A developmentally disabled teenager arrives in the emergency department with a temperature of 105 degrees. You mobilize the staff, diagnose and treat the patient, and send them home. The patient will be fine, but it’s a time-consuming, resource intensive, and extremely expensive visit. Not to mention the stress on the child.
This is the kind of challenging situation that caused James Powell, an internist in Long Island, to seek a telemedicine solution. Powell, who is the Chief Medical Officer at Long Island Select Healthcare in Suffolk County, New York, used a grant, and new MobileDoc technology from MedPod, to launch a program that enables him to improve care, extend his reach, and lower costs. Here’s Dr. Powell’s story.
I was practicing internal medicine about 15 years ago when I had an “aha” moment. A 22-year-old man came into my office. He was nonverbal, unable to communicate, and the staff was convinced he had ear pain. So I took my otoscope and started to put it into his ear. He turned around, hit me, and almost knocked me down. And I thought, I have a guy who has ear pain, who can’t communicate with me, and can’t tell me what’s going on. And I’m trying to shove a metal object toward his ear. He’s doing the right thing. At that moment when I realized that I had to revisit the way I look at this population, the way I look at myself, and the way I look at the examination techniques I utilize. For example, how can I manipulate my examination tools and stethoscopes and examine people when they don’t want to be touched? And how do I examine someone when they’re standing instead of lying down?
Now I’m medical director for several agencies which deal with people with disabilities — DDI and United Cerebral Palsy of Suffolk County. I’m also a former board member of the American Academy of Developmental Medicine and Dentistry (AADMD), which helps provide resources for providers that treat patients with developmental disabilities. Helping these patients has been my passion for the last 15 years, and for me, it’s been rewarding because it involves pediatrics and geriatrics, with a dose of Sherlock Holmes thrown in. Most importantly, it’s helping those who may need a little extra help to feel better — people who are wheelchair bound or who have autism, Down Syndrome, or cerebral palsy — with complicated and challenging issues.
A Tech-Enabled Solution
Enabled by a grant through the New York State Department of Health, we had the opportunity to use new technology to help my patients. We partnered with a health care technology company called MedPod to deploy their new MobileDoc, which is essentially a roller suitcase containing a range of medical diagnostic tools geared towards a remote patient encounter. The suite of devices in the suitcase can remotely treat over 70 conditions using an integrated vital signs monitor, stethoscope, dermascope, otoscope, ECG spirometry and other devices. At 30 pounds, this mobile doctors office can be wheeled into a patient’s home in minutes.
By conducting a pilot test, we’ve learned about the technology and how it can be effectively used by non-physicians, such as nurses familiar with this patient population. Before we rolled out the MobileDoc, we had patient volunteers, who came into our offices to be examined by nurses using MedPod technology. And I would listen to them from my office with the digital stethoscope. The quality of the data from the remote stethoscope was better than what I use in my office. For example, I can hear abnormal findings easier than I could before. We would then look at their throats and ears and take pictures to show the patient what we saw. And then the nursing staff would do the same thing; so I could determine later how effective the equipment and the examination were.
In the end, we weren’t picking a particular product for telehealth use; we were choosing a company to partner with to improve the lives of patients. That said, that actual devices included in the suitcase proved a huge success. We could use the Horus digital scope system including the otoscope to look in a patient’s ears and the general exam camera to look in his throat, and at his eyes. The multiscope has interchangeable attachments that allows us to look at a patient’s ears, throat and skin with a quick change of the lens. The technology also allows us to save pictures to refer back to for comparison.
Building the Necessary Infrastucture
Of course, there’s infrastructure necessary for this kind of operation. We have more than 2,000 people enrolled in our grant program. The program created a call center, which is serviced in part by a triage team that can dispatch a nurse to the patient’s house. The nurse will text me that he or she will be at the house at a certain time. I log into my E-Clinical Works system on my tablet, and I’ll prescribe directly to the pharmacy. For documentation, I’ll fax a note to the house about what took place, what we saw, what we did, and what we prescribed. And I’ll give instructions on what to do. If they are current patients, I can set up an appointment for them that night for follow up.
We have three providers in our group, who comprise two different teams. One is a Suffolk and Nassau county team and one is the New York city team, with two providers on call at all times. The largest number of patients I’ve had in one night was seven. Our hours are 6:00 P.M. to 10:00 at night. Sometimes I don’t get a call. But we usually handle a few calls a night.
Unexpected Benefits of the Video Examination
The main camera is directed at the patients face during the visit, but I can also have the nurses use the general exam camera so I can watch where they are pushing on the abdomen. The bottom line is that I feel like I’m doing my own exam! When I’m examining someone in my office, I’m looking at their face as I palpate their abdomen, looking for wincing, grimacing, signs of discomfort. So, in the telemedicine setting, I can guide them with my voice to tell them where to push. At the same time, on the same screen, I’m looking at their facial expressions. And, in this population, that’s extremely important.
The patients are engaged with the screen, so there’s constant interaction. I haven’t changed what I would normally do during an exam. But I’ve noticed myself focused on certain parts of the exam, maybe an inquisitive look, a laugh, or a smile. And I’ve seen myself engaged in a way you might not in an office setting. The patients love it. The staff love it. I see staff sneaking a look to just to see who’s on the other line. In my office, I start my exam with a handshake. I end it with a handshake. And, in this telehealth scenario, I start with a “hi” and it ends with a “goodbye” and a wave.
[Top of the screen] A nurse uses the MobileDoc to examine a disabled patient, connecting directly to Dr. James Powell in his office [above].
Long Island Case Study Just the Tip of the Iceburg
The potential of this new technology for telehealth is virtually limitless. There’s no population with whom this technology couldn’t be rolled out. I could see it in being used in hotels, cruise ship, prisons. I could see it at the Special Olympics or in a large corporation. If an employee is not feeling well, he or she could go up to fifth floor and get checked out for a sick visit or a routine visit for renewal of their blood pressure meds and they go right back to work.
Count on Cost Savings
The reason we’re so bullish on this telehealth deployment is the cost savings, especially among those with developmental disabilities, since they’re over lab-tested and over radiographed. They get more CAT scans to the heads than they need. We had a patient who had fallen in the shower; didn’t lose consciousness, but had a slight hit to their head. We went to evaluate him. We did a full exam on him with the MedPod MobileDoc and just told him to take Tylenol. I could almost guarantee that patient would have had a CAT scan of his head if he went to the ER and that would have been a thousand dollar ED visit. So the cost of Tylenol, plus the cost of a physician visit based on insurance is a dramatic savings.
But, of course, in the end, it’s all about sustainability. How are we going to make this into an ongoing, viable program? Right now, a grant pays the bills but ultimately, it will be our responsibility. So how do we look on our return on investment with the provider time, MobileDoc, call volume, and community engagement? We’re collecting data to try to develop a long-term business model for ourselves and others. And we’re trying to take advantage of our FQHC at Long Island Select Healthcare. After the grant, can we continue the project through our organization? I think that if you want to use the equipment through MedPod, it could be done through primary care providers or a network of providers. It doesn’t have to be done through urgent care facilities, hospitals, or health care systems. I think the goal would be to have more outpatients. Let’s try to keep patients out of hospitals.