Why is Healthcare Broken?
Why is healthcare broken? There is a multitude of reasons, but the poor delivery of care is often the result of ignorance. Yes, for years quality experts and specialists from all medical specialties have worked on guidelines that are based on scientific evidence. The problem is will physicians adapt them? Will hospital and hospital systems ensure compliance with the guidelines?
Let me give an illustration that recently appeared in DHealthcare Daily where the CEO of Methodist Health System was interviewed. The CEO is quoted as saying “So last year we spent a lot of hours working on a condition called sepsis, which has a very high mortality. It’s lethal in many cases, and it’s lethal not only in the elderly but the young as well. So our learning in that, learning the early symptoms and the early interventions that need to take place, and how the key is early intervention, and the impact that has had on the way we practice across Methodist as it relates to sepsis is dramatically different today than it was 12 months ago. And the impact, well, it’s a life saver. There’s no question about it. We were average in that area, I would say, among hospitals in America. Today I would say we’re in the top decile.”
What is disturbing is that sepsis had been around for years. The fact that the Society of Critical Care Medicine along with other professional societies published scientific guidelines on the recognition and treatment of sepsis back in 2002. Why 14 years later are healthcare professionals suddenly realizing this is a major problem that affects almost 800,000 patients a year? Why is the dissemination and utilization of sound medical evidence not being implemented immediately?
The above example is one of many that may be attributed of hospitals not having the expertise of quality programs or specialists in certain areas of medicine. It may also be the result of physicians either not accepting guidelines or not paying attention. Telemedicine may have a very significant impact on improving quality. Telemedicine may very well be the conduit to provide intensivist and infectious disease expertise to hospitals that lack these specialties. The same services may enhance both accessibility and speed to obtain highly efficient treatment modalities. There is growing evidence to suggest that remote care by distant intensivists and infectious disease physicians provide a significant quality benefit to patients often unable, because of geography, not have access to these providers.
Certain diseases that affect larger portions of our population often have associated evidence-based guidelines for physicians. It is up to hospital leadership to ensure compliance. When expertise is needed for patients that are complex, then telemedicine is certainly an alternative that must be utilized.
The evolving role of ICU Telemedicine is the cover story for Critical Connections (Volume 15, Number 1). At this time, more than 11% of nonfederal adult ICU beds in the United States are covered by ICU telemedicine. These programs are a means to fill the gap for the growing need for intensivists. Demand now exceeds supply. Many rural hospitals do not have on-site intensivists, but with telemedicine, they have an unparalleled link to critical care.
Early results from small studies show a reduction in ED delays, ICU length of stay, and a decrease in mortality. Some newer studies now show a decline in response times for abnormal laboratory values and alerts for abnormal physiological vital signs.
ICU telemedicine provides population management solutions that have been shown to increase adherence to best patient practices and reduce preventable complications which ultimately increase costs. Observers have also noted almost real time review of performance reports by an efficient ICU governance team.
Recent ICU telemedicine financial data has shown that these programs are extremely cost-effective in most cases and cost savings in some.
The Society of Critical Care Medicine’s Tele-ICU committee recently did a survey which demonstrated an increasing use of telemedicine as a useful tool. Additionally, the committee also identified that many ICU’s are incorporating personal electronics that are HIPAA compliant. Telecommunications are providing a means for families to be in contact with the ICU if they are traveling or at work. Use of electronic billboards identifies family questions and concerns. Families may even participate in patient rounds remotely.
“New telemedicine-related technologies are focused on more efficient critical care workflows that enable 0ff-site patient management using reliable standardized protocols and oversight.” Multipath medical device integration will now allow titratable therapy based upon laboratory results and physiological parameter monitoring.
Malpractice claims may also diminish.
The ultimate goal of ICU telemedicine is the improvement of the quality and safety of the care of critically ill and injured patients. As usual, further well-designed studies are required.
An analysis of direct-to-consumer (DTC) telemedicine in California suggests that the use of a commercial telemedicine provider disputes the value of access for rural patients.The data, published in the April issue of Telemedicine and e-Health, reveal telemedicine use is not higher in rural areas, a lower rate of diagnostic tests for low back pain, a significantly lower use of Streptococcal testing occurred, and higher use of antibiotics for bronchitis with the telemedicine provider .
The study compared the commercial provider Teladoc with office visits to primary care physicians who saw HMO patients insured by Blue Shield of California.
Most of the telemedicine encounters were by telephone and not videoconferencing suggesting a comparison with providers that utilize videoconferencing is imperative.
Teladoc patients were ordered a strep test only 5% of the time compared to 50% of the physician offices. The Infectious Disease Society recommends testing for all adults.
For bronchitis, for which antibiotics are not recommended, the Teledoc physicians performed worse (16.7%) than the physician offices (27.9%).
Quality data suggest that patients with low back pain often do not require an imaging study as symptoms often resolve within 30 days. Teladoc physicians seemed to do this more frequently than office physicians.
A total of 4, 657 Teladoc visits were used for analysis.
Slightly more patients using Teladoc were located in rural areas. There were no differences in drive time to a primary care office (3 minutes) or emergency room (10 minutes) compared to the advertised response time of 16-20 minutes for the virtual physician.
Teleadoc has embarked upon adding the ordering of diagnostic tests for patients with pharyngitis.
It is key remember that the study does not conclude that telemedicine is superior or inferior to office visits. It does educate the commercial providers of telemedicine that individual quality indicators be observed whether a patient is treated in person or virtually. A next good study should include comparison with providers of video encounters as well.
Another major outcome that needs further study is what happened clinically to the patients who did not receive a strep test? Were they later diagnosed? Detailed follow-up for outcomes is essential.
Urgent telehealth care quality varies by commercial provider. Quality may vary in six frequent conditions but the mode of delivery videoconferencing, telephone, and web chat was not a cause for variation in quality.
The 6 conditions included: ankle pain, streptococcal pharyngitis, viral pharyngitis, rhinosinusitis, low back pain, and recurrent female UTI.
The eight providers of telehealth selected by the University of California at San Francisco included Ameridoc, Amwell, Consult a Doctor, Doctor on Demand, MDAligne, MDLIVE, MeMD, and NowClinic. The selection was based upon data obtained from the most frequently used sites.
Primary outcomes were based upon a complete history and physical, correct or incorrect diagnosis, and compliance with national guidelines. Sixty-seven standardized patients were used for a total of 599 virtual visits. The standardized patients were either an actor with experience in the simulation center at UCSF or medical students. Completeness of the exam occurred in almost 76% of the patients. Of the eight companies, completeness varied from 51.7 to 82.4%. Correct diagnosis varied from 65.4% to 93.8%. Compliance with guidelines ranged from 34.4% to 66.1%.
For making the correct diagnosis, videoconferencing (85.8%) and telephone consults (77.7%) were better than webchat (66.1%).
The authors noted that variability of care is also seen in the traditional setting. A prominent example is the prescription of antibiotics. Interestingly, the ordering of tests was lower in the virtual care compared to the traditional setting.
At odds with the Texas medical board, which has outlawed telephone consults, this study found no statistical difference in adherence to national guidelines based upon a mode of consultation.
The variability of the different providers supports the need for improvement and perhaps the need for accreditation as is available through the American Telemedicine Association.
Finally, the limits of the study are that we do not know if a telemedicine visit is inferior or superior to an in-person visit. Since this is the first study of this nature, additional research is needed.
Secure messaging can have a positive impact on diabetes clinical outcomes according to an ahead of publication posting on Telemedicine and e-Health. According to this new review, “President Barack Obama signed into law the Health Information Technology for Economic and Clinical Health (HITECH) Act in 2009. HITECH stated that from 2011 to 2015, healthcare providers would be offered financial bonuses for meaningfully using electronic health records (EHRs) and penalized for not doing so. ‘‘Meaningful use’’ (MU) is meant to improve care quality and engage patients while maintaining privacy of information, to obtain better clinical outcomes, population health outcomes, and increased efficiency. There are three stages. One of the stage 2 core objectives introduced in 2014 was for eligible providers to use secure electronic messaging to communicate with patients.”
However, earlier EHR studies reveal only limited evidence for the value of these tools in managing chronic diseases. One systematic review of articles assessing the value and clinical outcomes of using EHRs in chronic disease management published between January 2000 and September 2010 found only three prospective randomized trials, all centered around diabetes care. The authors from the University of Miami, reviewed the more recent studies to determine outcomes for diabetes management.
In this pre-publication review slated for September release, “evidence from 7 of the 11 included studies suggests significant improvement in patients’ hemoglobin A1c (HbA1c) with the use of secure messaging. However, improvements in patients’ secondary outcomes, such as blood pressure and cholesterol, were inconsistent. Further work must be done to determine how to best maximize the potential of available tools such as secure messaging and EHRs to improve patient outcomes.”
The ideal stroke network with telemedicine is described in Endovascular Today (February, 2016). C3O’s Dr. Jeff Wagner, estimates that more than 10% of ischemic strokes are due to large vessel occlusion (LVO), and many of these strokes will not be effectively treated with IV tPA alone. Enter intra-arterial (IA) therapy which can be effective in such patients.
“Because strokes are time-sensitive hospitals must be able to quickly obtain CT imaging to exclude a hemorrhage and efficiently prepare and administer IV tPA. When necessary, transfer to a hub hospital must be rapid for IA and other advanced therapies.”
Rapid response by teleneurologists neurologists, are the single most important factors that drive performance of a stroke system of care, especially at hospitals without onsite neurologists.
Table 1 from the Endovascular Today article “details some key quality metrics Dr. Wagner tracks to measure our performance. Each of the listed metrics has improved annually over the past 5 years, and many other metrics are evaluated, which has allowed us to identify areas of inefficiency.”
BENEFITS RESULTING FROM NETWORK DEVELOPMENT
- Improved delivery of therapies for acute stroke
- Increased IV tPA delivery at spoke hospitals results in increased reimbursement to the spoke hospital.
- A decreased transfer rate from spoke to hub hospitals results in less revenue lost by spoke hospitals.
- Improved stroke quality metrics, which are likely to factor into hospital reimbursement for services rendered in the future.
- Liability is shared as though the stroke specialist is physically present in the emergency department of the spoke hospital. Our malpractice insurance provider is increasingly recommending stroke telemedicine coverage when in-person stroke specialist coverage is not available due to reduced liability exposure.
- From a public health perspective, reducing unnecessary transfers, many of which involve an emergent critical care air ambulance, confers significant savings to the health care system as a whole. Medicare-funded studies are ongoing to determine the cost-effectiveness of telemedicine in neurology and neurosurgery as compared to availability of specialists by phone.
Jeffrey C. Wagner, MD, is Medical Director at the Swedish Comprehensive Stroke Center and CODOC Telemedicine Program, and is affiliated with Blue Sky Neurology in Englewood, Colorado and C3O Telemedicine. He has disclosed that he is on the speakers bureau for Genentech. Dr. Wagner may be reached at firstname.lastname@example.org.
Telehealth growth accelerates as challenges in workflow, interstate licensing and reimbursement continue to be addressed . Dr. Naomi Watts of Biogen Idec says “patients clamoring for physician access”.
Dr. Roy Schoenberg, CEO of AmWell says telehealth is providing the right way of getting in front of a physician.”The value of seeing a patient – visual is key” says Schoenberg.
Jason Sibley of Flare Cap Parnters believes telehealth’s business is to build a system that meets the needs of specific group of patients. One group that comes to mind is the large number of patients with chronic diseases such as Diabetes, Heart Failure, and Hypertension.
John Moore, MD, PhD of Twine Health noted that patients want to have “a low friction channel to access physicians particularly when they are experiencing an emotional need”.
This has been a preview of what’s to come at HIMSS at the end of February and is reported by Brian Dolan of Mobihalth News.
One story which never made the mainstream press is the humanitarian gesture of a group of ICU Telemedicine specialists providing civilian ICU care in war-torn Syria. Reported in the February issue of the Annals of American Thoracic Surgery, a network of approximately 20 participating intensivists was providing clinical decision support 24 hours per day to five civilian ICUs in Syria. The program utilized inexpensive, off-the-shelf video cameras, free social media applications, and a volunteer network of Arabic-speaking intensivists in North America and Europe. Launched in 2012 and within 1 year, 90 patients per month in three ICUs were receiving tele-ICU services. What would normally take numerous committee meetings including budgetary constraints was done on an all volunteer basis at a much lower than expected cost.
The program is implementing a cloud-based electronic medical record for physician documentation and a medication administration record for nurses. There are virtual chat rooms for patient rounds, radiology review, and trainee teaching. The early success of the program shows how a small number of committed physicians can use inexpensive equipment spawned by the Internet revolution to support from afar civilian health care delivery in a high-conflict country.
The critical care community and the world will be waiting to see data from this extraordinary and courageous endeavor. Congratulations to Drs. Moughrabieh and Weinert from the University of Minnesota Medical School, Minneapolis, Minnesota.
A National ICU Telemedicine Effectiveness Study
Just released ahead of publication is another study by Khan and group from the University of Pittsburgh. Using Medicare data only this is a pre and post icu telemedicine comparison which shows some slight benefit as described.
Intensive care unit (ICU) telemedicine is an increasingly common strategy for improving the outcome of critical care, but its overall impact is uncertain.
To determine the effectiveness of ICU telemedicine in a national sample of hospitals and quantify variation in effectiveness across hospitals.
- A multicenter retrospective case-control study using 2001-2010 Medicare claims data.
- Using ICU admissions from 2 years before and after the adoption date, we compared outcomes between case and control hospitals using a difference-in-differences approach.
- A total of 132 adopting case hospitals were matched to 389 similar nonadopting control hospitals.
- The preadoption and postadoption unadjusted 90-day mortality was similar in both case hospitals.
- In the difference-in-differences analysis, ICU telemedicine adoption was associated with a small relative reduction in 90-day mortality
- However, hospitals with a significant mortality reduction were more likely to have large annual admission volumes and be located in urban areas compared with other hospitals.
Although ICU telemedicine adoption resulted in a small relative overall mortality reduction, there was heterogeneity in effect across adopting hospitals, with large-volume urban hospitals experiencing the greatest mortality reductions.
Inconsistencies with brain death criteria: telemedicine to help?
Is there a role for telemedicine in the determination of brain death? An article in JAMA Neurology December 28th included 52 organ-procurement organizations obtaining brain death policies from 492 qualified hospitals across the United States. The researchers evaluated the policies based upon:
- who is qualified to perform the determination of brain death,
- what are the necessary prerequisites for testing,
- details of the clinical examination,
- details of apnea testing, and
- details of ancillary testing.
There remained significant variability across all 5 categories of data, such as excluding the absence of hypotension (276 of 491 policies [56.2%]) and hypothermia (181 of 228 policies [79.4%]), specifying all aspects of the clinical examination and apnea testing, and specifying appropriate ancillary tests and how they were to be performed.
Additionally the study revealed:
33.1% required specific expertise in neurology or neurosurgery for the health care professional who determines brain death,
- 43.1% stipulated that an attending physician determine brain death;
- 150 policies did not mention who could perform such determination.
CONCLUSION: Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters. Hospitals should be encouraged to implement the 2010 AAN guidelines to ensure 100% accurate and appropriate determination of brain death.
COMMENT: ROLE OF TELEMEDICINE?
The issue is what is the role of telemedicine, if any, in the determination of brain death? At first glance, one would think that the determination of brain death is such an emotionally challenging procedure that the presence of a physician would be expected. Working closely with families which at times requires the holding of the hand, the provision of a tissue or reassurance is an important aspect of providing care by both physicians and nurses. Can this be achieved remotely? One might easily agree that in hospitals that do not have a physician available, telemedicine as a proxy might be better than no physician presence. On the other hand, an Emergency Medicine physician who is trained in this evaluation could serve in the capacity of providing the proper assessment. The telemedicine neurologist or intensivist promote the utilization of the AAN guidelines. Most importantly as the study has shown, there is no reason why all hospital brain death policies should not be in compliance with the 2010 AAN guidelines. In the end, telemedicine should serve as a clinical service that augments on site physicians and brain death procedures might be the alternative and not the preferred solution.