Dallas, Texas

Telemedicine

Mitch Hall

Katherine Lusk, MHSM, RHIA, FAHIMA

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Dallas, Texas

Children’s HealthSM

• Dallas Campus: 490 bed

trauma center

• Plano Campus: 72 bed full

service acute care hospital

including Andrew’s Institute for

Orthopedics and Sports

Medicine

• Our Children’s House, 39 bed

specialty hospital

• 50+ subspecialty services

lines

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Dallas, Texas

Children’s HealthSM

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Mission: To make life better for children

Vision: To be among the very best medical centers in the

nation

Dallas, Texas

Electronic Medical Record Vision Statement

• Our Electronic Medical Record (EMR) is patient-family centered with Quality, Safety and Accessibility at its core.

• It supports anytime, anywhere:

– Our Children in both Wellness and Illness

– Clinicians in Care, Advocacy, Research, & Education

– Business Operations, both Financial and Legal

• We accomplish this through a strategic relationship with a primary vendor, an organizational commitment to accuracy, efficiency, effectiveness and continuous improvement of processes and practices.

Children’s established electronic medical record vision in 2006 for improving safety

and quality of care…

Dallas, Texas

Electronic Health Record Journey

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Date Implemented

Oct 2008 Electronic Health Record (EHR) infrastructure (EMPI, HIM, Registration), Scheduling & Revenue Cycle

May 2009Emergency Department, Operating Room, Inpatient Nursing / Ancillary, Intensive Care Units, My Chart (Patient access to EMR), Community

Physician Access, Bar code medication administration, Pharmacy & Speech recognition transitions

Aug 2009 Medical / Surgery inpatient physician documentation

Nov 2009 Computerized provider order entry inpatient house-wide & back-end voice engine

Oct 2008 – Apr

201055 ambulatory areas

Jul - Dec 2010Ophthalmology, Transplant, Anesthesia, Radiology & Oncology Epic applications. Bar coded specimen collection and expressed breast milk via

3rd party system

2011 E-Prescribing, Health Information Exchange, Spanish My Chart, Patient Portal, Iphone applications and Data Warehouse

2012Physician Mobile Devices, Medical Necessity, Clinical Documentation Improvement, E-APG & Computer Assisted Coding, Epic expressed breast

milk scanning

2013 Direct Messaging PHR (Health Vault), & Telehealth NICU

2014 Telemedicine Robot, Transitions of Care with continuity of care document, hosting 60+ private practices EMR & School based telehealth

2015

HISP (connecting to external EMRs), integration with local fire departments, auto generated queries using natural language processing &

Potentially Preventable Event Identification tools for population health. Our Children’s House inpatient on 11/3/2015. Interactive patient system for

patient engagement, entertainment and education. Telehealth ED

2016Our Children’s House ambulatory locations phased implementation completed 5/2016. Code documentation in ED. Tele-monitoring medication

adherence.

2017 Beaker Epic Laboratory System, Bar-code blood administration, Code documentation inpatient

2018Integration of clinical information regardless of where created for a single medical record for clinicians and patient portals (encounters, Lab &

scanned images), Tele-behavioral health

Dallas, Texas

Large, Growing Market:

• 1 of 9 children in U.S. live in

Texas

• Significant Community Needs

• 29% of Dallas County children

live in poverty

• 2 of 3 children need financial

assistance

• 7 out of every 10 public school

children in Dallas County

eligible for free and reduced-

price meals

• 18% of Dallas County children

are uninsured

• Only 31% of TX physicians

accept new Medicaid patients

(down from 42% in 2010)

Significant Pediatric Medical

Needs:

• 50,000 children in N. Texas with

asthma

• 36% of Dallas County kids are

overweight or obese

• 28% of Dallas County children

are malnourished

• 30% of toddlers not fully

immunized

Extending Care Into Community

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Dallas, Texas

Shifting Focus from Patient to Consumer

Through technology Children’s HealthSM is connecting care to patients

and families where they live, work, play and go to school.

PATIENT CONSUMER POPULATIONS

Sources: Valence Health, Lori Palminteri

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Dallas, Texas

Virtual Health Today

Office/Clinic/School

Home

HospitalTeleER/TeleNICU

• Interactive consults on critically-

ill children for stabilization &

evaluation for transport

Hospital TeleConsultations (non-

emergent)

• Neonatology (Sub-specialty)

• Neuro-Immunology

Technology Enabled Remote

Study Interpretations

• Cardiology (Echos, etc.)

• Ophthalmology (ROP)

• Radiology (1st & 2nd Reads)

Behavioral Health

Plastics

Neurodevelopmental

Neurology

Acute Care

Remote Patient

Monitoring

Asthma (Propeller)

Mobile Apps

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Dallas, Texas

TeleNICU

• In 2012, Children’s Health designed the neonatal-specific telemedicine program

- TeleNICU

• Implementation with the first partner began in September 2013. TeleNICU was designed to benefit key stakeholders

- Families

- Affiliates

- Payers

- Children's Health and UT Southwestern

• TeleER in 2015

Twenty-four hour access to Level IV NICU, expert UT

Southwestern board-certified neonatologists and

pediatric subspecialists to interpret medical data,

confirm diagnoses and confer on treatment plans.

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Inpatient-Consults

• Neuro-Immunology

- Limited specialists

- Service-line specific

- Non-dependent on a nurse or other

personnel to accompany

- Operated from a mobile device

(tablet/iPad)

- Mapped by floor – physician can

select any pre-mapped room or

drive the robot to the destination

• Injury Prevention

- Medical car seats

The RP-VITA has enabled us to evaluate and consult with families

and patients as needed – regardless of where I am. While away at

research meetings or for any other reason, I can stay connected

with our patients and assist in their complex care. It gives me the

capability of doing thorough evaluations while not relying on other

staff members to “bring” me to rooms. It is the next best thing to

being there in person.

– Benjamin Greenberg, MD

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Dallas, Texas

Remote Patient Monitoring

The Remote Patient Monitoring (RPM) program enables Children’s Health to

monitor and connect with patients with chronic diseases, post-surgery or who may

need monitoring after discharge.

Sources: Vivfy

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Dallas, Texas

Proteus Medication Adherence

• June 2016, first pediatric institution to utilize digitized drugs to monitor medication adherence in pediatric transplant patients.

• 19 cases on-boarded at Children’s

Medical Center

• Average days on Proteus is 41 ± 20

(standard deviation)

• 74% ± 13% patch adherence

• 93% ± 9% medication adherence

• Over 50 patients are now currently

using Proteus

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Asthma Management

The Propeller solution

pairs sensor-enabled

asthma device with

clinical outreach in order

to potentially improve

asthma management.

My Asthma Pal is a mobile app

designed to enhance asthma self-

management and education, with the

long-term goal of reducing preventable

events, such as Asthma-related ED

admissions.

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Uncontrolled asthma may lead to multiple emergency room visits, missed school,

missed work for parents, and overall poor quality of life. Control is possible with

appropriate inhaled corticosteroid controller therapy and regular follow up.

Dallas, Texas

Virtual Visit

Family Health Virtual Visit provides consumers

access to a trusted, quality care provider via a

virtual platform.

Delivering high-quality care to the patient virtually

anywhere. After registration in Virtual Visit

Kiosk, app or use our web portal options to

videoconference with a health care provider.

Virtual Visit is available to Children’s Health

employees in Dallas and Plano Occupational

Health offices.

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Dallas, Texas

Patient Feedback

• I think it is a great thing! I will use it whenever I can! I was able to see

a doctor in the facility I work in, get my prescription filled and drive home

and start the process in feeling much better, MUCH faster! I didn't have

to drive elsewhere and wait for an appointment and sit in a waiting room

while not feeling well! I give my experience 5 stars plus. Thank you

Children's Health for allowing me to have this in a place that cares

about my health as much as the patients we serve!

• The virtual visit saved me having to call into work to visit the doctor. My

visit took less than 30 minutes, there was not wait, and my prescription

was sent to the Children's Pharmacy. I am very pleased with this service

and I will use it again.

• It is fine for small issues but for larger ones, it is best to see a physician

that knows you, your diseases, your allergies, and what other things to

look for that maybe contributing to how you feel.

• Wonderful experience!! Quick, easy, thorough, and resolved my

problem in less than 15 minutes.

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Dallas, Texas

Why Schools

• Reaching children where they

spend most of their day - schools.

• Approximately 95% of all U.S.

children and youth attend

school

• Healthy children learn better

• Smarter children are healthier

• Win-Win relationship between

healthcare and education sectors

• Schools benefit by keeping

kids in schools

• Families benefit by staying at

work, reduced unnecessary ER

utilization

Dallas, Texas

Care Innovation in Schools

• Carts include Scopes (stethoscope,

otoscope, and general exam

camera)

• Each unit is networked to Children’s

Health and all data is encrypted

• True partnership between

Children’s Health and School

District

• No cost to School District

• Children’s Health provides all

training, set-up and marketing, and

is responsible for all school nurse

training

Dallas, Texas

What We Treat

❑ Upper Respiratory Infections

❑ Cuts and scrapes

❑ Allergies and Asthma

❑ Fever

❑ Earaches

❑ Pinkeye

❑ Rash and skin irritations

❑ Head Lice

Dallas, Texas

How it works

Step 1

• Student presents to School Nurse

• School Nurse calls the parents then our Appointment Desk

Step 2

• School Nurse collects vitals/history and sends to registration staff

• Registration Staff enters information into EMR

• Provider is notified that the patient is ready

Step 3

• Provider calls the nurse and patient via video and proceeds through visit

• Provider then assesses, makes diagnosis and develops treatment plan

• Prescriptions are e-prescribed and After Visit Summary is sent home and to the PCP

Dallas, Texas

Program Highlights

❑ 1-844-4Telemed

❑ Dedicated Provider and Support Team

❑ Point of Care Testing

▪ Strep and Flu

❑ After-Hours Nurse Advice Line

❑ School Nurse EMR Access

❑ Medical Home Connection / Referral

❑ School Nurse Engagement

▪ User Group Forum and Newsletter

▪ Children’s LIVE access

▪ School Nurse Conferences

Dallas, Texas

• Children’s Health℠ School-based Telehealth is the fastest growing telemedicine program in the country.

• Since 2014, we have:

• Provided over 12,000 virtual health visits for students

• Expanded into 100+ schools, 19 school districts

• Achieved 94% satisfaction rate from parents

• K-12 schools: Rural, Urban, Charter and ISD’s

Our Reach

Dallas, Texas

Program Challenges / Lessons Learned

▪ Technology / Infrastructure

▪ Internal Challenges

• Compliance / Legal

• Staff

• Cost

▪ External Challenges

• Billing

• School Nurses

• Parents

• Community Providers

▪ State Regulations

Dallas, Texas

What Makes Telehealth a Success?

• School Engagement:

a. Leadership- School Board

b. Superintendent/School

Leadership

c. School Nurses

d. Teachers

• Nurse Readiness

• Parental Acceptance

• Access/Outcomes

The metrics are clear. Since we began telehealth in 2014, our

absenteeism rate has dropped 2%, resulting in $500,000 of increased funding for our school district. Most importantly, our kids are benefitting

from more classroom time and better health.

Dr. Michael McFarland,

Superintendent, Lancaster Independent School

District c

Dallas, Texas

Next Steps: Future Growth

• Technology solutions

• Voice of Customer

• Nurse Engagement

• Additional billable services

• Growth in the Community

• Pediatric Spaces/Rural

• Listening

Dallas, Texas

Telemedicine and the Legal Medical

Record

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Dallas, Texas

Regulatory

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• Joint Commission:

– The legal medical record is defined as the account compiled

by physicians and other health care professionals of a

variety of patient health information, such as assessment

findings, treatment details and progress notes. Data

obtained from the records or documentation maintained on

a patient in any health care setting.

• State of Texas

– Health information means information recorded in any form

or medium that identifies a patient and relates to the history,

diagnosis, treatment, or prognosis of a patient.

Dallas, Texas

Children’s Dallas Definition

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Dallas, Texas

Example Notes

Telemedicine Consult Note

Requesting Emergency Department/Urgent Care: Rural Texas Hospital

Requesting Emergency Department/ Urgent Care Center: Rural Texas Hospital, Dr. John Smith

Time of Consult: 12:34

Chief Complaint:

Patient presents with chemical burn

HPI comments: 5-year- old female w/no significant PMH with burns to face, neck, trunk, back, and abdomen. No fever, vomiting or diarrhea. No recent URI symptoms. Swam in a pool with mother on Saturday. Developed erythema of skin on Sunday. Was evaluated at an urgent care center on Sunday and started on prednisolone. Vesicles developed over areas yesterday. Lesions are painful.

Telemedicine Consult Note

Requesting Emergency Department/Urgent Care: Urban ER

Requesting Emergency Department/ Urgent Care Center: Urban ER, Dr. Patty Smith

Time of Consult: 1800

Chief Complaint:

Nausea and vomiting

HPI comments: 3 month old, ex-27 week preemie boy with fever and decreased activity. Allergies not on file. No past medical history on file. No past medical history pertinent negatives. No past surgical history on file.

Relevant Labs:

CBC: WBC is negative

Imaging:

Other: none

Medications:

If UA is positive for UTI – recommend amoxicillin

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Dallas, Texas

Summary Telehealth Can:

• Provide healthcare in underserved areas

• Allow access to specialty services

• Shift healthcare delivery to the individual’s location

• Decrease time away from work

• Decrease potentially preventable healthcare

encounters

• Provide a cost effective delivery of quality health care

services

• The medical record is the medical record regardless

of how the care is delivered

Dallas, Texas

References

• Amatayakul, Margaret et al. “Definition of the Health Record for Legal Purposes (AHIMA Practice

Brief).” Journal of AHIMA

http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_009223.hcsp?dDoc Name-

bok1_009223 – Reference Date 7/21/2008

• The Joint Commission (2016). The Joint Commission Comprehensive Accreditation and

Certification Manual E-dition.

• Texas Administrative Code § 241.151. SUBTITLE B. LICENSING OF HEALTH FACILITIES

• Children’s Health, Health Information Management Department Policy, Definition of the Legal

Medical Record, 08/23/2016

• Center for Connected Health Policy, April 1, 2019

https://www.cchpca.org/resources/search?search_api_fulltext=TExas

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Questions?

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