Building a Telehealth System of Care

Children's Hospitals Today, Winter 2011

An interview with Joe Yoder looks at the implementation, challenges and value of telemedicine consultations.

Joe YoderThe Children’s Hospital at Legacy Emanuel in Portland, OR, recently launched a telehealth service to provide pediatric support to emergency department physicians within the six-hospital Legacy Health system. The telehealth service allows emergency room physicians at the system’s community-based hospitals to connect and consult with pediatric hospitalists and intensivists at The Children’s Hospital about diagnosis and treatment approaches and to assist them with decisions about transporting pediatric patients that would be better served at the hospital based on their injury or illness.

Joe Yoder, of One Call and Outreach Services for Legacy Health, manages the pediatric telehealth service. He shares his insights on development and implementation of the telemedicine program and talks about its expected future influence on diagnosis, treatment and long-term, follow-up care for patients.

Q. What business case prompted your system’s move to video/computer-centered telemedicine consulting?

A. We were prompted by the need for specialist care in communities that did not have immediate access to neurologists and pediatric critical care. There are some situations when a patient does not require transfer to a higher level of care. Allowing the specialist to assess the patient where he or she lives helps deter unnecessary transfers, saves the patient and family on transport costs and allows them to remain closer to home.

Some challenges we are still working out relate to reimbursement. Oregon was one of the first states to require commercial payers to reimburse for telemedicine consults, though the level of reimbursement is up in the air. Medicare and Medicaid laws are more stringent; payment is only provided for urban facilities providing consulting for rural facilities; so right now, Medicare and Medicaid won’t reimburse for our in-system telemedicine consults because our facilities don’t meet those requirements.

Q. When did The Children’s Hospital at Legacy Emanuel start moving to a video-centered telemedicine system, and how was that implementation coordinated with the health care system?

A. The Children’s Hospital at Legacy Emanuel began exploring this possibility in the summer of 2008. We actively engaged our pediatric specialists to test equipment and define what the needs would be for a high-value consult. A dedicated medical director for the pediatric telehealth program has been instrumental in helping keep the momentum moving forward.

The implementation began with the selection of a telehealth technology. We decided on InTouch Health RP-Lite systems and workstations. After the equipment was installed, we spent months testing the various applications. We started with a small trial-period of simply using the technology to round on patients in the pediatric ICU. Once the physicians felt comfortable using the equipment, we expanded to our system hospitals and began providing consults to those emergency departments. We are now working with our aligned regional partners to develop our consult capabilities in their communities.

Q. How long did rollout of the service take, and who was necessary for the process?

A. Once we selected a vendor to provide the technology, it took a year before we were ready to do live consults. The necessary team included medical staff services for credentialing and privileging, legal experts, information services staff, billing and reimbursement staff, a physician champion (or medical director), an administrative leader, and a service line coordinator. Other areas key participants to a successful program include marketing, outreach and continuing medical education.

Q. How many patients are being served at your remote facilities? Is this volume providing the expected value on your investment?

A. We are currently seeing two to four patients (total) per month via a telemedicine connection in our EDs, but that’s coming from just two hospitals in our system. We’re looking at this as a trial or training period. Our system is in suburban hospitals with fewer than 30 miles of travel to our children’s hospital. The big wins for this technology will come when we’re providing telemedicine consults for sites that are hours away. We expect utilization will increase as more and more providers become comfortable with the technology.

Joe YoderQ. What is your plan going forward, especially in regard to telemedicine implementation outside your health care system?

A. We are currently working with the two large health care systems in Oregon where we already have a relationship. We’ve met with them to explore their needs and how we could use our specialist panel to help fulfill those needs. Increasing access to pediatric care throughout our region is a top priority of this program.

Our grand scheme is much broader than just providing ED consults. Critical care in ED is the initial phase. Once telehealth capabilities are present in rural areas, a lot of remote facilities will be able to keep kids they would not have been able to keep before because they can use us for live remote access to specialists. The next step would be to start scheduling remote appointments for non-critical patients, rheumatology consults for instance, saving hundreds of miles of travel time and transportation costs.

Q. What challenges have you encountered and what lessons learned could help another hospital working on a similar system?

A. Training on the use of the equipment has been our biggest issue. There are times when weeks pass without the equipment being used at a particular hospital, so ongoing training is key. The technology is only useful if both sides know how and are comfortable using it. Staying engaged and putting the connection to use in a variety of ways helps keep skills fresh.

Q. What has the response been from staff? From patients?

A. The response has been great. Staff members feel excited to be using leading-edge technology and feel like they are providing ever higher levels of care to their patients.

After any telemedicine interaction, we ask our patients and families to complete a survey based on their experience. The families are very impressed that they are able to access such specialized care in their community and that they don’t have to travel. One mother whose child had previously been an inpatient in our pediatric ICU at The Children’s Hospital said that when she saw a familiar face and voice, she felt reassured and knew that her child was receiving the care needed.

Q. How do you expect this technology to expand and change over the next five years, and what new functionality do you foresee?

A. Telemedicine technology will continue to evolve and become easier to use. It will become even more ingrained in physician practice as the relationships between originating and remote sites become more solidified. I see the technology getting to a place where it can be used on one of the numerous handheld devices many of us already carry around, thus reducing the need to be connected to a computer.

Q. What is one facet of telemedicine you wish existed but doesn’t?

A. The current laws create a lot of redundant work and unnecessary costs. We need a federal policy that allows for the sites originating the telemedicine consult request to accept the credentialing/privileging decision of the remote facility providing expertise. Right now, if our system approaches a rural site and needs to provide pediatric consults for it, we can’t just put a machine in place. Federal law for any Medicare and/or Medicaid facility that accepts reimbursement from CMS insists that the remote facility has to approve and credential every specialist that provides services there, including telemedicine consults. This is easily a three to four month process, accompanied by cumbersome fees and paperwork. It is burdensome to do this for 10 – 15 specialists per site, and small, remote facilities in particular can’t pay for it. It’s not necessary to ensure quality care.

Interviewed by Tim Haynes, Assistant Director, Communications, NACHRI