Telehealth for Specialist Care
The Virtual TeleConsult Clinic
The idea for the Virtual TeleConsult Clinic (VTCC), the project for which Samir M. Fakhry, M.D., Chief of the Division of General Surgery at MUSC, won a $500,000 Duke Endowment grant, came to him as he watched his once computer-averse wife chat happily from their home in Charleston with their granddaughter in the Washington, DC, area using easily available and inexpensive video software. That morning he had seen a patient for a ten-minute follow-up visit; that visit had required the patient to take a day off work, find a companion to accompany her (who had also had to take time off work), drive two to three hours to Charleston, find parking and locate the treatment clinic, and drive two to three hours back home, all for the visit that lasted only ten minutes. Why not, thought Dr. Fakhry, handle such specialty consultations via simple teleconferencing software similar to that which his wife used to speak to their granddaughter, sparing patients inconvenience and saving them time and money without sacrificing quality of care?
Dr. Fakhry’s coinvestigators on the Duke Endowment grant are James T. McElligott, M.D., the IT Medical Director for Telehealth and CoChair of the Telehealth Development and Operations Council at MUSC, and Elisabeth Pickelsimer, DA, who will help interpret survey results to determine the success of the program. To help realize his idea of expanding access to telehealth for specialist care to even the most remote regions of the state, he hired a project coordinator, Laura Langston, BA, and set up a consulting team from the South Carolina Area Health Education Consortium (David Garr, M.D., Deborah Carson, PhD, and Ragan DuBose-Morris, MA) who have extensive experience with outreach projects to rural areas.
“Try to think of telemedicine less as going into uncharted territory in the future than as going back to the old days when the doctor had a little black bag and drove around to everyone’s house—we’re bringing the care back out.” James T. McElligott, M.D.
Keeping It Simple
In a digital age comfortable with new and constantly evolving technology, Dr. Fakhry and his team are convinced that patients will welcome and soon demand such expanded access to their physicians via telemedicine.
To be successful, Dr. Fakhry believes that the telemedicine solution should be simple and user-friendly. The technology used should not pose a barrier to the physicians, other health care professionals or the patients who will be using it.
The equipment he has chosen for the VTCC consists of a $50 high-definition webcam for the office of each specialist involved and each participating telemedicine partner and relatively inexpensive and easy-to-use video software. A secure line is used to protect patient privacy.
Dr. Fakhry had ventured into the world of telemedicine once before with the CREST (Critical Care Excellence in Sepsis and Trauma) project, in which he and Dee W. Ford, M.D., set up a telemedicine network with several small hospitals in South Carolina to provide emergent trauma and sepsis care. That project taught Dr. Fakhry both the value of telemedicine as a means of providing specialty care to patients in rural or underserved areas and a healthy respect for the speed with which technology advances. The state-of-art telemedicine carts ($12,000 each) they had purchased for the two-year study had become dinosaurs by its completion: “Telemedicine devices went from something you had to wheel somewhere to something you put on your desktop—pretty soon they will be something you can carry around—it is scary how quickly the monitors became dinosaurs.”
Dr. Fakhry has designed his TeleConsult Clinic to be nimble when the next evolution in technology comes. It will be far easier and less expensive to replace the $50 webcams than the $12,000 monitors.
FIGURE 1. A nutritional consultation via VTCC
The referring physician equipped with the proper equipment need only schedule a TeleConsult and then call in with the patient at the appointed time. Necessary test results and imaging studies can be submitted in advance. With the implementation of EPIC, the specialist can enter notes into the electronic medical record as he or she talks with the patient, notes that will be immediately available for those local providers whose institutions have adopted EPIC.
Dr. Fakhry and the VTCC team believe the referring physician plays a critical role in the TeleConsult, providing important information about the patient’s history and clinical status and helping the patient better understand and implement the specialist’s recommendations.
The VTCC lends itself particularly well to initial screening and follow-up visits. It is not intended to replace in-person care but to help expand access to specialty care, streamline the referral process, provide added convenience to the patient and improve overall coordination of care. The follow-up patient whose day-long trek inspired the VTCC would only, after implementation of VTCC, have had to drive a few minutes to her local physician’s office, keep her ten-minute appointment and then drive a few minutes home. Dr. Fakhry believes that the convenience of such appointments will enhance patients’ adherence to recommended follow-up care.
FIGURE 2. A digital otoscope, which provides the remote physician with high-definition images of the ear.
Modeling himself after internet entrepreneurs who devise a device and then allow users to create the applications they need or want, Dr. Fakhry is making the video teleconferencing equipment available to specialists in any field and allowing them to tailor it to their needs. Although telemedicine can be useful to almost any specialty, no two telemedicine programs will be just alike.
The heterogeneity of the uses to which telemedicine can be put is illustrated by the first four programs that have agreed to participate in the VTCC: a nutritional counseling program, a school-based program in specialty pediatrics care, a program screening patients for kidney transplantation and a program following up patients who undergo complete pancreatectomy with islet cell transplantation.
FIGURE 3. A “total exam cam,” which provides high-definition images to remote specialists.
Rural residents of South Carolina have among the highest rates of obesity, hypertension and diabetes in the country but have poor access to dietitians trained to help them manage those diseases or to change their eating patterns to avoid developing them. Stacy Renouf, RD, an outpatient dietitian at MUSC, is using equipment purchased by the VTCC to provide nutritional counseling to patients at physicians’ offices in rural areas of the state (Figure 1). In September 2012, she began performing teleconsults for Danette McAlhaney, M.D., of Bamberg Family Practice and hopes to soon be counseling four to five patients per week. Dr. McAlhaney was eager to participate in the program because “We are in a very rural town. Our hospital closed the end of April this year. Telehealth seemed like the up-and-coming thing and I felt like it would be a great advantage to my patients.” Other rural practices have been provided with telemedicine equipment and should soon also be able to benefit from this nutritional counseling.
I hope that, through telemedicine, ER visits will go down and the amount of preventive care will go up.” James T. McElligott, M.D.
School-Based Pediatric Specialty Consultations
The potential of telemedicine to help address health care disparities drew Dr. McElligott to the VTCC project. Dr. McElligott had earlier worked with the Southeastern Virtual Institute for Health Equity and Wellness (SEVIEW) to provide school-based primary care for rural and/or underserved children (see page 6). With VTCC, he hopes to provide school-based pediatric specialty care. Dr. McElligott fully endorses Dr. Fakhry’s philosophy of “keeping it simple” because he can help more underserved children by providing inexpensive technology to a large number of schools than very expensive technology to a few.
During a VTCC specialty pediatric consultation, the school nurse, with the child at her side, calls in to a specialist at MUSC for a teleconsult. He or she can use special instruments—a digital stethoscope, a digital otoscope, a “total exam cam”—to provide high-definition images and audio to the specialist at MUSC (Figures 2 and 3).
In an effort to bring specialty care to disadvantaged youth, Dr. McElligott has partnered with both rural schools (eg, Johnsonville High School), where distance poses a barrier to care, and urban schools (eg, Charleston-based Meeting Street Academy), where a missed day’s work is not an option for inner city parents living paycheck to paycheck.
Both Gaye Douglas, a nurse practitioner at Johnsonville High School, and Jennifer Robinson, a school nurse at Meeting Street Academy, welcome the program because it offers a solution to a frustrating problem. Too often, school nurses treat a child for symptoms that result from an underlying condition such as asthma. Although notified of the need to follow up with a physician, some parents do not seek treatment for their child. Telemedicine allows the child to be seen during the school day without necessitating special trips or appointments by the parents, making it possible to catch and manage root problems earlier and helping control the spread of infection. According to Jennifer Robinson,“early treatment and diagnosis have helped decrease the spread of infectious disease such as pink eye or skin diseases like impetigo and ring worm,” resulting in fewer days missed from school.
By bringing specialty care conveniently to the patient, Dr. McElligott believes that telemedicine will begin to make real inroads into the health care challenges of our state: “It’s pretty rare that you come across a chance to make a big change like this and that’s what makes me excited. I hope that, through telemedicine, ER visits will go down and the amount of preventive care will go up.”
Screening Potential Kidney Transplant Recipients
This project, headed by Charles F. Bratton, M.D., Assistant Professor of Surgery at MUSC, aims to leverage the power of the VTCC to better screen potential kidney transplant recipients before they come to MUSC. South Carolina has one of the highest percentages of patients with end-stage renal disease who are receiving dialysis and so have an increased mortality risk. Kidney transplantation can improve survival and enhance the quality of life of these patients provided they meet screening requirements.
As a transplant center, MUSC is meant to serve the entire state and screen all potential kidney transplant recipients. However, many people with chronic kidney disease live in rural areas of the state and may not have the means to travel to Charleston several times to be evaluated for transplantation. Dr. Bratton believes that telemedicine will be able to remove some of these barriers: “If we can do something that has broad-reaching impact that would allow patients throughout state to be evaluated remotely, increasing access to transplantation, that would be an excellent and laudable goal.”
Follow-up After Autologous Islet Cell Transplantation
MUSC’s Digestive Disease Center is a respected center of excellence for diseases of the pancreas, attracting patients from around the country and the world. The debilitating pain felt by patients with chronic pancreatitis can be relieved in select cases by complete pancreatectomy followed by autologous islet cell transplantation. Islet cells are harvested from the excised pancreas and reinfused into the patient to prevent the brittle diabetes that would otherwise follow complete pancreatectomy.
The second busiest center offering this procedure, MUSC attracts 80% of its patient from beyond the tricounty region and 50% from beyond the state. Follow-up of these patients has been difficult because they travel such great distances for the operation. The VTCC will help to erase that distance and continue to make multidisciplinary care available to patients once they return home. According to Stefanie Owczarski, a Clinical Instructor at MUSC who is helping coordinate the VTCC program for surgeons David B. Adams, M.D., and Katherine A. Morgan, M.D., “MUSC is really moving in the direction of being a destination center of excellence and I really think ironing out the details of telemedicine is important for all programs to be able to provide that sort of destination care for these patients.”
More information about the Virtual TeleConsult Clinic. If you are interested in participating in the program, please call MEDULINE at 800- 922-5250 or 843-792-2200 and ask for Laura Langston, the VTCC coordinator.
“I really think ironing out the details of telemedicine is important for all programs to be able to provide that sort of destination care for these patients.” Stefanie Owczarski