mhs15 sossong slides 9.26.2015...

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Now part of the

The Connected Patient: the Mass General Hospital ExperienceWednesday, November 11th 2015

Sarah Sossong, Director of TeleHealthMassachusetts General Hospital

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INTRODUCTION

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• Introduction to MGH and MGH TeleHealth

• The Connected Patient: The MGH TeleHealth Experience– Differentiate the 4 major domains of the MGH telehealth model

– Identify 5 key challenges addressed by telehealth

– Review real-world applications of telehealth in each of the 4 major domains

– Framework vis-à-vis system goals, participating clinical areas, and potential value for your organization

• What’s Next

• Takeaways

INTRODUCTION

LEARNING OBJECTIVES

INTRODUCTION

MASSACHUSETTS GENERAL HOSPITAL

3rd Oldest General Hospital in the US • Founded in 1811 • Flagship teaching hospital for Harvard Medical School

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Massachusetts General Hospital

1.9 million outpatient/ED visits 999 beds • 48k inpatient admissions

INTRODUCTION

FOUNDATIONS OF TELEHEALTH AT MASS GENERAL

INTRODUCTION

HEALTHCARE – AN UNCERTAIN LANDSCAPE

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Population Health

Episodic Care

INTRODUCTION

MGH & TELEHEALTH – ONE FOOT IN TWO CANOES

THE MASS GENERAL TELEHEATLH EXPERIENCE

USE CASES AND SUPPORTING TECHNOLOGIES

Acute CareAcute Care Post-Acute Care

Post-Acute Care

Outpatient Care

Outpatient Care

Second OpinionSecond Opinion mHealthmHealth

Video Phone Imaging EMR

Prescribing Paging Monitoring Smart Phone Apps

TextMessaging

SocialMedia Email Secure

Messaging


WHERE TO FOCUS

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Real Time “Synchronous” Store and Forward “Asynchronous”

Visit

s(P

rovid

er to

Pati

ent) Virtual Visits eVisits

Video visit between MD and patientFormalized online exchange of medical info between MD & patient (e.g., structured questions, interactive forms)

Cons

ults

(P

rovid

er to

Pro

vider

) Virtual Consults eConsults

Video consult from MD to referring MD(with or without patient)

2nd OpinionsComplex 2nd opinions requested by outside

providers

eConsultsLess complex consults requested by outside

providers

THE MASS GENERAL EXPERIENCE

THE MASS GENERAL TELEMEDICINE MODEL

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THE CONNECTED PATIENT: HAS IT HAD AN IMPACT?

THE MASS GENERAL TELEHEALTH EXPERIENCE

Population Health

Episodic Care


FOCUS AREAS

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FOCUS AREAS – IMPROVING VALUE IN 5 AREAS

1. Urgent Access

2. New Specialty Referrals

3. Chronic Disease Follow‐Up

4. Transitions in Care

5. Patient Engagement


IMPROVING VALUE IN 5 AREAS

1. Urgent Access





MGH (MA)

BWH (MA)

IMPROVING VALUE – NEW SPECIALTY REFERRALS

REAL TIME – VIRTUAL CONSULTS VIA TELESTROKE

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TELESTROKE IMPACT

72 77

138

85 8981

97

122115

101

126

75

Consult Services

•TeleStroke•TeleNeurology•Acute Stroke•Acute Neuro

Launched in 2001

2013‐2014 Volume2800 Cumulative Consults


TELESTROKE IMPACT


VIRTUAL CONSULT CLINICAL AREASDepartments• Brain Tumor • Critical Care• Dermatology • Emergency Department*•Neurology• Pain Management• Pediatrics• Pulmonology• Surgery• Urology

* Exploratory

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IMPROVING VALUE – URGENT ACCESS

MANY OPTIONS!

A Mehrotra, JAMA 2013; July 3: 310



1. Urgent Access






CONTEXTSpecialist visits and referrals to specialists are increasing

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STORE & FORWARD - eCONSULTS

Question from Local MD • From PCP or Specialist

eConsult Referral• Discrete questions about

treatment or referral

MGH Specialist Advice to Local MD • Sent to patient’s MD• Local MD treats or refers

patient to specialist

Less Complex Consults Requested By Outside Providers


STORE & FORWARD – eCONSULT IMPACT

100 eConsults requested Jan‐July 2014

Case Outcome (n=100)

eConsult refused1 and converted to a traditional visit

14/100 (14%)

In‐person cardiology visit recommended

11/100(11%)

Patient eventually had a traditional cardiology visit without a visit recommended

10/100 (10%)

Patient did not have any type of traditional cardiology visit within at least 6 months of follow up

65/100 (65%)

eConsult patients were younger than traditional consult patients (55.3 vs. 60.4 years, p < 0.001).

1 Patient or referring provider requested in person visit after eConsult recommendations received.

CREDIT: WASFY ET AL. AHA QUALITY AND OUTCOMES 2015




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• Growth in traditional cardiology consults less than matched specialties (4.5% vs. 10.1%, p < 0.001)

• Satisfaction overwhelming among PCPs and patients



STORE & FORWARD – eCONSULT CLINICAL AREAS

Departments• Cardiology• Dermatology• Diabetes• Endocrine• Hem/Onc•Nephrology•Neurology•OB/GYN•Orthopedics• Pain Medicine• Pedi‐GI• Psych‐Depression• Rheum• UroGyn• Urology• VascularLaunched in 1/2014

568 124

196

383474

890

573

197

393

776

1250

2140

0

500

1000

1500

2000

2500

Oct‐Dec 2013Jan‐Mar 2014Apr‐Jun 2014 Jul‐Sep 2014 Oct‐Dec 2014Jan‐Mar 2015Apr‐Jun 2015

MGH eConsult Volume Growth ‐ Quarterly Quarterly Volume Cumulative

2,000+ eCONSULTS


STORE & FORWARD – SECOND OPINIONS

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STORE & FORWARD – SECOND OPINIONS


SECOND OPINION IMPACT

“Studies show as much as 20% of patients seek second medical opinions; in specialties such as oncology, the rate is more than 50%. And recent research has found that second opinions often result in different diagnoses or treatments.”

‐Wall Street Journal, Aug. 24, 2015

“New Ways for Patients to Get a Second Opinion”, Reddy, Sumathi Wall Street Journal, August 24, 2015


SECOND OPINION CLINICAL AREAS

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1. Urgent Access





IMPROVING VALUE – CHRONIC DISEASE FOLLOW-UP

CONTEXT

Significant savings opportunity in ambulatory follow up carePatients making 3 or more visits per yearReduce visits by 1 visit per yearSaving of $7.6M in Partners Medicare ACO patients*$1.9 billion nationally

*Assumes a median per visit cost of $286

JAMA April 16, 2015“What Is the Right Number of Clinic Appointments? Visit Frequency and the Accountable Care Organization”Ganguli I, Wasify J and Ferris T


STORE & FORWARD - eVISITS

• Patient answers a set of condition-specific questions via secure website• Clinician reviews and replies to patient with care plan/next steps

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STORE & FORWARD – eVISIT IMPACT

CREDIT: JOHN SCHMUCKER, RON DIXON, MGH HEALTHCARE 360

Dixon RF, Rao LR. Asynchronous Virtual Visits for the Follow‐up of Chronic Conditions: A Telemedicine and e‐Health, July, 2014

PATIENT

• Average time to complete: 8.3 min• More convenient• More likely to check in for evaluation and management

• Reduced time and expense

PAYER

• Improves health and chronic disease management for members

• Reduces non‐medically necessary ER visits and readmissions

HEALTH SYSTEM

• Prevents lower acuity visits• Opens up physical space and access for more complex patients

• Decreases no‐show rate and late appointments

• Direct savings in ACO model

PROVIDER

• Average time to complete‐ 3.6 min• 5 times efficiency gains• Enables increase in panel size• Flexibility


STORE & FORWARD – eVISIT CLINICAL AREAS

Launched in 1/2012

Departments• Primary Care• Psychiatry• Pediatrics• Gastroenterology

0

1000

2000

3000

4000

5000

6000

Jan‐13

Feb‐13

Mar‐13

Apr‐13

May‐13

Jun‐13

Jul‐1

3

Aug‐13

Sep‐13

Oct‐13

Nov

‐13

Dec‐13

Jan‐14

Feb‐14

Mar‐14

Apr‐14

May‐14

Jun‐14

Jul‐1

4

Aug‐14

Sep‐14

Oct‐14

Nov

‐14

Dec‐14

Jan‐15

Feb‐15

Mar‐15

MGH eVisit Volume

Web Visits Phone Visits

7,000+ eVISITS

•Now in 15 MGH clinics•Primary Care & Specialties•150+ clinicians•3,000+ patients



1. Urgent Access





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IMPROVING VALUE – PATIENT ENGAGEMENT AND TRANSITIONS IN CARE

REAL TIME – VIRTUAL VISITS



In the home, post-acute, inpatient, outpatient clinic, & beyond...




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VIRTUAL VISIT CLINICAL AREAS

Launched in 4/2012

Departments• Cancer Center• Cardiology• Dermatology•Neurology• Pain Management• Pediatrics• PM&R• Primary Care• Psychiatry• Pediatrics• Surgery

Cumulative Program Volume (2013-2015): 5,000 Visits


VIRTUAL VISIT CLINICAL AREAS

Cancer Center

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Primary Care

75

Pediatrics ‐ 6

PM&R ‐ 2

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VIRTUAL VISIT CLINICAL AREAS, SITE, & FUNDING

15+ Clinical Specialties ▪ 6,000+ Annual Encounters

Service Location Clinical “Tele” SpecialtyFunding Source

Contracts Internal Payers

Acute-ED Neurology/Stroke ● Neurosurgery (Brain Tumor) ● Pediatrics ● Surgery (Burns, Trauma) X

Outpatient Clinic Dermatology ● Pain Mgmt ● Neurology ●Oncology ● Pediatrics ● Psychiatry X

In-PatientCritical Care ● Neurology ● Pediatrics (PICU/NICU) ● Surgery (Burns, Plastics, Ortho) ●Urology

X X

Patient Home Cancer ● Cardiology ● GI ● Neurology ●Pediatrics ● Primary Care ● Psych ● Surgery X X X

Second Opinions Multiple Specialties X


VIRTUAL VISIT IMPACTPATIENT

• Greater flexibility and convenience• Saves on the cost of commuting, parking, taking time off of work

• Offers more touch points with provider outside of in‐person visits

• Allows caretakers and other family members to be present for visits

PAYER

• Improves health and chronic disease management for members

• Reduces non‐medically necessary ER visits and readmissions

HEALTH SYSTEM

• Opens up physical space and access for more complex patients

• Decreases no‐show rate and late appointments

MEDICAL

• Complex issues requiring recurring follow‐up

• Therapy or counseling for mental health conditions

• Managing anxiety or concerns associated with conditions

• Sensitive discussions


REAL TIME – VIRTUAL VISIT IMPACT

We know what time to be onand we just connect. I find asense of comfort doing virtualvisits with the doctor in myown home. It allowed us toachieve what we want toachieve. I feel like we're ateam.‐TelePsychiatry patient

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REAL TIME – VIRTUAL VISIT IMPACT

I have found virtual visits to bean outstanding addition to myclinical practice. I was able toprovide very specific exposuresfor patients and work withthem in their homes, which issomething that we had beenunable to do before.‐TelePsychiatrist


REAL TIME – VIRTUAL VISIT PATIENTS

Technically Challenging?88% of patients do not find this to be complex77% of tech difficulties self resolved or patients resolved by themselves

Patient visit experience82% of patients said no different or better on “Comfort patients feel sharing private or personal information”87% said no different or better on “Confident that their healthcare concern could be taken care of”

Distance to travel? Not distance, convenience!48% of patients are traveling from less than 1 hour away24% of patients are travelling from 60‐89 minutes away

patient n = 332 51


LESSONS LEARNED FROM PATIENTS

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provider n=61 52

Providers were comfortable with technology more quickly than anticipated

Majority were comfortable with platform in 1‐2 visits 73.3% (1‐2 visits); 13.3% (3 or more); 5% (comfort varies with the device/technology the patient is using, 5% (not comfortable); 3.3% (not sure)


LESSONS LEARNED FROM PROVIDERS

Providers71.7% of providers said VVs better for timely patient access to followup appointments

Patients 80% of patients said VVs better for finding a convenient time for appointments95% of patients said it was better for travel time

Patients and Providers were in agreement on the value of Virtual Visits for access and convenience

patient n = 332 / provider n=61 53


WHERE ARE PATIENTS AND PROVIDERS ALIGNED?

Patients felt more positive than providersabout “Personal Connection”

Patients 67.5% of patients said no difference or better

Providers53.3% of patients said no difference or better

1.6%patient n = 332 / provider n=61 54


WHERE ARE PATIENTS AND PROVIDERS NOT ALIGNED?

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VIRTUAL VISIT IMPACT

International patient visits from:•Cochabamba, Bolivia – 4,137 miles•London, UK – 3,269 miles

St Augustine, FL 1,186 mi

Frisco, TX1,770 mi

Parma, ID2,700 mi

Danville, CA 2,911 mi

Scottsdale, AZ2,637 mi

Boulder, CO1,991 mi

Waukesha, WI1,085 mi

Novi, MI736 mi

Portland, ME 108 mi

Washington, DC440 mi

New York, NY213 mi


VIRTUAL VISIT IMPACT

Total Miles Saved:224,800

Total Savings‐ Direct Costs

$60,832

2 YEAR IMPACT(April 2013 – April 2015)

Total Savings‐Indirect Costs$103,824

Total = $165,000


REAL TIME – VIRTUAL VISITS • 2.1 miles

• MGH Physician:• Travel time to SRH(door to door): ~40 mins• Office visits often not reimbursed• Care communication: variable outcomes• Decreased satisfaction

• MGH Patients with long LOS, numerous readmissions

• SRH Patients: • Travel time (door to door): 4-5 hours•½ Day of Therapy Loss by the Patient • Long LOS• Billed for ambulance trips (not reimbursed by insurance)• Not patient centric

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POST-ACUTE VIRTUAL VISIT OUTCOMES FOR MGH

• 45 Hrs of Clinician Travel≈ 4 Days of MD Capacity

• 10 Same Day Surgeries= 40 Bed Days Gained

• 100% Provider Satisfaction

• 45 Clinic Slots Gained

• 0 Readmissions


POST-ACUTE VIRTUAL VISIT OUTCOMES FOR SRH

• 134 Ambulance Trips Saved= $86,076 Cost Savings

• 3 Rehab Days Saved/Pt= 135 Bed Days Gained

• 100% Provider Satisfaction

• 0 Acute Transfers to ED

• 0 Readmissions


POST-ACUTE VIRTUAL VISIT OUTCOMES FOR PATIENT

• 0 Post Op. Days at MGH

• Adherence to Rehab. Plan

• 100% Patient Satisfaction

• Increased Autonomy

• Home Sooner

• 0 Ambulance Trips for Follow‐Up Appointments

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POST-ACUTE VIRTUAL VISIT OUTCOMES FOR PATIENT

•The convenience of being able to stay at Spaulding and still be in contact with my MGH doctors was huge. It was just like talking to my doctor face-to-face.

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SO WHAT’S NEXT?


WHAT’S NEXT

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TAKEAWAYS

Determine Strategic Priorities

Identify “ready” and “relevant” Clinical Areas

Select appropriate Telehealth Tools, i.e., Virtual Visits/Consults, eVisits, eConsults

Implement in coordination with your Quality Improvement Toolkit & Colleagues

TAKEAWAYS

A FRAMEWORK FOR YOUR ORGANIZATION

Sarah SossongDirector of TeleHealthMassachusetts General [email protected]

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