This limited-run pilot has shown early success and Hopkins hopes that the final stats will warrant broad expansion. We caught up with Dr. Junaid Razzak, the architect of the program, to learn more about the effort, and where he sees telemedicine heading globally.
Telemedicine: Can you give us a little bit of background on the telemedicine work you’re currently doing in at Johns Hopkins?
Dr. Junaid Razzak: Johns Hopkins has established an Office of Telemedicine and we have an ophthalmology faculty who’s heading that. What we [in emergency medicine]are working on is to see if we could use telemedicine to reduce the “left without being seen” rate. We have these patients who would come in to the ED, especially at odd hours, later at night and in the early morning. They would get triaged and if they were not considered critically ill but sick enough to be seen, they would have to wait. And many of them would leave if the ED was busy. They didn’t know how long the wait would be and they felt like they were not getting the care they needed.
To address this issue, the department started what we call “the screening process.” After the nurse triages you, you are seen by a provider – a physician or a PA – who starts the treatment and some investigations, as well as give pain and fever medicine. That way, once you’re actually seen by a person who can make a decision and physically discharge you, they have all the information. Because while you are waiting, we are processing you.
We were doing that screening process during the daytime, most of the time. But we had periods of time during the night where there was a need but it was intermittent. There were a couple of hours that we needed some help and it didn’t make financial or logistical sense to bring somebody in.
Around this same time we were also feeling a shortage of physicians. We thought: What would be an out-of-box solution? And one of the things that came out was tele-screening, using telemedicine at the front door of the emergency department.
Telemedicine: Where did this fall in your workflow?
Dr. Razzak: After triage and before the patient is traditionally seen by a physician, we have this telemedicine-based screening process. We started doing that between 1:00 A.M. and 3:00 A.M., then we increased it to early morning hours and weekends.
Telemedicine: How well is it working?
Dr. Razzak: We’re assessing the quality of the program by asking four questions. Number one, how good is the quality compared to in-person screening? Then, what is the level of efficiency? Third, how are patients feeling about it? Finally, how are the providers feeling about it? We looked at quality of care in terms of the care being provided for pain patients as a surrogate marker for care overall.
We wanted to collect the numbers. We wanted to make sure that we actually do prove that it works or doesn’t work in a scientific way. We wanted to know the limitations. We have screened over 4,000 patients and that data is being written up right.
Telemedicine: What have you discovered so far?
Dr. Razzak: We looked at the use of payment and we found that there is no difference between telemedicine screening versus in-person screening.
Secondly, we were looking at the efficiency piece. We were questioning how the efficiency of telemedicine compares to a person who is there in person. What we found is that it’s all about comfort level. We saw a learning curve. That learning curve showed us that after about six months, the person on tele-screening is just as efficient as an in-person physician. We’ve also done some basic data collection on patient satisfaction and the results are very encouraging.
Telemedicine: Is the six month lag in efficiency simply a matter of getting used to a new technology platform?
Dr. Razzak: Yes. Primarily it’s getting used to looking at the screen on one side and EPIC on the other screen, all while engaging the patient. The patient’s comfort level is on a curve as well. They are trying to get used to a physician talking to them.
In terms of efficiency, we also had to get consent from the patient, so you’re talking to them a little longer. They would ask questions about the system. It was surprising to me that the efficiency difference when we started was not that great, and it gradually went away completely. That’s when started wondering if this remote physician could actually provide care that was both at the same quality and efficiency as in-hospital care.
Telemedicine: Perhaps someone in Australia, helping out during your night shift.
Dr. Razzak: Exactly. So that opens up so many opportunities to provide care. It’s just changed the paradigm completely. It also made us ask: Can we do this in multiple hospitals with one provider? Hopkins has several hospitals across the state. Can we do it in a couple of hospitals at the same time, with this one provider? That’s what we are learning now.
It made a human resource sense because we already had a shortage of people, especially at odd hours. We have learned that it is as good in terms of quality. Patient satisfaction wise it is as good. Provider satisfaction is pretty good because they’re working from home. They don’t have to drive an hour and go back; so you save all that time. This can make financial sense if you can prove the quality of care is good and the patients are satisfied and they feel that there is a value in this whole process. That is something we’re still working on and hopefully we’ll come to that.
Telemedicine: How well to doctors adapt to the technology?
Dr. Razzak: There can always be minor issues. But I think the technology is so good and the internet is so great because everything else in the hospital is based on that infrastructure. We have a whole system working on it. We use peripherals, like a stethoscope and an otoscope, and once in a while you get into issues with those. But generally speaking, they’re quite reliable.
Telemedicine: Has anything surprised you about the program so far?
Dr. Razzak: What was surprising to me was that it worked out so well! When you work with technology you always feel like something is going to go wrong. And things always go wrong when you try to do something.
Telemedicine: Tell me more about the tech that you chose.
Dr. Razzak: We bought [a telemedicine cart]off the shelf from Global Med, and then our IT person went to spend a week at their headquarters working with them to customize it for our needs.
Telemedicine: What’s coming next for this project?
Dr. Razzak: What we really want to do is figure out how to integrate telemedicine into the working of emergency departments. We have a toe in the water right now. I don’t think telemedicine is ready for replacement of people in the emergency department. I think there are areas where it could augment the care process, like with patients who are waiting to be discharged from the observation unit. They have already been seen.
Telemedicine: Almost like a health navigator guiding you towards your next point of care.
Dr. Razzak: Exactly. So lots of those kinds of options, which would allow our providers to focus on the sickest patients who need them most. And we’d use tele- medicine to take some of the peripheral work out and put it somewhere else. That’s where I’m thinking about.
The other thing that we see developing is complex decision-making support – IT- based guidance to augment and support physician decisions. We see patients with multiple disease properties going on at the same time. And we are trying to make complex decisions based on multiple pieces of information. The human brain has limitations of how many variables can it consider at the same time. But machines do not. This is low hanging fruit. First line providers are actually at the one point in time maybe caring for 20 patients. Each patient is very complex and then you multiply by 20, you need some help and that’s where the error happens. And technology can help there. I think there is a big hope for that.
Another hope of telemedicine is that sometimes when you’re outside the unstable environment of the ED you can make better decisions. Say I am seeing a patient from my office, in a quiet room. Compare that to seeing the same patient in the middle of a chaotic emergency department. I’m getting all these signals from the environment and my ability to focus and make correct decisions is limited. So can we take some of those environmental factors and position the decision maker away from that noise level. When a surgeon goes to the operating room, you don’t have a lot of input coming in. It’s a very controlled environment. But the emergency department is not. Can we use technology to bring the provider and their mindset to a geographical space where the decision making can be more accurate?
Telemedicine: You do these telemedicine screenings all of the time. How have you felt about the quality of the interactions that you’ve had?
Dr. Razzak: There are many patients where I feel very comfortable. For example, you have a patient who comes in with ankle pain. And you can focus on their ankle and you can make them walk. You can actually tell the patient: Where is it hurting you? And it gives a lot of information and whether to get an X-ray. There are some patients where I feel that telemedicine has a limitation. A patient comes in with abdominal pain; that becomes more complex. I need a little more information than what my telemedicine system can give me. Chest pain? I think I’m okay with telemedicine.
Telemedicine: What will be the life cycle of this particular Hopkins telemedicine experiment last?
Dr. Razzak: We’re going to add other hospitals. We’re going to continue to learn how we can improve it. We started with four providers. It’s a smaller group who was committed. We expanded to other providers. We feel like we need to go out and see how we can make it sustainable. That tele-screening right now is not billable. What can we do to make it sustainable in terms of service? There is a lot of scope for us to learn. What we also wanted to do was to make us as emergency physicians and as a department feel comfortable with the technolog y. We’re moving away from a very traditional way of patient care, the doctor-patient relationship. We wanted do so in a way that shows success, learn from our mistakes and then expand it to other areas. We have achieved some of those goals. But new technology is coming all the time.
Telemedicine: As things move forward do you see in the near future improving certain aspects of the technology that you’re using?
Dr. Razzak: We will probably use EPIC to its fullest. Right now it is not integrated into EPIC. We would like to have integration, although right now it’s not making that big of a difference. We run two systems and they work fine. But if it was one system, it would be better. I don’t know how that will eventually look like but that will be something we’ll be doing.
Telemedicine: The trend we’re seeing is that it’s not about the technology. It’s about implementation. Does that ring true? That basically the technology exists to do this. The challenges are in how to do it and get paid for it.
Dr. Razzak: I’d agree with that completely. The tele part of telemedicine has been there for a while. However, on the technology side, I think the ability to feel is where there’s room to grow. We can hear. We can see. We can’t feel with telemedicine. So abdominal exams are not possible. And a lot of what we do, even though we use a lot of technology and tests, still is based on our touch for the patient and patient’s different body organs.
Telemedicine: Can a physician extender be your hands?
Dr. Razzak: That’s what you’re doing right now. But that sometimes is a skill that requires a lot of time. We use our nursing assistants when we do tele-screening. And we train them on what parts of chest do you want to hear for heart sounds vs. breath sounds. Where do you put your stethoscope? How do you use the camera? How do you look inside the ear?
But abdominal exams are a little bit more interesting because, you know, sometimes you distract patients. It’s a whole technique because it’s so subjective sometimes. I would be very excited with a technology, sort of a glove or something that if I put my hand in it I can feel the patient’s abdomen.
Telemedicine: Given your work internationally, how do you see telemedicine playing out around the globe?
Dr. Razzak: I see a much bigger role for telemedicine outside the U.S. Internationally, the demand for services is so high. There is a very large middle class in many parts of the world who are willing to pay for healthcare but they do not have expertise. So I feel that if we can find a McDonald’s or Coca-Cola solution that can be exported at a reasonable price point for cash, I think it’ll be a huge success.
For example, in Karachi, there’s 23 million people. You know, if you go to see a specialist there, you’re not paying hundreds of dollars as we charge here; but $20, $30, $40. But the volume is very large. And that’s true for now most of Africa, where there’s a pretty big middle class, and Asia, India and China. I think a lot of companies are focused too much on the American market.