A Telemedicine Opportunity

ATelemedicineOpportunityoraDistraction? 1

ATelemedicineOpportunityoraDistraction?Janis L. Gogan, Bentley UniversityMonica J. Garfield, Bentley University

Copyright © 2012 by the Case Research Journal and by Janis L. Gogan and Monica J. Garfield. Allrightsreserved.Theauthorsdevelopedthiscaseforclassdiscussionratherthantoillustrateeffectiveorineffectivehandlingofanadministrativesituation.AnearlierversionofthiscasewaspresentedattheITManagementTrackoftheNorthAmericanCaseResearchAssociation(NACRA)annualmeetinginSanAntonio,Texas,October2011.ResearchfundingwasprovidedbyBentleyUniversityandtheNorthAmericanCaseResearchAssociation.Wethankthesetwoinstitutionsandtheanonymousreviewerswhomadehelpfulsuggestionsonearlierversionsofthiscase,andthecliniciansandmanagerswhoagreedtobeinterviewedforthiscase.Somefactsandfigureshavebeendisguised.

ShawnFarrell,ExecutiveDirectorofthePartnersTeleStrokeprogram,glancedathissmartphonewhilestridingtowardhisofficeatMassachusettsGeneralHos-pital(MGH)inBoston;henearlycollidedwithLeeSchwamm,MD.Knowing

thatDr.Schwamm’soverfullscheduleasViceChairmanofNeurologyandDirectorofAcuteStrokeandTeleStrokeServicesmeanthehadlittletimetochat,Farrellusedthenear-collisionasanopportunitytoquicklymentionarecentconversationwithanursefromFalmouthHospitalonCapeCod.

Anactiveparticipant intheTeleStrokeservice,FalmouthHospitalwasregularlyhonoredforitsadherencetobestpracticesinstrokecare.“RecentlysomeFalmouthnursesaskedhowwecanconvinceotherMGHdepartments—suchasincritical-carepediatrics—toprovidesimilartelemedicineconsultationservices,”Farrellstated,add-ing“Theirnursestrokecoordinator,JeanEstes,isahugecheerleaderforTeleStroke.”

Dr.Schwammcontinuedmovingtowardhisofficeashereplied,

Shawn,don’twealreadyhavetoomuchtodo?Ineedtoseepatients,complete theanalysisforastudyIamworkingon,submitagrantapplication.NextweekIwillspeakataninternationalneurologyconference.Telemedicinecancertainlybeinvaluableinmanyclinicaldomains,buttherejustarenotenoughhoursinthedayforustogetinvolvedbeyondstrokecare.

Before entering his office and shutting his door, Dr. Schwamm added one lastremark:“Wecan’tdoeverything,Shawn—butwecandoTeleStrokeverywell.”

Shawn Farrell was not a medical doctor. A graduate of the Boston UniversitySchoolofManagement,hehadworkedasanoperationalmanagerinseveralBostonareahospitalsbefore joining theTeleStroke team.Farrellwas enormouslyproudoftheTeleStroke service,whichwashelping to save livesand to speed strokevictims’recoverysinceitsinitiationin2000.Asamanagerhewasalsopleasedthatin2011TeleStrokewasfinanciallyself-sustainable.Nowhewondered:HowshouldherespondtotheFalmouthnurses’request?

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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.

2 CaseResearchJournal•Volume32•Issue2•Spring2012

Telemedicine

Physicians used telemedicine systems to provide second opinions or other medicalservices(suchassupervisionofsurgicaloremergencyprocedures)overdistances.Sometelemedicineservices,suchasteleradiology,involvedasynchronousexchangeofmedi-cal images.Others utilized video conferencing technologies,making it possible forcliniciansindifferentlocationstoconferwithoneanotherand/orwithpatients.Ac-cordingtotheAmericanTelemedicineAssociation(ATA)a“specialistreferralservice”wasatypeoftelemedicineconsultationservicethatmightinvolve“aspecialistassistingageneralpractitionerinrenderingadiagnosis...[via]alive,remoteconsult[withthepatientpresent]orthetransmissionofdiagnosticimagesand/orvideoalongwithpatientdatatoaspecialistforviewinglater.”1

Farrellmadeapointofkeepingupwithtelemedicinedevelopmentselsewhere.Tele-radiologywaswidelyused.TheATAreportedthataboutfiftyothermedicalsubspe-cialties successfullyusedtelemedicine.Dermatology,ophthalmology,mentalhealth,cardiology,andpathologywereamongtheclinicaldisciplinesusingtelemedicineforspecialistreferralservices.Oneliteraturereviewreportedthatthefieldwas“maturing,”asevidencedbythebroadgeographicanddisciplinaryscopeoftelemedicineservices.2However,anotherauthoritativepaperreportedthatmosttelemedicineinitiativeshadnotadvancedbeyondthepilot-testingstage.3Fewtelemedicineconsultationserviceshadreachedlong-termfinancialviability,andevenfewerweredirectedtowardurgentcare.Oneobstaclewasreimbursement;mosttelemedicineserviceswerenotyetcoveredininsurancepolicies.Anotherobstacle:thecomplexityofmedicallicensure(whichintheUnitedStateswasdoneonastate-by-statebasis)andcredentialing(theprocessbywhichanindividualdoctorwasauthorizedtoprovidecareataparticularhospital).Furthermore,manyhospitals—fromsmallcommunityhospitalstolargetertiarycarecenters—hadproblematicnetworkarchitecturesandextensiveinteroperabilityissuesthatneededtobefixed.UntilthosehospitalswereabletoupgradetheirITinfrastruc-tures,itwouldbedifficulttoimplementinnovativenewservicessuchastelemedicine.

PartnersTeleStrokeservice—arealtimeconsultationservice—wasoneofonlyasmallnumberoffinanciallyviable,ongoingtelemedicineofferingssupportingurgentcareintheU.S.

The ParTners healThcare TelesTroke service

IntheUnitedStates,mostprimarycarewasprovidedbyafamilyphysicianorgeneralpractitioner,eitherinprivatepracticeorthroughahealth-maintenanceorganization(HMO).Secondarycarewasprovidedbyspecialists,usuallyatcommunityhospitals.When a patient needed to see a higher-level of specialist for a complicated condi-tion,theywereusuallyreferredtoatertiarycarehospital,suchasMGH.Manyofthephysicianswhoworkedattertiarycarehospitalshadreceivedadditionalsub-specialtytraining(suchasapediatriciantrainedinneonatologyorpediatricintensivecare,oraneurologistwhospecializedinacutestrokecare).

In 1994 two prominent Harvard-affiliated tertiary care hospitals—MGH andBrigham&Women’sHospital (hereafter, theBrigham)—merged, formingPartnersHealthCare.Overtheensuingyears,otherhospitals joinedordevelopedaffiliationswithPartners(Exhibit1).



In2000,Dr.SchwammbeganusingtelemedicinetohelpemergencyphysiciansataPartners-affiliatedinstitution—Martha’sVineyardHospital(MVH)—todetermineifpatientswereexperiencinganacuteischemicstrokeandifso,whethertoadministeralife-savingdrug—tissueplasminogenactivator(tPA).Acuteischemicstroke,causedwhenaclotblocksbloodflowtothebrain,wasaleadingcauseofdeathanddisability—especiallywhentreatmentwasdelayed.StrokewasthethirdleadingcauseofdeathintheU.S.,withabout795,000casesand140,000deaths.4Worldwide,about15millionpeoplesufferedstrokeseachyear.Astrokecouldcausedevastatingdisabilities(suchasparalysisandspeechloss).Apatient’schanceofrecoverygreatlyimprovediftPAwasgivenwithinthreetofourhoursofthefirstonsetofsymptoms.However,apatientcouldsufferfromanotherconditionwhichexhibitedstroke-likesymptoms,butwhichcouldnotbe treatedwith tPA. In fact, tPAcouldharm—evenkill—apatientwhowasexperiencinginternalbleedingorwasalreadytakingbloodthinners.Aneurolo-gistwithexpertiseinacutestrokecarewasthebestjudgeofwhetherapatientwasacandidatefortPA.

Martha’sVineyardHospitalcouldnotafford24/7strokeneurologycoverage,sotheyagreedtotestatelemedicineservice.MVHwouldelectronicallysendapatient’sbrainscanimagesforDr.Schwammtoreview.FromhisMGHofficeSchwammwouldthenparticipateinavideo-conferencesessiontoremotelyexaminethepatient.AftertestingthissystemwithMVHandtrainingthetwentystrokespecialistsinMGH’sneurologyprogramtousethesystem,Schwamm’steamstartedofferingthis“TeleStroke”servicetootherMassachusettshospitals.Data gathered inTeleStroke consultation sessionswereanalyzed,andSchwammandhisteambegantopublishscholarlypapersontheefficacyoftelemedicineforacutestrokeconsultations.

TheTeleStroke initiativegained significantmomentumwhen in2005 theMas-sachusettsDepartmentofPublicHealthissuedregulationsrequiringthatambulancepersonnelbringapatientwhoexhibitedstroke-likesymptomstoacertified“PrimaryStrokeCenter”tobeevaluatedasacandidatefortPA(Exhibit2).Onerequirementforcertificationwasthatalicensedphysicianwithacutestrokeexpertisemustbeavail-ableona24/7basis.Hospitalsthatlacked24/7neurologycoveragecoulduseaservicesuchasTeleStroketosatisfythisrule.

Partners’ChiefInformationOfficeratthetime,JohnGlaser,providedfundssup-portingthebuild-outoftheTeleStrokeservice.5InofferinghissupportforTeleStroke,Glaserhad toldFarrell thathe realized thatDr.Schwammhad“gainedbuy-in”byperforming“high-qualitystudiestogaugetheimpactoftelemedicineonacutestrokecare.”Glaserrecalled,

Thosestudiesverifiedthattelemedicineconsultationsaresafeandcanimprovepatientoutcomes.TeleStrokeaddressesarealclinicalneed.Ididnotrequiremuchinthewayofabusinesscase;the‘grant’weprovidedwasbasedmoreonthecaliberoftheidea.

Afull-timesoftwareapplicationspecialistwashiredtodevelopbrowser-basedsoft-warethat(muchlikeanelectronicmedicalrecord)wasusedtorecorddataabouteachconsultation(e.g.,patientage,timeofonsetofsymptoms,vitalsigns,labresults,scoresonvariousneurological tests,etc.—100state-mandateddataelements inall).Asof2011thisapplicationanditsdatabasewerenotyetfullyintegratedwithpatientmedi-calrecordsatMGH,theBrigham,orparticipatingspokehospitals.ThedatabasedidsupporttheTeleStrokeprogrambillingrequirementsandresearchstudiesonstroketreatmentandoutcomes.



AssomeofthetwentyphysiciansintheMGHneurologyprogramgainedexperi-encedoingTeleStrokeconsultations,thevalueoftheservicebecameevident.In2006adecisionwasmadetocollaboratewiththeBrigham;theireightstrokeneurologistsalsowantedtoofferaTeleStrokeservicebutfeltitwouldbemorecost-effectivetojoinforceswithMGHratherthandeveloptheirownsoftware.Asdual“hubs,”MGHandtheBrighamprovided24/7backupcareforeachother,incaseofunexpecteddemandornetworkconnectivityproblems.

TeleStrokewasdesignedtoservehospitalsthatordinarilyreferredpatientstoMGHortheBrigham;Dr.SchwammdidnotplantoextendthisserviceoutsidePartners’catchmentarea.6By2011,twenty-sevenspokehospitalsinMassachusetts,MaineandNewHampshireparticipatedintheservice(Exhibit3).Onespokewasaboutthreemilesaway;thefurthestwas130milesaway(FalmouthHospitalwasseventy-sevenmilesaway).

ToestablishapricingstructureforTeleStrokeconsultations,FarrellandSchwammgathered data about stroke rates in various communities in order to estimate howmanypatientswithsymptomsofacute ischemicstrokewouldlikelygotodifferentcommunityhospitals,howmanypatientsmightbesuitablecandidatesforaTeleStrokeconsultation,andhowmanywouldqualifyfortPA.Theylearned,forexample,thatCapeCodHospital inHyannis (a sister hospital toFalmouth)was especially busyduringthesummertouristmonths(withabout27,500emergencydepartment(ED)visitsinJune,JulyandAugust,accountingforaboutthirty-onepercentofEDvisitsin2009),andthatCapeCod’spermanentpopulationincludedalargenumberofeld-erlyretiredpeopleandhencehadahigherrateofstrokethanyoungercommunities.Also, some hospitals needed 24/7 stroke neurology coverage, while other hospitalsonlyneededweekendorlatenightcoverage.

Having analyzed the varied needs of spoke hospitals and the populations theyserved,apriceof$10,000wassetfora“book”oftenpre-paidTeleStrokeconsulta-tions,withanoptiontopurchaseadditionalconsultations.Inthefirstfewyearsthattheservicewasoffered,nospokehospitalusedalltenTeleStrokeconsultsbeforetheendofacontractyear.However,overtimeparticipatinghospitalsimprovedtheirwork-flows,enablingthemtoprocessincomingpatientsmoreefficiently(mindfulofthe3–4hourtPA“window”).This increasedthenumbersoftPA-eligiblepatients,whichinturnincreasedTeleStrokeusage.Asof2011,eachparticipatingspokehospitalpre-paidtheirprimaryhub(MGHortheBrigham)fortenTeleStrokeconsultationsandsomepurchasedadditionalblocksoffivepre-paidconsultations,witharolloverprovision(similartounusedcellphoneminutes).SomehospitalspaidPartnersadditionalfeesfortechnologysupportandonsitetraining.

Over time the TeleStroke software was enhanced to include decision support,clinical reporting, and other functions. In 2011 two full-time technical employeessupportedthesystem.OthermembersoftheteamincludedShawnFarrellandtwootherfull-timeemployees:onehandledcoordinationandcredentialing(allPartnersstrokeneurologistswerecredentialedatalltwenty-sevenspokehospitals)andanotheremployee was in charge of video/imaging, IT, and information security engineer-ing.HalfofDr.Schwamm’stimewasdevotedtotheTeleStrokeprogram,andhalfofanotherPartnersemployee’stimewasdevotedtomarketingandnetworkdevelopment.



“Time is Brain”

Cliniciansunderstoodthat“timeisbrain;”everyminutecountedsinceastrokepatientneededtoreceivetPAnolaterthan3–4hourssincelastseenwell.Ambulanceperson-nel(EmergencyMedicalSpecialist,orEMS)wereexpectedtophoneaspokehospital’semergencydepartmenttosaythatapossiblestrokevictimwasenroute.Anattemptwouldbemadetodeterminewhenthepatient’sstrokesymptomsbegan(forexample,afamilymemberorco-workermightbeabletosaythattheysawthepatientinnormalconditionand then“he suddenlycouldn’tmovehis arm”).TheEMScheckedvitalsignsandconductedasimplestrokescreeningtestintheambulance.

Once alerted, anurse in the spokehospital readied a room for thepatient andgrabbedastrokecarepacketcontainingapatientconsentform,EmergencyDepart-ment Stroke Algorithm, National Institute of Health (NIH) Stroke Scale, a sheetremindingtheteamoftimetargets(suchas“TimefromorderofCTscanorMRIscantoperformance:Within25minutesoforderbeingwritten”),andotherforms.TheStrokeAlgorithmdocument(Exhibit4)describedtheclinicalworkflow(forexample,step1cstatedthatRadiologyshouldbenotifiedtoplacethispatientnextinthequeueforaCTscan).

Apatientwasbroughttoatreatmentroomthatwasequippedforvideoconferenc-ing(witheitheramobilevideocartorapermanently-installedunit).Anurseundressedthepatientandattachedamobilemonitorsothatvitalsignscouldbeobservedandrecorded.Anemergencyphysician(EP)examinedthepatientandreviewedhisorhermedicalhistorytoidentifyanythingthatwoulddisallowtPA(suchasrecentsurgeryorbeingonbloodthinner).Ifs/hewasagoodcandidatefortPA(inclusioncriteriasatis-fied,noexclusioncriteriaidentified),theEPsentthepatienttotheCTscanlabandrequestedaTeleStrokeconsultation.7

BeforethepatientreturnedfromtheCTscan,anurseorotherstroketeammemberwouldensurethatthevideoconferencingequipmentwasconnectedtothenetwork.Forbestviewingbythehubneurologist,thecamerawasplacedata45degreeangletothepatient’sbed.A“superuser”mightassisttheattendingnurse.“Superusers”werenursesorassistantswhohadreceivedextratrainingsothattheycoulddosometechni-caltrouble-shooting.SuperuserswerealsoexpectedtopromoteappropriateuseoftheTeleStrokesystem(whentouseitandwhennottouseit—suchasincaseswhenthepatientorhis/herfamilycouldnotidentifywhenstrokesymptomsstarted).

TheneurologistinBostonneededtoquicklyreceiveandreviewtheCTscan(targetfortimefromcompletionofscantointerpretationbyconsultant:twentyminutes)ataTeleStrokestationonthehubneurologyunit.IfthescanrevealedthatthepatientshouldnotreceivetPA(afrequentoccurrence)theneurologistphonedthespoketeamtoletthemknow(inwhichcase,aTeleStrokeconsultationwouldnottakeplaceandthespokehospitalwouldnotbechargedforthephonecall).Aboutoneinfivephonecallsactuallyledtoavideoconsultation.

Ifthescandidsupportadiagnosisofacuteischemicstrokewithoutexclusionarycomplications,theneurologistwouldgetreadyforaTeleStrokeconsultation(Exhibit5). During the initial call and subsequent video consultation, the hub neurologistenteredthepatient’slabresults,TimeLastSeenWell,TimePresentedintheED,and



otherdataonthebrowser-basedTeleStrokesoftware.Similartodrug-druginteractionsoftware,theapplicationwasrule-basedandhaderror-checkingcapabilitiestoensurethatthedatacapturedwasofhighqualityandthatthephysiciandidnotmakeerrorsthatcouldleadtoapoordecision(e.g.,ifmorethan3hourshadpassed,thesystemalertedthedoctorthattPAmightnotbeaviableoption).Ifthepatienthadnotbeenruled out as a tPA candidate, the NIH Stroke Scale appeared on the neurologist’sscreentosupportinputoftheresultsofthistestintotherecord.

TheBostonneurologistused thevideosystemtocollaboratewitha spokenurseputtingthepatientthroughtheNIH(NationalInstituteofHealth)StrokeScaletasks(stickoutyourtongue,raiseyourrighthandandholditthereforfiveseconds,etc.seewww.nihstrokescale.com).Theneurologistremotelycontrolledthespokecamera,zoominginorpanningoutasneeded.OncetheStrokeScaletestwascompletedtheneurologist would confer with the attending emergency physician, who was legallyresponsibleforthepatient’scare.IftheneurologistdecidedthattPAadministrationwasaviableoption,thentogetherthetwophysicianswoulddiscussbenefitsandriskfactorsoftPAwiththepatientandfamilymembers.Atsomepointtheywouldusuallypausethevideoconnectionandstepawaytogivethepatientand/orfamilyamomentalonetomakeadecision.Ifthedecisionwas“Yes”aconsentformwasfilledout,tPAadmin-istered,andthepatientwasimmediatelytransferredtoMGHortheBrighamforclosemonitoring(this“dripandship”requirementwasspecifiedintheTeleStrokecontract).

Alternatively,theneurologistmightconcludethatthispatientshouldnotreceivetPA.Inthatcase,theneurologistmightrecommendothertreatmentoptions,suchasatypeofcatheterizationthatusedasuctioningdevicetopullclotsoutofbloodvessels,oranothertypethatusedatinycork-screwshapeddevicetowraparoundaclotandpullitout.Or,thephysiciansmightjudgethepatient’sconditiontobetoounstablefor such treatments at that time, and theymight recommendways to stabilize thepatientorjusttokeephimorhercomfortable.

ThedatarecordedbythehubneurologistwastheofficialTeleStrokeconsultationrecord. Authorized personnel could print this off or cut-and-paste the record intotheirhospital’selectronicmedical record(afterverifyingthedataagainst theirownpatientcharts).

Technical and Process issues

Several constraints affected the TeleStroke system architecture, especially MGH’scomplexandagingITinfrastructureandtheheterogeneityofspokehospitals’clinicaldatabasesandapplications.Incompatibilityamongspokeclinicalsystemsandincom-pleteinternalintegrationatMGHnecessitatedre-keyingofsomepatientdata(suchas a patient’s medication history and blood type) that were already maintained inotherdatabases.

UnderDr.SchwammasmedicaldirectorandFarrellasexecutivedirector,MGHdevelopedanimplementationmethodologyandstandardsforpreparingspokehos-pitalstoparticipateinTeleStroke.Spokeinstitutionsneededtopurchasevideocon-ferencingequipment.Althougha fewhospitals installedfixedequipment inanEDtreatmentroom,mostboughtamobilevideoconferencingconsole(atacostlessthan$10,000)andstoreditinacloset(withanelectricoutlet;itsbatterywaschargedwhilestored).Whenneeded,thecartwasbroughtintoadesignatedtreatmentroomwiredforbothInternetandISDN(ISDNwasbeingphasedout,andafewspokeswerealso



experimentingwithwirelessconnections).Partnersspecifiedoff-the-shelfequipmentthatwaseasytodeployanduseandthatsupportedremotecameracontrolfromthehub(whichgavetheconsultanttheabilitytofocuscloselyonthepatient’sface),andmulti-usersupport(sobothaconsultantandacolleaguecouldattendaconsultationviaseparatedevices).Multipleportswererequired,sinceoneportwasdedicatedtoadigitalvideorecorderforarchiving.

Eachhospital’sstroketeamincludedemergencyphysiciansandnurses.Teammem-bersreceivedtrainingaboutusingtPAtotreatacuteischemicstrokes.Dr.Schwammoftenusedtheterm“brainattack”insteadof“stroke,”inthehopethatclinicians(aswellaspatientsandfamilymembers)wouldthinkofitasaconditionrequiringanimmediate response, like a heart attack. Some clinicians had only recently learnedaboutthetPAthree-hourwindow.Anurseexplained:

I,likemanyothernurses,thoughtthatstrokewasmymoststablepatient,becausetheydidn’tlookliketheyneededme.. . Somebodyhadchestpainnextdoor;Ineededtotreatthatbecausethatcouldbeaheartattack...Mywholeperceptionofstrokewas:ThisisaprocessthatisgoingonandthereisnothingmuchIcandoaboutit...Somestrokepatientscan’tspeak;theyaresittingveryquietlyhavingtheirstrokeandmeanwhileyou’retakingcareofsomebodyelsewhoislouder...Whenthesemandatescameout,Irealized...Thereareinterventionsthatwecanprovideforthispatient.Everybodyhastoworkalittlebitfaster.

Partners provided advice regarding network connections, appropriate lighting,videocartplacement,andsoon.Stroketeamsweretaughthowtohookupandusethe video conferencing equipment, and each team analyzed their hospital’s patientintakeandevaluationprocedures tofindways to reducedelaysateachstepandtoensuretheshortesttimefromapatient’sfirststrokesymptomstotPAadministration.Forexample,atonehospitalwheretreatmentroomswerequitesmall,nurseslearnedtoplacethevideocartinacorner,useashortcordsonoonetrippedonit,andtoturnthepatient’sbedaround.Thisrequiredalittlepractice.

Videoconsultationsalsogaverisetoanadjustment intheorderofstepsontheNIHStrokeScale.With the traditional scaleapatientwasasked toalternatelyusetheirface,upperbody,andlegs.Inavideoconsultation,thehubclinicianhadtozoominandoutonthepatientmultipletimes.Sinceeverysecondcounts,apeer-reviewedstudywasconductedtoverifythatthealteredscalewasclinicallyvalid.ThenewNIH-approvedscalewasincorporatedintoPartners’software.

When theTeleStroke service started, most radiology departments were alreadytransmittingCTscanstoexternalpartnersusingtheDICOM(DigitalImagingandCommunicationsinMedicine)standard.Atfirst,hubneurologistscomplainedthattheywaitedtoolongtoreceivetheCTscandataattheirworkstations.InvestigationrevealedthatthebrainscanswerefirstbeingsenttotheMGHmainserverandthencopiedtotheTeleStrokeserver.Toreducedelays,thesystemwasredesigned:CTscanswerefirstsenttotheTeleStrokeserver,thentotheMGHmainimageserverforarchiv-ing.Withthatchange,atechnicalmanagerstated,“Ourphysicianopensuptheoneimageviewer...andboom!Thescansarerightthere.”

Eachspokeinstitutionwasaskedtoconductaonce-weeklytestoftheradiologyimagetransfersystem(bysendingasampleCTscantothehub’sdatarepositoryforradiologyimages),andthevideoconferencingsystem(byconnectingtoadevicethatstreamedbothvideoandaudio).



Soon,othertertiary-careinstitutionsbegantoaskPartnersforguidanceonhowtosetupsimilaracutestrokecaretele-consultationservices.ThisledtheTeleStroketeamtoestablishanewconsulting service,“TeleStrokeNetworkPartnerProgram,”whosemissionwastohelpotherinstitutionssetuptheirowntelemedicinenetworks(Exhibit6).

Telemedicine for criTical-care PediaTrics: oPPorTuniTy or disTracTion?

Reachinghisownoffice,ShawnFarrellsatathisdesk,wherehisthoughtsreturnedtotheFalmouthnurses’requestformoretelemedicineservices,suchasinpediatrics.MassGeneralHospitalforChildren(MGHfC,aPartnershospitalthatwasaffiliatedwithMGH)hadusedtelemedicinewithafewotherhospitals(seeExhibit7),soFar-rellphonedDr.NatanNoviski,theMGHfCChiefofPediatricCriticalCareMedicine(Pediatriccriticalorintensivecare,arelativelynewsub-specialtyinpediatrics,aroseasaresultofresearchthatdemonstratedthatcriticallyillorinjuredchildrenexperienceddifferentsymptomsandrequireddifferentcarethanadults.MGHfCofferedoneofthepremiertrainingprogramsandafourteen-bedpediatricintensivecareunit,orPICU.)

Dr.Noviskifirstexperimentedwithtelemedicineinthelatenineties,incollabora-tionwithNorthShoreHospitalinSalem,16milesfromBoston.(NorthShoresub-sequentlyjoinedthePartnersorganization.)Noviskiexplainedthatemergencyphysi-cianssometimesneededassistanceinstabilizingacritically-illchildbeforetransferringthepatienttothePICUforspecializedcare:

Around1997theideaarosefromtheneedtostabilizekidsandtakecareofthembeforetheyaretransferredtoourhospital.Weusedtodothisbyphone,anditwasfrustratingformeandforthedoctorontheotherside.Ratherthantakingcareofthepatientheneedstositonthephoneandaskformyadvice.IwasfrustratedbecauseIcouldnotseethepatient.Telemedicinewasadvancingatthattime,butnoonewasusingittotakecareofacutecarepatients.So,wedecidedtotryitout.

TheemergencyroompediatricianatNorthShorewouldcallwhentheyneededtotrans-ferasickkidoverhere,andwe’dseethepatientthroughtelemedicine.Weremotelycontrolled three cameras that theyhadover there.Wecould see all themonitoringequipment;seethepatient;seethex-rays,theEKG’s,andalltheotherstuff.Today,oursituationwithNorthShoreisalittledifferent,becausenowtheyarenotjustareferralhospital;theyarepartofMassGeneralHospitalforChildrenandourphysiciansrotatebetweenthetwo locations.Westilloffercritical-careconsultationsbutnowwealsoscheduledailyvideoconferencestodiscusscomplexcases.

NorthShorewastheonlylocationoutsideBostonthatactivelyparticipatedintheMGHfCtelemedicineconsultation service (otherhospitalsused it for routinecon-sultationsandotherformsofvideoconferencing,butnotforcriticalcareconsulta-tions).Noviski’sshort-termprioritywastousetelemedicinemoreextensivelywithinMGHfC.Forthepastyear,sixintensivistshadparticipatedinapilottestofatele-medicineapplicationusing“PICU-Bot.”Eachon-callintensivisthadaworkstationathome.OnthefloorofthePICU,atelemedicineunit(a“bot”)couldbeplacednexttoanyPICUbedwhenanattendingphysicianrequestedadvicefromtheintensivist.“Theresultssofarareveryencouraging,”Noviskistated.

Farrellasked:“Woulditbeagoodideatoexpandyourtelemedicineofferingstootherspokehospitals?”Noviskireplied,“I’mnotsure.”



Manyhospitalsgetmaybeonlysixpediatriccritical-carecaseswithinayearwhentheycoulduseourhelp;Idon’tknowwhethertheyarewillingtopayareasonablepriceforustoofferthisservice.Oneofthefewhospitalsthatsignedontoourinitialtelemedi-cineservicedidnotkeeptheirequipmentuptodateandnolongerinitiatestelemedi-cineconsultations;theysaytheycan’taffordtoupgradetheirequipment.

After he hung up, Farrell thought for a moment about what Dr. Noviski said.Pediatriccritical-careincidentswerefarlesscommonthanstroke.Whilechildrenwithconcussions,brokenbones, rashesandotherconditionswereoften treated inEDs,critically-illorcriticallyinjuredchildrenwererarelyseen).So,thepricingmodelthatworked forTeleStrokemightnotbe ideal for critical carepediatrics.AlthoughFal-mouthnurseswereclamoring formore telemedicine services,FarrelldidnotknowwhetherFalmouthadministratorswouldbewillingtopayforthem.

TelemedicineconsultationserviceswerenotcentrallymanagedatPartners;eachmedicaldepartment(suchasneurologyorcritical-carepediatrics)madeitsowndeci-sionsaboutservicestooffer.Oneorganizationalunit—PartnersCenterforConnectedHealth(CCH,Exhibit8)—wastestingvarious“tele-health”services(usinginternet-connecteddevicestomonitorpatients’bloodpressureorbloodsugarlevels,toconnectpatientswithPartnersphysiciansforsecondopinions,andotherservices).CCHhadhelpedDr.Noviski’sgroupwiththePICU-Botpilottest.However,CCHdidnothaveamandatetooverseealltelemedicineservices.

Laterthatday,Farrellchattedwithanotherpediatricintensivist,Dr.Ricardo,whodescribedamemorabletelemedicineepisode:

OneNorthShorecasestandsoutveryeasily:achildwhocameinwithseizures.Thechildwasnotbreathingeffectivelyandneededabreathingtube.Usingtelemedicine,I’mwatchingthepatient,andInoticethatwhentheanesthesiologistisabouttoinsertthe breathing tube, the abdomen begins to contract. I said, ‘I think the patient isgoingtovomit,youneedtoturnhim.’Nooneresponds,soI’myelling,‘Thepatient’sgonnavomit;turnhim,turnhim,turnhim!’Finallytheyturnhim,thechildvomits,theysuction,andtheyeventuallygetthetubeinandtransportthepatienttous.Thatevening,thedadwalksintoourICU.Iintroducedmyself.Hegoes,‘You!Isawyouonthescreen!Youweretellingthemtoturnhimandtheyweren’tlisteningtoyou.’

Thatwasafewyearsago.Itisgettingmoreandmorecosteffectiveanditworksbetternow.Thereusedtobeadelayinthefeed—sortoflikeintheoldmovies.You’dhearthesoundandthenallofasuddenthepatient’smouthmoves.Theimagesaremuchlesschoppynow.Mobileapplicationsarestartingtotakeoff,whichisexciting.However,theyarestillworkingondesigningafirewallorencryptionforwirelessapplicationsthatwillprotectpatientprivacyyetnotcauseachoppyvideoimage.

Wedidatonetimeconsiderextendingthisservicetootherhospitals,suchasMartha’sVineyardandNantucket.It’sburdensometoputachildonaferryforafewhoursinordertoseeasub-specialistonthemainland.Wecanprovidethatspecialtycareviatelemedicine.However,Ihavenotactuallyusedtelemedicineinabouttwoyears.

Farrellstated,“TeleStrokeservestwenty-sevenhospitalsrightnow.”

WithtwentystrokeneurologistsatMGHandeightattheBrigham,wecouldcomfort-ablyprovideTeleSrokeconsultationstotwiceasmanyhospitals.Yourunithassevenpediatricintensivecarespecialists,butIdon’tknowanythingabouttheirworkload.Howmanyhospitalscouldyourgroupsupportviatelemedicine?



“Idon’tknow,”repliedDr.Ricardo.“Idoknowthis:Whenweprovidehelpusingtelemedicine,itoftenmeansthatthepatientcanstayrightthereatthecommunityhospital.”

Dr.Ricardofocusedontreatingthosepatientswhocouldbenefitfromherspecial-ized skills. If a patient could receive appropriate care at a community hospital, shewantedthepatienttostaythere.Similarly,mostTeleStrokeconsultationsresultedinthepatientnotbeingtreatedwithtPAandnotleavingthespokehospital.TheTeleStroke“dripandship”stipulationdidbringsomepatientstoMGHortheBrigham,butthesewerethepatientswhomostneededtobecaredforbythehighlytrainedneurologistsintheirresidencyandpost-residencyfellowshipprograms.

ShawnFarrelldescribedhis recent conversationwith theFalmouthnurse. “Oh,yes,”repliedDr.Ricardo.“WehavehadconversationswithFalmouthandsixorsevenotherhospitals.”

And,IthinkDr.NoviskididtalkwithDr.Schwammaboutaddingapediatricconsulta-tionlayertotheserviceyouprovide—somethinglikeapackageofthreeorfourcon-sultationsperyear.However,itwasunclearhowwewouldcompensateyourTeleStrokeprogramfortheinvestmentyoualreadymadeintechnicalinfrastructureandoperations.Ihopewecanreachanagreementonareasonablefeetopayyourgroupandafeetochargehospitalstoparticipateinacritical-caretele-pediatricsservice.

Returningtohisoffice,Farrellfeltalittleuneasy.ItwasonlynaturalthatFalmouthandotherhospitalswouldwant to take fuller advantageof the video conferencingequipmentintheiremergencydepartments,sincetheTeleStrokeservicewasworkingwellandsavinglives.Onthefaceofit,theadditionofapediatrictele-consultationservice seemed likeagreat idea.However,FarrellworriedthatusingtheTeleStrokeplatform for other purposes could be problematic. Most spoke EDs had only onetelemedicinecart.Farrellwondered:ifacritically-illchildandanelderlystrokepatientweretoarriveatanEDatthesametime,wouldn’tclinicianshavetochoosebetweenusing the telemedicineequipment for thechildversus for theelderlypatient?Thatscenariowas fairlyunlikely, sinceDoctorNoviskihad stated that complex critical-carepediatricepisodesoccurredveryinfrequently.Also,critical-carepediatricsencom-passedawiderangeofconditions(fromachilddyingofcancertothevictimofanautomobileaccidentorpoisoning).“Thetelemedicinecartismulti-purpose,”Farrellmused,“butourprocesses,whichareoptimizedforacutestrokecare,maynotbeide-allydesignedforadifferentclinicaldomain.”

Althoughhewantedtobehelpful,Farrellneededtothinkthroughthefinancialandworkflowimplicationsandotheraspectsbeforeproceedingfurther.Still,hedidfeelobligedtorespondtothenursesatFalmouthHospital.



noTes

1. www.americantelemed.org2. DemirisG.,TaoD.Ananalysisofthespecializedliteratureinthefieldoftelemedi-

cine.Journal of Telemedicine and Telecare11(6):316–319,2005.3. GrigsbyB.,BregaA.G.,BennettR.E.,DevoreP.A.,PaulichM.J.,Talkington

S.G.,FloerschN.R.,BartonP.L.,NealS.,ArayaT.M.,LokerJ.L.,KrohnN.,GrigsbyJ.Theslowpaceofinteractivevideotelemedicineadoption:Theperspec-tiveoftelemedicineprogramadministratorsonphysicianparticipation.Telemedi-cine Journal and e-Health13(6):645–656,Dec2007.

4. www.stroke.org5. SubsequentlyGlaserleftPartnerstobecomeCEOoftheHealthServicesBusiness

ofSiemensHealthcare.6. Acatchmentareaisthegeographicareaservedbyaparticularinstitution.7. Somespokehospitalsdidsometimeshaveneurologistsonsiteoroncall.Atthose

hospitals,anurseorclerkhadtodetermineiftheon-callneurologistcouldreachtheemergencydepartmentwithin15minutes.Ifnot,aphonecallwasmadetorequestaTeleStrokeconsultation.



Exhibit 1: Partners HealthCare Members and Affiliations

Partners HealthCare, founded in 1994 by Brigham and Women’s Hospital and Massachusetts General Hospital, is an integrated health care system that offers patients a continuum of coordinated high-quality care. The system includes primary care and specialty physicians, community hospitals, the two founding academic medical centers, specialty facilities, community health centers, and other health-related entities. Partners HealthCare is a non-profit organization.Major Teaching Affiliate of

• Harvard Medical School Founding Members

• Brigham and Women's Hospital • Massachusetts General Hospital

Members• Faulkner Hospital• Martha's Vineyard Hospital• McLean Hospital• MGH Institute of Health Professions• Nantucket Cottage Hospital• Newton-Wellesley Hospital• North Shore Medical Center• Partners Community Healthcare, Inc.• Partners HealthCare at Home• Spaulding Rehabilitation Network

Partners HealthCare Programs• Asthma Center• Center for Connected Health• Center for Personalized Genetic Medicine• Online Specialty Consultations• Research Ventures and Licensing• Mongan Institute for Health Policy• Telestroke Center

International Programs• Partners Harvard Medical International• Partners International Medical Services

Community Health Centers• BWH Brookside Community Health Center• BWH Southern Jamaica Plain Health Center• MGH Charlestown HealthCare Center• MGH Chelsea HealthCare Center• MGH Revere HealthCare Center• Boston Healthcare for the Homeless• Codman Square Health Center• Dorchester House Multi-Service Center• East Boston Neighborhood Health Center• Geiger-Gibson Community Health Center• Lynn Community Health Center• Martha Eliot Health Center (Jamaica Plain)• Mattapan Community Health Center• Neponset Health Center (Dorchester)• North End Community Health Center• Salem Family Health Center• Peabody Family Health Center



• South Boston Community Health Center• South End Community Health Center• Upham’s Corner Health Center • Whittier Street Health Center

Collaborations• Center for Integration of Medicine and Innovative Technology• Dana-Farber/Partners CancerCare• Harvard Clinical Research Institute• Ragon Institute of MGH, MIT and Harvard

Source: www.partnershealthcare.com.



Exhibit 2: Massachusetts Department of Public Health Primary Stroke Center Regulations (DPH 105 CMR 130.1400 through 105 CMR 130.1413)

To be certified as a Primary Stroke Center under the above regulations, a hospital is assessed on the following capabilities, which must be available 24 hours a day, seven days a week:

1. A licensed physician with acute stroke expertise serves as Stroke Service Director or Consultant. 2. Written care protocols “including both the emergency and post-admission care of acute stroke

patients by a multidisciplinary team” are available in the Emergency Department and include time targets that help ensure that eligible patients will receive tPA within the three-hour window.

3. Hospital and Emergency Medical Service (EMS) personnel coordinate effectively so that the patient with acute stroke symptoms is efficiently admitted, tested, diagnosed and treated.

4. Hospital can quickly perform and interpret brain computed tomography (CT) or magnetic reso-nance imaging (MRI) scans.

5. Hospital can quickly perform and evaluate chest x-rays and electrocardiograms and various laboratory services.

6. Neurosurgical evaluations and/or interventions are performed within acceptable time targets.7. If patients need to be transferred to another hospital, there is a transfer agreement in place.8. Hospital collects and analyzes process and outcomes data and submits required data to the

Department of Public Health.9. Physicians, nurses, allied health professionals and EMS personnel receive appropriate training

on a continual basis.10. Hospital offers community education regarding stroke.

Source: http://www.mass.gov/eohhs/docs/dph/regs/105cmr103–140-amend.pdf.



Exhibit 3: Partners TeleStroke Network

Source: Presentation developed and delivered by Lee H. Schwamm, MD using Google Maps.



Exhibit 4: Falmouth Hospital Emergency Department Stroke Algorithm1 Entry into system via ED. START STROKE PACKET.

Patient arrives in ED as a walk-in with symptoms of stroke: Patient is triaged by a registered nurse. If symptoms began within 3 hours (document time of onset and how the time is known), patient is at least an ESI 2 Triage Level.Patient arrives by EMS: Stroke Screening Tool will be completed prior to arrival and ED notified that a possible stroke is coming in. Patient will be triaged upon arrival.CT is alerted to hold the next bed.

2 Patient is taken to appropriate room (a monitored bed with a scale). EP is notified immediately and assesses patient.

*3 Patient goes to CT within 20 minutes of arrival. CT is read within 45 minutes of arrival.

4 If patient DOES NOT meet criteria for thrombolysis . . . patient continues on appropriate path-way for treatment.

5 If CT is consistent with a hemorrhage, prepare for transfer, as recommended by physician. Call MedFlight or ground transport; follow transfer protocol. Do not delay transfer of patient secondary to awaiting Neurologist. Neurosurgical intervention may need to be implemented.

*6 If patient DOES meet criteria for thrombolysis . . . alert the following:Go to Teleneurology* algorithm.If teleneurology consultation is to take place, use green Teleneurology packet (located with teleneurology cart)Stroke Team: Call the group pager: “84” and extension number.LaboratoryNeurologist on call, if available.Pharmacy

7 Lab work is drawn and sent ASAP in red Translogic container. Stroke Panel (CBC, BMP, PT/PTT/INR, blood bank hold). Tubes are sent in the red Translogic container to alert the Lab that it is a high priority.

8 Stroke Orders/Packet will be instituted.

9 If tPA is ordered, it is mixed by Pharmacy if they are in house (0700–2200). When Pharmacy is not in-house, RN mixes the drug following directions in packet, and admin-isters dose, checking with another clinician before administering the dose. Document double signatures on dosage sheet.

10 Call Lab to complete type and screen. Alert Lab that tPA has been given.

11 Patient is transferred (to the Brigham or MGH) after utilizing Teleneurology Service or per Neurologist order. Follow transfer protocol.

12 Stroke packet is to be used for all stroke patients. *Simultaneous actions need to occur in the interest of the critical timing criteria for stroke victims.

Source: Falmouth Hospital*Note: Falmouth Hospital refers to the TeleStroke service as the “Teleneurology” service.Presentation by Jean Estes, Falmouth Hospital’s Nurse Stroke Coordinator: http://wn.com/The_Use_of_TPA_in_strokes_Jean_Estes_



Exhibit 5: Partners TeleStroke Consultation Overview

KeyCT: Computed Tomography (see CT-Scan)DICOM: Digital Imaging and Communications in Medicine standard, used for distributing and view-ing medical images CT-Scan: Computed Tomography scan, a medical imaging method TCP-IP: Transmission Control Protocol (TCP) and Internet Protocol (IP), a set of computer network protocolsISDN: Integrated Services Digital Network, a set of tele-communications standardsVC: Video Conferencing unit

Source: presentation developed and delivered by Lee H. Schwamm, MD



Exhibit 6: Telestroke Network Partners Program: Web Page Description

NetworkPartnersOverviewIf your hospital already employs a team of skilled stroke neurology physicians, and you are planning for or are already designated as a comprehensive stroke center, you may have already begun explor-ing what it takes to implement a telestroke program. Forging ahead independently can be very costly, technically challenging, and prone to errors.The “TeleStroke Network Partner” Program offers a proven service delivery model that will flatten out your learning curve, get a successful “hub and spoke” telestroke network up and running quickly and cost-effectively, and allow your institution or hospital network to continue focusing its scarce resources on improving patient care and achieving better patient outcomes.ImplementationImplementing the “TeleStroke Network Partner” Program in your hospital will enable you to provide 24/7/365 clinical expertise to any surrounding hospital that joins your local telestroke network, regard-less of whether they are part of your integrated hospital network, part of another hospital network, or independent. Many of our own telestroke-networked “spoke” hospitals have used this arrangement to successfully secure designation as “Primary Stroke Centers” in the Massachusetts state-based stroke designation system. A successful telestroke program can represent a possible new revenue stream for your own institution; enhance network cohesion within your own integrated hospital system; and gener-ate good will and positive publicity throughout the state and surrounding communities.As part of the “TeleStroke Network Partner” Program implementation, your hospital will receive all the necessary materials, software tools, training, and implementation support to develop your own branded telestroke “hub and spoke” network, including:

• Marketing Materials• Contracting Materials• Credentialing Materials• Video/Radiology Network Layout Guidelines• Software Admin Tools• TeleStroke Consult Software Use• Clinical Protocols• Remote Unit Technology/Installation Guidelines• TeleCME Guidelines

In addition, the Telestroke Network Partner “hub” hospitals interact with each other in a collaborative fashion to share best practices and drive innovation.Please contact us at (617) 724-3999 or [email protected] for more information and to discuss the benefits of the “TeleStroke Network Partner” Program.

Source: http://telestroke.massgeneral.org/servicesNetwork.aspx



Exhibit 7: Mass General Hospital for Children: Pediatric Critical Care

Critical Care at a World-Renowned Academic Medical Center: The Mass General Hospital for Children Pediatric Intensive Care Unit (PICU) is a fourteen-bed, multidisciplinary unit, which has dis-tinguished itself by providing high quality care for critically ill infants, children, and adolescents. Our patients present with a wide variety of life-threatening issues, such as severe infections, respiratory diseases, trauma, and post-operative care of various complex surgeries.Our Mission: Our mission is to provide state-of-the-art critical care medicine by bringing together the most sophisticated technology and scientific advancement in an environment sensitive to the multicul-tural patients and families we serve. Excellent communication with the family and primary care pediatri-cian is seen as a critical success factor in optimizing outcomes. We have a complete range of pediatric consultant services, including:

• Pulmonology• Endocrinology• Cardiology and cardiac surgery• Gastroenterology• Hematology/Oncology• Infectious diseases• Neurology• Nephrology• Trauma surgery• General surgery• Orthopaedic surgery• Neurosurgery• Transplant surgery

The telemedicine program provides live video conferencing between the PICU and select patient rooms in emergency departments at outlying community hospitals, including North Shore Medical Center and Newton Wellesley Hospital. Via this link, the PICU staff may provide on-demand medical advice and guidance to help assess, and if needed, stabilize critically ill infants and children and pre-pare them for transport to the PICU. This telemedicine technology also supports an international link between the Buen Samaritanu Hospital in Aguadilla, Puerto Rico and the PICU.There are three components to the telemedicine service provided through the MGH PICU. First, through our state-of-the art telemedicine link, we provide live video conferencing between the PICU and select patient rooms in emergency departments at outlying community hospitals. Via this link, fellows provide on-demand medical advice and guidance to help assess, and if needed, stabilize critically ill infants and children and prepare them for transport to the PICU. Secondly, our telemedicine technology currently supports an international link between the Buen Sa-maritanu Hospital in Aguadilla, Puerto Rico and our PICU. Under the supervision of the on-service attending, the fellow provides teaching and consultation on challenging pediatric cases presented by faculty in Puerto Rico.Finally, this innovative technology is designed to support live video conferencing between the PICU team in-house overnight and the on-service attending, at home. Any member of the team may request a teleconference with the attending for the purpose of virtual bedside evaluation of a new patient, reas-sessment of a patient whose condition may be deteriorating, or a team meeting with other subspecialty consultants and family members at the bedside. One of the many advantages of this technology is that it allows the on-call fellow the opportunity to be on the frontline, independently leading the unit overnight while still having access to appropriate faculty supervision. All faculty live in close proximity to the hospi-tal and can return to the hospital within minutes to provide direct supervision of the fellow when needed.

Both the inpatient unit and pediatric emergency department at Mass General for Children at North Shore Medical Center are staffed by jointly appointed NSMC and MGHfC staff. Daily teleconferences are held between the two facilities to review complex cases with key specialists. Through this powerful collaboration we are able to offer common standards and protocols, as well as a network of subspecialists on staff at MGHfC.

Source: http://www.massgeneral.org/children/specialtiesandservices/critical_care_medicine_picu/default.aspx



Exhibit 8: About Partners Health Care Center for Connected Health (CCH)

The term “connected health” reflects the range of opportunities for technology-enabled care programs and the potential for new strategies in healthcare delivery.Founded in 1995 by Harvard Medical School teaching hospitals, the Center for Connected Health develops new strategies to move health care from the hospital and doctor's office into the day-to-day lives of patients. Leveraging information technology—cell phones, computers, networked devices and simple remote monitoring tools—the Center helps providers and patients manage chronic conditions, maintain health and wellness, and improve adherence, engagement and clinical outcomes.Actively involved in sponsored research, the Center evaluates new technologies and programs and develops and executes fea-sibility studies and randomized controlled clinical trials. It has generated over 100 scholarly publications and helped over 30,000 patients. What unites these efforts is an emphasis on practical innovations that make a difference in peoples’ lives. Guided by a relentless focus on what works and what doesn’t, the Center aims to change the way doctors and nurses deliver services even as it expands the ability of patients to manage their own health. Its staff serve on government advisory com-mittees and corporate boards and are active speakers.Annually, the Center convenes a Symposium attracting over 1,100 thinkers, innovators and funders from all over the world. The meeting has become the preeminent global conference of ideas about healthcare, technology and policy.Research and evaluation is a critical component of connected health innovation and adoption. Our focus is on nurturing and evaluation new ideas, products and delivery models by rigorously testing them via feasibility pilots as well as randomized controlled trials. Our goal is to understand how people interact with technology, and how we can change behaviors to achieve better clinical outcomes. Learn more.Our programs in heart failure, hypertension, diabetes, and other chronic conditions, as well as on-line second opinions and enhanced medical education and training, are being successfully integrated across the Partners HealthCare network and implemented by major employers.

• Diabetes Connect and Blood Pressure Connect—These programs offer patients and their care providers a way to keep track of their blood sugar or blood pressure readings, and to collaborate on a care plan between office visits.

• Connected Cardiac Care—A home telemonitoring and education program for patients with Heart Failure who are at risk for hospitalization.

• Partners Online Specialty Consultations (POSC)—This program offers patients and their treat-ing physicians from around the world online access to thousands of leading specialists at Mas-sachusetts General Hospital, Brigham and Women’s Hospital and Dana-Farber/Partners Cancer Care. POSC has helped more than 10,000 patients with a life-threatening or unusual diagnosis to better understand their options, find answers or, simply, have peace of mind that their treatment plan is right for their situation. Visit econsults.partners.org for more information.

• Collaborative Media Services—Provides video-conferencing and streaming media services that facilitate teaching and learning for clinicians and patients worldwide. Our expertise includes pod-casting and web conferencing, streaming media hosting and cross-platform video on demand. Visit collaborative-media.partners.org for more information.

Source: adapted from http://www.connected-health.org/about-us/about-us.aspx


Documents

A Telemedicine Opportunity