and leveraging cloud and internet technologies coupled with RPM devices, are used to treat numerous conditions, such as patients battling chronic illness or requiring post-operative monitoring. As the use of these capabilities continues to grow, it is important to ensure the infrastructure supporting them can maintain the confidentiality, integrity, and availability of patient data, as well as ensure the safety of patients, according to NCCoE.

To address these security, privacy and safety concerns, NCCoE aims to provide a practical solution for securing the telehealth RPM ecosystem. The NCCoE project team will perform a risk assessment on a representative RPM ecosystem in the laboratory environment, apply the NIST Cybersecurity Framework and guidance based on medical device standards, and collaborate with industry and public partners. The project team will also create a reference design and a detailed description of the practical steps needed to implement a secure solution based on standards and best practices, according to the organization.

This project will result in a publicly available National Institute of Standards and Technology (NIST) Cybersecurity Practice Guide, a detailed implementation guide of the practical steps needed to implement a cybersecurity reference design that addresses this challenge.

The NCCoE sought public feedback on the project, which was detailed in a draft released in November called “Securing Telehealth Remote Patient Monitoring Ecosystem.”

The American Medical Informatics Association (AMIA) is one industry organization that has voiced support for the NCCoE project to develop guidance around security and privacy risks associated with remote patient monitoring.

In written comments about the project, AMIA president and CEO Doug Fridsma says he “foresees a future of care delivery and disease management that will rely heavily on RPM,” due to a “confluence of shifting and/or diminished reimbursement, aging and chronically ill population growth, and continued depopulation of rural areas.”

Securing these systems and ensuring trust in the data generated by these systems is an utmost priority, and is at the heart of consumers’ ability to obtain care and manage their health, Fridsma noted in the written comments.

Among its recommendations, AMIA advises the NCCoE to leverage existing mobile infrastructure and health IT standards.

“The ultimate spread, scale, and usage of these RPM tools will likely depend more on the commercial marketplace than the short-and long-term plans of healthcare institutions. Further, patients/consumers will use the tools that they are familiar and fits best into their individual ‘workflows.’ Securing the existing mobile infrastructure where individuals perform most of their day-to-day living will improve the likelihood that healthcare specific tasks will succeed,” Fridsma noted.

Fridsma also noted that AMIA recommends NIST focus on data security and integrity that provides data provenance and supports consistent semantic meaning of the data across RPM manufacturers.

 

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