Due to leadership of pioneers like Kristi Henderson, Mississippi – a state which has struggled mightily against poor health trends – has emerged as a telemedicine leader. Now, Henderson and others want to share this success with the nation, all while turning Jackson into the South’s hub for health tech innovation. Interview by Logan Plaster
Some have described the Mississippi telehealth program as the best statewide telemedicine system in the country. How did you get where you are today?
KRISTI HENDERSON: More than ten years ago I was helping run the emergency department, the trauma center here at University of Mississippi Medical Center (UMMC). The chairman of our department and I were brainstorming: How do we impact outcomes of patients that are needing emergency care in rural areas of the state? They’re getting transferred to us but having bad outcomes because they didn’t have an intervention done sooner. Over a period of time we sketched out a telemedicine plan. It ultimately took us three years to get through regulatory boards to allow us to do it the way we wanted to do it.
In 2003 we started with three community hospitals, connecting them 24 hours a day to unscheduled episodic emergency care. Little did we know that was the hardest area to start. We could have started with something more controlled like teledermatology, but instead we jumped into emergency medicine because that’s where we knew the need. I think, looking back, that played a big piece into the success and the model that we’ve continued to replicate. It’s based on the need. We’re not coming up with a project and shoving backwards. We’re having people say: Help us. Here’s our need. And we look for innovative programs, which happen to use technology.
What were those early days like, starting with episodic care in these initial spoke site?
HENDERSON: First, we said: Let’s find out who the clinicians are in those towns, instead of trying to use temporary help or flying in people that are going to not be a part of the community. We didn’t think that was a good and sustainable. Most of those communities had nurse practitioners or family physicians who were also covering the emergency department around their day job. So we went in and offered a training program that was a series of clinical and didactic training for the generalist: the family practitioner, whether that was a nurse practitioner or a physician. They got trained in how to recognize emergencies and how to treat the patients in emergency rooms. Then we gave them 24-hour video access – audio and video – to our UMMC emergency physicians that are board certified. So when they did see those high risk but low frequency patients – the poisoned child or the near drowning or the multi-vehicle car accident – we were there for them. What was interesting was that when we did this, the communication between the two sites led to a collegial relationship. Discussions went beyond trauma and medical emergencies and become good collaborative care, a team approach where people bounced ideas and treatments off of one another. What we found was that the care that was being given at these tertiary sites became comparable to what was being given at the academic medical center. And we’ve done studies to prove it. Take cardiac arrest, where unfortunately the rate of death is higher in a rural area because of lack of resources and transportation challenges. We were finding that we were having the same outcomes with the patients in those areas now just by having that kind of team approach to healthcare, using telemedicine. We started with those three sites in 2003, not knowing what in the world was going to happen, and then word of mouth led to more and more hospitals wanting to do it because they were challenged with keeping their hospitals open.
We grew to eight or nine hospitals, and then it was time for us to do a deep dive study. I went and did a pre and post analysis on lots of things, one of which was cost. We found that not only were these sites saving money but they were also having an increased number of admissions to their local hospital, which was critical for them to stay open. And that was because they now were not sending inappropriate patients to us. They were able to really stabilize them, get a second opinion and determine that they could keep them in their local hospital. So now they had a decrease cost to staff their emergency department, even with the telemedicine, and an increase in local admissions. So it was a win-win to say the least. And then what we were getting in our trauma center was now more appropriate. We weren’t getting the things that needed to stay in the community hospital that were backlogging our waiting room. We were now getting more appropriate patients to utilize the tertiary and quaternary services. We didn’t start with some grand scheme to launch a statewide telehealth program. When I started my background was clinical emergency medicine – I had been a nurse practitioner for years, had been an administrator of an ER. But it worked. And then it snowballed and the tertiary sites said, “Could you also give us psychiatry? What about derm? And cardiology?” And then it just slowly kept evolving to where it is today.
Some of the greatest challenges in telemedicine surround the reimbursement issue. How did you make sure that you got paid appropriately for your services?
HENDERSON: A pivotal point in the whole process was when we worked out the reimbursement issue. For sustainability of this program, I have to work in the policy realm and the reimbursement world and regulatory space to make sure all those different angles are addressed so that it’s easy for the healthcare community to adopt and use this and it’s one financially we can sustain. Little did I know how much I would live in that space. And so I began working with the Governor to change legislation that would require insurance companies in the state to pay for this the same as they would for in-person care. We got unanimous support and it went into law in 2012. We followed it with additional legislation to expand it into the home. In 2003 we were completely dependent on grant funding but eventually the contracted revenue sustained us. And now we have a robust statewide program because we have reimbursement for it and we have a business plan with our contracts that sustains it.
How do you handle the extensive logistical challenge of having so many spoke sites connecting on one network? From connectivity to hardware to software, telemedicine presents a daunting operational challenge.
HENDERSON: Ours really is a turnkey solution. We manage all the equipment, all the endpoints. We do the support and maintenance. We are on call 24 hours a day so nobody has to worry about how to understand telemedicine or how to deal with equipment, the network or connectivity when it doesn’t work in the middle of the night. We handle all of that. If anybody in the state wants our services, they can call and customize our program to their needs. So they may be a small hospital and they need pediatric services or they need all the way up to a connected EICU type model. We come up with an a la carte program basically, we develop the technology solution that’s the best fit to match all their needs; so that they don’t have redundant or duplicated efforts in their technology solution. We do all the IT assessment, put all that recommendation together. We purchase the equipment. We put it there. We manage it and maintain it. And then they pay for only the services that they need. It really makes it very easy for them.
One of the pieces is that we keep up to date with all the regulatory and privacy and security issues that they just don’t have the capacity to do. It’s hard enough for me. They already had a shortage of medical people. Well, guess what? They have a shortage of technology and legal folks and compliance folks and everything else. So we basically become the hub for all that type of information and we take the worry out of that.
You started in 2003 with 3 sites. Give us a snapshot of where you are today.
HENDERSON: We currently have 176 sites in the state, all linking to UMMC. And we’re not that big of a state. We have 2.9 million people in the state, and we’re signing contracts every week. And it’s not just hospitals and clinics. We’re in schools. We’re in community colleges and four-year colleges. We’re in businesses and in the home. We even have a mobile van, and we’re in the prison. We’re trying to create a web.
How has the impact of Telemedicine gone beyond healthcare, to the health of communities as a whole?
HENDERSON: These small communities and towns are dying. And if they have to close their hospital, the business community leaves as well. But for them to stay alive maybe they don’t need a hospital. Maybe they need a telehealth access point that brings the needed healthcare to them, but it’s at the right size that they can sustain financially. We’re asking: What does the healthcare model need to look like for our state and for each city? We have to think about the economic driver side of healthcare, which is essential if our state’s going to turn anything around and continue to bring businesses into the state. So telemedicine is a part of our business development at the state level. When a company comes here, I can have healthcare for their employees in the workplace, so they don’t have to worry about where they physically locate their business. Because that’s always a piece of that assessment: What’s the education system, the healthcare system and the workforce look like? I’m going to take a piece of that puzzle out of there and say that no matter where you go in Mississippi, I’ve got the healthcare for you.
Given how large this system is, describe for me what the center of the wheel, the hub, looks like. How does UMMC take care of these 176 sites.
HENDERSON: Last year we expanded and are off-campus from the medical center because we needed more space. But in our hub operation there is administrative, clinical and technical folks. And the center runs 24 hours. When you come in, there are several nurses that are interacting with patients. I have nurses that are doing the home remote patient monitoring program. Then I have nurses that are monitoring EICU beds and stepdown beds of patients that they need to monitor. So it looks like an air traffic control with screens everywhere. And we even do remote telemetry monitoring; so there’s lots of monitors and activity and video conferencing going on. And then I have nurse practitioners that are doing all of our corporate telehealth, employee health. So they have workstations where they are interacting with patients here as well.
If somebody wants to call for an appointment for telemedicine or schedule even education via our telehealth network, they call in and we schedule them for a provider. If they need a psychiatrist or a pediatric child development specialist, we schedule them into virtual clinics. We’re the connector between the healthcare provider, the physicians and the patients. If they need an acute service like ER, stroke or neonatology, that happens immediately. We connect it and push it to the on call physician for that service.
In the beginning, medical providers had to work physically in the center. But then we decided that that provision defeated the purpose of telemedicine. So now the ER has a dedicated space that’s off of the main emergency room in our trauma center. We can pull in the trauma doc or the surgeons if we need to. But with any of the other physicians that do telemedicine, we get into their workflow, rather than the other way around. We typically have a telemedicine workstation for them in their existing clinic, in their office, and a lot of them in their home. If it’s a service like a stroke neurologist, they have an iPad mini in their pocket so that they don’t have any delay in connecting.
We’re trying to be just as user friendly and accommodating to our physicians as we are to our customers. We have a master grid of who’s on for what at what time. And we’re the connector that makes that happen and schedule them or connect them immediately if it’s an emergency.
Looking back over the last decade, what would you have done differently?
HENDERSON: I wouldn’t have done anything differently. Of course, I say that now because it’s worked. But the challenge that we continue to have is just integration of information and sharing of information. So whether that be an image or an entire electronic medical record, that is still a challenge. We do not have one consistent way to do that because our customers don’t have one consistent workflow. We still have people on paper systems, so I can’t integrate with them. So how do I get that information to provide coordinated care that also creates a lifetime clinical record for the patient, that is in one place? It’s still a work in progress.
I also wish that there had been more communication and discussion when the health information network was being set up for our state. I think now it’s a little different, but when we first started the business, there was still a lot of distrust between health systems and sharing of information. I mean, information and data is power and money and so people don’t want to give it up. There’s things that we could have done much better and set up in a more coordinated fashion and saved money; instead of having fragmented systems that we’re going to now have to try to reconnect. So I think data sharing is the biggest challenge. Our health information network and our partnerships around the state have a good process for sharing data, but it’s still very time-consuming and very costly when these systems don’t want to talk to each other and then you have to pay for the interfacing and everything else.
What made a huge difference was centralizing telehealth for our institution. So doing that sooner would have allowed there to be a more organized strategy to roll this out statewide. But you know, it’s working now and I would say that I’d recommend that for any other institution that you centralize those efforts. To the customer it’s confusing if pathology, cardiology and radiology departments are all selling them different telemedicine solutions. I can assure you they’re buying equipment that’s redundant and duplicative, that would not have happened if you had coordinated through a central office that can keep up to date with all of that.
What are some of the best ways that you have found to get providers and consumers on board with telehealth?
HENDERSON: It’s interesting. When we went to pass the legislation for this at first representatives and senators were concerned that they didn’t need it. But we’d been touching lives around the state for years, so I’d say, “Go back to talk to your constituents.” It was a grass roots effort that we didn’t know we’d created. So the power and the voice of the individuals when they’re touched by this is very powerful. So having the consumer of these services be your champion and advocate is extremely powerful. So I would say that’s one of the most successful things that we have; is that we have people that are telling their story, that people are coming and doing documentaries on our program and they want me to take them places. They want me to fly them to Washington to tell people about what this has done for their life. And that’s far more powerful than me sitting up there doing a PowerPoint slide presentation about how this is going to change the world. When somebody with tears in their eyes says, “This saved my child’s life,” that’s huge.
But I think that the education piece has to go from every angle; from the political side, regulatory boards, medical community, health system administrators. And so our strategy has been to just knock on all of those doors and share the message. And once they hear it and word of mouth travels fast; so then all of a sudden you’re doing that every day. But I would say we can’t underestimate the need for the education; that until we create the value of this to whoever, whichever spoke of this audience we’re talking about, you won’t get the adoption and use and you’ll have a great idea that doesn’t get adopted.
How have you successfully gotten buy in from local legislators?
HENDERSON: The Governor formed the Mississippi Telehealth Association and one of their main objectives is education. I serve as the executive director for that program. One of the things we did was when the legislative session was about to begin, we polled what the agenda items were for all the representatives and senators. Then we went and had a dinner to talk about how telehealth can play a part in education; how it can play a part in prisons; you name it. Whatever the legislative agenda was, I could connect it to telehealth. It’s just eye opening.
You spoke in front of a Senate committee a few months ago I understand and explained the need for more federal support for these kinds of programs. What came of those hearings?
HENDERSON: I’ve done two now. The first one was to the Senate commerce committee and that one was really about advocating for continued funding and support of broadband connectivity because this can’t be done without the broadband connection. Then the next one was to approach the committee on the appropriations around rural healthcare. And my message there was very similar but to point out the fact that at the federal level we need to clear regulatory barriers to reimbursement and adoption of telehealth. And I know the concern at the federal level is: We’ll go broke doing this and there’s no true outcomes. Well, I’m here to tell you our Mississippi story, that we cleared those same barriers at the state level. And not only did we not go broke, we started improving our health and we lowered cost of care. So use us as your example to magnify the impact that this could have at a federal or national level.
So I think the biggest thing was that from the first one, the momentum built up to where I got invited to come back again just a few weeks later to testify to another group. And now I sit on several committees – the National Governor Association and National Council of State Legislators work groups on telehealth – to continue to try to give the information that’s needed to the right folks so that policy can be changed.
What are the legislative hold-ups? What’s the pushback?
HENDERSON: The biggest pushback is around reimbursement. There are I think 75 codes that reimburse for telemedicine, but there’s geographic restrictions on it. Because their thought is that we just need to do this in areas where they don’t have access. Well, anybody in an urban area can tell you how hard it still is to get in to a healthcare provider and it’s still inconvenient and so people don’t go. And so I think the misconception is that there’s not challenges in the urban areas to access to care. The other challenge is that they think people will abuse this and it’ll cost more money. If we give them access, they’re just going to spend more money and want to stay at the doctor all the time. Well, that’s just not the reality that we’ve seen.
How unique do you think Mississippi is? Or is this something that really can be replicated easily in most places?
HENDERSON: It can be replicated. It’s not about the technology. It’s about people and process. And so somebody has to take the time to go a little bit deeper than just buying a piece of equipment and saying: You’ve got telemedicine. Poof, it’s going to work. It takes nurturing. It takes relationships and partnerships. And you’ve got to have buy-in across the key stakeholders. And so it’s not an easy journey but it can be done. We did it here and we’re being asked to go and help other states all over the country replicate. And people are flying here from all over the world to look at what we’re doing. And I wish that there were some really magical secret thing that I could say: Go do this and you’ll have it. It takes time to build the necessary relationships with the citizens of the state and the key stakeholders.
Does there need to be a single dominant healthcare entity within the state to really be the hub? If there are too many players, is that an impediment?
HENDERSON: Yeah, that is an impediment and it’s something I’m dealing with now. We knew we had to clear barriers for our program to be able to flourish. But when I clear those barriers, that opens a great playing field for anybody in the entire world to come do telemedicine in Mississippi. And so of course the dollar signs are going off in people’s minds. Competition is good. The challenge with that it dilutes the effect because people don’t know who is what. Let’s say we have a hospital that I’m providing services to and then another group comes in and sells them a piece of telemedicine equipment. Now, who knows which one is for what? And the end user gets confused and so then they get frustrated because they can’t remember if this piece of equipment goes to UMC cardiology or if that one is for dermatology.
I don’t want people to create another network and put more equipment out there when the equipment’s there. So, I’ve pulled back to say my network is an open platform. So you don’t have to use our clinical services but use our technology and our infrastructure and don’t duplicate that and waste money. Clearly, there’s still technology vendors that are going to want to compete and run it themselves. But I do worry that there’s different levels of quality. There are some that don’t care and it’s just about the money; they are going to start tainting the reputation of telehealth if we don’t set a minimum standard. So at a national level, you know, I do worry. Do we need to have some kind of minimum standard for telehealth service providers?
Does there need to be one central location? Not necessarily. There could be multiple hubs and multiple spoke sites that still share. But there needs to be some type of strategy led at a state level.
You bring up the idea of competition. And this is certainly a hot market with hundreds of small businesses jumping in. Are there some emerging technologies that you’re particularly excited about in terms of their ability to help what you’re doing?
HENDERSON: They’re a dime a dozen coming out. It feels like every day. We’re actually building a new building that’ll open next year that’ll be our Center for Telehealth and Innovation. And a piece of that is a Living Lab where we’re going to let startups bring their product into a real life telemedicine scenario so that they can test it in a robust model.
One of the benefits of being in the program for this long is I can tell you where there’s still gaps and things aren’t good enough. And so working with the technology vendors to help address that puts us on the forefront to keep our competitive edge and keep us delivering the best solution at the lowest cost and has the most mobility and inner operability and all those things that are important. We want those companies and startups in our space, testing things, working through, brainstorming with us; so that we become a hub of innovation. Right now the target date is July of 2016 that we’ll move in, and we hope you’ll join us. Innovation doesn’t all have to happen in Silicon Valley.