September/October 2019 - Treating Our Patients with Telehealth

Sept/October 2019

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Treating Our Patients

Telehealth With

In This Issue: • • • •

Telehealth in the Metro – and Beyond Meet the new HCM Executive Director Mixed Results from Legislative Session Luminary of Twin Cities Medicine

“Your patients will thank you for referring them to Dr. Crutchfield.”

A FAC E O F A M I N N E SOTA DE R M ATOL O GIST Recognized by physicians and nurses as one of the nation’s leading dermatologists, Charles E. Crutchfield III MD has received a significant list of honors including the Karis Humanitarian Award from the Mayo Clinic, 100 Most Influential Health Care Leaders in the State of Minnesota (Minnesota Medicine), and the First a Physician Award from the Minnesota Medical Association, for positively impacting both organized medicine and improving the lives of people in our community. He has a private practice in Eagan and is the team dermatologist for the Minnesota Twins, Wild, Vikings and Timberwolves. Dr. Crutchfield is a physician, teacher, author, inventor, entrepreneur, and philanthropist. He has several medical patents, has written a children’s book on sun protection, and writes a weekly newspaper health column.

Dr. Crutchfield regularly gives back to the Twin Cities community including sponsoring academic scholarships, camps for children, sponsoring programs for children with dyslexia, mentoring underrepresented students from the University of Minnesota, and establishing a Dermatology lectureship at the University of Minnesota in the names of his parents, Drs. Charles and Susan, both pioneering graduates of the U of M Medical School, class of 1963.

As a professor, he teaches students at both Carleton College and the University of Minnesota Medical School. He lives in Mendota Heights with his wife Laurie, three beautiful children and two hairless cats.

AES

THET I C

L OF APPROVA L SEA

CRU TCHFIELD DERMATOLO GY

CRUTCHFIELD DER MATOLOGY Experience counts. Quality matters.

Mayo Clinic Medical School Graduate | University of Minnesota Dermatology Trained Top Doctor Minneapolis St. Paul Magazine | Best Doctors for Women Minnesota Monthly Magazine Team Dermatologist for the Minnesota Twins, Vikings, Timberwolves and Wild 1185 Town Centre Drive, Suite 101, Eagan | 651.209.3600 | www.CrutchfieldDermatology.com

September/October Index to Advertisers

Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Physician Co-editor Peter J. Dehnel, MD Physician Co-editor Thomas E. Kottke, MD Physician Co-editor Robert R. Neal, Jr., MD Physician Co-editor Marvin S. Segal, MD Physician Co-editor Richard R. Sturgeon, MD Physician Co-editor Charles G. Terzian, MD Medical Student Co-editor Zineb Alfath Medical Student Co-editor James Pathoulas Managing Editor Nancy K. Bauer Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Annie Krapek MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, Broadway Place West, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

For advertising rates and space reservations, contact: Betsy Pierre phone: (763) 295-5420 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

2

September/October 2019

Children’s Hospital.......... Outside Back Cover

TCMS Officers

President: Ryan Greiner, MD President-Elect: Sarah Traxler, MD Secretary: Andrea Hillerud, MD Treasurer: Rupa Polam Austria, MD Past President: Thomas E. Kottke, MD At-large: Matthew A. Hunt, MD

Clinical Scribes, LLC........................................21 Crutchfield Dermatology......................................

Inside Front Cover Fairview Health Services..................................31

TCMS Executive Staff

Ruth Parriott, MSW, MPH, CEO (612) 362-3799; rparriott@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com Kerry Hjelmgren, Executive Director, Honoring Choices Minnesota (612) 362-3704; khjelmgren@metrodoctors.com

HealthPartners.......................Inside Back Cover iCure ...................................................................... 4 Lakeview Clinic..................................................31 MedCraft..............................................................11 North Memorial Health..................................... 8

Lynn Betzold, Program Coordinator, Honoring Choices Minnesota (612) 362-3703; lbetzold@metrodoctors.com

PNC Bank.............................................................. 1

Annie Krapek, Program Manager (612) 362-3715; akrapek@metrodoctors.com

PrairieCare PAL..................................................28

Amber Kerrigan, Program Coordinator (612) 362-3706; akerrigan@metrodoctors.com

PrairieCare............................................................29

PSP/LifeBridge....................................................30 University of Minnesota Health....................26

Confidential Peer Support and Wellness Resources for Minnesota Physicians and Their Families www.psp-mn.com

Physicians Serving Physicians

Physicians Serving Physicians (PSP) is a discrete program that provides free peer support, mentoring, and referral to physicians, their families and colleagues who are affected by substance use disorders. For 35 years, PSP has supported physicians through recovery and successful return to practice. Find help at www.psp-mn.com or by calling 612-362-3747.

PSP has recently expanded its offerings to include wellness resources and four free, confidential counseling sessions through LifeBridge for all Minnesota physicians, residents, medical students, and their family members.

Learn more at www.psp-mn.com/wellness

MetroDoctors

The Journal of the Twin Cities Medical Society

CONTENTS 5

VOLUME 21, NO. 5 SEPTEMBER/OCTOBER 2019

IN THIS ISSUE

Welcome to a “Brave New World” By Peter J. Dehnel, MD

6

PRESIDENT’S MESSAGE

10 Activists for 10 Years By Ryan Greiner, MD

7

TCMS IN ACTION By Ruth Parriott, MSW, MPH, CEO TELEHEALTH

9 • Telemedicine: its Past, the Present and our Future

By Zoi Hills, MA, MHI 12 Page 32

• SPONSORED CONTENT:

The Evolution of Telemedicine in Hospital Care

By LeeAnn S. Heim, MHA and Jerome Siy, MD

14 • Allina Health Providing Access to Patients Near and Far via Telehealth

By Barb Andreasen 15

• Expanding Partnerships in Pediatric Virtual Care — the Children’s Minnesota Way

By Mark Bergeron, MD

16

• SPONSORED CONTENT:

Extending Access to Specialist Care via Telestroke: Treating Emergent and Non-Emergent Cases

By Christopher Streib, MD

18 Page 16

• Technological Advances in Women’s Health Care

By Lisa Saul, MD and Kathryn Komaridis, MS

19 • Project ECHO at Hennepin Healthcare

By Brian Grahan, MD, PhD 20 • Telehealth in Diabetes Management: Improving Health Through Innovation

By Thomas W. Martens, MD 22 • Telehealth in Psychiatry and Psychotherapy

By Todd Archbold, LSW, MBA 23 • Telemedicine and the Minnesota Poison Control System

By Travis Olives, MD, MPH and Lauren Prnjat, MPH • SPONSORED CONTENT:

Community Paramedicine & Page 7

Telehealth — Health Care at the Right Time and Place

By Peter Tanghe, MD and Dale Pampuch, CMPA

27

• Now a Chargeable Service—Remote Device Monitoring

Sept/October 2019

24

Doctors Metro MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

Treating Our Patients

Telehealth With

By Maureen Ideker, RN, BSN, MBA

28 • Environmental Health — Reducing Health Care’s Carbon Footprint with Telemedicine

By Aaron Rosenblum, MS2 29

Page 24 MetroDoctors

The Importance of Advance Care Planning Conversations: The Next Generation

By Kerry Gervais Hjelmgren

31 32

LUMINARY OF TWIN CITIES MEDICINE

Stanley M. Goldberg, MD

Spotlight on Books/In Memoriam/Career Opportunities

The Journal of the Twin Cities Medical Society

In This Issue: • Telehealth in the Metro – and Beyond • Meet the new HCM Executive Director • Mixed Results from Legislative Session • Luminary of Twin Cities Medicine

There is no question — telehealth is here to stay. Read how your colleagues are employing this new technology in the care of their patients. Articles begin on page 9.

September/October 2019

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IN THIS ISSUE...

Welcome to a “Brave New World” This edition of MetroDoctors describes the growing applications of telehealth in both the scope of services provided and the variety of settings available.

“Telemedicine” and “telehealth” are often used interchangeably. Classically, telemedicine is used for more illness and disease-specific activities in a virtual interchange with either patients or other clinicians. Telehealth technically refers to a broader scope of health-related activities, of which telemedicine is one example.

Formatted a little differently than our usual offerings, the articles begin with a very broad overview of telemedicine by Zoi Hills, MA, MHI. She has been a tireless advocate and supporter of telemedicine since the 1990s and provides great historical context for this topic, as well as a view of the opportunities that lie ahead.

Next are three examples from the perspectives of health systems on their use of telehealth services. The article by LeeAnn Heim, MHA and Jerome Siy, MD, highlights the implementation of telemedicine within the HealthPartners system. This spans the spectrum from Virtuwell, the online consumer-based program, to the ability of hospitalists based at Regions to connect with outlying hospitals in Minnesota and western Wisconsin. Burn care is another area of clinical activity, relying on the specialists in Regions Hospital Burn Center.

Allina Health Director of Telehealth and Regional Development, Barb Andreasen, describes how Allina is extending their care delivery. Since 2011, they have provided specialty services to communities in need and now are also providing home-based services in a variety of practice areas.

Mark Bergeron, MD describes the journey of Children’s Minnesota since entering into this arena in 2015. They initially provided pediatric emergency medicine support for a number of outlying hospitals. This outreach has now expanded to eight clinical areas, including some non-traditional partnerships with schools in the management of asthma.

We next turn to five articles on more specialty-specific programs. Christopher Streib, MD, writing for M Health, discusses the great advances in stroke care through the use of their Telestroke program. The eventual goal is to ensure that all people have access to comprehensive stroke care regardless of their location. Lisa Saul, MD and Kathryn Komardis, MS, highlight the

By Peter J. Dehnel, MD Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

value of virtual visits during pregnancy and the postpartum period as well as the added benefit of connectedness to other clinicians for pregnancy management. Project ECHO, a program of Hennepin Healthcare, as outlined by Brian Grahan, MD, PhD, describes their “innovative telehealth initiative to spread best practices in opioid and opioid use disorder management across Minnesota.” The Project ECHO format has been adapted by a variety of organizations nationally to help manage complex conditions at a local level. There is an open invitation for interested clinicians to join in this effort.

Thomas Martens, MD describes the work done at Park Nicollet’s International Diabetes Center. Telehealth greatly enhances touch points with patients, and this article also describes the considerable array of remote electronic options for glucose control. Todd Archibold, LSW, MBA describes how telehealth is being used at PrairieCare to help improve patient care and increase access to mental health professionals. Mental health is one of those areas where there is truly a lack of qualified professionals nationally, and telehealth is one way to help mitigate this shortage.

Three articles describing important affiliated programs follow.

Travis Olives, MD and Lauren Prnjat, MPH, of the Minnesota Poison Control Center discuss the earliest application of telemedicine — telephone care — and how that is still essential for the work of the Center. Peter Tanghe, MD and Dale Pampuch, CMPA describe how North Memorial Health Community Paramedics are able to deliver an expanded scope of service with telehealth support. Finally, Maureen Ideker, RN, BSN, MBA discusses how to charge and actually get paid for remote device monitoring — how novel!

The Environmental Health article in this issue focuses on how telemedicine has the potential to reduce the substantial carbon footprint of health care.

The Luminary of Twin Cities Medicine, Stanley Goldberg, MD is a shining example of a physician who has been able to combine strong academic involvement and a private practice career in colorectal surgery.

I truly hope you enjoy this edition of MetroDoctors.

September/October 2019

5

President’s Message

10 Activists for 10 Years RYAN GREINER, MD

Next year will mark the 10th Anniversary of the Twin Cities Medical Society. Some may not know that a merger in 2010 between the East and West Metro Medical Societies resulted in the formation of the Twin Cities Medical Society and marked the beginning of a new decade of activist physicians in the Twin Cities. Dr. Edward Ehlinger was the first president of the society and in his MetroDoctors inaugural address he beautifully summarized the call to action for this new organization: “At a time when our medical care system is costing too much and excluding too many, when our public health infrastructure is crumbling because of lack of sustained investment, and when urbanization is affecting the lives of everyone in our society, there arises a critical need for leadership — not just individual leadership but organizational leadership. Not only is there a challenge and opportunity for the TCMS to assume this leadership, there is also a profound responsibility to do so.”

I couldn’t have stated it better and the call to action continues. As TCMS approaches its 10th anniversary in 2020, I invite you to join me in preparing for a year of exceptional growth and impact. Below are just some of the initiatives to which members have devoted their time and expertise over the past decade. As you review, begin to think about the physicians you know who would welcome an opportunity to contribute to similar critical public health and healthcare issues…

Program initiatives: • Honoring Choices Minnesota — founder and leader among the state and region supporting advance care planning and education • Physicians Serving Physicians — management agreement to promote physician wellness and resources for physicians with substance use disorders • The Convenings — founder and local Emmy Award winning program promoting discussion of end-of-life care Public Health initiatives: • Public Health Advocacy Fellowship to mentor and engage medical students in activism • E-cigarette and cessation education for providers and support for Tobacco 21 policies • Environmental Task Force Advocacy work: • Reducing gun violence • Increasing access to care • Improving maternal and child health • Earned sick and safe time leave policy Educational webinars and forums: • Sponsor of Bounce Back Resilience Conference • Prediabetes: Turning the Tide webinar • Summer of Zika forum • Telemedicine forum Our future continues to be grounded in the partnerships and grassroots networks that have made our Medical Society engaged and successful. My challenge to you is “10 activists for 10 years.” Find 10 partners, colleagues, or friends to become members and set the stage for the next decade of the Society’s work. We are a home for your ideas, for your energy, and for your passion. Please join us in ensuring the next 10 years are as fruitful as the first and stay tuned for a year of celebration in 2020!

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September/October 2019

MetroDoctors

The Journal of the Twin Cities Medical Society

TCMS IN ACTION RUTH PARRIOTT, MSW, MPH, CEO

It is said that the only constant in life is change, and there were some big changes afoot at the Twin Cities Medical Society this past summer. First, Karen Peterson, who ran the Honoring Choices Minnesota program for the past five years, moved to the Minnesota Home Care Association. Those were some big shoes to fill, but we were quickly delighted to announce that Kerry Gervais Hjelmgren accepted the role of Executive Director of Honoring Choices Minnesota and came into the position with a keen vision for the future.

For the past two years, Kerry served as the Advance Care Planning Coordinator for Allina Health in Faribault and Owatonna. In that role, she successfully built an advance care planning program in two cities, complete with an active advisory council, education curriculum, and volunteer ambassadors. Kerry also piloted partnerships for advance care planning conversations in the Somali and Latinx communities, which parallels nicely with culturally appropriate models developed by Honoring Choices partners with American Indian and African American community organizations.

Prior to joining Allina Health, Kerry managed education and certification programs for Northfield Hospital and Clinics. She holds a BA from St. Olaf College and is currently earning her MS degree in Palliative Care from the University of Maryland. Kerry lives in Northfield with her spouse, five-yearold daughter, and a delightful bunch of orange cats.

Kerry has a personal and professional passion for advance care planning, which she shared during her remarks at MetroDoctors

the TCMS Annual Celebration in May. Her story had such an impact that evening we asked if we could share it with our entire membership in MetroDoctors.

Please read Kerry’s story on page 29 and I have no doubt you will join me in being thrilled to welcome her to the TCMS team!

There are few things more central to the mission of the Twin Cities Medical Society than advocating for change to promote health in individuals, families, and communities. There were several policy initiatives TCMS endorsed during the 2019 state legislative session that passed and are now being implemented: • As of August 1st, Minnesota’s clean indoor air law also prohibits the use of e-cigarette devices.

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The Journal of the Twin Cities Medical Society

$3 million was appropriated so that the Minnesota Department of Health can prepare to administer the state’s tobacco cessation Quitline when Clearway Minnesota sunsets in a few years. $150,000 was awarded to Reach Out and Read Minnesota, an organization that partners with pediatric

healthcare providers to provide a developmentally-appropriate book to families during each well-child visit from 6 months to 5 years of age.

• A medication repository was established that can donate unused, unopened medications from long-term care facilities to low-income patients under the care of a physician.

The 2019 legislative session also produced some big disappointments.

First, the two-pronged approach to gun violence prevention — criminal background checks and “red-flag” laws — did not come to a full vote in the legislature.

Societal shifts take time (remember mandatory seat belts, fluoride in public water, or smoking on planes?) and the approach to gun ownership is no exception. TCMS will continue to keep our membership updated on ways you can add your physician voice to the efforts to reduce injury and death from gun violence.

Second, the state appropriation for promotion of advance care planning was not renewed. This decision hit close to home for TCMS as Honoring Choices Minnesota (HCM) had received a grant from this source for the past two budget cycles. Luckily, HCM is financially healthy and its community and health system partnerships continue. However, the state grant supported several subcontracts, including those within the African American and American Indian communities. This health equity work is vital, so we are seeking other sources of support. More to come!

September/October 2019

7

Telehealth

Telemedicine: its Past, the Present and our Future Minnesota History

Minnesota planted its telemedicine roots in the mid 1990s with a few telemedicine projects, primarly funded by federal grants, that ended one way or another due to lack of funding, interest, provider availability, and/or patient adoption. However, despite all the failures and low interest by the health systems, hospitals and clinics, the flame of telemedicine was kept alive.

Today, 25 years later, almost every health system, and many of the hospitals and clinics in the state, urban and rural, are involved in some kind of telemedicine program. The telemedicine landscape has changed, not just in its adoption, but also the technology.

The first telemedicine program in Minnesota was initiated in 1994 with a grant from the Office for the Advancement of Telehealth (OAT) with one site, Tri-County Hospital in Wadena, MN. The grant was awarded to the University of Minnesota Medical School for three years. Two additional three-year grants followed allowing the project to continue and Fairview Health Services to become a partner creating the first telemedicine program in the state: The Fairview-University of Minnesota Telemedicine Network.

The program included six sites: five rural hospitals and one rural clinic. In August 2006, the grant ended, and with no funding, so did the program. However, with forward thinking by both the University of Minnesota and Tri-County

By Zoi Hills, MA, MHI

MetroDoctors

acknowledge some of the early adopters, teachers, and champions for their leadership, passion, enthusiasm and vision of this exciting phase and future in health care. The individuals that played a key role include (in no particular order): Ted Thompson, MD (deceased), James House, MD, Stuart Speedie, PhD, Stanley Finkelstein, PhD, Maureen Ideker, RN, MBA, and Robin Klemek, RN. Minnesota Telehealth Policy and Regulation

Hospital, the original program was terminated and under a new grant from OAT to Tri-County Hospital, a new telemedicine program was established: The Minnesota Telehealth Network. That program grew substantially with 32 sites in Minnesota and part of North Dakota. This program ended in August 2009 when the grant was not renewed by OAT. Around that same time, many of the health systems in Minnesota started or re-started telehealth programs. Today, nearly every health system has a telemedicine program offering different models and services. Initially, the care was provided by clinicians who were either part of the same health system or connected to that system. Today, these services are provided in various ways: within the same system; contracted with systems from another state (e.g. Avera eCare, Sanford, etc.); or contracted with a clinical services vendor (e.g.

American Well, Specialists on Call, etc.).

For this kind of success to have been achieved, it is important to recognize and

The Journal of the Twin Cities Medical Society

In June 2015 Minnesota passed the Minnesota Telemedicine Act to provide consistent reimbursement of healthcare services, which are provided both in-person, and via telemedicine technologies. This legislation played a key role in the initiation and development of many telehealth programs that exist today in our state. It is worth noting this is a payment parity legislation and one of the best policies in our region.

In addition, Minnesota has a teledentistry policy in place — one of the very few such policies in the country.

Key highlights of the telemedicine parity law: • The law requires parity of coverage AND payment for services provided either in-person or by telemedicine.  Commercial plans are prohibited from charging a higher co-pay or deductible for telehealth services.

• Limits eligible providers to those licensed healthcare providers able to

(Continued on page 10)

September/October 2019

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Telehealth Telemedicine (Continued from page 9)

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deliver the service within Minnesota in their established scope of practice, without direct supervision. In other words, any provider not qualified to provide and bill for a service without direct supervision by another provider cannot provide or bill for the service via telehealth.  MD (147), PA (147A), Chiropractors (148), Nurses (148.171), Speech Language Pathologists (148.511), Optometrists (148.52), Dieticians/Nutritionists (148.621), OT/OTA (148.6401), PT/PTA (148.65), Psychologists (148.79), Marriage and Family Counselors, Licensed Professional Counseling (148B), Social Work (148E), Alcohol and Drug Counselors (148F), Dentistry (150A), Podiatry (153).  Minnesota Medicaid does not consider Athletic Trainers and Doulas as eligible providers.  Providers NOT required to be covered include Pharmacists, Respiratory Therapists and Genetic Counselors. However, Minnesota Medicaid will cover Pharmacists and Genetic Counselors.

Payment of the originating site fee (Q3014) will not be covered (some commercial payers may cover).

An initial in-person visit is NOT required prior to seeing a patient using telemedicine.

Rural and/or professional shortage service area restrictions have been removed. Services can be provided via telehealth to all areas of the state.

Originating site of service restrictions have been removed. A patient can access services via telehealth from their home/apartment, place of work, nursing home, hospital, clinic, etc.

Telemedicine may be provided using real-time, two-way, interactive audio/visual communications, including secure video conferencing and September/October 2019

store-and-forward technology, which facilitates the assessment, diagnosis, consultation, treatment, education and management of a patient’s care.  Telephone, email and fax communications between providers are not included in the definition of telehealth.  Under Medicaid, telephone, email and fax communications between provider and patient are excluded from the definition of telehealth.

Commercial payers may pay for text visits.  For commercial payers, email and fax communications between provider and patient are excluded from the definition of telehealth.

It is currently unclear if telephoneonly encounters with the patient are included.  For Remote Patient Monitoring (RPM), beginning January 1, 2019, Minnesota Medicaid started to reimburse for Chronic Care Remote Physiologic Monitoring for three CPT codes: 99453, 99454 and 99457.

• Medicaid continues to limit telehealth/telemedicine services to no more than three visits per week. This limitation does not apply if the patient is in the hospital.

• The bill authorizes the Commissioner to establish criteria for patient safety protections and billing/documentation standards, which providers must attest to meeting to ensure the safety and efficacy of the telemedicine services provided.

What We Have Today and What We Might Have in the Future (Globally)

In the last decade, many changes have occurred in the telehealth space. Prior to 2007-2008, the majority of telehealth programs were the traditional hub and spoke model. Around that time, along with some major shifting in broadband, the genesis of the smartphone and mobile

devices, new areas in telehealth started to emerge. Some of these new areas include: telehealth education, telehealth research, supporting evidence, and direct-to-consumer telemedicine.

Telehealth education is provided by several sources: • The National Consortium of Telehealth Resource Centers, HRSA funded, provides training opportunities.

• Several local and national universities offer Master’s and PhD programs with telehealth concentration, medical education and telemedicine building.

• Numerous Health IT and related programs incorporate telehealth resources.

Telehealth research is growing. Some of the “starters” include: • Telehealth Centers of Excellence: Medical University of South Carolina and the University of Mississippi Medical Center were awarded grants from HRSA recognizing their roles for expanding the footprint of telehealth and providing models of care.

• Rural Telehealth Research Center, University of Iowa, funded by HRSA. • Supporting Pediatric Research on Outcomes & Utilization of Telehealth (SPROUT).

• Society for Education & Advancement of Research in Connected health (SEARCH).

Supporting Evidence: • Numerous systematic reviews.

• Far beyond “will it work,” “are users satisfied.”

• Outcomes data.

• Significant increase in telehealth specialty journals, society meetings.

• Technology/platform companies are consolidating.

• Big companies entering the market.

• Successful Direct-to-Consumer model(s).

• Patients want/demand for telehealth.

Direct-to-Consumer Telemedicine: There are many user-friendly models available to consumers offered by companies

MetroDoctors

The Journal of the Twin Cities Medical Society

focused on health systems, employers, retail stores, grocery stores, “Uber/Gym subscription” models, and apps for everything you can think of: dental, vision, women’s health, men’s health, smoking cessation, genomics, diagnostics, vitamins, hearing, hangover, skincare, pharmacy — the list grows daily.

What’s Ahead

Technology is unstoppable. Many of today’s technologies will probably be obsolete in the next decade. Some of the future technologies have already started to emerge and new ones that we have never thought about will dominate the way we communicate in the future. Here are a few that are already on the market: • Ubiquitous Sensors (wearables, smart pills, flexible sensor, smart wristband).

• Smart Environments (Smart Cities, Smart Transport, Smart Buildings, Smart Energy, Smart Industry, Smart Homes, Smart Health).

• •

5G Cellular networks/5G Mobile.

AI (Artificial intelligence).

for the benefit of the patient. We should be able to accomplish this by: • Educating and training the future healthcare workforce on how to utilize information to improve detection, diagnosis and treatment efficacy and efficiency.

• Empowering patients to acquire, manage and interpret healthcare data to make informed care decisions.

• Integrating information and care — any person, anywhere, anytime.

Non-Traditional Participants

The big players in the healthcare technology market have not yet come out of the woods, but we should not be surprised by what could come from companies like Google, Microsoft, Amazon or others.

Google will roll out a new tool to help health providers solve medical record challenges. Microsoft will launch HealthVault, a platform available to both businesses and consumers which will store personal health information and generate insights from it.

Amazon will reportedly sell software that reads medical records.

Zoi P. Hills, MA, MHI has worked in the field of telemedicine since 2002. Currently she is the Program Manager for Great Plains Telehealth Resource & Assistance Center (gpTRAC), a regional telehealth resource center and member of the National Consortium of Telehealth Resource Centers within the Institute for Health Informatics at the University of Minnesota. She can be reached at hills069@umn.edu.

Some Future Key Challenges

There is no longer a question of whether telemedicine is here to stay. It already has advanced 100% in the last decade. The challenges lie with the delivery of healthcare information and how it can be used

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Sponsored Content

The Evolution of Telemedicine in Hospital Care Contributed by LeeAnn S. Heim, MHA and Jerome Siy, MD

On-demand services have become the norm in the United States. We order groceries from smart phones and stream movies at home. Increasingly, though, people are expecting to receive health care in a more convenient way, too. Some of the big businesses that have redefined convenience are even creeping into the healthcare space.

Amazon, for example, partnered with J.P. Morgan and Berkshire Hathaway to create a healthcare company called Haven, which will LeeAnn S. Heim, MHA Jerome Siy, MD serve the 1.2 million combined employees of the founding companies (Farr, significantly among fee-for-service Part B 2019). While it’s still unclear how Haven beneficiaries. The most common type of will deliver on its claim of “…simplified, telemedicine, according to both CMS and high-quality, and transparent health care the Minnesota All Payer Claims Database, at a reasonable cost,” its arrival has already is telepsychiatry. Mink, Huckfeldt, Gildaffected competitors’ stock value and maremeister and Abraham in a Health Affairs ket share (Farr, 2019). The digital retail article noted that use of video telemedicine giant also purchased online pharmacy Pillin Minnesota between 2010 to 2015 was Pack, which can ship prescriptions to all highest among people with commercial 50 states. The move is yet another example insurance. These commercially insured of Amazon’s desire to make prescription telemedicine users were more likely to use drugs and health care more simple and afdirect-to-consumer telemedicine services, fordable (Ballentine, 2018). This paradigm typically provided by a Nurse Practitioner, shift is not unique to Amazon, though. while government insured individuals were Perhaps the most visible and widespread more likely to use real-time provider-inititactic healthcare companies are using to ated telemedicine services from a physician move healthcare technology forward is (Yu, 2018). Patients in metropolitan lotelemedicine. cations typically used direct-to-consumer In the past several years, telemedicine telemedicine models for acute primary care has expanded greatly in Minnesota and services whereas patients in nonmetropolthe nation. A Medicare Payment Advisory itan areas used real-time provider-initiated Commission report to Congress in 2018 telemedicine services for specialty care. noted that between 2006 and 2016 the This fact points to one of telemedicine’s number of video telemedicine services grew greatest opportunities: Improving access 12

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to specialty care where it’s currently not available. The country’s lack of behavioral health specialists is just one example of the current specialty care shortage (Duenow, 2017) — and likely one of the driving factors behind the use of telepsychiatry. Telemedicine can bring the specialist to the patient in their local community. Identifying gaps in care and leveraging digital tools wisely and strategically is essential to set the pace of telemedicine trends and how HealthPartners has grown telemedicine services across the organization and region.

Simple and Affordable

HealthPartners defines telemedicine broadly as the use of modern communications technology to exchange medical information from one person to another to improve health. This includes a growing variety of applications and services that use the phone, video, images, interactive online interview engines, email and other digital tools.

Perhaps HealthPartners’ most wellknown and popular online diagnosis and treatment service is Virtuwell — a 24/7 online clinic that saves consumers time and money by blending proven clinic practices with a refreshingly simple online platform.

Also popular among consumers who prefer interacting with their doctor is HealthPartners’ phone visits. Patients appreciate this option particularly for follow-up care and a variety of mental health conditions.

And coming soon is a new service called

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e-consults designed to save consumers time and money on getting expert specialty advice.

Telemedicine and Burn Care

Oftentimes, people mistakenly think about telemedicine as something only for simple things. But our experience at the Regions Hospital Burn Center debunks that myth. In fact, the Regions Hospital Burn Center, which is the leading burn treatment center in the five state region, has been using telemedicine since 1998 to reduce the burden on patients and families recovering from burns.

Most burns require a lot of follow-up care which often means lots of time off work and travel. So, the burn center developed a safe approach to make followup more convenient using live video technology.

Also, rural critical access hospitals are not large enough to support a fulltime burn team. But by capitalizing on modern video communications, Regions Burn Center physicians can participate in live consultations with local hospital staff to assess the severity of a burn and help determine if it can be treated locally. This helps patients and families get the expertise of a Level 1 Burn team, avoid unnecessary trips and save time and money. Using this telemedicine model, Regions Burn Center supports more than 60 rural locations and is growing.

Hospital medicine team collaborated with the Western Wisconsin Hospitals’ inpatient leadership to reimagine how overnight coverage could be done. The team uses data such as length of stay, readmission rates and patient satisfaction collected by the HealthPartners Institute’s Center for Evaluation and Survey Research (CESR), to inform and drive telemedicine innovation. In addition, the hospital telemedicine service changed the staffing model at these locations from a 1:1, one provider to one hospital, to a 1:3 staffing model; one hospitalist covers three hospitals for nighttime admissions. Hospital Medicine has grown to include nighttime coverage at St. Croix Regional Medical Center in 2017 and Hutchinson Health in 2018. This service is unique in that the telehospitalist completes a full admission advancing care overnight through video telemedicine so the daytime in-person clinician does not have to do the full history and physical the next morning. The initial virtual exam includes a head to toe assessment, including heart and lung sounds, a brief neurologic exam, check on edema, pupil dilation, abdominal exam and other functions facilitated by an RN acting as the hands of the Hospitalist. This results in patients seeing a doctor sooner, receiving care faster and going home quicker.

Overall satisfaction with the service has been positive by both patients and staff.

Rethinking Reimbursement?

More Connected Hospitals, Better Care

Before 2016, HealthPartners’ hospitals in Western Wisconsin — Hudson and Amery Hospitals, and Westfields Hospital in New Richmond — covered inpatient service with community primary care doctors who at times would have to go into clinic the morning after tending to hospital patients throughout the night. This created an unbalanced work/life and in some cases negatively impacted job satisfaction.

But HealthPartners hospitalists at Regions Hospital travel to these Western Wisconsin hospitals during the day and had the capacity to expand their hours to include overnight coverage. The Regions MetroDoctors

The biggest challenge facing the hospital telemedicine service is reimbursement.

Currently the Hospital telemedicine services are not eligible for reimbursement with several payers, including CMS. Because the service being provided is an initial inpatient visit, not a consult or outpatient visit, many payers do not recognize this as a service that can be provided over video telemedicine due to the need for a physical exam as a part of the H&P. The collaboration between the hospitalist and nursing staff to complete a comprehensive and thorough initial inpatient evaluation mirrors the in-person exam the hospitalist would perform when in-house.

This is especially important as the needs

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for — and benefits of — telemedicine continue to grow. Telemedicine is a welcomed disruption within the healthcare industry and has already demonstrated immediate, tangible improvements for care delivery. It will allow clinicians to better serve patients in communities near and far. As systems like HealthPartners continue to advance capabilities, reimbursement policy must also evolve so that patients can have better access to more affordable, convenient care.

LeeAnn S. Heim, MHA is Telemedicine Program Manager at HealthPartners, overseeing hospital-based telemedicine programs across the organization. Prior to HealthPartners, Heim also supported telehealth initiatives at the Minneapolis Veterans Affairs Medical Center.

Jerome Siy, MD is the Division Medical Director of Hospital Specialties for HealthPartners and practices Hospital Medicine across the HealthPartners system.

References 1. Ballentine, C. &. (2018, June 28). Amazon to Buy Online Pharmacy PillPack, Jumping Into the Drug Business. Retrieved from The New York Times: https://www.nytimes.com/2018/06/28/ business/dealbook/amazon-buying-pillpack-as-it-moves-into-pharmacies. html?module=WatchingPortal&region=c-column-middle-span-region&pgType=Homepage&action=click&mediaId=thumb_ square&state=standard&contentPlacement=1&versi.

2.

Duenow, L. K. (2017, March). A Mental Health Workforce Crisis: Roadmap for Enhancing Recruitment & Retention in Minnesota, Iowa & Wisconsin. Retrieved from MNSU.edu: http:// sbs.mnsu.edu/socialwork/mental_health_ workforce_policy_brief_final3_21_17.pdf.

3. Farr, C. (2019, March 14). Everything We Know About Haven, The Amazon Joint Ventur To Revamp Health Care. Retrieved from CNBC: https://www.cnbc.com/2019/03/13/ what-is-haven-amazon-jpmorgan-berkshire-revamp-health-care.html.

4. MedPAC. (2018, October 26). Medicare Payment Advisory Commission. Report to Congress: Medicare Payment Policy. Retrieved from MedPAC.gov: http://www.medpac.gov/docs/ default-source/reports/mar18_medpac_entirereport_sec_rev_0518.pdf?sfvrsn=0.

5. Virtuwell. (2019). Virtuwell. Retrieved from https://www.virtuwell.com: https://www.virtuwell.com/.

6. Yu, J. M. (2018). Population-Level Estimates of Telemedicine Service Provision Using An All-Payer Claims Database. Health Affairs, 1931-1939.

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Telehealth

Allina Health Providing Access to Patients Near and Far via Telehealth

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elehealth is changing the way patients access their providers and care. For Allina, telehealth has become a standard part of the care delivery services from the metro to the furthest reaches of Minnesota and Wisconsin.

Allina Health has been providing telehealth services since 2011 with 55 locations served over five states. More than 12,000 telehealth visits of all kinds were logged in 2018, nearly double the number of visits from the previous year, and we expect 20,000 visits in 2019.

From the patient perspective, it can feel just like another office visit. The high-definition, two-way screen and microphone allow the patient and provider to see and hear each other with amazing clarity. The visits are submitted to insurance payers in the same way as in-person visits.

Allina’s initial focus was to extend specialty access to communities that did not have the expertise. Telestroke was the first service implemented as a 24/7 service focused on early diagnosis for patients with stroke. Early detection and diagnosis is critical to improving patient outcomes and the goal is to treat these cases as soon as possible. Allina currently provides this service in 35 communities over three states.

It has become an important part of the Emergency Department (ED) services for these communities. The telestroke services have expanded to include follow-up visits and stroke intervention in the Medical/ Surgical units. They have also added inpatient neurology consultations and continue to grow this service.

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Shortly thereafter, Allina added a hospital-based mental health service in the ED that responds to patients experiencing a crisis related to mental health, helping some of the most vulnerable patients get the assistance they need at a critical moment. In participating Emergency Departments, these services are provided 24/7. In 2018, Allina added telepsychiatry services at all Allina hospitals. These services are available in all Emergency Departments, as well as some Medical/Surgical units and inpatient units to provide telepsychiatry consultations.

With the initial services in the ED going strong, Allina Health moved into the outpatient arena, introducing cancer genetic counseling consultations. This was quickly followed by the development of our outpatient cardiology service, referred to as teleheart. Allina provides consultations for general cardiology as well as electrophysiology, advanced heart failure, valve, vascular and cardiac surgery. Allina Health continues to add new outpatient services and currently provides: weight management, palliative care, integrative medicine, concussion management, pain management, and primary care.

Allina Health is expanding its services to patients at home. They currently provide weight management, integrative medicine, medication therapy management,

OB/GYN follow-ups, OB education, post-surgery follow-ups, and established patient services for primary care and Courage Kenny Rehabilitation Institute patients. These visits are known as virtual visits and are provided to patients on their own devices (smartphone, tablet, laptop, PC). Patients report high satisfaction and like the convenience of these visits.

Allina Health also provides remote home monitoring services to patients with chronic diseases. Patients receive a tablet with scale, blood pressure cuff and pulse oximeter. They take their measures and answer daily questions that are monitored by a nurse who connects with patients when data is outside normal parameters.

These patients are followed by a care management team and have been diagnosed with heart failure or COPD. Telehealth services will continue to expand across the continuum with a focus on senior care, complex care services, and expanding primary and specialty care services. This year Allina will transition its telehospitalist service from vendor-supplied to in-house with plans to expand over the next three years. The telehospitalist service is provided every night from 7:00 pm to 7:00 am at three Allina hospitals.

Barb Andreasen is the Director of Telehealth and Regional Development for Allina Health.

Her focus includes strategic planning, development, and deployment of services across the healthcare continuum and patient’s homes.

Barb has worked at Allina Health for 16 years. Her previous work includes project management consulting and implementation for two healthcare software vendors. Barb graduated from the University of MN.

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Expanding Partnerships in Pediatric Virtual Care — the Children’s Minnesota Way

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e know that 80% of a child’s health happens outside of a clinical setting, so how do we continue to innovate the way we reach and impact kids? Virtual care continues to reshape the healthcare landscape, creating innovative paths to forge new partnerships and providing a more patient-centric platform to improve quality of care. Children’s Minnesota has witnessed the success of virtual care in reaching past, present and future patients, often positively impacting outcomes. Through virtual care, Children’s offers a more convenient experience for patients, reaching them where they are, be it at a different hospital, local clinic, school or simply at home.

Development Children’s Minnesota began its journey with virtual care in 2015 when our Emergency Medicine department partnered with rural hospitals to provide physician-to-physician consults that support the delivery of care in the local community.

To reach kids at home, we expanded our virtual services to eight clinical areas: eating disorders, pain and palliative, sleep, diabetes, immunology, genetics, psychiatry, and psychology. By offering virtual follow-up for these clinical service lines, we aimed to lessen the burden on our patients. Patients who may have anxiety coming to a clinic for care or who commute long distances don’t have to bear the added weight of the trip.

Patients can instead choose how to follow-up with providers, further empowering them on their health journey.

Expansion While exploring opportunities beyond more traditional partnerships, Children’s recently

By Mark Bergeron, MD

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piloted a virtual care pediatric asthma program with a St. Paul school thanks to a generous grant from Kohl’s Cares. School nurses virtually connected with our clinicians while assessing a child and collaborated on treatment options. The feedback was striking. School nurses felt more empowered and patient families appreciated the virtual care that allowed their children to receive more immediate medical assistance, without the added stress of families leaving work.

Our latest virtual expansion has been in neonatology, focusing on how we can better impact the health outcomes of potential future patients. In 2018, Children’s Neonatal Virtual Care Program partnered with rural hospitals to provide consultations on post-delivery, acute-care services. Children’s Neonatologists and Neonatal Nurse Practitioners support local healthcare teams in neonatal situations we see daily, but may be more uncommon in community hospitals. We believe that simply being present virtually and acting as an extra set of eyes and ears can improve the physician’s self-efficacy and lead to greater confidence, as well as better outcomes. Virtual Care can also help the Children’s team improve care if the baby’s physician determines an infant requires transfer to Children’s NICU. But a more striking outcome, and one that has been noted by physicians nationally, has been a decrease in referrals to higher-level NICU centers as babies receive the care they urgently need in their local setting.

Challenges and the Way Forward Despite progress made, challenges in integrating virtual services are still common.

Some physicians are concerned about the quality of care delivered. There’s also a learning curve with technology and new

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considerations including how to present oneself or make a connection virtually.

Insurance, which continues to evolve, can sometimes present a barrier for patients.

With virtual care, there will always be some limitations, but a growing number of physicians and patients understand its value.

Children’s continues to map a course for other applications to support kids throughout the region. What new partnerships can be forged? How can we provide better care by partnering across the community — medical and otherwise? While we have made strides, the future is still ripe with untapped possibilities.

Mark Bergeron, MD, MPH is the Medical Director of Children’s Minnesota Special Care Nurseries, Neonatal Virtual Care and Associate Medical Director of Level IV NICU. Dr. Bergeron attended medical school at Creighton University in Omaha, Nebraska. He completed his Pediatrics residency at Doernbecher Children’s Hospital at The Oregon Health & Science University in Portland, followed by a Neonatal-Perinatal Medicine fellowship at the University of Minnesota. He holds a master’s degree in Public Health (Maternal and Child Health) from the University of Minnesota. He can be reached at: Mark.Bergeron@childrensmn.org.

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Sponsored Content

Extending Access to Specialist Care via Telestroke: Treating Emergent and Non-Emergent Cases Contributed by Christopher Streib, MD

Effective stroke care requires rapid response to stroke patients arriving in the Emergency Department and early specialist follow-up for secondary stroke prevention. The therapeutic window for getting effective treatment can be a matter of hours, and even within that time window, accelerating treatment by minutes improves clinical outcomes and prevents permanent neurologic injury.

After a stroke, secondary stroke prevention should begin immediately. Stroke patients are at high risk of recurrent stroke, especially in the days to weeks after the initial stroke. Stroke patients, however, often face significant delays in evaluation and treatment, especially in hospitals without on-site stroke specialists. Some stroke patients will never even see a stroke specialist for their emergent evaluation or optimization of secondary prevention.

Telemedicine has helped make neurologists and stroke specialists more accessible to patients experiencing stroke or stroke symptoms. Through telemedicine technology, aka telestroke, patients can receive a specialist assessment and be treated in their local hospitals, even if they are far from advanced stroke teams or comprehensive care centers.

Telestroke directly connects a centralized stroke specialist physician with the stroke patient. The telestroke cart is an advanced, two-way, HIPAA-compliant audiovisual connection and video system. The physician can be seen on the 16

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telestroke screen and is able to interact with the patient and families and also perform the neurologic evaluation in real time via the audio-visual connection. The physician has far-end camera control, allowing them to zoom in on the subtlest exam findings in order to clearly visualize signs of stroke. In addition to the neurologic exam, the patient’s emergent neuroimaging and laboratory studies are available through the electronic medical record. Armed with this information, the telestroke physician is able to work together with the remote medical team to determine if emergent interventions are indicated.

Telestroke is proven to increase the number of stroke patients who receive intravenous tissue plasminogen activator (aka “the clot-buster”) and endovascular thrombectomy. University of Minnesota

Health stroke neurologists located in our comprehensive stroke centers, the University of Minnesota Medical Center and Fairview Southdale Hospital, utilize telestroke to provide emergent stroke coverage to other hospitals in the Fairview system. Since emergent telestroke coverage was initiated at Fairview Ridges Hospital in 2018, for example, almost 20 stroke patients have received the intravenous clot-buster medication (Alteplase), an increase of over 300%. Additionally, the clot-buster medication is being given more rapidly, which leads to improved outcomes.

Telestroke is commonly used to treat stroke patients who present in the Emergency Department and who have the most severe strokes that could lead to disability and death. For our team, by facilitating specialized assessment and rapid interventions, the technology has helped improve outcomes. In one case, our team was called to evaluate an otherwise healthy 45-year-old male who had developed the inability to speak or comprehend language. As the patient was sent to the CT scanner, I reviewed his scans and was waiting on the telestroke cart screen to examine him before he returned to his room. I spoke with the patient’s wife, who provided the medical history, which, in conjunction with his physical exam, confirmed he was an ideal candidate for the clot-buster drug.

The neurointerventional team was also activated simultaneously. The patient

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received the clot-buster treatment and subsequently underwent successful endovascular thrombectomy. Later that day, the patient began to regain his normal speech. Supported with telestroke, timely intervention resulted in an excellent recovery and discharge home.

The University of Minnesota Health stroke team also utilizes telestroke technology in a novel way: to conduct follow-up inpatient evaluations and non-emergent stroke care. Up to 80% of follow-up strokes in patients with a stroke or mini-stroke can be prevented.

With the assistance of telestroke, our partnership between University of Minnesota Health stroke and neurocritical care specialists and the Fairview Hospital system can ensure that all stroke patients are evaluated by a stroke specialist in order to minimize the risk of recurrent stroke. As my colleague Jae Kim, a stroke specialist and interventional neurologist, explains, the approach is “a logical extension of telestroke coverage in the Emergency Department.”

This use of telestroke can also help reduce expenses and improve patient outcomes and satisfaction. Before inpatient telestroke, over 50% of stroke patients were transferred from Fairview Ridges to Fairview Southdale Hospital.

Telestroke allows us to keep most stroke patients in their community hospital, while still receiving stroke specialist care.

This was the case for one stroke patient of mine. The patient had experienced a MetroDoctors

Telestroke system at Fairview Southdale Hospital (patient not pictured). ©Fairview Health Services

vertebral artery dissection, which caused a small stroke in the back of the brain, making it difficult for her to walk. In the past, patients with this condition would have required transfer to a specialist center. After examining this patient via telestroke and reviewing her neuroimaging, however, it was clear we could manage her condition without requiring transfer. Telestroke allowed the patient to see stroke specialists without incurring the costs of transfer or being moved away from friends and family for the hospitalization. For patients that live some distance from comprehensive stroke centers, this is a huge benefit.

In fact, an essential part of our mission is to give patients the opportunity to see a stroke specialist and get the best possible care in their own community hospitals. After initiating telestroke, Fairview Ridges Hospital is transferring only 20% of its stroke patients compared to more than 50% previously. In response to the success of inpatient telestroke, University of Minnesota Health and Fairview are collaborating to expand emergent and inpatient coverage throughout all Fairview-legacy hospitals by the end of 2019. This includes hospitals as far away as Grand Itasca in Grand

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Rapids and Fairview Range Hospital in Hibbing.

Living at a distance from a comprehensive stroke center should not mean that you are less likely to get critical stroke interventions or that you are at higher risk of recurrent stroke: everyone should have access to stroke specialist care. A comprehensive telestroke program helps to ensure that these resources are available whenever and wherever patients need them the most. We’re very excited about how the use of emergent and inpatient telestroke has improved stroke care and see many additional opportunities for expansion, including staffing urgent transient ischemic attack clinics, conducting routine outpatient follow-ups, and offering opportunities to participate in cutting-edge clinical research into stroke.

Christopher Streib, MD, is a vascular neurologist and University of Minnesota Health and Fairview South Region Stroke Director. He is a member of the American Academy of Neurology, the American Heart Association, and the Society of Vascular Interventional Neurology. At the University of Minnesota, he serves as the Fellowship Program Director of the medical school’s Vascular Neurology Fellowship.

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Telehealth

Technological Advances in Women’s Health Care

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ealth care is rapidly changing, but the women’s health landscape has been slow to respond — until now. From convenience and information at one’s fingertips to the provision of the highest quality care for the most complex patients, technology is having an impact at every point along a woman’s healthcare journey. Allina Health is leveraging digital technologies to help educate mothers about their pregnancies, improve the convenience of obstetric appointments, address mental health concerns during pregnancy and following the birth of their baby, and enhance connections between providers to improve access to timely consultation.

In response to patients’ desires to receive high quality, clinical information in a more direct and interactive way, we moved away from providing patient education in a static didactic fashion and transformed the journey with interactive education and planning tools through our “Beginnings: Pregnancy, Birth, and Beyond” app. The app is designed to allow patients to receive valuable information about pregnancy, birth and newborn period, and also to play an active role in her health care along the way.

Recently noted by Becker’s for its quality and delivery of clinical content, the Beginnings app provides week-by-week pregnancy health information that allows mom to track her pregnancy journey and her baby’s developmental milestones. A trimester-by-trimester to-do list helps guide preparations that can be overwhelming for families. These tools enable the patient to be more engaged in her care, and provide a convenient tracking

By Lisa Saul, MD and Kathryn Komaridis, MS

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mechanism for information and questions that can be shared with her provider.

Research has shown that digital visits are a viable option in pregnancy, and to ease the burden of the usual 14 visit prenatal course and meet patients’ needs, we have begun offering a virtual visit for the initial nursing education visit in pregnancy. Targeting experienced mothers, virtual visits are conducted securely within the Epic medical record and the patient’s MyChart tool. Using a real-time video stream, the patient and the obstetric nurse can complete their visit anywhere the patient has an internet connection, whether that is on her computer or smartphone.

Before the visit, the patient is sent an email to test the equipment and ensure that the virtual visit will work for her; if it does she follows the link that is provided. The visit is conducted much as an in-person visit would be, and the nurse can show items via the video screen. The “Beginnings: Pregnancy, Birth, and Beyond” app is referenced in the visit as the patient’s primary education tool to guide her pregnancy.

While technology can enhance the connection between the patient and her provider, it also serves to connect providers to one another. Reliable, timely access for patients is important to provide necessary care, prevent the escalation of psychiatric symptoms, and improve the patient’s ability to manage her medical conditions. When an obstetric provider has a concern about a patient’s mental health, he or she can request an electronic psychiatric consult via a routed telephone encounter, including the assessment and recommendation — all within the medical record. A psychiatrist will conduct a thorough chart review and make medication and/or intervention recommendations within one business day. When the assessment

Lisa Saul, MD

Kathryn Komaridis, MS

need is more immediate, such as the need to assess a patient in labor or newborn baby, our telemedicine program allows the patient to remain in their community and receive a needed consultation, giving the referring provider the information and support they need to manage her care. The availability of this service increases timely access to needed support.

With an emphasis on supporting the patient and family in her healthcare journey, Allina Health is focused on building programs that will capitalize on new and emerging technologies.

Dr. Lisa Saul is the President of the Mother Baby Clinical Service Line at Allina Health.

She leads quality improvement, facilitated care model improvements for those patients at highest risk, and program/service developments that improve the health of our community and address care disparities. In addition to her role as president, Lisa works as a perinatologist with Minnesota Perinatal Physicians. Her area of clinical focus is fetal cardiology.

Kathryn Komaridis, MS has more than 10 years of experience in healthcare administration and for the last three years has worked in Allina’s Mother Baby Clinical Service Line as the Director of Operations covering Allina’s perinatology, obstetric hospitalist, and midwifery practices.

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Project ECHO at Hennepin Healthcare

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ennepin Healthcare is leading an innovative telehealth initiative to spread best practices in opioid and opioid use disorder management across Minnesota using a tele-mentoring program called “Project ECHO.” In collaboration with other ECHO hubs, we help communities develop a comprehensive response to the opioid epidemic by mentoring clinicians and teams to screen for problematic opioid use, diagnose and triage appropriately, then manage opioid use disorder (when present) in clinic with buprenorphine and other office-based approaches. As the landscape around pain management and addiction care rapidly changes, our program’s practical mentoring can turn clinical headaches into rewarding professional and clinical relationships.

Project ECHO links a set of experts to healthcare teams in any Minnesota community via a user-friendly videoconference platform. Created at the University of New Mexico, Project ECHO’s goal is to build local capacity to manage complex conditions.

Our Integrated Opioid and Addiction Care ECHO connects addiction medicine and behavioral health experts with primary care teams state-wide who seek education and support to care for patients with potentially problematic opioid use, including addiction. Funded by the Minnesota Department of Human Services, we partner with Catholic Health Initiative’s St. Gabriel’s clinic and Wayside Recovery Center. To date, we have worked with over 86 organizations and 40 communities to provide better care for people who have potentially problematic opioid use.

How ECHO Works Each Project ECHO session facilitated by the Hennepin Healthcare team includes a

By Brian Grahan, MD, PhD

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brief 15-20 minute lecture on a given topic (e.g., concurrent opioid and benzodiazepine management, opioid use disorder diagnosis algorithm, etc.) and 30-35 minutes of case-based learning, where healthcare professionals present de-identified cases to the learning community and discuss clinical issues with the specialist hub team and other community partner spokes. All teach, all learn. All types of healthcare professionals are welcome. Sessions are held over the lunch hour on Thursdays.

Expanding Project ECHO The Project ECHO program at Hennepin Healthcare is expanding their scope to include additional types of support and education. As part of Minnesota’s opioid-focused ECHO initiatives, we work with CHI-St. Gabriel’s, Minnesota Hospital Association, and other partners to offer buprenorphine boot camps. These 2-day, immersive in-person boot camps give healthcare teams (providers, nurses, social workers, and administrators) the nuts and bolts details they need to start appropriately managing people with opioid use disorder, as well as kickstart the relationships to support ongoing tele-mentorship provided via ECHO sessions.

In addition, this fall we will launch two new ECHO programs. The Midwest Tribal ECHO is a partnership with the Native

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American Community Clinic in Minneapolis to address opioid and addiction care specific to Native American communities, which have been severely affected by the opioid epidemic. Hennepin Healthcare will also start Minnesota’s first Viral Hepatitis ECHO to help clinics manage hepatitis B and C locally. This effort will be the first Project ECHO program in the nation to specifically address the management of HBV infection. We are committed to increasing the scope of topics available in response to clinical demands in rural and underserved communities.

How to Join ECHO Healthcare professionals from across Minnesota are invited to join Project ECHO sessions at any time. Project ECHO welcomes physicians, advanced practice providers, nurses, psychologists, counselors, social workers, healthcare administrators, community health workers, pharmacists, and public health practitioners to join the sessions.

Integrated Opioid and Addiction Care ECHO sessions are held every Thursday 12:15 to 1:15 pm. Professionals can register to receive emails about the ECHO programs through the website below, and then join ECHO sessions via links to the weekly video conferences.

To learn more about Project ECHO visit hennepinhealthcare.org/echo.

Brian Grahan, MD, PhD is the lead for the Project ECHO program at Hennepin Healthcare. Dr. Grahan focuses on the care of people with substance use disorders as well as the social, medical, and psychiatric conditions that often occur together. His PhD work focused on the behavioral economics and outcome measurement issues related to substance use in adolescents and young adults.

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Telehealth

Telehealth in Diabetes Management: Improving Health Through Innovation

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he management of diabetes, especially for individuals requiring insulin, can be a significant burden in terms of optimization of therapy.

Optimized glycemic management requires frequent titration of medication, and insulin-based management requires modification of dosing in response to daily schedules, diet, illness, changes in activity, and many other variables that can be difficult to predict or quantify. It is therefore not surprising that the A1c goal is the least likely of the “Minnesota D5” diabetes quality measures to be met,1 and that individuals managing their diabetes with insulin have the most difficulty in optimizing glycemic management.

Frequent touchpoints with the healthcare system allow titration and optimization of medication management in diabetes, but can be a significant burden to patients in terms of inconvenience and time requirements for clinic-based visits. Value-based care models hold the promise of improved health for populations, but also intensify the strain on patients and clinicians to optimize glycemic metrics.

Recent innovations in diabetes technology, combined with the widespread use of connected technologies — smartphones, apps, and cloud-based data sharing — have created significant opportunities to improve health by remote management. By allowing blood glucose data from fingerstick blood

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glucose monitoring or continuous glucose monitoring (CGM) to be transmitted easily from patient-managed devices to cloud-based repositories or EMR systems, data can be reviewed remotely, allowing titration and lifestyle-based management outside of traditional clinic visits. Currently available continuous glucose monitor (CGM) technology, for instance, allows both real-time glucose data to be easily available on a reader or smartphone, without fingersticks, while at the same time seamlessly transmitting data to a cloud-based repository where it can be viewed by patients, caregivers, and clinical care teams remotely and retrospectively. With the evolution of payment models, and the development of systems to support clinicians in managing care remotely, telehealth management of diabetes is poised to become a significant advance in optimizing diabetes care.2 The HealthPartners care system has made considerable progress in leveraging this opportunity to improve patient care.

Park Nicollet’s International Diabetes Center (IDC) has been a national and international leader in developing the tools and technology to manage diabetes care remotely. The IDC has pioneered the development of the Ambulatory Glucose Profile, a standardized single page report designed to simplify the interpretation and management of downloaded or remote glycemic data as provided by both fingerstick and CGM glucose monitoring .3,4 The Ambulatory Glucose Profile has become a recognized standard for evaluation of glycemic data and is rapidly being adopted by the diabetes device industry. The IDC also supports a broad diabetes research program and is actively involved in studies of both automated insulin delivery systems, and the use of remotely-accessed and retrospective CGM data to optimize the management of type 1 and type 2 diabetes.

Innovations developed by the IDC and others are already allowing specialists in the departments of Endocrinology and Pediatric Endocrinology at Park Nicollet and HealthPartners to improve the care of individuals with type 1 diabetes by managing insulin-based therapy using remote cloud-based data. Access to glycemic data at times other than clinic visits allows optimization of therapy by titration of therapies between visits, decreasing the burden on patients and improving the efficiency with which clinicians can help individuals reach their diabetes goals.

Advances in diabetes technology are making inroads into the world of

MetroDoctors

The Journal of the Twin Cities Medical Society

primary care and type 2 diabetes management. Based on decreasing costs of this advanced technology and increased availability to the type 2 diabetes population, coverage by insurers has improved as has connectedness. These advances create the potential for data to be made available to clinicians seamlessly through smartphone devices and cloud-based technology.5 Our organization is actively building the systems to allow our primary care clinicians to access this data securely, and with minimal burden to patients.

Remote management of diabetes using telehealth technology and connected devices holds the promise of both optimizing glycemic metrics, while at the same time dramatically decreasing the burden of care for individuals with diabetes.6,7 As the American healthcare

system moves to performance-based and value-based reimbursement models, telehealth management of glycemic metrics will likely be not just another tool, but the dominant tool, in revolutionizing the care of individuals with diabetes.

Thomas W. Martens, MD is an internal medicine physician with a primary care practice at Park Nicollet’s Brookdale office.

He works as a medical director at Park Nicollet’s International Diabetes Center, where he is involved in diabetes research, diabetes education and quality improvement. Dr. Martens received his medical degree from the University of Wisconsin and completed an Internal Medicine residency at Hennepin County Medical Center. He is board certified in Internal Medicine.

He can be reached at: thomas.martens@ parknicollet.com.

References: 1. https://www.health.state.mn.us/diseases/ diabetes/diabetes-dashboard/index.html#CareGoals accessed 22 June 2019.

2. Klonoff DC. Using telemedicine to improve outcomes in diabetes—an emerging technology. J Diabetes Sci Technol. 2009;3(4):624–628.

3. Johnson ML, Martens TW, Criego AB, Carlson AL, Simonson GD, Bergenstal RM. Utilizing the Ambulatory Glucose Profile to Standardize and Implement Continuous Glucose Monitoring in Clinical Practice. Diabetes Technology & Therapeutics. May 2019. Vol. 21 S2: 17-25.

4.

International Diabetes Center. AGP—Ambulatory Glucose Profile [Internet]. Available from http://www.agpreport.org/ Accessed, 23 June 2019.

5. Hirsch IB, Wright EE. Using Flash Continuous Glucose Monitoring in Primary Practice. Clinical Diabetes 2019 Apr; 37(2): 150-161.

6.

Lee SWH, Chan CKY, Chua SS, Chaiyakunapruk N. Comparative effectiveness of telemedicine strategies on type 2 diabetes management: a systematic review and network meta-analysis.

Sci Rep 2017;7:12680.

7.

Faruque LI, Wiebe N, Ehteshami-Afshar A, etal.

Effect of telemedicine on glycated hemoglobin in diabetes: a systematic review and meta-analysis of randomized trials. CMAJ Mar 2017, 189 (9) E341-E364.

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The Journal of the Twin Cities Medical Society

September/October 2019

21

Telehealth

Telehealth in Psychiatry and Psychotherapy

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he history of telehealth dates back over a century, first documented in the Lancet in 1879 referencing the use of the telephone to reduce unnecessary office visits. Societies have been able to leverage various technologies to improve wellbeing for as far back as any historical record exists. Examples range from Morse code to now encrypted video and wireless biometric data transfers. Humans have been able to find creative and adaptive ways to communicate with one another, especially when in crisis — such as severe health conditions and life-threatening situations. No longer are such factors like distance, geography, or time zones an impediment to providing immediate information exchange.

Modern medicine has significant advantages today thanks to telehealth platforms that allow for timely exchange of critical patient information, encrypted video feeds, biometric monitoring, assessment, and more. Rural areas have the most to gain by vastly increasing access to specialists across the country and reducing the need for travel and waitlists. In the field of mental health, timely access to psychiatrists, psychologists, and psychotherapists has been a barrier to individuals receiving care nationwide. Underneath the barriers in access to mental health care is a fundamental shortage of these specialty clinicians. The issues of both access and the shortage are equally distinct problems; however, telehealth services can offer relief for both.

Where shortages of mental health professionals are less profound, televideo has

By Todd Archbold, LSW, MBA

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the potential to expand their reach and allow for more individuals to get care. Unfortunately, the shortage of psychiatrists, in particular, means that televideo does not add capacity — only creates opportunities to distribute services more evenly. In many ways, high-quality televideo is perfectly suited to help enhance the reach of mental health professionals. As long as a patient is safe and does not have additional medical complications, the clinician’s assessment and treatment methodologies focus mostly on verbal exchange, body language, and processing thoughts and emotions.

There is rarely a need for actual physical interaction. Oftentimes patients report that televideo allows for a more private, safe, and convenient experience. Other telehealth features, like online scheduling and screening, make it easier to connect patients with mental health care which can otherwise be a confusing and even stigmatizing process.

PrairieCare has been using a variety of telehealth features to provide more efficient care that is also aimed at improving the patient experience. PrairieCare has developed a secure televideo platform (prairiecareonline.com) that is offered to patients who have barriers to transportation. Patients are easily able to message clinicians and schedule appointments by video. This platform is also used in collaboration with other organizations ranging from residential treatment programs, primary care clinics, and schools. This has allowed psychiatrists from PrairieCare to provide highly specialized and sought-after

care directly to those settings eliminating the need for either the patient or doctor to have to travel, and allowing for care to be provided in a familiar and comfortable setting.

PrairieCare Medical Group manages the statewide Psychiatric Assistance Line (PAL), while leveraging a public online portal to allow healthcare providers to expeditiously access psychiatric consultation through online scheduling, messaging, and telephonic triage. This service is funded through a grant from the Department of Human Services and is aimed at connecting primary care providers to psychiatrists for consultation on cases, and also enhancing training and education on evidence-based mental health treatments.

The team at PAL has been able to provide thousands of consultations over the years due to the convenience and efficiency of telehealth capabilities.

Todd Archbold is a licensed social worker and the Vice President of Business Development at PrairieCare. tarchbold@prairie-care.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

Telemedicine and the Minnesota Poison Control System

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hen it comes to telemedicine, many people think of newer technology such as virtual provider visits or videoconferencing. However, certain forms of telemedicine have been around for decades.

Poison control centers are one example as they handle millions of phone consultations each year with both patients and providers.

About Poison Control Centers The Minnesota Poison Control System (Poison Center) has served the residents of Minnesota since 1972 and is designated by the Minnesota Department of Health (MDH) to provide medical treatment recommendations for poisonings and drug overdoses to the entire state. It is one of only 55 poison control centers accredited by the American Association of Poison Control Centers (AAPCC), which sets stringent criteria to ensure quality service and care.

All AAPCC-certified poison control centers share the same Poison Help phone number, 1-800-222-1222. This free service is HIPAA-compliant and operates 24 hours a day, 365 days a year. Each center answers calls from a designated geographic area, including calls from the public, emergency medical services (EMS) personnel, and healthcare providers. Anyone calling from Minnesota is connected to the Minnesota Poison Control System, which manages over 60,000 poisoning cases annually.

Who Answers the Phone Pharmacists with specialized toxicology certification who are supported by board credentialed physician toxicologists staff the Poison Center. The Poison Center is fortunate to have consultants who provide specialized knowledge in a variety of fields including plant and mushroom identification,

By Travis Olives, MD, MPH and Lauren Prnjat, MPH

MetroDoctors

Additionally, the Poison Center provides poison treatment recommendations to EMS personnel while they are on scene. This is especially helpful for rural areas, where the nearest hospital may be a significant distance away.

snake bite treatment, hyperbaric medicine, radiation, as well as occupational and environmental toxins.

Benefits for the Public The Poison Center’s staff has over 300 years of combined experience in managing poisoning and overdose cases. When a Minnesotan calls the Poison Center, specialists are able to immediately assess the situation and provide poisoning triage and treatment recommendations. This wealth of knowledge and experience allows over 90% of callers to be safely managed at home. In addition to providing immediate reassurance, the Poison Center saves taxpayers millions of dollars every year by preventing unnecessary use of ambulance services and emergency department visits. Studies conservatively estimate for every dollar spent on poison control centers, $13.39 is saved in healthcare costs and lost productivity.

Benefits for HealthCare Professionals The Poison Center also provides telemedicine support for healthcare professionals, with providers accounting for 30% of its annual case volume. For patients with more serious poisonings which require specialized medical care, poison specialists offer upto-date cutting edge advice. Poison Center experts will talk with the physician and care team to develop a patient-specific treatment plan and monitor the patient until discharge.

The Journal of the Twin Cities Medical Society

Public Health Surveillance The Poison Center collects data in real-time, making it an important resource for allhazards exposure and illness surveillance. In partnership with the AAPCC, MDH, and federal agencies, the Poison Center provides early warning signs of a public health event.

Collected data can provide information on substances, clinical effects, and severity, allowing the Poison Center to alert the appropriate agencies in the event of a poisoning that is a threat to public health.

Summary The Minnesota Poison Control System provides vital poison exposure and information services over the phone to both the general public and healthcare professionals across the state. Furthermore, the Poison Center’s real-time data collection contributes to public health surveillance throughout Minnesota.

To learn more about the Minnesota Poison Control System’s services as well as its public and professional education programs, visit mnpoison.org.

Travis Olives, MD, MPH is Associate Medical Director of the Minnesota Poison Control System and practices emergency medicine and medical toxicology with Hennepin Healthcare in the HCMC Emergency Department.

Lauren Prnjat, MPH is the Poison Center’s public educator and is responsible for planning outreach, awareness, and prevention efforts.

Reference The Lewin Group, Inc. Final Report on the Value of the Poison Center System. 2012. http://bit.ly/1ANfdnt.

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Sponsored Content

Community Paramedicine & Telehealth— Health Care at the Right Time and Place Contributed by Peter Tanghe, MD and Dale Pampuch, CMPA

North Memorial Health Community Paramedics are delivering nonemergency care to people in their homes or wherever is most convenient for the customer. Several studies show that an estimated 33-50% of all ambulance transports are being used for non-emergent care* according to the National Association of EMS Physicians.

Community paramedicine helps people use healthcare resources more cost effectively and often with better outcomes.

While most people have insurance and access to a physician, many face obstacles to staying healthy and accessing care with barriers like financial poverty, poor health literacy and fragmented support systems.

Community paramedics ensure customers get what they need by helping them access medical care as well as community resources like emergency food, social services and transportation.

Community paramedics use telehealth daily to connect with the program Medical Director and other healthcare providers to perform healthcare assessments, provide prescriptive services, follow-up care after a discharge, wound care and more. Telehealth allows North Memorial Health Community Paramedics to connect customers and doctors quickly and efficiently while they deliver care tailored to the customer’s needs. Telehealth also reduces physician drive time, enabling them to care for more people throughout the community.

North Memorial Health Community Paramedics partner with primary care provider teams to coordinate all aspects of care while they are in the customer’s home environment and can observe first-hand any concerns for the customer’s health and safety. If a physician consultation is needed 24

September/October 2019

Peter Tanghe, MD

with EMS, primary care or a specialist, the community paramedic utilizes telehealth.

For customers who do not have a good support system, a community paramedic can accompany them to a clinic appointment as their advocate, taking notes and reiterating the care plan when they return to the customer’s home.

Training Community paramedics are seasoned and experienced 911 paramedics with additional training in chronic disease management, home safety, social determinants of health, and healthcare navigation. With approximately two years of additional technical college coursework and clinical hours, community paramedics also complete CME credits annually.

The North Memorial Health Community Paramedic Medical Director and the customer’s primary care team provide medical oversight while they partner with the community paramedic to establish the care plan. The team has access to primary and specialty care plans via Epic where they document and identify opportunities for early intervention and needed support; they also send notes to the primary care provider or other care partners via Epic.

Services Community paramedics are both advocates and educators for their customers’ health.

Common services include: • Health screenings and helping customers access primary and specialty care, dental services and more; they’re instrumental with customers who are not following up on their care plan.

• Supporting customers during transition times to help them learn a sustainable way to care for themselves including post-hospital follow-up care.

• Helping customers make needed changes in their care plan or medication routines.

• Wound care.

• Chronic disease monitoring and education.

• Advanced care planning.

• Performing environmental and safety assessments of customers’ homes.

• Connecting to community services.

• Coordinating transportation from guiding customers through how to use public transportation to showing them how to use ride sharing apps. Thanks to a grant from UCare, North Memorial Health Community Paramedics also have access to a van to bring customers to time-sensitive appointments while they identify sustainable transportation solutions.

Community paramedics bring a vast array of experience into customers’ homes and know how to easily adapt environments to improve safety and comfort. For example, when a customer needed a bedroom rearranged to improve safety and access, the community paramedic helped the customer marshal the assistance of family members

MetroDoctors

The Journal of the Twin Cities Medical Society

and other North Memorial Health team members. In less than an afternoon, the room was rearranged, the bed adjusted, and the customer was relaxing in a safer, more comfortable environment.

Another customer faced seizures that were identified as “pseudo-seizures.” After a neurologist determined that there wasn’t a need to go to the hospital after every seizure episode, the community paramedic created a lanyard with information on the customer’s condition and various medical contacts (including the community paramedic). This helped reduce hospitalizations and trips to the emergency department each time someone new encountered the customer having one of their spells.

Partnering with Home Care Community paramedics see various living situations and work creatively to get each customer what they need. For example, the North Memorial Health team has worked with a functionally home-bound, 300+-pound customer who has not been able to leave their home and get to a clinic for three years. Through telehealth and an EMS doctor who can see the customer virtually via telehealth, home health care was established and other transition plans put in place to help the customer get the immediate care they needed while they worked toward getting the customer to the clinic for subsequent care.

Payment Typically, when a community paramedic is involved with a customer, total costs go down over time. These cost savings result in lower per-member, per-month costs for value-based contracts. Some community paramedic care is included in the transitional care plan as part of their post-hospital care reimbursement. In Minnesota, Medicaid pays for most community paramedic services that meet their requirements. With other insurers, it’s hit or miss, depending upon what type of care the community paramedic is delivering.

The North Memorial Health community paramedics are empowered to work with customers whose care needs can be met at home — saving money by not incurring a hospital stay or missing a clinic visit. Many times, care is started at home with an EMS physician via telehealth (which also helps to reduce cost of care) and a care plan is MetroDoctors

developed to address any additional needed services, along with other issues that need further care, coverage or coordination.

The Future North Memorial Health is now in its sixth year of providing community paramedicine. The Community paramedics provide in-home, one-on-one support (or program was started maybe advocacy) while utilizing telehealth as a way to connect to with a small group of the customer’s care team. providers to test work customer by doing things differently within flows and technology. Over the last year, the existing system of rules and boundaries. the program has integrated telehealth into Striving to deliver health care better — by the daily work of community paramedics examining each customer’s needs and doing and EMS physicians to increase efficiencies the right thing for the customer every time. and improve customer care. Community paramedics now partner with primary care, specialty and pharmacy providers via telePeter Tanghe, MD, is an EMS physician at health consultations, but ultimately, the goal North Memorial Health Hospital and Maple is to have community paramedic facilitated Grove Hospital. He has dual board certificatelehealth visits with a wide group of primary tions in Emergency Medicine and EMS. Dr. care doctors and specialists.

Tanghe also serves as the chairperson of the North Memorial Health envisions a Minnesota Ambulance Association’s Commufuture where a customer can make a virnity Paramedic Advisory Committee. tual visit with their primary care provider Dale Pampuch, CMPA, is a community parafor routine things like blood pressure and medic at North Memorial Health. As a member cholesterol check-ins, as well as colds and of the pioneer class of community paramedics, cough treatments. To address more comDale’s wide-ranging experience also includes plex medical needs, a community paramedic being a traditional 911 and critical care parafacilitated telehealth visit can provide real medic as well as a flight medic. time advance diagnostics and assessments including point-of-care lab testing, IV fluids/ medications, and monitoring.

Community paramedics are delivering care in a way that’s centered around the

The Journal of the Twin Cities Medical Society

*www.naemsp-blog.com/ emsmed/2019/3/15/ article-bites-11?rq=telehealth.

What Physicians Need to Know About Community Paramedicine

1. A community paramedic is not far away. Physicians have access to community paramedics with most Twin Cities healthcare providers offering some form of the service and more programs being introduced throughout the state.

2. At North Memorial Health, anyone can refer a customer to a community paramedic, including 911 paramedics, primary and specialty care providers, and even the police.

3. Don’t be surprised if a community paramedic shows up with your customer at a clinic visit — know that their goal is to be an advocate for the healthcare system as well as the customer.

4. Embrace this new team-based care system and evolving technology of telehealth as tools to innovate. The North Memorial Health Community Paramedic program was built on collaborative relationships between EMS, home care, hospital, specialist and primary care providers.

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is for kids.

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Now a Chargeable Service— Remote Device Monitoring

O

ne of the fastest growing trends in telemedicine services is using sensor data or remote device monitoring to decrease readmissions to acute care or the emergency room.

A scale for measuring daily weights for patients with heart failure is the most commonly used remote monitoring application. Nurses at a central monitoring station located at a medical clinic receive the once daily weight downloaded from a secure Blue Tooth or Internet based application from the patient’s home.

Nurses or techs review the daily weights and react to changes that are automatically flagged as outside preset parameters based on an individualized care plan and provider-generated treatment protocols.

The nurse then contacts the patient to conduct further assessment and to institute orders based on the patient’s treatment protocols.

A resulting action might include a medication dosage adjustment of the fluid retention medicine for two days, or a visit that day with the attending provider. Typically initiated immediately after an acute care hospital discharge, the equipment including a scale and a daily diary logging device is sent directly to the patient’s home and installed by the family. The daily diary provides symptom information, but also serves as a valuable self-management tool in terms of behavior choices and consequences.

A different resulting action might be a visit to the attending provider that day in person at the clinic. In the future, and

By Maureen Ideker, RN, BSN, MBA

MetroDoctors

even now in some programs, that visit might be conducted via videoconferencing direct-to-consumer in their home over the Internet or via their mobile phone using a secure connection sent out from the clinic. Currently Minnesota Medical Assistance and most Minnesota commercial insurers will reimburse the professional fees for this type of visit.

However, Medicare will not reimburse for direct-to-consumer telehealth video visits.

Effective January 1, 2019 Medicare started covering codes for remote device monitoring when services are provided through a medical clinic. Those codes include: a one-time installation fee, a monthly monitoring fee, and codes for the monthly clinical interaction times with patients, clinicians and providers.

Guidelines for the new codes are available at the American Medical Association (AMA CPT 2019) Evaluation and Management section of the code book.

In the future, commercial payers are expected to follow Medicare’s lead for coverage.

The Journal of the Twin Cities Medical Society

Essentia Health Duluth Clinic’s Heart and Vascular Center, recently recognized nationally for its outstanding outcomes, typically monitors over 125 patients with heart failure daily.

This program is conducted by RNs and NPs, and the monitoring application is integrated into the Epic EMR. Over many years at Essentia Health, the annual readmission rate average is less than 1% when remote monitoring is used.

The equipment is leased, not owned, and the company handles all the shipping, returns, cleaning, maintenance, and inspections. No videoconferencing options are currently used with patient interactions.

Great progress has also been made in the use of sensor data provided by remote monitoring devices, such as: motion sensors, steps walked for fitness, glucose levels reported to mobile devices, cardiac rhythm monitors, “wearables” such as heart rate monitors or stockings for balance detection, bed alerts and home appliance use. However, capturing the daily weight has given the most direct impact and results.

Maureen Ideker, RN, BSN, MBA is one of Minnesota’s and the Midwest’s pioneers in telehealth, starting her work in telemedicine in 1994. Maureen served as the System Director of Telehealth for Essentia Health-Duluth, MN from 2011-2018, and now serves on a casual basis at Essentia Health as a Senior Adviser-Telehealth.

She can be reached at: Maureen.ideker@ essentiahealth.org.

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Telehealth

Your Link to Mental Health Resources

Environmental Health —

Reducing Health Care’s Carbon Footprint with Telemedicine

T

855.431.6468 mnpsychconsult.com Available Monday-Friday from 8am-6pm

Next available CME approved training November 21, 2019- PrairieCare Institute To register visit our website

Mental Health Training and Psychopharmacology Education for Primary Care Training offered for primary care providers and healthcare professionals that are focused on mental health assessment and treatments.

Each training is a full day and limited to 30 attendees.

The PAL team will present in the morning from 8am-12pm.

A Nationally Certified Trauma Therapist will present in the afternoon from 1-5pm.

28

September/October 2019

he World Health Organization calls climate change the most significant worldwide threat to public health. In the United States, health care accounts for about 10% of all greenhouse gas (GHG) emissions. One recent study estimates between 123,000 and 381,000 disability-adjusted life-years (DALYs) in future health damages can be attributed to a year’s worth of health care GHG emissions, and an additional 405,000 DALYs due to other pollutants. These numbers are similar to those attributable to medical error.1 One path forward is telemedicine.

Researchers in Sweden showed a 40-70 times reduction in carbon emissions when two hospital rehabilitation units integrated virtual visits into their workflow.2 An analysis of the Access to Critical Cerebral Emergent Support Services (ACCESS) program in New Mexico, which links the Neurology and Neurosurgery departments at an academic medical center with 12 rural hospitals, showed savings of 618.77 metric tons of CO2 over 2,020 teleconsultations, by reducing patient transfers 70%.

Besides the reduction in GHG emissions, the ACCESS program saves money and improves care.3 While telemedicine is likely to result in reduced emissions, it is not a given.

Factors including equipment purchase, electricity to run equipment, and patient transportation should be considered. The authors of the Swedish study note that a patient would need to travel more than 2.24 miles (or 4.47 miles depending on the analytical method) for a one hour

By Aaron Rosenblum, MS2

appointment so that the teleconsult would reduce emissions.

Locally, HealthPartners telemedicine programs, including Virtuwell, provide telemedicine services for their members.

HealthPartners is crunching the numbers to determine the decrease in emissions for these services. Preliminary data for 242,311 patient encounters between 2014 and 2018, avoiding in-person clinic visits that average 10 miles of driving, show a total reduction of 1,009 metric tons of CO2. This is the equivalent of removing 210 cars from the road.

All of these numbers are drops in the bucket compared to the estimated 5,268 million metric tons of CO2 released in the US in 2018.4 Nevertheless, telemedicine strategies, if fully utilized, are a valuable tool to help fight this urgent threat to public health.

Aaron Rosenblum, MS2, University of Minnesota Medical School Class of 2022.

References 1. Matthew J. Eckelman, Jodi D. Sherman, “Estimated Global Disease Burden From US Health Care Sector Greenhouse Gas Emissions,” American Journal of Public Health 108, no.

S2 (April 1, 2018): pp. S120-S122. https://doi. org/10.2105/AJPH.2017.303846.

2. Holmner Å, Ebi KL, Lazuardi L, Nilsson M, “Carbon Footprint of Telemedicine Solutions— Unexplored Opportunity for Reducing Carbon Emissions in the Health Sector,” PLoS ONE 9(9): e105040 (September 4, 2014). https://doi. org/10.1371/journal.pone.0105040.

3. Justin Whetten, Julianna Montoya, and Howard Yonas, ”ACCESS to Better Health and Clear Skies: Telemedicine and Greenhouse Gas Reduction,” Telemedicine and e-Health, Online Ahead of Print (October 25, 2018). http://doi. org/10.1089/tmj.2018.0172.

4. US Energy Information Administration—EIA —Independent Statistics and Analysis. (2019, May 15). Retrieved July 3, 2019, from https:// www.eia.gov/tools/faqs/faq.php?id=77&t=11.

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The Journal of the Twin Cities Medical Society

The Importance of Advance Care Planning Conversations: The Next Generation This essay was adapted from a presentation at the 2019 Annual Celebration of the Twin Cities Medical Society on May 6, 2019.

I coordinated the Honoring Choices Advance Care Planning Program for Faribault and Owatonna where our program helps people muster the courage to acknowledge their mortality and choose how to be cared for near the end-of-life. My work contributed to a societal shift from “I don’t want to die, so I’m not going to think about it,” to “I don’t want to die, but because it’s inevitable, I want to experience it this way.” Along this spectrum between denial and taking control lies an array of justifications for idleness: discomfort, fear, grief, and indifference. I strive to help people understand that feeling uncomfortable, expressing their fears, or acknowledging their grief will be less perilous for themselves and their loved ones than an unanticipated health catastrophe. Unfortunately, my family experienced how risky not having an advance care planning conversation could be.

My 54-year-old brother was in a motorcycle accident and wasn’t wearing a helmet. He was broken from head-totoe, but resuscitated. He hadn’t expressed end-of-life wishes to his family. He hadn’t written a healthcare directive. Our family had to make treatment decisions for him without a compass — just hoping that they were choices he would have made for himself. Now, a year and a half later, living with a severe traumatic brain injury that requires round-the-clock care for ADLs, movement, and interventions to

By Kerry Gervais Hjelmgren, Executive Director, Honoring Choices Minnesota

MetroDoctors

improve his quality-of-life, he wishes he hadn’t been saved. His accident and my family’s experience have made me even more passionate about encouraging people to engage. I want to save them from experiencing what it’s like when it’s too late to have a conversation.

However, there is hope for the future.

My five-year-old daughter has experienced my work by overhearing conversations, and it turns out she’s a great listener.

Out of nowhere, she asked: “Mom, what would you like when you die — to be in a cemetery, or for your ashes to be with me?” I was stunned that this was on her mind, and answered, “I’m comfortable being wherever you need me to be.” She responded: “That’s good. Then you will always be with me.”

For my five-year-old, the end-of-life is an ordinary topic of conversation. I felt proud that this wasn’t a hard question for her to ask, and relieved that the notion of my impermanence wasn’t met with overwhelming fear and grief. I’m hopeful that the next generation will be just like this — that they won’t need their courage fostered — but will simply be willing to have the conversation.

at PrairieCare Medical Group is now offering integrated mental health services at Ridgeview Medical Center!

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Kerry Gervais Hjelmgren is the Executive Director of Honoring Choices Minnesota. She came to the Twin Cities Medical Society in her third year of coordinating the Honoring Choices Advance Care Planning Program for Faribault and Owatonna, Minnesota where her mission was to educate communities about the importance of advance care planning conversations, and to develop community engagement opportunities to make advance care planning an easier process for all adults.

The Journal of the Twin Cities Medical Society

September/October 2019

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Physicians Serving Physicians

Confidential Peer Support for Physicians with Substance Use Disorders Physicians Serving Physicians (PSP) is a discrete program that provides free peer support, mentoring, and referral to physicians, their families and colleagues who are affected by substance use disorders. For 35 years, PSP has supported physicians through recovery and successful return to practice through one-on-one counseling, serving as a liaison between clients and treatment centers, and offering a monthly support group to participants.

We welcome you to join us at our confidential monthly meetings which are held by a community of physicians (only) to offer mutual support, education, and discussion of issues that are unique to physicians in recovery.

Confidential Peer Support and Consultation for Individuals & Organizations: 612-362-3747 • www.psp-mn.com

Free Confidential Wellness Resources for Minnesota Physicians & Their Families LifeBridge provides a safe harbor to empower and equip you with the tools you need to take care of yourself as well as your patients.

Minnesota physicians, residents, medical students, and their immediate family members qualify for four free, confidential counseling sessions to address stressors like: • Depression and anxiety • Relationship issues • Loss and grief • Financial concerns In addition to counseling services, LifeBridge offers a comprehensive, web-based resource with a rich library of interactive tools and information about wellness and other everyday life issues.

Physician Wellness Resources: 800-632-7643 and mention PSP • www.psp-mn.com/wellness

Spotlight on Books MetroDoctors is pleased to promote books recently published by past and present TCMS members. To include your recent publication, contact Nancy Bauer at nbauer@metrodoctors. com. Disclaimer: Publication of book titles does not constitute endorsement by TCMS or the MetroDoctors editorial board.

With Mirth and Laughter: Finding Joy in Medicine After Cancer In 2016, as a practicing internist Dr. Heather Thompson is diagnosed with breast cancer, and must abruptly enter the healthcare system as a patient. Her experiences, observations, and process of growth and transformation are outlined in her first book, “Mirth is God’s Medicine.” A continuation of the story, “With Mirth and Laughter” now moves beyond the early days of breast cancer treatment and describes how a cancer diagnosis impacts her friendships, family dynamics, teaching and mentoring roles. More importantly, it changes her practice style and what it means to provide patient-centered care.

“With Mirth and Laughter” is available online at Amazon and Barnes and Noble and also in the University of Minnesota Bookstore at Coffman Union.

In Memoriam STEPHAN EVERLY, MD, passed away on June 22, 2019. Dr. Everly served as the Chief of Anesthesiology at North Memorial Hospital, retiring in 1998. Dr. Everly joined the medical society in 1971.

JOHN LARKIN, MD, passed away on July 14, 2019. An Orthopedic surgeon, Dr. Larkin performed the first total joint replacement procedures in the Twin Cities. Dr. Larkin joined the medical society in 1968.

WESLEY MILLER, MD, passed away on July 15, 2019. Dr. Miller served as the Head of the Department of Medicine at the University of Minnesota from 20092015. He joined the medical society in 2005.

MetroDoctors

The Journal of the Twin Cities Medical Society

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September/October 2019

31

LUMINARY of Twin Cities Medicine

By Marvin S. Segal, MD

STANLEY M. GOLDBERG, MD It was the summer of ’48, and the tall, confident camp counselor was leading his youthful charges on a nature hike through the central Minnesota woods. Those adolescent chaps respected him because of his engaging brightness, his energy, his fortitude and his striking leadership qualities. What do you suppose ever became of that admired guide?

Dr. Stanley Goldberg was born in Minneapolis and has lived in the Twin Cities area his entire life. As an honor student, he earned two bachelor’s degrees and his MD from our U of M. His post graduate training was extensive and included a Minneapolis General Hospital internship, general surgical and colon rectal (CR) residencies at the V.A. and University Hospitals, and a fellowship at St. Mark’s Hospital in London, UK. On completion of his formal training, he embarked upon a highly successful career in his chosen field, making the most of his profound talents — heading up a large private CR practice and becoming a pre-eminent academic surgeon. Early on, Dr. Goldberg’s associations with mentors and colleagues proved meaningful in his professional development — the most notable of which included: Dr. Rich Lillehei (Head of Red Surgery during residency and co-author of Stan’s first published paper); Dr. Howard Frykman (esteemed private practice partner and, along with Dr. Manny Balcos, “the most gifted of technical surgeons”); Dr. Owen Wangensteen (Luminary 2011, the enduring Chief of Purple Surgery and Stan’s father’s medical school classmate); and Dr. Ed Humphrey (the “wise V.A. Surgical Chief ”).

Dr. Goldberg became the long-standing Professor and Head of CR Surgery at his alma mater, held a similar appointment at HCMC, and continues even currently as an active Senior Surgical Consultant at the V.A. Medical Center.

While carrying out those activities, he found the time and energy to publish some 130 journal articles and over 70 book chapters covering essentially every conceivable topic of CR practice — from Crohn’s to cancer, and anastomoses to sphincterotomies. His visiting Lectureships and Professorships number in the hundreds — internationally covering every continent but Antarctica, and nationally from Boston to Los Angeles.

Leadership positions, awards and honorary fellowships held by the good doctor — virtually too numerous to 32

September/October 2019

recount — cover the globe and still continue to be achieved just as they have over the past three decades. Notable among them are: Royal College of Physicians (England) Fellowship; Minnesota Medical Foundation Diehl Award; International Society of University Surgeons 2018 Mastership in CR Surgery; and the establishment of the U of M Stanley M. Goldberg Chair in CR Surgery.

Among the many facets of medicine in which he’s been involved, teaching in the OR stands out as his most cherished. Having trained young surgeons from Stanford to Minnesota to Harvard to Oxford, he states, “Though laparoscopes and staples are important elements in our present armamentarium, deft surgical technique is and will remain the most relevant factor.” Dr. Goldberg is proud of the role he has played in making CR training fellowships among the most sought after of the surgical specialties.

The number of certificates increased from six to 100+ per year since his CR Board involvement began in 1972.

Dr. Stan’s family has played a most important role in his very full life, and the pride he exudes when speaking of Luella, his highly successful wife of 60 some years, and their accomplished three children is palpable when speaking with him.

So . . . that provides you with a flavor of what has become of that industrious young camp counselor who has spent a fruitful lifetime honing his competence and imparting superb clinical care and knowledge to others. Our Luminary continues to share his skills, just as he did with those adoring kids so long ago — take it from one of those campers.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine.

Please forward names of physicians you would like considered for this recognition to Nancy Bauer, Managing Editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society

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