WESLEY VALDES D.O.

Telemedicine and Remote Monitoring

Wesley Valdes D.O.

University of Illinois at Chicago

Acting Medical Director Office of Telehealth Research and Innovation

Assistant Professor of Clinical SurgerySection of Wound Healing and Tissue Repair

Clinical Assistant ProfessorBiomedical and Health Information Sciences

Wesley Valdes D.O.

Take care of Patients

Improve Patient’s Health (when possible)

Perform professionally and responsibly

Opportunity

Health Care Reform in Kuwait By reorganizing the way data is collected and

managed, chronic diseases outcomes can be greatly affected Healthier population Reduction in cost of care (i.e. less complications) More efficient care Manage resources more appropriately Increase quality

What to remember!

Centralization of clinical data in monitored centers can significantly improve patient care

Government or non-profit supported data centers can enhance adoption of physician participation

Remote patient monitoring is a proven process than can help physicians manage patients, improve quality of care, and significantly reduce cost of care.

Fact

Advances in information technology have surpassed the current business model of medicine

The Business Model of Medicine

Ambulatory Patient Care

Designed for Acute Care

You saw a doctor when you were sick

Chronic Disease

Diabetes

Obesity

Hypertension

Hyperlipidemia

Asthma

Coronary Artery Disease

Hospital Medicine

Chronic Diseases

Telemedicine

Arizona Telemedicine Program $2,600,000 savings over 6 month study

Department of Corrections $1,000,000 annual cost savings

Chronic Care

Efficiency ≠ Quality

Quality + Efficiency = Efficient Quality

Care-Giver Focused

Department Focused

Progression from Back Office to Bedside:

Accounting

Billing

Registration

Order Processing

Operational Support

Clinical Support

Laboratory, Radiology, Pharmacy, Etc.

Care Plans, Nursing Documentation, Physician Order Entry, Etc.

Healthcare and Advances in Technology

1960s Enactment of Medicaid and

Medicare Cost-based reimbursement Focus on financial needs

1970s Still focused on financial and

accounting systems Technology focused on

mainframes 1980s

PPS introduces focus on cost containment

PCs coming into vogue Ancillary support expanding

1990s More pressures on cost

reduction Technology begins to gain focus

as a quality improvement vehicle

Integration becomes the key, how to service clinicians with disparate systems

2000s Patient safety becomes a focus CPOE becomes huge Mobility and universal

connectivity opens new opportunities and challenges

PROFESSIONAL ISSUES

EMRs don't guarantee quality care, a review of 50,000 patient records shows on 14 of 17 measures, physicians using paper records did equally well as those using EMRs. They even outperformed electronic record users in one area.

By Kevin B. O'Reilly, AMNews staff. Aug. 13, 2007.

Electronic Health Record Use and the Quality of Ambulatory Care in the United StatesJeffrey A. Linder; Jun Ma; David W. Bates; Blackford Middleton; Randall S. StaffordArch Intern Med. 2007;167:1400-1405.

EMRs don't guarantee quality care!

Quality indicator EMR No EMR

Antithrombotic therapy for atrial fibrillation 54% 60%

Aspirin use for coronary artery disease 45% 40%

Beta-blocker use for coronary artery disease 40% 38%

Diuretic and beta-blocker use for hypertension 64% 60%

Statin use* 33% 47%

Inhaled corticosteroid use for asthma 44% 44%

Treatment of depression 82% 86%

No benzodiazepine use for depression* 91% 84%

Selected antibiotic use for acute otitis media 68% 67%

Smoking cessation counseling 30% 23%

Diet counseling for high-risk adults 28% 33%

Exercise counseling for high-risk adults 20% 21%

Blood pressure check 68% 71%

No routine electrocardiogram 97% 96%

No routine urinalysis* 94% 91%

No routine hemoglobin/hematocrit 86% 86%

Avoiding potentially inappropriate prescribing in elderly patients 93% 93%

Quality indicator EMR No EMR

Antithrombotic therapy for atrial fibrillation 54% 60%

Aspirin use for coronary artery disease 45% 40%

Beta-blocker use for coronary artery disease 40% 38%

Diuretic and beta-blocker use for hypertension 64% 60%

Statin use* 33% 47%

Inhaled corticosteroid use for asthma 44% 44%

Treatment of depression 82% 86%

No benzodiazepine use for depression* 91% 84%

Selected antibiotic use for acute otitis media 68% 67%

Smoking cessation counseling 30% 23%

Diet counseling for high-risk adults 28% 33%

Exercise counseling for high-risk adults 20% 21%

Blood pressure check 68% 71%

No routine electrocardiogram 97% 96%

No routine urinalysis* 94% 91%

No routine hemoglobin/hematocrit 86% 86%

Avoiding potentially inappropriate prescribing in elderly patients 93% 93%

Quality indicator EMR No EMR

Antithrombotic therapy for atrial fibrillation 54% 60%

Aspirin use for coronary artery disease 45% 40%

Beta-blocker use for coronary artery disease 40% 38%

Diuretic and beta-blocker use for hypertension 64% 60%

Statin use* 33% 47%

Inhaled corticosteroid use for asthma 44% 44%

Treatment of depression 82% 86%

No benzodiazepine use for depression* 91% 84%

Selected antibiotic use for acute otitis media 68% 67%

Smoking cessation counseling 30% 23%

Diet counseling for high-risk adults 28% 33%

Exercise counseling for high-risk adults 20% 21%

Blood pressure check 68% 71%

No routine electrocardiogram 97% 96%

No routine urinalysis* 94% 91%

No routine hemoglobin/hematocrit 86% 86%

Avoiding potentially inappropriate prescribing in elderly patients 93% 93%

Abnormal Finding

Action by Healthcare professional

TIME

Abnormal Finding

Action by Healthcare professional

TIME

Abnormal Finding

Action by Healthcare professional

TIME TIME

Patient

follows plan

Communication

Evidence based decisions

Enhanced measurement

Compliance

Clinical Integration Chronic Disease Management

Members of a health care team working in concert to implement a plan of care.

Members of a healthcare team including the patient working in concert to implement a plan of care.

Communication

Evidence based decisions

Enhanced measurement

Compliance

Behavior Change Management

Key Points

Technology has made a lot of data almost instantaneously available

Traditional physician offices are not set up to manage large amounts of clinical data

Clinical outcomes can be significantly improved with better data management

Technology is available that can assist and enhance physician performance

Telemedicine vs. Telehealth

Medical care provided via telecommunications technologies

Delivery of health-related services and information via telecommunications technologies

TELE - HEALTH

TELE - MEDICINE

Tele-health

Home monitoring – patient safety Gas leaks Alzheimer patient alarms Bed wetting Water overflow (sinks and baths) Fall alarms Telecom activated Key boxes 911 / Healthcare interoperability

Tele – health / medicine

Home patient educationPatient data monitors

Real Time Technology

Utilization of cellular networks

Diabetes – helping change

Real time availability of data allows – Utilization of resources Early identification of poor control Rapid response to non-compliance Increased compliance Improved communication between patients and

providers Better clinical control

A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus Steven Shea, MD, Ruth S. Weinstock, MD, PhD, Justin Starren, MD, PhD, Jeanne Teresi, EdD, PhD, Walter Palmas, MD, Lesley Field, RN, MSN, Philip Morin, MS, Robin Goland, MD, Roberto E. Izquierdo, MD, L. Thomas Wolff, MD, Mohammed Ashraf, BA, Charlyn Hilliman, MPA, Stephanie Silver, MPH, Suzanne Meyer, RN, Douglas Holmes, PhD, Eva Petkova, PhD, Linnea Capps, MD, Rafael A. Lantigua, MD for the IDEATel Consortium

J Am Med Inform Assoc. 2006;13:40-51. DOI 10.1197/jamia.M1917

8.35% to 7.42% in the subgroup with baseline HgbA1c 7% (n = 353).

Shea study on telemedicine

For test patients with HgbA1c above 7% 0.93 reduction in HgbA1c (353 patients) 0.25 for control group (831 patients)

Reduction in blood pressure and cholesterol levels seen as well

Remote Patient Monitoring

One component gathering medical data

One telecommunication component

One evaluation component

Remote Patient Monitoring

One component gathering medical data

One telecommunication component

One evaluation component

Next Steps

Remote Monitoring Clinical Data Center

SecureConnection

Kuwait Health Reform(at least as far as chronic disease is concerned)

48

Recognize the financial and quality impact of poorly controlled chronic diseases.

Collect and manage the data for these diseases.

Invest in (or participate in existing) clinical data centers to provide real time management of chronic disease states in affected individuals.

Invest in aggressive patient education and community outreach for disease management.

Repurposing the investment

Data-intensive diseases

Diabetes Hypertension Congestive Heart

Failure Asthma

Data-intensive situations

Emergency ResponseMass Casualty Renal Dialysis Infusion Centers Intensive Care Units Stroke Heart Attack

49

Care Bundles

ICU intensivist staffing is associated with a reduction of 40% in ICU mortality and 30% in overall hospital mortality.

Clinical decision support systems reduce adverse drug reactions - 86% reduction in 4 years post-implementation.

Use of “bundles” significantly improve clinical outcomes

Raising the bar with bundles: Treating patients with an all-or-nothing standard. Joint Commission Perspectives on Patient Safety. 2006 Apr;6(4):5-6.

54

eICU Operational SolutioneICU Operational SolutioneICU Operational SolutioneICU Operational Solution

eICU®

Video AssessmentVideo Assessment

Hospital

Network

eCareManager &The Source

Real-TimeWave Forms

PBX‘Hot Phone’

Smart Alerts

Video Assessment &Video Conference

BedsideMonitor

Camera Ceiling/WallMount Speaker

MicrophoneICUPatient Room

Audio/VideoServer

Healthcare Data StandardsMany Applications with Different Message and Coding

Standards

Radiology

Hospital Pharmacy

Knowledgebases

Physiological Monitors

Medical Devices

Bedside Computer

Laboratories

Admission

Transfer Discharge (ADT)

Billing

Payers

Community

Pharmacies

Orders & Results

Patient Patient Medical Medical Record Record

Information Information (PMRI)(PMRI)

Pharmacy Benefits

ManagersClinical Content

HL7DICOM

HL7

HL7

HL7ASTM

HL7ASTM

HL7 &proprietary

HL7 &

HL7

HL7ASTM

HL7ASTM

HL7

ASC X12NNCPDP

ASC X12NNCPDP

X12NNCPDP

Protocolsproprietary

LOINC

Where’s the EHR – Challenges with Information Sharing

Hospitals

Laboratory andDiagnostic Centers

Ambulatory CareClinics

Physician Offices

Long Term Care

Medical Suppliers

RehabilitationCenters Payer

Organizations

Pharmacies

Home Health CareElectronic

Health Record

Patient RoomsNurse's Station

**Central Monitor

X-ray Scanner

Patient Monitoring

Telephone

Bedside Monitors

Video Voice

Bedside Monitors

Video VoiceHot Phone

Laser printer

Video Conferencing

eCareManager/The Source

Remote ViewingGateway

Patient RoomsNurse's Station

**Central Monitor

X-ray Scanner

Patient Monitoring

Telephone

Bedside Monitors

Video Voice

Bedside Monitors

Video VoiceHot Phone

Laser printer

Video Conferencing

eCareManager/The Source

Remote ViewingGateway

Patient RoomsNurse's Station

**Central Monitor

Patient Monitoring

Telephone

Bedside Monitors

Video Voice

Bedside Monitors

Video VoiceHot Phone

Laser printer

Video Conferencing

eCareManager/The Source

Remote ViewingGateway

Patient RoomsNurse's Station

**Central Monitor

X-ray ScannerX-ray Scanner

Patient Monitoring

Telephone

Bedside Monitors

Video Voice

Bedside Monitors

Video VoiceHot Phone

Laser printer

Video Conferencing

eCareManager/The Source

Remote ViewingGateway

Technical ArchitectureTechnical Architecture

Data CentereICU®

Clinical Workstation

HCA Workstation

/

eVantageServer RackeCareManag

erSmart Alerts

Interface Engine

HA Database (2)

Domain Controllers

(2)

HIS SystemADT SystemLab SystemPACS System

MICU (10)

GICU (10)Hospital Network

Patient RoomsNurse's Station

**Central Monitor

X-ray Scanner

Patient Monitoring

Telephone

Bedside Monitors

Video Voice

Bedside Monitors

Video VoiceHot Phone

Laser printer

Video Conferencing

eCareManager/The Source

Remote ViewingGateway

Patient RoomsNurse's Station

**Central Monitor

X-ray Scanner

Patient Monitoring

Telephone

Bedside Monitors

Video Voice

Bedside Monitors

Video VoiceHot Phone

Laser printer

Video Conferencing

eCareManager/The Source

Remote ViewingGateway

Patient Rooms

**Central Monitor

Patient Monitoring

Bedside Monitors

Video Voice

Bedside Monitors

Video Voice

Remote ViewingGateway

Patient Rooms

**Central Monitor

Patient Monitoring

Bedside Monitors

Video Voice

Bedside Monitors

Video Voice

Nurse's Station

Telephone

Hot Phone

Laser printer

Video Conferencing

eCareManager/The Source

Nurse's Station

Telephone

Hot Phone

Laser printer

Video Conferencing

eCareManager/The Source

Remote ViewingGateway

Internet

The SourceASP Hosted

X-ray ScannerX-ray Scanner

eCareManagerHIS/PACS

CICU (10)

SICU (14)

ICU Bedside Monitor ‘A’Network

Hospital A

HIS ‘A’InterfaceEngine ‘A’

HL7 InterfacesDigitized Vital Signs

ADT (IN)

Lab Results (IN)

Med Orders (IN)

Flowsheet (IN)

Notes (OUT)

eCareManager

Near Real-TimeVital Signs

Hot Phone

Smart Alerts

Video Assessment &Video Conference

eICU®

Audio & VideoAudio/Video

Switch

Monitor ‘A’Network Gateway

Audio & VideoNurse Videoconference

In-room Video Assessment

Hospital B

HIS ‘B’InterfaceEngine ‘B’

Audio/VideoSwitch

Monitor ‘B’Network Gateway

Audio & Video

ICU Bedside Monitor ‘B’Network

HL7 AcceleratorSQL Server

Windows 2000

Rack MountedApplication & DB Servers

ICU-to-eICU Interfaces

eCareManager Smart Alerts HA Database

Interface Server

Near Real-Time Vitals (waveforms)

Sentara Healthcare: eICU® Case Study1

Critical Care Medicine 32:31-38;2004

(1) Severity Adjusted

0

200

400

600

800

1,000

1,200

1,400

Hospital Mortality ICU Length of Stay Hospital Length of Stay

(27)%

(17)%

(13)%

Baseline eICU

0

1

2

3

4

5

6

7

VA

P in

fec

tio

ns

/ 1

00

0 d

ev

ice

da

ys

0

20

40

60

80

100

120

% V

en

t B

un

dle

co

mp

lian

ce

VAP infections / 1000 device days % Compliance

95% Goal

Ventilator Bundle Compliance

1.491.36

0.8

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Pre-Intensivists Intensivist Program eICU Program &Intensivist

Ob

serv

ed /

Pre

dic

ted

IC

U M

ort

alit

y*(8.6%)

(36%)

*Ohio Hospital Association

(18 months) (12 months)(12 months)

Ohio Health, DH – Care Model Comparison

Overall Program Performance - Q3 2006

0%

20%

40%

60%

80%

100%DVT Prophylaxis

Ventilator Days (100% = 0 Days)

Stress Ulcer Prophylaxis (Vent at risk)

Low Tidal VolumeBlood Transfusion Threshold

Beta-blockers

Glycemic Control

All eICU Centers AICU ICUs

Cost Analysis

6-Hospital System Outcomes

70

0.6

0.8

1

1.2

1.4

Q1 06 Q2 06 Q3 06 Q4 06 Q1 07

ICU Mortality

Hospital Mortality

ICU LOS

Hospital LOS

Sev

erity

– A

djus

ted

Res

ults

N = 3800 patients

*

*

*P< 0.001

P< 0.001

P< 0.02

*P<0.001

Cost Reduction in U.S. eICUs

71

$100K in Routine Cost/bed/yr/day of stay

$170K in Ancillary Cost/bed/yr/day of stay

$5K per patient not admitted to ICU

30 Bed eICU with 70% occupancy = $4.5M cost reduction/year net of eICU cost, or $150K /bed/year