Boston Children's Hospital Monitors Young Patients with Data from Caregivers; Parents, Teachers and Coaches
Dr. Eugenia Chan sat patiently waiting for her fidgety first grade patient and her frustrated mother to answer her question. "How was the new medication working to help Janie with her ADHD"? Janie's mom hadn’t had a chance to fill out an ADHD behavior questionnaire in the chaotic waiting area, so she tried to summarize her impressions since their last doctor’s appointment a few months ago. She hadn’t heard specific feedback from Janie’s teacher, and had also forgotten to give the ADHD questionnaire to her teacher so that they would understand how she was doing in school.
In 2011, Dr. Chan, MD, MPH, a developmental-behavioral pediatrician and health services researcher in the Division of Developmental Medicine at Boston Children’s Hospital, felt that she needed a better way to monitor her patients and gather insight into how they were doing with their medications and treatment plans. With a grant from the Croll Family Foundation, Dr. Chan collaborated with Dr. Eric Fleegler, MD, MPH, a pediatric emergency medicine physician and health services researcher in the Division of Emergency Medicine at Boston Children’s Hospital, on the development of a new software tool, eDMC (electronic Developmental Medicine Center).
Their goal was to gather and interpret the information from parents and teachers more effectively and gain a more comprehensive view into patient behavior between visits. The doctor determines when the system will email the parents, typically a week or two before the appointment. When the parent receives the email with a link into the software platform, she logs in and answers a set of questions about symptoms, school performance, quality of life, global functioning and improvement since the beginning of the treatment. The parent gives the email addresses of the patient’s teachers and other important observers of the child (e.g., sports coaches, behavioral therapists, tutors) to the clinician to get them set up in the system so they can answer similar questions.
With this information, Dr. Chan is able to determine how her patient is doing throughout the day, week and over time. During the visit, she shares this information with her patient and family, points out trends and discusses what has transpired. On the graphs, each line shows data from a different caregiver; parent, teacher and coach. The clinician can also drill down to see specific symptoms and their ratings that are incorporated into a score. With the treatment plan in mind, the clinician evaluates the data and focuses in on any discrepancies to determine what is really happening. This exchange supports her clinical decisions and enables her to participate in shared decision making with her patient and his family.
“I’ve already started using the system to work with my adolescent patients who want to go off their medications. When I agree to let them try coming off meds, I suggest that we use the questionnaires to monitor results. At the next appointment, patients are often surprised to view parent and teacher ratings and comments, that she was ‘disruptive’ or was ‘unable to pay attention’”, describes Dr. Chan.
Another feature of the platform is the ability to notify the clinician when there is a “red flag” patient problem that may require action (i.e. severe depression). Even though parents are made aware that this is not a real time monitoring system, there is someone responsible for ensuring that clinicians have seen the red flag alert.
Since the program started, over 3,000 pediatric patients have participated. One parent comments on the value that she sees with the system, “it is very easy to use and I like that we save the time at the doctor’s appointment and all of the information is there”. Dr. Fleeger adds that the system “transforms how patients are interacting with their clinicians. At the appointment, the clinician can show them the graphs and tables on the computer to understand where they are and have a fruitful conversation”. Dr. Leonard Rappaport, Chief of the Division of Developmental Medicine at Boston Children’s, says that the platform “is the first major improvement we have made in individualized care for developmental disorders in the past two decades.”
Currently the clinician can copy patient level summary information from the system into the EMR. Although the platform is web- based, Dr. Chan mentioned they were creating a mobile interface for access through smartphones and tablets.
Expanding ICISS Health; More Patients & Populations
In 2012, Dr. Chan and Dr. Fleeger renamed the platform the Integrated Clinical Information Sharing System (ICISS Health) to be more generalized for expansion into other pediatric patient populations.
“We have extended the ICISS Health platform to additional clinics at Boston Children’s that treat patients with ADHD, as well as private practices affiliated with Boston Children’s, and we are expanding into new conditions such as autism, asthma, depression and epilepsy”.
For each new condition, they have convened a cross disciplinary team to define the data that need to be collected to support decisions. “For example, we are working closely with clinicians from the Boston Children’s Autism Center to devise a questionnaire for patients, since there is no standardized set of questions for this patient population” explains Dr. Chan. “For asthma, we would like to invite the school nurse to participate and provide insight into frequency of nurse office visits and rescue medication use by the patient, and whether they used the patient’s asthma action plan.”
The team at Boston Children’s is in the process of collecting information to evaluate the ICISS Health platform impact on patient health outcomes and healthcare utilization and costs. Dr. Chan also mentioned their interest in calculating potential cost savings from the platform by identifying problems early and intervening in time to prevent emergency department visits and hospitalizations.
“As we think about the future of the platform, we are interested in going beyond the electronic questionnaires to capturing and integrating information from devices and mobile applications”, Dr. Chan concludes.
In October 2012, Mercy Hospital Springfield of Missouri, and two other health systems launched a Centers of Excellence program with a major retailer to provide spine care for associates and their family members covered by the company’s medical plans. When an associate chooses to receive care at a Center of Excellence, they do not pay any out-of-pocket costs. In addition, the retailer picks up the tab for travel, lodging and food for the patient and caregiver. Mercy was chosen based on three factors: ethics, quality and value. Mercy Hospital is a Stage 6 Hospital in the HIMSS Analytics EMR Adoption Model (EMRAM).
The following October, Mercy Hospital Springfield added another contract with the Pacific Business Group on Health (PBGH), which includes large employers like Walmart and Lowe’s. This agreement established a Center of Excellence for knee and hip replacements.
With patients coming in from other parts of the country for various procedures, it became apparent to Mercy that patients needed some information before arriving in Springfield, Missouri. “One of the challenges that we addressed was how to effectively deliver patient education and a good patient experience when the patient is not in front of us,” explained Pam Holt, director of Patient Education and Care Management at Mercy. “We needed a way to empower remote patients with information about what will happen and what to expect during their surgery. Easing patients’ anxiety and ensuring they are comfortable is a top priority for us.”
Mercy selected EmmiEngage, a patient engagement solution which provides an interactive health information platform certified for Stage 2 Meaningful Use for Patient-Specific Education. Each patient in the Destination Program receives an email from Mercy. The email contains a unique link enabling access via the web or mobile to customized videos with simplified medical information. Patients can view the videos many times and share them with friends and family. “Some of our older patients may go to their adult children’s homes because they don’t have a computer or they just want to watch the video together,” said Holt. “Plus, the back-end system allows our clinicians to know if patients have reviewed the educational information. If they have not, we’ll reach out to ensure the patient gets that prior education and is prepared for surgery.”
When traveling for care, it is particularly important for patients to prepare for discharge before hopping on the airplane. “For example, if their bedroom is upstairs, they may want to use a spare bedroom downstairs during their recovery,” Holt explains. “This information helps them think about their needs ahead of time. In fact, that’s good preparation for all of our patients, which is why we use this tool for patients who are local as well those who travel here.”
EmmiEngage provides a personalized informative overview. It is not intended to take the place of conversations between the patient and their doctor, but instead supports the relationship between them. “At Mercy, we view the solution as a technology to relay ‘general treatment’ information in an approach that suits patients’ learning style. However, we know that each patient has a unique set of circumstances that will impact their surgery and only their doctor can deliver those specific instructions,” described Holt.
Patient Related Measures
Mercy greatly values patient feedback and the responses to the program reinforces the belief that this approach is working.
“I was very impressed with the presentation! It was most helpful. Some things I already knew and it gave me some new ideas of what I can do to help myself. I have a lot more questions I will be asking my doctor the next time I see him.”
“The video was very informative and insightful. I feel I am going into this procedure with a better understanding of the procedure I am facing.”
“Rather enjoyed knowing what will happen and the risk involved. Very helpful overall”.
In addition to qualitative feedback, Mercy monitors specific patient related success measures. “We know that 85% of patients are consuming educational content through their portal. Ten percent have asked questions and 15% have contacted their doctors after reviewing the educational information. From a patient experience standpoint, 80% of patients report that the portal programs answered questions that the patient would have asked their doctor,” Holt added.
Mercy clinicians also value using technology to support patients prior to their surgery. “Patients who view a program are more prepared for their procedure and have a better understanding of their health. The benefit is two-fold: it pays off in saved clinic time and helps the patient feel more comfortable about their care,” concluded Dr. John Brown, Mercy Family and Travel Medicine.
Patient education is a key component of Meaningful Use Stage 2 but also there is growing evidence that effective patient education can impact patient outcomes as well as improve patient engagement and satisfaction. Providing these tools for patients, whether remote or local, as part of a risk sharing agreement or through traditional reimbursement, is an effective approach to patient engagement.
Massachusetts General Hospital (MGH) and parent organization Partners HealthCare have a long history in telemedicine and innovation. In 1967, Drs. Ken Bird and Jay Sanders were early pioneers in telemedicine, providing care to patients at Boston’s Logan Airport. The innovation continued in 1995 when Dr. Joe Kvedar founded the Partners Center for Connected Health (CCH). In 2001, Dr. Lee Schwamm launched the Partners TeleStroke Program, through which MGH and Brigham and Women's Hospital provide 24/7 TeleStroke care to 30+ community hospitals in New England. The program also enables other US hospitals to deliver TeleStroke services.
In 2011, MGH launched a small startup within the organization’s walls, a hospital-wide initiative called Massachusetts General Hospital TeleHealth. Building on the TeleStroke Program success and in partnership with CCH, the team is focused on achieving the goals of better, accountable, and affordable care for individual patients and populations using technology. The program enables clinicians across multiple specialties to provide high-quality, coordinated care to patients and families using familiar technology; phone, video, text, email, mobile apps and remote monitoring.
MGH has successfully embedded telehealth into patient care in several specialty areas and believes telehealth to be a mode of care delivery to help achieve the triple aim. While 21 states and the District of Columbia have laws mandating telehealth coverage under health insurance plans, Massachusetts is not among them. Given the lack of payer reimbursement, MGH is committed to paying its clinicians to provide telehealth services to patients. However, for MGH and others to expand telehealth services, universal mechanisms for funding healthcare need to align to new models of healthcare delivery.
MGH TELEHEALTH JOURNEY
“In our early days, we were willing to try most anything, and have learned a lot through trial and error and close partnership with clinicians across the institution,” says Sarah Sossong, Director of the Mass General TeleHealth program.
Building off the TeleStroke model, clinicians in Pediatrics, the Burn Center, and the Brain Tumor Program now offer emergency consults to clinicians treating patients in community hospitals. Cardiac ICU attending physicians use a robot to virtually round on patients. Multidisciplinary teams in the MGH Cancer Center conduct virtual case conferences with community hospitals. Specialists in cardiology, dermatology, and neurology provide virtual curbside consults to MGH PCPs to facilitate timely and comprehensive medical advice. “By fostering innovation in multiple areas, our goal is to identify the ‘sweet spots’ for telehealth,” Sossong explains.
The Mass General TeleHealth program continues to implement and expand virtual offerings. “Virtual visits” replace an in-person office visit using familiar technology like video and email on a smartphone, tablet, or computer. Since launching in spring 2013, 50+ clinicians across five divisions have conducted more than 1,200 video-enabled virtual visits with existing MGH patients in their homes and other settings.
Mass General’s Department of Psychiatry was one of the first to launch video-enabled virtual visits to patients in the home, with a focus on children and adolescents with autism spectrum disorder under the clinical leadership of Dr. Janet Wozniak , associate director of the Bressler Program for Autism Spectrum Disorders at MGH and director of the Child and Adolescent Outpatient Psychiatry service. Dr. Wozniak calls virtual visits an “outstanding addition” to her clinical practice. Following autism pilot success, virtual visits rolled out with patients across 20+ disease conditions including depression, anxiety, and ADHD. “One surprising finding has been that patients who spoke very little during office visits have become more open and able to discuss their symptoms via video,” explains Wozniak.
Mass General’s Department of Neurology has been an early adopter of virtual visits for patients with benign conditions like migraines, and others for which long-distance travel can be challenging (i.e. Lou Gehrig's disease, stroke, multiple sclerosis, muscle diseases, movement disorders, seizures).
Dr. Adam Cohen, TeleNeurology and Neurology’s inpatient director, comments that “virtual visits allow us to see our patients from every corner of the state. The ease of virtual visits offers huge benefits to our patients who no longer have to trek into Boston and also for our patients who have difficulty traveling. Virtual visits also make it easier to check-in with our patients, often for just a few minutes.”
Dr. Stephanie Moore in Mass General’s Heart Center has been pioneer of telehealth through her work in remote monitoring for Heart Failure patients with CCH. Remote monitoring has become standard practice for many heart failure patients discharged home. Dr. Moore has incorporated virtual visits into patient care to facilitate patient education by her nursing team and is exploring how virtual visits can work with other virtual tools like remote monitoring.
Dr. Ami Bhatt, a specialist in treating adult congenital heart disease, has found virtual visits enhance patient care. “My patients are busy and often live several hours away. A quick visit to review test results ends up being costly, and a call is not enough to explain results and educate patients to be their own advocates.” With virtual visits, Dr. Bhatt walks patients through their heart images and test results.
At the MGH Burn Center, Dr. Shawn Fagan developed a successful program providing follow-up care to patients at Boston’s Spaulding Rehabilitation Hospital. The program has benefited many patients including Boston Marathon bombing survivors treated at MGH and subsequently treated at Spaulding. With Spaulding’s telemedicine nurse, the patient connects to the TeleBurns team with a virtual visit instead of a trip to MGH.
One patient shared that “staying in contact with Dr. Fagan from the convenience of Spaulding was huge. It was like talking to him face-to-face. He had the equipment to see me, make decisions and treat me.”
MGH TELEHEALTH SUCCESS EVALUTATION
Healthcare providers at MGH and elsewhere have shown that telehealth lowers costs when compared with traditional in-office visits. There is also a significant improvement in patient access to medical expertise, convenience, and care quality through collaborative care opportunities that otherwise would not exist in specific clinical case scenarios.
In the first few years, the MGH TeleHealth team worked on building and implementing scalable technology platforms and integration with existing clinical workflows. “The past year has been focused on feasibility and adoption by patients and clinicians, and feedback from both groups has been overwhelmingly positive. As we continue to expand the program, long-term sustainability is our top priority,” says Sossong.
Patient Experience & Satisfaction:
Overall, patient feedback about the telehealth experience has been very positive. The clinical team has learned that virtual visits are most successful with patients who have frequent touch points with the healthcare system or who are geographically distant.
“The virtual visits have helped me save on gas, parking, and still achieve what we want to achieve”, shares one telehealth patient. With virtual visits, “I have my doctor in my living room, and I feel like we're a team.”
“Our early surveys show high rates of satisfaction and willingness to pay,” Sossong adds. “While there aren’t any national benchmarks for patient satisfaction with telehealth, we have patient feedback on virtual visits around quality, privacy, ease of use of the technology, and satisfaction (i.e. CAHPS). While it’s not an apples-to-apples comparison, initial patient feedback about the virtual visit experience in selected domains reflects higher satisfaction rates than in-person visits.”
Clinician and Department Experience:
Clinicians across multiple programs have also found that virtual visits allow them to stay focused on delivering patient -centered care.
Specialists providing follow-up care for patients discharged to Boston’s Spaulding Rehabilitation Hospital typically take the shuttle between MGH in Boston and Spaulding. By enabling MGH specialists to conduct virtual visits with patients at Spaulding, patients receive more timely clinical care, and specialists have additional time to see patients in clinic, instead of sitting on a shuttle.
One high-volume medical practice reported that patients receiving care through virtual visits were more likely to show up for their scheduled appointments, reducing the overall no-show rate for the department. The practice manager explains, “Like anything, it takes time to learn a new way of doing things, but we’re excited to see how virtual visits become incorporated into standard medical care as clinicians and patients become increasingly comfortable with the technology and processes”.
FUTURE TELEHEALTH DIRECTION
The MGH TeleHealth team is developing plans to expand the program in 2015. “In the coming year, our goal for video-enabled virtual visits is to more fully integrate them into the standard practice of care by deepening adoption in existing departments and expanding to new departments. In the future, there are a number of exciting possibilities,” says Sossong.
Multiple Modalities: “While there is tremendous value in interventions using a single technology, such as video-enabled virtual visits, I’m eager to explore how we can design a seamless, convenient, patient-friendly experience by putting all the pieces together. For example, a patient being treated by a psychiatrist for depression could have a treatment plan which includes using an app for tracking mood changes throughout the day, receiving text reminders about medication or an upcoming appointment, exchanging emails with the clinician about symptoms in between visits and conducting a video-enabled virtual visit for therapy, or checking in on medication symptoms. When it’s necessary to be ‘touched’ by the healthcare team, the patient can come into the office for an in-person office visit.”
Patient Education: “While our current work is focused on everything that goes into making the video-enabled virtual visit happen, there’s interest in exploring related educational tools for patients as well. For example, a recording of the virtual visit, or even the in-person visit, could be helpful as an educational tool for patients and families to review once settled back home. I can envision a future where we’ll discharge surgery patients with online portal access to a recording of their own clinician’s instructions for post-operative care, which could be one of a suite of tailored educational tools including condition specific videos or articles, or even seasonal tools for things like cold/flu season.”
The MGH TeleHealth team is determined to identify where telehealth can work to bring care access, convenience, and education to patients. “People bank online, shop online and Skype with family and friends online. Patients will start to expect to receive healthcare this way too,” Sossong concludes.
Geisinger has been investing in mobile technologies to engage patients and their families in their care since 2011. In my blog post last year, I shared Geisinger’s texting programs, mobile data capture and experiences with their first mobile app to support Cardiac Rehab.
Geisinger continues to explore new technologies to involve patients and to improve the patient and physician interaction. “Mobile apps are just another way to drive patient engagement. We think we will have better adoption by patients if we use technology that they have already adopted in their lives”, explains Chanin Wendling, Director, eHealth, Geisinger Health System. “Our goals are to improve patient outcomes and reduce costs. We pursue patient engagement because of studies from folks like Hibbard & Greene 2013 and Veroff & Wennberg 2013 that show that engaged patients have better outcomes at lower costs. We want to provide patients with tools that help them understand their condition and follow their care plans so they can stay as healthy as possible.”
Piloting Mobile App Supporting Bariatric Surgery
Geisinger began piloting their second mobile app Get~2~Goal in September, 2012 to help manage patients’ surgical weight loss expectation and provide a journal for tracking weight loss after the surgery. The Get~2~Goal app presents the patient with personalized weight management goals using her own entered data (e.g. age, weight, height). She can monitor her weight loss towards that goal and see how she is doing compared with other patients like her.
The app was developed by Geisinger’s Obesity Institute in collaboration with Bucknell University’s computer science staff and students.
Patients have shared positive comments including:
“Great App! Surgery on Tuesday, so this will be a great motivator”
“I like it. It's very helpful and lets you know whether you're on the right track or not weight wise. So far I'm doing above average. Woo hoo to us!”
The clinical sponsor for the Get~2~Goal project was Dr. Christopher Still, Director of Geisinger Obesity Institute and Medical Director for the Center for Nutrition & Weight Management. He uses the app when discussing bariatric surgery with his patients and, recommends that they download it to their mobile devices. Dr. Still has observed an improved patient/physician interaction when a patient sets realistic weight loss expectations with the guidance of the clinician. “This app allows patients and their physicians to discuss patient specific outcomes regarding gastric bypass surgery. It is important for both the patient and their physician to have real expectations and assess the risk/ benefit of the procedure.”
Building Mobile Apps Ourselves
In addition to experimenting with Cardiac Rehab and Get~2~Goal apps, Geisinger wants to expand into apps for different chronic conditions and set out to research the market. “We were disappointed with what we found. Most vendors had apps focused only on one chronic condition. Although vendors had plans to expand into other chronic conditions, we had a hard time picking a reasonable partner based on their stated direction”, Wendling explains.
Wendling feels the mobile health app market is still in the early stages. She explains that vendors are approaching her organization with a business model that just doesn’t scale. “If a vendor charges us a rate of $10+ per member per month, how do we make that work for patients with multiple conditions? We have over 75,000 patients with hypertension and 30,000+ with asthma. Although the app will not be appropriate for all of these patients, the costs add up rather quickly.”
After evaluating many mobile apps, Wendling points out that the patient experience is not thought through. She has asked vendors about how patients can personalize their app. “I may be a patient who works night hours so why shouldn’t I be able to set the time of the reminders to fit my schedule? Also, why can’t I select the method of receiving the reminders, through email or text messages”, adds Wendling.
The final reason that Geisinger has decided to build mobile apps internally is because integration is important. “We’ve found that many solutions do not integrate with our EMR which is essential since we need to incorporate the patient information into our clinical workflow” Wendling explains. “Although it is not unusual that the early innovated apps do not integrate with the EMR, vendors do recognize that they need to get there. So any app we purchase, we would most likely have to do the integration ourselves anyway. We haven’t made any decisions that we will always develop our own apps. If we see something out in the marketplace that works and we have the budget, we will go for it. We just may need to wait a little longer until the marketplace matures.”
Mobile App Development Journey
As their first venture into internal mobile app development, Geisinger selected a simple procedure and defined key capabilities which are replicable across more complex procedures. With the new Colonoscopy mobile app scheduled to be launched next month, patients can prepare for their procedure through:
- Education: explains what will happen during the procedure
- Shopping: lists can be created and transferred as a note to the mobile phone
- Reminders: for days before the procedure directing the patients to steps that need to be done
- Pictures: visual guides of their bowel movement during the preparation process
“Geisinger’s colonoscopy mobile app is unique among health care related apps in that it provides a personalized experience for the patient. From prep instructions based on scheduled appointment time, interactive ’am I ready for my procedure’ section to the ability to easily set reminders/alerts; this app takes advantage of a lot that mobile technology has to offer. As a gastroenterologist, my hope is that this app will allow patients to feel more empowered and in control of their bowel preparation; typically the most difficult part of the colonoscopy experience. We know that with improved prep comes better outcomes and thereby, over time, lives saved. I feel that modern health care needs to embrace mobile technology as a rapidly growing and exciting tool to improve patient care”, explains Dr. Amitpal S Johal, Director of Endoscopy, Geisinger Medical Center.
“We are looking into other surgical procedures which can use this same set of capabilities. One area that we are considering is Vascular surgeries since we work closely with our Vascular department at Geisinger”, shares Wendling.
Future Mobile Health Roadmap
As they look to the future, Geisinger is working on enhancing current mobile apps and is exploring the use of mobile to support patient care before, during and after a hospital visit.
The next version of the Get~2~Goal app is under development. Geisinger is improving the patient experience through a better user navigation, the capability for patients to enter their own weight loss goals, and the addition of recently developed calculations for other bariatric surgery outcomes (i.e. likelihood for remission of diabetes).
Geisinger is also looking into ways that mobile devices and apps can help patients pre, during and post hospital stay. They are starting with their Janet Weis Children’s Hospital which treats kids with complex conditions such as cancer, heart or neurological issues. Geisinger understands that being in the hospital is scary for the child and their family. “With mobile apps, children and their parents will be able to prepare for the surgery, use an iPad during their hospital visit to capture pain levels and then track their recovery at home”, describes Wendling.
In the future, Geisinger is planning for a personalized patient experience. “Our dream is to be tailored in our patient care. Given the patient’s profile, s/he will have technology options and tools to gather preferences and schedules to guide the care plan. We want to use this information to also match the appropriate intervention”, Wendling concludes.
In January 2013, University Hospitals Rainbow Babies & Children’s Hospital launched the Rainbow Care Connection, a pediatric accountable care organization (ACO) with a $12.7 million CMS innovation grant to support children in Northeast Ohio, a third are enrolled in Medicaid. This innovative ACO has developed several successful mobile health initiatives to drive care collaboration with patients as part of their Physician Extension Team. This blog focuses on two key mobile health initiatives; iPads Minis for children with complex chronic conditions and HealthSpotSM, a community- based telemedicine kiosk.
iPad Mini For Care Collaboration
“We wanted to help children with chronic medical conditions, especially those who have difficulty speaking or getting around. For children that cannot walk, it is challenging to get them to the office. By giving them an iPad Mini, these children are able to communicate with their care team including physicians, nurses, social workers and dieticians”, explains Dr. Richard Grossberg, Medical Director of University Hospitals Center for Comprehensive Care. “Our goal with this project is to reduce office and ER visits with this video connectivity.”
In partnership with UH’s Rainbow Care Connection, the Center for Comprehensive Care strives to pioneer innovative ways to support children with complex chronic conditions, which can often seem overwhelming from a family’s perspective. As medical care continues to grow more complex, healthcare professionals acknowledge that families may need support beyond the clinic and hospital walls in order to be successful.
Children with complex chronic conditions make up about 5% of children who access health care services but account for up to 50% of Medicaid dollars spent. “We were looking for an additional layer to outpatient care; providing families with an opportunity to manage less acute issues in the comfort of their own home”, Dr. Grossberg shares. “Launched in December 2013, we felt that video calls would be the most innovative and cost effective solution to accomplish this and have currently distributed 10 iPad mini devices to families.”
How do video calls work? A family uses their iPad mini to conduct a “video call” with the office. During their telemedicine visit, a Comprehensive Care nurse helps the family triage what is happening and can resolve or escalate care to a physician/nurse practitioner or acute care setting when needed. Additional applications of the video call are being trialed including conducting nutritional counseling and education by UH’s Comprehensive Care dietitians and therapeutic counseling completed by their Comprehensive Care social workers.
After the video call, the visit summary is documented and sent to the patient’s PCP. If a video call is escalated to include an ED or hospitalization, the UH acute care team has full electronic access to all of the video calls and assessment notes. Having the necessary tools to help guide a family though those moments when their child’s complex conditions go awry and help them overcome barriers to care is critical to helping families receive better care, achieve better health and gain a healthcare partner to share in their patient experiences.
UH’s Rainbow Care Connection aims to reduce ER costs by finding new ways to support patients who go the ER with minor medical problems.
“Since we know that 70% of Medicaid patients in the ER can be managed in a less acute setting, we were looking for an alternative to provide access to care after hours. We wanted to test offering a solution in a community setting to see if this population would feel more comfortable getting after hours care in their own neighborhood rather than from a medical setting. We felt that telemedicine would be the most cost effective solution to accomplish this”, shares Dr. Andrew Hertz, Medical Director of University Hospitals Rainbow Care Connection. We had already piloted a HealthSpotSM kiosk running in our clinic and were ready to place a kiosk into a community setting”, Dr. Hertz explains.
“We decided on the HealthSpotSM kiosk vs other telemedicine units because of the incredible patient experience provided by the HealthSpotSM unit, including diagnostic equipment and the ability to transmit real-time vital signs and physical images.” Dr. Hertz and his team thought carefully about where to place the kiosk. “We started with a zip code analysis of patients coming into our ER to select potential locations and met with Community Neighborhood Association Leaders to discuss options. We chose the Friendly Inn Settlement (community building) in Cleveland and launched the program in October 2013.”
How does the HealthSpotSM kiosk work? A patient and their family members step into the fully enclosed kiosk with a medical assistant who helps support them during their high-definition video conference visit with the doctor who may be located a few towns away. “Our doctor is on the computer screen, with video and audio connectivity to instruments (i.e. scale, blood pressure cuff, stethoscope, otoscope, thermometer, dermascope, pulse oximeter) and decides which tools to use and when by unlocking the door at the right time. It is cool when they unlock it. It is magical to see the door open and the instrument there. Our patients and their families see what physician is seeing as they use their different devices. It is a wonderful educational experience”, describes Dr. Hertz.
Patients use the HealthSpotSM kiosk to take care of minor ailments and get check-ups, as an alternative to an emergency room visit. A parent/guardian can accompany a child from age three to 18 during their visit to the UH Rainbow HealthSpotSM station during weekdays from 5:30 – 11 p.m. and weekends from 1 – 11 p.m.
Since the launch of HealthSpotSM, Dr. Hertz and his team at UH have met with over 50 patients, with problems including rashes, fever, strep throat and pink eye.
After the remote appointment with the doctor, the visit summary is documented and sent manually to the patient’s PCP. “Our physicians currently document the visit on paper and fax it to the PCP who may be outside of the UH network. Over 50% of these patients are not in UH Rainbow’s system so we share their information like a retail clinic. We have an interest in having HealthSpotSM integrate this visit information into our hospital EMR,” explains Dr. Hertz.
“Anytime we can spend time with a patient in their own environment, we can better understand and address their needs.” Dr. Hertz adds that by understanding why patients choose the ER as their source of care enables his team to identify opportunities to change that behavior and meet patient needs. Certainly, having after-hours access to quality care in the inner city is valued by patients since the ER is often their only after-hours option.
Patients and family caregivers have had a very positive experience with the telemedicine visit within UH’s HealthSpotSM kiosk. 85% have indicated that if they did not have the HealthSpotSM visit, they would have gone to the ER. Over 90% would use it again. Here are some comments around value of the visit to them:
It's convenient and less time consuming.
I love the equipment and technology.
The one on one with the doctor.
That you get to see what's going on inside the little areas most doctors won't show you.
Close to home and speed of service.
Very helpful for my community.
Future Opportunities for UH Patient & Family Engagement
The team at the UH Rainbow Babies & Children’s Hospital Rainbow Care Connection is already planning ways to use the HealthSpotSM kiosk to bring care access to other patient populations. “Next we want to use telemedicine to enhance access to care in rural areas, where there are not a lot of specialists or after hours care options. We are planning to place a kiosk in a community building or a school”, Dr. Hertz adds.
In addition to expanding the HealthSpotSM kiosks, Dr. Hertz is interested in finding patient engagement tools that will help patients receive care through their phones to support the lower social economic population that tends to own mobile phones rather than computers. “No one has developed the mobile app for patients to receive care through smart phones which would enable a ‘meaningful clinical interaction’,” concludes Dr. Hertz.