Telehealth - Four Steps to our Future

April 2015

​​The impact of telehealth on patients with stroke and type 1 diabetes, plus a $2 million grant to compare outcomes of traditional and technology-based care 

As departments across our campus look for ways to increase efficiency, reduce costs and maintain high levels of quality and patient satisfaction, teams increasingly rely on telehealth to deliver care and education throughout our region. 

Creating an Integrated Telehealth Delivery Model

John “Fred” Thomas, PhD is the director of telehealth at Ch​ildren’s Hospital Colorado​. He believes telehealth can improve efficiency, satisfaction and, most importantly, outcomes. 

“It’s about providing the right care, at the right place, at the right time,” says Thomas, who is charged with helping Children’s Colorado create an integrated telehealth delivery model. Thomas explains how clinical encounters, especially for patients in rural areas, can increase family involvement, reduce travel and related costs and improve communication.​

Thomas describes a situation typical in surgery, where patients are required to have pre- and post-operative appointments with the surgeon. Say a patient lives in Grand Junction—the travel time alone is a great burden. Add in poor weather, the cost of gas or an inability of one parent to take time off work, and the situation quickly becomes stressful. “When pre-surgical encounters take place remotely, it reduces the stress for families and allows more family members to take part in the decision-making process,” he says. “If a post-operative complication arises, the ability to connect with someone on the clinical team can offer peace of mind or identify and rectify problems before a readmission may be necessary.”

Children’s Colorado is also part of a telehealth program that helps primary care providers across the state practice at the top of their licensure. Project ECHO (short for Extension for Community Healthcare Outcomes) is a statewide system of training and practice support to increase capacity to manage complex health care problems in primary care settings and to prevent disease in communities. Community providers log in and participate in ECHO clinics with School of Medicine faculty. Each community practice has the opportunity to present de-identified cases, receive support in managing those cases and learn from other providers who are presenting their own challenging cases. And, they receive CME/CNE credit for participating in the session. ECHO programming for 2015 will cover 16 disease states across the age spectrum, and plans for expansion are underway.

Understanding the Business Case for Telehealth

Kathy Deanda is the program director for telehealth for University of Colorado Health. Last July, she helped University of Colorado Hospital (UCH) take a big step into telehealth through the launch of its TeleStroke program (featured below). Since the successful implementation of TeleStr​oke​​, Deanda and other UCHealth stakeholders formed a telehealth steering committee with the goal of determining “what’s next” for the system. 

Deanda says creating a business case for a telehealth program is a key first step. It’s critical to understand the impact on things like licensure, contracting, payment and reimbursement. And everyone needs to understand the role of technology and its limitations. “Telehealth is a different care model, another tool to provide the same care we are giving today,” says Deanda. “Not all patients will be seen and treated via telehealth, but when appropriate, it is an efficient tool for providing health care.” 

Deanda is currently working with various UCH departments to assess capabilities and develop programs using telehealth technology. For example, the same system used by TeleStroke may be used for a teleburn and movement disorders. Like Children’s Colorado, UCH is also exploring uses for VIDYO (similar to Skype but HIPPA-compliant), which lends itself to patient encounters such as nutrition consults or behavioral health assessments. 

TeleStroke Quickly Connects Board-Certified UCH Stroke Specialists to a Patient’s Bedside

TeleStroke was created out of necessity, when Memorial Hospital needed back up call coverage. Now, 10 days per month, six UCH stroke specialists are on call using TeleStroke. Here’s how it works: When a suspected stroke patient presents to Memorial’s emergency department, the on-call specialist at UCH is paged. From there, everything happens very quickly. “I can be at the patient’s bedside within 5-8 minutes,” says William Jones, MD, medical director of the stroke program. 

The stroke specialist uses a computer to remotely connect to a “robot” at the patient’s bed. The neurologist can maneuver the robot’s camera for a physical exam, speak directly with the patient via video feed, and view and work within the patient’s electronic health record in Epic.

The TeleStroke specialists have had more than 40 patient encounters. Dr. Jones says that the experience has been well-received by patients and providers alike. “My sense from the patients I’ve seen is that their experience with telehealth consults have been very positive.” he says. “They are very grateful for the thorough evaluation and level of expertise they’ve received so close to home.”

Providers have also expressed satisfaction with the program, though Dr. Jones admits that there was a learning curve. “The first consults felt a little awkward. But once you got used to the technology and the new process, it became routine.”

Providers also appreciate the flexibility of being on call for TeleStroke. As long as they have their equipment and a Wi-Fi connection, they can be ready to consult within minutes. In fact, the team will soon be adding telehealth capabilities into the emergency department at UCH, to allow stroke specialists to provide remote consults, which can actually be quicker than waiting for an on call physician to physically arrive. 

Telehealth Connects Type 1 Diabetes Patients with Specialty Care

The Barbara Davis Center for Diabetes (BDC​) is increasingly recognized for innovative uses of telehealth to connect with patients at outreach clinics throughout Colorado and Wyoming. In fact, they have just launched a major clinical study​ to explore innovative approaches to the treatment of type 1 diabetes using telehealth.

The telehealth program started a few years ago, in part, because of a request from Wyoming’s Medicaid program. Many in this patient population were not being seen regularly by diabetes specialists, and Medicaid reasoned that telehealth could reduce complications and acute events. And it has, according Paul Wadwa​, MD, associate professor of pediatrics and director of telemedicine at the BDC. 

Beyond Medicaid patients, current BDC patients living in rural areas typically alternate between being seen via telemedicine and being seen in person at their local clinic. According to Dr. Wadwa, telehealth encounters are similar to regular in-person visits. “We’re connected directly to the patient’s electronic health record, and we’re able to do everything we do in a regular visit—provide lab orders, review tests, e-prescribe—everything aside from the physical exam. If they need hands on care, patients are encouraged to meet with the diabetes educator or with their PCP,” he says.

So far, data have shown an increased frequency of patient visits. Patients who weren’t being seen regularly report in-person improved care and satisfaction because of telemedicine. Other measures suggest:

• Telemedicine is equivalent to in person visits for maintaining A1C 

• Families and patients miss significantly less school and work 

BDC providers see telemedicine as a way to increase access and decrease financial burden, and think that over time, these factors will improve overall diabetes care and compliance.

$2 Million Grant Funds a Telederm Program at University of Colorado Hospital

April Armstrong, MD, associate professor of dermatology​, received a $2 million grant for comparative clinical effectiveness research in which outcomes for psoriasis patients seen traditionally will be compared with outcomes for patients seen via telehealth. It’s the first dermatology grant funded by PCORI, which provides funding for research that supports informed health care decision-making. 

Dr. Armstrong and her team are currently enrolling 300 patients in California and Colorado. Patients will be randomly assigned to see dermatologists traditionally or via telehealth. 

Patients will upload images and health information through a secure online platform. Specialists will review the information and provide recommendations to the patient, either directly or through the patient’s primary care provider. 

The study is based on the success of a pilot project. “We found we could assess an online image with a reasonable degree of diagnosis and management accuracy,” said Dr. Armstrong, who added that patients will undergo training in image standardization. 

Dr. Armstrong and her team hypothesize that those who are enrolled online will have similar outcomes to patients seen in person.

The Future of Telehealth

As the School of Medicine and its affiliated hospitals continue looking for ways to improve efficiency, reduce costs and improve clinical outcomes and patient satisfaction, it’s clear that telehealth will be part of these plans. 

"Telehealth is proving to be a critical mode of providing timely and convenient care that is locally based for patients and enables access to high quality specialty clinicians," says Stefannie Emerson, vice president of business development and planning at University Physicians, Inc​. 

Dr. Jones agrees. “There are a lot of applications of telehealth that are good for both patients and physicians. With the right plan, the sky is the limit. I encourage people to think creatively about all the things they could do.”