Telehealth, Telemedicine

1. Lisa Gwynn, DO, MBA, FAAP, CPE
Assistant Professor, Clinical Pediatrics
Medical Director, Pediatric Mobile Clinic
University of Miami Miller School of Medicine
Establishing a Multi-Specialty Clinic via
Telemedicine in a Mobile Clinic Setting

2. Objectives
• Illustrate the innovative telehealth modalities of service
delivery in a mobile clinic setting.
• Gain insight into the challenges in establishing a
successful specialty clinic in a mobile setting and how
to overcome them.
• Identify strategies for establishing and sustaining a
successful telehealth program.
I have no relevant financial relationships with commercial interests and no
conflicts of interest exist.

3. To provide comprehensive primary health
care services free-of-charge to children
most in need, specifically those with no
access or limited access to health care.
University of Miami
Pediatric Mobile Clinic
Mission

4. The Program
•Established in 1992 as a response to hurricane Andrew
•Has provided medical care to uninsured children in need for 22
years
•Services provided include well-visits, sports physicals,
immunizations, management of chronic conditions, urgent care,
mental health, and social work
•Staffed by Board Certified Pediatrician, 2 ARNP’s, Social
Worker/Mental Health Counselor, Clinical Psychologist,
Driver/Registrar, Interpreter, Program Coordinator, Patient
Access Representative

5. 1987: After a year of visiting New
York City’s welfare hotels
and researching the needs of the
City’s homeless, Irwin Redlener, MD,
and singer/songwriter Paul Simon
launched the New York Children’s
Health Project. Paul Simon donates
funds to purchase and equip a
mobile medical unit to bring health
care to homeless and other children
who do not have access to care in
New York City.

9. •The unit is fully equipped to
handle medical emergencies
and has three complete exam
rooms, a laboratory and a small
waiting area for parents.

10. Services
• Comprehensive primary care
• School Physicals (Medical/Sports)
• Immunizations
• Management of acute and chronic illnesses
• Laboratory testing
• Prescriptions
• Hearing and Vision screenings
• Mental Health Counseling
• Social work services
• Case management
• Psychology services
• Nutritional assessment
• Weight monitoring
• Referrals to subspecialty and dental care
• Referrals to legal services

11. Communities We Serve
•The UMPMC visits community centers, churches,
and schools in the most impoverished areas of
Miami-Dade County
•Areas include: Homestead, Florida City, Little Haiti,
Sweetwater, Miami Beach, West Kendall, Little
Havana
•In addition, the unit participates in community
health fairs

12. Our Patient Population
• Children from all over the world
• Many are undocumented
• Some are in 5-year waiting period for Florida Medicaid
• High percentage from Latin America – entitlements depend on country
of origin
• Recent increase in children from Central America
• 25% of patients from Haiti

13. 2013 Statistics
•Over 3000 clinical visits
•Nearly 650 mental health visits
•Over 3000 immunizations administered
•68% Hispanic; 25% Haitian; 5% African
American; 2% Other

14. Assessing the Need…

16. Compliance

17. State of the Uninsured…
Florida has the nation’s second-highest rate of uninsured
residents younger than 65 — a total of about 3.8 million
people, or about 25 percent of the state’s population,
including more than 500,000 younger than 19, according
to U.S. Census data.
And out of all 67 counties in Florida, Miami-Dade has the
second-highest rate of uninsured for the same age group
at 34.4 percent, trailing only Hendry County, with an
uninsured rate of 35 percent or about 11,500 residents.
Miami-Dade also is home to the largest number of
residents without health insurance in the state younger
than 65 — an estimated 744,000 people.
The Miami Herald, August 29, 2013 (US Census)

18. The Solution:
Bring specialty care to the patients
through telehealth technologies.

19. How do we get there?
• Needs assessment
• Equipment
• Connectivity
• Technical support
• Staffing/Workflow
• Clinical care coordination
• Funding

20. Needs of the community
• Patient population served
• Services needed
• Specialists available
 Participating specialists
 What if needs referral for in-person visit

21. Equipment
• Choose best option for services to be provided and setting in
which the consultations will be taking place

22. Equipment Options
• Depends on services offered
• Space restrictions
• Examples:
 Stationary carts
 Mobile carts - robots
 iPhones/iPads – Facetime
 Portable teleclinic
 Laptop with webcam

23. Equipment on Our Mobile Unit
Portable TeleClinic is a self-contained telemedicine system that has the combined
functionality of a desktop telemedicine solution and a mobile cart, and is completely
transportable. Packaged in an industrial case, this system includes an integrated
tablet PC, CAT5 connection and industrial grade powered USB ports and can be
customized with encounter management software and medical devices for a clinical
exam.
This “pack-and-go” system is perfect for healthcare applications that require clinical
telemedicine equipment that they can carry into medical situations and/or set up in
mobile clinics with limited space
AMD

24. Equipment Options
Software
• “Agnes Interactive” - Once installed, the web-based software aggregates
clinical device diagnostics, vital signs data, encounter documents and live
video conferencing and then securely exchanges that information in real-
time to the remote consulting physician.
• Videoconferencing services – Is Skype HIPAA compliant?
FUZE

25. Connectivity
• Wireless carrier – mapping of 4G reception areas
• 4G LTE
• Cradlepoint router
• Antenna on mobile unit
• Information transmitted wireless must be encrypted and
HIPAA compliant (WPA2 Enterprise security)

26. Technical Support
• The MOST challenging piece of the puzzle
• Recommend bringing on support from the beginning
• Equipment support, network support, EMR integration
• Challenges in an academic setting
• This CAN be done. If your support personnel claim that it
can’t, you have the wrong support team!!

27. Staffing/Workflow
• Identify staffing needs – number of people; skill sets
• Frequency of telehealth clinics – daily; monthly; etc…
• Training – depends on type of services offered (operation of
medical devices, video camera, etc…
• Utilization of existing staff
• How to integrate into regular clinic operations
• Our model

28. Arrival
• Equipment set up and connectivity established with specialist
• Patient arrival/check-in
• Clinical staff member takes patient into room where consult
takes place
Consult
• Specialist first interviews patient then clinic staff member
operates the medical device with guidance from the specialist
• Diagnosis and disposition of patient
• Follow-up

30. Clinical Care Coordination
• Identify target patients
• Referral process
• Pre-clinical chart review
• Patient disposition
 Prescriptions
 Follow-up
 Referrals
• Integration into EMR

31. Funding
• Ability to bill for services varies by State

32. Regulation
Telemedicine is regulated by State Medical Boards and face complex
regulatory challenges and patient safety concerns in adapting
regulations and standards historically intended for the in-person
provision of medical care to new delivery models involving
telemedicine technologies, including but not limited to:
Determining when a physician-patient relationship is established
Assuring privacy of patient data
Guaranteeing proper evaluation and treatment of the patient
Limiting the prescribing and dispensing of certain medications

33. Regulation
Federation of Medical Boards released guidelines in
April 2014
“Model Policy for the Appropriate Use of Telemedicine Technologies
in the Practice Of Medicine”
• Place the welfare of patients first
• Maintain acceptable and appropriate standards of practice
• Adhere to recognized ethical codes governing the medical profession
• Properly supervise non-physician clinicians
• Protect patient confidentiality

34. Funded through grant support from CHF/Verizon Foundation June 2013
Objective 1: Develop a system to link uninsured children to
specialists via telehealth
Activities Quarter 1 - Installation/Training
1. Install on MMC necessary technological equipment
2. Train staff
3. Conduct connectivity tests at various clinic sites
4. Secure agreements with participating subspecialists
5. Develop scheduling system for telehealth appointments with existing EHR
Our Telehealth Project

35. Telehealth
Objective 2: Increase children's access to subspeciality care
Activities (quarter 2)
Pilot telehealth services on MMC
1. Trial with one specialty service
2. Trial with second specialty service
3. Trial with both during month
Activities (quarter 3)
Pilot additional specialty services on MMC
1. Trial with third specialty service
2. Trial with fourth specialty service
3. Trial with both during month (one day for each)

36. Telehealth
Activities (quarter 4)
Process evaluation of pilot
1. Determine best delivery model of services
2. Evaluation to include feedback from patients, staff and specialists
2. Implement plan
3.
3.

37. The Future…
• Currently offering Cardiology, Dermatology, Nutrition
• Adding Mental Health, Endocrinology
• Obesity Intervention/Technology Grant Verizon
• Let’s Talk Medical Translation Project with JMH Residents

38. Thank you!
lgwynn@med.miami.edu