For Doctors Without Borders, Telemedicine Brings Specialized Care to the Front Lines | Heather Landi | Healthcare Blogs Skip to content Skip to navigation

For Doctors Without Borders, Telemedicine Brings Specialized Care to the Front Lines

December 22, 2017
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For the past 46 years, Médecins Sans Frontières (MSF), or Doctors Without Borders, has been providing emergency medical and humanitarian aid around the world where the need is greatest, particularly to people afflicted by conflict, epidemics, disasters or exclusion from health care.

In 2016, Doctors Without Borders provided humanitarian assistance in 71 countries, providing 9.7 million outpatient consultations, performing 92,000 surgical interventions and the organization also has rescued and assisted more than 30,000 migrants and refugees at sea. Every day, the organization’s medical teams treat people displaced by conflict and extreme violence through field missions in countries such as Syria, Yemen, South Sudan, Nigeria and the Democratic Republic of Congo.

To support the medical work of doctors and nurses on-the-ground in remote areas, Doctors Without Borders leverages a telemedicine platform to provide clinicians in the field with access to medical specialists. I recently spoke with John Lawrence, M.D., a pediatric surgeon, and MSF-USA’s board of directors’ president, about the organization’s telemedicine platform and how it helps to bridge the gap between remote areas and large hospitals, linking patients with specialists around the globe. While telemedicine is not a cutting-edge technology, for doctors and nurses working in remote locations like Aweil, South Sudan with limited resources, that link to a specialist can literally help to save patients’ lives.

For the past 20 years, Lawrence has been a practicing pediatric surgeon, primarily in academic settings. He has completed eight surgical missions with MSF since 2009 in areas such as the Central African Republic, Ivory Coast, Haiti, Syria and the Democratic Republic of Congo. For the past nine months, he has been involved with the organization’s telemedicine program, providing his expertise as a specialist to doctors in the field.

The organization’s telemedicine service consists of three coordinators working 24/7 who receive alerts from field teams requesting assistance from a specialist. The coordinators then forward the request to one of the system’s 280 experts. Since 2010, more than 3,000 cases have been treated using the telemedicine service. The platform enables MSF staff to manage remote medical consultations and currently there is an average of five to ten cases received each day.

On the consulting side, Lawrence says he has found the process to be quick and seamless. “I have access to the patient’s clinical history, laboratory data, X-ray data, and sometimes, depending on the circumstances, a picture of the patient. There will also be a comment chain of other referral doctors that have been consulted on this case,” he says, noting that the general physician in the field may send a case to a pediatrician or pediatric infectious disease specialist, or send X-rays to a pediatric radiologist for input, and then request input from a pediatric surgeon.

Lawrence, who specializes in neo-natal surgery, notes one particular case he consulted on that involved an infant, whose family lived in Guinea, who was born with a severe birth defect. Based on the child’s clinical history and a photo provided, Lawrence was able to remotely diagnosis that the child was born with cloacal exstrophy, a birth defect in which much of the abdominal organs are exposed.

“It’s one of the most difficult conditions to reconstruct in all of pediatric surgery. Not every medical consultant is in the position where they’ve worked in the field and understand what the resources are like and the level of care in that setting. My response was that this was not something that could be cared for in a small, community hospital and that they needed to transfer the patient to the capital city to get the highest level of pediatric care,” Lawrence says.

In another case, physicians operating a MSF pediatric hospital in the eastern part of Lebanon, near the Syrian border, requested Lawrence’s expertise for a case involving a five-year old with a possible tumor. “The family were Syrian refugees who had just crossed the border from Lebanon and the child previously had surgery done to remove a pelvic tumor, but was experiencing symptoms that suggested it had reoccurred. The doctors in the field described the physical exam and sent X-rays and wanted my recommendation on how best to proceed,” Lawrence says. “The family had been trying in the last year or two to get care for the child, but they hadn’t been able to access care within Syria. Looking at the X-rays and knowing the capabilities of the facilities that we are running in East Lebanon, which is a good hospital, but it’s not a tertiary care hospital, it was my recommendation to refer the child to the main pediatric hospital in Beirut where the child could be treated by the appropriate oncology surgical team and receive a high standard of care.”

Lawrence believes that the telemedicine platform greatly enhances the care that physician and nurses on-the-ground can provide to patients in greatest need. “The teams we work with are exceptionally dedicated and skilled, but this allows for the full spectrum of medical or surgical specialists that you would typically have access to in a high-income setting. More often than not, our projects on-the-ground are straight-forward care, whether it’s pediatrics, gynecology or primary care, in each discipline, people are generalists with a good, broad knowledge base and can care for a wide range of common things. But, when you get into the uncommon, that’s the value of resourcing people," he says.

More broadly, Lawrence says his field work with Doctors Without Borders has been an eye-opening experience and has raised his awareness of the critical healthcare needs throughout much of the world.

“It’s been the most rewarding and most valuable part of my surgical medical career. From a patient perspective, the needs that exist for so much of the population of the world are not well addressed. In terms of how I view healthcare globally, I think it should be a basic human right, but it’s still largely a privilege. And, of course, there’s discrepancies in healthcare inside the U.S. as well, but it’s so different in the context that we work in,” he says.

Continuing he says, “Our focus is often in areas of conflict; a little over half of our projects are near or adjacent to conflict zones, so that instability often leads to deterioration of healthcare systems overall, systems that may or may not have been functioning in a pretty good state previous to the conflict or violence.” And, he adds, “From a surgical side, there is a gross maldistribution in terms of where surgical care is offered—the richest third of the population wind up getting 75 percent of the operative procedures, and the poorest third of the population only get about 3 percent of the operations. This is a void that I think we help to fill and I think what this organization offers in that regard is very valuable.”

As another takeaway, Lawrence says he has been impressed with the efficiency of the operating rooms of the Doctors Without Borders field hospitals. “They are the most efficient that I’ve ever been in. People in the U.S. are shocked to hear me say that, but there is so much more you can get done in a day there, than is possible here.”

Speaking with Lawrence about his experiences working in the field in areas like South Sudan and Syria, it brings to mind that while the U.S. healthcare system is in the midst of accelerating change and uncertainty—federal policy changes, possible cuts to Medicare, the ongoing transition from volume-based reimbursement to value-based care and payment, rapidly rising healthcare costs—there is much to appreciate and applaud about the U.S. healthcare system and the progress the industry is making to increase quality of care. And, healthcare professionals in the U.S. should perhaps appreciate that even with limited budgets they are operating with more financial resources and working in safer, more stable environments compared to many of their physician colleagues located in conflict areas throughout the world.

Moving ahead in 2018, technology and digital innovation will continue to play a large role in ongoing efforts to meet the “Triple Aim,” providing high-quality care and improving the health of populations at lower cost. And as healthcare IT leaders focus on leading-edge and next-generation technologies—whether artificial intelligence, machine learning, virtual reality, robotics and advanced analytics—it’s worth recognizing the benefits of more fundamental technologies, such as telemedicine, as highlighted by the work that Lawrence and other physicians are doing in their humanitarian and medical relief efforts around the world.

 

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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.

James McElligott, M.D.

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.

Dee Ford, M.D.

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].

Kathryn King Cristaldi, M.D.

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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Seven Companies, Four Individuals Indicted in Billion-Dollar Telemedicine Fraud Conspiracy

October 16, 2018
by Rajiv Leventhal, Managing Editor
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Four individuals and seven companies have been indicted in a $1 billion telemedicine fraud scheme, the Department of Justice announced this week.

The District Court for the Eastern District of Tennessee unsealed a 32-count indictment on the individuals and companies. The indictment stated that HealthRight LLC, a telemedicine company with locations in Pennsylvania and Florida, and Scott Roix, 52, of Seminole, Fla., and the CEO of HealthRight, pleaded guilty to felony conspiracy for their roles in the telemedicine healthcare fraud scheme in a criminal information. Roix and HealthRight also pleaded guilty to conspiring to commit wire fraud in a separate scheme for fraudulently telemarketing dietary supplements, skin creams, and testosterone, according to DOJ officials.

In addition, three other individuals were indicted along with their compounding pharmacies, Synergy Pharmacy Services, located in Palm Harbor, Fla. and Precision Pharmacy Management, located in Clearwater, Fla.. Another co-conspirator, Larry Everett Smith, of Pinellas Park, Fla. also a pharmacy compounder, and his companies Tanith Enterprises, ULD Wholesale Group, Alpha-Omega Pharmacy, all located in Clearwater, Germaine Pharmacy located in Tampa, Fla., and Zoetic Pharmacy located in Houston, Texas, were all also named as defendants. All the defendants were charged with conspiracy to commit healthcare fraud, mail fraud, and introducing misbranded drugs into interstate commerce, per the indictment.

The indictment alleges that from June 2015 through April 2018, these individuals and companies, together with others, “conspired to deceive tens of thousands of patients and more than 100 doctors” located in Tennessee and elsewhere across the country “for the purpose of defrauding private healthcare benefit programs such as Blue Cross Blue Shield of Tennessee out of approximately $174 million. The indictment further alleges that the defendants submitted not less than $931 million in fraudulent claims for payment,” according to the indictment.

More specifically, according to the indictment, the defendants “set up an elaborate telemedicine scheme in which HealthRight fraudulently solicited insurance coverage information and prescriptions from consumers across the country for prescription pain creams and other similar products.” The indictment states that doctors approved the prescriptions without knowing that the defendants were massively marking up the prices of the invalidly prescribed drugs, which the defendants then billed to private insurance carriers.

In addition to their roles in the healthcare fraud conspiracy, Roix and HealthRight were also charged with conspiring to commit wire fraud as part of a scheme to use HealthRight’s telemarketing facilities to fraudulently sell millions of dollars’ worth of products such as weight loss pills, skin creams, and testosterone supplements through concocted claims of efficacy and intentionally deficient customer service designed to stall consumer complaints, according to the indictment.

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With $6.3M PCORI Contract, UPMC Health Plan to Study Tech-Based Approach to Chronic Disease

September 25, 2018
by Heather Landi, Associate Editor
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The UPMC Center for High-Value Health Care was recently awarded a $6.3 million contract from the Patient-Centered Outcomes Research Institute (PCORI) to study different care delivery models to improve outcomes for patients with chronic disease and a co-existing behavioral health condition.

The multi-year study will highlight payer-provider collaboration to support individuals with both physical and behavioral health conditions. The UPMC Center for High-Value Health Care is housed within the UPMC Insurance Services Division, which includes UPMC Health Plan, and is part of Pittsburgh-based UPMC health system.

The focus of the study is to better understand how to design systems to manage chronic disease and will compare a technology-centric approach with a team-based, high-touch intervention, according to UPMC.

PCORI awarded the UPMC Center for High-Value Health Care support for a five-year study with a long-term objective to enhance the ability of health care systems to better support individuals with chronic diseases like inflammatory bowel disease (IBD) and behavioral health conditions, reduce variations in practice, connect patients with care that is best for them, and improve meaningful, patient-centered health outcomes.

This PCORI study is related to a recently completed one-year pilot study, which showed that participation in an IBD specialty medical home, a care delivery model that is uniquely designed to provide comprehensive and well-coordinated health services, increases patients' quality of life while decreasing levels of disease activity and use of unplanned care. In fact, the pilot study demonstrated a 50 percent decline in emergency room visits and a 30 percent decline in hospitalizations among participants.

“The early successes of the pilot study are encouraging and now this multi-year PCORI study will allow us to further align the payer and provider to develop long-term benefits and applications in a variety of clinical settings," William Shrank, M.D., chief medical officer for UPMC Insurance Services Division, said in a statement. "The use of technology as a key component of the study underscores the role that emerging trends will play in the future of health care."

Participants who enroll in the study will receive IBD specialty medical home care through either a team-based or tech-based approach.

The team-based approach is a personalized service design that includes gastroenterologists, behavioral health specialists, registered nurses, and health coaches who provide intensive, in-person support and resources. The tech-based approach leverages a digital platform using remote monitoring, digital behavioral interventions, and telehealth to deliver team-based care at the patient's convenience, at home and in the community, with the guidance of health coaches.

“By examining the effectiveness of a 'team vs. tech' approach, we expect that this research will provide insight on the most effective methods to provide both physical and behavioral health care to individuals with IBD and most importantly, a better quality of life for patients both now and into the future,"  principal investigator for the study, Dr. Eva Szigethy, professor of psychiatry at the University of Pittsburgh and senior faculty at the UPMC Center for High-Value Health Care, said in a statement.

Co-investigators of the study include clinical experts from the UPMC Center for High-Value Health Care, the University of Pittsburgh, Mount Sinai Health System in New York, and Brigham and Women's Hospital in Boston.

This marks the fifth PCORI contract awarded to the UPMC Center for High-Value Health Care over the past five years.

 

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