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					         EDPMA Solutions Summit XI
         Las Vegas, NV May 15, 2008

   Telehealth and Emergency Telehealth:
   The High-Tech Point of Entry to the ER
              and the Hospital


        David G. Ellis, MD, FACEP
 Director, Division of Telehealth and Healthcare Informatics
             Department of Emergency Medicine
University at Buffalo, State University of New York (SUNY)
                 Erie County Medical Center
                   Goals

 Review applications of Telemedicine /
  Telehealth making it relevant to current
  medical systems of care delivery and
  education.
 Review lessons learned and critical elements
  of a successful effort in Emergency
  Telemedicine
             BioMedical Informatics

   Clinical Informatics
   Nursing Informatics
   Electronic Health Records
   Personal Health Records
   Syndromic Surveillance / Public Health
   Pharmacologic Informatics
   Translational Research Informatics
   Telehealth
   Ontology
   Simulation
   Human Factors
   Distance Learning
     A Brief History 1959 - 1990

 Nebraska 1959
 Papagos Indian Tribe Arizona NASA
 Boston Logan Airport
 Texas Tech
 University of Texas Medical Branch at
  Galveston UTMB
      Telehealth Programs: National
      and International Perspective
   Arizona                 Alaska
   Ohio                    Texas
   Georgia                 New York
   Iowa                        Buffalo
   West Virginia MDTV          Cooperstown
   North Carolina (ECU)        Syracuse / Cornell
   Tennessee               Eastern Montana
   Kansas                  Ontario (NORTH)
   Nebraska
Arizona
Telemedicine
Program
Alaska Telemedicine Program
NORTH
Networks
(Ontario
Telemedicine
Network)
Province of Ontario
Canada


Criticall
24x7 Critical
Care Transfer
Center

Back-up for
system by US
hospitals
        Kentucky
         TeleCare

 PROACT - Preparedness and Response Over
  Advanced Communications Technology
 Stakeholders
      Department of Public Health
      Community Public Health Departments
      UK and UL Medical Centers
      Regional Hospitals
      Community healthcare providers
      First responders
      All other stakeholders that are tasked with disaster
       preparedness and response
         Nighthawk TeleRadiology

 1,350 client hospitals in US
 Reading sites in Australia, Switzerland, US
 64-slice Cardiac CT
 Publicly traded, acquiring other teleradiology
  companies
 Nighthawk service delivery model
     Consultants, Software
   Telehealth Specialties: National
    and International Perspective
 Teleradiology
       eICU

 Centralized critical
  care monitoring
  and management
  24x7
         Mental Health Services

 Adult TelePsychiatry
 Emergency Evaluations
 Child & Adolescent
  Psychiatry
 Primary Care-based
  Psychiatric Consultation
   Telehealth Specialties: National
    and International Perspective
 Telepathology
 Teledermatology
 Teleopthalmology
 Telesurgery
 Teleoncology
 Telecardiology
   Telehealth Specialties: National
    and International Perspective
 Home Telehealth
           The Continua Alliance

 Major companies aligning to develop
  industry standards for remote monitoring
     Health and Wellness
     Disease Management
     Elderly Monitoring
       Medical-Surgical Robots

 InTouch RP-7
 daVinci
  EMS

 Radio command
 Telemetry
ECMC Emergency
Telemedicine Network
July 1994



    ECMC-Buffalo


    Erie County
    Holding Center
ECMC Emergency
Telemedicine Network
January 1996



     ECMC-Buffalo
            Attica

                     Groveland
    Collins




 New York State Dept. of Correctional Services
 (NYSDOCS)
ECMC Salamanca Rural
Emergency Telemedicine
Rural Project April 1997



      ECMC-Buffalo




  Salamanca Healthcare Complex
 Salamanca HealthCare Complex

9pm - 9am
• average 1.2 patients per 12 hour
  shift

Staffing In-House
• RN, LPN
• Paramedic on flycar

On-Call
• Practitioner (PA, NP)
• Physician
  Salamanca HealthCare Complex

Admissions / Transfers
• Abdominal Pain

Sign-Outs

Diagnostic Testing

Medications / Prescriptions
  Results

97% of patients able to be managed by
telemedicine

7/9 patients, practitioner responded for
lacerations

18% transfer rate (chest pain, abd pain)
Training, Training, Training….

                    Protocols,
                     Protocols,
                     Protocols…
                    Teaching
                     staff to work
                     effectively in
                     a telehealth
                     environment
     More Importance of Training

 Pushing the limits of traditional scope of
  practice (procedure training)
 When necessary, actions must be done
  quickly and efficiently
 Need to evaluate the effectiveness of training
 Manage anxiety / resistance in the staff /
  network
ECMC Emergency
Telemedicine Network
                  Riverview
October 1999



     ECMC-Buffalo




  New York State Dept. of Correctional Services
  (NYSDOCS)
2008




       57 Facilities
        Statewide
         Network
            Corrections and
         Emergency Telemedicine
 Low volume in rural facilities can be barrier to
  training emergency department staff
 Corrections setting provides volume and
  reimbursement (2002 - 2600+, 2003 - 3000+)
 Closed system for risk management
 Win-win / Decrease transports = Decreased
  prisoner visibility
      Kaleida Millard Gates TeleStroke
                                              T

                                      T               T
 ReachMDConsult                                          T

 Rapid Access to
  Specialty Neuro                                 T

  Consultation, CT                T
  review
                              T   T
 Emergency decision      T
  process for                                         T
                                          T
  thrombolytics in non-                                       T
  hemorrhagic stroke
University of Vermont
    TeleTrauma
            Issues in Telehealth

 Reimbursement
 Licensing
 Bandwidth
 Medico-Legal
 Credentialing / Privileging
 Throughput
                Reimbursement


 Reimbursement for services in rural areas
 Consultative services, renal dialysis, patient
  team management, mental health
 3 part reimbursement
 Store-and-Forward not reimbursed
 New York state Medicaid
 Contracting for services
             Overcoming Barriers to
                Reimbursement
 Show effectiveness of                  Percent ER Trip Avoidance
  system                           100
      Admit to Facility
                                   80
      Admit to Infirmary
                                   60
      Direct to Specialist
      Direct to Diagnostic Test   40
      Direct Admission            20
      Transfer to Emergency
       Department                   0
                                          1997   2000   2001   2002
                      Licensing

 Licensing for medical practice an issue left to
  the states
     Protectionism
     Malpractice
 Emergency care models, VA
 General rule: If more than episodic practice,
  should have a license in the state of patient
                     Bandwidth

 High cost of rural connectivity
 FCC Universal Services Fund
 State-wide networks
     Internet 2, fiber networks, gigabyte ethernet
 Rural economic development
                 Medico-Legal

 Malpractice track record
 Problems with remote provider
     Tele-Radiology
 Overall issues with malpractice coverage,
  state limits
      Credentialing / Privileging

 Granted by each organization
 JCAHO review
 Current practice
      Multi-state consortia, resource
                  centers

 Multi-state resource centers
 International telehealth efforts
   Development of Telehealth & Healthcare Informatics Services

   Issues: Emergency Telemedicine
 Throughput
 Risk Management
 Reimbursement
     5 Level Triage Overview
       Response Time Goal
 Level 1 – Patient is dying - Immediate
 Level 2 – Emergent, requires prompt medical
  attention < 15 minutes
 Level 3 – Urgent Care < 30 minutes
 Level 4 – Less Urgent < 60 minutes
 Level 5 – Does not require immediate care
         Telemedicine Patient Flow
         Management
   Call to Secretary
   MERS Dispatching
   Light System
   Emergency Telemedicine Services Support 8a – 1p
   Telehealth White Board
   Quality TIMES for Hospitals
       Throughput Information Management for Emergency
        Systems
 Transfer Center
   Emergency Department
   Connectivity
 Wireless Rollabouts
 Secure IP Networks
 Call Services
              Telehealth and Disaster
                   Management
 Tele-Trauma
 Telehealth Emergency System Linkages - PROACT
  (Preparedness and Responsiveness Over Advanced Communications Technology)

 New telecommunications pathways
  (Low Earth Orbit satellite systems)
 Computer miniaturization (PDA, TabletPC)
 Artificial intelligence,
 Advanced sensor systems
Questions?

				
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