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Clinical Video TeleHealth Clinical Video TeleHealth (CVT) in an (CVT) in an

ENT Outpatient ClinicENT Outpatient ClinicCristie Roush, DNP, GNP-BC

Nurse Practitioner

VA Ann Arbor Healthcare System

DisclosureDisclosure

� Disclosure: The comments and ideas presented here are those of the author and do not necessarily reflect those of the Department of Veteran Affairs or the United States Government.

� Conflict of interest: I have no conflict of interest to disclose

ObjectivesObjectives

�List 3 types of telehealth

�Triage 5 consults for appropriateness for CVT vs face-to-face appointments

�Discuss at least 3 different ways CVT could be used in ENT specialty care

Case StudiesCase Studies

�Let’s consider these possible

opportunities…

�{Cases omitted}

Case #5Case #5

Consider which cases you may

schedule for CVT vs traditional face-

to-face visit.

Use of TechnologyUse of Technology

� Have you ever used technology to improve your healthcare experience?

◦ Secured messaging with provider

◦ Text reminders for appointments

�Would consider the use of technology to improve your healthcare experience?

◦ To save time?

◦ To save money?

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Technology Technology in use than everin use than ever◦ Fewer publications/newspapers

◦ Cellphones for a wide variety of purposes

� Communications – phone, text, FaceTime

� Healthcare using email/secured messages

� Online access to personal health info

Improving Access to HealthcareImproving Access to Healthcare

Access to HealthcareAccess to Healthcare

�Top priority for Veterans Health Administration (VHA).

� Extensive nationwide Telehealth network increases opportunity for success

�VHA is one of the world leaders in use of CVT technology.

�High satisfaction rate among Veterans related to their experience with CVT

Healthcare and TravelHealthcare and Travel

� How far do travel you for healthcare?

◦ Primary care

◦ Specialty care

◦ Would you travel further if included in your plan?

� Impact of travel time for you

◦ Time away from family/work

◦ Cost of gas or use of public transportation

◦ Wear and tear on personal vehicle or friend’s

Why Telehealth in VAWhy Telehealth in VA Why Telehealth in VAWhy Telehealth in VA

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VISN 11 CATCHMENTVISN 11 CATCHMENT

This line shows the catchment area for the ENT clinic at the VA Ann Arbor Healthcare System. The distance from Ann Arbor varies from 37-528 miles roundtrip.

Why Telehealth in VAWhy Telehealth in VA� Travel Reimbursement- $0.415/mile� Veterans qualify for travel benefits if: Veteran has a service-connected (SC) disability of 30% or more (travel for care relating to any condition)

� Travel is in connection with care for SC disability� In receipt of a VA pension� Previous year income does not exceed maximum VA pension rate

� Projected income in travel year does not exceed maximum VA pension rate

� Travel is for a C&P exam� Travel is to obtain a service dog� Travel is in relation to VA transplant care

TelehealthTelehealth

� 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

Types of TelehealthTypes of Telehealth

�Home Telehealth

�Store and Forward

�Clinical Video Telehealth (CVT)

Types of TelehealthTypes of Telehealth

�Home Telehealth

◦Monitoring physiological information

◦Allows for changes in medications

◦ Improved adherence to recommendations

Used with diabetes and hypertension

Home TelehealthHome Telehealth

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Types of TelehealthTypes of Telehealth

�Store and Forward◦ Asynchronous review of clinical information

◦ Information: data, image, sound, video

◦ Allows for clinician to review offline at a convenient time

◦ Frequently used in Dermatology and ENT

Tele dermatology Tele dermatology

http://clickmedix.com/wp-content/uploads/2009/11/Tele-derm-how-it-works3.jpg

ENTENT-- Audiogram Review Audiogram Review –– S&FS&F� A retrospective review of 100 audiograms showing asymmetrical SNHL:

� 1) MRI of the internal auditory canals with gadolinium to rule out retrocochlear lesion=32

� 2) Auditory Brainstem Response to assess for possible retrocochlear lesion=12

� 3) Medical clearance given for hearing aids with retest of hearing in 6-12 months=32

� 4) Medical clearance given for hearing aids=24

Outcome of Audiogram S&FOutcome of Audiogram S&F

� ENT clinic appointments saved

100 appointments

� Average days for initial evaluation

5.4 days

� Potential VA travel reimbursement savings $4,606.50

� Total travel miles saved for Veterans

10,804 miles

Types of TelehealthTypes of Telehealth

�Clinical Video Telehealth (CVT) ◦ Synchronous appointment with both parties and a communication link that allows a real-time interaction.

◦ Video-conferencing equipment is one of the most common forms of technologies used

◦ Use of peripheral devices, such as otoscopes, stethoscopes, and total exam cameras

Keys to success for CVTKeys to success for CVT

� Infrastructure:

◦ Equipment - include high definition monitors, excellent network connections, knowledgeable medical staff

◦ Create a protocol where each individual’s roles are clearly defined.

� Include the patient in his/her care, expecting a video conference,

◦ The telehealth coordinator obtains and documents verbal consent for CVT visit prior to first CVT visit

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Clinical Video TelehealthClinical Video TelehealthItem Telehealth variation: Does the

introduction of telehealth modalities result in variations to the normal clinical routine? If so, describe:

Recommended solution: (Technology, Travel Patient, Travel provider, Telepresenter skill, Local source, Other)

Pre-visit activities

Clinical reminders

none .

Vital signs & wieight

yes VS taken by patient TCT, recorded inCPRS, verbally reported to providerduring CVT visit

Histories

Interview Yes Will use web cam and/orvideoconferencing equipment

Review of intervention results from previous visits

No-- CPRS

Assessment/Evaluation, by system

HEENT (Head, eyes, ears, nose, throat)

yes Patient: primary care cart, otoscope,total exam camera per providerdirection. Provider: videoconferencingand/or webcam

Pulmonary Yes—but rarely Patient: See above + stethoscopeProvider: Stethoscope receiver.

Cardiac Yes—but rarely Patient: See above + stethoscopeProvider: Stethoscope receiver.

Neurological By inspection only By inspection Via webcam or CVTequipment

Consultation/referral

yes ENT will screen current consultsand follow up appts for CVTappropriate patients

Medication/pharmacy

no

In-office procedure

Yes—Suture removal at directionof provider

TCT (if LPN) or Nurse at patient sitemay need to remove visible stitches atdirection of provider prior to, duringor after CVT ENT appointment

Education Yes Use CVT equipment for education

Consent Yes Telehealth will obtain and document verbal consent for CVT visit prior to first ENT CVT visit

Providerendpoint

yes Webcam if inspection and consultationonly. Clinical assistant if peripherals areneeded

Patientendpoint

yes Primary care cart, total exam camera, otoscope, stethoscope at provider’s direction

CVT vs Traditional VisitsCVT vs Traditional Visits

� Key Factors for success of CVT

◦ Proper Triage

◦ High quality photos/images/video

◦ Effective infrastructure and culture

� CVT advantages:

◦ Better, cheaper, and faster

◦ Patients travel shorter distances

◦ Decreased time away from work/home

◦ Decreased wait times for appointments

Advantages to providersAdvantages to providers

�Often take less time

◦ No waiting for pt to get to or leave from exam room

◦ Vital signs, EKG, labs, etc all completed outside of visit

◦ Removal of sutures/bandages and replacement, when needed by TCT

◦ Plan CVT for patients who are f/u or simple new problems

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Case #1Case #1

� {Cases Omitted}

Impact of CVTImpact of CVT

� Introduction of CVT in Jan 2014

� By the End of July 2014:

◦ Completed 35 H&Ps

◦ Completed 20 Post op visits

◦ Completed 32 consultations

◦ Saved 87 clinic appointments

� Saved $7181 potential travel reimbursements

� Saved 17,303 miles of travel

Improvements/Next StepsImprovements/Next Steps

� CVT consult to better track appointments� H&Ps

� Post ops with time frame, +/- sutures to remove

� New consults

� Inception of consult March 2015- increase 4 fold

� Keeping residents/staff aware of CVT availability◦ Change every 3 months

ReferencesReferences� Grady, J. (2014). Telehealth: A Case Study in Disruptive Innovation. American Journal of Nursing, 38-45.

� Head, B. A., Keeney, C., Studts, J. L., Khayat, M., Bumpous, J., & Pfeifer, M. (2011). Feasibility and Acceptance of a Telehealth Intervention to Promote Symptom Management during Treatment for Head and Neck Cancer. Journal of Supportive Oncology, e1-e11.

� Iannitto, J. M., Dickman, K., Lakhani, R. H., & June, M. (2014). Telehealth Insulin Program: Managing Insulin in Primary Care. The Journal for Nurse Practitioners, 567-574.

� Jackson, G. L., Krein, S. L., Alverson, D. C., Darkins, A. W., Gunnar, W., Harada, N. D., et al. (2011). Defining Core Issures in Utilizing Infomation Technology to Improve Access: Evaluating and Reserach Agenda. Journal of General Internal Medicine, 623-627.

� Kehle, S. M., Greer, N., Rutks, I., & Wilt, T. (2011). Interventions to Improve Veterans' Access to Care: A Systematic Review of the Literature. Journal of Internal Medicine, 689-696.

� Kitt, S. M., & Clayton, L. (2002). The Cost-effectiveness of telehealth in metropolitan hospitals. Journal of Telemedicine and Telecare, S3:42-43.

� Landow, S. M., Mateus, A., Korgavkar, K., Nightingale, D., & Weinstock, M. A. (2014). Teledermatology: Key factors associated with reducing face-to-face dermatology visits . American Academy of Dermatology, 1-7.

� Monteagudo, J. L., Salvador, C. H., & Kun, L. (2014). Envisioning patient safety in Telehealth: a research perspective. Health and Technology, 79-93.

� Murray, P. (December, 5 2014). Use of time and CVT. (VHA, Interviewer)

� Telecare Program Effectively Manages Pain, Reduces Opiod use in VA Patients. (n.d.). Retrieved September 30, 2014, from www.usmedicine.com: http://www.usmedicine.com

� US Department of Veteran Affairs.{n.d.). (n.d.). VA Telehealth Services. Retrieved March 7, 2014, from US Depeartment of Veteran Affairs: http://www.telehealth.va.gov/real-time/index.asp

� VA Healthcare VISN 4. (n.d.). Retrieved from Clinical Video Telehealth (CVT).

� Veterans Health Administration. (n.d.). Travel Reimbursement. Retrieved September 15, 2014, from Benefits.gov: http://benefits.gov/benefits/benefits-details/314

� VHA. (n.d.). Telehealth: Technology for All Veterans. Retrieved December 29, 2014, from ncsl.org: http://www.ncsl.org/documents/environ/Grewe_2_PPT.pdf

� Wade, V. A., Elshaug, A. G., & Hiller, J. E. (2010, November 8). A Systematic review of economic analyses of telehealth services using real time video communication. Retrieved March 15, 2014, from BioMed Central Health Services Reserach.

� Wootton, R. (2012). Twenty years of telemedicine in chronic disease management- an evidence synthesis. Journal of Telelmedicine and Telecare, 211-220.