1. Telemedicine- the Cleveland Clinic Experience October 14, 2010 Matthew Faiman, MD, MBA Director Telemedicine Services

2. Virtual Medical Clinic l October 14, 2015 l 2 Disclosures There is no FDA on-label or off-label content in this lecture. Abbott Laboratories- speaker’s bureau, which has no relationship with the content of this lecture.

3. Virtual Medical Clinic l October 14, 2015 l 3 Lecture Overview Virtual Medical Clinic at Cleveland Clinic. An historical perspective of telemedicine. History of telemedicine at Cleveland Clinic. Current and Future Telemedicine projects at Cleveland Clinic. Questions.

4. Virtual Medical Clinic l October 14, 2015 l 4 Virtual Medical Clinic and Telemedicine What is Telemedicine? It is the transfer of electronic medical data (video, sound, image, EMR) from one place to another or…. “A picture is worth a thousand words…..” (Fred Barnard 1921)

5. Virtual Medical Clinic l October 14, 2015 l 5 Uses sophisticated, real- time technology to connect Cleveland Clinic physicians with patients requiring specialized consultations, anytime, anywhere Facilitates physician collaboration and interaction for specialty consultations Cleveland Clinic physician conducting personalized patient exam utilizing real- time connectivity technology Virtual Medical Clinic

6. l October 14, 2015 l 6 Location A: Exam Room Patient sees and speaks to Cleveland Clinic physician in real-time through secure technology Location B: Cleveland Clinic Physician conducts examination, interacts with patient and nurse, and documents encounter in the My Practice Electronic Medical Record system

7. Virtual Medical Clinic l October 14, 2015 l 7 The Virtual Medical Experience Conducts interaction from Telemedicine studio Cleveland Clinic Physician Interacts with patient and nurse / technician at remote exam location

8. Virtual Medical Clinic l October 14, 2015 l 8 The Virtual Medical Experience Easily navigates real-time views and online medical information (X-Rays, scans, etc.) Cleveland Clinic Physician Directs nurse / technician through exam, seeing and hearing diagnostic details (heart sounds, etc.)

9. Virtual Medical Clinic l October 14, 2015 l 9 The Virtual Medical Experience Sees and hears physician; asks and answers questions Cleveland Clinic Patient

10. Virtual Medical Clinic l October 14, 2015 l 10 The Virtual Medical Experience Receives and complies with physician instructions Cleveland Clinic Patient

11. Virtual Medical Clinic l October 14, 2015 l 11 The Virtual Medical Experience Nurse / Technician transmits diagnostic equipment data directly to physician for review in real-time Cleveland Clinic Patient

12. Virtual Medical Clinic l October 14, 2015 l 12 Virtual Medical Clinic

13. l October 14, 2015 l 13 Is examined utilizing all pertinent diagnostic criteria; nurse / technician follows physician direction Cleveland Clinic Patient The Virtual Medical Experience

14. Virtual Medical Clinic l October 14, 2015 l 14 The Virtual Medical Experience Conclude exam with discussion, final questions, physician instructions, and appropriate future treatment strategy Cleveland Clinic Physician and Patient

15. Virtual Medical Clinic l October 14, 2015 l 15 The Virtual Medical Experience Places orders for medications, follow-up tests or other labs into My Practice Electronic Medical Record System Cleveland Clinic Physician Fully documents encounter in My Practice Electronic Medical Record System

16. Virtual Medical Clinic l October 14, 2015 l 16 The Virtual Medical Experience Concludes Telemedicine Visit Cleveland Clinic Physician

17. Virtual Medical Clinic l October 14, 2015 l 17 Telemedicine- Historical Review Since the creation of EKG by Einthoven, there has been an attempt to transmit EKG over telephone lines circa,1906. In the 1920s, telemedicine was used by radio to help ships in distress. This would link physicians standing watch on shore stations for emergencies.

18. Virtual Medical Clinic l October 14, 2015 l 18 Telemedicine- Historical Review 1924, Radio Marvel Magazine illustrated this in action: Courtesy of Dennis J. Streveler, PhD.

19. Virtual Medical Clinic l October 14, 2015 l 19 Telemedicine- Historical Review 1950s- Nebraska Medical Center. Their psychiatry unit was one of the first in the US to have closed-circuit tv in 1955. In 1964 and later 1971, developed links between psychiatric institute and hospitals (including the VA) remotely. 1960s- NASA began to use telemedicine during its space program as physiological parameters were sent via telemetery from both space suits and spacecraft during missions. NASA provided much of the funding for most other projects and demonstrations, specifically satellites.

20. Virtual Medical Clinic l October 14, 2015 l 20 Telemedicine- Historical Review 1967- Mass General/Logan International Airport. This station was established to provide occ. health and emergency services to travelers. Staffed 24 hrs/day and used a two-way audiovisual microwave circuit. 1971- Alaska ATS-6 Satellite Demo. Utilized satellites from NASA to deliver video consultation to rural health care in 26 remote villages in Alaska and Canada. 1972-STARPAHC; NASA and Papago reservation in Arizona. Staffed by 2 Indian paramedics in a van and linked to a public hospital via 2-way microwave audio and video transmission.

21. Virtual Medical Clinic l October 14, 2015 l 21 Telemedicine- Historical Review 1984- Australia. Satellite communications network set up to provide health care to remote towns of which 2/3rds were Aborigines. 1989- NASA SpaceBridge to Armenia/Ufa. After the earthquake that hit in December 1988, the US extended an offer to assist the disaster site for medical consultation. Same assistance to the burn victims after railway accident in Ufa.

22. Virtual Medical Clinic l October 14, 2015 l 22 Telemedicine- Historical Review 2010. Price Waterhouse Coopers lists the top 10 healthcare issues for 2010 and #8: Alternative care delivery models will emerge as traditional care delivery models will give way to alternative models of care outside of physicians’ offices and hospitals. Expect to see an increase in the number and scope of services offered by work site… email, telehealth and remote patient monitoring. ( http://www.pwc.com/us/en/healthcare/publications/top- ten-health-industry-issues-in-2010.jhtml)

23. Virtual Medical Clinic l October 14, 2015 l 23 Telemedicine at Cleveland Clinic Telemedicine at Cleveland Clinic: began in 2005 with a relationship with UTMB. Dr. Cosgrove imagined telemedicine as an opportunity for increased access for patients living in hard to reach areas. Telemedicine felt to be inline with CC/CCHS approach to innovation.

24. Virtual Medical Clinic l October 14, 2015 l 24 Telemedicine at Cleveland Clinic In 2006, Virtual Medical visits began from Wooster to main campus in Peds GI and Neuro with Drs. Hsich, Wyllie and later Psychiatry with Dr. Tesar. In late 2006 a telemedicine council was set up to address the needs of CC/CCHS domestically and internationally.

25. Virtual Medical Clinic l October 14, 2015 l 25 Virtual Medical Clinic and Telemedicine On January 23 rd,2008 services began with the Parker Virtual Medical Clinic. This employee-based clinic sees patients for urgent visits and some chronic care. To date almost 500 patients have been seen. Patient satisfaction scores are as high or higher than regular brick and mortar visits.

26. Virtual Medical Clinic and Telemedicine Other Institutes using Telemedicine: Orthopedics: since 2008 from Wooster, approx 60 visits and 10 surgeries. In 2009 operations from Canfield (St E’s). Visit yield is 6:1 whereas dept average 10:1! Bariatrics: first visit from CCC Toronto 6/09. Transplant Medicine-Discussions began 1/10. Virtual Medical Clinic l October 14, 2015 l 26

27. Virtual Medical Clinic and Telemedicine Other Institutes using Telemedicine: Cleveland Clinic Canada- Toronto practitioner’s utilization of main campus for 2 nd opinions. Emerging Business: both domestic and international opportunities are being explored including home monitoring and wellness. Tele-stroke service fall 2010 along with EEG. ? Las Vegas. Virtual Medical Clinic l October 14, 2015 l 27

28. Virtual Medical Clinic l October 14, 2015 l 28 Virtual Medical Clinic and Telemedicine Final Thoughts Options are endless. In the fast-paced world that we live in, telemedicine affords a complementary approach to health care. Will not substitute but will augment the health care that we have today.