Mass General’s new TeleHealth initiative reflects a broader effort to provide world-class care in ways that are more convenient and less expensive.

Recently, a multiple sclerosis patient in his early 60s had an appointment with his Massachusetts General Hospital neurologist. But this newly diagnosed patient didn’t have to take the day off work, drive two hours into Boston or spend time in a waiting area. Instead, the man stayed at home and benefited from Mass General’s TeleHealth initiative, which strives to connect patients and healthcare providers using telecommunications and other information technology.

At the appointed time, Mass General neurologist Eric Klawiter, MD, used his laptop to connect with the patient, whose home computer is equipped with a web camera, some hospital-provided software and an internet connection. The two could see each other as they discussed changing medications and reviewed the patient’s MRI brain images on a split screen. “It’s important to me to have Mass General expertise for important decision-making,” said the patient, who asked that his name not be used. “This is a much more convenient way to get it.”

Mass General launched its TeleHealth initiative in 2012, building on the success of the neurology department’s Telestroke program. The TeleHealth program reflects Mass General’s determination to satisfy a growing demand for the expertise of its doctors while also exploring innovative ways to deliver world-class care that is more convenient and less expensive. Studies of telemedicine have shown numerable benefits including reducing hospitalizations and emergency room visits, improving compliance with taking medications, and lower work and school absenteeism.

Through pilot initiatives in cardiology, neurology, psychiatry, burns and other departments, Mass General is exploring clinical uses of virtual technology. This includes videoconferencing with patients at home or in other hospitals, remote monitoring on hospital floors using robotic devices, and even communication as simple as email between providers to coordinate health care.

“TeleHealth is like a return to the home visit, 21st century style,” says Lee Schwamm, MD, medical director of Mass General’s TeleHealth initiative.

“TeleHealth is like a return to the home visit, 21st century style,” says Lee Schwamm, MD, medical director of Mass General’s TeleHealth initiative, director of Mass General TeleStroke and Stroke Services, and executive vice chair of the Department of Neurology. “Right now, it seems new and different, but within four to five years it will be just another way we practice medicine.”

TeleHealth Builds on Success

TeleHealth has its roots in Mass General’s TeleStroke program, pioneered more than a decade ago. TeleStroke now provides 31 community hospitals with emergency care advice for stroke patients via videoconferencing.

With stroke, time and correct diagnosis are particularly critical because the clot-busting drug tPA is lifesaving in the first 4.5 hours if it’s one kind of stroke, but destructive if it’s another. More than 1,300 patients last year alone benefited from a TeleStroke evaluation, with 180 receiving tPA. Referring hospitals asked Mass General to expand coverage to other neurology emergencies, and to inpatient and outpatient neurology consultations.

Together with executives from the Partners HealthCare System, Dr. Schwamm began working on ways to build on TeleStroke’s success and use some of the same technology to manage some of Mass General’s own patients and for other specialties. The Partners Center for Connected Health is also collaborating with Mass General on this initiative.

Mass General Magazine 2013-07-18: Dr. Lee Schwamm-TeleHealth
Right now, TeleHealth “seems new and different,” says Lee Schwamm, MD, medical director of Mass General’s TeleHealth initiative, “but within four to five years it will be just another way we practice medicine.”

Currently, reimbursement is an issue because third-party payers do not reimburse for telehealth visits to the same extent that they do for traditional office visits. Although many state legislatures are working on amending that situation, for the moment, Mass General is funding its own TeleHealth pilots. But as the American healthcare system moves away from a fee for service approach toward managing people’s health for a set amount per month, telehealth advocates maintain the concept could reduce costs as well as provide overall improvements in overall quality, service, and convenience.

Continuity of Care

At Mass General’s Division of Burns, Shawn Fagan, MD, is leading a TeleHealth pilot with Spaulding Rehabilitation Hospital. The program enables burn specialists like himself to regularly consult on their patients who move on to Spaulding for rehabilitation. “The patients still see us as their doctors and this makes the move smoother and less anxiety-provoking for them,” says Dr. Fagan, who is medical director of Mass General’s burn division and the Sumner Redstone Burn Center.

Otherwise, for an appointment with Mass General specialists, Spaulding patients must go via ambulance—a lengthy and uncomfortable process for those recovering from burns. They’d also end up losing almost a full day of rehabilitation exercises. Research shows that every day lost takes more than a day to make up.

One of the patients benefiting from this TeleHealth arrangement is a survivor of the Boston Marathon bombing who had undergone numerous skin grafts for burns. After moving on to Spaulding for rehabilitation, he continued to see Dr. Fagan once a week via a video hookup. In his room with him for appointments were his physical therapist and Spaulding’s telemedicine nurse. Also, there was a big video cart holding a laptop computer, a high definition camera, and a video screen on which Dr. Fagan appears.

From his office during such TeleHealth sessions, Dr. Shawn Fagan can control the camera and zoom in on a wound or pan down to an area of the body to see if it’s functioning with full mobility. “I can see as much detail as if I were there,” Dr. Fagan explains.

From his office during such TeleHealth sessions, Dr. Fagan can control the camera and zoom in on a wound or pan down to an area of the body to see if it’s functioning with full mobility. “I can see as much detail as if I were there,” Dr. Fagan explains, noting that he can look at the pores on a patient’s face. “We have found that for the majority of patients properly positioned and lighted, there really are no limitations to our evaluation.”

Virtual a Better Reality for Some

In March, Mass General’s Department of Psychiatry launched a TeleHealth pilot program focused on children and adolescents with autism spectrum disorder. Although there are no medications to treat or cure autism, these patients often have other co-occuring psychiatric conditions such as mood disorders, anxiety or attention deficit hyperactivity disorder (ADHD), which can be managed with medications, but require regular follow-up visits to monitor.

Those with autism spectrum disorder can experience sensory overload easily. For them, disrupting school routines, driving into Boston and walking through the busy hospital can be overwhelming. “By the time I see them, they are stressed, irritated and unhappy,” explains Janet Wozniak, MD, who is associate director of the Bressler Program for Autism Spectrum Disorders at Mass General and director of the hospital’s Child and Adolescent Outpatient Psychiatry service. “The benefits of these virtual visits have been immediate and obvious.”

At Mass General’s Division of Burns, Shawn Fagan, MD, is leading a TeleHealth pilot with Spaulding Rehabilitation Hospital.
At Mass General’s Division of Burns, Shawn Fagan, MD, is leading a TeleHealth pilot with Spaulding Rehabilitation Hospital.

Dr. Wozniak was surprised to find that children who spoke very little during office visits became more open and able to discuss their symptoms via video. “They are so much less stressed at home,” says Dr. Wozniak, who believes the video format allows her to do a better mental status assessment.

She is finding other advantages as well. After hours visits are more feasible for her patients and their families. When a patient has a crisis, she has the option to set up a quick video visit and get to the root of the problem and set up a solution much more readily than with an extended phone call. “The video visit is the perfect way to intervene quickly in a crisis,” says Dr. Wozniak, who is expanding the program to include other clinicians and plans to involve patients with ADHD and other conditions.

For its part, the Department of Neurology is piloting several TeleHealth initiatives, including follow-up home visits and inpatient and outpatient consults for other hospitals and physician practices.

Transforming Best Practices Through TeleHealth

For its part, the Department of Neurology is piloting several TeleHealth initiatives, including follow-up home visits and inpatient and outpatient consults for other hospitals and physician practices. The department has also received a grant to set up a tele-insomnia program as well as a Tele-ALS (amyotrophic lateral sclerosis, a neurodegenerative disease) remote consult program for patients in Maine.

Primary care physicians participating in one of the neurology pilots can page the Mass General neurologist if they have a patient in their office who, say, reports having bad migraines. Using desktop computer software, the neurologist calls back while the patient is still in the primary care physician’s office. Altogether they discuss treatment or whether a referral is necessary.

“Providers have access to Mass General specialty expertise and the patient doesn’t have to wait months for an appointment to get answers,” says Juan Estrada, MBA, the manager of Mass General Telestroke and TeleNeurology.

Meanwhile, two intensive care units (ICUs) at Mass General are also piloting a form of telehealth known as “virtual staffing.” The Pediatric ICU is using a video cart equipped much like the one used for burn patients at Spaulding. James Januzzi, MD, director of the Cardiac ICU, is piloting a robot called VGo that can roll around the ICU. He controls it from home, enabling him to monitor and talk to patients at night.

Though the applications of telehealth at Mass General are very much a work in progress, the doctors involved are excited about the potential. With an eye toward expanding into other specialties, they are closely evaluating such programs for their impact on quality, cost and patient satisfaction.

Telehealth is not appropriate for every patient but determining where it can work is the right thing to do, says Sarah Sossong, MPH, director of Mass General TeleHealth. “People bank online, shop online, Skype with family and friends online,” she adds. “Patients will start to expect to receive health care this way too.”

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