UC Health—the University of Cincinnati Academic Health Center—is a two-hospital integrated health system that encompasses the University of Cincinnati Medical Center in Cincinnati and West Chester Hospital in nearby West Chester, as well as the University of Cincinnati Physicians medical group, a post-acute care facility, and an ambulatory surgery center. UC Health, with $1.3 billion in annual revenues, was formed as an integrated health system in the fall of 2010, though Cincinnati Medical Center had been in existence for nearly 200 years. The health system, with over 1,000 beds, sees more than 35,000 inpatient admissions per year, and more than 120,000 ED visits. Meanwhile the University of Cincinnati Physicians encompasses more than 800 board-certified physicians, and is the largest physician group of its kind in the region. The integrated system is affiliated with the University of Cincinnati School of Medicine.
Leaders there, including Anya Sanchez, M.D., enterprise director, special projects, and Pam Kimmel, R.N., director of telehealth, have been working with the Cincinnati-based Intelemage to strengthen and expand their telehealth program. Sanchez and Kimmel spoke recently with HCI Editor-in-Chief Mark Hagland regarding their organization’s ongoing journey into telehealth. Below are excerpts from that interview.
Tell me about your partnership with Intelemage and the recent expansion of your telehealth program?
Anya Sanchez, M.D.: We’ve been working with the people at Intelemage for a few years now. They’re an image exchange-based company that we had been using for tumor board uses. Physicians would review images collaboratively through their tumor board. But a few years ago, our stroke team expressed interest in using that system as a platform for our telestroke program. Also, one of the things that we’re doing that’s of note is that we’re piloting other program types, too. We’ve just rolled out a video visit program for primary care, and have launched a telenephrology consult service with a local hospital as well.
When did you start the telestroke program?
Sanchez: In April 2012.
Pam Kimmel, R.N.: We engaged 18 physicians who share call. About half are neurologists, and the other half are ED physicians with neurocritical care training. They currently provide care to all the surrounding hospitals in the Cincinnati area, about 18 hospitals. And they travel by car to those facilities. And we were covering hospitals in rural areas by phone. So we began implementing telestroke in those facilities first. It was more of a robot-based model initially and that was expensive, but through the partnership with Intelemage, we were able to expand to all the hospitals. It’s a product that’s device-agnostic and allows the images to be shared as well as a video link that can be shared, encrypted for HIPAA security reasons.
So a patient comes into an ED and if that patient has stroke symptoms, is cared for through the telestroke program?
Kimmel: Yes, and the patient receives a CT scan, which is pushed to the Intelegrid, which is the product platform. That’s the image exchange component of the platform. Once that CT image is pushed to Intelegrid, it creates a case for both hospitals to see. So the emergency room in one facility can watch a video and the stroke physician can see it.
A CT tech does this?
No, all the background work is arranged by our program manager here, working with Intelemage. So it doesn’t require any special person; just normal workflow.
And a series of CT scans is performed on the patient?
Yes, and the physician can see the images as well as the patient, and ED physician, in the remote location.
One of the advantages, obviously, must be the simultaneous or instantaneous ability of the remote specialist to see the patient live via the connection, and to view the images immediately after they’ve been produced?
Yes, it allows the physician to examine the patient and view the images live.
How many images are in any given stack, usually?
For one study? It’s a large number. It can be in the 20-30 range of slices.
How many telestroke consults have taken place so far, through the program?
Over the past year, from our eight rural hospitals, we’ve had 300 calls, and of them, 100 of them have led to telestroke consults. The stroke team here takes an average of about 3,000 calls a year, from among the eight hospitals we have up and running, for the small hospitals. What we’re doing now is that some of our busiest hospitals, where our physicians are doing the majority, the vision is to be able to have ubiquitous telestroke coverage, so that every facility could have telestroke, not just the remoter ones. In the future, we’ll be able to do a telestroke consult at any site they’re arriving at. Even among the larger hospitals, most don’t have stroke specialists. We had had since 1987, telephone telestroke coverage. We’ve had longstanding relationships of that sort.
This all will improve the potential for tPA administration, correct?
Yes, this improves that and adds to the comfort level of the local physician administering tPA, knowing that he has had that specialist consult. And even in larger and urban hospitals, the time is shortened to reach the stroke neurologist.
When were you fully live with video consults?
Back in 2012, but that was through the typical robot-based systems that are very capital-intensive, so we could only afford to outfit the outlying hospitals with those robots. With this new technology that’s technology-agnostic and can work on different types of hardware, we can expand to every hospital, and even if it’s five miles away, that can pose a significant time lag for treating a patient. The innovation is using this new platform and we just had our first site go live the fall of 2015.
And how many sites are live now?
We have a pilot site now, and are getting ready to launch two more in the next couple of months. And eventually, we’ll be live in around 30 sites, including city hospitals. Imagine if we could have telestroke in all these hospitals, 3,000 consults per year would have the availability of live video.
Do you have any clinical outcomes metrics available yet?
We do have some metrics relative to our existing sites. Among other things, our door-to-needle times been reduced at all the sites. I’d have to pull data. But the key standard is to administer the drug in 60 minutes or less, and they’re beating that mark.
Sanchez: We like for our rural partners to have comparable door-to-needle times to our flagship medical center. And they do now.
What are physicians saying about the program?
Sanchez: After we got the robots up and live, our physicians really like to have that capability to visualize the patient, because some of our physicians more reticent to use new technology—for them, that became the new standard for those consults. So our physicians are very enthusiastic about having the ability to visualize any stroke patients in a consult.
Do you have video visits available yet for primary care?
Sanchez: Yes, it’s just gone live with one of our primary care groups. And we using it for urgent care visits. So the patient calls in with a certain set of conditions, and we have appointments available for them on an urgent basis within 24 hours, and are using it for follow-up visits; we can identify patients for follow-ups within a week.
Which conditions are typically being handled this way?
Kimmel: We have a list, but common cold symptoms, headache, diarrhea, typical consults that don’t require a physician to touch the patient. Allergy symptoms including sinus congestion, upper respiratory infections, cold and flu, cough, sore throat, eye conditions, constipation or diarrhea, urinary conditions, birth control consults, nausea or vomiting without belly pain or bleeding, and depression or anxiety, and headaches.
When did you go live with video visits?
Sanchez: It was September 30.
And what is the current volume of video visits?
We’re doing one to two a week. The medical group has five physicians. We should mention that we’re expecting higher numbers. We’re only doing this within one medical group, with patients covered under our UC Health Plan. So that’s made our pool of eligible patients much smaller. Most telehealth is not reimbursed. So we’re covering the video cost, there’s no co-pay for this, and we’re only doing this with patients in our plan.
How many patients are involved?
The pool is about 300 patients in the plan who receive care in that practice. That’s also why we’re doing proactive follow-up visits.
How will that program ramp up?
Kimmel: We want to run this pilot for another three months, and we’re expanding to another primary care practice that has more US Health patients, and are looking also to expand to our weight loss center. So we’ll be rolling that out in the next three months.
What is your hope for the program overall, as it evolves forward?
We want to improve access for our patients, to make it a more patient-centric experience. So they don’t have to take off a half day of work to come in for a follow0p visit, for example, so to improve satisfaction and access. We also want to be able to see patients more quickly and efficiently.
You had also referenced telenephrology earlier. You’re building a telenephrology program also, correct?
Sanchez: Yes, and that model is being based on the telestroke model. We’re providing service to the more rural hospitals that do not have nephrologists on staff. Often, a patient on outpatient dialysis who needs to be admitted for something other than a kidney issue, cannot remain at the local hospital because they need dialysis. This allows the patient to stay in the local hospital, and the physicians here at UC provide the coverage for the dialysis.
What is the scope of that program so far?
We have just launched at one pilot site so far, and that launched a couple of weeks ago; we have five nephrologists sharing that call. We already have another hospital that is asking if they could partner with us on this
What have been the biggest lessons learned so far? And what advice might you have for our audience members who might be considering programs like these?
Sanchez: The biggest lesson—telehealth—we’ve found is best leveraged through things we’re already doing well. It’s not a silver bullet that will give you something you hadn’t done before. Telestroke, we had done that for decades. It’s tool that can extend our reach and build on our relationships. A lot of organizations think they can break into new markets, but we’ve found that it works as an augmentation of things we’re already doing well.
Kimmel: And you have to have physician buy-in; it has to be supported from the beginning by the physicians, and they have to have the desire to work with you, otherwise, it will fail miserably.