Connecting With Technology – Where We Are Going?

W.L. Clifford, M.D., FCFPFebruary 1st 2017

Tele Televideo Telehealth Virtual Visits Virtual Care Virtual Presence

Definitions

“A combining form meaning “distant,” especially “transmission over a distance,” used in the formation of compound words (Dictionary.com)

From Greek “têle” far, akin to “telos” end.

Tele

UC Irvine medical education center with a 60 seat “Televideo” auditorium

Televideo

“Clinical telehealth uses videoconferencing and supporting technology to put patients and providers in touch with each other, overcoming barriers including distance, time, mobility and weather.” (Northern Health Telehealth Strategic Plan, 2017)

Telehealth

“In practice, virtual healthcare delivery1 is defined by asynchronicity, outsourcing, and anonymity. Real or traditional healthcare delivery, by way of contrast, is characterized by the patient and practitioner meeting in real-time, face-to-face, utilizing a provider organization facility.”

Virtual Care Delivery

1Nothing virtual about care itself – it is real.

Who Would You Rather Receive Discharge Instructions From?

1=definitely prefer doc, 4=neutral, 7=definitely prefer agent

36% prefer agent48% neutral16% prefer doc or nurse“I prefer Louise, she’s better than a doctor, she explains more, and doctors are always in a hurry.”

“It was just like a nurse, actually better, because sometimes a nurse just gives you the paper and says ‘Here you go.’ Elizabeth explains everything.”

“Remote audio and/or video consultations with physicians on mobile devices or desktop computers”

Virtual Visits

https://benefits.ornl.gov

In conjunction with virtual reality, it “is based on concepts of presence and telepresence , which refer to the sense of being in an environment, generated by natural or mediated means, respectively” ( Steuer, 1992 , p. 76).

Virtual Presence

Dream Capability Normalization

Embedded“Faster, Easier” Distance

Normalization – Coherence / Cognitive Participation

“Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.” (Sir William Osler)

“Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone you can become expert.” (Sir William Osler)

Use Your 5 Senses

Learn to see

Marshall McLuhan – “the content of the medium is the juicy piece of meat carried by the burglar to distract the watchdog of the mind”.

“The Medium is the Message”

Mehrabian’s Rule, 1967 (Applies only to communication of feelings)

STARTEC Survey, 2016

Global Customer Experience Report, Cisco 2013

BC 2014/15 – 8,000 family physician and 13,000 specialist virtual visits billed to MSP

Northern Health – 8000 administrative, 230 educational and 10,000 clinical televideo visits per year

First Nations communities – 27 telehealth enabled health centres facilitating 26 administrative, 30 educational and 600 clinical televideo visits per year

Landscape

Out of 110 million patients, 59 million connected through online portals, virtual visits or apps last year

Landscape - Kaiser

Walk-In Clinics – Virtual Walk-in

Provides accessible care Supports active participation of individuals and communities in decisions that

affect their health and life Provides health promotion and illness prevention throughout the life experience Adapts health promotion and health care delivery to the determinants of health Provides continuity of care through a longitudinal relationship which better enables providers

to understand needs including attending to the illness experience, preferences, contraindications and risk tolerance.  Continuity fosters trust.

Coordinates and wraps care around the patient Provides a generalist expert approach and holistic view

Collaborates with communities, other disciplines and sectors to improve the health care system and health care delivery

Overall, lowers the cost of care while improving outcomes

Value Proposition for Primary Care

EMR/PHRHealth Authority

ClinicianHealth Authority

HL7 CDA Version 2

EMR/PHREMR/PHR

Provider

Distribution System

RepositoryAdministration/Reporting

Provider

ProviderClinician

Subscription Configuration

Document Distribution

Provider Lookup(Directory)

Provider Search

Personal Health Records

Evidence for Benefit

Renal Telehealth Interdisciplinary Care  Dr. Anurag Singh and his team provide virtual visits in Kidney Care. • Initial consultation, follow-up and

educational orientation happen virtually via videoconferencing to prevent unnecessary travel

• Patients get access to care that is consistent with provincial and national best practices and enabled by interdisciplinary kidney care team

• Reduces wait time to see a specialist• Links with family physicians to

strengthen continuity “After doing this for several years, we have many examples where delivering care in this way addresses patient concerns, delivers both clinical care and information and helps people stay at home.” Dr. Anurag Singh

The “Starfield Model”

From “The Starfield Model: Measuring comprehensive care for system benefit”. Southey and Heydon, 2014

Categories of Outcome (Starfield, 2005)

The Dorval Model

- Relative value

Northern Health Chronic Disease Service Flow

Health Data Coalition – Primary Care Metrics

Health Data Coalition – Primary Care Metrics

Collective Action - Remove Barriers

Need clear definitions The technology must be normalized as a tool to support the usual

important elements in care – access, relationship, continuity, coordination, data collection etc. – in accordance with our health care strategy

To normalize, will need to break down system and technical barriers – e.g. physician remuneration, effective EMRs, deployment of PHRs, auto-bridging etc.

Evaluate the technology by measuring changes in what is valued in health care and needed to deliver on our strategy– especially primary care

Be alert to new technology options and incorporate them wisely

Conclusions

From Telepresence

To Tele-Immersion & 3D