Connecting ‘Here’ and ‘There’

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Technologies, pilot programs boost UI telemedicine, ehealth services

By Catie Malooly

“John” is having a stroke. The left side of his body is weak and his speech is slurred. A blood vessel is clogged with a clot, restricting blood flow to his brain.

John is rushed to the Mercy Medical Center emergency department in Clinton, Iowa, the only hospital in a community of nearly 27,000 residents on the Mississippi River. There are no neurologists at Mercy–Clinton, and the physician on call wants assistance determining if John should get a powerful clot-busting medication, rtPA. Meanwhile, John is losing nearly 2 million neurons every minute, leading to potential permanent brain damage.

Time to bring in the robot.

Rolled into the room is a machine with a monitor transmitting the face of University of Iowa vascular neurologist Enrique Leira, MD (’98F). From his office at UI Hospitals and Clinics in Iowa City, Leira asks John’s wife about the onset of John’s stroke symptoms. He reviews John’s vitals, examines the CT scan images taken in Clinton, and conducts a rapid neurological evaluation, all from 85 miles away. He advises the Mercy physician to administer the rtPA, and soon after, John is airlifted to UI Hospitals and Clinics to receive specialized care and undergo a procedure to remove the clot.

In a time-dependent emergency like stroke, every second counts. The telestroke robot that enabled a specialist in Iowa City to diagnose and treat a patient more than an hour’s drive away is just one example of emerging telemedicine services that are part of a new standard of care around the country and the world.

Embracing this technology is especially important in Iowa, a predominantly rural state with an aging population and hospitals and health systems located in dozens of small- to medium-sized communities like Clinton, many of which have a shortage of specialists, like neurologists. In less than a year, a team of UI Health Care providers and champions of ehealth and telemedicine has evolved to develop pilot programs that make specialized medical care from UI Hospitals and Clinics available to patients across the state in real time. And they’re just getting started.

A solution for Iowa

The UI Health Care eHealth and eNovation Center© was created to improve access to UI Health Care specialists and services for patients across Iowa. The term “ehealth” broadly encompasses videoconferencing and telemedicine, and includes mobile health and home monitoring, as well as wellness technology.

“There’s a plethora of different technologies that facilitate electronic transfer of data and exchanges between physician and physician or physician and patient,” says Brian Wayling, MBA, director of the UI Health Care eHealth and eNovation Center.

The “eNovation” part of the center looks at future opportunities and technologies.

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Brian Wayling (left), MBA, and Patrick Brophy, MD, head the UI Health Care eHealth and eNovation Center, which aims to improve access to specialized care for patients throughout Iowa.

In 2013, the UI Health Care executive committee asked Patrick Brophy, MD, director of pediatric nephrology (and now assistant vice president for ehealth and innovation), and Sabi Singh, MS, MA, co-chief operating officer, to put together a comprehensive document listing who was doing what with telemedicine within the institution.“What was fascinating was that there was so much stuff that was already going on, but it wasn’t a coordinated effort,” says Brophy, who also has a master of health care delivery science degree.

Since the creation of the center, more and more specialties are coming on board.

“It’s been a really diverse range of physicians and service lines that have been doing different (ehealth) practices, so we’re continuing to identify those individuals and pilots and then work with those practices to figure out how we can turn them into an operational model,” says Wayling.

“Our goal with telemedicine is really to provide access to our specialties and for patients to remain in their communities,” he adds. “Through telemedicine, we believe that can be achieved.”

Paving the way

The UI telestroke program was one pilot that began before the formal creation of the eHealth and eNovation Center. Neurology fellow Jeffrey Boyle, MD, PhD (’13 R), has been working since spring 2012 as a liaison for stroke care between UI neurologists and the physicians at Mercy-Clinton and Grinnell Regional Medical Center, two hospitals currently involved in the program using the telestroke robot. The UI Stroke Center—the only one in Iowa named an Advanced Certification Comprehensive Stroke Center by The Joint Commission and the American Heart Association/American Stroke Association—already conducts telephone consultations with up to 59 emergency departments and hospitals in Iowa.

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UI neurology fellow Jeffrey Boyle, MD, PhD, demonstrates the telestroke robot’s capabilities with a simulated patient, while UI neurology professor Harold Adams, MD, director of the UI Stroke Center, presents on-screen as the consulting UI physician.

“What I would like to show is that (telestroke) works in Iowa, which, by every way you look at it, it should,” says Boyle. “Iowa is a rural state, it’s an aging state, there are great distances between hospitals, and there are great critical access hospitals and medium-sized hospitals that have fantastic physicians, physician aides, physician assistants, and nurse practitioners.”

But UI Health Care ehealth services are not limited to stroke care. Staff members in the eHealth and eNovation Center have been working to develop pilot programs in a number of different areas and specialties, including burn and wound care, orthopedics, infectious diseases, otolaryngology, psychiatry, pediatric behavioral health and psychology, and pediatric nephrology. They hope to not only promote and expand UI specialty services throughout the state, but also to provide services that are needed most in different Iowa communities and hospitals.

Timothy Blair, MD, emergency department and ambulance service medial director at Van Buren County Hospital in Keosauqua, Iowa, utilizes UI H Health Care telemedicine services.
Timothy Blair, MD, emergency department and ambulance service medical director at Van Buren County Hospital in Keosauqua, Iowa, utilizes UI Health Care telemedicine services.

UI emergency telemedicine services, for example, are used when a call for a consult comes from the Van Buren County Hospital emergency department in Keosauqua, Iowa. Once the UI emergency medicine physician staffing the telemedicine office is notified, he or she is able to access the patient’s electronic medical records. Then, through a secure server, the UI physician can videoconference with the physician and patient in Keosauqua. At the end of the consultation, the UI physician documents his or her recommendations, which are sent electronically to the community provider.

A dedicated UI faculty physician staffs the emergency telemedicine service from 10 a.m. to 6 p.m. daily, while the on-duty faculty cover both the emergency department and telemedicine service at other times. As the emergency telemedicine program grows, however, its champions hope to add more dedicated providers in order to make video consultations available around the clock.

“Being able to actually deploy these specialists’ expertise at a critical time when it’s needed can sometimes either abbreviate an emergency department visit, negate an emergency department visit, or actually help stabilize somebody who was unable to be stabilized,” says Brophy.

Since the program launched, UI emergency medicine physicians have reduced the number of patients transferred from Van Buren County.

UI physicians Jodi Tate, MD, and Azeemuddin Ahmed, MD, use ehealth technologies to serve patients in need of psychiatric and emergency care in Keosauqua, Iowa.
UI physicians Jodi Tate, MD, and Azeemuddin Ahmed, MD, use ehealth technologies to serve patients in need of psychiatric and emergency care in Keosauqua, Iowa.

“Van Buren County Hospital has been able to keep more patients than they may have previously without telemedicine, mainly because we’re able to see the patient, reassure them, and give providers advice,” says Azeemuddin Ahmed (’00 MD), UI executive vice chair of emergency medicine. “It’s good for the local hospitals and the local patients. If they don’t need to be sent to Iowa City, most people don’t want to leave their hometowns.”

Timothy Blair (’89 MD), medical director of emergency room and ambulance service at Van Buren County Hospital, has seen the program’s influence in Keosauqua.

“The patients appreciate the fact that they can see and talk with an emergency specialist at UI Hospitals and Clinics,” says Blair. “They have told us the experiences were positive and allowed them a higher comfort level regarding their care.”

The next stage of developing the emergency medicine pilot program includes incorporating telepsychiatry services into the current work being done with Van Buren County Hospital and all future critical access hospital partners.

“More patients are able to get coverage because of the Affordable Care Act, but timely access to mental health professionals across our state is difficult, if not impossible,” says UI psychiatry professor Jodi Tate, MD (’00 R). “Clinics have long waiting lists and our inpatient units are full. Unfortunately, this results in individuals coming to emergency rooms for psychiatric care.”

The telepsychiatry pilot program aims to address such a significant need. Soon, patients in rural areas can have face-to-face interactions with UI psychiatry specialists. As it is for most patients using ehealth services, some will need more extensive care and will be transferred to UI Hospitals and Clinics or another facility. But this technology allows fewer unnecessary transfers, keeping patients in their own communities and increasing the ability of primary care providers across Iowa to enlist the expertise of UI specialists in diagnosing and treating patients with mental illness.

“There is a subset of patients that may benefit from just having a real-time conversation with a psychiatrist,” says Ahmed.

NICU consultation

Pediatrics professor Jeffrey Segar, MD (’89 R, ’92 F), and the UI Children’s Hospital neonatology team have also started a pilot in the UI Children’s Hospital Neonatal Intensive Care Unit (NICU). Using a web-based application, providers at two different hospitals are able to contact UI pediatric fellows in the NICU directly for a consultation. From there, the UI doctors can communicate with outside providers from a computer or any mobile device to provide a consultation.

“It allows us to visualize the patients,” says Segar. “We can see how much respiratory distress a baby is in, for example, and help the provider stabilize and manage the patient.”

Not only will UI neonatologists be able to speak with the outside physician and the patient’s family via video, the audio of the consultation will be recorded and saved in the patient’s electronic medical record. Additionally, fellows have the option to use the application’s three-way calling feature to hold a video-conference with the outside provider and other UI specialists who may be needed for a case.

The success of the NICU pilot program could have global implications in the future, allowing communication and consultations with UI physicians doing medical mission work abroad.

A comprehensive, nationwide approach to ehealth and telemedicine services that addresses issues like licensing and reimbursement is yet to be seen. But until then, UI Health Care will continue advancing new and improved ehealth programs to increase statewide access to specialized health care.

“We consider ourselves a startup within the infrastructure of UI Health Care,” says Wayling. “We’re starting from scratch, and we’re trying to figure out how to best leverage the technology to help facilitate improved access to the excellent services that UI Health Care offers.”

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Regulations lacking

By Catie Malooly

The technology behind telemedicine can provide a seamless transition among health care services, but state laws and regulations have revealed bugs in the process.

“Telemedicine has been restricted by licensing laws, privileging laws, and specific state requirements,” says Patrick Brophy, MD, assistant vice president for ehealth and innovation with University of Iowa Health Care. “There’s a lack of a national strategy on virtual medicine and its possible role in reducing health care expenditure.”

Provider and hospital reimbursement are among the biggest hurdles for those wishing to implement ehealth services. Fewer than half of the states have enacted telehealth parity laws, which dictate that all services that can be conducted via telemedicine are paid as an in-person visit. No such law exists in Iowa yet.

Another issue is how to handle telehealth services provided by a health care professional not licensed by the state where the patient resides.

“If you come and see me here at the University of Iowa and you are from Missouri, I don’t have to worry because you accept my credentials and my licenses the way they are,” says Brophy. “But if I see you while you’re in Missouri, I have to have a Missouri license right now.”

Aside from the red tape, another major challenge to telemedicine as a mainstream practice involves staffing, at both UI Hospitals and Clinics and community hospitals.

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Enrique Leira

“The issue is to have the adequate manpower as the number of hospitals (we partner with) increases,” says UI vascular neurologist Enrique Leira, MD (’98 F). “Telemedicine takes care of the shortage of expertise locally, by breaking the distance barrier, but it still requires an adequate workforce of professionals available around the clock that can provide such service.”