Sharing Expertise through Telemedicine

By Todd J. Vento, Medical Director for the Infectious Diseases Telehealth Program, Intermountain Healthcare

Todd J. Vento, Medical Director for the Infectious Diseases Telehealth Program, Intermountain Healthcare

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. The purpose of the new Infectious Diseases Telehealth program is not only to provide consultative advice for individual patients, but also to provide population-level input on antibiotic usage and disease condition monitoring, to all providers within the Intermountain system. These services are of great value for small community hospitals in Utah and Idaho that might 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 over approximately 15 months, addressing and answering their infectious diseases needs. The demand was evident, and consequently, we implemented a formal program to support all sixteen community hospitals. Any physician, mid-level provider, nursing staff, pharmacist, or administrator concerned about an individual case or a rising trend in infectious diseases can request our expertise.

The ID telehealth consultation service 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 requested by clinicians who require prompt infectious disease expertise for managing their patients’ needs. Secondly, since we have access to system-wide EHR and EMR data, we can review a chart and give more comprehensive consultative recommendations to individual clinicians that request it, in a more formal manner, which is called an 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 guide the small community hospital provider in the management of their patient.

"The whole concept of the ID telehealth program is to provide centralized expertise to empower small community hospital staff"

At a population level, we use a proprietary software known as Vigilanz, which is tied to our EHR, monitoring all antibiotic use and specific disease conditions (e.g. blood stream infections) as part of a system-wide antimicrobial stewardship (AMS) program. In the first ten months of this program, we monitored system-wide infectious diseases and found that bloodstream infections accounted for approximately 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 Centers for Disease Control (CDC) subsequently created guidelines and recommendations on antimicrobial stewardship programs for all hospitals. Thereafter, the Joint Commission for the accreditation of hospitals, and the Centers for Medicare and Medicaid Services (CMS) chimed provided additional requirements and conditions of participation. Each facility in the Intermountain Healthcare system has a team comprised of a physician champion, a pharmacist champion, a patient safety or quality management representative and, depending on the size of the hospital, nursing staff and administrative leadership. These teams implement their antimicrobial stewardship program, with the guidance and direct involvement of an ID physician and an ID pharmacist centrally.

An ID pharmacist and physician connect with all sixteen AS teams electronically in each of their quarterly meetings, and meet in-person with each of the small community hospital stewardship teams annually. With our access to population-level data fromthe CDC’s National Healthcare Safety Network, Vigilanz surveillance, and our integrated system-wide EHR, we provide the AS teams centralized data that they can directly act upon to help reduce the inappropriate use of antibiotics, decreasing antibiotic resistance, and improve individual patient care.

We recently added a system-wide monthly education program, known as the Education in Antimicrobial Stewardship and Idea Exchange (EASIE). All the individuals and teams collaborate on a WebEx platform, and we provide education on common antibiotic use issues and specific disease topics, followed by an idea-sharing segment where the AS teams can discuss recent challenges and solutions in their respective hospitals. The whole concept of the AS program is to use centralized resources (ID subject matter expertise and central data monitoring) to then empower local AS teams to make decisions on what projects they want to work on based on their own unique issues and population-level data.

To that end, these initiatives have been very rewarding, giving us an opportunity to provide far-reaching education using technology, in addition to facilitating interactions between these AS teams. The ID physician and ID pharmacist are integrated as part of each small community hospital’s AS team.

3. How has this program been received by physicians and patients, and where do you intend to proceed with it?

After the first 6 months of the ID telehealth program, we conducted surveys of patients, physicians, nurses, pharmacists, and administrators. The mean age of patients surveyed was 63 years, and to our delight, we scored between 97-100 percent on our program assessments for patients and providers. We have had many teary-eyed elderly patients, who have never used a smartphone or computer, state that they wish this technology and service could be available to everyone, everywhere. Our program helps patients like these stay close totheir families and communities, avoiding transfer to a distant large hospital due to a lack of subspecialty resources. It is also amazing how small community hospital providers have used the telemedicine-based expertise to create better patient experiences and clinical outcomes. Despite initial concerns by some of our telemedicine providers that they might lose some of the personal connection with their patients, they have been pleasantly surprised to find the same level of patient-physician connection and impact using a telemedicine platform.

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 care to a broader number of providers and patients.

b. The EHR is also well integrated with Vigilanz and other antibiotic use-monitoring systems, making the data instantly available on those platforms. This is a part of the macro-trend of system interconnectivity we see in the healthcare sector.

c. Last year, Intermountain also expanded the telemedicine capabilities of other specialties such as wound care and oncology. We have also grown geographically, reaching small community hospitals outside of the Intermountain Healthcare system, as part of our Telehealth Outreach program.