Using Telemedicine to Expand Access to Care July 2017 · Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded,

1 Proprietary & Confidential Creating a Sustainable Futurefor Healthcare Organizations

Using Telemedicine to Expand Access to Care

June 2017

Til Jolly, MD

Chief Medical Officer

Specialists On Call

2 Proprietary & Confidential


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Dr. Jolly is a board-certified emergency physician who serves as Chief Medical

Officer of Specialists On Call, the largest national provider of specialty

telemedicine services. In that capacity he oversees medical staff administration,

clinical quality, and clinical service delivery across a multistate and multispecialty

physician practice. He has practiced emergency medicine in the Washington, DC

area for 25 years and continues to practice at Inova Fairfax Hospital, and retains an

appointment as Clinical Professor of Emergency Medicine at the George

Washington University. He has extensive experience in academic medicine, private

industry, and government. Prior to joining SOC, he served for five years in senior

leadership positions in the US Department of Homeland Security, and also

previously lead medical preparedness planning for eleven Super Bowls. Dr. Jolly is

a graduate of the University of North Carolina where he was a Morehead Scholar

and the Wake Forest University School of Medicine. He completed his residency

training in emergency medicine at the combined Georgetown/George Washington

University Residency Program.

About The Speaker

B. Tilman Jolly, MD, FACEP


• Largest provider of acute care telemedicine services

• Virtual hospital w/ 24 x 7 x 365 coverage

• Serving 400+ client hospitals in 35 states

• First telemedicine company to earn Joint Commission Accreditation (2006)

• 170+ provider physician practice - Neurologists, Psychiatrists, Intensivists - US trained, board certified - Utilize only evidence-based clinical protocols

• Full-service innovation center and technology team

Specialists On Call (SOC) Overview


Scope and Scale of SOC Clinical Services

Critical Care SMARTRounds®

Critical Care On Demand: >1,300 consults

Psychiatry: >68,000 consults Neurology: >280,000 consults

>2,000 Cumulative

Years of Clinical

Experience

~2%

ICH for tPA Stroke

Cases

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

IVC Reversal Rates

>40%

0

200

400

600

800

1,000

2014 2015 2016

0

5,000

10,000

15,000

20,000

25,000

2011 2012 2013 2014 2015 2016

0

100

200

300

400

500

600

700

800

Oct

-15

No

v-1

5

De

c-1

5

Jan-

16

Feb

-16

Mar

-16

Ap

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Ma

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Jun-

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Jul-

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Au

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6

Sep

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Oct

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SMARTRounds®


The Drivers of Telemedicine Demand


• Rural and Suburban

• For-profit and Not for profit

• Every region

• Every system

The Nationwide Need


Demand and Supply Dynamics

Increasing Demand for Healthcare with Insufficient Supply of Providers

Source: Association of American Medical Colleges, 2015

Exhibit 11: Projected Total Physician Shortfall, 2013-2025 Figure 29. Cumulative Percent Growth in Population, by Age Group (relative to 2006)

Source : Analysis of US Census Bureau Population Projections


Geographic Mismatch Compounds Supply Challenge


• Easily and cost-effectively access care remotely

• Increase capacity for care through increased productivity of providers

• Data driven platform enables continuous improvements in an evidence based manner

• Provides convenience and faster response time to patients

• Opens up opportunities for new care models that optimizes all available clinical resources

The Telemedicine Solution: More from Existing Resources


Definition & History of Telemedicine


Telemedicine is the use of medical information exchanged from one site to

another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications and

services using two-way video, email, smart phones, wireless tools and other forms of telecommunications technology

– American Telemedicine Association

A Definition of Telemedicine


A Little History


• Early review of telemedicine for critical care

• Grundy et al

• Cleveland, OH

• Service to a distressed hospital with a 7-bed ICU

• 18 months of “interactive television”

FINDINGS:

• Telemedicine enabled university-based critical care physicians to provide regular consultation in an hospital with no intensivist of its own

• Reliability and costs of the telecommunication link presented few limitations

• Organizational difficulties and problems in the design and implementation of the demonstration limited the impact of telemedicine consultation on patient care

Early Telemedicine Program


• Early review of telemedicine for critical care

• Grundy et al

• Cleveland, OH - 1982

• Service to a distressed hospital with a 7-bed ICU

• 18 months of “interactive television”

FINDINGS:

• Telemedicine enabled university-based critical care physicians to provide regular consultation in an hospital with no intensivist of its own

• Reliability and costs of the telecommunication link presented few limitations

• Organizational difficulties and problems in the design and implementation of the demonstration limited the impact of telemedicine consultation on patient care

Early Telemedicine Program


Evaluation Framework for Telemedicine


• Joint Commission

• American Telemedicine Association

• National Quality Forum

• American Academy of Neurology

• American Psychiatric Association

• American Academy of Pediatrics

• Society of Critical Care Medicine

• …and more…

Evolving Standards


Draft Category Recommendations

•Access to Care

• Financial Impact/Cost

• Patient/Provider Experience

• Effectiveness

National Quality Forum: Framework for Performance Measures


• TeleDermatology:

VA Puget Sound study – 5000 veterans, 370 major cases across 27 rural outpatient clinics – better patient care and quality assurance

• TeleOphthalmology:

Retinopathy of prematurity – 67 infants over one year

Diagnostic accuracy of telehealth equal to diagnostic accuracy of in-person evaluation

Access to Care

Eastman KL, Lutton MC, Raugi GJ, et al. A teledermatology care management protocol for tracking completion of teledermatology recommendations. J Telemed Telecare. 2012;18(7):374–378. Chiang MF, Wang L, Busuioc M, et al. Telemedical retinopathy of prematurity diagnosis. Arch Ophthalmol. 2007;125(11):1531-1538.


• TelePsychiatry in Indiana:

Before and after implementation of telemedicine – Median time to consult 14.2 hours vs. 2.6 hours

Similar effect on LOS

• TeleNeurology in California:

Randomized to Telemedicine vs Phone – 98% correct decision vs. 82%, 3% non-complete data vs. 12%

Access to Care

Southard EP, Neufeld JD, Laws S. Telemental health evaluations enhance access and efficiency in a critical access hospital emergency department. Telemed J E Health. 2014;20(7):664-668. Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol. 2008;7(9):787-795.


• TeleENT in Alaska:

1,458 patient encounters of which 85% resulted in no travel

Cost avoidance of $496,420

• SOC Internal Study:

Partner hospital reported 28% fewer admissions, 38% fewer transfers, 48% reduction in hospitalist unpaid care costs

Financial Impact/Cost

Lustig TA. The Role of Telehealth in an Evolving Healthcare Environment: Workshop Summary. Washington, DC: National Academies Press; 2012. Specialists On Call Internal Case Study, Reston, VA, 2012


• TeleNeurology


ImprovePa entVolume• Fasterresponse mestoseepa ents

• Posi veimpacttopa enttransfers

• IncreasedNeurologyadmissions

• TJCStrokeCer fica on

ImprovedClinicalOutcomes• Reduc onofDoorToNeedle me

• IncreasedtPAadministra onrates

HospitalEmployed:

$1,008,000*/yrWithAverage

Neurologistsalaryof$280,000/yr

LocumTenens:$2,409,000/yr

With24hours/dayat$275/hr

SOC’sSolu onDeliversthebestvalue

SCENARIO:ahospitalneeds25ENand10GNconsultspermonth

Key Drivers of ROI Comparison of Alternatives

SOCSolu on:$300,000/yr

*Note:Assumes20%oftaxes&benefitsandnoPTOfor24/7coverage.


• TelePsychiatry


Reduc oninAverageLengthofStay• Fasterresponse mestoseepa ents

• Increaseddischargerates

• Reduc oninboardingcosts

• Reduc oninotherdirectexpenses(e.g.–si erfees,securitycosts,etc.

IncreasedEDBedCapacity• Re-alloca onofbed metohigheracuitypa ents

• Increasedrevenuebyreducingopportunitycostsfrompsychiatricpa ents

HospitalEmployed:

$828,000*/yrWithAverage

Psychiatristsalaryof$230,000/yr

LocumTenens:$1,927,200/yr

With24hours/dayat$220/hr

SOC’sSolu onDeliversthebestvalue

SCENARIO:ahospitalneeds25On-Demandand10C&Lconsultspermonth

Key Drivers of ROI Comparison of Alternatives

SOCSolu on:$228,000/yr

*Note:Assumes20%oftaxes&benefitsandnoPTOfor24/7coverage.


• TeleNeurology:

Majority of neurology departments rate exam as equivalent to in-person

Challenges – Reimbursement, Technology, Licensure

Only 6% cited patient lack of interest

• TelePsychiatry:

Patient and provider satisfaction rated generally 4.5/5 in multiple surveys.

Technology problems usually operator error solved by training

Patient/Provider Experience

Lustig TA. The Role of Telehealth in an Evolving Healthcare Environment: Workshop Summary. Washington, DC: National Academies Press; 2012. Williams M, Pfeffer M, Boyle J; Telepsychiatry in the emergency department: Overview and case studies, California HealthCare Foundation, December 2009


Patient/Provider Experience

Patient Experience Provider Experience


• TeleStroke:

Well beyond acceptance – Defined in 2005 recommendations and 2009 policy guidelines

• TelePsychiatry:

Performs as well as, if not better than face-to-face

• TeleICU:

Findings of reduced mortality, reduced LOS, and increased adherence to best practices

Effectiveness

Hubley S, et al: Review of key telepsychiatry outcomes, World J Psychiatry 2016 June 22; 6(2) 269-282 Wechsler, LR et all: Telemedicine Quality and Outcomes in Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association AHA/ASA Policy Statement, Originally published November 2016 Kumar S, Merchant S, Reynolds R; Tele-ICU: Efficacy and cost-effectiveness of remotely managing critical care


Effectiveness RESULTS - TeleNeurology:

• In 2014 CRMC’s DTN rates were trending at 120 minutes and had been

reduced to as low as 38 minutes by April of 2016.

• As of Q3 of 2016, process improvements continued to have positive effects.

On a volume basis, utilization of tPA for acute ischemic stroke continued to rise. Data from August 2016 shows a secondary effect of

increased attention to acute stroke care. Endovascular therapy is now widely accepted as a part of the health system’s strategy to manage these patients.

• SOC allows CRMC to order a much higher volume of consults for patients displaying neurological symptoms in the Emergency Department by

educating and partnering with CRMC’s clinical staff to improve patient safety, patient satisfaction and clinical outcomes.

• Despite these significant improvements in the past 6-12 months, the CRMC and SOC teams continue to streamline processes and set new goals to

improve patient care even further - Continuous Improvement

Community Regional Medical

Center (CRMC)

Fresno, California

• Largest healthcare provider and

private employer in the region

• 670 Beds

• 100,068 Annual ED Volume

• The Central California Neuroscience

Institute at CRMC offers one of the

most advanced neuroscience centers

in the state.


Effectiveness

Community Regional Medical

Center (CRMC)

Fresno, California

• Figure 4: Increase in tPA

Administration

• Figure 5: Increase in

Thrombectomy volume

• Figure 6: Decrease in Door to

Needle time

RESULTS - TeleNeurology:


• Telemedicine well-established as a method for delivering care

• Primary focus is on providing good clinical care

•New emphasis on standards

•Access, Financial Impact, Experience, Effectiveness

Summary

An inevitable and vital part of the practice of medicine in order to increase access to quality care in a cost effective manner



Upcoming Programs

• Trustee Update #6 July 11, 2017 12:00 pm Central Time

• Trustee Update #7 September 12, 2017 10:30 am Central Time

• Trustee Update #8 October 10, 2017 10:30 am Central Time

Register at www.qhrlearninginstitute.com

http://www.qhrlearninginstitute.com/


• Thank you for joining us today. We value your feedback and hope that you will take a few minutes to evaluate this program so that we may continue to improve and bring you the quality educational programming you expect.

• As a reminder, you will have two opportunities to complete an evaluation and receive a completion certificate: At immediate conclusion of webinar

Post event: within two business days of the webinar, you will receive an email containing links to the online evaluation.

• Upon completing the online evaluation, certificates will be sent to you within five (5) business days.

Program Evaluation

34 Proprietary & Confidential Creating a Sustainable Futurefor Healthcare Organizations

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Documents

Using Telemedicine to Expand Access to Care July 2017 · Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded,