In Pennsylvania, a Telemedicine Stroke Program Proves Worthwhile | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

In Pennsylvania, a Telemedicine Stroke Program Proves Worthwhile

October 26, 2016
by Rajiv Leventhal
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Neurologists at Penn State Hershey Medical Center connect with partner site providers to improve care and lower costs for patients at a distance

For patients who suffer a stroke, the amount of time between the first sign of symptoms and treatment makes a significant difference in the amount of brain damage and speed of recovery. That’s why the American Heart Association/American Stroke Association (AHA/ASA) recommends the use of telemedicine, or telestroke, to improve stroke care—especially in underserved areas.

Four years ago in Pennsylvania, Ray Reichwein, M.D., co-director of the Penn State Hershey Stroke Center, and a stoke neurologist himself, set out to create a telestroke program, as he wanted to improve the continuity of care and access to care in the region (Mount Nittany Medical Center in State College is the only hospital for 30 minutes in any direction). “We wanted patients be able to stay in their homes rather than drive long distances for care,” says Morgan Boyer, R.N., head of Penn State's telestroke program, called LionNet. “The whole stem of it, and where telestroke really comes from, is that emergency department providers aren’t as comfortable with stroke [care] like neurologists are, so they don’t treat it as much. If neurologists are involved more readily, it easily could lead to better patient outcomes,” says Boyer. But the issue is that there are simply not enough neurologists available on-site relative to the amount of people in the U.S.

As such, LionNet has evolved into a partnership between Penn State Hershey Medical Center (PSHMC) and regional hospitals to provide specialized stroke care to rural areas of Pennsylvania. Established in the summer of 2012, the LionNet network includes 15 partner site facilities, with a 16th in the works, within two hours of PSHMC, and averages between 75 and 80 telestroke consults per month.

Morgan Boyer, R.N.

Boyer explains how a normal telestroke consult occurs within the LionNet network: First, she says, with the initiation of a stroke alert at a community site, a computerized tomography (CT) scan is taken while the attending clinician assesses the patient for stroke symptoms. Or, on the inpatient side, if a hospitalist thinks a patient is having a stroke, he or she will call the LionNet number and get connected with a neurologist on call at Hershey. They will discuss the case together; the neurologist will ask what the clinician on the other side sees and what help is needed, and they will then go forward with the telemedicine consult, Boyer explains.

By then, the patient is in the room, vitals are collected, and the CT scans are back, at which point the non-contrast scan get pushed to telemedicine solutions vendor REACH Health, “so the consulting provider can then view the images in a timely fashion while they assess the patient in a real-time audio and video connection,” Boyer says. The provider then assesses the patient with help from a nurse—or whoever else is available to help—completes the exam, confers with the ED provider to go or not go with the clot-busting intravenous tissue plasminogen activator (known as IV tPA), and finally discuss if transferring the patient is needed.

A key point in this process is that if tPA is administered in the wrong conditions, the drug has the potential to cause a brain hemorrhage. To this end, Boyer notes that some community ED doctors do not have the level of comfort and neurological expertise to always make key treatment decisions. “Often times, the [ED provider] needs the neurology relationship to fall back on and expedite the transfer. So that has to happen one way or another, be it through telephone or telemedicine,” Boyer says. Officials at Hershey further note that the Penn State Hershey stroke team is able to help make the decision to administer tPA and are more likely to capture tPA candidates that may have otherwise gone untreated.

Speaking to the program’s results, Boyer says that all but three of Hershey’s partner sites have become primary stroke centers. “Some were in process of doing so before we became partners, and some were already, but well over half of the sites became primary stroke centers because of our relationship and guidance, so we have helped them achieve that designation,” she says.

Beyond that, Boyer notes how door-​to-​needle times have decreased by up to 20 minutes at some facilities, and by 28 percent since the inception of the program. The door-​to-​needle time goal set by AHA/ASA is 60 minutes, and Boyer says that the partner sites continue to get better at driving the process and getting their times down, first from 81 to 72 minutes, and now, “We are more consistently seeing times around 45 minutes now, which we are setting our benchmarks to. At the same time, we want our patients to be safe and stay in the [patient care] facility when appropriate. So our complication rate is less than 2 percent as well,” she says.

What’s more, within this program, officials note that 29 percent of ischemic stroke patients are treated with tPA (compared to nationwide average of 5 to 10 percent); tPA administration rates have increased by 500 percent at some facilities; and 75 percent of patients are now treated in their local community. All of these results point to the system working and the core goals that were laid out four years ago being achieved, Boyer notes.

As is the case with many telemedicine initiatives, there can be apprehension from both providers and patients who are unfamiliar with this new care delivery model. Boyer says, like with anything in the beginning, there has been mixed feedback when new provider sites join. But she adds that there is an accountability piece to the program that gets providers on board sooner rather than later. “We have report cards every month on neurologists’ performances where we are looking at specific data elements that are important to the quality of their documentation and the [telestroke] encounter,” Boyer says. “And there is a peer review process for them to be able to basically ‘peer review’ each other’s reports and documentations, and eventually this works into the shadowing of each other. So they are held accountable, they see how they’re doing, and if they’re falling behind.” Ultimately, they don’t want to be seen as the doctor who gets graded poorly on these report cards, Boyer says, additionally noting that the telestroke providers do get paid for each consult.

Meanwhile, the patients have taken strongly to the program, Boyer says. “There has been no hesitation so far on the part of patients—the young or the elderly—outside of the Amish community, who will actively not participate,” she says.  Boyer adds that they had one patient who actually wanted to relive the telestroke consult experience and watch the video after receiving tPA. The LionNet program doesn’t record the consults, making the patient’s request moot, but Boyer says it struck her team that the patient was so engaged.

Moving forward, Boyer notes that future plans include outpatient follow-up for Hershey’s partner sites that don’t have neurology support, and also for patients that come to the medical center from a long distance and don’t necessarily want to come back for a follow-up. For them, it would be much easier to do the next visit in the comforts of their own primary care office and just have a telemedicine consult there, Boyer says. “We are trying to close the gap in the continuum of care by hitting the pre-hospital world and also with outpatient follow-ups. The idea is to get the whole picture of stroke care. Prevention is key and getting patients timely care is important, so these are the two main areas to focus on,” she says.


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KLAS: EHR Integration, Enterprise Scalability Key Challenges Facing Telehealth Vendors

December 11, 2018
by Heather Landi, Associate Editor
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Healthcare organizations report high satisfaction with their telehealth virtual care platforms (VCPs), however there are significant differences in how broad the various platforms are and in the quality of the vendors’ service. What’s more, integration with electronic health record (EHR) systems is a key challenge facing every telehealth vendor, according to a KLAS report.

In its report, “Telehealth Virtual Care Platforms 2019: Which Telehealth Vendors Have the Scalability Customers Need?,” KLAS evaluates some of the top telehealth companies including American Well, MDLive and Epic, and analyzes what capabilities will set vendors apart as more healthcare organizations adopt virtual health technology solutions.

Most virtual care platform vendors receive positive performance ratings, but the depth and breadth of their capabilities vary, and this can impact scalability for organizations looking to grow, according to KLAS. No two vendors are alike in their capabilities, offering different combinations of functionality and experience.

Of the companies KLAS evaluated, the most common type of visit varied—most of American Well’s visits were on-demand urgent care, while the majority of Epic’s visits were associated with virtual clinic visits.

A key factor of scalability is the ability to support multiple visit types, KLAS researchers note. While multiple vendors offer support for all three visit types (on-demand or urgent care, virtual clinic visits and telespecialty consultations) no single vendor has a large proportion of customers using all three (only 12 respondents across all vendors said they were doing so).

American Well, a market share and mindshare leader, and MDLIVE, two of the vendors used most frequently for multiple visit types, receive generally positive—but lower than average—performance scores. Vendors more specialized in specific visit types or component layers (e.g., Vidyo and Zipnosis) have high scores but narrower expectations from customers.

No one vendor meets all needs equally well, but several are reaching for “all-purpose” status with internal development and/or recent acquisitions (American Well acquired Avizia; InTouch acquired TruClinic), according to the report.

KLAS’ analysis also uncovered a general trend of poor integration. In most cases, the addition of a virtual care platform also means the introduction of a second EHR into the clinician workflow.

“Although integration between EMRs is generally understood to be important for care quality, patient safety, efficiency, and productivity, few interviewed VCP customers have full bidirectional transfer in place. Most say that they are too early in their virtual care programs to pursue integration or that it simply costs too much,” KLAS researchers wrote.

Only American Well, Epic, and MDLIVE have more than half of interviewed customers currently on an integrated path, KLAS found. Epic has placed virtual care capabilities directly into their top-rated MyChart patient portal, which many patients already use. Epic integration means clinicians are able to stay within their existing workflow environment as well.

Many provider organizations are in the early phases of their virtual care programs where showing an ROI is an important milestone and one that organizations want to achieve as soon as possible, KLAS notes. “A key promise from vendors is that their technology and accumulated expertise will result in a fast start and continuous acceleration. When this comes at significant cost or progress is slower than expected, provider organizations can experience disappointment,” the KLAS researchers wrote.

When it comes to getting their money’s worth and achieving desired outcomes, Epic and InTouch are rated highest among fully rated vendors, and swyMed and Vidyo perform well among their smaller groups of respondents, KLAS researchers note.

“For each vendor, the current value proposition is somewhat narrow but well understood: Epic’s use is limited to existing patients of Epic EMR customers; InTouch is used primarily for consults; swyMed is used by respondents primarily for mobile, first responder needs; Vidyo delivers video-conferencing tools,

which are typically combined with other VCP solutions. SnapMD is seen as a low-cost option, but some customers say the impact has been limited. Commentary from VSee customers suggests a similar experience,” KLAS researchers wrote in the report.

Many healthcare organizations are early on in their virtual care journeys, and their ability to achieve desired results depends on guidance from vendors. According to KLAS’ analysis, swyMed and InTouch receive the most praise for taking initiative in proactively guiding customers and also in quickly responding to support problems.

While respondents praise American Well’s platform scalability, some customers blame the vendor’s “exponentialgrowth for staffing shortages that have led to implementation holdups and backlogged service requests. Some SnapMD customers say hard-to-beat pricing comes with a support model that is spare in terms of providing tailored guidance, according to the KLAS report.

Most vendors offer two additional options that can help accelerate customers’ expansion and growth—supplemental services, including added-cost advisory and outsourced services, and tools that automate patient-facing tasks that traditionally require additional staff. I

KLAS found that few customers mentioned these options in top-of-mind conversations. “Respondents who spoke of their vendor’s supplemental services most often referred to marketing support or strategic planning services from vendors American Well, MDLIVE, or Zipnosis. Those who referred to task automation report patient-self-service capabilities around check-in, scheduling, surveys, and/or patient flow from InTouch Health (TruClinic), Epic, MDLIVE, or Zipnosis,” the KLAS researchers wrote.

 

 

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Study: Neonatal Telehealth Reduces Hospital Transfers, Saves Money

December 11, 2018
by Heather Landi, Associate Editor
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Neonatal video-assisted resuscitation reduces transfers from hospitals without newborn intensive care units and provides significant cost savings, according to study published in the November issue of Health Affairs.

The study authors, led by Jordan Albritton of Intermountain Healthcare, examined a newborn telehealth program implemented at eight Intermountain Healthcare community hospitals in November 2014–December 2015 and the impact on the transfer of newborns from those eight hospitals to level 3 newborn intensive care units.

Studies show that 10 percent of newborns require assistance breathing at birth, and 1 percent require extensive resuscitation. At Intermountain Healthcare, approximately 1–2 percent of all babies born in suburban and rural hospitals are transferred to newborn intensive care units (NICUs) for higher-level care, according to the study.

In response to the need to improve outcomes for complex newborn patients, an innovative telehealth program was established at Intermountain Healthcare in 2013 to provide synchronous, video-assisted resuscitation (VAR), bringing a neonatologist to the bedside. As a result, access to specialized neonatal services in rural and suburban settings is no longer limited to telephone calls or the arrival of a neonatal transport team, the study authors wrote.

While telehealth can facilitate video connections between neonatologists at tertiary care centers and providers at smaller hospitals, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation, according to the study authors.

Although Intermountain Healthcare began using telehealth technologies in 2013, the current VAR program was implemented in the period November 2014–December 2015. Today, neonatologists from four level 3 NICUs provide VAR support for nineteen referring hospitals.

As part of the study, the researchers evaluated eight hospitals that contained either well-baby (level 1) or special care (level 2) nurseries staffed by physicians, advanced practice clinicians, nurses, respiratory therapists, and other health care professionals. T

The study found that video-assisted resuscitation was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn’s odds of being transferred. Annually, this resulted in 67.2 fewer transfers and an estimated cost savings of $1.2 million per year.

The study authors conclude that reducing transfers keeps families closer to home, increases community hospital revenue, and reduces risk associated with transfers.

“This program helps keep newborns in level 1 or 2 nurseries, which in turn allows families to stay closer to home, improves social support, and increases the revenue of community hospitals while reducing costs and risks associated with transfers,” the study authors wrote. “Payers should consider reimbursement for pediatric subspecialty telehealth consults for neonates in level 1 and 2 nurseries. Through improvements in care quality and cost savings, this service would likely pay for itself many times over.

However, the authors also note that lack of reimbursement for telehealth services limits widespread implementation.

“Policy changes are necessary to align payment incentives and promote the use of telehealth services,” the study authors wrote.

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Can Telehealth Slow the Traffic Between Nursing Homes, Emergency Departments?

December 6, 2018
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The RUSH Act seeks to reduce the 1.3 million transfers from skilled nursing facilities to emergency rooms each year

There are 1.3 million transfers from skilled nursing facilities (SNFs) to emergency rooms each year, and CMS estimates that two-thirds of those are avoidable. The result is as much as $40 billion in unnecessary spending. Could telehealth be part of the solution?

That question led Timothy Peck, M.D., formerly chief resident in the Emergency Department at Beth Israel Deaconess/Harvard, to co-found a startup company, Call9, and become an advocate for legislation, the RUSH (Reducing Unnecessary Senior Hospitalizations) Act of 2018, to support reimbursement for connecting emergency physicians and SNFs.

Peck has spent considerable time studying the issue. “I didn’t know much about nursing homes when I started,” he said.  “I went and lived in one for three months. I wound up sleeping on a cot in a conference room.”

Peck was trying to understand nursing home finances and operations and why the patients are being transferred. They usually have things like urinary tract infections or pneumonia, which could be treated in the outpatient setting, but the SNFs aren’t equipped with the right tools to be able to treat these patients. Those patients come in without their families and 43 percent have dementia, he said. “Most become delirious upon transfer. We don’t have much information about them so we order every test under the rainbow, driving up the bill unnecessarily. We put them in hallways. They get bedsores. We inevitably admit these patients for an average of $15,000 to $20,000 per admission.”

The two-thirds of transfers that are avoidable represent about $40 billion in unnecessary spending for something that harms patients,” he said. “We are spending money on hurting patients.”

Peck zeroed in on three operational issues:

• First, on average, nurse to patient ratios in nursing homes are 1 to 36. If one patient becomes acutely ill and spikes a fever, that nurse does not have time to take care of that patient when they have 35 other patients to take care of. Also, most nursing home nurses are trained to handle chronic care, not emergency or acute care. It is a mismatch of skills, not a people problem in any way, he said.  

• Second, diagnostic equipment is sparse, and EKGs and lab tests take 24 hours to 48 hours to come back. That doesn’t work well for acute care.

• Third, physicians are not present in nursing homes. “When I was living in that nursing home and walking the halls weekends and nights, I never once saw another physician. Long-term care patients are seen once a month by their primary care doctors.”

Peck described the Call9 service: They embed 24x7 a paramedic or EMT or a nurse with emergency experience in the SNF. They go to the patient’s bedside and connect to a remote emergency physician who is available 24x7 and working from home. They can see a patient in nursing home A with a paramedic by the bedside and then jump to nursing home B and see a patient there with a first responder with them. “It makes the physician a scalable resource,” Peck said. “Believe it or not, they are our least expensive resource because they get scaled.”

Call9 has full integration with the three most commonly used EHRs in the SNF world. The solution also deploys a suite of mobile diagnostics and can return lab test results in a few minutes. It offers real-time telemetry and real-time ultrasound.

After treating a few thousand Medicare Advantage patients, he said the model has shown that it can save payers more than $8 million per nursing home per year. That allowed Call9 to get involved with Medicare shared savings value-based contracts with several payers nationally. But he notes that 60 percent of patients in nursing homes are Medicare patients. “We took that data to CMS and showed it to them,” Peck said. “The Ways and Means Committee in the House of Representatives got ahold of the data and got excited and started writing the Rush Act.”  He stressed that Call9 is not the only organization creating a program like this. There are others working on similar solutions.

Peck said CMS is interested in using telehealth in this way, he said. “But they don’t have any way to change payment mechanisms in a quick manner. They would have to ask CMMI to run demos, which takes years. But Congress could pass new legislation.” He described the RUSH Act as creating a value-based shared savings arrangement with Medicare where 50 percent of the savings goes back to Medicare, and 37.5 percent goes to a company like Call9 or a physician group or medical staffing group that administers the program and 12.5 percent goes to the nursing home, aligning all stakeholders, he said. “The bill has been introduced by a bipartisan group, because it is a nonpartisan issue.” With time running out in this session, he said, the bill still has strong support among Democrats set to take over House leadership in 2019.

Besides bipartisan sponsors in Congress, the bill also has support from patient advocacy groups such as the Alzheimer’s Association, Michael J. Fox Foundation for Parkinson’s Research, American Heart Association, the National Alliance on Mental Illness, and the American Telemedicine Association. “They are saying that the patients need it; the taxpayers benefit; why are we not doing this?” Peck said.

As someone who has seen family members and friends make that repeated, disruptive round trip from nursing home to emergency room, I concur.  

 

 

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