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Expanding Telemedicine to medical homes for
comprehensive care delivery.
Roshni Kulkarni, Colleen Vallad–Hix, Laura
Carlson and Rebecca Malouin
Michigan State University
,

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Telemedicine Definition
The use of medical information exchanged from one site
to another via electronic communications to improve
patients’ health status.
American Telemedicine Association www.ata.org

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Telemedicine and Telehealth
Telemedicine: Billable Interactive Clinical
Services
• Telehealth: Includes
• Telemedicine + other services:
 Tele-education
 Disaster and terrorism response
 Regional health information sharing
 Research and administration
TeTelemedicine
(Billable)
Telehealth
Homeland Security
Public Health
Consume
r
Education
Administration
Research
Health
Professional
Education
Regional Health
Information
Sharing
http://www.caltrc.org/general-information/what-difference-between-
telemedicine-and-telehealth
Burke B. M.D U of Arkansas; umtrc.org

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Background Information
Patients with hemophilia live an average of 58 miles from
their Hemophilia Treatment Center (HTC) ~20% live >90
miles from their HTC making comprehensive care delivery a
challenge. CDC

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The Need for Telemedicine
• Augments services, improves access
• Reduces travel time &costs
• Alleviate Physician shortage
• Provide specialist access to rural populations
• Increase physician utilization
• Widen pool of available physicians
• Deliver Comprehensive care
• Types of Telemedicine:
• Store and forward
• Real Time

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Synchronous/Real-Time Interactive
Telemedicine
• Requires presence of both parties at the same
time and a communications link to allow a real-
time interaction.
• Uses HIPAA secure Video Conferencing +
teledevices
• (HIPAA = Health Insurance Portability and Accountability Act. Privacy act
to protect individuals health information)

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Tele-Comprehensive Care Delivery
1990 Marquette outreach clinics
1998 Telemedicine (TM) Marquette,
2011 Traverse City Telemedicine
2013: Combined outreach and Telemedicine Services
for a patient with severe hemophilia in a hospital
2014: TM follow up of above patient at a PCP office

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Tele-comprehensive Care Follow up
8
2 weeks
4 months
5 months
1 month

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• Upper Great Lakes Family
health Center (UGLFHC)
Portage located in
Houghton/Hancock in
Keweenaw Peninsula
• Population: 53,461
• Home to MI Technological
University ( Michigan Tech)

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MSU/NHPCC grant
• Goals
–Increase access to family-centered and
culturally competent specialty care
–Increase the number of patients with bleeding
disorders that are timely and accurately
diagnosed and referred for specialty care

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MSU/NHPCC Grant: Objectives
• Objectives
– To understand the feasibility of telemedicine between specialists and
medical home for children with bleeding disorders by specialists, medical
homes, and families
– To assess the acceptability by patients, families, primary care physicians,
primary care staff, specialist physicians, and specialist staff
– To assess the cost of telemedicine visits versus traditional visits from the
societal perspective

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Measures addressed : HP2020 and NHPCC
• Enhancing comprehensive care services
• Increasing coordination with medical homes
• Improving access to comprehensive care services, including
telemedicine and assisting patients in obtaining insurance coverage
• Referral to genetic services as needed
• Enhancing access and services to underserved populations
• BDBS-15: Increasing the number of people with severe VWD who are
diagnosed before age 21

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Measurable Objectives
• Objective I: To understand the feasibility of telemedicine between specialists and
medical home for children with bleeding disorders by specialists, medical
homes, and families.
• Objective 2: To assess the acceptability of telemedicine between specialists and
medical home for children with bleeding disorders by patients, families, primary
care physicians, primary care staff, specialist physicians, and specialist staff.
• Objective 3: To assess the cost of telemedicine visits versus traditional visits
from the societal perspective

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Outcomes
• Understanding of feasibility of implementing TM between specialists and medical
homes for patients with bleeding and clotting disorders
• Understanding of patient/family, physician, and staff acceptance of TM for care
for patients with bleeding and clotting disorders
• Cost estimates for relative cost of TM versus traditional visits to specialist for
patients with bleeding and clotting disorders
• Improved access to comprehensive and coordinated care for patients with
bleeding and clotting disorders in medical homes
• Improve access to comprehensive services for patients with bleeding and clotting
disorders from specialists
• Increased number of families involved in planning, evaluation, and
implementation activities
• Improved data tracking in the ATHN database

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Evaluation Plan: Rebecca Malouin
Background:
-PhD and MPH in public health from Johns Hopkins University and a MS in
epidemiology from MSU
-Assistant professor: Family medicine and pediatrics and Human Development
-Associate Chair for research in family medicine
-Expert in evaluation of health services interventions using mixed methods,
focusing on new models of care in primary care
-Previous to position at MSU, first newborn screening/genetics epidemiologist at
MI state health department (MDCH)
-Published two recent monographs for AAP on evaluation of pediatric medical
home initiatives as well as best practices in family-centered care

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Telemedicine
*Standardized using SNOMED CT, LOINC and First DataBank’s NDDF, Core data element
Telemedicine Clinics
Time period June 2014- Oct 2014
Clinic Dates June 10th, July 8th, Aug 5th, Sept. 23, Oct 21
No. of patients 9
Telemedicine visits 10
Age range 2 weeks -16 years
Frequency of TM Clinics 1 per month
No of patients seen/clinic 1-2
Videoconferencing system Vidyo

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Telemedicine Stats
*Standardized using SNOMED CT, LOINC and First DataBank’s NDDF, Core data element
Telemedicine Clinics Portage Clinic
Types of disorders Others tested
Epistaxis/possible Ehlers Danlos
Von Willebrand disease (VWD*) Parents and 2 sibs
Cervical lymphadenopathy
Spherocytosis
Iron def anemia/ hemoglobinopathy Family members (thal intermedia)
VWD* * Same patient
Menorrhagia, anemia, abn coag profile
Menorrhagia, abn coag profile
VWD Mother, sibling and maternal uncle

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Costs of Telemedicine at Portage
Demographic Parameters Portage
Average distance that patients travelled 33.4 (2.4 -42.3 ) miles
Distance patients lived from local center. N=7
patients with 8 visits
30-50 miles : 2 patients
10-15 miles ; 2 patients
<10 miles ; 3 patients
Distance for Patients to MSU (RT) 960 -1000 miles RT (460-503 miles OW)
Commercial airline ticket cost $1142 to $1184
Driving time 9 hrs OW or 18 hrs RT
Time lost from work 20 hrs ( 9 hrs travel time OW)
Physician cost saving $3850
One Way= OW, Round Trip = RT

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Patient Cost Items
Portage Clinic
Houghton
Patient comes
to MSU, East
Lansing
Patient to attend clinic at MSU- Driving costs
(Driving, meals and lodging)
$615
Time lost from work (RT) hours @ $33/hr wage 20 hr x$33=$660
Total with driving $1275
If patient flies ( $1184 airline costs + travel time =
16 hours @$33/hr = 528
$1712
Meals and Lodging $175 /night S175
Total with flying $1887
Patient
attends clinic
locally at
Portage
Patient to attend clinic at local facility (Driving) $18.7
Time lost from work (RT) @$33/hr wage 3 hrs x$33= $99
Total- attending local clinic $117

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Physician /Comp care team costs
Physician/team location Costs
Physician costs to do clinic at
Portage
Physician cost for outreach clinic $2266
Time lost from work 14 hrs @
$150/hour
14 hrs X $150
=$2100
Total cost to conduct clinic at
Portage
$4366
Comprehensive care team Cost for 3 team members ~$12,000
Physician/comp team cost of
Telemedicine (TM) clinic at MSU
Physician cost for TM clinics $00.00
Time lost from work 0hrs

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Site visit to Portage MI : Sept 25th 2014
• MSU staff: Physician, Nurse and Social worker
• Dr. Rebecca Malouin joined by Teleconference using Vidyo
• Transportation: MDOT plane
• Combined with drive to Iron River to see a sever hemophilia baby, and a clinic
next day at Marquette General Hospital.
• Portage staff met: Dr. Vallad-Hix, Adult hematologist, pediatrician, nurses, IT
staff, Lab specialist
• Meeting to inform about NHPCC grant aims/methodology
• Discussed barriers, needs
• Educational material distributed
• Local pediatric patient with cancer in follow up phase seen

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Happy Family!!

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Nursing Roles
1. Grant coordinator
2. Clinic Nurse
3. Clinic coordinator
4. Follow up with billing

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Grant Coordinator
Assisted with pieces of the grant
• Budget/ Justification
• Monitoring Grant Budget and Account
• Writing Standard Operating Procedures for clinical and office staff
• Site Visit
• Staff Education
• Coordination
• Outreach staff – Scheduling, Lab templates
• Physicians – Both Portage Health and MSU
• Information Technology (IT) – Both Portage Health and MSU

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Clinic Nurse Role
• Gather all referral information from outreach location, review with Dr.
Kulkarni, order any other testing desired prior to visit
• Nursing assessments with telemedicine patients
• Patient teaching and education
• Clinic follow up needs:
• Further patient and family testing desired after evaluation
• Coordination with Portage staff for follow up
• Assist in scheduling return visits if needed
• Documentation and data- making sure both institutions have visit
documentation
www.google.com

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Practical considerations: Key Points
• Pre Clinic Visit: Communication and Coordination
• Scheduling telemedicine clinic visit dates and times
• Exchange of information for billing and review prior to visit
• Obtain further testing prior to visit if desired
• Inform IT on both ends for testing if needed

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Day of Visit:
• Send the link for the telemedicine visit to IT, physicians and other
staff necessary for visit
• Open up the telemedicine room 15 minutes prior to the
scheduled visit
• Obtain all signed forms, Release of information, Consents, Etc.
• Conduct the visit
• Hematologist, PCP, nurse & staff, HTC Nurse ,Social worker
• History, Physical examination with PCP and discussion and
education with patient about possible diagnosis and
treatment
• Nursing and Social Work visit with patient and family
PCP= Primary Care Physician
HTC= Hemophilia Treatment Center

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Post Visit: Follow-up
• PCP and HTC exchange office visit notes and test results
• Place in ATHN Clinical Manager
• HTC nurse will follow up with PCP office for further test results
• Order Stimate® for Stimate® trials – sent directly to PCP
along with protocol, Stimate® information, fluid restrictions
and education materials.
• PCP office will schedule and carry out trials and patient
education
PCP= Primary Care Physician
HTC= Hemophilia Treatment Center

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Nursing Obstacles
• Portage Health restructuring –
• Difficult communication and coordination due to staffing changes in the
PCP office and management group
• Difficulty in finding time for
• Nursing assessment
• Having the appropriate staff present for needed portions of the visit.
Finding the right mix to allow the PCP to continue to carry out clinic
while CBCD staff are seeing the consultation
• Follow up: what office does what?

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Social Work: Responsibilities
•Review referral information from UGLFHC
•Ensure patient has sufficient insurance
•Contact patient, parent/guardian, UGLFHC for clarification
•Participate in telemedicine sessions
•Provide follow-up to all entities for local & state referrals
•Provide educational materials to staff, patient, families
•Consult on coordination plans with health department, schools and primary
care physician office
Upper Great Lakes Family health Center (UGLFHC)

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Early Obstacles
•Incomplete referral packets received from UGLFHC
•Patients, parent(s) & guardian(s) expressed concerns about medical care and
provider coordination
•Lack of UGLFHC Staff knowledge of social work availability
•Lack of UGLFHC Staff knowledge of telemedicine process
•Technology barriers at both sites for staff
•Duplication of services to patients
-Example: Patient had both HTC and UGLFHC providing referrals to
health department and completed two CSHCS Diagnostic Evaluation requests
Upper Great Lakes Family health Center (UGLFHC)
Children's Special Health Care Services (CSHCS)

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Coordination
•Understood need to not duplicate patient services and put a procedure in place
for referrals (i.e. CSHCS/Health Dept.)
•Participated in Houghton meeting for CBCD & UGLFHC staff
•Toured Portage Hospital and UGLFHC facility
•Attended formal presentation & conducted informal discussions with medical,
technical and laboratory staff
•Provided educational resources for UGLFC staff and patients regarding bleeding
disorders, school plans & insurance
•Followed up with UGLFHC staff to continue improved coordination of social work
support and patient care

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Evaluation
Rebecca Malouin PhD
Dept. of Pediatrics and Family
Practice
MSU

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Measurable Objectives
• To understand the feasibility of telemedicine between specialists and
medical home for children with bleeding disorders by specialists,
medical homes, and families
• To assess the acceptability by patients, families, primary care
physicians, primary care staff, specialist physicians, and specialist
staff
• To assess the cost of telemedicine visits versus traditional visits from
the societal perspective

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Feasibility Questions
• Is medical home based on TM feasible?
• What types of services are appropriately delivered via TM at
various sites?
• What serendipitous applications emerge?
• How many patients can be seen? Unable to be seen?
• What kinds of technical issues arose?
• What kinds of new patients were seen?
• How many and what types of laboratory diagnostic tests were
performed?

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Feasibility Methods
• Measures extracted from the EMR, ATHN dataset and
surveys
• List of measures tracked
• Phone calls tracked from patients and providers
• Patients enrolled through project will be documented
in ATHN dataset, HDS and CDC surveillance project

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Acceptability Questions
• How do providers (hematologists, primary care physicians, center
staff, medical home staff) perceive this application in regard to
satisfaction and perceived quality of care?
• How do patients and/or caregivers perceive this application in
regard to satisfaction and perceived quality of care?

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Acceptability Methods
• Key informant interviews with physician and staff during first and
last period of the project
• Key informant interviews with families within one month of first
telemedicine visit
• Interviews audio recorded, transcribed, coded by multiple
coders, analyzed etc.

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Acceptability by Staff at Primary Care Site
• Accustomed to protocols; would benefit from telemedicine protocol for
hematology consults
• Protocol would assist with better organization for family participation in
visit as well
• Would be helpful to have information for families as to what to expect
from the consult
• Importance of planned visits and keeping to the calendar due to
difficulty in scheduling in a busy pediatric practice
• Stressed demand for telemedicine consults by specialist in rural areas
– becoming more common and so much more convenient for families

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Acceptability by Families
• Would be helpful to be given written information about what
to expect from the consult and specific information on why
the consult is necessary
• Would be helpful to have primary care physician in room at
all times to help explain what the consulting physician is
sawing (due to both accent and content)
• Having so many of the team members on the video on the
specialist side is confusing to the families, especially if
multiple people are talking at once. Would be preferable to
speak to each one at a time, if necessary.

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Acceptability by Families contd…..
• The roles of each of the people on the specialist side were not
clear. It was not clear to the family why a social worker was present.
• Would be helpful to be given clear options (multiple) at the end of
the visit with potential outcomes if each option is not followed.
• Family had extensive experience with telemedicine consults with
other specialists and appreciated the availability to see a specialist
in this format.