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
  • Umth for gapth_2.21.14.final.6

    1. 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. 2. I have no conflicts of interest to disclose.
    3. 3. ?
    4. 4. UM TeleHealth is a catalyst for healthcare transformation in Florida.
    5. 5. Access
    6. 6. Convenience
    7. 7. Quality
    8. 8. Cost
    9. 9. Synchronous Real-time interactive Asynchronous Store-and-forward We use 3 operational telehealth systems
    10. 10. Synchronous Real-time interactive Asynchronous Store-and-forward We use 3 operational telehealth systems Hybrid
    11. 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. 12. Approved 2007 2007
    13. 13. Approved 2007 2007 “Based on the history and images provided, my impression is as follows.”
    14. 14. Approved 2007 Endorsed by American Academy of Dermatology 2007 “Based on the history and images provided, my impression is as follows.” 2008
    15. 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. 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. 17. Our strategy: • Contracts • Grants • Advocate for policy change
    18. 18. Dept of Health Children's Medical Services • Teledermatology • Telegenetics • Telenutrition • Telepsychiatry
    19. 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. 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. 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. 22. Eczema herpeticum Generalized herpes simplex infection + atopic dermatitis
    23. 23. Eczema herpeticum Generalized herpes simplex infection + atopic dermatitis Sent to ER for hospitalization with IV acyclovir and antibiotics
    24. 24. Eczema herpeticum Generalized herpes simplex infection + atopic dermatitis Sent to ER for hospitalization with IV acyclovir and antibiotics
    25. 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. 26. Training in telehealth • Dermatology residents • Genetics fellows • Medical students • ARNP and DNP nursing students
    27. 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. 28. Acute teleneurology to hospital emergency departments • Specialists on Call, Inc.
    29. 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. 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. 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. 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. 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. 34. Telemedicine for Trauma, Disaster, and Emergency Management Eds: Latifi R, Poropatich R. Artech House, Boston. 2010
    35. 35. Cutis 88, 213: 2011
    36. 36. Store-and-forward Teledermatology
    37. 37. Nashville Area Oklahoma Area Albuquerque Area MICMAC Pleasant Point, ME Oneida, NY Catawba, SC
    38. 38. 4 yo: 3 days itching, sores hands & stomach
    39. 39. 4 yo: 3 days itching, sores hands & stomach ………Scabies
    40. 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. 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. 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. 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. 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. 45. Ship MD UM Dermatology ConsultantPhotos Consult Form PC PC Internet UM Server S Workflow
    46. 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. 47. Tinea versicolor Alopecia areataContact dermatitis Wart
    48. 48. Candida intertrigoErysepelis Bullous cellulitisLeishmaniasis
    49. 49. “3 day painful rash with vesicles, left trunk. On Acyclovir 800mg every 4 hours. Correct?”
    50. 50. “3 day painful rash with vesicles, left trunk. On Acyclovir 800mg every 4 hours. Correct?” Agree with Herpes zoster and treatment
    51. 51. Rare Diseases Multiple acral reticular histiocytosis Hidradenitis suppurativa Relapsing polychondritis
    52. 52. Oral lesions: Torus palatinus New England Journal of Medicine, April 11, 2013
    53. 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. 54. STAT case: Hand dermatitis, violinist
    55. 55. STAT case: Fever + coryza + rash, R/o Measles
    56. 56. STAT case: Erythema multiforme major
    57. 57. UM TeleHealth is enhancing healthcare in Florida and beyond.
    58. 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

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