1. Genetic Telemedicine from the Medical
College of Georgia/ Georgia Health
Sciences University
1995 to the Present
David Flannery, MD
Department of Pediatrics
Medical College of Georgia of GHSU

2. Disclosure
• I am an uncompensated member of the Board of
Directors of the Georgia Partnership for
Telehealth, a not-for-profit 501c3 corporation

3. Medical Geneticists
• Physicians trained to diagnose and treat genetic disorders
such as Neurofibromatosis, Marfan Syndrome, Down
Syndrome, and PKU,
– and provide genetic counseling to patients and families
• There are only 1400 MD Clinical Medical Geneticists in the US
• There is a geographic misdistribution of Clinical Medical
Geneticists in all states
• As a result, almost all Clinical Genetics programs in the US
provide services to patients in distant sites by conducting
outreach clinics where they travel by auto to distant sites and
see patients and families
– This is very time-consuming, expensive, inefficient , and creates
delays in access to care

4. Georgia, is the largest state in land area east of the
Mississippi. We have few concentrated areas of
specialty medical care

5. Original State Telemedicine System
was called GSAMS

6. Medical College of Georgia Telemedicine
Genetic Services – The Early Years
• In 1995 we offered acute or urgent consults on the
GSAMS telemedicine network
• First telemedicine consult was on July 4, to Albany,GA on a baby
who we diagnosed with Pfeiffer syndrome, a severe dwarfism. We
were able to send orders for DNA testing for the disorder, and then
were able to test the parents and determine that the disorder was not
inherited, and would not recur in future children
• Despite our offering availability there was little uptake

8. Time for a New Idea
• We then tried a new model - regularly-scheduled
“virtual clinic” using Telemedicine, with Children’s
Medical Services in Waycross, GA, in December
1995, which was successful for several years
– The Telemedicine Clinic was supplemental to
our Bi-monthly in-person Outreach clinic in
Waycross
This was successful
- many patients were seen on telemedicine, and
we freed up appointment slots for our on-site
outreach clinic, decreasing the time to next
appointment at our outreach clinic to 2 months

9. Challenges with GSAMS Telemedicine
• High start-up costs for facilities
• High monthly line maintenance fees (~$2600/mo)
• Distant sites began dropping out in the late 90’s

10. GSAMS’ decline and Waycross’
response
• The Southeast Health Unit (Health Department) in
Waycross was committed to continue
Telemedicine services, and set up a dedicated
system between one of their Health Department
offices and MCG in 2000
– Here is one lesson about “sustainability” of
Telemedicine programs
• This internet-based point-to-point system is still in
active use
• The nurse who was tasked with developing this
system is now well-known to you all:

11. Paula Guy

12. The rest of Georgia languished without
telemedicine genetics

13. Then came the Creation of a New Statewide
Georgia Telemedicine Program in 2005
 The result of Negotiations by Insurance Commissioner
Oxendine regarding Anthem and WellPoint Merger
 Result – Oxendine’s Rural Health Initiative
• $100 million over the next 20 years in rural capital
bonds
• Statewide Telemedicine Program
 $11.5 Million over 3 years
 Transitioned to Not for Profit 501 (3) c -
Georgia Partnership for TeleHealth, December, 2007
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14. GPT – “Open Access”
Network Model
• Creates a web of access points
• Any Presentation Site can connect to any other site
Presentation
Site
Specialty
Center Presentation
Site
Specialty
Presentation Center
Site
Presentation
Site
Specialty
Center

15. Transition to Not for Profit 501 (3) c
Georgia Partnership for TeleHealth, Inc December, 2007
Mission
• Improve and promote the availability and provisioning of
specialized healthcare services in rural and underserved
areas of Georgia.
• Educate and provide training to hospitals and healthcare
facilities that furnish, administer and finance Telemedicine
programs and facilities.
• Reduce the service barriers that exist for patients who live in
rural areas of Georgia at a distance from hospital and other
medical facilities.
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16. Georgia TeleHealth Infrastructure
 Georgia Telemedicine Centralized Scheduling
 Dedicated 800 phone # and staffing to support Program
 Scheduling capabilities for Presentation Sites and Specialty Sites
 Field-Based TM Liaisons
 Regionalized coverage with specific targeted areas
 Division of responsibilities between presentation and specialty sites
 Expanded Reimbursement
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17. 17

18. Current GHSU Genetic Telemedicine
Activity
• Using GPT network
– Expanded to 2 Half-day scheduled clinics per month
• Using Waycross telemedicine hook-up
– 1 half-day per month

19. Current GHSU Genetic Telemedicine
Activity – GaPartnership Network Clinics
– Typically averaging 5 patients seen per session
• No-show rate 0 – 33%
– Multiple distant sites
• i.e., I encounter a patient in a TM room in
Douglas,GA, then switch to a TM site in Valdosta,
and then switch to a site in Hazelhurst, and then
back to Valdosta
– Most patients have developmental delay plus
something else – dysmorphic features, growth
problems, family history
– 75% are New Consultations
– History, Family History, Exam, fax orders for testing
– Diagnosis rate same as on-campus consults

20. Current GHSU Genetic Telemedicine Activity –
Proprietary Waycross Telemedicine Clinic
– Typically 4-6 patients scheduled
• Typically 25 -50% no-show rate
– Most patients are follow-up patients
• Recent clinic:
– Down syndrome +FAS,
– Tuberous sclerosis,
– Beckwith-Wiedemann,
– Dysmorphic unknown syndrome

21. GHSU Genetic Telemedicine –
Revenue Metrics
Summary of Activity for Telemedicine Services
FY11 Financial Activity through May for the Population Defined by Telemedicine List
Zero balance accounts only
All Locations
Date of Service Charges Payments Contractual Bad Debt Collections Bad Debt Other NCR II
FYTD 2011 through May $XXXXXXX $XXXXXX $XXXXXX $0.00 $0.00 100.0%
NCR = “Net Collection Rate” – i.e., what percent of the allowable
Payment did you receive
Collections average $125.34 per encounter

22. Lessons from More than a Decade of
Telemedicine Genetics
• Genetics can be done by telemedicine
– Quality of the interaction with patients and families is
good
– Image quality is good for dysmorphology
• Patients are satisfied
– Formally assessed several years ago
• Show rates vary
– seem to correlate with the enthusiasm of the
nurse/coordinator at the distant site with regard to
their interaction with the patient being scheduled

23. Up-slanting Palpebral
Able to see minor
Fissures physical variations
(Dysmorphic Features)
http://medgen.genetics.utah.edu/index.html

24. Other Lessons from More than a
Decade of Telemedicine Genetics
• Most patients/families take to TM like ducks to
water,
–BUT
• Some people DO NOT
– And it can be painful and cringe-worthy
• The Consultant can’t know this, but the Physician
and Coordinator at the remote end need to look at
the patient/family and reflect on their suitability
before making the referral for TM

25. Why has this worked so well for so long?
• Local “champions” for telemedicine in distant site
communities
• Availability of Centralized Scheduling into our
“virtual clinic” sessions
• Open architecture of the network, which allows
hopping from site to site during the “virtual clinic”
session

26. Other Opportunities for Genetic
Telemedicine
• Follow-up of patients with Inborn errors of
Metabolism, like PKU and other disorders
detected by Newborn Screening
– We have experience with this
• TM works fine
– Physician component would be reimbursable
– Would need a waiver for Dieticians to bill for services

27. Genetic Counseling by Telemedicine:
Tremendous Opportunity
• Telemedicine would be good for counseling for:
– Cancer Genetics – Breast, Colon, etc.
– Patients with already diagnosed Mendelian Disorders
– Already diagnosed Multi-factorial disorders
• But, Genetic Counselors are not licensed in the
vast majority of States, and are not recognized by
payers

28. Untapped Opportunities
• “Store-and-Forward “ Telemedicine Consultations
– A great “fit” for Dysmorphology consultations
– Could easily go across State boundaries
• Informally already occurs, even across national
boundaries:
– Skeletal dysplasias listserv
– Every Geneticist who has “expertise” with a particular
syndrome frequently receives inquiries from other
physicians regarding patients
– Probably needs to be formally structured to be able to
meet a definition of “practice of medicine” that would be
recognized by State Medical Boards

29. There are challenges,
BUT - It’s Worth the Effort!
• Improved Access
– Connecting Patients and Families with Genetic
services that they would otherwise not receive
• Decreasing cost of care
– Patient/families’ travel
– Genetic consultants’ travel
– “Green” service – how to calculate?
• Enhanced revenue
– Geneticist avoids lost opportunity encounters at
home institution that would occur while they are on
the road to do outreach clinics
– BECAUSE

30. With Telemedicine,
You Can Be In Two Places At The Same Time !