The use of telemedicine across the healthcare continuum to improve access to care

1. ACCESS TO CARE
THE USE OF TELEMEDICINE ACROSS THE
HEALTHCARE CONTINUUM
Kevin Broder, MD
Telehealth Director, Department of Surgery
Section of Plastic Surgery
VA Medical Center – San Diego, CA
October 24, 2015
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

2. 2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
RUBE GOLDBERG (1883-1970)

3. HIGHLY RURAL, RURAL AND CENSUS DEFINED URBAN AREAS
Map generated by VHA Planning
Systems Support Group2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

4. ELDERLY TRANSPORT
• Costly Travel
• Special Assistance
Personnel
• Special Equipment
(Gurneys, Wheelchairs,
Vehicles)
• Long Clinic Wait Times
• Family Inconvenience
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

5. TELEMEDICINE
4 MODALITIES
• Store and Forward Telehealth
– Images/Data obtained by remote site and uploaded Imaging Database
for later review by provider
• Home Telehealth
– Home monitoring devices
• Clinical Video Telehealth (CVT)
– Real Time ‘Live’ Videoconferencing
• Specialty Care Access Network (SCAN)
– Consultation, Care Planning and Education with Tele-video
conferencing

6. • Establish Conditions of Participation and Service
Agreements
• Formation of Telehealth Team
• Identify Patients
• IT Collaboration/Equipment Allocation
• Informatics Collaboration
• Integration into Continuum of Care
• Ongoing Provider/Patient Support
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
STEPS FOR PROGRAM DEVELOPMENT

7. Telehealth
Coordinator
Facility
Leadership
Providers
(Central ‘Hub’)
Informatics
Administrative Staff
Technical
Staff (IT/BioMed)
PCP
RN
Patient/Family
(Remote ‘Spokes’)
Case Manager
TELEHEALTH TEAM

8. IDENTIFY THE PATIENTS
VISIT TYPES
• Wound Care/Skin Assessment
• Specialty Consultation
• Medical Optimization
• Post-Op Evaluation
• Medication Reconciliation
• Psychology
• Nutrition
• Education
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

9. MORE VISIT TYPES
VETERAN AFFAIRS EXAMPLES
• TeleCardiology
• TeleGenomics
• TeleICU
• TeleNeurology
• TeleNutrition
• TelePrimary Care
• TelePulmonology (Sleep Services)
• TeleRehabilitation
• TeleAmputation Clinics
• TeleKinesiology
• TeleOccupational Therapy
• TeleSpinal Cord Injury/Disorder
• TeleMOVE! (Weight Loss)
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

10. • Broadband Network
• Tele-video Conferencing
Equipment
• Peripherals
IT SUPPORT/EQUIPMENT

11. PERIPHERALS
Digital Stethoscope
Exam Camera
12 Lead ECG
Ultrasound
Spirometer
Vital Signs Monitor

12. • Customized automated
Consult Requests for
SCAN-ECHO and CVT
• Software based query
of remote site patient
data
• Template for guiding
remote provider input
INFORMATICS COLLABORATION
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

13. 2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
CONTINUUM OF CARE
Interdisciplinary
Team
SCAN
Telehealth
Modalities
Spoke Clinics
Hub
Clinics
Specialists
Geriatrician/
PCP
NursingNutrition
Physical
Therapy
Psychology/
Social Work
Multi-
Specialty
Consultation
Inpatient
Rounds
Home Care

14. • Telehealth Coordinator - RN
• Telehealth Clinical Technician (TCT) – Health Tech/LPN
• IT Support
• Vendor Support
• Routine Education and Training
• Administrative Oversight
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
ONGOING TELEHEALTH SUPPORT

15. CLINICAL VIDEO TELEHEALTH
CVT
Patient/PCP at Spoke
Provider at Hub
‘Consult/Post -op/Follow-up/Pre-op’
Patient/Provider at Hub
PCP/Family/Home RN at Spoke
‘D/C Planning’
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

16. USE OF TELEHEALTH REDUCES ADMISSION BED DAYS

17. CVT TO HOME
PROCESS
• Schedulers Create
Appointments in Custom
Web App
• Email Confirmation Sent
to Patient for Secure
Login
• HIPAA Compliant
Software
– Virtual waiting room
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

18. CVT TO HOME
PROCESS
• Patients Connect to
Enterprise Video Network
from Home
– Desktop
– Laptop
– Tablet
• Connect to Hospital
Provider for Encounter
• Electronic Health Record
Documentation
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

19. CVT TO HOME
EQUIPMENT
Patient/Home RN at Home
Provider at Hub
‘Real Time Home Visit’

20. CVT TO HOME
MEDICAL PROBLEMS ADDRESSED
• Wound Care
• Nutrition
• Smoking Cessation
• Pressure Relief
• Medication Reconciliation
• Compliance
• Disposition (Remain home vs Urgent Care vs ED)
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

21. 2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
SAFETY NET

22. SCAN
SPECIALTY CARE ACCESS NETWORK
• An innovative model utilizing clinical tele-video
conferencing equipment to allow healthcare
specialists from an inter-professional care team to
provide expert advice to remote providers in
rural/underserved healthcare settings
• A ‘Grand Rounds/Tumor Board’ style multipoint tele-
video consultation
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

23. • Consent - verbal
• Inter-Facility Consultation Request Placed
• SCAN-ECHO Tele-Video Session
– Case Presentation
– Case Discussion
– Didactic Lecture
• Documentation
SCAN PROCESS

24. • Formation of an Interdisciplinary Team of Consultants
• Identify Hub and Spokes
• IT Collaboration
• Informatics Collaboration
• Develop Didactic CME/CEU Accredited Lectures
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
STEPS FOR PROGRAM DEVELOPMENT

25. • Plastic Surgeons
• Rehabilitation Physician
• Clinical Nurse Specialist/ Rehab Case Manager
• Physical Therapist
• Dietitian
• Telehealth Nurse Coordinator
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
INTER-PROFESSIONAL TEAM EXAMPLE
SCI PRESSURE ULCERS AND COMPLEX WOUNDS

26. HUBS AND SPOKES
VA SCI EXAMPLE

27. • Wound Debridement
• Pressure Ulcer Reconstruction
• Adjuncts to Wound Healing
• Comprehensive Assessment of Pressure Ulcer Patients
• Topical Wound Care
• Nutrition for Wound Healing
• Pressure Relief Surfaces
• Specialty Mattresses & Beds
• Prevention of Amputation & Foot Screening
• Bioethics Roundtable: Autonomy and Other Issues
• Pre-Op Optimization Part I – The Surgical Checklist
• Pre-Op Optimization Part II – Nutritional Optimization for
Wound Prevention and Healing
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
DIDACTIC LECTURES

28. BENEFITS FOR PATIENTS AND PROVIDERS
• No-cost continuing education credits (CME/CEU)
• Opportunity to translate new knowledge into practice to
improve outcomes
• Professional networking with colleagues of similar interests
• Avoid costly and time consuming travel to distant medical
centers that puts patients at risk
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

29. 2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
SCAN
FAR REACHING

30. 2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
TELEHEALTH
CONTINUUM OF CARE

31. HIGH PATIENT SATISFACTION
Veteran TeleWound Care: Initial VA San Diego
Experience Utilizing Real-time Clinical Video
Telehealth, Store and Forward Telehealth and
Home Telehealth Technology in
Comprehensive Wound Management.
Broder KW 1,2, Li A 3, Tesfamicael R 1, Bodor R 1,2
1 Section of Plastic Surgery, VA San Diego Medical Center, San Diego, CA
2 Division of Plastic Surgery, UCSD Healthcare, San Diego, CA
3 Department of Surgery, Harbor UCLA Medical Center, Torrance, CA
2010 Fall Symposium on Advanced Wound Care and Wound Healing Society Meeting, Anaheim, CA

32. CVT TO HOME
TRANSPORT COST SAVINGS & INCREASED ADOPTION
SCI CENTER – SAN DIEGO
Projected
0
50
100
150
200
250
2011 2012 2013 2014 2015
Encounters
2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

33. CONTINUUM OF CARE
WHERE TELEMEDICINE FITS IN
• SCAN-ECHO
• Spoke Telehealth Consultation
• Home Telehealth Monitoring
• Face to Face Consultation
• Clinic Visit
• Admission
• Inpatient Rounds
• Education
• Telehealth D/C Planning
• Telehealth Follow-up

34. 2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium
NO MORE WAITING FOR THE DOCTOR TO ARRIVE
THANK YOU
KEVIN BRODER, MD