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Samuel S. Lyness, MD, FACSDirector, Tele-Neurosurgery Program
Wendy Baynard, MSWProgram Manager, Tele-Neurosurgery Program
The Walter Reed Tele-Neurosurgery
Program
American Telemedicine Association2007 Annual MeetingNashville, Tennessee
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James M. Ecklund, MD, FACS, COL, MC, USAProfessor/Chairman, National Capital Consortium Neurosurgery
ProgramWalter Reed Army Medical Center, National Naval Medical Center
andUniformed Services University of the Health Sciences
Leon E. Moores, MD, FACS, COL, MC, USAChief, Department of SurgeryWalter Reed Army Medical Center
John Posey, MDAssociate Professor of NeurosurgeryTulane UniversityNew Orleans, Louisiana
Alan AndersonClinical Business Analyst, Resource ManagementNorth Atlantic Regional Medical Command
Tele-Neurosurgery Program
Contributors
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Tele-Neurosurgery Program Agenda
Objectives
Scope of Care
Clinical Process
Case Management
Consult and Referral Sites
Consult Site Team/Functions
Referral Site Team/Functions
Resource analysis (earnings)
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Tele-Neurosurgery ProgramWalter Reed --- Ft Bragg
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Tele-Neurosurgery Program
Afghanistan ---- Walter Reed
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Tele-Neurosurgery Program Objectives
Optimize Specialty Care Delivery Neurosurgeon focuses on surgical candidates PA and PT evaluate patients for treatment options Nurse case manager and LPN support providers
Increase Access-to-Care with Neurosurgeon VTC
Improve Clinical Outcomes with Treatment Options Physical therapy Anesthesiologist pain management Surgical care
Ensure Continuity-of-Care from PC Referral to PC F/U PA and LPN manage evaluation and conservative care Nurse case manager coordinates all surgery-related care Patient documentation stored in single electronic record
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Tele-NeurosurgeryScope of Care
Not Robotic Surgery
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Tele-Neurosurgery Program Scope of Care
All Ages
Routine and Urgent Care
Intracranial and Spinal ConditionsVascular LesionsTumorsCongenital Malformations and DeformitiesDegenerative Diseases
Acute Brain and Spinal Injuries?
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Tele-NeurosurgeryScope of Care
Works well in sub-acute conditions in which a large proportion of patients recover without surgery
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Tele-Neurosurgery ProgramClinical Process
Referral guidance for primary care providers
Patient evaluation and diagnostic imaging/lab tests
Non-operative treatment as first tier intervention
Neurosurgeon VTC consult and surgery assessment
Patients come to Walter Reed if surgery is needed
Pre-operative assessment and surgery
Post-op care and primary care F/U
Return to duty
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Tele-Neurosurgery Program
Case Management
PA Conducts Referral ScreeningGuide primary care provider on referral guidelinesEvaluate referrals for neurosurgical conditions
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Tele-Neurosurgery Program Case Management
PA Performs Patient EvaluationObtain comprehensive problem-focused historyPerform neurological examinationOrder imaging studies and labs testsMake diagnosis
Non-Operative Conservative Care as First Tier InterventionDevelop treatment plan with neurosurgeon input as neededPrescribe PT and/or pain management interventionsAssess treatment results periodicallyRequest neurosurgeon VTC consult if conservative care fails
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Tele-Neurosurgery Program
Case Management
PA/LPN Manages Neurosurgeon VTC Consult Process
Schedule VTC consult and obtain patient consentForward digitized radiology images to neurosurgeonManage VTC session between patient and neurosurgeonNeurosurgeon discusses surgical options vs continued non-operative management
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Tele-Neurosurgery Program Case Management
PA/LPN and Nurse Case Manager Coordinate SurgerySchedule and manage pre-op evaluation and careSchedule surgery at WRAMCNeurosurgeon-led surgical team performs surgery
PA Manages Post-Surgery Follow-up CareDirect follow-up treatment and VTC specialist F/URefer patient to other health care providers as neededReturn patient to primary care with follow-up guidance
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Tele-Neurosurgery ProgramConsult and Referral Sites
Consult Site: Walter Reed Army Medical CenterAll neurosurgical subspecialties represented on faculty Center of Excellence for: Comprehensive clinical care and resident training Academic research on head and spinal cord/column injuries
Referral Sites: FT Bragg, FT Knox, Andrews AFB, QuanticoMRI and PT services available or in vicinityReasonable travel to Walter Reed if surgery is requiredCurrent/projected enrollment to sustain service demand
Fort Bragg
Walter Reed
Fort Knox
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Tele-Neurosurgery ProgramConsult Site Team/Functions
Neurosurgeon Performs Consults and Surgery
Neurosurgery PA Conducts Screening ClinicsWalter Reed three days per weekAndrews AFB and Quantico on-site one day/week each
Nurse Case Manager Supports NeurosurgeonCoordinates VTC clinics and neurosurgeon clinical support Provides case management for surgical patients
Surgical Team Supports Surgery (late afternoon )Operating Room Nurse and techAnesthesiologist (runs pain management clinic 3 days/wk)
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Tele-Neurosurgery ProgramReferral Site Team/Functions
Physician Assistant Manages Neurosurgery Care
LPN Supports and Optimizes Physician Assistant
Physical Therapist Provides Non-Operative Care
Pain Management if Available
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Level of Surgeries DRG Earnings Monthly Annual DRG
Effort per Month per Surgery Earnings Surgery Earnings
Level 1 5 $10,330 $51,650 $619,800
Level 2 10 $10,330 $103,300 $1,239,600
Level 3 15 $10,330 $154,950 $1,859,400
level 4 20 $10,330 $206,600 $2,479,200
Level 5 25 $10,330 $258,250 $3,099,000
Level 6 30 $10,330 $309,900 $3,718,800
Effort Neurosurgeons PAs PTs Anesthesiologists LPNs NCM OR Nurse OR Tech
Level 1 0.4 1.0 0.0 0.0 1.0 0.4 0.0 0.0
Level 2 0.6 2.0 1.0 0.2 1.6 0.6 0.2 0.2
Level 3 0.8 3.0 1.6 0.4 2.0 0.8 0.2 0.2
level 4 1.0 3.0 2.0 0.4 2.4 1.0 0.4 0.4
Level 5 1.0 3.0 2.4 0.6 3.0 1.0 0.4 0.4
Level 6 1.0 4.0 3.0 0.6 3.0 1.2 0.6 0.6
Level of RVUs by Clinical Projected FTEs ( est. $85 per RVU)
Effort Neurosurgeons PAs PTs Anesthesiologists LPNs NCMs OR Nurse OR Techs
Level 1 800 1,500 0 0 0 0 0 0
Level 2 1,200 3,000 1,500 500 0 0 0 0
Level 3 1,600 4,500 2,400 1,000 0 0 0 0
level 4 2,000 4,500 3,000 1,000 0 0 0 0
Level 5 2,000 4,500 3,600 1,500 0 0 0 0
Level 6 2,000 6,000 4,200 1,500 0 0 0 0
Tele-Neurosurgery Program Resource Requirements
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Tele-Neurosurgery Program Resource Requirements
TEAM: 20 spinal operations per month 1.0 Full-Time neurosurgeon 3.0 Physicians Assistants 2.0 Physical Therapists 1.0 Anesthesiologist 0.4 OR/0.6 Pain Mgt 2.4 LPN 1.0 Nurse case manager 1.0 OR Nurse 0.4 OR/0.6 Pain MGT 1.0 OR Tech 0.4 OR/0.6 Admin. Assist.
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1 Neurosurgeon $170,000 3 Physician Assistants 382,500 2 Physical Therapists 255,000 0.6 Anesthesiologists 125,500
TOTAL $933,000 Generated for Hospital
Tele-Neurosurgery ProgramAnnual Projected Earnings
Outpatient Visits Only
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Tele-Neurosurgery ProgramAnnual Projected Earnings
Surgery
Neurosurgeon (240 cases/yr) $2,470,200
Generated for hospital
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Tele-Neurosurgery Program Annual Projected EarningsOutpatient visits +Surgery
Total: $3,472,220/yr
Generated for Hospital
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Tele-Neurosurgery Program Startup Costs Equipment
POLYCOMs x 6 COMPUTERS x8BLACKBERRYs x4
About $60,000
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Tele-Neurosurgery Program
Fixed Costs
Personnel per/yr $1,800,000Blackberrys per yr 10,000
TOTAL $1,810,000
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Tele-Neurosurgery ProgramNet Annual Revenue
Income $3,472,200Fixed costs 1,810,000
NET + $1,662,200
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The Walter Reed Tele-Neurosurgery Program
Summary
Patient care objectives are being metFinancial objectives are being metTravel burden to and from WRAMC has, thus far, not been a problem nor increased the complication rateEnhanced resident exposure to the “bread and butter” cases
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The Walter Reed Tele-Neurosurgery Program
Plan: Resume svc to AAFB and Quantico Market the program to other remote sites (Aberdeen, Carlisle) Tele-mentoring link to acute care sites
that lack a neurosurgeon Recruit personnel as needed
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POC: Dr. Samuel LynessPhone: 202-782-5123Email: [email protected]
POC: Wendy BaynardPhone: 202-782-6416Email:[email protected]
Tele-Neurosurgery Program Questions?
