The Role of Telecardiology in a Critical Access Hospital

1. The Role of Telecardiology in a Critical Access Hospital One Critical Access Hospital’s Success Story Stephanie Laws, RN, BSN Project Associate Union Hospital Health Group’s Richard G. Lugar Center for Rural Health Linda Lewis, RN, BSN CNIV Staff Nurse- SCU Union Hospital- Clinton

2. What are the Issues • Limited ability to obtain specialty care in rural settings. 1. Socio-economic/demographic characteristics 2. Geographic barriers 3. Limited availability/dispersal of specialists • Increasing number of patients seeking primary care services in Emergency Room (ED)

3. State of Emergency? • National crisis • Overcrowding • Primary source of care for uninsured • Fewer ED’s, more visits • Fragmented care/Quality issues • On-call specialist shortage

4. Institute of Medicine Recommendations • Improve efficiency • Patient flow patterns • Increase observation unit usage • Technology implementation (telemedicine) • Mitigate medical malpractice • Greater reimbursement and funding

5. Emergency Medicine Malpractice Trends • Age- 61% under 45 • Gender- higher percentage of females • Resolution- 23% of claims result in indemnity payment • Allegations- Most prevalent medical misadventure is diagnostic errors • Frequency- MI, appendicitis, and symptoms involving the abdomen • Indemnity- Average payment $249,000 - Missed MI’s resulted in indemnity payments 55% of the time-

6. Emergency Medicine- Malpractice Risk • National Data: 1: 17,000- 20,000 • Average: 1 lawsuit per MD/ 7 years • Frequency decreasing- severity not • Multimillion dollar verdicts account for 1 out of 4 jury verdicts • The cost of defense and awards have doubled in the past five years

7. High Risk Categories“Red Flags” • Time of care (Change of Shift) • Return visit • Language/cultural barriers • Uncooperative patients • CHEST PAIN COMPLAINTS

8. Specific Practice Failures • Failure to diagnose • Lack proper examination • Errors in ordering/interpreting tests ***MI- serial enzymes and EKGS, observation***** • Failure to treat • MI- primarily females, middle age, many treated as GI complaint, normal EKGs, shortness of breath complaints • Failure to consult/refer

9. Specific Practice Failures Continued • Failure to admit • Failure to monitor/observe • Inappropriate transfer • Inadequate follow up plan

10. One Method to Reduce the Barriers and Challenges • Telemedicine- The use of medical information exchanged from one site to another via electronic communications to improve a patients’ health status. Clinical Services- Store and Forward- Digital Imaging Live- “Real-time” patient and provider interaction

11. Tele-Cardiology

12. Why Cardiology? • Cardiovascular Disease is the single leading cause of death in the U.S. • More than 1 million new and recurrent coronary attacks each year • Greater than 16 million Americans diagnosed with “angina” • Cardiovascular Disease number one cause of Hoosier mortality. • Effective Risk Management- (Missed MI’s, number of ED discharges). • Outward migration patterns

13. Project Goal • To provide timely cardiology consults for patients seeking care and treatment at WCCH for low risk Acute Coronary Syndromes (ACS)- (Chest pain rule in/out) utilizing telemedicine technology.

14. Plan • Develop policies and procedures that would coordinate and streamline implementation with key processes already in place. Focused cardiac assessment Easy to follow checklist Routine Admission Orders Consult ordered by ED physician, primary care physician, or hospitalist

15. How To Screening Guides: TIMI Risk Score Medical Calculator: Goldman Risk Score

16. Education Carotid Auscultation Points Cardiac Assessment Points Process Technical Training

17. Process Cardiology Consult Ordered Cardiologist Provides 1:1 Consult in Person at WCCH Can patient participate in a tele-cardiology consult? (alert and oriented, no sensory deficits, not hallucinogenic, able to interact) NO Cardiology group notified of patient and their ability to participate in tele-consult. Checklist completed and faxed to cardiologist office Consult time coordinated by cardiologist

18. Process Continued Dr. Bittar- Providence Cardiology Nurse at WCCH prepares patient for consult Consult completed by cardiologist via live, videoconference. Orders written and faxed to WCCH. Dictation entered on patient consultation Dr. Desai- AP&S Cardiology

19. IMPACT 29 cases completed Jan. 26, 2009 – Apr. 31, 2009 • First 29 cases: - $49, 458.00 retained revenue - 432.97 patient miles saved - $13, 050 EMS transportation fees saved - 23.6 hours of cardiologist “windshield” time - 941.22 hours of cardiology travel time

20. WCCH Emergency Department Outward Migration Patterns By Specialty August 2008 – April 2009 *Average 47.85 Total Transfers* Program Live- Jan. 26, 2009 ED Physician Education

21. Lessons Learned • Credentialing • Lighting • Technical • Standardization

22. What do you need to get started???

23. Connectivity

24. Equipment Device at Behavioral Health and Cardiology Practice Sites Digital Stethoscope Devices at WCCH

25. Economic Impact • Recruitment and retention tool • Decreased cost of travel/amount work time missed for patients who would have had to travel. • Improved hospital-based efficiencies (Reduced LOS, reduced outward migration) • Retention of outpatient occasions of services (labs, x-ray, etc.)

26. Next Steps • Expand to additional sites and replicate model. • Additional specialties. • Measure economic impact and quality outcome measures. • Satisfaction measurements

27. Special Recognition/Acknowledgement • Indiana State Department of Health’s – Office of Rural Health • West Central Community Hospital • Union Hospital • Hamilton Center, Inc • Providence Cardiology • AP&S Cardiology

28. Stephanie Laws, RN, BSN Richard G. Lugar Center for Rural Health www.lugarcenter.org slaws@uhhg.org 812-238-7479 Linda Lewis, RN, BSN West Central Community Hospital 765-832-1234 Contact Information