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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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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