The Telemedicine Tourniquet
Inside the Mayo Clinic’s Center for Innovation in Rochester, a new initiative is taking shape: the development of Mayo’s Center for Connected Care.
“This is a major initiative of the Mayo Clinic across all of its campuses,” says Dr. Bart Demaerschalk, director of the Mayo Clinic’s telestroke and teleneurology program and a vascular neurologist with the Mayo Clinic Hospital in Phoenix. The vision is to “provide virtual care to patients regionally, within states that are historically Mayo Clinic territories, but also nationally and globally.” And not just in Demaerschalk’s specialty of stroke diagnosis and treatment.
“We imagine that Mayo Clinic can provide telemedicine across every medical and surgical discipline that our institution provides service for,” he says.
Mayo, like many other health care systems, is already engaged in virtual care on a number of fronts: in radiology, dermatology, infectious diseases, and other fields. Demaerschalk’s work in Arizona six years ago helped pave the way.
He and colleagues used technology to improve the speed and effectiveness of communication between Mayo’s stroke neurologists in Scottsdale and the emergency room teams at Arizona’s small regional hospitals. The telestroke platform’s audio, video, and digital connections put a Mayo specialist in the ER virtually, able to talk with patients, see and be seen by them, monitor vital signs, and use diagnostic tools. It was a big improvement over the norm of simply doing consults with emergency physicians on the phone, or transferring the patient to a stroke center. The result, in a clinical study, was a 14 percentage point increase in the accuracy of diagnosis and emergency treatment for stroke.
Mayo eventually installed one of the telestroke units in its own hospital emergency room in Scottsdale, even though, unlike rural hospitals, Mayo had specialized neurologists on staff.
“Our emergency department doctors at Mayo Clinic Hospital were jealous, because in fact, our response to the remote hospitals was faster than our ability to respond to our own emergency department,” Demaerschalk says. Having neurologists on call to phone in or come in during evenings and weekends couldn’t match the telestroke protocol’s median response time of one minute.
Big Wins Through Big Shifts in Capacity
There are demonstrable care upgrades with the telestroke program on all fronts, Demaerschalk points out. Those include better outcomes for patients, especially those who would otherwise be at a disadvantage because of rural-urban disparities in availability of care, and viability for rural hospitals that lack specialists and often must transfer patients far from home and lose those billings. And it also helps the Rochester-based Mayo Clinic system with new revenue from subscription fees that smaller hospitals pay for the telestroke service, not to mention growing Mayo’s business geographically without building or buying facilities.
Throughout the health care industry, people are looking for big wins from “telehealth,” the umbrella term for a whole range of ways to provide care through digital and telecom connections between clinicians and patients.
Telehealth is one major way that the health care system seeks to reform itself. It’s a means to reach the much-discussed “triple aim” of improving the quality of care for patients, improving the health of populations, and reducing per capita cost. Telehealth could contribute to achieving those goals because it has the potential to bring about big shifts in health care system capacity.
You might even be a part of those shifts if you’re among the hundreds of thousands of Minnesotans who’ve made an “e-visit” to an online clinic. (And you thought you were just taking advantage of a convenience.)
“Our patients say that they’re saving more than two and a half hours of time” compared with an in-person clinic visit, says Kevin Palattao, vice president of clinic patient care systems, including the Virtuwell 24/7 online clinic, for Bloomington-based Health-Partners.
Virtuwell promises users a diagnosis and treatment plan in 30 minutes for a fee of $40. It’s available to anyone in Minnesota or Wisconsin, not just members of HealthPartners, which is a care provider and an insurance provider. Fairview Health Services promises something similar through a partnership with local technology startup Zipnosis: a diagnosis and treatment plan within an hour for $25. Anyone can use the service, not just patients of Minneapolis-based Fairview. Other providers offer e-visits, including Mayo Clinic and Twin Cities–based Allina Health and Park Nicollet.
For minor problems such as allergies, rashes, and sinus or bladder infections, e-visits are a convenient way to go. You spend a few minutes online giving information about your symptoms, and most e-visit programs respond within a few hours by email or phone and send a prescription, if you need one, to your pharmacy. Your cost is about what you’d shell out for a copayment if you made a real clinic visit, but you’re in and out of the system in a fraction of the time—all while you’re still at work or in your pajamas at home.
And because you’re elsewhere, someone else can be seen at the clinic. “This effectively takes some of that easier stuff to diagnose and treat off our schedules and will allow our care system to spend more time with the people who need to be seen in person,” Palattao says.
In other words, “this not only creates conveniences,” he says, “it’s moving care to the right venue.”
About two years ago, Fairview equipped all of its hospital ICUs with telehealth technologies—webcams, remote monitoring, a suite of capabilities resembling the Mayo telestroke platform—and connected them to a central hub and an advanced ICU team at the University of Minnesota Medical Center, a Fairview affiliate. The goal, says Dr. Terry Martinson, Fairview’s design principal and executive medical director for innovation and transformation, is to raise care to a consistent standard across all Fairview ICUs without having to move patients to a different hospital. As with the telestroke program, Martinson says this leverages the scarce resource of skilled, specialized physicians.
At the same time, he says, virtual care “keeps less complex patients out of the university ICU, so they have capacity and can accept the more complex patients.”
Mining More and Better Data
Minneapolis-based Allina is digging deeper, mining the stores of data that telehealth enriches. “I think we’re just scratching the surface” of telehealth’s potential, says Susan Heichert, chief information officer for Allina Health and a registered nurse.
Allina uses software called MyChart to let its patients make e-visits with clinicians. Hundreds of other care systems in Minnesota and nationally also use MyChart, including Park Nicollet and Fairview. In addition to serving patients with minor ailments, MyChart can accommodate follow-up from an in-person appointment or treatment for a chronic condition such as diabetes.
A product of Epic Systems Corporation of Wisconsin, MyChart is an electronic health records system, the digital equivalent of the hard-copy charts that doctors and nurses have traditionally used to record patients’ exam and test results, health episodes, and treatments.
Every time someone uses MyChart to get virtual care, the software captures the information and adds it to that patient’s electronic health record.
Allina runs the hospital in-patient records through its own set of algorithms every two weeks. “We have a very strong analytics group,” Heichert says, “and we’ve put a lot of focus behind that.”
The algorithms flag people who are at high risk of a hospital re-admission based on combinations of factors that could include age, number and kind of chronic health problems, test results and other physical indicators, a history and pattern of care needs, and the supports that the person does or doesn’t have at home. Reducing the cost of health care by reducing preventable hospital re-admissions is a hot-button issue and a mandate of the Affordable Care Act. “We’ve been able to predict with pretty high accuracy whether an event is going to occur with a particular high-risk person,” Heichert says. Allina can’t predict exactly what the “event” will be for a given patient, just that extra care and attention are needed to prevent a serious health issue.
“We produce a list, we give it to physicians, the patients are contacted,” she says, “and of course it’s up to the patient if they wish to engage.”
Similarly, in Fairview’s Ebenezer senior living facilities, sensors and other technologies are used to remind residents to take medications, to check their weight—which can be an indicator of trouble in people with heart failure—and even to monitor changes in patterns of activity as a sign of problems. In the Zipnosis service, Martinson has piloted the addition of a video connection between patients and clinicians, and expects to add it to the entire system by the end of 2013.
Mayo’s Demaerschalk says, “My colleagues in technology indicate that it may not be too long before we can . . . insert our arms into gloves at our end and have some kind of tactile capability” to touch and physically examine patients in a remote environment.
“You can really start to think futuristically,” Heichert says, as new technologies provide more data to round out the picture of a patient’s health, and analytics make it possible to intervene and prevent problems. “That’s where we’re trying to get to in health care. We want to get ahead of the curve. We don’t just want to treat you after you have the heart attack.”
Working at ‘the Top of Their Licenses’
It’s easy, given telehealth’s emphasis on technology, to overlook a significant fact about the people who are putting the technology to work: They’re not all physicians.
Telehealth isn’t just opening up capacity in the health care system for higher-need patients. It’s enabling a shift to the thinking, expressed in an industry buzz phrase, that clinicians should “practice at the top of their license.” In other words, they should be tapped for the most advanced training and specialized skills they have, and shed other tasks. A stroke neurologist shouldn’t do what a general practitioner can. In practice, this means, for instance, that the vast majority of e-visit diagnoses and treatment plans come from nurse practitioners and physician assistants.
So if higher-need patients at brick-and-mortar facilities are getting the system’s most highly skilled care, does it mean that lower-need patients online are getting lower-quality care? Health care providers are working to counter that perception.
HealthPartners has submitted surprising study results and hopes to see them published soon in a peer-reviewed medical journal. Looking at data from all of its 2011 Virtuwell encounters with patients, HealthPartners found better adherence to industry guidelines for prescribing antibiotics than it has been able to achieve at its traditional clinics.
Overprescription and a resulting increase in antibiotic-resistant bacteria is a problem that health care has grappled with for years. “All Virtuwell cases were antibiotic-appropriate, and that’s a really important discovery because at in-person clinics we don’t approach those numbers,” Palattao says. Face-to-face with patients who don’t understand the science of antibiotics but are determined to get them, physicians find it hard to say no, he suggests. Remotely, it’s easier.
Dr. Pat Courneya, medical director for the HealthPartners health plan, says that patients are more willing to hear a “no” and the reasons behind it when they haven’t invested all the time and effort that an in-person appointment takes.
‘Can You Get With It?’
More study is needed to prove the efficacy of telehealth care. Right now, “the burden of clinical science and evidence to support clinical effectiveness of virtual consultations versus face-to-face is not there for every discipline,” Mayo’s Demaerschalk says.
Clear protocols are important in all medicine, but maybe more so in telehealth, where they help unify the work of people who operate removed from each other and their patients. HealthPartners and Fairview both want to expand the list of health conditions handled through Virtuwell and Zipnosis, but can only make additions where the profession has arrived at clear, consistent guidelines for diagnosis and treatment.
As it is, two-thirds of Virtuwell users and about half of Zipnosis users get politely bumped from the system when their symptoms and needs turn out not to be a good match for the programs’ capabilities. If a user’s responses to an online interview start to deviate from the guidelines for making a safe and certain diagnosis, the interview terminates with a recommendation to seek in-person treatment.
There are other hurdles before telehealth can do all the heavy lifting and shifting that people hope for. One of them might be a patient impression that telehealth, at least in the form of e-visits, is uncaring—too templated, generic, and remote.
Providers expect those patients will be outnumbered by patients who feel empowered, that their scarce time and technology-centered day-to-day routines are being respected.
Heichert says people are “demanding it. ‘What is wrong with this industry? Can you get with it? We are online.’ ”
Denise Logeland is a freelance writer and editor based in Minneapolis.