Lisa Gwynn, DO, MBA, FAAP, CPEAssistant Professor, Clinical Pediatrics

Medical Director, Pediatric Mobile ClinicUniversity of Miami Miller School of Medicine

Establishing a Multi-Specialty Clinic via Telemedicine in a Mobile Clinic Setting

Objectives

• Illustrate the innovative telehealth modalities of service delivery in a mobile clinic setting.

• Gain insight into the challenges in establishing a successful specialty clinic in a mobile setting and how to overcome them.

• Identify strategies for establishing and sustaining a successful telehealth program.

I have no relevant financial relationships with commercial interests and no conflicts of interest exist.

To provide comprehensive primary health care services free-of-charge to children most in need, specifically those with no access or limited access to health care.

University of Miami Pediatric Mobile Clinic

Mission

The Program

•Established in 1992 as a response to hurricane Andrew

•Has provided medical care to uninsured children in need for 22 years

•Services provided include well-visits, sports physicals, immunizations, management of chronic conditions, urgent care, mental health, and social work

•Staffed by Board Certified Pediatrician, 2 ARNP’s, Social Worker/Mental Health Counselor, Clinical Psychologist, Driver/Registrar, Interpreter, Program Coordinator, Patient Access Representative

1987: After a year of visiting New York City’s welfare hotelsand researching the needs of the City’s homeless, Irwin Redlener, MD, and singer/songwriter Paul Simon launched the New York Children’s Health Project. Paul Simon donates funds to purchase and equip a mobile medical unit to bring health care to homeless and other children who do not have access to care in New York City.

•The unit is fully equipped to handle medical emergencies and has three complete exam rooms, a laboratory and a small waiting area for parents.

Services• Comprehensive primary care• School Physicals (Medical/Sports)• Immunizations• Management of acute and chronic illnesses• Laboratory testing• Prescriptions• Hearing and Vision screenings• Mental Health Counseling• Social work services• Case management• Psychology services• Nutritional assessment• Weight monitoring• Referrals to subspecialty and dental care• Referrals to legal services

Communities We Serve

•The UMPMC visits community centers, churches, and schools in the most impoverished areas of Miami-Dade County

•Areas include: Homestead, Florida City, Little Haiti, Sweetwater, Miami Beach, West Kendall, Little Havana

•In addition, the unit participates in community health fairs

Our Patient Population

• Children from all over the world• Many are undocumented• Some are in 5-year waiting period for Florida Medicaid• High percentage from Latin America – entitlements depend on country

of origin• Recent increase in children from Central America• 25% of patients from Haiti

2013 Statistics

•Over 3000 clinical visits

•Nearly 650 mental health visits

•Over 3000 immunizations administered

•68% Hispanic; 25% Haitian; 5% African American; 2% Other

Assessing the Need…

Compliance

State of the Uninsured…

Florida has the nation’s second-highest rate of uninsured

residents younger than 65 — a total of about 3.8 million

people, or about 25 percent of the state’s population,

including more than 500,000 younger than 19, according

to U.S. Census data.

And out of all 67 counties in Florida, Miami-Dade has the

second-highest rate of uninsured for the same age group

at 34.4 percent, trailing only Hendry County, with an

uninsured rate of 35 percent or about 11,500 residents.

Miami-Dade also is home to the largest number of

residents without health insurance in the state younger

than 65 — an estimated 744,000 people.

The Miami Herald, August 29, 2013 (US Census)

The Solution:

Bring specialty care to the patients through telehealth technologies.

How do we get there?

• Needs assessment• Equipment• Connectivity• Technical support• Staffing/Workflow• Clinical care coordination• Funding

Needs of the community

• Patient population served

• Services needed

• Specialists available Participating specialistsWhat if needs referral for in-person visit

Equipment

• Choose best option for services to be provided and setting in which the consultations will be taking place

Equipment Options

• Depends on services offered• Space restrictions• Examples:

Stationary carts Mobile carts - robots iPhones/iPads – Facetime Portable teleclinic Laptop with webcam

Equipment on Our Mobile Unit

Portable TeleClinic is a self-contained telemedicine system that has the combined functionality of a desktop telemedicine solution and a mobile cart, and is completely transportable. Packaged in an industrial case, this system includes an integrated tablet PC, CAT5 connection and industrial grade powered USB ports and can be customized with encounter management software and medical devices for a clinical exam.

This “pack-and-go” system is perfect for healthcare applications that require clinical telemedicine equipment that they can carry into medical situations and/or set up in mobile clinics with limited space

AMD

Equipment Options

Software • “Agnes Interactive” - Once installed, the web-based software aggregates

clinical device diagnostics, vital signs data, encounter documents and live video conferencing and then securely exchanges that information in real-time to the remote consulting physician.

• Videoconferencing services – Is Skype HIPAA compliant? FUZE

Connectivity

• Wireless carrier – mapping of 4G reception areas• 4G LTE• Cradlepoint router• Antenna on mobile unit• Information transmitted wireless must be encrypted and

HIPAA compliant (WPA2 Enterprise security)

Technical Support

• The MOST challenging piece of the puzzle• Recommend bringing on support from the beginning• Equipment support, network support, EMR integration• Challenges in an academic setting• This CAN be done. If your support personnel claim that it

can’t, you have the wrong support team!!

Staffing/Workflow

• Identify staffing needs – number of people; skill sets• Frequency of telehealth clinics – daily; monthly; etc…• Training – depends on type of services offered (operation of

medical devices, video camera, etc…• Utilization of existing staff• How to integrate into regular clinic operations• Our model

Arrival

• Equipment set up and connectivity established with specialist

• Patient arrival/check-in

• Clinical staff member takes patient into room where consult takes place

Consult

• Specialist first interviews patient then clinic staff member operates the medical device with guidance from the specialist

• Diagnosis and disposition of patient

• Follow-up

Clinical Care Coordination

• Identify target patients• Referral process• Pre-clinical chart review• Patient disposition

Prescriptions Follow-up Referrals

• Integration into EMR

Funding

• Ability to bill for services varies by State

Regulation

Telemedicine is regulated by State Medical Boards and face complex

regulatory challenges and patient safety concerns in adapting

regulations and standards historically intended for the in-person

provision of medical care to new delivery models involving

telemedicine technologies, including but not limited to:

Determining when a physician-patient relationship is established

Assuring privacy of patient data

Guaranteeing proper evaluation and treatment of the patient

Limiting the prescribing and dispensing of certain medications

Regulation

Federation of Medical Boards released guidelines in April 2014

“Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice Of Medicine”

• Place the welfare of patients first

• Maintain acceptable and appropriate standards of practice

• Adhere to recognized ethical codes governing the medical profession

• Properly supervise non-physician clinicians

• Protect patient confidentiality

Funded through grant support from CHF/Verizon Foundation June 2013

Objective 1: Develop a system to link uninsured children tospecialists via telehealth

Activities Quarter 1 - Installation/Training

1. Install on MMC necessary technological equipment2. Train staff3. Conduct connectivity tests at various clinic sites4. Secure agreements with participating subspecialists5. Develop scheduling system for telehealth appointments with existing EHR

Our Telehealth Project

Telehealth

Objective 2: Increase children's access to subspeciality care

Activities (quarter 2) Pilot telehealth services on MMC

1. Trial with one specialty service2. Trial with second specialty service 3. Trial with both during month

Activities (quarter 3) Pilot additional specialty services on MMC

1. Trial with third specialty service 2. Trial with fourth specialty service 3. Trial with both during month (one day for each)

Telehealth

Activities (quarter 4)

Process evaluation of pilot1. Determine best delivery model of services2. Evaluation to include feedback from patients, staff and specialists2. Implement plan 3.3.

The Future…

• Currently offering Cardiology, Dermatology, Nutrition• Adding Mental Health, Endocrinology• Obesity Intervention/Technology Grant Verizon• Let’s Talk Medical Translation Project with JMH Residents

Thank you!

lgwynn@med.miami.edu