8Saving Lives. Protecting Americans.

Case #1: Gastroenterology Clinic at a Rural

Academic Medical Center

Eric Shah, MD, MBA

Dartmouth-Hitchcock Medical Center

Lebanon, NH

https://en.wikipedia.org/wiki/History_of_general_anesthesia#/media/File:Southworth_&_Hawes_-_First_etherized_operation_(re-enactment).jpg

Grigsby J, Sanders J. Telemedicine: Where It Is and Where It's Going. Ann Intern Med. 1998 Jul 15;129(2):123-7.

Shah E, Rothstein R. Gastrointest Endosc. 2020 May;91(5):1183-1186.

Shah E, Rothstein R. Gastrointest Endosc. 2020 May;91(5):1183-1186.

The reality of what GI actually is

https://www.niddk.nih.gov/health-information/health-statistics/digestive-diseases

Peery, et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018. Gastroenterology. 2019 Jan; 156(1): 254–272.e11.

Cash BD, Schoenfeld P, Chey WD. The utility of diagnostic tests in irritable bowel syndrome patients: a systematic review. Am J Gastroenterol 2002; 97: 2812–9.

Spiegel BM, DeRosa VP, Gralnek IM, Wang V, Dulai GS. Testing for celiac sprue in irritable bowel syndrome with predominant diarrhea: a cost-effectiveness analysis.

Gastroenterology. 2004 Jun;126(7):1721-32.

Primary care office

Visit for motility testing

2nd visitto discuss

resultsDiagnosis!

Motility specialist referral (tertiary care)

GI referral Diagnosis!Motility testing

No local motility testing available

Walk down the OTC aisle

One procedure at a time

TCAs

9 FDA-approved IBS and CIC drugs

Dietician visits

Psychiatry referrals

Second opinions and repeated tests

ER visits, hospitalizations, and frustration

https://www.niddk.nih.gov/health-information/health-statistics/digestive-diseases

Peery, et al. Burden and Cost of Gastrointestinal, Liver, and Pancreatic Diseases in the United States: Update 2018. Gastroenterology. 2019 Jan; 156(1): 254–272.e11.

Reality check

$1,000 to $5,000average per patient

annuallyin wasted healthcare costs

(+ out-of-pocket costs, missed work, and missed family time)

Primary care office

GI referral

Diagnosis!Direct-access testing

Telemedicine consultative program

Visit for motility testing

2nd visitto discuss

resultsDiagnosis!

Motility specialist referral (tertiary care)

Our roadmap for your Motility Center

How far we have come

0

200

400

600

800

1000

1200

1400

3/1

6

3/1

8

3/2

0

3/2

4

3/2

6

3/3

0

4/1

4/3

4/7

4/9

4/1

3

4/1

5

4/1

7

4/2

1

4/2

3

4/2

7

4/2

9

5/1

5/5

5/7

5/1

1

5/1

3

5/1

5

5/1

9

5/2

1A

pp

oin

tme

nts

per

Day

Telemedicine Appts Telephone Office Visits

Objectives

• Cover the basic terminology

• Healthcare access inequities

• Discuss scheduling challenges and opportunities

• Q&A

What is telemedicine?

Totten AM, McDonagh MS, Wagner JH. The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the

COVID-19 Pandemic. White Paper Commentary. (Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University

under Contract No. 290-2015-00009-I). AHRQ Publication No. 20-EHC015. Rockville, MD: Agency for Healthcare Research and Quality.

May 2020

Telemedicine 101

Term Definition

Originating site Where the patient is located

Distant site Where you are located

Facility fee For qualifying originating sites only

Parity law Similar reimbursement for in-person and

telemedicine visits

Telemedicine 101

Term Definition

Synchronous care Real-time care over audio or video

Asynchronous care

(store-and-forward)

Provider-to-provider consults

Not in real time (i.e. email, photos)

Ensure equitable access to telemedicine

Nouri, et al. Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic. NEJM Catalyst. May 4, 2020.

Broadband penetration in rural America

Fewer than 10% of physicians practice in rural communities…

…where 25% of Americans live

But it takes more than bandwidth

1. Licensing restrictions

2. Reimbursement policies on “qualifying originating sites”

3. Incentives for AMCs for tele-education

Drake, et al. The Limitations of Poor Broadband Internet Access for Telemedicine Use in Rural America: An Observational Study. Ann Int Med. 2019 Sep 3;171(5):382-384.

Struminger, et al. Leveraging Telehealth to Improve Health Care Access in Rural America: It Takes More Than Bandwidth. 2019 Sep 3;171(5):376-377.

Health system-created barriers

• Requiring patient portal use

• Inadequate interpreter access

• Inadequate planning for

technical/internet access challenges

Patient barriers

• No access to electrical outlet

• Living in a group setting

• No internet

• Poor digital and health literacy

Don’t require patient portal

Interpreter access

Test visits, video tutorials, shifting staff roles

Advance planning (social work)

Advance planning (social work)

Advocate for expanded broadband access

Video tutorials, shifting staff roles

A learning process for everyone

Nouri, et al. Addressing Equity in Telemedicine for Chronic Disease Management During the Covid-19 Pandemic. NEJM Catalyst. May 4, 2020.

How do I transition my schedule?

• Start small• One or two visits end-of-day

• Short weekend/after-hours session

• Longer visits

• Expect technology hiccups

• Your practice manager as champion

Shah E, Amann S, Karlitz J. ACG Practice Management Toolbox: Essential Guide to Telemedicine in Clinical Practice: EASY STEPS TO RAPID DEPLOYMENT. April 2020.

What types of visits do I need?

1. Telehealth (E/M) (real-time video)

2. Telephone calls (audio only)

3. In-person

Shah E, Amann S, Karlitz J. ACG Practice Management Toolbox: Essential Guide to Telemedicine in Clinical Practice: EASY STEPS TO RAPID DEPLOYMENT. April 2020.

How do I create a scheduling process?

1) Identify priority patients for telehealth

2) Educate patients using a script

3) Convert patients to telehealth

4) Visit by telehealth

…but have a back-up plan

My telemedicine lifehack is…

Organize your scheduling workflow

Resources

• Shah E, Amann S, Karlitz J. The Time Is Now: A Guide to Sustainable Telemedicine During COVID-19 and Beyond. Am J Gastroenterol. Am J Gastroenterol. 2020 Jul 16:10.14309/ajg.0000000000000767. Epub ahead of print.

https://journals.lww.com/ajg/Citation/9000/The_Time_Is_Now__A_Guide_to_Sustainable.99228.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382421/

• ACG Practice Management ToolboxEssential Guide to Telemedicine in Clinical Practice: EASY STEPS TO RAPID DEPLOYMENT

http://webfiles.gi.org/docs/Toolbox/Essential_Guide_to_Telemedicine_in_Clinical_Practice.pdf

Gastrointestinal Motility, Esophageal, and Swallowing Disorders Center

Richard Rothstein, MD

Rosemarie Addante

MBA, MPAS, PA-C

Emily Sieglinger,

MSN, APRN

Jessica Salwen-Deremer,

PhD

GI Behavioral Health

Catherine Giguere-Rich,

RD, LD

GI Dietician

Jamie Sanchez,

MSN, APRN

Michael Curley, MD

Advanced Motility Fellowship

Program Director

Eric Shah, MD, MBA

Center Director

GI Motility Lab

Carol Greeley, RN

Elizabeth Pelletier, RN

Eridana Harder, RN

GI Clinic Nurses

Kathy Del Giudice, RN

Eridana Harder, RN

Tammy Wilson, RN

Scheduling

Mariah Connolly

Shari McBride

Elizabeth Arruda

https://www.dartmouth-hitchcock.org/gi/center-gastrointestinal-motility.html

28Saving Lives. Protecting Americans.

Your Telemedicine Questions,

Answered

Please submit your questions through the Q&A box