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?