In every service area, there are new incentives for large and small hospitals—plus outpatient facilities, home health agencies and community practices—to work in greater harmony than ever before. Some of those incentives are based on the Accountable Care Organization (ACO) paradigm, which is steadily gaining ground as a collaborative, patient-centered standard of care.

The ACO model is intently focused on collaboration to improve patient outcomes, and telemedicine is already playing a key role in the transition. Telemedicine lets large hospitals begin building relationships with smaller hospitals and health organizations in the community, and it can dramatically improve outcomes—from initial diagnosis to long-range results.

Take, for example, the treatment of strokes. Here’s a hypothetical scenario that illustrates how telemedicine can build ACO-style relationships:

A patient goes to the emergency room at Northern Hospital of Surry County or Davis Regional Medical Center in North Carolina suffering stroke-like symptoms. The small community hospital doesn’t have a staff neurologist, but it can rapidly set up a telemedicine consultation with a top neurologist from SOC, obtain expert diagnosis and treat the patient quickly with the clot-busting drug tPA if needed or if necessary, send the patient for a higher level of care and possible intervention at Forsyth Medical Center.

To use a well-worn phrase, it’s a classic win/win/win scenario for both the smaller community hospital, the medical center and the patient. It’s a matter of leveraging telemedicine to provide clinical expertise to smaller facilities, ensuring that each part of an ACO is able to offer patients the optimum care available.

The benefits are even greater when telemedicine is combined with EHR technology. In most healthcare settings today, stroke therapists don’t communicate well with each other. The hospital therapist’s clinical notes are rarely shared with the home health staff. And when a stroke patient has recovered enough to go to an outpatient facility, therapists there make a brand-new assessment. Yet each provider at every stage is required to have the neurologist’s approval for a plan of care. And in the ACO model, they’re all accountable for the desired patient outcome.

Clearly, telemedicine can foster the teamwork needed for success as ACOs coalesce in each community. Many large hospitals are looking for a way to “break the ice” with potential ACO partners in their areas—and telemedicine provides the perfect entrée. By putting these partnerships in place now, hospitals both large and small will soon enjoy the benefits: greater quality of care and the financial results that accompany it.

Most televised reunions are gimmicky and superficial, but there was nothing trivial about the reunion of Sandra Bowden and Todd Samuels, M.D., at this year’s American Telemedicine Association (ATA) annual meeting in Tampa.

What the “Human Touch of Telemedicine” conference video crew captured that day was a vision of our medical future: a teleneurology advocate and stroke patient from Texarkana, Texas, getting to meet the neurologist who assessed her from his office in Baltimore, Maryland—and helped improve her outcome and recovery time. Here, in her own words, is Sandra Bowden’s account of her very personal introduction to the benefits of teleneurology.

Telemedicine Made Personal

There are many ironic moments in life, but few that compare to my stroke assessment last year.

I am director of medical post-surgical services at Christus St. Michael Health System in Texarkana, Texas—a city perhaps best known for being the hometown of one-time presidential candidate Ross Perot. Although our facility includes a 312-bed acute care hospital, Texarkana is still a fairly small city—ranking 288th in the latest U.S. census. We don’t have as many local neurologists to call as do hospitals in Boston or Los Angeles. For that reason, teleneurology has played a key role in our hospital’s campaign to become a certified stroke center.

In 2010, during an early morning meeting with the Christus stroke team, I began to feel a tingling sensation in my ear and face. It spread down my left arm, and a colleague noticed that the left side of my face was starting to droop. She quickly escorted me to the ER, where the doctor ordered a CT scan. By the time I returned to the ER, Specialists On Call, our recently implemented teleneurology provider, had been notified and neurologist Todd Samuels was speaking with my physician.

With the help of the attending nurse, Dr. Samuels began a complete neurological assessment. Throughout the entire consultation, I was the center of his attention. He answered all the questions my husband and I had, and made us both feel comfortable during a very difficult time.

Dr. Samuels told me that he believed I was having a stroke that would respond well to the clot-busting drug called tPA. He also explained the risks and benefits of the therapy. I assumed he would order the drug and be done, but he stayed and checked in on me. In a short time, I started having resolution of my symptoms—and Dr. Samuels seemed very pleased with the outcome.

I was soon transferred to the ICU, where my condition steadily improved. The left side of my face continued to droop for a few days, and I had some minor issues with gait and balance. But physical therapy resolved those conditions, and today I live a normal life with no deficits.

So when I attended the ATA annual meeting earlier this year, I had no idea that I would be meeting Dr. Samuels in person. It was a complete surprise to me. I knew I’d never forget his face, and it was wonderful to express in person how grateful I was. I couldn’t have asked for higher quality care.

I have long been a teleneurology advocate, but it wasn’t until I was the recipient of this innovative approach to care that I completely understood its importance. This is the way that medicine is going. We already have far too few specialists to meet the growing needs of people in areas of the country like mine. But I’ve experienced first-hand how teleneurology can help solve the specialist shortage and offer wonderful, life-saving care. After my encounter with SOC, I more firmly than ever see telemedicine as the wave of the future.

–Sandra Bowden, RN-BC, MSN

A relatively recent European study documented the high cost of psychiatric misdiagnoses in emergency departments (EDs). What it found: misdiagnosed panic attacks were costing hospitals a small fortune.

Because they’re not psychiatric specialists, ED physicians often were baffled by patients’ symptoms, unable to tell if they were having bad reactions to illicit drugs or having a problem requiring immediate psychiatric intervention. In many cases, on-call cardiologists and endocrinologists were summoned—and both time and money were lost.

The problem is arguably even worse in the U.S., where most psychiatric practices haven’t implemented electronic health record (EHR) systems. Remember that meaningful use incentives weren’t extended to behavioral healthcare in the original HITECH legislation; as a result, psychiatry lacks some of the financial incentive driving other specialties toward EHRs. Since there’s very little interoperability between most hospitals and nearby psychiatric practices, the case for telepsychiatry is a compelling one.

In the case of panic attacks, for instance, hospitals can waste precious hours and countless resources investigating a patient’s cardiac and glandular health. A wide cross-section of people experience these attacks, including celebrities like Johnny Depp, Barbra Streisand, and football Hall of Famer Earl Campbell. Yet most EDs don’t have rapid access to highly trained, board-certified psychiatrists who can quickly identify mental problems masquerading as physical ones.

For example, depression often appears to present as a sleep disorder—which means an ED patient could be sent home with medications that can deepen depression. With a telepsychiatrist as the ED’s first line of defense, these kinds of critical misdiagnoses can be prevented.

There are other advantages to on-call telepsychiatry as well. Beyond panic attacks and depression, an ED is often required to handle a myriad of psychiatric evaluations to address suicide attempts, substance abuse, physical abuse, mental illness, and psychiatric medication issues. Further complicating an ED’s ability to treat patients are the complexities of state psychiatric systems—often something in which an ED physician is not fully versed. A highly qualified telepsychiatrist can ensure complete compliance with state mental health regulations. Rapid response time is another huge plus. Many communities have a shortage of psychiatrists, especially those willing to be on-call throughout the night.

This can be especially problematic when a patient has been placed on a psychiatric hold. Without the proper assessment from a psychiatrist, the patient must remain in the hospital, but often times given the proper medical attention it becomes evident that the patient can be released early. The hospital can then free up a bed space and lessen overcrowding in the ED.

Sigmund Freud had a lifelong struggle with panic attacks. It’s fitting that the profession he launched can now accurately pinpoint the condition far better than most generalists in today’s emergency departments. And in the case of telepsychiatrists, far faster, too.

May is Stroke Awareness Month…it’s a perfect time to think about the prevalence of stroke in the U.S., as well as what we can do to help drive down its devastating effects. It’s also a perfect time to thank our Specialists On Call (SOC) neurologists for all they do to improve stroke care.

Every 40 seconds someone in the U.S. has a stroke. It’s the third leading cause of death and the number one cause of disability in the country. But SOC neurologists are helping to change all of that.

To date, SOC physicians have seen close to 30,000 emergency neurology patients. They understand that time is of the essence in stroke care, and dedicate themselves to responding to any request for their expertise within 15 minutes—no matter whether it’s day or night, weekday, weekend or holiday.

That’s vitally important, because swift access to experienced care is a key factor in reducing the number of deaths and disabilities from stroke. One recent study slightly expands—up to 4.5 hours—the window of time for providing lifesaving tissue plasminogen activator (tPA) therapy. At the same time, however, it very clearly warns, “…delays in evaluation and initiation of therapy should be avoided, because the opportunity for improvement is greater with earlier treatment.”

Unfortunately, too many patients still suffer delayed stroke treatment. The problem is one of simple supply-and-demand: the national shortage of specialty physicians makes it hard for hospitals to provide round-the-clock access to qualified neurologists. What’s more, statistics from the Association of American Medical Colleges (AAMC) show the problem will only intensify without increases in residency training.

Telemedicine helps overcome these obstacles by making the expertise of specialty physicians available quickly to patients anywhere, at any time. One physician in Boston can help a patient in Texarcana, then immediately turn his attention to a case in Boca Raton. Geography doesn’t have to be a limiting factor any more.

The administration of tPA is just one example of how telemedicine helps save lives. tPA, the clot busting and life changing drug, should be given within a few short hours of the onset of stroke symptoms. Yet traditionally, a patient suffering stroke symptoms shows up at a local emergency department, spends time with the emergency physician for initial evaluation, then waits while the neurologist on call is contacted and arrives—if a neurologist is available at all. All the while, precious minutes are wasted.

Meanwhile, the swift availability of SOC neurologists has allowed more than 1,400 patients to benefit from tPA administration. It is not something just any physician can do—it requires specialty expertise and strict adherence to evidence-based protocols. However, through telemedicine, that life-enhancing knowledge can be provided quickly, easily, and cost-effectively to hospital emergency departments nationwide.

Every day, stroke takes a serious toll on patients throughout the country. SOC providers are fighting back using technology to offer their expertise wherever it is needed. On behalf of patients everywhere, we thank them.

Medicine, like most human endeavors, is all about collaboration. The EHR is one tool currently being touted as a way to aid collaboration by making patient data more accessible. But how does the data benefit a patient if the right specialist isn’t available to use it to guide care? EHR technology and data management are helpful only when they speed and simplify the collaborative process.

To illustrate the point, let’s take an example from the movie business. There’s a process called “looping” in movie post-production. It’s a way to add dialogue after the film has been shot. Thanks to technology, a movie director in Los Angeles can communicate with an actor in New York and a sound editor in Chicago. They watch a scene together, and the actor adds dialogue that might have gotten muddied during filming. It’s a perfect example of long-distance collaboration aided by technology.

But that type of seamless collaboration is in short supply in modern medicine, according to Ken Congdon, editor-in-chief of Healthcare Technology Online. In a recent article, he notes that the U.S. has spent some $32 billion on EHR technology, but has done little to solve an underlying problem: shortages (and uneven distribution) of health professionals. Congdon’s point is that the finest EHR system in the world achieves nothing if it doesn’t bring health professionals closer together in genuine collaboration.
Without universal access to specialists, for instance, a gap in care still exists.

This is particularly true in America’s emergency departments – and not just in remote places like Coldfoot, Alaska. In a recent survey of California hospital CEOs, more than
half are finding it difficult to obtain enough on-call specialists to meet the state’s legal requirements.

That’s why Congdon is so enthusiastic about the benefits of teleconsultations, which let ED professionals and on-call specialists transcend the most daunting geographic and financial barriers. An ED at a small critical access hospital in Idaho, for example, might find it difficult and costly to attract a full-time, on-call neurologist. Why should it have to shoulder that burden, when its physicians could speedily collaborate with a top-quality neurologist who happens to be in Boston?

Teleconsultations make sense financially and they’re achieving better outcomes as well. In one study reported in Archives of Internal Medicine, teleconsultations reduced ICU deaths by 20% and shortened the average length of stay in the ICU by more than a day.

In a wide range of industries, tele-collaboration is crucial to success. If Steven Spielberg can collaborate long-distance with his colleagues to improve something as non-essential as a movie, why shouldn’t the medical community start doing the same to close existing gaps in care and better our nation’s health?

The 2011 ISC in Los Angeles marked the first time that SOC data has been highlighted at international meeting and the first time that our vast collection of data has been mined and presented in poster form and submitted for publication. Latish Ali and colleagues from UCLA and SOC presented a poster entitled,  A National US Telestroke Delivery System: Patient Characteristics and Frequency of Thrombolytic Therapy Delivery. All SOC hospitals in 2009, were plotted on a map and the population within 30 minute driving time was calculated. Over 34 million people had access to our teleneurology hospitals, representing 12% or the US population.  This number is only growing as we continue to contract with more hospitals in multiple states. It’s amazing to realize that when I’m on call for SOC that, from my home office, I could potentially provide emergency Neurology care to over 12% of the US population!

Author: Joe Peterson, M.D.

This past November, Joe Peterson, MD, CEO and John Moynihan, CTO were invited to participate in the Cisco Collaboration Virtual Launch Experience on the new Cisco Collaboration Website.

Enjoy!

Specialists On Call “In their words”

Author: Joe Peterson, M.D.

The First Annual HealthGrades Emergency Medicine in American Hospitals Study examined more than 5 million Medicare records of patients admitted through the emergency department at 4,907 hospitals from 2006 to 2008. It then identified hospitals that performed in the top 5% in the nation in emergency medicine. Healthgrades is the leading independent healthcare ratings organization.

Author: Joe Peterson, M.D.

The old lessons that have proven true in this new medium called telemedicine are primarily clinical ones. Quality, as Ford once said, has to be job #1. It has to be built into operating systems and managed as, or more aggressively with, distributed groups of physicians, as it does in traditional bricks and mortar institutions. There should be no reason that providers of physician services at a distance enjoy any holiday from the same accepted quality and privacy standards that traditional institutions are held to: Joint Commission accreditation, HIPAA compliance, etc. Of note, the fact that connecting to physicians remotely requires an electronic flow of information does give telemedicine a leg up in managing quality.

Author: Joe Peterson, M.D.

Emergency teleneurology and telestroke care—the importation of stroke and emergency neurology specialists to the patient’s bedside using videoconferencing technologies—is growing steadily in magnitude, impact and validation. Early in the decade some hundreds of patients each year were connected to specialists by video conferencing; in 2010 literally thousands of acute stroke patients will have a distant specialty neurologist involved in the critical phases of their care. The typical associated conclusion is that the evolution of technology has allowed the growth of telemedicine in general, and specifically teleneurology and telestroke. Nothing could be further from the truth, and it’s time the word gets out that the breakthroughs driving the successful growth of this one dimension of telemedicine are financial, not technical.