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ALEXANDER NASON
JOHNS HOPKINS MEDICINE INTERACTIVE
PROGRAM DIRECTOR
Strategic Opportunities and
Challenges in Telemedicine
Agenda
• Landscape @ Johns Hopkins Medicine
• Telemedicine Primer
– Challenges and Lessons Learned
• Johns Hopkins Telemedicine
• „Things to Consider‟
Conclusions
• Potential for Improved Service Delivery
– Cost, Efficiency, Greater Satisfaction
• No Universal Solution
– Environment Specific, Standards are the
Key
• Sustainability is of Primary Concern
– Collaborative System Architecture
• Technology Allows for a “Relationship”
Historic Billings Building
4
New Clinical Building
5
6
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Current Systems (9+)
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JHH JHBMC HCGH Suburban JHCP
Patient Portal
Health Information
Exchange(CRISP)
Registration/Scheduling
EpicMEDITECH, Epic,
GE (IDX)MEDITECH MCKESSON GE (IDX)
ADT Keane MEDITECH MEDITECH MCKESSON
N/A
Inpatient EMR Eclipsys MEDITECH MEDITECH MCKESSON
Ambulatory EMR Eclipsys (limited) MEDITECH/LSSMEDITECH/LSS
(limited)GE (Centricity
EMR)GE (Centricity
EMR)
Specialties Varied Varied Varied Varied N/A
EPR2020 Enterprise clinical data and document repository
Hospital Billing Keane MEDITECH MEDITECH MCKESSON N/A
Professional Billing GE (IDX) GE (IDX) GE (IDX) GE (IDX) GE (IDX)
Core Clinical System Vision
• Patient-centered
• Single tightly integrated solution
• Encompasses all major areas of EHR
functionality
• Includes workflow as well as content and data
• Enables seamless coordination of care delivery
• Requires careful TCO and ROI analysis
• Require redesign of care
10
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IT@ Johns Hopkins Medicine
• Critical juncture
• Entity centric approach has reached its limits
• Patient centered care requires coordination of care across JHM
• Populations and preventive health require longitudinal patient and data management
• Must enable operational efficiencies, cost controls, and productivity
• Must achieve quality and patient safety well beyond meaningful use
TELEMEDICINE PRIMER
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Definition
Telemedicine, Telehealth, Telecare…
• The use of electronic information and
telecommunications technologies to
support long-distance clinical health care,
patient and professional health-related
education, public health and health
administration.
Health Resources and Services Administration‟s - Office for the Advancement of Telehealth
Benefits of Telehealth to the
Community
• Helps Overcome Distance and Access– Physician Shortage Areas
• Improves Local Health Care
• Offers Diagnostic and Clinical Support
• Supports Knowledge Transfer
• Improves Responsiveness in a Changing Environment
• Decreases Costs; Improves Resource Utilization
Telemedicine “Synchronicity”
• Synchronous (Real-time)
– Data Transmitted As They
Are Generated And
Received With No
Perceived Delay
– Natural Person To Person
Interactions
– High-Bandwidth
Telecommunications
– Examples: Patient
Monitoring In ICU, Stroke,
ED Support
Telemedicine “Synchronicity”
• Asynchronous (Store-
forward)
– Data Collected Offline
– Unnatural Or No Person-To-
Person Interactions
– Low-bandwidth Or Long
Distance Telecommunication
– Examples: • Radiology
• Dermatology
• Second Opinion Service
Services
Model of Telehealth Success
Development
InfrastructureTraining
Assessment
Challenges - Internal
• Human Factors and Culture
– Acceptance by Physicians/Patients/Users
• IT Department
• Facilities
• Reimbursement
• Costs
• Licensure / Regulatory
• Evaluation and Research
• Business Planning - Sustainability
Third party reimbursement for
telemedicine is expanding…slowly
20Source: American Telemedicine Association
States – 11 states now
require reimbursement of
telemedicine by all private
insurers
Medicaid – 14 states
require reimbursement
Medicare –reimburses
telemedicine services in
rural areas
Alternative Reimbursement
Models
21
Subscription
Models
Contractual
Services
Grants Philanthropy
Challenges - External
• Communication – Client
• Infrastructure
• Vendor Conflicts
• Cultural Considerations
• Environment
• Local Legal Issues
• Costs
• Time Zones (DST)
• Customs/Shipping
Overcoming Barriers
• Create Partnerships (Relationships)
• Know Your Client/Audience (Culture, Time Zones, Work Week, Motivation)
• Experience Telehealth
• Incentivize Users (Not Only Money)
• Integrate it into Strategic Mission
• Be “Non-Threatening”; Be Complimentary
• Show Return On Investment
• Recognize What You Cannot Control
Real World Problems
• Acute Care Response– Stroke
• Chronic Disease Management– Diabetes, Obesity, CHF
• Physician Shortages– i.e. Intensivists
• Global Issues– Pandemic Flu
– SARS
– Hurricane Katrina - Asian Earthquake
– Bio-terrorism
– Global Economics
25
Demand for care at home is
growing…
Source: Chronic Care in America available at http://www.rwjf.org/qualityequality/product.jsp?id=15733; Agency for Healthcare Research and Quality
Percent of the population with a
chronic condition
79% of individuals with long-term chronic care needs
live at home and account for 75% of health expenditures
26
… and increasingly feasible
TELEMEDICINE @ JOHNS
HOPKINS
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The Challenge: Sharing
Knowledge and Expertise
Effectively, Efficiently and
Economically
Telehealth @ JHM
• Anesthesiology / Critical Care
– Intensive Care
– PICU
• Cardiology
• Dermatology
• Emergency Medicine
• Gastroenterology
• Infectious Diseases
• Johns Hopkins Community Physicians
• JHM International
• Johns Hopkins Healthcare
• Johns Hopkins Homecare Group
• Minimally Invasive Surgical Training Center
• Neurology
• Obstetrics and Gynecology
• Ophthalmology
• Otolaryngology
• Pediatric Psychiatry
• Physical Medicine – Rehab
• Radiology
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THINGS TO CONSIDER
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• Mobile Platform
• Social Networks / Social Media
– Wisdom of Crowds
• Education
• Accountable Care Organizations
– Patient Protection and Affordable Care Act
37
Lessons Learned
• Challenges are Likely
• Collaborative & Adaptable
• The Road is Long
• Keep It Simple
• Not Everyone Will Participate
• Successes Will Outpace Failures
• Focus on Don Berwick‟s (CMS
Administrator) goals:
– Better care (IOM-Chasm Report)
– Better health
– Lower cost
• Expand evidence base
• Ensure information continuity
• Help to lead care system redesign39
Conclusions
• Potential for Improved Service Delivery
– Cost, Efficiency, Greater Satisfaction
• No Universal Solution
– Environment Specific, Standards are the
Key
• Sustainability is of Primary Concern
– Collaborative System Architecture
• Technology Allows for a “Relationship”
Source: Gartner Group