ALEXANDER NASON

JOHNS HOPKINS MEDICINE INTERACTIVE

PROGRAM DIRECTOR

ANASON@JHMI.EDU

Strategic Opportunities and

Challenges in Telemedicine

Agenda

• Landscape @ Johns Hopkins Medicine

• Telemedicine Primer

– Challenges and Lessons Learned

• Johns Hopkins Telemedicine

• „Things to Consider‟

Conclusions

• Potential for Improved Service Delivery

– Cost, Efficiency, Greater Satisfaction

• No Universal Solution

– Environment Specific, Standards are the

Key

• Sustainability is of Primary Concern

– Collaborative System Architecture

• Technology Allows for a “Relationship”

Historic Billings Building

4

New Clinical Building

5

6

7

8

Current Systems (9+)

9

JHH JHBMC HCGH Suburban JHCP

Patient Portal

Health Information

Exchange(CRISP)

Registration/Scheduling

EpicMEDITECH, Epic,

GE (IDX)MEDITECH MCKESSON GE (IDX)

ADT Keane MEDITECH MEDITECH MCKESSON

N/A

Inpatient EMR Eclipsys MEDITECH MEDITECH MCKESSON

Ambulatory EMR Eclipsys (limited) MEDITECH/LSSMEDITECH/LSS

(limited)GE (Centricity

EMR)GE (Centricity

EMR)

Specialties Varied Varied Varied Varied N/A

EPR2020 Enterprise clinical data and document repository

Hospital Billing Keane MEDITECH MEDITECH MCKESSON N/A

Professional Billing GE (IDX) GE (IDX) GE (IDX) GE (IDX) GE (IDX)

Core Clinical System Vision

• Patient-centered

• Single tightly integrated solution

• Encompasses all major areas of EHR

functionality

• Includes workflow as well as content and data

• Enables seamless coordination of care delivery

• Requires careful TCO and ROI analysis

• Require redesign of care

10

11

IT@ Johns Hopkins Medicine

• Critical juncture

• Entity centric approach has reached its limits

• Patient centered care requires coordination of care across JHM

• Populations and preventive health require longitudinal patient and data management

• Must enable operational efficiencies, cost controls, and productivity

• Must achieve quality and patient safety well beyond meaningful use

TELEMEDICINE PRIMER

12

Definition

Telemedicine, Telehealth, Telecare…

• The use of electronic information and

telecommunications technologies to

support long-distance clinical health care,

patient and professional health-related

education, public health and health

administration.

Health Resources and Services Administration‟s - Office for the Advancement of Telehealth

Benefits of Telehealth to the

Community

• Helps Overcome Distance and Access– Physician Shortage Areas

• Improves Local Health Care

• Offers Diagnostic and Clinical Support

• Supports Knowledge Transfer

• Improves Responsiveness in a Changing Environment

• Decreases Costs; Improves Resource Utilization

Telemedicine “Synchronicity”

• Synchronous (Real-time)

– Data Transmitted As They

Are Generated And

Received With No

Perceived Delay

– Natural Person To Person

Interactions

– High-Bandwidth

Telecommunications

– Examples: Patient

Monitoring In ICU, Stroke,

ED Support

Telemedicine “Synchronicity”

• Asynchronous (Store-

forward)

– Data Collected Offline

– Unnatural Or No Person-To-

Person Interactions

– Low-bandwidth Or Long

Distance Telecommunication

– Examples: • Radiology

• Dermatology

• Second Opinion Service

Services

Model of Telehealth Success

Development

InfrastructureTraining

Assessment

Challenges - Internal

• Human Factors and Culture

– Acceptance by Physicians/Patients/Users

• IT Department

• Facilities

• Reimbursement

• Costs

• Licensure / Regulatory

• Evaluation and Research

• Business Planning - Sustainability

Third party reimbursement for

telemedicine is expanding…slowly

20Source: American Telemedicine Association

States – 11 states now

require reimbursement of

telemedicine by all private

insurers

Medicaid – 14 states

require reimbursement

Medicare –reimburses

telemedicine services in

rural areas

Alternative Reimbursement

Models

21

Subscription

Models

Contractual

Services

Grants Philanthropy

Challenges - External

• Communication – Client

• Infrastructure

• Vendor Conflicts

• Cultural Considerations

• Environment

• Local Legal Issues

• Costs

• Time Zones (DST)

• Customs/Shipping

Overcoming Barriers

• Create Partnerships (Relationships)

• Know Your Client/Audience (Culture, Time Zones, Work Week, Motivation)

• Experience Telehealth

• Incentivize Users (Not Only Money)

• Integrate it into Strategic Mission

• Be “Non-Threatening”; Be Complimentary

• Show Return On Investment

• Recognize What You Cannot Control

Real World Problems

• Acute Care Response– Stroke

• Chronic Disease Management– Diabetes, Obesity, CHF

• Physician Shortages– i.e. Intensivists

• Global Issues– Pandemic Flu

– SARS

– Hurricane Katrina - Asian Earthquake

– Bio-terrorism

– Global Economics

25

Demand for care at home is

growing…

Source: Chronic Care in America available at http://www.rwjf.org/qualityequality/product.jsp?id=15733; Agency for Healthcare Research and Quality

Percent of the population with a

chronic condition

79% of individuals with long-term chronic care needs

live at home and account for 75% of health expenditures

26

… and increasingly feasible

TELEMEDICINE @ JOHNS

HOPKINS

27

The Challenge: Sharing

Knowledge and Expertise

Effectively, Efficiently and

Economically

Telehealth @ JHM

• Anesthesiology / Critical Care

– Intensive Care

– PICU

• Cardiology

• Dermatology

• Emergency Medicine

• Gastroenterology

• Infectious Diseases

• Johns Hopkins Community Physicians

• JHM International

• Johns Hopkins Healthcare

• Johns Hopkins Homecare Group

• Minimally Invasive Surgical Training Center

• Neurology

• Obstetrics and Gynecology

• Ophthalmology

• Otolaryngology

• Pediatric Psychiatry

• Physical Medicine – Rehab

• Radiology

30

31

THINGS TO CONSIDER

36

• Mobile Platform

• Social Networks / Social Media

– Wisdom of Crowds

• Education

• Accountable Care Organizations

– Patient Protection and Affordable Care Act

37

Lessons Learned

• Challenges are Likely

• Collaborative & Adaptable

• The Road is Long

• Keep It Simple

• Not Everyone Will Participate

• Successes Will Outpace Failures

• Focus on Don Berwick‟s (CMS

Administrator) goals:

– Better care (IOM-Chasm Report)

– Better health

– Lower cost

• Expand evidence base

• Ensure information continuity

• Help to lead care system redesign39

Conclusions

• Potential for Improved Service Delivery

– Cost, Efficiency, Greater Satisfaction

• No Universal Solution

– Environment Specific, Standards are the

Key

• Sustainability is of Primary Concern

– Collaborative System Architecture

• Technology Allows for a “Relationship”

Source: Gartner Group