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A Telemedicine Opportunity

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     A Telemedicine Opportunity or a Distraction? 1  A Telemedicine Opportunity or a Distraction?  Janis L. Gogan, Bentley University  Monica J. Garfield, Bentley University   Copyright © 2012 by the Case Research Journal   and by Janis L. Gogan and Monica J. Garfield. All rights reserved. Te authors developed this case for class discussion rather than to illustrate effective or ineffective handling of an administrative situation. An earlier version of this case was presented at the I Management rack of the North American Case Research Association (NACRA) annual meeting in San Antonio, exas, October 2011. Research funding was provided by Bentley University and the North  American Case Research Association. We thank these two institutions and the anonymous reviewers who made helpful suggestions on earlier versions of this case, and the clinicians and managers who agreed to be interviewed for this case. Some facts and figures have been disguised. S hawn Farrell, Executive Director of the Partners eleStroke program, glanced at his smart phone while striding toward his office at Massachusetts General Hos-pital (MGH) in Boston; he nearly collided with Lee Schwamm, MD. Knowing that Dr. Schwamm’s overfull schedule as Vice Chairman of Neurology and Director of  Acute Stroke and eleStroke Services meant he had little time to chat, Farrell used the near-collision as an opportunity to quickly mention a recent conversation with a nurse from Falmouth Hospital on Cape Cod.  An active participant in the eleStroke service, Falmouth Hospital was regularly honored for its adherence to best practices in stroke care. “Recently some Falmouth nurses asked how we can convince other MGH departments—such as in critical-care pediatrics—to provide similar telemedicine consultation services,” Farrell stated, add-ing “Teir nurse stroke coordinator, Jean Estes, is a huge cheerleader for eleStroke.” Dr. Schwamm continued moving toward his office as he replied, Shawn, don’t we already have too much to do? I need to see patients, complete the analysis for a study I am working on, submit a grant application. Next week I will speak at an international neurology conference. elemedicine can certainly be invaluable in many clinical domains, but there just are not enough hours in the day for us to get involved beyond stroke care. Before entering his office and shutting his door, Dr. Schwamm added one last remark: “We can’t do everything, Shawn—but we can do eleStroke very well.”Shawn Farrell was not a medical doctor. A graduate of the Boston University School of Management, he had worked as an operational manager in several Boston area hospitals before joining the eleStroke team. Farrell was enormously proud of the eleStroke service, which was helping to save lives and to speed stroke victims’ recovery since its initiation in 2000. As a manager he was also pleased that in 2011 eleStroke was financially self-sustainable. Now he wondered: How should he respond to the Falmouth nurses’ request? NA0 1 8 6 This document is authorized for use only in Health Information Technology (HCIT) by Professor Adam C Powell at Indian School    2 Case Research Journal ã Volume 32 ã Issue 2 ã Spring 2012 T ELEMEDICINE Physicians used telemedicine systems to provide second opinions or other medical services (such as supervision of surgical or emergency procedures) over distances. Some telemedicine services, such as teleradiology, involved asynchronous exchange of medi-cal images. Others utilized video conferencing technologies, making it possible for clinicians in different locations to confer with one another and/or with patients. Ac-cording to the American elemedicine Association (AA) a “specialist referral service”  was a type of telemedicine consultation service that might involve “a specialist assisting a general practitioner in rendering a diagnosis . . . [via] a live, remote consult [with the patient present] or the transmission of diagnostic images and/or video along with patient data to a specialist for viewing later.” 1 Farrell made a point of keeping up with telemedicine developments elsewhere. ele-radiology was widely used. Te AA reported that about fifty other medical subspe-cialties successfully used telemedicine. Dermatology, ophthalmology, mental health, cardiology, and pathology were among the clinical disciplines using telemedicine for specialist referral services. One literature review reported that the field was “maturing,” as evidenced by the broad geographic and disciplinary scope of telemedicine services. 2  However, another authoritative paper reported that most telemedicine initiatives had not advanced beyond the pilot-testing stage. 3  Few telemedicine consultation services had reached long-term financial viability, and even fewer were directed toward urgent care. One obstacle was reimbursement; most telemedicine services were not yet covered in insurance policies. Another obstacle: the complexity of medical licensure (which in the United States was done on a state-by-state basis) and credentialing (the process by  which an individual doctor was authorized to provide care at a particular hospital). Furthermore, many hospitals—from small community hospitals to large tertiary care centers—had problematic network architectures and extensive interoperability issues that needed to be fixed. Until those hospitals were able to upgrade their I infrastruc-tures, it would be difficult to implement innovative new services such as telemedicine. Partners eleStroke service—a real time consultation service—was one of only a small number of financially viable, ongoing telemedicine offerings supporting urgent care in the U.S. T HE  P  ARTNERS  H EALTH C  ARE  T ELE S TROKE  S ERVICE In the United States, most  primary   care was provided by a family physician or general practitioner, either in private practice or through a health-maintenance organization (HMO). Secondary   care was provided by specialists, usually at community hospitals.  When a patient needed to see a higher-level of specialist for a complicated condi-tion, they were usually referred to a tertiary   care hospital, such as MGH. Many of the physicians who worked at tertiary care hospitals had received additional sub-specialty training (such as a pediatrician trained in neonatology or pediatric intensive care, or a neurologist who specialized in acute stroke care).In 1994 two prominent Harvard-affiliated tertiary care hospitals—MGH and Brigham & Women’s Hospital (hereafter, the Brigham)—merged, forming Partners HealthCare. Over the ensuing years, other hospitals joined or developed affiliations  with Partners ( Exhibit 1 ). This document is authorized for use only in Health Information Technology (HCIT) by Professor Adam C Powell at Indian School of Business (ISB) from February 2014 to April 2014.     A Telemedicine Opportunity or a Distraction? 3 In 2000, Dr. Schwamm began using telemedicine to help emergency physicians at a Partners-affiliated institution—Martha’s Vineyard Hospital (MVH)—to determine if patients were experiencing an acute ischemic stroke and if so, whether to administer a life-saving drug—tissue plasminogen activator (tPA). Acute ischemic stroke, caused  when a clot blocks blood flow to the brain, was a leading cause of death and disability—especially when treatment was delayed. Stroke was the third leading cause of death in the U.S., with about 795,000 cases and 140,000 deaths. 4  Worldwide, about 15 million people suffered strokes each year. A stroke could cause devastating disabilities (such as paralysis and speech loss). A patient’s chance of recovery greatly improved if tPA was given within three to four hours of the first onset of symptoms. However, a patient could suffer from another condition which exhibited stroke-like symptoms, but which could not be treated with tPA. In fact, tPA could harm—even kill—a patient who  was experiencing internal bleeding or was already taking blood thinners. A neurolo-gist with expertise in acute stroke care was the best judge of whether a patient was a candidate for tPA.Martha’s Vineyard Hospital could not afford 24/7 stroke neurology coverage, so they agreed to test a telemedicine service. MVH would electronically send a patient’s brain scan images for Dr. Schwamm to review. From his MGH office Schwamm would then participate in a video-conference session to remotely examine the patient. After testing this system with MVH and training the twenty stroke specialists in MGH’s neurology program to use the system, Schwamm’s team started offering this “eleStroke” service to other Massachusetts hospitals. Data gathered in eleStroke consultation sessions  were analyzed, and Schwamm and his team began to publish scholarly papers on the efficacy of telemedicine for acute stroke consultations.Te eleStroke initiative gained significant momentum when in 2005 the Mas-sachusetts Department of Public Health issued regulations requiring that ambulance personnel bring a patient who exhibited stroke-like symptoms to a certified “Primary Stroke Center” to be evaluated as a candidate for tPA ( Exhibit 2 ). One requirement for certification was that a licensed physician with acute stroke expertise must be avail-able on a 24/7 basis. Hospitals that lacked 24/7 neurology coverage could use a service such as eleStroke to satisfy this rule.Partners’ Chief Information Officer at the time, John Glaser, provided funds sup-porting the build-out of the eleStroke service. 5  In offering his support for eleStroke, Glaser had told Farrell that he realized that Dr. Schwamm had “gained buy-in” by performing “high-quality studies to gauge the impact of telemedicine on acute stroke care.” Glaser recalled, Tose studies verified that telemedicine consultations are safe and can improve patient outcomes. eleStroke addresses a real clinical need. I did not require much in the way of a business case; the ‘grant’ we provided was based more on the caliber of the idea.  A full-time software application specialist was hired to develop browser-based soft- ware that (much like an electronic medical record) was used to record data about each consultation (e.g., patient age, time of onset of symptoms, vital signs, lab results, scores on various neurological tests, etc.—100 state-mandated data elements in all). As of 2011 this application and its database were not yet fully integrated with patient medi-cal records at MGH, the Brigham, or participating spoke hospitals. Te database did support the eleStroke program billing requirements and research studies on stroke treatment and outcomes. This document is authorized for use only in Health Information Technology (HCIT) by Professor Adam C Powell at Indian School of Business (ISB) from February 2014 to April 2014.    4 Case Research Journal ã Volume 32 ã Issue 2 ã Spring 2012  As some of the twenty physicians in the MGH neurology program gained experi-ence doing eleStroke consultations, the value of the service became evident. In 2006 a decision was made to collaborate with the Brigham; their eight stroke neurologists also wanted to offer a eleStroke service but felt it would be more cost-effective to join forces with MGH rather than develop their own software. As dual “hubs,” MGH and the Brigham provided 24/7 backup care for each other, in case of unexpected demand or network connectivity problems.eleStroke was designed to serve hospitals that ordinarily referred patients to MGH or the Brigham; Dr. Schwamm did not plan to extend this service outside Partners’ catchment area. 6  By 2011, twenty-seven spoke hospitals in Massachusetts, Maine and New Hampshire participated in the service ( Exhibit 3 ). One spoke was about three miles away; the furthest was 130 miles away (Falmouth Hospital was seventy-seven miles away).o establish a pricing structure for eleStroke consultations, Farrell and Schwamm gathered data about stroke rates in various communities in order to estimate how many patients with symptoms of acute ischemic stroke would likely go to different community hospitals, how many patients might be suitable candidates for a eleStroke consultation, and how many would qualify for tPA. Tey learned, for example, that Cape Cod Hospital in Hyannis (a sister hospital to Falmouth) was especially busy during the summer tourist months (with about 27,500 emergency department (ED) visits in June, July and August, accounting for about thirty-one percent of ED visits in 2009), and that Cape Cod’s permanent population included a large number of eld-erly retired people and hence had a higher rate of stroke than younger communities.  Also, some hospitals needed 24/7 stroke neurology coverage, while other hospitals only needed weekend or late night coverage.Having analyzed the varied needs of spoke hospitals and the populations they served, a price of $10,000 was set for a “book” of ten pre-paid eleStroke consulta-tions, with an option to purchase additional consultations. In the first few years that the service was offered, no spoke hospital used all ten eleStroke consults before the end of a contract year. However, over time participating hospitals improved their work-flows, enabling them to process incoming patients more efficiently (mindful of the 3–4 hour tPA “window”). Tis increased the numbers of tPA-eligible patients, which in turn increased eleStroke usage. As of 2011, each participating spoke hospital pre-paid their primary hub (MGH or the Brigham) for ten eleStroke consultations and some purchased additional blocks of five pre-paid consultations, with a rollover provision (similar to unused cell phone minutes). Some hospitals paid Partners additional fees for technology support and onsite training.Over time the eleStroke software was enhanced to include decision support, clinical reporting, and other functions. In 2011 two full-time technical employees supported the system. Other members of the team included Shawn Farrell and two other full-time employees: one handled coordination and credentialing (all Partners stroke neurologists were credentialed at all twenty-seven spoke hospitals) and another employee was in charge of video/imaging, I, and information security engineer-ing. Half of Dr. Schwamm’s time was devoted to the eleStroke program, and half of another Partners employee’s time was devoted to marketing and network development. This document is authorized for use only in Health Information Technology (HCIT) by Professor Adam C Powell at Indian School of Business (ISB) from February 2014 to April 2014.
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