Today's Des Moines Register has an interesting article on Iowa's first accountable care organization (ACO) at Ft. Dodge's Trinity Regional Medical Center. Trinity is part of Iowa Health System. You can find the article HERE.
The article presents an example of care provided to one cardiac patient, them explains the ACO concept. It goes on to present arguments from both supporters and critics of the ACO concept.
Side Note: On June 1, 2012 the Des Moines Register is changing it's subscription model. Therefore, I'm not sure if this link will be valid after that date.
Friday, May 18, 2012
Thursday, May 17, 2012
Telemedicine Technology Planning Questions
Most bad technology solutions are not created by bad decisions, but by bad questions. In this post we’ll look at questions which should be part of a telemedicine technology decision making process. For additional background on telemedicine, please refer to my previous telemedicine posts including a telemedicine overview, terminology, and technology options. As I've said in my earlier posts, I'm not an expert in telemedicine. I'm just passing along what I've learned as I explore this very interesting topic.
I’m going to lay out questions and considerations which you
can use to facilitate your planning process.
I hope that as you read this you’ll think of many more questions nested
within each area. And that’s really the
purpose of this post, to get you thinking of the right questions.
Before making any technology decisions, it’s important to
have a defined telemedicine business case and strategic need. Technology is the means to an end, not the
end itself. If technology is selected
without a defined business case and strategic need, it increases the odds of
making improper and costly technology decisions.
Not to put too fine a point on it, but technology decisions
are wrapped up in general operations decisions, which are ultimately
constrained by a budget. The budget, of
course, is constrained by reimbursement, whether fee-for-service or some flavor
of capitation. So figure out how much
you can receive before you commit to how much you have to spend.
Information needs
What information will be received?
What information will be sent out?
What is the quality of the information to be received and
sent?
What is the quantity of information to be received and sent?
When is the information to be received and sent?
What is the format of the information to be received and
sent?
This may seem obvious, but it’s important to define information
needs. If a provider needs patient
history prior to the telemedicine encounter, there needs to be someone and some
process to make that happen. If there is
need for vital sign or mental state screening during the encounter, there needs
to be someone and some technology to make that happen. Maybe it’s an inexpensive fax machine, maybe
it’s and EMR, maybe it’s a full-scale integrated telemedicine cart. Whatever it is, unless information needs are
clearly defined, it’s not possible to make an informed technology assessment.
Wrapped into this discussion is sharing of patient
information. This includes
considerations for EMR and HIE. If there’s
a need to send out referral letters and CCD/CCR, the system will either need to
handle it or there needs to be a manual process. Volume counts here, a couple patients per day
are much different than managing the process for 15 patients per day.
At some point there must be charge capture, so that will
need to be considered. How does the clinical information flow to the billing
clerk or CBO?
The Who
Who is the patient population?
Who is facilitating the encounter for the patient (patient
helper)?
Who is the provider?
It’s my hope that planners will consider patient population
needs. The environment, tools, and
process should create a positive patient experience. A repainted closet entered from a busy
waiting room may not be optimal for mental health patients. A cool room with only technology devices may
not be the best setting for an elderly population.
Patient population also impacts the telemedicine
setting. Ambulatory mental health
patients can go to a fixed telemedicine location. Elder care facilities may require a cart solution. If the telehealth equipment is to be moved
between facilities, then an even more mobile solution is called for.
Regarding the patient helper, if they need to attach an ECG,
take vitals, or ask screening questions, they’ll need the proper clinical
credentials and training. They’ll also
need aptitude and training to operate, troubleshoot, and maintain telemedicine
equipment. Finally, working with a remote
provider is different than working with one shoulder to shoulder, so the
patient helper will need the appropriate skills and training to be effective.
Regarding the provider, this person will need to facilitate
the technology to successfully conduct a telemedicine encounter. This includes
technical skill, but also skill and training on conducting a successful remote encounter.
Where
Where is the patient location?
Where is the provider location?
Does the location have adequate Internet connectivity?
Is the equipment secure?
Does the patient encounter location provide privacy and
security for patient and data?
If you’re thinking of telemedicine, you’re probably already
considered the care facility or setting.
But within that facility the equipment will need to be stored and
secured. The patient encounter location
will need adequate privacy and security.
There will need to be a process for handling the patient and PHI before
and after the encounter. Any patient information
will need to be secured and protected, which includes all pieces and parts of
the telemedicine technology solution. After all, you don’t want unauthorized people
surfing the internet or playing with a camera and come across some bit of patient
PHI.
It’s also important to consider where the provider will be
located. Most of the time they may be in
their practice office, but will they also be available when making rounds or
when otherwise out of the office? If so,
you’ll need to address a laptop or mobile solution for the provider.
How
How is the telemedicine encounter and related information
intended to be used?
This may seem basic, but will patient visits be diagnostic,
follow-up, or chronic disease maintenance?
Knowing this may steer your technology decisions. Assessing a patient’s lightheadedness differs
from discussing their hypertension plan compliance.
When
When will encounters be conducted?
Will appointments be scheduled, walk-in, or on-call?
Are the patient care site, the patient helper, and the provider
available for the appropriate days and time?
Typically we think of “when” in terms of scheduling method:
scheduled, walk-in or on-call. However,
telemedicine presents its own set of coordination challenges. This may not seem like a technology issue but
it is. If the remote patient location
needs to be scheduled, there needs to be a way to track that. Same goes for the patient helper and
provider. Is there shared scheduling
software? If it’s a paper schedule (a no-tech
solution), who manages the schedule and coordinates the people and locations?
Conclusion
I hope these questions have provided some insight into what
it takes to plan a telemedicine technology solution. As I said at the beginning, this was intended
to prompt to you think of additional questions if you’re exploring
telemedicine and telemedicine technology. If you’d like to discuss telemedicine and technology
further, please feel free to reach out to me through this blog or via email.
Straight ahead,
Bob
Wednesday, May 16, 2012
Seth Godin: Digital analogs are no longer sufficient
I'm happily writing my next post, Telemedicine Technology Decisions, when Seth Godin once again writes something that forces me to stop and think. Darn you Seth Godin! You can find his blog HERE.
Look for my Telemedicine Technology Decisions post tomorrow.
Look for my Telemedicine Technology Decisions post tomorrow.
Thursday, May 3, 2012
Part 3: Telemedicine Technology
“Rampart Hospital, this is Squad 51. Dixie, you read me? Out.”
The sultry cool nurse Dixie McCall, complete with white nursing uniform
and hat, calmly coos, “Rampart, copy.
What’s your situation 51?” And with that, many Americans were introduced
to telemedicine by the TV show Emergency. It seems that in every episode, paramedics Gage
and Desoto arrive on scene to treat a patient with chest pain, open up their
toolbox, screw in a silver antenna, and start communicating with Rampart
Hospital. The paramedics talk with the unflappable Dr. Kelly
Brackett, and eventually send an ECG over their radio unit to Rampart Hospital
where it’s read by Dr. Brackett. “Squad
51, this is Brackett. Give the patient 2
units Ringers Lactate, stabilize and get him here STAT. Out.”
Pretty cool stuff back in 1972.
In this post I’ll explore some of the telemedicine
technology available today. Remember my
focus is on solo and small group practices, so I’m not going to discuss
enterprise level technology in detail. Or
emergency medicine (sorry Emergency fans).
For unfamiliar technical terms, try referring to my prior
post, Telemedicine: Terminology LINK.
I’m going to break this down into the following components:
telecommunications (audio/video); diagnostic devices and information; patient
record; and aggregation tools (which bring together or combine capabilities of
the other components).
The “tele” part
So how does the audio and video move between the doctor and
the patient? Well, it most likely is not
over POTS service. POTS stands for Plain
Old Telephone Service, and it is the type of telephone service in most homes
and many small businesses. It’s the basic
analog service that has been around almost unchanged since the late 19th
century. In allows for two-way voice
communication, and with a modem allows a user low-bandwidth access to the
Internet. It’s good for voice, but too
slow for video and data.
Most likely the “tele” will be provided by a digital
service. This is due to the larger
bandwidth requirements for video. So
what are our digital options?
From a network perspective, there are three possible topologies
when deploying a teleconference system: 1) Private internal network; 2) Teleconference
service network provider; and 3). Public Internet.
Private internal network
A private internal network requires that the doctor and
patient sites all be on one network. This is called a wide area network (WAN) and
is more typical of a hospital system with outside clinics and multiple
locations. This is not normally the case for a solo or
small group practice. For a private
internal network the owner must make sure there is enough bandwidth to support
video teleconferencing and configure the network to optimize the teleconference
network traffic. They will typically
purchase dedicated video teleconferencing equipment such as Polycom RealPresence or Cisco TelePresence. These systems enable group video teleconferences
as well as one-to-one.
Teleconference service
network provider
In this scenario the teleconference network, hardware and
software needs are handled by a vendor.
Teleconferencing will typically run as a service they overlay onto the
Internet using their servers, and they may sell or lease and support the teleconferencing
equipment. Think of it as a turnkey
solution. This may be used in a
situation where a practice doesn’t have a WAN or the technical resources to
support teleconferencing, but needs to have robust teleconferencing
capabilities.
The same type of
dedicated video teleconference equipment could be used here as we discussed
above. However, if one-on-one patient encounters are the primary purpose
for teleconferencing, then less expensive desktop devices can be
used. Desktop devices incorporate a
codec unit with audio and video capabilities.
It can take the form of a telephone with video screen, or a high quality
monitor with built in camera, codec and networking hardware. Or, instead of a separate piece of hardware it
could even be a software application installed on a computer with microphone
and video camera capabilities.
Whichever desktop device is ultimately chosen, the
technology behind the scenes is the same.
In fact, it could be that the patient station has a standalone desktop
device, and the provider station has a computer application. You just need to determine which device best
suites your needs, which is a topic we’ll address in the next post.
Public Internet
Our third option is the public Internet. The teleconference will run on the doctor’s
internal network, travel over the public Internet, and be connected to the
internal network at the patient location. This is a likely scenario for small
business and medical practices.
The advantage of using the public Internet is that it’s less
expensive and requires less technical knowledge. The disadvantage is there is less control
over the performance of the network. And
that’s important because video requires an orderly and consistent network. Video, just like everything else on the
Internet, is broken into little pieces called “packets”. These packets travel willy-nilly across the
Internet, sometimes traveling different paths.
But because they have delivery address information imbedded in them,
they get to their destination. Once
there, the packets are reassembled into video.
For video, the order the packets arrive in is important because the 30th
second of video must run before the 31st second and not before the
29th second. If the 30th
second is delayed, you see a jerky image.
On a private internal network and vendor supported network, the network
administrator can give the video packets priority so they always move in the
fast lane. But the public Internet is the
Wild West. More often than not this
works fine, but sometimes it doesn’t.
So what are our options when using the public Internet?
Well, first let’s look at a common Internet program, Skype. Skype is an online service which provides
audio and video communication between subscribed users. Computers at both ends need Internet access, the Skype software, video camera, microphone and speakers.
Skype has limited video capabilities (low definition) which
are dependent on the bandwidth available at both ends of the call. And while the call is encrypted, there are
still questions as to whether Skype is HIPAA compliant. So Skype could be an option for a specialty
such as mental health which may not require “medical quality” video. “Medical quality” video refers to video of a high
enough quality to enable the viewer to perform assessment and diagnosis.
While mental health has been using of Skype for a few years,
a specialty such as dermatology, with its need for medical quality video, would
not be appropriate for Skype.
Skype is just one of a whole marketplace of teleconference
applications. Another one is Cisco
WebEx.
For higher quality audio and video, we look to desktop
teleconferencing devices. A desktop
teleconferencing device consists of a user station with audio and video
capability at both the doctor and patient sites, and the audio/video signal is
compressed and decompressed as it passes from one station to the other. This type of equipment is typically used with
a high speed Internet connection such as DSL or T1. Another option, ISDN, is available, but is typically
cost prohibitive for smaller applications.
The teleconference session is just like a standard phone
call. At one station the user calls the
other station, either using a phone number, an IP number (a device’s unique
Internet address), MAC (a device’s unique hardware address), a user name, or
some other unique identifier. The person
on the receiving end is notified and answers the call, thereby initiating the
session. Typically the teleconferencing
equipment is preset with a directory so users know how to initiate a session.
Polycom and Cisco are two of the leading manufacturers of
video teleconferencing products. Typically a customer will with work with a
local teleconferencing vendor who will sell and install the equipment.
It’s important to remember that the teleconference will run
over the doctor’s network and the doctor’s Internet connection, as well as the
network and Internet connection at the patient’s end. Be sure to follow manufacturer
recommendations on bandwidth requirements, this is not the place to skimp. Both sides of the call need sufficient
bandwidth.
With the booming popularity of mobile devices, their
improving audio/video capabilities, and faster mobile and wireless networks,
Polycom, Cisco and other venders are rolling out robust mobile device apps
which integrate into the video teleconferencing ecosystem.
Confused yet? Don’t
worry, we’ll look at how to make technology decisions in the next post.
Diagnostic devices and information
If you can think of a diagnostic tool, someone has probably configured
it to connect to a computer. And if it
can connect to a computer, it can be used for telemedicine.
Here is a list of diagnostic tools I recently found at AMD GlobalTelemedicine’s website: colposcope, dermascope, Otoscope, Ophthalmoscope, General
exam camera, ECG, Spirometer, Vital sign spot monitor, Medication dispenser,
Non-mydriatic retinal camera, high definition (HD) camera and illumination, standard
definition (SD) camera and illumination, x-ray, x-ray scanner, ultrasound
system, ultrasound probes, endocavity probe, stethoscope, dental camera, nasopharyngoscope,
vital sign continuous monitor, vital sign spot monitor, microscope w/ video
and/or camera output, and weight scale.
Connecting a diagnostic tool to a computer or computing
device is accomplished with a physical connection (USB, serial port), network
connection (Ethernet port and cable) or wirelessly (BlueTooth, wireless
network). For more detail on this, refer
back to my posts on connecting medical devices LINK.
So how do we get the diagnostic information from the patient
site to the provider? That answer will
depend on how you handle patient information in general. Ideally that information will be aggregated into
a patient electronic medical record (EMR) which is available to the provider. Another option is to use an aggregation device
or software application which pulls all the patient data together and makes it accessible
to the provider. The next two sections
address these area in more detail.
Lacking an EMR or means of aggregation, we can fall back on the
good old fax for low resolution diagnostics.
HIPAA compliant email is an option, but not a good option. The need for security and passwords makes
this cumbersome. Another option could be
a secure file storage site on the Internet where files can be placed and later
accessed by a provider. Again, this must
be HIPAA compliant, and is still cumbersome, especially if storing large files
such as radiology images.
Patient Record
At some point the telemedicine provider will want to review
the patient’s history. Optimally, both
the provider and patient sites will have access to the same EMR software, or
the doctor will have access to a portal containing the patient’s medical record. Lacking that, the patient helper will need to
transmit the patient record to the doctor via fax or HIPAA-compliant email.
A benefit of an EMR is that it can incorporate diagnostic
information gathered at the patient site.
To access a provider-supplied EMR, the patient site would need access to
the EMR. That would require either an
EMR hosted outside the provider’s network, or configuring the provider’s
network and EMR to allow outside access. Appropriate licensing and user training would
also need to be addressed.,
Aggregation tools - Bringing it all together
Aggregation tools are hardware and software tools which
bring together the audio/video conference, diagnostic information, and the
patient record.
Aggregation software is the software which unifies
the on-screen presentation of the video conference, patient record, and diagnostic
information. For example, at the patient
end an ECG is connected to the computer and the reading is captured in the ECG
software. The patient helper enters
chief complaint and HPI into the EMR. At
the doctor’s location, the user has a menu which allows her to select what information
to view: live video, EMR, ECG software, or tile some combination of these on
the screen. The specific functionality
varies between software packages, but you get the idea.
Aggregation appliances are equipment which physically
incorporates communications, diagnostic, and medical record access into one
package. Typically these are carts which
can be wheeled around as needed and include batteries and wireless
communications.
So what now?
Now that we’ve surveyed the telemedicine technology landscape,
we need to figure out how to select the appropriate technology. In my next post I’ll look at some scenarios
and discuss how I would approach the technology selection process.
As always, if you have corrections, clarifications or additions,
please feel free to let me know. As I
said in the first post of this series, I’m not a telemedicine expert. I’m just passing along what I’m learning.
http://en.wikipedia.org/wiki/Plain_old_telephone_service
http://ctel.org/
http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html
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