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Overview of Telemedicine ProgramOverview of Telemedicine Program
December 16, 2009December 16, 2009
Management TeamManagement Team
CEO and Founder
Chief Medical Officer
Chief Financial Officer
VP, Business Development
VP, Operations
Paul I. Bulat, M.D., FACEP
Daniel J. Shea, M.D., FACEP
Maureen Petersen, CPA
Sam Shen M.D., M.B.A, FACEP
Brenden Hayden, EMT-P
Overview- ChallengesOverview- Challenges
Across the nation, skilled nursing facilities face similar challenges.
Patients
Nurses
Physicians
Skilled nursing facilities
Hospitals
Access to real time medical consultation
Timely access to physicians for non-urgent, urgent, and emergent clinical issues during off-hours.
Responsibilities span office visits, nursing home visits, and on call coverage limiting availability
Regulatory compliance, unnecessary transfers to local Emergency Departments
Readmissions
Overview- DemographicsOverview- Demographics
The elderly population is expected to grow dramatically relative to other age groups. By 2050, the over 75 age group will comprise 12% of total population
0
10
20
30
40
50
60
<18 18-54 55-64 65-74 >75
2000
2004
2050
Source: Chartbook on trends in the Health of Americans, Health, United States, 2005
% o
f p
op
ula
tio
n
LimitationsLimitations There are limitations in the current model of physician coverage at Skilled Nursing Facilities
• Limited supply of primary care physicians, especially geriatricians
• Response times to clinical questions in SNF can range from hours to days
• Physician consultation over the phone is constrained by:• Limited time of the provider• Limited knowledge of the patient• Lack of visualization of the patient• Lack of access to medical records
• Consultation results in blind diagnosis or unnecessary transfer to the Emergency Department
SolutionSolution
PhoneDOCTORx is an innovative company targeting the growing medical needs of the nursing home population
• Physician coverage service for skilled nursing facilities in New England
• Utilize existing telemedicine technology to perform physician consultation with patients
• Implemented at our first trial site in June 2006 in a 154 bed SNF in New Bedford, MA
• Currently in 3 sites, expanding to 6 facilities January, 2010• Operational 7 days/week
• 5pm-11pm Mon-Friday• 10am-7pm Sat., Sun.
• Staffed by Board Certified physicians in Internal Medicine, Family Medicine, and/or Emergency Medicine
Technology SolutionTechnology Solution
• Wireless cart is portable and self-contained• Tandberg equipped camera• High definition capability• Camera operated remotely by physician at
call center• Additional wound/dermatology camera
available• Battery operated• Ability to bring multiple providers on screen
to patient• 3 process patents and 2 patents pending
Overview- OperationsOverview- Operations
Clinical Process
1. Clinical question or concern arises at a SNF2. SNF nurse contacts PhoneDOCTORx at our call center3. Medical triage assistant prioritizes call4. Physician pulls up patient records electronically
• Discharge summary• Medication list• Progress notes
5. SNF nurse discusses case with physician by phone6. Nurse rolls telemedicine cart to patient room to initiate
consultation7. Physician writes orders as needed and electronically
transmits progress note of encounter to SNF
Clinical BenefitsClinical Benefits
PhoneDOCTORx can improve quality of care and life at skilled nursing facilities:
1. Reduce time delay in responding to clinical problems at SNF2. Visualization of patients can provide physicians more information
to make better decisions3. Access to medical records allows better decision-making
• Review labs, XRays, medications4. Assist in stabilization of emergent patients being transported to
the ER5. Documentation of clinical encounters ensure better continuity of
care6. Address pain/behavioral issues immediately
• Adjust pain medications• Control agitation without restraints
Overview- Additional BenefitsOverview- Additional Benefits
Providing our telemedicine service creates real benefits to the patients, clinical staff, physicians, and SNF
1. Provide higher level of acuity of service at SNF• Our physicians provide immediate care and manage the
spectrum of acuity2. Reduce unnecessary transfers/readmissions to hospitals
• 2007 New York Study by Grabowski approximates 31% of inpatient admissions avoidable
3. Increase admissions and occupancy• Marketing opportunities to community/family/hospitals
4. Attract PCPs with large practices• Decrease the burden on PCPs during afterhours/weekends
5. Improve nursing recruitment & retention• Nursing satisfaction very high with program• Provides real-time support to nurses
Unnecessary HospitalizationsUnnecessary Hospitalizations
Reducing nursing home hospitalizations is an area of cost savings based on recent study
“Costs and Potential savings associated with Nursing Home Hospitalizations” by David Grabowski, et.al (2007)
• In New York State, between 1999-2004, spending increased 29% on nursing home hospitalizations
• During that time period, $972 million in aggregate spending• Total cost per hospitalization $12,160 (2004)• 40% deemed avoidable admissions based on diagnosis• This results in $223 million potential cost savings• Admissions result in increased iatrogenic disease and delirium• Conclusion “…policies directed at decreasing nursing home
hospitalizations may generate major cost savings for Medicare program”
OverviewOverview
Telemedicine program is a platform for additional/future services
PhoneDOCTORx Service
Increased access to physicians
Specialist consultation
Family conferences
Education• Continuing medical education• Lectures/seminar via telemedicine
• Discussion with family
• Wound care• Psychiatry
• Real-time medical consultation
Clinical Summary: OverviewClinical Summary: Overview• There have been over 10,000 documented encounters between June 1, 2006 and present at three sites
Clinical Summary: DispositionClinical Summary: Disposition
For all encounters, the majority of patients remain in the skilled nursing facility while a minority (5%) are transferred to the Emergency Department.
ER 5%
Nursing Home95%
Overall Disposition Distribution
Emergency Department
Nursing Home
Clinical Summary: Chief ComplaintsClinical Summary: Chief ComplaintsThere is a wide distribution of cases seen during the first year.
Distribution of Chief Complaints
Medication13%
Psychiatry/Behavioral4%
Pulmonary8%
Radiology2%
Endocrine2%
Orthopedic3%
Opthalmology0%
Cardiac3%
Laboratory23%
Infectious Disease/Fever
2%
GI7%
Gynecology0%
Neuro3%
Other10%
Skin8%
Trauma7% Allergy
0%
GU4%
ENT1%
Allergy
Cardiac
Endocrine
ENT
Gastrointestinal
GU
Gynecology
Infectious Disease/Fever
Laboratory
Medication
Neuro
Opthalmology
Orthopedic
Other-see comments
Psychiatry/Behavioral
Pulmonary
Radiology
Skin
Trauma
Clinical Summary: TransfersClinical Summary: Transfers
Clinical Summary: TransfersClinical Summary: Transfers
Clinical Summary: Overall BenefitsClinical Summary: Overall Benefits
How do you value the service PhoneDOCTORx provides?
Value
PhoneDOCTORx Access Fee
Potential cost savingsfrom unnecessary ED transfers
Access to care/improved care
Marketing tool
Staff retention/recruitment
$/month
Patient/family satisfactionAdditional benefit
Financialbreakeven point
$
Physician recruitment
Regulatory compliance
Legal ConcernsLegal Concerns
• Received support from Massachusetts Department of Public Health
• Operating as covering physicians for primary care physicians
• No impact on malpractice premiums for telemedicine physicians
• Telemedicine consult enables a more thorough and informed evaluation versus status quo
Business ModelBusiness Model
Chains52%
Independent48%
The market size is approximately $3 billion in the United States per year.
Nursing Homes
17,000 Skilled Nursing Facilities
United States Massachusetts
456 Skilled Nursing Facilities
Chains52%
Independent48%
Barriers to AdoptionBarriers to Adoption
There are several real and perceived barriers to adoption of our program
Costs Nursing homes bear cost of program with limited resources
Subsidize costs by insurers/government• Senior whole health• Medicare
Barriers Solutions
New technology Healthcare slow to adopt new technologies
• Demonstration projects• Marketing• Consumer driven demand• Policy changes
Expansion StrategyExpansion Strategy
After successful trial at existing sites:
• Market to local and regional nursing home chains• Market to physician groups that provide nursing home care• Partner with third party payers
• Regional payers (SCO’s)• Large private/government payers
• Market to large national nursing home chains• Academic prospective study with Grabowski, Professor, Harvard
University
PhoneDOCTORx ServicesPhoneDOCTORx Services
SNF• Consultation services to develop customized
telemedicine programs for individual sites • Implementation of telemedicine program
Hospital• Consultation services for customized “30 day
readmission” program• Coordination of SNF/Hospital continuum of care
Questions?Questions?1-866-539-PDRX1-866-539-PDRX
www.phonedoctorx.comwww.phonedoctorx.com