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Expanding Telemedicine to Medical Homes for Comprehensive Care Delivery for Persons with Hemostatic disorders: A pilot study of the American Thrombosis and Hemostasis Network

(ATHN)/National Hemophilia Program Coordinating Center (NHPCC)

METHODS

• Telemedicine (TM) is the delivery of health services through HIPAA secure synchronous videoconferencing to patients in remote sites with limited access to specialist services.

• Telemedicine can also be used to delivery cost effective diagnostic and comprehensive services for management and monitoring of patients with hemostatic disorders.

• Our goals were to provide increased access to family-centered and culturally competent specialty care and to

• Increase the number of patients with bleeding/blood disorders that are timely and accurately diagnosed and referred for specialty care

Objectives• To assess feasibility of telemedicine between specialists and

medical home for children with hemostatic disorders• To assess the cost of telemedicine visits versus traditional

visits from the societal perspective• To assess the acceptability by patients, families, primary care

physicians, primary care staff, specialist physicians, and specialist staff

• To assess resource, referral, support assistance and patient confidentiality of medical and mental health services

• TM site was the Medical Home/primary care physician (PCP) pediatrician’s office at the Upper Great Lakes Family Health Center in Hancock/Houghton, MI, located ~500 miles from Michigan State University Center for Bleeding and Clotting Disorders (MSUCBCD)

• Types of comprehensive team services provided were recorded. • Personnel, equipment type and as well as the cost savings of travel

by the care team were recorded. Cost savings were analyzed.• Synchronous HIPAA regulated bidirectional videoconferencing

technologies, Vidyo TM (web based), was utilized in all phases • Written photo releases with permission to utilize them for education

were obtained

CONCLUSIONS

Roshni Kulkarni* 1, Rebecca A. Malouin1, Colleen Vallad-Hix2, Laura Carlson1, Marcia Bird1, Diane Aschman3, Ann Forsberg3, Zachary Trost1, Robert Greenhoe2 1Michigan State University, East Lansing MI, 2Portage Health Pediatrics, Upper Great Lakes Family Health Center , Hancock, 3American Thrombosis and Hemostasis Network, Illinois,

  INTRODUCTION & OBJECTIVES

• TM allows care delivery by specialists for diagnosis and monitoring and follow up of remote patients. Critical social worker and nursing evaluation and interventions can be accomplished via TM.

• Successful care delivery is possible at Medical Home using telemedicine• There is significant cost and time savings for the patients, physician and

health care facilities.• Besides patient satisfaction and education of patients and providers, TM

allows state of the art specialized care to be provided to remote patients.

Clinic Location

Results: Costs

Outreach Nurse/ Coordinator Roles Outreach Nurse Role:Gathered referral information, including labs & pertinent history and labs from outreach location;

Reviewed patient information with hematologist, ordered necessary testing desired prior to visitDuring Telemedicine visit: Provided nursing assessments and family education

Post TM clinic follow up:Coordinated patient and family testing, medications, education, implementation of plan of careDocumented patient care and data entry to ensure that both clinics have visit documentation. Updated contact information

Coordinator Role:Coordinated with Portage, MSU staff, and physicians, and IT department regarding dates and times for monthly telemedicine

clinics. Assisted with grants and site visits

Acceptability and Lessons Learned

Social Work (SW) Role and Perspectives• Facilitated services such as education programs, mental health

support programs among patients, family members, MSUCBCD and PCP

• Provided bleeding disorder education in specialty care, insurance and patient assistance programs to PCP and staff

• Built a rapport with patient and family members and assured all participants of confidentiality, which was integral to success

• Researched and offered alternatives for parent/child, in-home, early intervention, special education and social work services not available to patients in rural area

• Assisted families in overcoming barriers due to low economic status, unemployment, learning disabilities and transportation through CBCD, local resources and Helping Hands

• Provided post-telemedicine contacts for on-going HTC communication and referrals to bleeding disorder state and national recreational, educational activities and support services

• Families and clinic staff found telemedicine to be an acceptable form of care, especially as it is becoming common among other specialties in rural areas

• In most cases families preferred telemedicine as their trusted healthcare provider was close by and they did not need to travel

• Lessons learned from staff• Staff were accustomed to protocols and desired a telemedicine

protocol for hematology consults• Tools to provide families with information about what to expect from

the consult would be helpful• Planned visits are necessary due to scheduling in a busy pediatric

practices• Lesson learned from patients

• Written information about the purpose of and expectations during and following the telemedicine consults are needed

• Having the primary care physician in the room to explain what the hematologist is recommending might be helpful

• Having many team members on the video on consultant side is confusing - fewer is preferred

Results: Demographics and types of disorders

Abstr. No. ISTH15ABS-2041Vitamin K Antagonist II

References Whitten P et al. Applied Clinical Informatics 2010;1:132. Grosse SD et al. Medical Care. 2009;47:594Study supported by ATHN NHPCC grant; Project Number: ATHN2014-NHPCC-1; Funding source: HRSA#UC8MC2409 through ATHN

Telemedicine Clinics: Houghton MI

Time period June 2014 - May 2015

No. of patients 13

Telemedicine visits 15

Age range 2 weeks -17 years

No. of Clinics 1 per month

No of patients seen/clinic 1-3

Videoconferencing system VidyoTM

Types of Disorders NoFamily members tested/counseled

Epistaxis/possible Ehlers Danlos

5/2 Family 

Von Willebrand disease (VWD)

2 Parents and siblings and uncle

Cervical lymphadenopathy 1

Spherocytosis 1 FamilyIron deficiency anemia/ hemoglobinopathy (Thalassemia)

1Family

Hereditary Hemorrhagic Telangiectasia

1Patient and Father

Menorrhagia, anemia, abnormal coagulation profile, thrombophilia

3/1Mother and siblings

Sickle cell trait1 Parents

Demographic Parameters

Portage Clinic

Average distance that patients travelled

33.4 (2.4 -42.3 ) miles

Distance patients lived from local center. N13 patients with 15 visits

30-50 miles : 4 Visits10-15 miles : 4 Visits<10 miles : 7 Visits

Distance for Patients to MSU (RT)

960 -1000 miles RT (460-504 miles OW)

Commercial airline ticket cost

$1142 to $1184

Driving time 9 hrs OW or 18 hrs RT

Time lost from work 20 hrs ( 9 hrs travel time OW)

Physician cost saving $3850

  Patient Costs

Patient seen at HTC MSU, East Lansing

Patient to attend clinic at MSU- Driving costs (Driving, meals and lodging)

$615

Time lost from work, round trip (RT) hours @ $33/hr wage

20 hours x$33=$660

Total Costs with driving $1275If patient flies ( $1184 airline costs + travel time = 16 hours @$33/hr = 528

$1712

Meals and Lodging $175 /night $175Total Costs with flying $1887

Patient seen locally at Portage clinic

Patient to attend clinic at local facility (Driving)

$18.7

Time lost from work (RT) @$33/hour wage

3 hrs x$33= $99

Total costs attending local clinic $117

Challenges• Patient no shows• Technology challenges:

• Portage network upgraded, firewalls blocking telemedicine

• New laptop computers not set up with email to send telemedicine link

• Clinic cancellations – due to meetings or lack of patients

• Inability to do platelet function testing (platelet aggregation) and specialized coagulation tests in Upper Peninsula