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Growing Pains While Shrinking Wounds Updates and Reviews of the San Diego Plastic Surgery / Spinal Cord Injury Telehealth Program, from Inception and Implementation.

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Presentation on theme: "Growing Pains While Shrinking Wounds Updates and Reviews of the San Diego Plastic Surgery / Spinal Cord Injury Telehealth Program, from Inception and Implementation."— Presentation transcript:

1 Growing Pains While Shrinking Wounds Updates and Reviews of the San Diego Plastic Surgery / Spinal Cord Injury Telehealth Program, from Inception and Implementation to Development and Challenges, a Multi-Year Experience Kevin Broder, MD Director, Plastic Surgery/Spinal Cord Injury Telehealth Program Plastic Surgery Section VA San Diego Healthcare System Richard Bodor, MD Medical Director of Wound Care Plastic Surgery Section VA San Diego Healthcare System Health Sciences, Associate Clinical Professor UCSD Plastic Surgery Andrew Michael, MD Research Physician VA San Diego Healthcare System UCSD Plastic Surgery

2 TeleWound Care –Utilizing Telehealth Technologies to improve access to specialty wound care, remotely assess wounds and facilitate prevention and treatment of complex wounds and pressure Sores SCAN-ECHO –Specialty Care Access Network - Extension for Community Healthcare Outcomes –A new interdisciplinary team approach to wound care utilizing innovative telehealth technology

3 W HAT IS S AN D IEGO SCI P LASTICS SCAN-ECHO? An innovative model utilizing clinical tele- video conferencing equipment to allow healthcare specialists from the San Diego SCI Center to provide expert advice to primary care providers in rural healthcare settings. A ‘Grand Rounds/Tumor Board’ style multipoint tele-video consultation

4 VHA N ATIONAL SCAN-ECHO G OALS /O BJECTIVES Increase specialty care services to rural areas in which access to specialty care is not readily available Improve access to specialty care via non face-to face consults Improve healthcare outcomes and quality Improve patient satisfaction Avoid delays to diagnosis and treatment for difficult medical conditions

5 S AN D IEGO SCI P LASTICS SCAN-ECHO M ISSION /G OALS /O BJECTIVES Prevention of Pressure Sores Early Interdisciplinary Intervention for Pressure Sore Treatment Knowledge Transfer for Patients, Families, Providers Continuing Medical Education

6 P ROVIDER B ENEFITS No-cost continuing education credits (CME/CEU) Opportunity to translate new knowledge into practice to improve outcomes Professional networking with colleagues of similar interests Sustainable network participation Avoid costly and time consuming travel to distant medical centers that puts patients at risk Support the Patient Aligned Care Team (PACT) model

7 VA SCAN-ECHO C ENTERS VA Connecticut HCS (VISN 1) VA Pittsburgh HCS (VISN 4) Richmond VAMC (VISN 6) Salem VAMC (VISN 6) Cleveland VAMC (VISN 10) VA Ann Arbor HCS (VISN 11) New Mexico VA HCS (VISN 18) VA Eastern Colorado HCS (VISN 19) Portland & Seattle VAMCs (VISN 20) San Francisco VAMC (VISN 21) Greater Los Angeles & San Diego VAMCs (VISN 22)

8 P ROGRAM D EVELOPMENT Replication Site Visit Formation of an Interdisciplinary Team of Consultants Hub and Spokes IT Collaboration Informatics Collaboration Didactic CME/CEU Accredited Lectures Consultation Documentation and Workload Credit

9 S AN D IEGO SCI P LASTICS SCAN ECHO T EAM Plastic Surgeons SCI Rehabilitation Physician SCI Clinical Nurse Specialist/ Rehab Case Manager SCI Physical Therapist SCI Dietitian SCI Telehealth Nurse Coordinator


11 I NFORMATION T ECHNOLOGY C OLLABORATION Clinical Video Telehealth (CVT/Real Time) Tele- video conferencing equipment Multipoint tele-video conferencing

12 I NFORMATICS C OLLABORATION Customized automated Inter-Facility Consult (IFC) developed specifically for SCAN- ECHO and CVT Remote site requests IFC for SCI/Plastics SCAN Consultation Software based query of remote site CPRS Template for guiding remote provider input

13 CME/CEU A CCREDITED L ECTURES CME – Continuing Medical Education for Physicians –AMA PRA Category 1 Credit™ –University of California – San Diego School of Medicine CEU – Continuing Education Units for Nurses –VA San Diego Healthcare System Nursing & Patient Care Services

14 D OCUMENTATION & W ORKLOAD C REDIT CPRS consult note –Main note – Plastic Surgeon –Sub notes attached – Interdisciplinary team Automated note delivery to remote site via IFC process Workload credit for consultant contributions

15 S AN D IEGO SCI P LASTICS SCAN-ECHO P ROCESS Consent - verbal Inter-Facility Consultation Request Placed SCAN-ECHO Tele-Video Session –Case Presentation –Case Discussion –Didactic Lecture Documentation

16 C ASE P RESENTATION Primary care provider presents patient history Wound images are reviewed

17 C OMMON SCI P LASTICS I NTERDISCIPLINARY P ROBLEMS Pressure Sores Traumatic Wounds Malnutrition Osteomyelitis Vascular Insufficiency Positioning, Surfaces Psychosocial, Compliance Consult Coordination

18 C OLLABORATIVE C ASE D ISCUSSION All participants from Spokes and Hub contribute to develop practical team recommendations Focus on Interdisciplinary Team Approach for comprehensive Pressure Ulcer Prevention and Management

19 D IDACTIC L ECTURES Wound Debridement Pressure Ulcer Reconstruction Adjuncts to Wound Healing Comprehensive Assessment of Pressure Ulcer Patients Topical Wound Care Nutrition for Wound Healing Pressure Relief Surfaces Specialty Mattresses & Beds Prevention of Amputation & Foot Screening Bioethics Roundtable: Autonomy and Other Issues Pre-Op Optimization Part I – The Surgical Checklist Pre-Op Optimization Part II – Nutritional Optimization for Wound Prevention and Healing Psychosocial Impacts of Prolonged Bed Rest

20 D OCUMENTATION & E NCOUNTER C REDIT SCI Hub Center formalizes recommendations and completes CPRS consult Interdisciplinary team members contribute to main consult note

21 S AN D IEGO SCI P LASTICS SCAN-ECHO P ARTICIPANTS VA San Diego Healthcare System, San Diego, CA Southern Arizona VA Healthcare, Tucson, AZ Phoenix VA Healthcare, Phoenix, AZ Northern Arizona VA Healthcare, Prescott, AZ VA Loma Linda Healthcare, Loma Linda, CA New Mexico VA Healthcare, Albuquerque, NM Louis Stokes Cleveland VA Medical Center, Cleveland, OH VA Puget Sound Health Care System, Seattle, WA VA Black Hills Health Care System, Fort Meade, SD VA Eastern Colorado Health Care System, Denver, CO VA Caribbean Healthcare System, San Juan, Puerto Rico Tennessee Valley VA, Nashville, TN VA North Texas Health Care System, Dallas, TX Edward Hines Jr. VA Hospital, Hines, IL Miami VA Healthcare System, Miami, FL VA Palo Alto Health Care System, Palo Alto, CA Hunter Holmes McGuire VA Medical Center, Richmond, VA


23 SCAN O UTCOMES –Cost Savings –Decreased Length of Stay –Decreased Time to Surgery –Improved missed opportunities –Increased Patient/Family Satisfaction –Increased Provider Satisfaction –Increased Veteran access to specialty care

24 A LIGNED WITH VHA I NITIATIVES AND D IRECTIVES VHA National Initiative for Pressure Ulcer Prevention VHA National Telehealth Initiative VHA Specialty Care Transformation Initiative


26 S AN D IEGO HAS 4 CONSULT OPTIONS FOR S POKE SCI PATIENTS WITH WOUNDS SCI Plastics SCAN-ECHO –Patient unable or unwilling to present to spoke or hub –Safety Net of SCAN recommendations can indirectly reach patient via spoke team Clinical Video Telehealth (CVT) –Quick access to Hub Specialist without long travel burdens CVT to Home – Patient at home, provider at hospital Traditional Face to Face Consultation –Always available for patients who prefer to travel to the Hub Center

27 C ONTINUUM OF C ARE I MPORTANCE OF I NTERDISCIPLINARY T EAM SCAN-ECHO Spoke Telehealth Consultation CVT to Home Home Telehealth Monitoring Face to Face Consultation Admission Skin Rounds Education Telehealth D/C Planning Telehealth Follow-up Annual Evaluation

28 VA San Diego SCI/Plastics Telehealth ■ Hub ■ SCI Center – San Diego, CA ■ Spokes ■ Phoenix, AZ ■ Tucson, AZ ■ Prescott, AZ ■ Las Vegas, NV ■ Loma Linda, CA

29 Type of Telehealth ■ Telemedicine – Hub provider ■ Privileges vs ■ Teleconsultation – Remote provider ■ Physician, NP ■ Orders by remote PCP ■ f/u by remote PCP

30 Clinical Video Telehealth Patient/PCP at CBOC/Spoke Surgeon at Hub ‘Consult/Post -op/Follow-up/Pre-op’ Patient/Surgeon at Hub PCP/Family/Home RN at CBOC/Spoke ‘D/C Planning’

31 Clinical Video Telehealth Patient/Home RN at Home Surgeon at Hub ‘Real Time Home Visit’

32 Telehealth Peripherals ■ Handheld Exam Camera ■ Ophthalmoscopes ■ Otoscopes ■ Stethoscopes ■ Integration with Endoscopes

33 Veteran Access to Care Markedly Improved

34 Use of Telehealth Reduces Admission Bed Days

35 $ Cost Savings $ ■ $1,700 saved per patient per bed day ■ $500 saved per patient for travel ■ $168,500 saved over 7 months

36 VA San Diego SCI/Plastics and TeleSurgery Program Development ■ Logistics ■ Memorandum of Understanding ■ Telehealth Service Agreements

37 VA San Diego SCI/Plastics and TeleSurgery Program Development ■ Equipment ■ Mobile Carts ■ HD video camera ■ Handheld exam camera ■ Desktop Displays (EX90) ■ PC/Laptop with Jabber ■ Wall mounted displays

38 Telehealth Team ■ Hub ■ Plastic Surgeon ■ SCI Physician ■ SCI PA ■ SCI Telehealth Coord ■ PT ■ Dietician ■ Psychologist ■ SCI Nurse Specialist ■ SCI Patient Coord ■ Spoke ■ PCP (Physician or NP) ■ CLC Physician ■ Patient ■ Family ■ Caretaker

39 VA San Diego SCI/Plastics and TeleSurgery ■ Performance Measures ■ Cost Savings ■ Improved Patient/Provider Satisfaction ■ Less Travel Time for at risk patients ■ Decreased peri-operative length of stay ■ Improved Communication amongst providers ■ Education of patient, family caregivers, spoke providers ■ Provider Workload

40 TeleSurgery Program Development ■ TeleSurgery ■ Plastic Surgery/TeleWound Care ■ Neurosurgery ■ Orthopedics ■ Head & Neck Surgery ■ Cardiothoracic Surgery

41 Spokes ■ Community Based Outpatient Clinics (CBOC) ■ Community Living Centers ■ Patient’s Home ■ Remote Hospitals (Between VISNs)

42 Telehealth Nurse Care Coordinator Facility Telehealth Coordinator Surgeon (Main ‘Hub’ Center) CAC Administrative Staff (PSA & DSS) Technical Staff (IT/BioMed) PCP/RN/TCT Patient/Family (Remote ‘Spokes’) Case Manager Telehealth Team

43 High Patient Satisfaction Veteran TeleWound Care: Initial VA San Diego Experience Utilizing Real-time Clinical Video Telehealth, Store and Forward Telehealth and Home Telehealth Technology in Comprehensive Wound Management. Broder KW 1,2, Li A 3, Tesfamicael R 1, Bodor R 1,2 1 Section of Plastic Surgery, VA San Diego Medical Center, San Diego, CA 2 Division of Plastic Surgery, UCSD Healthcare, San Diego, CA 3 Department of Surgery, Harbor UCLA Medical Center, Torrance, CA 2010 Fall Symposium on Advanced Wound Care and Wound Healing Society Meeting, Anaheim, CA

44 Image Capture Software ■ Direct upload into Vista Imaging ■ 3 quick ‘clicks’ vs 38 long steps ■ Document/Track wound progress ■ Store and Forward ■ HIPAA compliant

45 Telehealth Benefits ■ Reduce number of clinic visits ■ Reduce admissions, re-admissions and length of stay ■ Permit routine & non-routine pt assessment ■ Less travel time ■ Improved communication/education ■ Improved patient/provider satisfaction ■ Cost Savings ■ Workload Credit ■ T21 Telehealth Initiative ■ National Interest

46 Ongoing Developments VA San Diego TeleSurgery Center ■ Large Dual Screen Tele-video System ■ Designed to meet Telehealth Mission and Goals ■ Real Time CVT patient encounters ■ Presentation capabilities for hub and spoke education of patients, family, staff, residents and students ■ CPRS/VISTA Imaging/PACS Access ■ Strategic Location ■ Close to OR and Surgeon offices ■ Surgical Specialties ■ Plastic Surgery ■ Complex Wound Consults ■ Post-ops ■ Follow-ups ■ SCAN/ECHO ■ Others - Gen Surg, Vasc, CT, Neurosurg, Head & Neck, Ortho, Urology

47 VA San Diego SCI/Plastics and TeleSurgery Program Development Objective ▪ Experienced based best practice model to assist future clinical champions with telehealth program development

48 VA San Diego SCI/Plastics and TeleSurgery Program Development Logistics ▪ Memo of Understanding/Service Agreements ▪ Equipment Evaluation/Purchase ▪ Clinic Setup ▪ Consult Request Template ▪ CPRS Note Template ▪ Sharepoint Site ▪ Facility Oversight Council

49 VA San Diego SCI/Plastics and TeleSurgery Program Development Collaboration ▪ VISN Telehealth Leadership ▪ Facility Telehealth Director ▪ Clinical Champion ▪ Practitioners ▪ Hub ▪SCI Patient Coordinator ▪SCI Telehealth Nurse Care Coordinator ▪Plastic Surgeons ▪SCI Physicians ▪Nurses ▪ Spoke ▪SCI Patient Coordinator ▪SCI Nurse Practitioner

50 VA San Diego SCI/Plastics and TeleSurgery Program Development Collaboration ▪ Telehealth Nurse Care Coordinator ▪ Tele-mental Health Program Personnel ▪ Patient Support Assistant - clinic setup ▪ National SCI Telehealth Initiative ▪ IT Support ▪ Vendors ▪Demonstrations ▪Ongoing Support ▪ Hub/Spoke Troubleshooting Sessions ▪ SCI Administration – Bi-weekly planning meetings

51 VA San Diego SCI/Plastics and TeleSurgery Program Development CVT Session Process ▪ IFC Consult Initiated by spoke facility ▪CPRS Consult Request Template Completed ▪Still Photography reviewed by hub facility practitioner via secure email ▪ Appointment Scheduling (spoke and hub) ▪ Equipment/Room Reserved ▪ IT Support Available

52 VA San Diego SCI/Plastics and TeleSurgery Program Development TeleSurgery ▪Head & Neck Surgery – Las Vegas ▪Challenge – skilled tele-presenter needed at spoke ▪Neurosurgery – 450 visits/yr ▪Challenge – skilled tele-presenter needed at spoke ▪Cardiothoracic Surgery – 50 visits/yr ▪‘Virtual Consults’ already being done ▪Plastic Surgery/Wound Care – within VISN ▪Challenges – home CVT capability, mobile tele-presenter

53 VA San Diego SCI/Plastics and TeleSurgery Program Development ▪ Summary ▪VA San Diego SCI/Plastics CVT Program as model ▪Collaboration ▪Clinical ▪Technical ▪Business ▪Develop Detailed CVT Session Process ▪Measure Performance ▪Develop TeleSurgery Program

54 Thank You “The right care in the right place at the right time” Andrew Michael, MD Kevin Broder, MDRichard Bodor, MD

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