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 San Francisco General Hospital Objectives 1. Basic telemedicine modalities 2. Telemedicine delivery models 3. Design of telemedicine applications and care for the underserved 1
3/12/2016 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 San Antonio Harlingen American Telemedicine Association, 2010 Five “types” of telemedicine Telemedicine modalities • Referring provider Specialist • Synchronous • Patient Provider ‒Live video • Asynchronous • Home monitoring ‒“Store-and-forward” • Remote medical education • Informational push American Telemedicine Association, 2010 2
3/12/2016 Synchronous live Asynchronous Telemedicine models Remote monitoring • Rural (“traditional”) • Urban • “Delivery system” model 3
3/12/2016 Telemedicine models “Hub and spoke” • “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 “Spoke and hub” Alaska Federal Health Care Access Network (AFHCAN) Neurosurgery Trauma Neurology Psychiatry Oncology 4
3/12/2016 Courtesy of Virtual Dental Home Frank Anderson IDEA Tel 5
3/12/2016 Rural telemedicine Urban telemedicine • Geographic barriers and access disparities • Higher density of specialists • Telehealth “carts”, video applications • Access to specialty services • Higher workflow burden • Health disparities and barriers to care • Hub and spoke Maxine Hall Health Center South of Market Health Center Haight Ashbury Free Clinic SF AIDS Foundation Black Coalition on AIDS 6
3/12/2016 “Delivery system” model • Urban telemedicine PLUS Delivery system Annually: • Design of telemedicine applications are contextualized to and aligned Capitation 110,000 inpatients Financial resources with system goals: 592,000 outpatients Primary care burden 33,000 mental health – Quality care Specialty access 3,300 trauma – Cost-effectiveness Fixed workforce Integrated care – Patient-centeredness Delivery system model: design considerations • “Partnership model” • System-wide context and benefits • Population health telemedicine • Chronic care management • Patient-centered care principles 7
3/12/2016 The Partnership Model The Partnership Model • Typically a primary care-specialty partnership Drivers: Facilitators: Partnership • Technologies must enhance these relationships Reasons to Supportive partner factors Components: Joint activities and processes Drivers determine outcomes Outcomes: How did we do? Ohio State University Global Supply Chain Forum Redrawn: Lambert et al., Harvard Business Review, 2004 The Partnership Model: Telemedicine Teledermatology Toby Maurer, MD Drivers: Chief, Dermatology at SFGH Access Facilitators: Telemedicine Inefficiencies Sponsors Costs Incentives Satisfaction Components: Technology Drivers align Workflows with institutional Outcomes: priorities Better access Efficient care Lower costs Satisfaction 8
3/12/2016 Teledermatology workflow Teledermatology Referring provider Medical SFGH Dermatology SFGH Dermatology Referring provider assistant Faculty Scheduler Log onto Automated Drivers: Notification Medical record email worklist Facilitators: Telederm Access Prop 1D Wait times Document consult Clear Review Appointment as Electronic record DSRIP in medical record Force multiplier camera and triage needed notification Components: Components: Technology Workflows Create Direct Submit report, Results posted to OUTGOING Take photos provider Workflows EMR automated email to medical record REFERRAL notification clinic Outcomes: Contact medical Upload assistant for and System-wide photos Submits spread/adoption Access DELETE photos Consults vs. third next available appointment 2014 2015 Apr May Jun July Aug Sept Oct Nov Dec Jan Feb Mar Apr 111 days 96 days Reports and images 90/month TNAA 65/month 72 days 42 days Consults 16/month 9
3/12/2016 Diagnosis n Force multiplier 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 Teleretinopathy Cynthia Chiu, MD Drivers: Associate Professor of Ophthalmology Facilitators: DR screening Poor screening Program Director Prop 1D rates Jay Stewart, MD DSRIP Technical Components: Components: Chief, Ophthalmology at SFGH capacity Technology Data Jim Larson Workflows Model Lead Technician Outcomes: Screening program 10
3/12/2016 Diabetic retinopathy screening rates Population Active Panel Diabetics (per clinic) 1500 750 0 Active panel patients with DM Active panel patients with DM IMPACT IMPACT • $60,000 camera • $60,000 camera • Demand? • Demand? • Local expertise • Local expertise • Capacity • Capacity • Quality assurance • Quality assurance • Integration • Integration FEASIBILITY FEASIBILITY 11
3/12/2016 Target need Active Panel Diabetics (per clinic) 1500 750 0 Home monitoring: positive airway pressure George Su, MD Medical Director Eula Lewis RRT, CTTS Outpatient Director, Respiratory Care Services Program Director 12
3/12/2016 Day 30 Effector arm Identify at-risk patients Phone interrogation PAP Clinic Enlist DME vendor(s) “POTS” Follow-up protocol R C S Day 60 Home monitoring pilot: 30 day Days with 4 hr/day use over 30 days (%) Day 30 Day 60 Day 30 Day 60 “POTS” Usual care 13
3/12/2016 Patient-centered care for the underserved Patient-centered care for the underserved • Welcoming environment, comfort, support • Respect for patients’ values and expressed needs • Patient empowerment or “activation” Community Specialty Health Center • Socio-cultural competence • Coordination and integration of care • Access and navigation skills Telemedicine • Community outreach Silow-Carroll, et al., 2006 Which statement regarding the use of telemedicine in community health centers Community health (CHCs) is correct? Center (CHC) A. Community health centers that provide 100% 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. Specialty service C. Telemedicine in CHCs increases access to specialty-level care and diagnostics, while maintaining a patient-centered focus and attention to needs of underserved 0% 0% 0% communities. D. Community health centers that provide telemedicine services have lower non- Community health centers th.. Telemedicine in CHCs increas.. Community health centers th.. The costs required to imple... physician staff ratios than CHCs that do not offer telemedicine. 14
3/12/2016 Provision of telemedicine by CHCs Telespirometry • Increases access to specialty-level care and diagnostics, while George Su, MD maintaining a patient-centered focus Medical Director • Point-of-service specialty services leverages local expertise and Eula Lewis RRT, CTTS resources Outpatient Coordinator, Respiratory Care Services Program Director Shin, et al, 2014 Telespirometry (pre- & post- comparison) Patient 16% 23% Data loops FAIL Acceptable 45% FAIL 25% 59% Caution Acceptable Virtual 32% Coach Caution n=985 15
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