Telemedicine Team Research Articles

Telemedicine With Wearable Technologies in Patients Undergoing Hematopoietic Cell Transplantation and Chimeric Antigen Receptor T-Cell Therapy (TEL-HEMATO Study): Prospective Noninterventional Single-Center Study.

Patients with hematological malignancies receiving hematopoietic cell transplantation (HCT) or chimeric antigen receptor (CAR) T-cell therapy are at risk of developing serious clinical complications after discharge. The aim of the TEL-HEMATO study was to improve our telehealth platform for the follow-up of patients undergoing HCT or CAR T-cell therapy during the first 3 months after discharge with the addition of wearable devices. Eleven patients who received autologous (n=2) or allogeneic (n=5) HCT or CAR T-cell therapy (n=4) for hematological malignancies were screened from November 2022 to July 2023. Two patients discontinued the study after enrollment. The telehealth platform consisted of the daily collection of vital signs, physical symptoms, and quality of life assessment up to 3 months after hospital discharge. Each patient received a clinically validated smartwatch (ScanWatch) and a digital thermometer, and a dedicated smartphone app was used to collect these data. Daily revision of the data was performed through a web-based platform by a hematologist or a nurse specialized in HCT and CAR T-cell therapy. Vital signs measured through ScanWatch were successfully collected with medium/high adherence: heart rate was recorded in 8/9 (89%) patients, oxygen saturation and daily steps were recorded in 9/9 (100%) patients, and sleeping hours were recorded in 7/9 (78%) patients. However, temperature recorded manually by the patients was associated with lower compliance, which was recorded in 5/9 (55%) patients. Overall, 5/9 (55%) patients reported clinical symptoms in the app. Quality of life assessment was completed by 8/9 (89%) patients at study enrollment, which decreased to 3/9 (33%) at the end of the third month. Usability was considered acceptable through ratings provided on the System Usability Scale. However, technological issues were reported by the patients. While the addition of wearable devices to a telehealth clinical platform could have potentially synergic benefits for HCT and CAR T-cell therapy patient monitoring, noncomplete automation of the platform and the absence of a dedicated telemedicine team still represent major limitations to be overcome. This is especially true in our real-life setting where the target population generally comprises patients of older age with a low digital education level.

#2933 Quality of care in patients after kidney transplantation with or without telemedicine

Abstract Background and Aims Patients after transplantation require special attention to avoid complications. This includes trained medical doctors but also adherent patients and the integration of other health provider. eHealth products have the potential to improve medical care further. Therefore, we established a telemedicine module in addition to the standard care, which is ongoing since 2019. Patients receive a smartphone app to provide vital signs, confirm the intake of medication and have access to their laboratory values, current medication plan and a medication alert. A telemedicine team values the incoming data and acts if needed (www.maccs-projekt.de). In this study, we want to evaluate how satisfied patients are with telemedicine compared to patients receiving standard care only. Method This is a monocentric and prospective cross-sectional study including a set of questionnaires. We have a positive decision of ethics committee at our center. The study started 2020 and is still ongoing. We ask patients with appointments at our center for participation. If a signed consent is available, patients receive a set of questionnaires. We choose the ZAPA (https://www.kbv.de/media/sp/ZAP_Fragebogen_Englisch.pdf) and ZUF-8 (https://gfqg.de/forschung/assessment/zuf-8), both validated questionnaires, to evaluate the quality of care. Results Demographic data: To date 247 patients participate, 156 (63.2%) with additional telemedicine and 91 (36.8%) as control (68% male). Median age is 57 years (±13.59 years). The youngest participant in the study is 21 years old, and the oldest is 85 years old, resulting in an age range of 64 years. In this population, the data indicate the following primary causes for transplantation: IgA Nephropathy (18.1%), ADPKD/Polycystic Kidney Disease (16.5%), unknown aetiology (8.6%), Chronic Glomerulonephritis (6.6%), and Focal Segmental Glomerulosclerosis (4.1%). Collectively, these conditions account for 53.9% of the underlying diseases leading to transplantation in this cohort. All patients are kidney recipients, 24 patients (9.7%) received a second kidney transplant, while only three patients (1.2%) received three kidneys. Nine patients (3.6%) had a mono pancreas transplantation, three patients (1.2%) received two pancreas and one patient (4%) had three pancreas transplantations. Two patients (8%) received a liver transplantation. The median after kidney transplantation is eleven years (± 9.4 years). The maximum of a functioning kidney is currently 39 years. Questionnaires: The ZAP evaluates the satisfaction of patients with their outpatient care centers. The questionnaire has five categories measuring various aspects of medical care (scale 0 to 100 points, higher values indicate greater satisfaction). The results are shown in Table 1. In average 94.7 to 96.8% of patients participated on this test. The questionnaire ZUF-8 evaluates the satisfaction of patients with the current care (every kind of care can be estimated). ZUF-8 includes eight questions and has a range of eight to 32 points. Higher sums indicate better satisfaction. The telemedicine group had a mean of 28.6 points (±3.2 points) and the control group a mean of 28.8 points (±3.4 points). Conclusion All over, patients are highly satisfied with the standard care after transplantation at our center. Patients with access to telemedicine seem to benefit from help regarding organization of their treatment plan. The data indicate trend to better doctor-patient interaction and cooperation of the doctor to support patients, although testing for significance could not rule out the null hypothesis. As the trial is still ongoing, we plan further evaluations with more participants.

HOW TO IMPLEMENT TELEMEDICINE IN A HEALTHCARE TRUST: THE "TEELEMEBII" STRATEGY

Abstract In this abstract we describe the “TEELEMEBII" strategy adopted by Healthcare Trust Bergamo Est to allow Telemedicine‘s development and to encourage a new healthcare managment model (the results obtained in terms of telemedicine processes activated are riported in a dedicated abstract). The “TEELEMEBII" strategy is composed of 7 steps (Figure 1): T: Top–down The Strategic Management analyses the feasibility of the project. If successful, a Manager with technical skills in the field of telemedicine and managerial competencies is appointed. In some cases, it is possible to set up a small group of professionals. E: Experiences The Manager, or the working group, performs a mapping of existing telemedicine experiences in the company. E: Experts While analysing experiences, the Manager identifies the professionals who already have expertise in the telemedicine field. This phase aims to identify a multidisciplinary Team composed of physicians, nurses, clerks, IT–technicians, management engineer etc., that is proposed to the Strategic Management. LE: LEgitimacy The Strategic Management analyses the proposal and the Constitution of the Telemedicine Team is legitimized through a formal act with the appointment of a Coordinator, the members and the adoption of a regulation. The organizational model of the Team is of a matrix type (Figure 2). ME: MEthod Once established, the Team defines a working method, a common language and specific tools for the organization of activities. B: Bottom–up The Team meets health professionals, explaining the aims of telemedicine and showing fields of application. The Team welcomes proposals from professionals themselves, following a bottom–up logic. For each new emerging project, a Working Group is created (see Figure 2). Adopting the logic of process analysis, the group maps the ordinary process at first, useful to effectively design the activities in telemedicine. It is composed of a member of the Telemedicine Team, with the role of Manager, and professionals who are directly involved in the project to be activated. II: Implementation of the HybrId model The model presented is Hybrid: the Strategic Direction legitimizes the activity of the Telemedicine Team and the Working Groups, while from below the requests made by the Operational Units are evaluated by the Team, which periodically reports them to the Strategic Direction for approval. The Telemedicine Team Coordinator is the interface between the two levels.

Satellite-Linked Remote Physiologic Monitoring During Simulated Rural Ground Ambulance and Rotor Wing Transports

Telemedicine and remote monitoring are rapidly gaining momentum in health care, including in-home and postdischarge monitoring. However, remote monitoring for telemedicine teams and receiving medical centers is yet to reach emergency medical services. When transporting a critically ill patient, continuous vital sign monitoring may be helpful to enhance receiving center collaboration and change care delivery before arrival when necessary. Our primary objective was to demonstrate successful transmission and reception of real-time physiologic summary data to a hospital base station during ambulance transport using a low-energy Bluetooth wireless wearable device linked to iridium satellite communications. We completed our proof-of-concept study on 2 simulated ground ambulance transports and 1 helicopter flight in rural areas surrounding Rochester, Minnesota. Each simulated transport used Mayo Clinic–developed wearable devices paired one-to-one with a physiologic communication kit. Electrocardiographic and photoplethysmographic waveforms were processed on the wearables every 5 minutes, with vital sign data generated and transmitted to an iridium satellite and relayed to a base station network–protected computer and mobile application with real-time display of summary and location. Data and geolocation were tracked in real time with a mobile application during the simulated transport, and summary data packets were saved on Mayo Clinic servers. During the 3 simulated rural transports, all (n=7; 100%) wearables successfully captured, recorded, and transmitted raw waveform physiologic signals. All devices transmitted successfully via the iridium satellite to the base station network–protected computer and mobile application. In all, 106 (69%) of 154 transmissions were successfully processed. Our project demonstrated successful remote monitoring of physiologic vital signs during transport in rural, low–cellular signal areas. The use of live remote monitoring should be explored to understand its utility in practice and outcomes.

Medical student perceptions and attitudes related to interprofessional collaboration at a student-run free clinic

Many medical universities have student-run free clinics that enable trainees to obtain hands-on clinical experience with underserved populations. This study takes place at one such clinic based at a multidisciplinary health sciences institution in the midwestern U.S. As part of a federally funded program, the research team conducted a survey of the clinic's student volunteers over a 6-month period. Students were queried about their experiences working in the clinic, including perceptions of collaboration with other student volunteers, satisfaction with shared decision-making, confidence with delivering care in various formats (including telehealth), and experiences working on interprofessional teams. Results indicated that overall, students reported a high degree of collaboration within the clinic and expressed confidence working in teams. Moreover, more experienced students reported greater satisfaction with the collaboration among team members, as well as more confidence with working as a member of a team, as compared to first-year students. Students who volunteered at the clinic more frequently also reported greater confidence working as part of a telemedicine team, as compared to students who spent fewer days staffing the clinic. This research can inform institutional efforts to improve the quality of interprofessional education and experiential learning for future physicians and other healthcare professionals.

Use of a Telemedicine Team to Improve Guideline-Based Antibiotic Prescribing

Assessing the impact of a virtual antibiotic team (VAT) on appropriateness of antibiotic prescribing behavior of older care physicians, regarding urinary tract (UTI), respiratory tract (RTI), and skin and soft tissue infections (SSTI), in residents of long-term care facilities (LTCF). Before-after trial; introduction of a VAT consisting of a clinical microbiologist, older care physician, and a pharmacist. Eight LTCFs in Amsterdam, the Netherlands. The VAT was introduced on April 1, 2019. Meetings were held via weekly teleconferencing. VAT advised about treatment indication, antibiotic choice, and additional diagnostics. Data were retrospectively extracted from resident files regarding infection episodes for which antibiotics had been prescribed during 12months before (period I) and 11months after VAT introduction (period II). Appropriateness of antibiotic prescriptions was assessed using national guidelines and an algorithm developed for antimicrobial stewardship in nursing homes. Antibiotic prescription rates per 100 person-years (py) were estimated and compared between periods using incidence rate ratio (IRR) with 95% confidence intervals (CIs). Proportions of appropriate antibiotic prescriptions were compared between periods using the chi-squared test. A total of 524 infection episodes for which antibiotics were prescribed were identified: 284 in period I and 240 in period II. Antibiotic prescription rates before VAT introduction were 73 per 100 py in period I and decreased to 68 in period II (IRR 0.9, 95% CI 0.8-1.1). Of all prescriptions, 23.9% were assessed as appropriate during period I, which increased to 40.4% in period II (P < .001). Appropriate antibiotic use increased after VAT introduction for RTI (12.5% to 48.2%, P < .001) and SSTI (47.5% to 74.3%, P= .02) but remained similar for UTI (23.5% to 28.8%, P= .29). After implementation of VAT in LTCFs, appropriate antibiotic use increased significantly overall, and for RTI and SSTI particularly. Improving prescribing behavior regarding UTI might need extra strategies.

Description of telepharmacy services by emergency medicine pharmacists.

PurposeUtilization of telemedicine and telepharmacy services has become increasingly popular, as specifically noted during the coronavirus disease 2019 (COVID-19) pandemic. This article describes the implementation of and services provided by emergency medicine pharmacists (EMPs) as part of a telemedicine team in the emergency department (ED).SummaryThis report describes the telemedicine and telepharmacy services provided to EDs in the Mayo Clinic Health System from the Mayo Clinic Rochester ED. Telepharmacy services provided by EMPs started in 2018. EMPs cover telepharmacy calls as part of their shift within the ED in Rochester. Recommendations and interventions are documented in the electronic medical record. A retrospective review evaluated interventions provided from November 18, 2018, through November 10, 2020. Baseline patient demographics, as well as the type and number of interventions provided by EMPs, hospital site, and time spent on the interventions, were collected. Telepharmacy consults could include multiple interventions and be classified as more than one type of intervention. During this time period, 24 pharmacists worked in the ED and were able to provide telepharmacy services. There were 279 consults included in this study, with 435 interventions. Most of the calls came from critical access hospitals (48.7%). The most common types of interventions documented were medication selection and dosing (n = 238), antimicrobials (n = 141), monitoring and follow-up (n = 65), discharge (n = 56), drug information (n = 55), and allergy review (n = 50).ConclusionTelepharmacy services can provide increased access to emergency medicine specialty pharmacists in areas that would not otherwise have these services.

Commentary on “Remote Advance Care Planning in the Emergency Department During COVID-19 Disaster: Program Development and Initial Evaluation”

Commentary on “Remote Advance Care Planning in the Emergency Department During COVID-19 Disaster: Program Development and Initial Evaluation”

Manifestaciones orales asociadas a SARS-COV-2: Revisión de la literatura

Objective: Identify the main oral manifestations associated with COVID19 and describe their location in the oral cavity. Methods: The literature search was conducted in PubMed, Medline, LILACS, LIVIVO, Web of Science, and SciELO. The following words were searched for: oral mucosa, oral mucosa lesion, oral manifestations, COVID-19, and SARS-CoV-2.&nbsp; Duplicate articles were eliminated, and the pieces were shortlisted. Finally, inclusion and exclusion criteria were applied. Results: This study included 47 articles. The main oral manifestations in patients with COVID-19 are taste disorders, xerostomia, ulcers, vesicles, and others located in different areas of the oral mucosa. Conclusions More studies are needed to determine the potential oral etiopathogenesis of SARS-CoV-2. Moreover, dentists play a significant role in the multidisciplinary and telemedicine team.

Remote patient monitoring after cardiac surgery: The utility of a novel telemedicine system.

ObjectiveWe examined cardiac surgery patients who underwent monitoring of postoperative vital parameters using medical monitoring devices which transferred data to a mobile application and a web‐based software.MethodsFrom November 2017 to November 2020, a total of 2340 patients were enrolled in the remote patient monitoring system after undergoing cardiac surgery. The medical devices recorded vital parameters, such as blood pressure, pulse rate, saturation, body temperature, blood glucose, and electrocardiography were measured via the Health Monitor DakikApp and Holter ECG DakikApp devices which reported data to web‐based software and a mobile application (DakikApp Mobile Systems, Remscheid, Germany). During the follow‐up period, patients were contacted daily through text and voice messages, and video conferences. Remote Medical Evaluations (RMEs) concerning patients' medical states were performed. Medication reminders, daily treatment were communicated to the patients with the DakikApp Mobile Systems Software.ResultsDuring a mean follow‐up period of 78.9 ± 107.1 (10–395) days, a total of 135,786 patient contacts were recorded (782 video conferences, 2805 voice messaging, and 132,199 text correspondence). The number of RMEs handled by the Telemedicine Team was 79,560. A total of 105,335 vital parameter measurements were performed and 5024 hospital application requests (6.3% per RME) were addressed successfully and hospitalization was avoided. A total of 144 (6.1%) potentially life‐threatening complications were found to have been diagnosed early using the Telemedicine System.ConclusionRemote Patient Monitoring Systems combined with professional medical devices are feasible, effective, and safe for the purpose of improving postoperative outcomes.

MO105TELEMEDICAL SURVEILLANCE AND OPTIMIZED TREATMENT OF BLOOD PRESSURE IN KIDNEY TRANSPLANT RECIPIENTS

Abstract Background and Aims Patients with chronic kidney disease suffer often from cardiovascular diseases, especially high blood pressure and its complications such as stroke and heart attack. After kidney transplantation, this condition persists and can in addition harm the graft. However, outpatient care surveillance is not ideal to treat high blood pressure sufficiently. mHealth solutions such as remote vital signs seem to have the potential to fill in this gap. Method To optimize the monitoring of kidney transplant recipients (KTR), the MACCS (Medical Assistant for Chronic Care Solution)-project offers participants an intensified control of home-measured vital signs via a smartphone app. Additionally, well-being and medical adherence can be forwarded. A telemedicine team reviews daily incoming data and takes action, if necessary. A self-programed telemedicine dashboard visualizes the data. KTR receive their updated medication plan and medical support. The pilot phase of project started in February 2020 and is ongoing. A randomized controlled trial will start in March 2021. The concept sticks to General Data Protection Regulation (GDPR) of European Union. Results Currently, 335 KTR participate in the project with 26 (7.76%) dropouts since beginning. Including the 26 dropouts, we received in total 15 973 blood pressure (BP) values (mmHg) (systolic BP [SBP] mean 128.56, standard deviation [SD] ±103.7, maximum (max) 220, minimum (min) 60; diastolic BP [DBP] mean 78.51, SD ±9.97, max 120, min 60) and 27 481 heart rate (HR) values in beats per minutes (bpm) (mean 70, SD ±14, max 200, min 40). For 278 times, an adaption of antihypertensive therapy took place. In total, 170/335 KTR were hospitalized, which made up for 338 hospitalizations (1.99 cases per patient, max 6, min 1), which led to 3 8547 days in hospital (mean 9.34, SD ±11.43, max 89, min 1). In 331 cases, the diagnosis (main or secondary diagnosis) was related to hypertension, and 196 cases the diagnosis may be a hypertension-related complication, e.g. myocardial infarct. Evaluation regarding significance is in process and requires further data. Conclusion mHealth solutions including remote vital signs and telemedicine personnel for regular evaluation have the potential to optimize blood pressure treatment. Acute onset of hypertensive crisis can be handled sufficiently at home and thus reduce treatment at emergency rooms. Since severe complications of high blood pressure levels manifest after years, long-term results are required to conduct conclusions.

An observational study of postoperative handoff standardization failures

BackgroundPatient handoffs from an operating room (OR) to an intensive care unit (ICU) require precise coordination among surgical, anesthesia, and critical care teams. Although several standardized handoff strategies have been developed, their sustainability remains is poor. Little is known regarding factors that impede handoff standardization. PurposeOur objectives are three-fold: (1) highlight compliance failures with standardized handoffs; (2) identify factors contributing to compliance failures; and (3) develop guidelines for sustainable handoff interventions and processes. MethodsWe used ethnographic data collection methods—general observations, handoff shadowing, and semi-structured clinician interviews—with 84 participants from OR, ICU, and telemedicine teams at a large academic medical center. We conducted thematic analysis supported by inductive and deductive coding using the Systems Engineering Initiative for Patient Safety (SEIPS) framework. ResultsPost-operative handoffs can be characterized into four phases: pre-transfer preparation, transfer and setup, report preparation and delivery, and post-transfer care. We identified compliance failures with standardized handoff protocols and associated risk factors within the OR-ICU work system including limited teamwork, absence of handoff-specific tools, and poor clinician buy-in. To improve handoffs, clinicians provided suggestions for developing collaborative Electronic Health Record (EHR)-integrated handoff tools and re-engineering the handoff process. ConclusionsCompliance failures are prevalent in all handoff phases, leading to poor adherence with standardization. We propose theoretically grounded guidelines for designing "flexibly standardized" bundled handoff interventions for ensuring care continuity in OR to ICU transitions of care.

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform.

The MACCS (Medical Assistant for Chronic Care Service) platform enables secure sharing of key medical information between patients after kidney transplantation and physicians. Patients provide information such as vital signs, well-being, and medication intake via smartphone apps. The information is transferred directly into a database and electronic health record at the kidney transplant center, which is used for routine patient care and research. Physicians can send an updated medication plan and laboratory data directly to the patient app via this secure platform. Other features of the app are medical messages and video consultations. Consequently, the patient is better-informed, and self-management is facilitated. In addition, the transplant center and the patient's local nephrologist automatically exchange notes, medical reports, laboratory values, and medication data via the platform. A telemedicine team reviews all incoming data on a dashboard and takes action, if necessary. Tools to identify patients at risk for complications are under development. The platform exchanges data via a standardized secure interface (Health Level 7 (HL7), Fast Healthcare Interoperability Resources (FHIR)). The standardized data exchange based on HL7 FHIR guarantees interoperability with other eHealth solutions and allows rapid scalability to other chronic diseases. The underlying data protection concept is in concordance with the latest European General Data Protection Regulation. Enrollment started in February 2020, and 131 kidney transplant recipients are actively participating as of July 2020. Two large German health insurance companies are currently funding the telemedicine services of the project. The deployment for other chronic kidney diseases and solid organ transplant recipients is planned. In conclusion, the platform is designed to enable home monitoring and automatic data exchange, empower patients, reduce hospitalizations, and improve adherence, and outcomes after kidney transplantation.

Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program

BackgroundAs telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.S. Department of Veterans Affairs, a virtual (distributed) hub of stroke specialists throughout the country provides 24/7 consultations nationwide. We examined how these specialists adapted to distributed teamwork, and we identified cohesion-related factors in program development and support.MethodsWe studied the virtual hub of stroke specialists employed by the NTSP. Semi-structured, confidential interviews with stroke specialists in the virtual hub were recorded and transcribed. We explored the extent to which these specialists had developed a sense of shared identity and team cohesion, and we identified factors in this development. Using a qualitative approach with constant comparison methods, two researchers coded each interview transcript independently using a shared codebook. We used matrix displays to identify themes, with special attention to team cohesion, communication, trust, and satisfaction.ResultsOf 13 specialists with at least 8 months of NTSP practice, 12 completed interviews; 7 had previously practiced in telestroke programs in other healthcare systems. Interviewees reported high levels of trust and team cohesion, sometimes even more with their virtual colleagues than with co-located colleagues. Factors facilitating perceived team cohesion included a weekly case conference call, a sense of transparency in discussing challenges, engagement in NTSP development tasks, and support from the NTSP leadership. Although lack of in-person contact was associated with lower cohesion, annual in-person NTSP meetings helped mitigate this issue. Despite technical challenges in establishing a new telehealth system within existing national infrastructure, providers reported high levels of satisfaction with the NTSP.ConclusionA virtual telestroke hub can provide a sense of team cohesion among stroke specialists at a level comparable with a standard co-located practice. Engaging in transparent discussion of challenging cases, reviewing new clinical evidence, and contributing to program improvements may promote cohesion in distributed telemedicine teams.

Retrospective evaluation of regional telemedicine team meetings for multiple sclerosis (MS) patients: Experience from the Caen MS expert center in Normandy, France.

Multiple sclerosis (MS) is a demyelinating disease requiring multidisciplinary care coordination. Recent development of diagnosis criteria and disease modifying treatments have encouraged the setup of regional team meetings by MS expert centers, known as CRC Sep, to improve the quality of care provided to patients with complex cases. The CRC Sep in Caen initiated regional telemedicine meetings named Télé-SEP, operating since 2016. The objective of this study was to evaluate the Télé-SEP used by neurologists, on MS patient care management in Normandy. An internal ex-itinere evaluation was conducted with a retrospective descriptive observational study from July 2016 to June 2018. The Télé-SEP meetings were organized with 41 neurologists using a regional telemedicine platform (Therap-e). Data were collected from online records and a declarative voluntary survey. Twenty indicators were classified in the categories: volume of activity, clinical profile, quality and impact. Fifteen meetings were organized with a median of 13 senior neurologists. One hundred forty MS cases were discussed and there was a 33% increase in the second year of Télé-SEP. Median patient age was 44 years with a 72-month median length of disease. Most patient cases required second-line treatment. Relapsing remitting MS was diagnosed in 51.4% of cases. Télé-SEP satisfaction rate was 4.5/5 and 96% of neurologists applied the medical decisions and recommendations given in the meetings. Without Télé-SEP, 54.5% of patients would have been referred to a physical expert consultation in the CRC Sep. This study showed the feasibility and relevance of regional telemedicine team meetings for MS cases in the Normandy region.

Changes in Health Care Following COVID-19

Changes in Health Care Following COVID-19

Best Practices for Medical Photography in Blood and Marrow Transplant (BMT) Long-Term Follow-up (LTFU) Telemedicine

Topic Significance & Study Purpose/Background/Rationale BMT survivors have complex follow-up needs including treatment of chronic Graft vs Host Disease (cGVHD). After the first 100 days, most care is provided in community settings. Our LTFU program supports greater than 6,000 survivors and their community providers via telemedicine, an on-site clinic and ongoing research. The use of photography in telemedicine allows LTFU to remotely assist patients who would otherwise need to travel a distance to the BMT center and prioritizes the most urgent cases for in-person evaluation. Photography is a useful tool for cGVHD affecting skin, oral, and joint/fascia, both for initial diagnosis and assessment of response to treatment. Education is essential to ensure patients and providers capture key diagnostic features in quality photos. Methods, Intervention, & Analysis LTFU clinic nurses take medical photos prior to BMT service discharge to establish a baseline, as well as with every LTFU visit. When patients or community providers contact LTFU to request consultation, they are asked to securely email photos to LTFU. Photos are saved in a private database filed by patient name and date. Photos are reviewed by the LTFU telemedicine team in rounds and compared to prior dates. Recently developed educational pamphlets and an instructional video are located on the LTFU website, providing detailed instructions for medical photography of skin, range of motion, and oral cavity. Photos of classic cGVHD signs are used in education materials for patients and providers. Findings & Interpretation A comprehensive photography program for LTFU patients should be based on best practices and be responsive to technology changes and process improvements. Standardized processes, consistent verbal and written communication, and concern for security of patient photos ensure the foundation for a successful photography program. Initial evaluations of process improvements to the photography program have been favorable. Discussion & Implications Continued access to LTFU experts is critical for community BMT survivors. The BMT center's photography program allows for improved diagnosis of cGVHD, reveals physical changes over time, and informs the triage process for scheduling patient visits on-site. Newer technologies may become available for digital file transfer to increase efficiency. Currently only still photographs are used, but looking ahead, LTFU is exploring videography or livestreamed physical assessments.

Novel Use of a Nurse-Led Telemedicine Team in Acute Stroke: A Retrospective Review of the Impact on a Regional Health Care System

IntroductionDespite the increasing incidence of acute ischemic stroke in the United States, many health care facilities remain unprepared to manage patients with acute stroke, including the administration of intravenous alteplase (recombinant tissue plasminogen activator [rTPA]). This has led to an opportunity for telemedicine systems to facilitate these evaluations and acute medical stroke treatment decisions. However, even telemedicine systems can fail to provide timely evaluation and management of the patient with acute stroke. The purpose of this retrospective study was to compare stroke outcome metrics pre- and postimplementation of a hybrid, local nurse-led “stroke-responder” telemedicine system. MethodsA retrospective chart review was performed on 21 patients at a regional community hospital between the years of 2014 and 2016. Data were collected pre- and postimplementation of a local stroke-responder system. Outcomes obtained included door-to-alert time, door-to-computerized tomography (CT) time, door-to-rtPA order time, and door-to-rtPA bolus dose administration time. Outcomes were compared among years. ResultsBetween 2014 and 2016, 21 charts were reviewed. Decreased mean times were observed for all metrics. The mean time for door-to-alert decreased from 21.19 to 5.84 minutes (P = 0.021), door-to-CT from 29.9 to 12.2 minutes (P = 0.022), door-to-rtPA order 88.4 to 53 minutes (P = 0.021), and door-to-rtPA administration from 106.94 to 64.65 minutes (P = 0.001). ConclusionIn an acute stroke telemedicine system, implementation of a local nurse-led “stroke responder” system resulted in significantly decreased acute stroke metrics for a community hospital within a regional hospital system.

Sustainable Telemedicine: Designing and Building Infrastructure to Support a Comprehensive Telemedicine Practice.

Telemedicine services in medical institutions are often developed in isolation of one another and not as part of a comprehensive telemedicine program. The Center for Connected Care is the administrative home for a broad range of telehealth services at Mayo Clinic. This article speaks of real-time video services, referenced as telemedicine throughout. This article discusses how a large healthcare system designed and built the infrastructure to support a comprehensive telemedicine practice. Based on analysis of existing services, Mayo Clinic developed a multifaceted operational plan that addressed high-priority areas and outlined clear roles and responsibilities of the Center for Connected Care and that of the clinical departments. The plan set priorities and a direction that would lead to long-term success. The plan articulated the governing and operational infrastructure necessary to support telemedicine by defining the role of the Center for Connected Care as the owner of core administrative operations and the role of the clinical departments as the owners of clinical telemedicine services. Additional opportunities were identified to develop product selection processes, implementation services, and staffing models that would be applied to ensure successful telemedicine deployment. The telemedicine team within the Center for Connected Care completed 45 business cases resulting in 54 implementations. The standardization of core products along with key operational offerings around implementation services, and the establishment of a 24/7 support model resulted in improved provider satisfaction and fewer reported technical issues. The foundation for long-term scalability and growth was developed by centralizing operations of telemedicine services, implementing sustainable processes, employing dedicated qualified personnel, and deploying robust products.

Pilot of a Home Telehealth Platform in a Pediatric OPAT Program

BackgroundPatients discharged with outpatient parenteral or prolonged oral antibiotic (OPAT) require monitoring to ensure optimal clinical outcomes. Advances in technology have allowed novel approaches for clinical interactions. We sought to develop a new home telehealth platform for a subsection of pediatric OPAT patients.MethodsWe used an existing infrastructure developed by our hospital telemedicine program to pilot the electronic home visit. A process was established to create a virtual connection at a pre-designated time using a HIPPA-secured web-based platform. Clinic staff performed a pre-visit technology check. Electronic Medical Record (EMR) scheduling platforms were created and the parent was coached on how to download and execute the necessary software. A virtual clinic was established between provider and family. Documentation occurred in the EMR with specific language and modifier codes for billing accuracy identified by the telemedicine team. Patients were selected based on medical complexity and travel time greater than 2 hours to our institution.ResultsTwo pediatric OPAT patients completed the pilot in Spring 2017 for treatment of 1) CLABSI with retained line and 2) chronic ulcer with osteomyelitis. Three visits between the OPAT ID provider, located in her office, and the patient, located at home, were successfully piloted with video and voice. A routine clinic visit was conducted with a parent-driven physical exam. A clinical note was documented in the EMR with specific telemedicine templates. This platform also allowed for multi-disciplinary visits with a hospitalist and home health nurse to address a central line related issue with ID provider present. Total time for each visit was under 20 minutes.ConclusionWe were able to demonstrate feasibility and functionality of this novel platform to conduct a billable OPAT clinic visit in a patient’s home. Health system infrastructure was a necessary and vital component to execution of the virtual clinic. Specific patient groups may benefit from this provider-patient interface. The use of telemedicine in OPAT may serve as a new platform for improving provider efficiency, lowering health system costs, and achieving greater patient satisfaction.Disclosures All authors: No reported disclosures.