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Umth for gapth_2.21.14.final.6

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  • Increased access to primary care and specialty care in rural and urban areas Decreased waiting time for consults, Virtual co-location of scarce specialistsDecreased waiting time for consults, Virtual co-location of scarce specialists
  • Reduced travel for patients and MDs, Less time away from work
  • Earlier diagnosis, Appropriate workup, Timely intervention, Collaborative care, Improved disease management, Improved compliance,
  • Cost avoidance, ED visits, Re-hospitalizations, Improved transportation decision-making, Use of physician extenders, Multisite coverage
  • ATA Board approval 2007, AAD 2008
  • ATA Board approval 2007, AAD 2008
  • ATA Board approval 2007, AAD 2008
  • 2 Family medicine physicians, RNs, MAs, ARNPs
  • Add Nutrition story: 3 girls 2 sisters and a friend getting nutrition group sessions, then only going to school for telenutrition so agreement with students and our nutritionist: go to school or no telenutrition! A double win!
  • UM Psychiatry for in-person visits and inpatient visits
  • 5 yo Haitian F, 3 day periorbital rash with crusted papules and swelling, blisters on palms, hand/wrist eroded papules and trunk with large eczematous plaques
  • 5 yo Haitian F, 3 day periorbital rash with crusted papules and swelling, blisters on palms, hand/wrist eroded papules and trunk with large eczematous plaques
  • 5 yo Haitian F, 3 day periorbital rash with crusted papules and swelling, blisters on palms, hand/wrist eroded papules and trunk with large eczematous plaques
  • 5 yo Haitian F, 3 day periorbital rash with crusted papules and swelling, blisters on palms, hand/wrist eroded papules and trunk with large eczematous plaques
  • Robot
  • Robot
  • 1 slide : guyana sept 09 SoCOm
  • 2010: 75 Indian nations in 29 states
  • Alaska Federal Health Care Access Network started 12/13
  • Alaska Federal Health Care Access Network started 12/13
  • RCL 51/month 38K on 33 ships 27-71, 33yr median. CCL 24/month 33K on 24 ships 24-68, 29yr median
  • Agree with herpes zoster and treatment
  • Itching or burning before vesicles appear: Herpes simplexPain in arm before vesicles appear in a dermatomal distribution: Herpes zoster
  • mucosal involvement, s/p HSV-related Stevens-Johnson syndrome. Check for other mucosal involvement, on genitals, conjunctiva and buccal mucosa

Transcript

  • 1. Anne E. Burdick, MD, MPH Professor of Dermatology Associate Dean for TeleHealth March 20, 2014 University of Miami TeleHealth Enhancing Healthcare for Floridians
  • 2. I have no conflicts of interest to disclose.
  • 3. ?
  • 4. UM TeleHealth is a catalyst for healthcare transformation in Florida.
  • 5. Access
  • 6. Convenience
  • 7. Quality
  • 8. Cost
  • 9. Synchronous Real-time interactive Asynchronous Store-and-forward We use 3 operational telehealth systems
  • 10. Synchronous Real-time interactive Asynchronous Store-and-forward We use 3 operational telehealth systems Hybrid
  • 11. University of Miami TeleHealth •1974: Dr. Jay Sanders, telemedicine in Miami jails •1994: Fellowship at MCG, ATA Board member •1994: Teledermatology for migrant workers, JAMA •1996: Developed American Academy of Dermatology Telemedicine Position Statement •1999: Founded ATA Teledermatology Interest Group
  • 12. Approved 2007 2007
  • 13. Approved 2007 2007 “Based on the history and images provided, my impression is as follows.”
  • 14. Approved 2007 Endorsed by American Academy of Dermatology 2007 “Based on the history and images provided, my impression is as follows.” 2008
  • 15. “Economic Evaluation of Telemedicine: Review of the Literature and Research Guidelines for Benefit–Cost Analysis” Dávalos ME, French MT, Burdick AE, Simmons SC Telemedicine and e-Health 15: 933-948, 2009. 2009 Manuscript of the Year Award
  • 16. Our challenge in Florida: Limited telehealth reimbursement • Medicaid: only Children’s Medical Services, waiver • Medicare: Rural and Health Provider Shortage Areas • No private payers
  • 17. Our strategy: • Contracts • Grants • Advocate for policy change
  • 18. Dept of Health Children's Medical Services • Teledermatology • Telegenetics • Telenutrition • Telepsychiatry
  • 19. Miami-Dade School Telehealth Initiative • 7 North Miami Beach schools: • Elementary, middle and high schools • Staff in school clinics supported by Children’s Health Fund, John T. MacDonald Foundation, AHEC • Equipment from a HRSA grant • UM specialists reimbursed by Verizon Foundation grant • Dermatology by hybrid telemedicine • Endocrinology, nutrition and psychiatry by VTC
  • 20. Miami-Dade School Telehealth Initiative • UM doctor provides primary care onsite and to schools by VTC • RNs, MAs or medical/nursing students present patients • UM specialists: scheduled clinics • Nutrition: onsite + VTC, groups
  • 21. Miami-Dade School Telehealth Initiative Expansion • Awarded an Innovation Grant from Centers for Medicare and Medicaid Services • Booker T. Washington High School added • New services and partners: • Larkin Hospital for telemental health • NOVA SE University for teledentistry
  • 22. Eczema herpeticum Generalized herpes simplex infection + atopic dermatitis
  • 23. Eczema herpeticum Generalized herpes simplex infection + atopic dermatitis Sent to ER for hospitalization with IV acyclovir and antibiotics
  • 24. Eczema herpeticum Generalized herpes simplex infection + atopic dermatitis Sent to ER for hospitalization with IV acyclovir and antibiotics
  • 25. UM pediatric mobile van teleconsultations • Route: Little Haiti, Sweetwater, Homestead • Verizon Foundation grant for specialist reimbursement and 4G network provided • Nutrition, dermatology, cardiology by VTC
  • 26. Training in telehealth • Dermatology residents • Genetics fellows • Medical students • ARNP and DNP nursing students
  • 27. UM TeleHealth: Educating residents in the “Core Competencies” required by American College of Graduate Medical Education • Interpersonal and communication skills • Systems-based practice • Patient care • Practice-based learning and improvement
  • 28. Acute teleneurology to hospital emergency departments • Specialists on Call, Inc.
  • 29. Discharge planning enhancement • Patients transfers from UM Hospital to Miami Jewish Home for the Elderly • Verizon Foundation grant for a Vgo robot • Interactions between nurses, doctors and patients • Goal: to decrease readmissions
  • 30. UM Employee TeleHealth • Employees at a UM satellite clinic 10 miles away • 45-60 minute by car or Metrorail • VTC specialty teleconsults with faculty at the medical campus • Neurology, dermatology, nutrition, cardiology
  • 31. Teletrauma: Ryder Jackson Memorial/University of Miami Trauma Center • Trauma bay resuscitations • ICU rounds, InTouch robot • Air ambulance optimization from Lower Keys Medical Center
  • 32. Teletrauma: Ryder Jackson Memorial/University of Miami Trauma Center • Brazil Olympic team, London • U.S. State Department contract for 24/7 teleconsults for personnel in Iraq + Afghanistan • 16 specialties: • Trauma and orthopedics • Anesthesia, cardiology, dentistry, dermatology, ENT, gynecology, internal medicine, nephrology, ophthalmology, psychiatry, pulmonology, radiology, urology
  • 33. Human assistance and disaster response: UM TeleHealth in Haiti Aerial view of University of Miami Hospital, Port-au-Prince, Haiti.Arrow A is the location of the operating room in the posterior part of the first tent. Jaffer A K et al. Ann Intern Med doi:10.1059/0003-4819-153- 4-201008170-00266 ©2010 by American College of Physicians • Trauma and critical care • Teleradiology • Pediatric subspecialties
  • 34. Telemedicine for Trauma, Disaster, and Emergency Management Eds: Latifi R, Poropatich R. Artech House, Boston. 2010
  • 35. Cutis 88, 213: 2011
  • 36. Store-and-forward Teledermatology
  • 37. Nashville Area Oklahoma Area Albuquerque Area MICMAC Pleasant Point, ME Oneida, NY Catawba, SC
  • 38. 4 yo: 3 days itching, sores hands & stomach
  • 39. 4 yo: 3 days itching, sores hands & stomach ………Scabies
  • 40. UM – Alaska store-forward Teledermatology Alaska’s healthcare challenge: • 49% MDs are primary care physicians, U.S. average is 28% • 59% residents live in medically underserved areas • 48th in doctor : resident ratio • 65% MDs are in Anchorage • Shortages in many specialties
  • 41. UM – Alaska store-forward Teledermatology Alaska’s healthcare challenge: • 49% MDs are primary care physicians, U.S. average is 28% • 59% residents live in medically underserved areas • 48th in doctor : resident ratio • 65% MDs are in Anchorage • Shortages in many specialties UM Teledermatology service, started 12/13 • ARNP at Alaska Native Medical Center, Anchorage • Reviews referrals from 180 community primary care centers in the Alaska Federal Health Care Access Network • Sends selected teledermatology cases to UM
  • 42. UM Cruise Ship Teledermatology • Provides rapid access to University of Miami dermatologists for crew and occasionally guests on ships all over the world • Within 72 hours or 24 hours • Royal Caribbean Cruise Lines since June 2010 • Carnival Cruise Lines since November 2012
  • 43. Teledermatology at Sea • Provides dermatology care for an employee population that’s geographically dispersed • Allows ship’s medical staff to effectively manage their crew’s skin conditions • Reduces onshore dermatology visits • Assists in medical evacuation decisions • Cost avoidance
  • 44. • UM selected Medweb software • Cruise IT teams evaluated software • Username/password assigned to each ship • Introduced service at RCL/CCL conferences • Lab and X-Ray capabilities determined • Additional drugs recommended • MDs and RNs reviewed UM’s online training • Test case submitted by each ship before sending consults Fleetwide Rollout
  • 45. Ship MD UM Dermatology ConsultantPhotos Consult Form PC PC Internet UM Server S Workflow
  • 46. Dermatology at Sea: Special Issues • Limited drug formulary • Challenging to access shoreside dermatologists • Diverse occupations • Off work or “dry” work difficult, no redundant crew • Maximum Medical Improvement • Medical isolation • Medical evacuation
  • 47. Tinea versicolor Alopecia areataContact dermatitis Wart
  • 48. Candida intertrigoErysepelis Bullous cellulitisLeishmaniasis
  • 49. “3 day painful rash with vesicles, left trunk. On Acyclovir 800mg every 4 hours. Correct?”
  • 50. “3 day painful rash with vesicles, left trunk. On Acyclovir 800mg every 4 hours. Correct?” Agree with Herpes zoster and treatment
  • 51. Rare Diseases Multiple acral reticular histiocytosis Hidradenitis suppurativa Relapsing polychondritis
  • 52. Oral lesions: Torus palatinus New England Journal of Medicine, April 11, 2013
  • 53. <5% Consults are referred to a dermatologist Present x 1 month Wart vs. squamous cell cancer vs keratoacanthoma New pigmentation of a single nail Probable melanoma Growing dark dot x 1 year Probable melanoma
  • 54. STAT case: Hand dermatitis, violinist
  • 55. STAT case: Fever + coryza + rash, R/o Measles
  • 56. STAT case: Erythema multiforme major
  • 57. UM TeleHealth is enhancing healthcare in Florida and beyond.
  • 58. Anne E. Burdick, MD, MPH Associate Dean for TeleHealth Professor of Dermatology aburdick@med.miami.edu (305) 243-8252 telehealth.med.miami.edu Thank you