Disclosures Telemedicine to Improve Care for the Underserved I have - - PowerPoint PPT Presentation

▶
disclosures
SMART_READER_LITE
LIVE PREVIEW

Disclosures Telemedicine to Improve Care for the Underserved I have - - PowerPoint PPT Presentation

Jul 29, 2023 144 likes •317 views

3/12/2016 Disclosures Telemedicine to Improve Care for the Underserved I have nothing to disclose March 11, 2016 George Su, MD Medical Director of Telehealth, San Francisco Department of Public Health Associate Professor of Medicine, UCSF

slide-1
SLIDE 1

3/12/2016 1

Telemedicine to Improve Care for the Underserved

March 11, 2016 George Su, MD Medical Director of Telehealth, San Francisco Department of Public Health Associate Professor of Medicine, UCSF San Francisco General Hospital

Disclosures

I have nothing to disclose

  • 1. Basic telemedicine modalities
  • 2. Telemedicine delivery models
  • 3. Design of telemedicine applications and care for the underserved

Objectives

slide-2
SLIDE 2

3/12/2016 2

San Antonio Harlingen

Definitions

  • Telemedicine: use of medical information exchanged from one site to

another via electronic communications to improve patients’ health status

  • Telehealth: same as above, but not restricted to clinical services

American Telemedicine Association, 2010

Five “types” of telemedicine

  • Referring provider Specialist
  • Patient Provider
  • Home monitoring
  • Remote medical education
  • Informational push

American Telemedicine Association, 2010

Telemedicine modalities

  • Synchronous

‒Live video

  • Asynchronous

‒“Store-and-forward”

slide-3
SLIDE 3

3/12/2016 3

Synchronous live Asynchronous Remote monitoring Telemedicine models

  • Rural (“traditional”)
  • Urban
  • “Delivery system” model
slide-4
SLIDE 4

3/12/2016 4

Telemedicine models

  • “Traditional” vs. “Urban”

Hub site Spoke/network member Rural health grant recipients

Center for Applied Research and Environmental Systems Office of Rural Health Policy, HRSA, 2011

“Hub and spoke” “Spoke and hub”

Neurosurgery Trauma Neurology Psychiatry Oncology Alaska Federal Health Care Access Network (AFHCAN)

slide-5
SLIDE 5

3/12/2016 5

Virtual Dental Home

Courtesy of Frank Anderson

IDEA Tel

slide-6
SLIDE 6

3/12/2016 6

Rural telemedicine

  • Geographic barriers and access disparities
  • Telehealth “carts”, video applications
  • Higher workflow burden

Urban telemedicine

  • Higher density of specialists
  • Access to specialty services
  • Health disparities and barriers to care
  • Hub and spoke

Maxine Hall Health Center Haight Ashbury Free Clinic Black Coalition on AIDS SF AIDS Foundation South of Market Health Center

slide-7
SLIDE 7

3/12/2016 7

“Delivery system” model

  • Urban telemedicine PLUS
  • Design of telemedicine applications are contextualized to and aligned

with system goals: – Quality care – Cost-effectiveness – Patient-centeredness

Annually: 110,000 inpatients 592,000 outpatients 33,000 mental health 3,300 trauma Delivery system Capitation Financial resources Primary care burden Specialty access Fixed workforce Integrated care

telemedicine

Delivery system model: design considerations

  • “Partnership model”
  • System-wide context and benefits
  • Population health
  • Chronic care management
  • Patient-centered care principles
slide-8
SLIDE 8

3/12/2016 8

The Partnership Model

Drivers:

Reasons to partner

Facilitators:

Supportive factors Drivers determine

  • utcomes

Components:

Joint activities and processes

Outcomes:

How did we do?

Partnership

Ohio State University Global Supply Chain Forum Redrawn: Lambert et al., Harvard Business Review, 2004

The Partnership Model

  • Typically a primary care-specialty partnership
  • Technologies must enhance these relationships

The Partnership Model: Telemedicine

Drivers:

Access Inefficiencies Costs Satisfaction

Facilitators:

Sponsors Incentives

Components:

Technology Workflows

Outcomes:

Better access Efficient care Lower costs Satisfaction

Telemedicine

Drivers align with institutional priorities

Teledermatology

Toby Maurer, MD Chief, Dermatology at SFGH

slide-9
SLIDE 9

3/12/2016 9

Facilitators:

Prop 1D DSRIP

Components:

Technology Workflows

Teledermatology

Drivers:

Access Wait times Force multiplier

Components:

Workflows EMR

Telederm Outcomes:

System-wide spread/adoption Access

Teledermatology workflow

Log onto Medical record Clear camera Take photos Upload and Submits Notification worklist Review and triage Submit report, automated email to clinic Appointment as needed DELETE photos Automated email

Referring provider Medical assistant SFGH Dermatology Faculty SFGH Dermatology Scheduler Referring provider

Create OUTGOING REFERRAL Contact medical assistant for photos Document consult in medical record Electronic record notification Results posted to medical record Direct provider notification

Reports and images

Consults vs. third next available appointment

Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Apr 2014 2015 16/month 90/month 42 days 96 days

TNAA Consults

65/month 72 days 111 days

slide-10
SLIDE 10

3/12/2016 10

Force multiplier

Diagnosis n Inflamed seborrheic keratosis 24 Nevus, non-neoplastic 14 Psoriasis vulgaris 13 Actinic keratosis 10 Acne vulgaris 6 Other atopic dermatitis 4 Ganglion, unspecified hand 4 Viral warts 3 Hemangioma unspecified site 3 Atopic dermatitis, unspecified 3 Nummular dermatitis 3 Vitiligo 3 Lichen simplex chronicus 2 Other prurigo 2 Alopecia areata, unspecified 2 Other rosacea 2

Teleretinopathy

Cynthia Chiu, MD Associate Professor of Ophthalmology Program Director Jay Stewart, MD Chief, Ophthalmology at SFGH Jim Larson Lead Technician Facilitators:

Prop 1D DSRIP

Teleretinopathy

Drivers:

Poor screening rates Technical capacity

DR screening Outcomes:

Screening program

Components:

Technology Workflows

Components:

Data Model

slide-11
SLIDE 11

3/12/2016 11

1500 750 Active Panel Diabetics (per clinic)

Population Diabetic retinopathy screening rates Active panel patients with DM

FEASIBILITY IMPACT

  • $60,000 camera
  • Demand?
  • Local expertise
  • Capacity
  • Quality assurance
  • Integration

Active panel patients with DM

FEASIBILITY IMPACT

  • $60,000 camera
  • Demand?
  • Local expertise
  • Capacity
  • Quality assurance
  • Integration
slide-12
SLIDE 12

3/12/2016 12

1500 750 Active Panel Diabetics (per clinic)

Target need

George Su, MD Medical Director Eula Lewis RRT, CTTS Outpatient Director, Respiratory Care Services Program Director

Home monitoring: positive airway pressure

slide-13
SLIDE 13

3/12/2016 13

S C R

Identify at-risk patients Phone interrogation “POTS” Enlist DME vendor(s)

Effector arm

Follow-up protocol PAP Clinic

Day 30 Day 60

Home monitoring pilot: 30 day

Days with 4 hr/day use

  • ver 30 days

(%) Day 30 Day 60 Day 60 Day 30 “POTS” Usual care

slide-14
SLIDE 14

3/12/2016 14

Patient-centered care for the underserved

  • Welcoming environment, comfort, support
  • Respect for patients’ values and expressed needs
  • Patient empowerment or “activation”
  • Socio-cultural competence
  • Coordination and integration of care
  • Access and navigation skills
  • Community outreach

Silow-Carroll, et al., 2006

Patient-centered care for the underserved

Specialty Community Health Center Telemedicine Community health Center (CHC) Specialty service

Which statement regarding the use of telemedicine in community health centers (CHCs) is correct?

A. Community health centers that provide telemedicine services are more likely to serve urban rather than rural communities. B. The costs required to implement telemedicine in CHCs are low, and do not pose a significant barrier to adoption. C. Telemedicine in CHCs increases access to specialty-level care and diagnostics, while maintaining a patient-centered focus and attention to needs of underserved communities. D. Community health centers that provide telemedicine services have lower non- physician staff ratios than CHCs that do not

  • ffer telemedicine.

Community health centers th.. The costs required to imple... Telemedicine in CHCs increas.. Community health centers th..

0% 0% 100% 0%

slide-15
SLIDE 15

3/12/2016 15

Provision of telemedicine by CHCs

  • Increases access to specialty-level care and diagnostics, while

maintaining a patient-centered focus

  • Point-of-service specialty services leverages local expertise and

resources

Shin, et al, 2014

Telespirometry

George Su, MD Medical Director Eula Lewis RRT, CTTS Outpatient Coordinator, Respiratory Care Services Program Director Patient Virtual Coach Data loops

Telespirometry (pre- & post- comparison)

23% Acceptable 32% Caution 45% FAIL 59% Acceptable

n=985

16% FAIL 25% Caution

slide-16
SLIDE 16

3/12/2016 16

Pulmonary function testing lab wait times

Wait times (weeks) 25.0 20.0 15.0 10.0 5.0 0.0

Community health center telemedicine

  • survey of 625 CHCs
  • 147 (23.5%) one telemedicine service
  • 82 (13.1%) ≥ 2 telemedicine services
  • ≥ 2 telemedicine services vs. without:

‒54.9% vs. 34.8% rural ‒28.0% vs. 47.0% urban ‒18.2% vs. 17.1% both ‒5.2 vs. 3.5 mid-level providers (FTEs per 10,000 patients) ‒25.9 vs. 23.2 other (FTEs per 10,000 patients)

Shin, et al., 2014

Telemedicine at community health centers

  • Limited budgets, low debt tolerance, competing demands for funds
  • Costs: technology, system upgrades, ongoing use, maintenance
  • Alternative funding (grants, group purchasing, open source solutions)
  • Medicare reimbursement: originating site is rural Health Professional

Shortage Area (HPSA) located outside of a Metropolitan Statistical Area (MSA)

Gaylin, et al., 2011; Fortney, et al., 2013

Question

Which statement regarding the use of telemedicine in community health centers (CHCs) is correct?

  • a. Community health centers that provide telemedicine services are more likely

to serve urban rather than rural communities.

  • b. The costs required to implement telemedicine in CHCs are low, and do not

pose a significant barrier to adoption. c. Telemedicine in CHCs increases access to specialty-level care and diagnostics, while maintaining a patient-centered focus and attention to needs of underserved communities.

  • d. Community health centers that provide telemedicine services have lower non-

physician staff ratios than CHCs that do not offer telemedicine.

FALSE FALSE FALSE CORRECT

slide-17
SLIDE 17

3/12/2016 17

TELE-MED Act of 2015

  • Amends title XVIII of the Social Security Act to permit certain

Medicare providers licensed in a State to provide telemedicine services to certain Medicare beneficiaries in a different State

  • Expands pool of eligible consultants, but doesn’t address

reimbursement gaps (particularly for non-rural setting)

n=985

Telemedicine to improve care for the underserved

  • Rural “traditional” telemedicine—geographic disparities
  • High potential to address disparities and barriers in urban settings
  • Can leverage CHCs to promote patient-centered care
  • Substrate for primary-specialty relationship (“partnership model”)
  • “Delivery system” model requires multidimensional design
  • Well-designed programs can align with health care reform principles
  • Well-established value proposition (cost/benefit) for rural model
  • Health outcomes/urban models need further evaluation
  • Reimbursement remains barrier

Thank you!

george.su@ucsf.edu George Su, Medical Director of Telehealth, SFDPH Bruce Occeña, Director of Telehealth, SFDPH