AcuteCare Telemedicine Blog


AcuteCare Telemedicine Shares Teleneurology Insights at 2012 GPT Conference

Dr. Matthews Gwynn, Partner, AcuteCare Telemedicine (ACT) delivered a presentation discussing the future of teleneurology in the next decade during the 2012 Georgia Partnership for Telehealth (GPT) Conference at the Ritz-Carlton, Reynolds Plantation in Lake Oconee, GA on Thursday, March 15th.

The conference attracted physicians, nurses, administrators, and other healthcare industry professionals and covered a wide variety of topics related to telehealth, including recent innovations, advocacy and education, policies and regulations, and case studies. GPT’s mission is to improve and promote the availability and provision of specialized healthcare services in rural and underserved parts of Georgia through telehealth technology. Presenters including healthcare network Optum, telecommunications provider USAC, and others addressed a variety of ways to overcome barriers that exist for patients living in rural parts of the state at a distance from medical facilities.

Dr. Gwynn’s presentation, visible in its entirety on the GPT website, was entitled “Beyond tPA: Teleneurology for This Decade.” Dr. Gwynn began by discussing the prevalence of stroke, and covered a brief historical outline of the integration of telemedicine technologies in cutting edge neurological care. He then offered case studies demonstrating the value of teleneurology in creating a higher standard of stroke care in the future. Dr. Gwynn illustrated that teleneurology will not only improve care, but also play a vital role in helping healthcare providers meet changing standards and tightening budgets.

“The partners of ACT truly believe that teleneurology is forging a path through a new frontier in medicine that will ultimately result in better patient care with a lower associated cost,” said Gwynn. “Presenting ACT’s outlook at the GPT Conference was an outstanding opportunity to share our vision with other industry leaders. Both healthcare providers and our patients benefit from this exchange of knowledge.”

For more information about Dr. Gwynn and ACT, visit www.acutecaretelemed.com.

 



The Importance of Recognizing Sleep Disordered Breathing in Patients with Cognitive Dysfunction

Awareness of sleep disorders has increased over the past several years, leading more physicians to appreciate that Obstructive Sleep Apnea (OSA) is an independent risk factor for hypertension, cardiovascular disease and stroke. Although seemingly overlooked, studies as far back as 15 years have also suggested that OSA may be a risk factor for cognitive dysfunction.

When patients present to a neurologist with complaints of cognitive dysfunction, most are screened for potentially reversible causes such as vitamin B12 deficiency, hypothyroidism, undiagnosed/untreated syphilis, or normal pressure hydrocephalus. If all laboratory and imaging studies are normal, these patients are often started on acetylcholinesterase inhibitors, in hopes of slowing down the rate of cognitive decline.  Screening for sleep apnea, however, is often times not performed. As a result, the opportunity to treat an otherwise harmful disorder and potentially reverse cognitive impairment is forfeited.

In 2010, an article was published in the New York Times entitled “When Sleep Apnea Masquerades as Dementia.” A case study was reported: “The woman was only in her 60s but complained that she was having trouble concentrating.” She couldn’t follow a television program or stay focused during a conversation. As he evaluated the woman, the physician asked, as he usually does, how she was sleeping. The woman, who lived alone, hadn’t noticed any problems. Her son, however, had stayed with her the previous night to drive her to the appointment. “She was snoring like a freight train,” he reported.  Overnight sleep testing determined that the woman had obstructive sleep apnea – nightlong interruptions in breathing that reduce oxygen flow to the brain and prevent deep sleep. The interruptions are quite common in older adults, exacerbating – or sometimes mimicking – dementia symptoms. Treated with a CPAP (continuous positive airway pressure) machine her scores on neuropsychological tests eventually climbed back into normal range.

Another recent study published in JAMA, also showed that sleep disordered breathing may contribute to the development of dementia. 298 women 65 years or older and without dementia were enrolled in this study, undergoing overnight polysomnography testing. Those who were found to have sleep disordered breathing were more likely to have developed cognitive impairment or dementia on follow up testing. It is thought that hypoxemia resulting from sleep disordered breathing is responsible. Dr Michael J. Thorpy, director of the Sleep-Wake Disorders Center at the Montefiore Medical Center in the Bronx, NY stated “We used to think that impaired sleep caused cognitive impairment, but this shows that nocturnal hypoxemia plays an important role and this suggests that the cognitive impairment might be partially reversible in some cases.

Although further studies are needed, these findings do stress the importance of screening patients with complaints of cognitive dysfunction for sleep apnea.  Because the large majority of people who develop dementia do so after the age of 65, it would seem imperative to screen younger patients with cognitive complaints for sleep disordered breathing.



Looking Backwards to See Ahead – Part 2: Accountability & Relationships

This is another in a series of blogs chronicling the development of AcuteCare Telemedicine (ACT). Much of this reflection involves lessons learned at 2011’s Annual Meeting of the American Telemedicine Association (ATA). What follows is an amalgam of facts, experience and opinions culled from that fantastic symposium and honed by hindsight. Today’s blog will focus on ACT’s approach to accountability and relationships.

Accountability refers to the promise of optimal healthcare outcomes while maintaining an expected return on investment. Patient and physician satisfaction are cornerstones of accountability, but to depend solely on these measures has become passé. Administrators want measurable financial and clinical outcomes, and to obtain and retain clients, will expect supporting data for all assertions.

One must constantly seek meaningful measures of the services promised; encounter surveys gather data on every patient interaction, regardless of outcome. This data measures service utilization (e.g. stroke vs non-stroke, tPA vs. non-tPA, etc.) and efficiency (e.g. response time, “door to needle” time, etc). Constant focus on patient outcome requires frequent Mordibity & Mortality conferences. This leads to continuing education, reduced miscommunication and shared responsibility. Finally, financial impact (more specifically than simply “satisfaction”) can be obtained with quarterly or annual reviews of year-to-date ICD-10 referenced charges or admissions. However, emotionally powerful patient anecdotes must complement the sterile numbers. It is this human component that provides the raison d’etre, separating telemedicine from any number of telecommunication ventures.

Accountability also extends to the development and maintainance of relationships with ACT’s clients. A client considering telestroke invests significant time and capital and must undergo a fundamental paradigm shift regarding what constitutes optimal patient care. To facilitate this endeavor, a telemedicine service needs to become as integrated as possible into the culture of its remote partners. One cannot afford to simply be the latest technological gimmick, but rather must provide an approachable solution.

Frequent contact is paramount and must not be limited to patient encounters. Not all interaction can take place in the cloud; physical meetings allow remote presence technology to become an alternate mode of communication between colleagues, rather than a proxy for an actual relationship. Communication is the foundation of every meaningful relationship. Listening to the client will uncover their goals and challenges.  The telemedicine service will integrate more fully with a remote partner, helping the client on their terms. This may result in vertical integration with mutually beneficial services including electrophysiology studies, clinical trials, medical directorships, etc.

Horizontal integration may include multiple disciplines such as telestroke, teleICU or telepsychiatry. Ultimately, integration into a client’s business model and culture is crucial for long-term sustainability. ACT assures clients are not simply invested in telemedicine services, but in their relationship with ACT.

 

 



Advances in Telemedicine and Technology Call for Changes in Standardization

Rudimentary forms of health care standardization in the United States can be traced back more than a century. The Joint Commission, for example, began its evolution with an elementary inception in 1910, when Dr. Ernest Codman proposed the “end result system of hospital standardization”. This system was designed to track patient care and outcomes to determine whether treatment was effective. In cases where treatment was unsuccessful, attempts were made to improve patient care. Three years later, the American College of Surgeons (ACS) was formed to promote this standards system, and in 1917, it developed the Minimum Standard for Hospitals. The following, year the ACS began on site hospital inspections, and of the 692 hospitals surveyed, only 89 met the standards set forth by the one page document. After the introduction of an 18 page manual in 1918, hospitals had increased incentive to meet these standards, and by 1950 standard of care had improved tremendously, with more than 3,200 hospitals approved by the ACS.

Needless to say, over the next 60 years, with countless advances in medicine and technology, there have been many changes to the ACA and its manual. The committee now known as The Joint Commission has expanded and upgraded standards in an effort to ensure that health care organizations are providing quality patient care. Although the Joint Commission is one of the most recognized and sought after accreditation programs, several other organizations such as Leapfrog, HealthGrades and Get With The Guidelines have also been formed in an attempt to foster improvement in quality of care throughout health care systems. The decision to seek accreditation by The Joint Commission or any other organization has always been voluntary, but because of its link to Medicare and Medicaid, Joint Commission accreditation has essentially become a default requirement. Because reputation, reimbursement and, most importantly, patient care may at minimum be presumed to be compromised without certification, a health care organization’s failure to achieve accreditation by the Joint Commission may be adversely perceived.

In 2003 The Joint Commission, in collaboration with the American Stroke Association, developed a Primary Stroke Center (PSC) Certification Program. This program was developed to recognize health care centers “that make exceptional efforts to foster better outcomes for stroke care”.  According to The Joint Commission, a PSC “is the best signal to your community that the quality care you provide is effectively managed to meet the unique and specialized care of stroke patients.” Demonstrating compliance with these national standards may help a facility obtain contracts from employers and purchasers concerned with controlling costs and improving productivity. Becoming a PSC has been shown, in one published study, to have increased the administration of IV- TPA to eligible patients 7 fold.

Unfortunately for many hospitals, this level of achievement in stroke care is not possible due to lack of availability of 24/7 neurology coverage. The reality is particularly challenging for smaller, rural hospitals. However, in 2011, the Brain Attack Coalition updated recommendations for PSCs, acknowledging the use of telemedicine as a means to provide remote diagnosis of acute stroke in facilities where this capability would otherwise be unavailable. Hospitals that do not have current PSC certification could use telemedicine services along with physicians that provide 24/7 expert care in acute stroke to become PSC certified or either transfer eligible patients to the closest PSC for IV- TPA administration. The Brain Attack Coalition has also recommended that EMS transport acute stroke patients to the nearest PSC facility, thereby potentially improving patient outcomes and increasing revenue at certified hospitals.

In 1997, The Joint Commission launched “ORYX: The Next Evolution in Accreditation” which incorporated the use of performance measures into the accreditation process. Under this initiative, hospitals had the flexibility to choose which performance measures they would submit for accreditation. This system posed problems in that there were no standard measurements across health care organizations. The Joint Commission has since put in place core measurement sets for which specific, standard accountability measures must be met in order to obtain and maintain accreditation. The initial core measurement sets were designated in 2003 and included Acute MI, Heart Failure and Community Acquired Pneumonia. As of 2011, Stroke has been added to the core measurement sets, giving facilities even more incentive to become Primary Stroke Centers.

Undoubtedly, the standards that have been initiated by the Joint Commission and other accreditation programs have lead to changes and improvement in health care outcomes for all specialties of medicine. Reaching a perfect level of standardization will always be a work in progress, particularly with the rapid advances in technology that have helped medicine evolve more quickly in recent years. As the landscape of medicine and technology continues to change and expand in the future, particularly regarding the management of acute stroke care, it is our expectation that hospitals will continue to strive to adapt to these changes in order to achieve the highest quality of patient care.