Sharing Expertise through Telemedicine
Intermountain Healthcare has embarked on a remarkable journey of extending its telemedicine consultation program to infectious disease (ID) conditions, helping sixteen hospitals in its system and beyond.
1. Give us an overview of this program and its structure.
When I joined Intermountain Healthcare a year ago, the telehealth and telemedicine program was well-established, especially for critical care. We provided our services, on an individual- as well as a population-level on antibiotic usage and disease condition monitoring, to all providers within the Intermountain system as well as outside of it. These services are of great value for small community hospitals, in Utah and Idaho that do not have access to resources like sub-specialist physicians, ICUs, and databases. In 2015, one of our providers fielded approximately 1000 phone calls from small community hospitals, in a 13 to 16 month period, addressing and answering their infectious disease needs. The demand was evident, and consequently, we finished the roll-out of our program to the sixteen hospitals. Any physician, mid-level provider, nursing staff, or administrator concerned about an individual case or a rising trend in infectious diseases can request our expertise.
The whole concept of the stewardship team is to stay centrally supported through subject matter expertise and using centralized data monitoring with local empowerment
For individual patients, the consultation is provided at three levels. The first one is in the form of telephone advice, which we provide 24/7 for the entire year and is usually activated for regular and immediate use of infectious disease expertise. Secondly, since we have access to system-wide EHR and EMR data, we can review a chart and give more robust and comprehensive consultation to individuals or small hospitals that request it, in a more formal way known as e-Consult. The third and most comprehensive input is in the form of a full-fledged telemedicine visit to the patient using two-way audiovisual (AV) technology, where we go into the room electronically and talk to the patient. This is essentially a full consultation to provide expertise for a very specific condition and help the provider, who needs assistance for infectious disease condition management.
At a population level, we use a proprietary software known as VigiLanz, which is tied to our EHR, monitoring all the providers in our system to track antimicrobial stewardship (AMS) progress and specific ID conditions. These include any case where a microorganism is involved. For instance, in the first ten months of this program, we monitored system-wide bloodstream infection and found it to account for 40 to 45 percent of all ID cases.
2. With this program, what is Intermountain’s role in the larger scheme of AMS?
There was a nation-wide push to combat the overuse of antibiotics and antimicrobial agents after the White House announced the National Action Plan in 2014. The Center for Disease Control (CDC) followed it up with guidelines and recommendations; the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) chimed in with their own set of requirements and conditions for participation. Each facility in the Intermountain Healthcare system has a team ideally led by a physician, a pharmacist, officials from patient safety, quality management, and depending on the size of the hospital, nursing staff and administrative leadership. The guidelines all recommend having an ID physician and ID pharmacist on the team as well.
Along with my ID pharmacist, I fill in those shoes and connect with all sixteen AMS teams electronically in each of their quarterly meetings, apart from trying to meet each of them physically at least once a year. With our access to population-level data from CDC’s National Healthcare Safety Network, VigiLanze and our integrated system-wide EHR, we provide the AMS teams centralized data that they can act upon individually, to help reduce the inappropriate use of antibiotics, decreasing associated illness and treatment predicaments.
We developed a monthly program known as Education in Antimicrobial Stewardship and Idea Exchange (EASIE). All the individuals and teams collaborate on WebEx, and we address and educate them on a different topic on ID management and AMS every month, with the second half focused on sharing ideas with their peer and us. The whole concept of the stewardship team is to stay centrally supported through subject matter expertise, using centralized data monitoring with local empowerment to make decisions on what they want to work on based on the data that we can show them.
To that end, these initiatives have been rewarding, giving us an opportunity to do mass education using technology in addition to facilitating interactions between these AMS teams that we helped develop and are a part of.
3. How has this program been received by physicians and patients, and where do you intend to proceed with it?
I shall answer the second part first. There have been three new developments that impact our telehealth program greatly:
a. We switched to a new EHR that allows us to extract data more effectively, making us more efficient in delivering the care to a broader number of providers and patients. This gives a significant uplift to our direct program known as Connect Care, which allows patients to request a provider electronically and have a two-way telemedicine visit in front of their laptops in their homes.
b. The EHR is also well-integrated with VigiLanz and other antibiotic use-monitoring systems, making the data instantly available to those platforms. This is a part of the macro-trend of system interconnectivity we see in the healthcare sector.
c. Last year, we expanded our telemedicine role to other specialties like wound care and oncology health programs. We have also grown geographically, reaching small community providers even outside of Intermountain Healthcare system.
These developments are more of a ‘pull’ reaction rather than ‘push’ initiatives, based on the acceptance surveys of patients, physicians, nurses, pharmacists, and administrators. The mean age of the patients surveyed was 63 years, and to our delight, we scored in the high 90s across the board, even running 100s in few critical areas. It is also amazing how providers have made use of our telemedicine-based expertise to create better patient experiences. We have had teary-eyed senior citizens, who have never used a smartphone, exclaim that this technology and service should be brought everywhere. We help those patients stay with their families and communities instead of being transferred to large hospitals due to a lack of resources or expertise in that specialty. I believe that human element in the results has been truly rewarding to us.