Telemedicine
Essential Telemedicine Elements (Tele-Ments) for Connecting the Academic Health Center and Remote Community Providers to Enhance Patient Care Brett C. Meyer, MD, Christopher A. Clarke, Tana M. Troke, MBA, and Lawrence S. Friedman, MD
Abstract The authors draw on their experience with the University of California, San Diego Medical Center’s successful enterprise-level clinical telemedicine program to present a paradigm for other academic health centers (AHCs) that wish to develop such a program. They detail key telemedicine program elements, or “tele-ments,” that they consider essential to the development of a centralized, structured telemedicine program and relevant to the development of smaller programs. These tele-ments include an overall
T he academic health center (AHC) offers a variety of essential services to its surrounding community: It is usually the health care facility that offers the most highly specialized clinical care providers as well as the most technologically advanced diagnostic equipment and care options, and it frequently serves as the cornerstone of the regional health care safety net. Often, the AHC’s mission includes commitments to community health and community partnerships.1 Although it is unclear how U.S. health care reform might change AHCs’ role or require them to adapt to anticipated structural and reimbursement changes, it is likely that changes in the health care payment system, the development of accountable care organizations, and more widespread exchanges of health Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Meyer, UCSD School of Medicine, 3rd Floor, Medical Offices North, Suite #3, Mailcode 8466, 200 West Arbor Dr., San Diego, CA 92103-8466; telephone: (619) 543-7760; fax: (619) 543-7771; e-mail: bcmeyer@ ucsd.edu. Acad Med. 2012;87:1032–1040. First published online June 20, 2012 doi: 10.1097/ACM.0b013e31825cdd3a Supplemental digital content for this article is available at http://links.lww.com/ACADMED/A92.
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organizational vision, a centralized telemedicine infrastructure, telemedicinespecific policies and procedures, medical record documentation, relationships between the AHC clinical hub and its remote (spoke) partners, identification of and training for specialty providers, a business plan based on service agreements and/or insurance billing, and licensure/privileging. They discuss the importance of delaying equipment purchases until a plan is in place for sustaining the telemedicine enterprise and of establishing measures to define
success at the outset of program development. In addition, they detail the benefits and concerns associated with telemedicine, provide a comprehensive listing of the roles and responsibilities of providers and staff involved in all aspects of telemedicine, and share samples of their program’s informed consent forms and workflow checklists. Their goal is to offer support and guidance to other AHCs entering the telemedicine arena, enabling them to replicate key elements of a successful, enterprise-wide telemedicine infrastructure.
information will encourage AHCs to develop stronger bonds with their community and regional partners.
via electronic communications to improve patients’ health status.”10 Telemedicine consultations can occur via live, bidirectional, “synchronous” communication, or they can be provided in a “store and forward” mode in which images are created and interpretation is done using the still images or in an asynchronous manner (i.e., not during the patient visit). Radiology has used the store and forward format for years, and other fields (e.g., dermatology,11 pathology12) now have the potential to be practiced similarly.
In many geographic areas, there is a disparity between patient need and health care provider availability. Inadequate public transportation, payment systems, and access to care may simultaneously contribute to limiting the specialty services available to many vulnerable populations. Such access problems are generalizable in that they may cut across multiple specialties and apply to both chronic and acute care settings. For example, there is often a need for services such as acute crisis psychiatry, perinatology, and emergency stroke management in which time is critical and treatment may be contingent on evaluations by specialists.2–9 Potential AHC-level solutions for closing geographic distances, improving access to specialty services, and making the AHC more valuable to its community may involve either deploying more care providers to affected regions or potentially offering telemedicine services. Experts define telemedicine as “the use of medical information exchanged from one site to another
We believe that telemedicine should be viewed as an extension of the way practitioners care for patients in a more technologically dynamic environment rather than as an entity distinct from standard clinical workflows. For an AHC, telemedicine may involve providing teleclinical care to patients in remote clinics, remote emergency departments, or even remote critical care units. Telemedicine may serve as a telecommunications portal between hub providers (located at the AHC/specialty location) and spoke providers (located at a remote facility), or even between hub providers at the same AHC. It also includes tele-training for practitioners and tele-education for
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students, practitioners, patients, and the community. AHC telemedicine services are often supported by a large investment of institutional information technology (IT) initiatives. There are many successful telemedicine programs at AHCs across the United States.13–21 In this article, we draw from our experience implementing and operating an enterprise-level telemedicine program at the University of California, San Diego (UCSD) Medical Center—a tertiary care and quaternary referral center—to offer recommendations to other AHCs regarding the establishment of such programs. Our telemedicine program has contracted with more than 40 remote locations, offering services in psychiatry, general neurology, HIV neurology specialty care, pain medicine, hepatology, internal medicine, endocrinology, neonatology, and oncology. (There are 15–20 other specialties at various stages of deployment.) We have reflected on our telemedicine program’s structure, strengths, and challenges and describe here the telemedicine elements, or “telements,” that we believe are necessary to develop an enterprise-wide telemedicine infrastructure and are important to consider when developing smaller-scale telemedicine programs. Tele-Ments
Below, we detail the tele-ments we consider necessary to garner the benefits of and address concerns related to telemedicine programs. We begin with organizational vision, telemedicine infrastructure, institutional policies and procedures, and medical records management. We next discuss the development of hub and spoke relationships, including the recruitment and training of hub specialty providers, and business plans to address issues of reimbursement. We conclude by considering licensure/privileging issues and requirements related to equipment and space. Organizational vision Developing an organizational vision is the essential first step in developing an enterprise-wide telemedicine program. Key issues of the stakeholders—including patients, providers, and facilities—should be addressed, as should benefits such
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as expanding care to the surrounding communities (Table 1). Among the issues to consider are already-saturated specialty clinics and long waits for appointments, the desire to improve community partnerships, financial risk and poor insurance reimbursements, subsequent or “downstream” patient care implications, and legal and malpractice risks. The strategies to address these issues should be tailored to the AHC’s overall strategic clinical vision and should take into account the resources, needs, and readiness of each element of telehealth care that would be required should the AHC head down this path. An AHC’s telemedicine vision may encompass specific specialties or types of care and should be driven by clear goals. At UCSD Medical Center, the Telemedicine Executive Committee envisions telemedicine as a centralized service that uses innovative technology to provide care to patients, to educate practitioners, and to create scientific knowledge. The committee considers key issues from various stakeholder perspectives before determining strategic directions for the telemedicine program. Telemedicine infrastructure At UCSD Medical Center, telemedicine plays a role in numerous clinical departments, so we have developed a process to centralize telemedicine resources. (A decentralized process may be more appropriate for an AHC that is implementing telemedicine in a single department.) To address our need, we created a telemedicine infrastructure that functions much like a “Department of Telemedicine” in that the telemedicine program has its own organizational chart and budgetary responsibilities. Its director reports to both the medical school’s Office of the Dean and to an executive committee at the medical center. We have found that having AHC leadership champions is integral to successful program development. As for any other AHC clinical service area, the leadership of the medical school and of the medical center ideally should collaborate to develop an organizational chart that clearly designates roles and responsibilities, including those of the following key telemedicine staff:
• a telemedicine director charged with global oversight of the project, • a medical director for telemedicine with experience developing, deploying, and using a telemedicine system and expertise in telemedicine care and workflows, • a telemedicine technical project manager responsible for all technical components (e.g., camera connectivity, selecting telemedicine cart systems/ workstations to be used by specialty providers), and • a departmental business officer responsible for budgeting, billing, reimbursement, service agreements, financial management, scheduling oversight, data management, and model options for programmatic sustainability. Telemedicine program staff interface directly with clinical department staff. Key roles at the AHC, hub, and spoke levels are detailed in Appendix 1. Policies and procedures Because telemedicine is considered a centralized service at UCSD Medical Center, we have developed institutional policies and procedures to ensure compliance and coordinate care across specialties. We suggest this approach to AHCs that offer services for more than one specialty because having individual departments develop rules and create subprograms independently poses potentially significant legal, contracting, and compliance risks and may result in redundant, repetitive, and inconsistent procedures within the AHC. We found it important to create specific policies and procedures that document the workflow for each clinical specialty. To this end, we created an overall medical center policy (MCP) specifically outlining the acceptable boundaries of telemedicine procedures, workflows, and documentation; developed and obtained approval for telemedicinespecific informed consent documents; created specialty-specific clinical workflows as needed; and created detailed checklists for hub and spoke providers to complete when performing telemedicine patient evaluations. (For samples of these documents and checklists, see Supplemental Digital Appendixes 1, 2,
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Hub facility
Hub clinical department
Hub Hub provider (specialist)
Spoke facility
Spoke provider
Enhances AHC’s overall strategic plan
Expands AHC patient care to the community and region
Benefits the AHC financially
Facilitates community partnerships
Expands hub provider’s care to more patients in more remote areas May increase throughput of patients through use of telemedicine Facilitates collaborating with multiple providers at once Can utilize standard telemedicine infrastructure; does not need to develop entire program independently Increases clinical income to department (via telemedicine billing and service agreements) Enhances community outreach
Increases market share through access to new specialty services Increases public relations/media relations for facility
Increases transfer options for step-up in care needs
Improves care for local community
Enables numerous providers to evaluate patient at one time Provides immediate access to specialist recommendations and clinical notes Increases number of patients in clinic panel due to specialty availability Allows access to multiple providers at once
Minimizes need to drive long distances
Stakeholders by location Benefits Spoke Spoke patient Provides immediate access to specialty care
Establishing a telemedicine relationship may result in establishing a duty to care for patients in the future Expanding telemedicine care in a given specialty may come at the expense of increasing waiting times for appointments with specialists for in-person evaluations —
Telemedicine reimbursement is poor when insurance is billed There are Health Insurance Portability and Accountability Act (HIPAA) risks due to possible loss of confidentiality (data transmission over Internet) There are medical risks due to providing diagnoses based on limited data
Increased time is required to develop the specialty’s telemedicine services
Patient–provider interpersonal communication may be adversely affected The provider cannot be at the bedside to perform some physical exam elements Multiple providers may give conflicting opinions
—
Costs are associated with providing new services
Confidentiality may be lost in transmitting data over the Internet Telemedicine may result in excessive transfers from spoke facility to hub facility
New technologies (e.g., large screen, high resolution, minimal audio delays) mitigate this concern Utilize strongly encrypted systems, but still require informed consent
Patient–provider interpersonal communication may be adversely affected Confidentiality may be lost in transmitting data over the Internet Privacy concerns may arise regarding who is evaluating the patient at any given time Patient–provider interpersonal communication may be adversely affected Patient throughput may decrease because of time required to assist with telemedicine evaluation Multiple providers may give conflicting opinions
—
Providing consultative recommendations only may minimize this risk; clarify in consent form that recommendations are based on data provided by spoke’s bedside care provider Financial benefits and concerns should be assessed as part of the AHC business plan for each potential hub–spoke partnership Care expansion concerns should be assessed as part of the AHC business plan for each potential hub–spoke partnership
Service agreements can limit reimbursement concerns; also, third-party insurers are increasingly likely to reimburse Utilize strongly encrypted systems, but still require informed consent
Collaboration with multiple providers enables discussion and determination of final care plans that are agreed to by all providers This concern is limited if central telemedicine infrastructure can be used for numerous specialty department implementations
Telemedicine peripheral devices enable increased physical exam possibilities
New technologies mitigate this concern
Specialty recommendations and evaluations enable more appropriate triage and ability to keep more patients at the spoke facility; only patients who truly require step-up in care will be transferred Costs may be justified in spoke facility’s business plan if the service improves care to patients and limits the need for transfers —
Efficiency improves with provider–provider communication and experience; also, provider may only be needed during portions of evaluation Participation by multiple providers enables them to discuss, determine, and agree on final care plans Utilize strongly encrypted systems, but still require informed consent
Provides learning experience for spoke provider; workflows can indicate to the patient which providers are “online” at any given time New technologies mitigate this concern
Comments and solutions
Concerns
Academic Health Center (AHC) Enterprise-Wide Telemedicine Programs: Benefits and Concerns for Stakeholders at the Spoke (Remote) and Hub (AHC) Locations
Table 1
Telemedicine
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and 3, available at http://links.lww.com/ ACADMED/A92.) The workflow for telemedicine evaluations need not be significantly different from standard, nontelemedicine workflows, other than the issue of consent. Patient scheduling, preliminary workflows for assessing vital signs and medication lists, and postevaluation workflows for sending clinic notes to referring providers are likely to follow standard clinical practices irrespective of the telemedicine modality. Medical records management Telemedicine triage unit. We recommend establishing a telemedicine triage unit to create a system-wide mechanism for obtaining preliminary medical records via mail, fax, or direct scanning technologies. From a clinical perspective, having previous medical records available before any specialty visit, whether that visit takes place via telemedicine or in person, can make the visit much more productive and efficient. Medical record documentation. The hub site’s documentation for telemedicine visits should follow the same principles as documentation for any other type of clinical encounter. This should be clearly spelled out in any MCP on medical record documentation of clinical care. The policy should require the hub site to create a unique patient medical record number for each telemedicine patient because the patient may present in the future as a hub ambulatory patient or inpatient. The spoke site should also document the visit in its medical record. If the telemedicine evaluation is recorded, there is no requirement to maintain copies of the actual recording itself, but the decision as to whether to archive such content should be made carefully at the AHC enterprise level. Electronic medical records interface. Using electronic medical records (EMRs) can help streamline an AHC’s approach to managing telemedicine patients. For example, making a scheduling notation that indicates that the patient will be evaluated via telemedicine allows the provider to understand ahead of time which patients will be seen by which technique. He or she can then shift more easily between types of evaluation visits (even alternating hourly within the same clinic day). Further, preliminary documents may be scanned into the patient’s EMR, permitting site-
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independent retrieval and review before, or during, the telemedicine evaluation. At the time of the scheduled visit (or acute care moment for emergency evaluations), the patient or health care surrogate can sign the informed consent document, which can be faxed to the consulting hub center or uploaded into the EMR. The informed consent document should be placed in the medical record; we believe the best practice is to include it in the medical record at both the hub and spoke locations. (Although legal requirements for telemedicine informed consent are evolving, we have chosen to continue obtaining written informed consent. At this time, we do not provide telemedicine consults on patients unless we have obtained their consent or that of their health care surrogates.) From a clinical care perspective, we have found that using EMRs helps both the hub and spoke providers. UCSD Medical Center hub providers are able to leverage the standard telemedicine template language present within the EMR to streamline their telemedicine evaluations and verify that full and complete details are noted in the patient’s record at each visit (e.g., identifying the evaluation as being performed via telemedicine, specifying that the patient is aware that his or her participation is voluntary and that future bedside evaluations may be necessary, applying standardized evaluation language). To expedite information sharing, licensed spoke providers can be granted access to their patients’ UCSD EMRs. This improves communication between hub and spoke providers and, we believe, increases the efficiency of telemedicine patient care. Hub specialty service and spoke relationship development Assessing AHC resources and evaluating how these resources fit into the AHC’s overall strategic plan is as important as determining which specialties are needed at the potential spoke sites. Developing hub specialties. On the hub side, telemedicine champions must determine whether there are specialists at the AHC with availability in the specialty or specialties that can fill gaps in potential spoke partners’ clinical services. The importance of identifying clinical champions who will be interested and effective in developing their departments’ roles in the AHC’s telemedicine program
cannot be overemphasized. These clinical champions and AHC business officers should meet to identify potential spoke partners, decide on services to provide and hours/days of operation, establish the medical center locations from which telemedicine services will be provided, determine how telemedicine will fit into the clinical department’s overall workflow, and develop a business plan (see below) that satisfies the stakeholders. Developing spoke relationships. Spoke organizations take various shapes and sizes. They tend to employ general practitioners (MDs, DOs, NPs, or PAs) and have variable information systems infrastructures. A needs assessment from both the IT and clinical service perspectives should be performed collaboratively by the spoke and hub in order to help develop a common ground for services provided. When an AHC takes steps to partner with a spoke facility to provide telemedicine services, it is important to optimize any current relationships that exist outside the telemedicine arena. There may be opportunities to modify existing contracts or to leverage existing relationships to incorporate telemedicine. The spoke site should develop a clear business plan as well. In our program, we have collaborated with spoke sites to help them understand their potential expenses and revenues from telemedicine. If spoke sites understand the potential benefits, the telemedicine partnership can be far more successful. It is imperative to make telemedicine training, deployment, operation, and maintenance as simple as possible for spoke facilities. The more operational work that the hub center can do, the more likely the program will meet with success. Identifying specialists and training staff. Once a specialty is selected, specialty providers should be identified. These providers should be able to easily transfer their clinical knowledge into the telemedicine environment; however, we recommend providing structured training on how to perform telemedicine evaluations (e.g., clinical history and physical exam techniques specific to telemedicine encounters, such as remote methods for listening to the heart or looking at a retina). UCSD Telemedicine has offered educational sessions in all aspects of telemedicine, including
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practice sessions using telemedicine equipment. Training spoke providers may also be essential. In addition, clinic staff at both the hub and spoke sites should be trained in telemedicine clinic workflows and should participate in mock evaluations before the “go-live” date. Checklists act as effective reminders to ensure smooth and complete telemedicine visits. Expansion and maintenance. Telemedicine programs usually start out small and, if successful, expand by adding additional specialties. Strong relationships between the hub and spokes (more important, between hub champions and spoke champions) can be a critical success factor.
live telemedicine evaluations, and navigating this dynamic reimbursement environment is incredibly difficult. Given this reimbursement landscape, other reimbursement possibilities should be considered, and community benefits, research benefits, and even potential downstream revenue should be taken into account. The reimbursement situation may change rapidly with health care reform, though. Numerous stakeholder groups—including the Center for Connected Health Policy, the American Telemedicine Association, and the California Telemedicine and eHealth Center—have invested significant time and resources in making the case for improved telemedicine reimbursement by all insurance companies.
A successful “go-live” may not always translate into a successful telemedicine program. As much work should be put into the maintenance of a telemedicine partnership as into its deployment. We recommend reassessing the workflow the day after the go-live, again one month after the go-live, and at set intervals throughout the year. Frequently, spoke sites get overwhelmed with nontelemedicine tasks, which results in “spoke fatigue.” This fatigue may adversely affect the volume of telemedicine consults requested, leading to a decline unrelated to the spoke’s clinical needs. Both the hub and spoke must commit resources to assess telemedicine clinics and patient scheduling continually to ensure that the care needed is requested and provided. Finally, success breeds success: The more patients who are seen, the more providers who get input from telemedicine consultants, and the more streamlined the telemedicine process, the more success the program will have. We recommend developing a marketing plan to advertise the successful program.
Until a new billing paradigm emerges, an alternative approach is to execute clinical service agreements or contracts between the AHC and its spoke affiliates. Contracts should specify the degree of services to be provided and the methods of payment—that is, whether the services will be provided for block time reimbursements (service agreement model), whether payment will come from a parent agency or from grants, or whether patients’ insurance companies will be billed per encounter (insurance billing model). Service agreements should include details that may become important regarding provision of services, including the following items:
Business plan
• minimal technical standard requirements and contingencies when there are technical problems,
At the present time, it is likely that an AHC’s telemedicine business plan would not be successful if it were to rely on insurance billing alone to justify the initiative. Store and forward telemedicine operations, especially for radiology, have shown cost benefits in the past,22 and reimbursement for such services likely still surpasses that for real-time consultation techniques. However, only a few third-party insurance carriers currently reimburse fully for
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• types and hours of services, • information that must be received by the hub before scheduling, • patient age ranges for services • whether add-on or emergency patients are allowed, • who is required to be present during an evaluation,
• expectations regarding patient followup, ownership of subsequent care needs, and how spoke providers will be notified about recommendations, • payment for services, no-shows, and instances of technical failures, and • whether the hub provider is obligated to accept downstream referral business.
Licensure, privileging, and malpractice Before implementing any telemedicine program, the AHC should verify relevant state regulations, which differ regarding licensure and privileging of hub providers. State laws require that the telemedicine provider must be licensed in the state where the patient resides. It is UCSD Medical Center’s position that telemedicine providers must be credentialed and privileged at the both the hub facility with which they are affiliated and the spoke facility for which they are evaluating the patient. New Centers for Medicare and Medicaid Services regulations (amendment to the Code of Federal Regulations, Title 42, Section 482.22)23 should make credentialing by proxy a reality and should reduce the complexity of telemedicine privileging. AHCs have policies in place regarding malpractice and coverage for their providers. It is important that participating hub providers assess with legal counsel their individual malpractice limits and the relationship of their malpractice coverage to any telemedicine services they may provide through their AHC. Equipment and space requirements Equipment. A common theme, which we have heard repeatedly, is that remote sites or AHCs have chosen to make substantial initial telemedicine equipment purchases (most often through pilot grant funding) but have not seen these investments translate into the development of successful or sustainable clinical telemedicine programs. For this reason, we strongly recommend that facilities not purchase telemedicine equipment until the key stakeholders have developed plans for sustainability. An essential part of the formula is understanding how and by whom the equipment will be used. Telemedicine equipment should directly serve the needs of the institution’s clinical (or educational) initiatives. We recommend that stakeholders work with their institution’s IT professionals to create a table that fully describes the desired equipment functionality before purchasing any equipment; the table can then be used to assess characteristics of specific pieces of equipment and how these characteristics would be necessary
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for the successful implementation of a clinical program in specific specialties. Keep in mind that “telecommunications” and “telemedicine” are not the same, although there are numerous telecommunications systems that can be effective in the medical environment. Also, there is no shortage of telemedicine equipment vendors. Those vendors who focus on the needs of the health care consumer when developing and supporting telemedicine systems are generally desirable partners.
At UCSD Medical Center, our providers evaluate both in-house and telemedicine patients while working in front of EMR monitors. For telemedicine consultations, we use a dual-monitor approach in which the provider is situated between one monitor displaying the patient and another displaying the patient’s EMR. This “catty-corner” arrangement is extremely effective for telemedicine evaluations. Other technologies enable the provider to toggle between the EMR and the patient video image as needed.
We have listed what we consider to be key telemedicine equipment and added features (List 1), but ultimately a facility’s choice of features and vendors depends on specialty needs. Telemedicine carts can usually be used at spoke sites, and telecommunications workstations can be used at the hub site. In many instances, however, these can be used in different combinations (e.g., cart to workstation, cart to cart, workstation to workstation) depending on the service being provided.
Privacy, confidentiality, and security. Privacy, confidentiality, and security are paramount considerations for telemedicine because patients’ personal health-related information is being transmitted, usually via the Internet. AHCs should take steps to address the inherent risks, such as inaccurate communication due to loss of video/ audio data or confidentiality breaches due to security intrusions via the Internet. We recommend using telemedicine systems that have a high degree of reliability to minimize risks related to loss of data packets. Similarly, we recommend using systems with a high degree of security encryption, consistent with mandates in the Health Insurance Portability and Accountability Act of 1996.
Evaluation space. It is not necessary to dedicate rooms to telemedicine. Initial scheduled telemedicine business may not be sufficient to maximize room utilization, so the space should be functional for bedside evaluations as well. Lighting in the hub-side exam room should be sufficient to allow the patient to see the hub provider’s face clearly; in the spoke-side exam room, lighting should permit the hub provider to see all details of the patient’s examination.
Especially when providing acute care evaluations, the telemedicine provider should be encouraged to use one of the evaluation rooms set up for telemedicine or to use a laptop-access system from an isolated, private location. If there is
List 1 Recommended Equipment and Features for an Academic Health Center’s Enterprise-wide Telemedicine Program 1. 2. 3. 4. 5. 6.
7. 8. 9. 10.
11.
Video: two-way, full screen, full resolution, full 29.97 frames per second Audio: two-way, minimal (if any) detectable delay, echo cancellation features Recording and streaming playback options Health Insurance Portability and Accountability Act of 1996 compliance Encryption (at least 128-bit) Compression algorithms that help enable transmission of large amounts of data through limited-capacity networks, with minimal delay; quality of service algorithms to ensure data quality Site-independent access to camera systems (i.e., provider can access the remote camera using a laptop with an Internet connection) Multiparty options (i.e., multiple providers can evaluate the patient simultaneously) Onscreen decision support tools Radiology image review capabilities, appropriate to Digital Imaging and Communications in Medicine standards for exchanging digital information between medical imaging equipment, if desired Peripheral equipment (e.g., otoscope, stethoscope, dermatologic camera, general exam camera), if desired
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any risk of someone else overhearing the interaction between the provider and patient, the provider should use headphones and a microphone to ensure that the conversation is private, even when the telemedicine system employs echo cancellation. Defining Success and Overcoming Challenges
At the outset of program development, it is essential to determine the measures that will later be used to define “success.” The telemedicine business plan may be built on a number of different potential benefits (clinical, financial, or educational), but the weight of each potential benefit depends on the AHC’s long-term strategic plans. Whatever the rationale for starting the program, all key stakeholders must understand how success will be defined (e.g., expansion of patient care, financial return on investment, community partnership development, teaching opportunities, clinical research, downstream referrals, clinical benefit to patients). For our telemedicine program, we determined that the key measures to track would include net increased patient volume, decreased wait times for in-person appointments at clinics in the same specialty, numbers of new and return visits for telemedicine evaluations, number of telemedicine-specific help desk calls, and downstream business to the AHC. Developing a successful enterprisewide telemedicine program is not without its challenges, but adopting a standard approach to implementing and providing telemedicine services will help limit the problems that arise along the way. In our case, numerous clinical departments were interested in implementing telemedicine partnerships with remote facilities, but there was redundancy in many of their efforts. It was initially challenging to inform providers of the newly developed telemedicine infrastructure and established procedures, including those related to telemedicine system security, medical record documentation, and informed consent requirements. Developing a specific MCP, as described above, has helped improve consistency and compliance among providers.
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In Sum
Health-care-related technology is evolving rapidly, and telemedicine is part of this quickly changing field. Critical elements of care—from store and forward dermatology consultations11 to emergency stroke management6—are being provided as telemedicine services. Medical education, training, and conferences are routinely augmented by telecommunications technologies. To prepare for and participate in telemedicine, AHC leaders should understand the related issues. As we have discussed, using UCSD Medical Center’s telemedicine program as an example, one key to establishing a successful telemedicine enterprise is developing a core infrastructure built on a single vision of extending care to patients. Developing relationships with spoke facilities and attracting champions charged with the success of the overall program and individual clinical department initiatives is essential. Understanding and balancing the needs and resources of both the AHC and the remote facilities will ultimately help define the program’s success. The importance of developing a business plan cannot be overemphasized. Finally, stakeholders should remember that telemedicine equipment has limited worth without an overall infrastructure to support a strong program and a strategic plan to guide the initiative. Many health care institutions are interested in using telemedicine to expand care and specialty options for their patients and those of partner facilities, but they are not sure how to begin or optimize this process. We believe that the key telemedicine elements, or tele-ments, that we have detailed represent essential aspects of developing a telemedicine program and offer generalizable guidance for other AHCs entering the telemedicine arena. Using these elements, AHCs and remote communities can begin to build successful telemedicine connections and, thereby, enhance patient care.
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Acknowledgments: The authors wish to thank the University of California, San Diego Medical Center leadership for their support in this enterprisewide telemedicine initiative. Funding/Support: None
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Other disclosures: None. Ethical approval: Not applicable. Dr. Meyer is medical director, University of California, San Diego (UCSD) Telemedicine, and codirector, UCSD Stroke Center, UCSD Medical Center, as well as associate professor, Department of Neurosciences, UCSD School of Medicine, San Diego, California. Mr. Clarke is telemedicine technical project manager, University of California, San Diego (UCSD) Telemedicine, UCSD Medical Center, San Diego, California. Ms. Troke is departmental business officer, University of California, San Diego (UCSD) Telemedicine, UCSD Medical Center, as well as assistant dean, Health Sciences Affairs, UCSD School of Medicine, San Diego, California. Dr. Friedman is telemedicine director, University of California, San Diego (UCSD) Telemedicine, and medical director, Ambulatory and Primary Care, UCSD Medical Center, as well as professor, Departments of Medicine and Pediatrics, UCSD School of Medicine, San Diego, California.
References 1 Wartman SA. Commentary: Academic health centers: The compelling need for recalibration. Acad Med. 2010;85:1821–1822. 2 Saver JL. Time is brain-quantified. Stroke. 2006;37:263–266. 3 The NINDS rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;333:1581–1587. 4 Kleindorfer D, Lindsell CJ, Brass L, Koroshetz W, Broderick JP. National US estimates of recombinant tissue plasminogen activator use: ICD-9 codes substantially underestimate. Stroke. 2008;39:924–928. 5 Schwab S, Vatankhah B, Kukla C, et al. TEMPiS Group. Long-term outcome after thrombolysis in telemedical stroke care. Neurology. 2007;69:898–903. 6 Meyer BC, Raman R, Hemmen T, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: A randomised, blinded, prospective study. Lancet Neurol. 2008;7:787–795. 7 LaMonte MP, Bahouth MN, Hu P, et al. Telemedicine for acute stroke: Triumphs and pitfalls. Stroke. 2003;34:725–728. 8 Demaerschalk BM, Miley ML, Kiernan TE, et al. STARR Coinvestigators. Stroke
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telemedicine. Mayo Clin Proc. 2009;84: 53–64. Hess DC, Wang S, Hamilton W, et al. REACH: Clinical feasibility of a rural telestroke network. Stroke. 2005;36: 2018–2020. American Telemedicine Association. Telemedicine defined. http://www. americantelemed.org/i4a/pages/index. cfm?pageid=3333. Accessed April 5, 2012. Armstrong AW, Sanders C, Farbstein AD, et al. Evaluation and comparison of store-andforward teledermatology applications. Telemed J E Health. 2010;16:424–438. Williams S, Henricks WH, Becich MJ, Toscano M, Carter AB. Telepathology for patient care: What am I getting myself into? Adv Anat Pathol. 2010;17:130–149. Krupinski EA, Patterson T, Norman CD, et al. Successful models for telehealth. Otolaryngol Clin North Am. 2011;44:1275–1288, vii. González-Espada WJ, Hall-Barrow J, Hall RW, Burke BL, Smith CE. Achieving success connecting academic and practicing clinicians through telemedicine. Pediatrics. 2009;123:e476–e483. Yellowlees PM. Successfully developing a telemedicine system. J Telemed Telecare. 2005;11:331–335. Shannon GW, Bashshur R, Kratochwill E, DeWitt J. Telemedicine and the academic health center: The University of Michigan health system model. Telemed J E Health. 2005;11:530–541. Arora S, Geppert CM, Kalishman S, et al. Academic health center management of chronic diseases through knowledge networks: Project ECHO. Acad Med. 2007;82:154–160. Alverson DC, Holtz B, D’Iorio J, DeVany M, Simmons S, Poropatich RK. One size doesn’t fit all: Bringing telehealth services to special populations. Telemed J E Health. 2008;14:957–963. Saffle JR. Telemedicine for acute burn treatment: The time has come. J Telemed Telecare. 2006;12:1–3. Luptak M, Dailey N, Juretic M, et al. The Care Coordination Home Telehealth (CCHT) rural demonstration project: A symptom-based approach for serving older veterans in remote geographical settings. Rural Remote Health. 2010;10:1375. Rheuban KS. Telehealth: ‘necessity is the mother of invention’. Pediatr Ann. 2009;38:570–573. Hailey D, Roine R, Ohinmaa A. Systematic review of evidence for the benefits of telemedicine. J Telemed Telecare. 2002;8(suppl 1):1–30. Condition of participation: Medical Staff, 42 CFR §482.22. http://ecfr.gpoaccess.gov/cgi/t/ text/text-idx?c=ecfr&rgn=div5&view=text&n ode=42:5.0.1.1.1&idno=42#42:5.0.1.1.1.3.4.2. Accessed April 25, 2012.
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Telemedicine
Appendix 1 Roles and Responsibilities of the Academic Health Center (AHC) Hub and Its Remote Spoke Partners in an Enterprise-wide Telemedicine Program Role/tele-ment by level
Responsibilities
AHC leadership School of medicine leadership
• Play an integral role in the successful development of the telemedicine program • Oversee the telemedicine infrastructure and core departmental teams • Oversee telemedicine as related to the AHC strategic plan
Medical center leadership
• Oversee the telemedicine infrastructure and core departmental teams • Oversee telemedicine as related to the AHC strategic plan and the clinical enterprise
AHC support infrastructure Medical records department, oversight and forms committees
• Manage storage and retention of outside medical records (by scanning) and site-specific documentation • Review and approve telemedicine documents, forms, checklists, questionnaires, and policies
Compliance office
• Ensure telemedicine program’s compliance with patient privacy issues and medical center policies
Contracts office
• Develop and review telemedicine service agreements between internal AHC department and remote spoke partner(s) • Develop and review internal memoranda of understanding for providing telemedicine services
Legal department
• Oversee and review telemedicine contracts and agreements for legal concerns • Ensure telemedicine program’s compliance with medical center policies as related to telemedicine
Media relations department
• Facilitate public relations and media interface regarding telemedicine services and AHC outreach related to telemedicine
Information technology (IT) team
• Manage telemedicine networking needs within the AHC • Enable connectivity for new partnerships between the AHC hub and remote spoke facilities
Electronic medical record (EMR) team
• Facilitate interface between telemedicine program and the EMR system for coordinated clinical notation, review of outside records, and spoke retrieval of hub notes • Develop template text to assist with telemedicine providers’ notation needs
Scheduling team
• Interface with spoke facility to schedule patients for telemedicine visits (unless this function is managed by telemedicine triage unit; see below)
Billing/revenue manager
• Manage invoicing of spoke facility for telemedicine services provided • Understand current and new billing codes and modifiers (e.g., “GT” for real-time/live telemedicine consults, “QT” for store and forward evaluations) • Manage billing procedures and charges related to billing of patient and third-party insurance for telemedicine services
Core telemedicine infrastructure Telemedicine director
• Oversee telemedicine program and its direction • Collaborate with AHC leadership regarding strategic plan and telemedicine
Medical director for telemedicine
• Interact with the telemedicine director and AHC leadership regarding strategic plan and telemedicine • Interact with core members of telemedicine team for deployments, maintenance, and expansion • Develop new partnerships with spoke facilities • Oversee the implementation in individual clinical departments of key elements required to deploy successful telemedicine partnerships • Oversee telemedicine clinical workflows • Develop telemedicine business plan and contracts as needed
Telemedicine technical project manager
• Interact with core telemedicine team members for deployments, maintenance, and expansion • Oversee technical aspects of new telemedicine deployments to spoke facilities • Interface with telemedicine systems and vendors • Interface with IT teams at both the AHC hub and the remote spoke facilities
Departmental business officer
• Oversee all financial management of the telemedicine initiative including budget development and financial reporting to AHC leadership • Oversee billing and reimbursements for telemedicine services • Oversee scheduling, data management, and model options for programmatic sustainability
Telemedicine service line/program director or coordinator
• Interact with core telemedicine team members for deployments, maintenance, and expansion • Develop new spoke partnerships for telemedicine • Develop business plan and telemedicine contracts • Manage clinical implementation of telemedicine workflows • Collaborate with the departmental business officer on financial management of the telemedicine initiative (including budget, reporting, billing, invoicing, scheduling, and data management)
Tele-education and tele-training director
• Train hub telemedicine providers, spoke care providers, and clinical support staff at both the hub and spoke in workflows related to telemedicine and telemedicine evaluation procedures • Manage all education aspects of the telemedicine program (including telemedicine education in the medical school curriculum, distant learning, simulation sessions) (Appendix continues)
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Telemedicine
Appendix 1, continued Role/tele-ment by level Telemedicine clinic manager
Telemedicine triage unit
Responsibilities • Oversee clinical workflows for telemedicine in all clinical arenas (outpatient and inpatient) • Oversee training of hub telemedicine providers, spoke care providers, and clinical support staff at both the hub and spoke regarding workflows related to telemedicine and use of telemedicine evaluation procedures • Oversee scheduling of telemedicine visits • Receive and review preliminary documents needed for telemedicine evaluations • Screen patients as to appropriateness for telemedicine visits with specialty (this should be done by an RN-level individual) • Provide preliminary documents to AHC telemedicine provider for review (e.g., scan documents into EMR)
Telemedicine hub Clinical department chair
• Collaborate with department specialists and telemedicine teams to implement telemedicine in department’s strategic plan
Clinical service chief
• Facilitate implementation of telemedicine into the clinical care specialty
Clinical department champion*
• Become clinical champion/telemedicine service line director for an individual clinical department of the AHC • Assist with implementing required telemedicine elements in that department • Perform telemedicine consultations • Engage in hub and spoke partnership sessions aimed at education, partnering, and community outreach
Clinical department telemedicine clinic manager
• Implement clinical workflows for telemedicine in individual clinical department of the AHC • Implement training of AHC providers and clinical support staff in telemedicine policies and system use • Implement scheduling of telemedicine appointments/consults for the department
Spoke Spoke facility leadership
• Oversee the telemedicine infrastructure at the spoke facility
Spoke clinical champion*
• Assist with implementing key elements needed at the spoke facility to deploy a successful telemedicine partnership with the hub • Assist with telemedicine consultations • Assist with hub and spoke partnership sessions aimed at education, partnering, and community outreach
Spoke telemedicine clinic manager or coordinator
• Implement clinical workflows for telemedicine at the spoke facility • Implement training of spoke providers and clinical support staff • Implement scheduling (into spoke clinic) of patients who require telemedicine evaluations
Contracts office
• Develop and review telemedicine service agreements
Media relations department
• Facilitate public relations and media interface regarding telemedicine services and spoke facility’s partnership with the AHC hub for community care purposes
IT team
• Manage telemedicine networking • Enable connectivity for new partnership with hub
EMR team
• Facilitate coordinated clinical notation with AHC
Scheduling team
• Interface with AHC to schedule spoke patients for telemedicine visits
Billing/revenue manager
• Oversee payment to AHC for services provided • Manage billing procedures and charges related to clinic billing and/or spoke telemedicine billing
*Clinical champions are typically clinical leaders with MD, DO, NP, or PA qualifications, but variations do occur.
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