Telehealth FY14 -FY15 Annual Report · (1) This growth trend played out across our nation in 2015...

Telehealth Annual Report

FY14 -FY15

Health care is rapidly transforming, with consumers seeking greater convenience and easier access to high-quality, affordable care. UPMC Telehealth continues to lead this transformation by leveraging technology to develop new models of care delivery that expand patient access to UPMC’s world class clinicians. The innovations of telehealth are delivering — and surpassing — patient and provider expectations.

Technology has already transformed every aspect of our lives — from the way we shop, book our flights, do our banking, request an Uber or Lyft pick-up — to the way that we communicate with each other on a daily basis through text messaging and FaceTime®. Consumers want and are beginning to expect the same technology revolution to come to health care, and that’s precisely the goal of the UPMC telehealth program.

At UPMC, we strive to create greater value in care delivery. That means maintaining or improving the quality of our services,

and increasing patient satisfaction, while reducing costs. Telehealth is at the forefront of our ability to deliver quality, efficient care through such approaches as ACOs (accountable care organizations), bundled care, and shared savings. This trend toward value-based, patient-centered care is expected to rapidly expand over the next few years as reimbursement continues to shift away from the current fee-for-service model. The successful integration of telehealth across the health care continuum is increasingly viewed as an integral part of this transformation.

Technology --> Capabilities --> Demand --> Technology --> . . .

We’re just in the infancy of telehealth right now. Technology is constantly evolving and rapidly increasing our capabilities. Use cases are on the rise, and nearly everyday we develop new ways to integrate telemedicine across the care continuum.

Couple this with increased demand from patients who expect on-demand access to care through virtual platforms, as well as a global patient population seeking the expertise of UPMC’s specialists — and the push to advance our capabilities by integrating technological advances is critical to meeting these growing demands. Through expanded telehealth availability, UPMC is well-positioned to maximize the evolving health care landscape.

This virtual availability delivers the excellence of UPMC’s clinical care to patients anywhere, regardless of geographic location. Access to UPMC clinicians now spans from rural areas of western Pennsylvania where health care is sparse, to locations across the United States, as well as to international locations across the globe in Europe, South America, and elsewhere through teleconsultative services.

At UPMC, we have developed the infrastructure to maximize new technology across multiple clinical use cases and are recognized as a leader in health care transformation and integration of telehealth.

Telehealth will not replace office visits or the doctor-patient relationship. The aim is not to replace all in-person visits, but to enhance the patient experience and better coordinate care. For situations and needs that don’t require in-person visits, telemedicine allows patients to facilitate online visits, freeing up doctors so that they can focus on the patients who really need to be seen in the office. Telemedicine allows patients to communicate with their doctor online, from the comfort of their home, work, or anywhere, in a timely manner.

With continued advances in value-based, patient-centered care, the “tele” part will disappear from “telehealth.” Telehealth is fast becoming an integral part of how health care is delivered and we anticipate that in the future, it will no longer have a separate name — it will simply be considered just another way that providers deliver high-quality health care.

UPMC currently has 35 telemedicine specialty services available across multiple locations. In addition, we are developing additional programs to meet the anticipated growth in the areas of remote monitoring, in-home services, skilled-nursing facilities, post-discharge care and follow-up, pre-and post-surgical assessments, and in the direct-to-consumer world to provide 24/7/365 days/year, on-demand care for low acuity conditions.

We welcome the opportunities that telehealth heralds to provide expanded access to high-quality care as we transform and advance the current practice of medicine.

Lawrence R. Wechsler, MD Vice President of Telemedicine Services, Physician Services Division

2006- 2008

2011

2012

2013

2014-2015

2016-2017

• Tele-Stroke • Tele-Psych

• Pre & Post Operative Visits

• Pediatric Specialty

• UPMC AnywhereCare Online Virtual Visits• Tele-Skilled Nursing Facility Visits• In-patient & Out-patient Specialty Services Expansion

• Online Chronic Care Visits

UPMC’s Telehealth Expansion

• Remote Monitoring• Teleconsult Center Expansion

• Integrate On-demand Specialty Visits Through PCP Practices

• Expanded sub-specialty visits across Adult and Pediatric services

• Transplant Behavioral & Nutrition Counseling

• Inpatient Dermatology • Teleconsult Centers

• Tele-Maternal Fetal Medicine• Surgical Oncology/Breast Visits• Infectious Disease

• Health Plan-Employer On-site Care

• Physical Medicine & Rehabilitation

• Expanded On-line eDermatology Visits

Telemedicine Annual Report | 1

An Overview of Telehealth Our Telehealth Program expansion is a direct result of UPMC’s commitment and investment

in technology and the development of new models of care delivery.

2 | Telemedicine Annual Report

UPMC Telehealth continues to experience extra-ordinary growth. Through a passionate and persistent commitment to developing new models of care delivery, Fiscal Year (FY) 2014 and FY15 resulted in significant advancement of virtual services, a double-digit increase in completed telemedicine visits, and expanded patient access to UPMC’s world-class clinical care.

Nationally, the use of telehealth services is expected to grow from 250,000 patients in 2013 to 3.2 million patients in 2018.(1) This growth trend played out across our nation in 2015 as 42 states introduced more than 200 telehealth-related bills(2), and 24 states and Washington, D.C., passed telehealth parity bills that mandate some level of telemedicine visit coverage by commercial insurers.(3)(4) These positive changes, coupled with the announcement from Centers for Medicare & Medicaid Services (CMS) that they would shift from traditional payment and benefit models to models tied to value-based purchasing, are driving the increased adoption and expansion of telehealth services.

This is evidenced by the amplified momentum of hospitals and health care systems that are adopting telehealth programs, and large insurance plans — such as Anthem and Highmark — announcing low-cost options for low-acuity conditions through the expansion of on-demand virtual visits.

In early 2015, CMS took the bold first steps to transform the traditional fee-for-service payment system by setting specific alternative payment goals. The goals include plans to have 30 percent of traditional Medicare benefits made in alternative payment models by the end of 2016 and 50 percent by the end of 2018. Additionally, the Department of Health and Human Services set a goal to have 85 percent of Medicare fee-for-service payments tied to certain value-based purchasing categories by 2016 and up to 90 percent by 2018.(5)

With this increased focus on value-based purchasing and a move away from direct fee-for-service payment models, payer-provider organizations such as UPMC are demonstrating how new models of care delivery can expand access to high-quality, affordable care.

Telehealth offers a strategy for providers to expand their services and better coordinate care across the continuum. By bringing health care services directly to patients, telehealth is changing the way patients and their families interact with providers and the health care system, while supporting the triple aim goals of better health care, improved health outcomes, and decreased costs.

In FY14 and FY15, UPMC expanded subspecialty clinical services from 20 to 35 clinical specialties. These services provide remote patient access to areas where it otherwise would not be available. UPMC’s telehealth activities span all four UPMC business units, which include: Health Services, Health Plan, Children’s, and International. In FY14, UPMC completed 11,767 virtual visits, and in FY15, the volumes grew to 15,762 virtual visits, representing additional growth rates of 21 percent and 33 percent year-over-year.

The UPMC Telehealth Program is run by a team of executives, managers, and physician leaders with years of experience in telemedicine development and deployment.

Allentown

Scranton

Philadelphia

Harrisburg

Pittsburgh Altoona

State College

New Castle

Chambersburg

Williamsport

Reading

Lancaster

Erie

Wilkes-Barre

UPMC Telehealth Services Map


A significant technology investment, along with a system-wide commitment to continuous technological innovation, has made UPMC an international leader among health care systems offering telemedicine service.

In addition to enhancing clinical care, the ongoing expansion of clinical telemedicine services across the UPMC Health System allows UPMC to foster physician and patient engagement and supports relationships of trust. By offering telemedicine visits in strategic locations, some of which are located on or near our UPMC campuses, we can provide convenient access to pre-and post-visit tests, labs, and radiology imaging. Maintaining these services within the UPMC Health System facilitates patient compliance and allows better care coordination.

In FY14, the UPMC Telehealth leadership team, in collaboration with the Technology Development Center, developed the first home-grown, direct-to-consumer visit platform through UPMC AnywhereCare. Unlike other direct-to-consumer national vendors, who shied away from direct-to-consumer platform integration with electronic health record (EHR) systems, UPMC Telehealth leadership recognized that in order to integrate telehealth visits into a patient’s care continuum, there should be integration with an outpatient medical record system.

Thus, UPMC AnywhereCare visits were developed as an integrated part of the MyUPMC patient portal, and each visit creates an EpicCare outpatient medical record that can be accessed by UPMC providers. UPMC AnywhereCare provides patients located anywhere in Pennsylvania with full access — 24 hours a day, 7 days a week, 365 days a year — to UPMC’s clinical care providers for low-acuity, non-emergency conditions. In FY15, UPMC AnywhereCare was expanded to include patients in Maryland.

As on-demand consumer care continues to expand, with consumers expecting convenient low-cost care options, UPMC AnywhereCare provides an established, high-quality service. UPMC providers completed 5,871 UPMC AnywhereCare visits between November 4, 2013, and June 30, 2015. In addition, through an economic analysis completed by the UPMC Health Plan analytics team, the potential savings per episode of care is $86.64 on average, when patients utilize UPMC AnywhereCare virtual visits instead of the Emergency Department, urgent care, retail clinic, or primary care office.

20,000

18,000

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

0FY14

FY14 and FY15 UPMC Telemedicine Volumes

Tele

med

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ne V

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s

15,762

11,767

FY15

20,000

18,000

16,000

14,000

12,000

10,000

8,000

6,000

4,000

2,000

0FY12

FY12 through FY15 UPMC Telehealth Growth Volume Trends

Vo

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es

9,706

FY13

15,762

11,767

FY14 FY15

6,575

47%

21%

33%

INT’L

118

463

798

847

WPIC

2,700

4,047

4,029

4,219

8,000

7,000

6,000

5,000

4,000

3,000

2,000

1,000

0

FY12

FY13

FY14

FY15

FY12 Through FY15 Trends by Business Unit

CHP

917

971

1,096

1,933

CPS

0

385

609

674

HP

766

1,510

2,203

3,836

HS

2,074

2,330

4,132

7,105

Business Unit Legend: CHP – Children’s Hospital of Pittsburgh | CPS – Community Provider Services | HP – Health PlanHS – Health System | INT’L – International | WPIC – Western Psychiatric Institute and Clinic

FY14 and FY15 UPMC Telemedicine Volumes

FY12 through FY15 UPMC Telehealth Growth Volume Trends

FY12 through FY15 Trends by Business Unit


(1) Japsen, B. “ObamaCare, Doctor Shortage to Spur $2 Billion Telehealth Market.” Forbes (2013). http://www.forbes.com/sites/brucejapsen/2013/12/22/obamacare-doctor-shortage-to-spur-2-billion-telehealth-market/#1da08a9b15fa

(2) Center for Connected Health Policy, State Telehealth Laws and Medicaid Program Policies: A Comprehensive Scan of the 50 States and District of Columbia. (Sacramento, Calif.: Children’s Hospital of Pittsburgh of UPMC, 2015). http://cchpca.org/sites/default/files/resources/STATE%20TELEHEALTH%20POLICIES%20AND%20REIMBURSEMENT%20REPORT%20FINAL%20%28c%29%20JULY%202015.pdf

(3) Thomas L, Capistrant Gary, American Telemedicine Association (ATA), State Telemedicine Gap Analysis, Coverage and Reimbursement, (May 2015). http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf

(4) By the end of FY15, three additional states passed parity laws (Indiana, Minnesota, and Nevada).

(5) Better Care, Smarter Spending, Healthier People: Improving Our Health Care Delivery System. (Sept 29, 2015). https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-09-29-2.html

UPMC AnywhereCare provides another example of the opportunity to integrate virtual care across the care continuum while expanding convenient access to high-quality clinical care at a lower cost than traditional in-person options.

As part of our FY15 Telehealth goals, UPMC Telehealth leadership began focusing on the expansion of remote monitoring as a way to identify high-risk patients who may benefit from ongoing monitoring and additional support post discharge. This effort, in part, focuses on decreasing the CMS penalties across multiple diagnoses. But more importantly, it would also allow UPMC to better manage our palliative care patient population. Thus, a subgroup was formed with experts across the UPMC enterprise who analyzed the areas of short-term and long-term opportunity, where remote monitoring can be leveraged to better manage certain patient populations and to decrease unnecessary high-cost care options, such as Emergency Department visits or hospitalizations.

A comprehensive vendor analysis and RFP process was completed in FY15. UPMC Telehealth leadership will continue to build on this work in FY16, with the goal of finalizing our vendor partnership and launching a comprehensive remote monitoring program.

In December 2014, UPMC Internal Audit shared a final report, returning a “green” audit rating for the UPMC Telemedicine programs and services. The audit included an assessment to evaluate the operational, technical, and regulatory controls associated with the UPMC Telehealth program and services. This audit rating is a direct result of UPMC Telehealth leadership’s focus over recent years to develop a comprehensive operational structure, incorporating standardized policies, procedures, IT equipment, and support.

The UPMC Telehealth program and services offer patients access to quality clinical care, regardless of geographic location, and the program is recognized as a leader both nationally and internationally.

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Top 20 Telemedicine Service Lines – FY14 and FY15

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Top 20 Telemedicine Service Lines FY14 and FY15


http://www.forbes.com/sites/brucejapsen/2013/12/22/obamacare-doctor-shortage-to-spur-2-billion-telehealth-market/#1da08a9b15fa

http://cchpca.org/sites/default/files/resources/STATE%20TELEHEALTH%20POLICIES%20AND%20REIMBURSEMENT%20REPORT%20FINAL%20%28c%29%20JULY%202015.pdf

http://www.americantelemed.org/docs/default-source/policy/50-state-telemedicine-gaps-analysis---coverage-and-reimbursement.pdf

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-09-29-2.html

UPMC Telehealth Financial Trends As UPMC Telehealth services expand, the health care system is realizing a positive financial impact.


UPMC Telehealth Payment Breakdown UPMC has seen a growth in insurance payments from FY14 to FY15. In FY14, 93 percent of revenue was from contracted services versus 90 percent in FY15 1. Insurance reimbursements grew from 7 percent in FY14 to 10 percent in FY15.

FY14

Total . . . . . . . . . . . . . . . . . . . . . . . . . . $2,417,542 Insurance Payments . . . . . . . . . . . $166,041 (7%) Contracted Services . . . . . . . . . $2,251,501 (93%)

FY15

Total . . . . . . . . . . . . . . . . . . . . . . . . . . $2,636,160 Insurance Payments . . . . . . . . . . $292,290 (10%) Contracted Services . . . . . . . . . $2,343,870 (90%)

(1) Insurance payments are collected for Children’s Hospital Gastrointestinal, Children’s Hospital Hem/Onc/Sickle Cell Program, UPMC AnywhereCare (Health System): Convenience Care, HS eVisits, HS Infectious Disease, HS Maternal Fetal Medicine (MFM), HS Stroke, and Community Provider Services (CPS) Remote Monitoring Service Lines. All other revenue gained across service lines is from contractual agreements.

HS48%

CPS4%

INT’L10%

WPIC13%

CHP25%

Total FY15 RevenueAcross Business Units

HS48%

CPS3%

INT’L9%

WPIC15%

CHP25%

Total FY14 RevenueAcross Business Units

While most of the current telehealth and telemedicine services are contract-based, the reimbursement landscape continues to evolve, and several commercial payers (including UPMC Health Plan and Highmark) are reimbursing for telemedicine visits.

We anticipate that this trend will continue as telemedicine visits become a standard of high-quality, low-cost health care delivery and consumers become familiar with on-demand, low-cost clinical care for low-acuity conditions.

As part of this trend, online, convenient care is projected to increase with expanded use of UPMC AnywhereCare visits and the anticipated expansion of online eDermatology visits.

Below is a summary breakdown of the percentage of telehealth revenue by UPMC business units for FY14 and FY15, as well as a breakdown of the percentage of telehealth payments received from contracted versus insurance payments.

Total FY15 Revenue Across Business UnitsTotal FY14 Revenue Across Business Units


UPMC Teleconsult Centers Through its Teleconsult Centers, UPMC provides patients with better access to its

world-class specialty services and high-quality health care in a timely manner close to home.


Hermitage

Seneca

Bedford

Pittsburgh

Philadelphia

Through this new model of care delivery, UPMC expands access to its world-class specialty services and high quality healthcare in a patient-focused and efficient manner.

PENNSYLVANIA

Health Services Division: Review of the UPMC Teleconsult CentersNatasa Sokolovich, JD, MSHCPMExecutive Director Telehealth, UPMC

Lawrence R. Wechsler, MDHenry B. Higman Professor and Chair, Department of Neurology VP Telemedicine, UPMC

UPMC Teleconsult Centers deliver on UPMC’s enterprise-wide goal of integrating technology to develop new models of care delivery. Each Teleconsult Center location incorporates the existing EpicCare EHR solution and mirrors the specialist’s in-person visit workflow.

The UPMC Teleconsult Centers are dedicated outpatient, multispecialty clinics located in rural areas outside of Pittsburgh and Erie, where patients are scheduled and registered to have an appointment with one of UPMC’s world-class physicians via live, synchronous audio- and video-enabled, HIPAA-secure technology.

In addition, the integration of the EpicCare EHR supports UPMC’s commitment to ongoing care coordination. Thus, the physician experience is seamless and allows the scheduling of telemedicine visits to be integrated into the providers’ standard Epic scheduling templates.

In Pennsylvania, existing Teleconsult Centers are located in Bedford, Seneca, and Hermitage. The Bedford and Seneca locations are in dedicated outpatient clinic areas on the hospital campuses of UPMC Bedford and UPMC Northwest. The location in Hermitage is located at the UPMC Urgent Care Center. Through the expansion of Teleconsult Center visit types, UPMC Telehealth continues to demonstrate that telemedicine can effectively and efficiently extend access to high-quality specialist care that may otherwise not be available.

As part of our commitment to ongoing quality review, UPMC Telehealth leadership, in partnership with the Wolff Center at UPMC, is identifying and analyzing the clinical quality metrics to track and monitor outcomes. The goal is to ensure that telemedicine visits are comparable to or better than in-person visits. In addition, patients complete a Press Ganey Telemedicine Patient Satisfaction Survey, which to date confirms high patient satisfaction. Providers are also polled regarding feedback and satisfaction when participating in virtual care delivery.


FY14 AND FY15 TELECONSULT CENTER SPECIALTY SERVICES

Specialty Service UPMC Northwest UPMC Bedford UPMC Urgent Care Hermitage

Cardiac Electrophysiology Available Available

Cardiothoracic Surgery Available Available

Colorectal Surgery (Pre- and Postoperative Consults) Available Available Available

Dermatology Available Available

Diabetes Management Available

Endocrine Surgery Available Available Available

Genetic Counseling Available Available In Development

Gynecological Oncology In Development

Heart Failure Available Available

Infectious Disease Available Available

Inflammatory Bowel Disease Available Available

Lipidology In Development

Maternal Fetal Medicine (MFM) Available Available Available

MFM: Diabetes Education Management (Gestational) Available Available

MFM: Diabetes Education Management (Type I and II) Available

Neurology: Movement Disorders Available

Neurology: Multiple Sclerosis Available

Neurosurgery: Cranial Nerve and General Available Available

Neurosurgery: Neuro-Oncology Available Available

Neurosurgery: Stroke Follow-up Available

Oncology: Breast Consultations Available

Pain Management In Development In Development

Pediatric: Allergy Available

Pediatric: Cardiology In Development

Pediatric: Gastroenterology Available Available

Pediatric: Nutrition Available Available Available

Plastics: Breast Reconstruction Oncology Available

Plastics: Hand Surgery Available Available Available

Plastics: Head and Neck Available

Plastics: Post-Weight Loss Available

Pulmonary Available

Reproductive Endocrinology and Infertility Available In Development

Rheumatology Available Available Available

Sleep Disorder Evaluations (Restless Leg Syndrome) Available

Vascular Surgery Available

Voice Therapy Available Available Available

Wound Evaluations Available In Development

In FY14 and FY15, UPMC increased teleconsult specialty services to include more than 35 different subspecialty services across both pediatric and adult specialties.

To the right is a table listing the available clinical services across each Teleconsult Center location.


Telemedicine Patient Scheduling Activity Across all UPMC Teleconsult Center Locations

Total visits completed since inception (6/28/2012) 1,947 patients

Telemedicine Patient Scheduling Activity: UPMC Teleconsult Center - Northwest

Total visits completed since inception (6/28/2012) 1,212 patients

Telemedicine Patient Scheduling Activity: UPMC Teleconsult Center - Bedford

Total visits completed since inception (2/28/2013) 443 patients

Telemedicine Patient Scheduling Activity: UPMC Teleconsult Center - Urgent Care Hermitage

Total visits completed since inception (3/11/2014) 288 patients

4.8

5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

All Telemedicine Locations & Providers

Combined Patient Satisfaction

Survey OutcomesVery Good

Good

Fair

Poor

Very Poor

4.9 4.8

5.0

4.5

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0

All Telemedicine Providers

Overall Patient Satisfaction Survey Outcomes

Very Good

Good

Fair

Poor

Very Poor

UP

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No

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est

UP

MC

Bed

ford

UP

MC

Her

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age

4.8

Below are summaries of the number of patient visits scheduled and completed through UPMC’s Teleconsult Centers (as of 6/30/15).

Combined Patient Satisfaction Survey Outcomes

Overall Patient Satisfaction Survey Outcomes

Teleconsult Center Patient Satisfaction

Through our collaboration with Press Ganey Associates Inc., UPMC Telehealth facilitated the development of the first Telemedicine Patient Satisfaction Survey. The survey is currently distributed in an electronic format, either via email or via iPad®, and allows telemedicine patients to rate their virtual visit experience. The results of the Telemedicine Patient Satisfaction Surveys are consistently high, with patient satisfaction scores averaging 4.80 out of a maximum score of 5.

Below are graphs of the Patient Satisfaction Survey scores across each UPMC location, and a combined graph across all providers at both locations.


SUMMARY OF TELEMEDICINE PATIENT DEMOGRAPHICS (AS OF 6/30/2015)

Specialty Service Average Age

% of Females

% of Males

# of Patients

Cancer Genetics 57 80.9% 19.1% 21

Cardiac Electrophysiology 71 45.5% 54.5% 11

Colorectal Surgery 51 43.7% 56.3% 32

Dermatology 50 66.6% 33.3% 6

Diabetes Management 53 51.9% 48.1% 185

Endocrine Surgery 62 81.0% 19.0% 221

Heart Failure 64 54.3% 45.7% 92

Infectious Disease 57 54.7% 45.3% 64

Inflammatory Bowel Disease 42 66.6% 33.3% 9

Maternal Fetal Medicine (MFM) 29 100.0% 0.0% 665

MFM: Diabetes Education 30 100.0% 0.0% 17

Neurology: Interventional Stroke 69 53.8% 46.2% 13

Neurology: Movement Disorders 67 59.5% 40.5% 37

Neurology: Multiple Sclerosis 55 62.5% 37.5% 32

Neurosurgery: Cranial Nerve and General 60 81.8% 18.2% 11

Neurosurgery: Neuro-Oncology 56 60.0% 40.0% 10

Pediatric: Gastroenterology 10 50.0% 50.0% 62

Pediatric: Nutrition 14 27.3% 72.7% 11

Plastics 63 0.0% 100.0% 1

Pre-op Evaluation Center 43 75.0% 25.0% 4

Pulmonology 64 67.7% 32.3% 31

Reproductive: Endocrinology and Infertility 30 100.0% 0.0% 22

Reproductive: Genetics 37 100.0% 0.0% 2

Rheumatology 54 83.8% 16.2% 259

Sleep Evaluation 51 38.7% 61.3% 31

Vascular Surgery 56 100.0% 0.0% 1

Voice Therapy 50 80.2% 19.8% 96

Wound Care 49 0.0% 100.0% 1

Grand Total 45 79.1% 20.9% 1947

Through our partnership with Wolff Center, UPMC Telehealth leadership has established the Telemedicine Evaluation Center (TEC), which is focused on collecting and analyzing the relevant clinical measures related to each telemedicine specialist visit. The TEC collaborates with our clinical specialist experts and identifies the key clinical components of each visit to compare telemedicine visits with in-person visits. Through this process, UPMC is determining which clinical services are best-suited to the telemedicine delivery model and which should remain as in-person.

For additional information about the TEC, please review this section of this Telehealth Annual Report.


Children’s Hospital of Pittsburgh of UPMC collaborates with hospitals across the world to improve health care globally, leveraging its expertise and technology by providing virtual consultations to physicians and patients at remote locations.

The Children’s Telemedicine Program utilizes video conferencing and store- and-forward technologies to ensure that urgent, emergency, and scheduled patients’ needs are consistently met.

The state-of-the-art digital technologies allow Children’s to provide complex pediatric care through remote and virtual means wherever the expertise is needed at any time of the day or night.

The Children’s Telemedicine Program development starts with modeling exceptional patient care experiences for children who need subspecialty care and ends with operations that are efficient for the patient, family, and referring physician.

Children’s Hospital of Pittsburgh of UPMC Telemedicine Program Mariel GarciaDirector, International and Telemedicine Services

Harun RashidVice President, International Services Division


Children’s Hospital of Pittsburgh international telemedicine collaborations consist of remote consultation of pediatric patients located in critical care units around the world. Children’s world-class intensivists are available when complex critical care expertise is needed. Several specialties have developed international programs based on specialized diagnoses:

• Virtual monitoring by intensivists from Children’s Cardiac Intensive Care Unit

• Consultations for transplant children and for pre- and post-surgical procedures to improve clinical outcomes and coordination of care

• Consultations for evaluations on neurodevelopmental and rare diseases

• Consultations regarding development and enhancement of new clinical programs

• Telenursing education in Cardiac Critical Care

• Education and training opportunities for clinical staff and administration, including observerships, CME, symposia, and video lectures

Children’s Telemedicine Program currently has locations in:

• Colombia (Fundación Valle de Lili, Cali; Fundación Cardiovascular de Colombia, Bucaramanga; Fundación Cardioinfantil, Bogotá)

• Brazil (Hospital Pequeño Príncipe)

• Italy (ISMETT, Palermo)

• Tampa, Florida (St. Joseph’s Children’s Hospital)

In February 2014, Children’s Hospital of Pittsburgh and Fundación Cardiovascular de Colombia further expanded their partnership to include telemonitoring of 24 intensive care beds. Other services in this agreement include telehealth, teleconferencing, tele-education, and teletraining in cardiac cath, heart transplant, and CT surgery.

In the August issue of Telemedicine and e-Health, the eCICU team at Children’s published the article Patient Outcomes of an International Telepediatric Cardiac Critical Care Program. The article described variables associated with patient outcomes during the implementation of an international

pediatric cardiac critical care telemedicine program. Several physicians from Colombia were co-authors.

Domestically, our Telemedicine Program is developing new care models that utilize both video conferencing and store-and-forward technologies in clinical areas, and the program will continue to expand the current scope to other pediatric subspecialties. Two areas of focus are partnerships with community hospitals and continued development of our outpatient clinics.

Currently, Children’s has eight active agreements, all of which utilize telemedicine within each community hospital’s nursery and emergency department. These hospitals include Armstrong County Memorial, Washington, Uniontown, UPMC Northwest and UPMC Horizon, UPMC Altoona, Charles Cole, and Indiana Regional.

As part of the agreement, Children’s also provides education in the form of webinars/WebEx, CME recordings, case review, simulation modalities, and other training tools.

The Children’s Telemedicine Program enables children living in remote communities to visit our pediatric subspecialists at Children’s Hospital of Pittsburgh of UPMC without having to travel long distances to the Lawrenceville section of Pittsburgh. Children’s continues to provide expert management in the areas of gastroenterology, Hem-Onc-Sickle Cell, post-op surgery, cardiology, epilepsy, and nutrition. During 2015, experts from transplant, pulmonology, palliative care, allergy and asthma, and endocrinology started providing live outpatient consultations to closely monitor patients without necessitating frequent face-to-face meetings.

UPMC provides telemedicine services to overseas hospitals and other health care institutions around the world. Our program is continually improving and evolving so that we can provide our global partners with added support in administering the best possible medical care to their patients, regardless of where they live.

AnnualVolumeFY2016

Projected

2,500

2,000

1,500

1,000

500

0.0

International

Domestic

Total

AnnualVolumeFY2012

AnnualVolumeFY2013

AnnualVolumeFY2014

AnnualVolumeFY2015

Children’s Telemedicine Program currently has locations in Colombia (Fundación Valle de Lili, Cali; Fundación Cardiovascular de Colombia, Bucaramanga; Fundación Cardioinfantil, Bogotá); Brazil (Hospital Pequeño Príncipe); Italy (ISMETT, Palermo); and Tampa, Florida (St. Joseph’s Children’s Hospital).

Children’s Utilization International and Domestic


Western Psychiatric Institute and Clinic of UPMC Telemedicine Program Jack Cahalane, PhD, MPHChief, Adult Mood and Anxiety Services Director, Telepsychiatry

In FY14 and FY15, the Telepsychiatry Program at Western Psychiatric Institute and Clinic of UPMC (WPIC) grew in size and scope, and provided additional services that build on our core business of providing psychiatric services to licensed mental health centers in rural Pennsylvania.

There was no turnover in the seven psychiatrists who provided telepsychiatry services in FY14 or FY15; in each year, the program had four senior residents/fellows in both direct care and scholarly projects. The Telepsychiatry Program provides psychiatric services in 4-hour blocks via a contractual arrangement with rural community mental health centers in Berks, Bradford, Cambria, Clarion, Jefferson, and Tioga counties in Pennsylvania.

The program continues to be a collaborative effort with the Community Care Behavioral Health organization, the UPMC-affiliated managed care organization for Medicaid. This partnership helps to expand psychiatric services to areas with little or no psychiatric services and, for many agencies, allows them to have sufficient psychiatric time to maintain licensure with the Department of Human Services.


The program also continues to partner with the Technology Development Center and has adopted Vidyo® as the video-conferencing platform across all sites. We also have moved from an exclusive office setting to the option of psychiatrists providing services from their homes. All psychiatrists use two screens, one with the patient image and the other displaying the electronic medical record (EMR). Currently, one agency has an EMR, and the psychiatrist(s) connects to this EMR and documents in that EMR. The majority of agencies use paper records, and a value-added component our program brings to the process is the use of our EMR, PsychConsult®. The Telemedicine technology team were able to use a firewall and partition a separate program for each agency so that only the agency and Western Psychiatric Institute and Clinic and put (WPIC) psychiatrist have access to patients’ clinical information. This addresses issues of scheduling and documenting clinical services, along with the ePrescribe functions (agencies with paper records can print the documentation).

In addition to these services, the Western Psychiatric’s Telepsychiatry Program began providing psychiatric consultation-liaison services using telepsychiatry for inpatients at UPMC Horizon. With the assistance of a mental health social worker, the psychiatrist uses mobile equipment to be at the patient’s bedside. Additionally, the Telepsychiatry Program began to provide donor and recipient transplant evaluations for patients at UPMC Hamot. A UPMC Health Plan pilot in the Digestive Disorders Program uses the psychiatrists and psychologists embedded in the program to provide services to patients in their homes. This is expected to increase compliance with treatment and positive outcomes, which prevent the need for higher levels of care. Finally, we have begun to provide services to individuals internationally once an initial face-to-face visit is completed.

Program participants submitted and completed presentations at the American Psychiatric Association in Toronto and the American Telemedicine Association in Los Angeles in the spring of 2015. The program also applied for a Beckwith Institute Frontline Innovation Program grant to support the purchase of pan-tilt-zoom cameras.

The Telepsychiatry Program received the Hospital & Healthsystem Association of Pennsylvania’s Innovation Award for 2014. The award recognized the breadth and scope of the program and the attention to quality in developing instruments and assessing patient and provider satisfaction. Western Psychiatric’s Telepsychiatry Program was selected as the winner from more than 100 submissions across all specialty areas in Pennsylvania.

The Telepsychiatry Program continues to develop quality projects, including the patient satisfaction project (within the Donald D. Wolff, Jr. Center for Quality, Safety, and Innovation — a UPMC initiative) that allows patients to use iPads® to complete modified Press Ganey satisfaction surveys. The Press Ganey surveys will be analyzed, and this patient sample will be compared to a similar sample of patients receiving face-to-face psychiatric services in FY16.

A provider satisfaction questionnaire was developed and distributed to psychiatrists who provide telepsychiatry services. While the results showed the psychiatrists’ experiences as positive or very positive, the results of another survey question showed that only half of the psychiatrists who responded felt that telepsychiatry services were comparable to face-to-face psychiatric services. This difference was not related to age, gender, or years of experience. A Western Psychiatric senior resident is developing a qualitative study to determine why this difference exists.

In FY14 and FY15, the Telepsychiatry Program focused on workflow and expansion into some new areas. In the next year, the Telepsychiatry Program will focus on growth, expecting to double the number of patient contacts by the end of FY16, and will begin to provide traditional outpatient appointments in patients’ homes, as well as grant supported teleconsultations to pediatricians in rural areas of Pennsylvania about the management of child psychiatric disorders in their practices.

The program was on target with continued growth, meeting projections with 3,696 services in FY14 and 4,048 in FY15. Gross charges averaged approximately $360,000 per year, with a margin of $106,000 per year.


UPMC’s own insurance plan (UPMC Health Plan) views telemedicine as a true innovation in improving access to those who need services most, as well as a service that optimizes treatment for those in need of acute care.

Health PlanKim JacobsVice President, Consumer Innovation & Strategic Business Development

Alissa MeadeSenior Director, Strategic Business Development & Commercial Strategy

Within the Insurance Services Division, telemedicine is viewed as an innovative vehicle to improve access and optimize care for acute and population-based needs while maintaining world-class quality of service. To that end, UPMC Health Plan has supported and driven the growth of telemedicine through policy and hands-on adoption of virtual care.

Throughout FY15, the Health Plan has undertaken a range of activities to promote, develop, and drive greater and more efficient usage of telemedicine services among its members.

The Health Plan continues to update its reimbursement policies to directly support UPMC physicians who offer virtual-care technologies in order to increase access to telemedicine options while improving quality and reducing costs.

The Health Plan also has developed a range of benefit plan designs to drive utilization of virtual visits through incentivized co-pay structures.


The UPMC Health Plan continues to directly partner with our colleagues in UPMC Health Services to grow UPMC AnywhereCare utilization and to develop and deliver telemedicine options for its members. From the launch of AnywhereCare in November 2013 through the end of the 2015 fiscal year, there were a total of 4,928 eVisits completed. Of those, 3,796 eVisits were performed for Health Plan members,

representing 77 percent of the total volume. The Health Plan views eVisits as a high-quality option that can provide optimized care and can achieve significant cost avoidance. Accordingly, the Health Plan has continued to support and drive AnywhereCare utilization.

In July 2015, UPMC AnywhereCare expanded services to offer UPMC eDermatology. This service allows individuals with nonurgent dermatological concerns, such as a rash or bug bite, to conduct a visit with a board-certified UPMC dermatologist via the eDermatology platform, with a guaranteed response within three business days, although most are completed within 6 hours. The Health Plan partnered on the eDermatology launch and offered this service with an incentivized co-pay to its members from the date of launch.

The Health Plan has also developed a range of targeted and condition-specific initiatives that leverage telemedicine. These initiatives include Remote Monitoring, Mobile Wound Care, CHF SimCoach, and Employer On-Site Clinics.

Given the importance of an effective video virtual-visit solution, an assessment was initiated to determine the key elements of a market-leading solution that includes the necessary user experience and functionality. A cross-enterprise process was launched in the spring of 2015 to assess the prospects of such a virtual-visit solution and potential vendors to deliver the desired strategy. A thorough review of the competitive landscape by the Health Plan resulted in identification of three potential vendors. Vendor presentations, due diligence, vendor site visits, financial assessment, and reference calls were all conducted with respect to several vendors. The data and information acquired during the diligence process were synthesized into a business case, which will be used to drive a decision regarding vendor and strategic approach with respect to a broad virtual-visit strategy to be launched in early FY17.

UPMC Health Plan deployed a Remote Patient Monitoring (RPM) program more than three years ago. The program identifies patients with chronic heart failure and wirelessly connects them to monitoring devices, such as a scale, blood pressure cuff, and pulse-oximeter. Any variance in output from one of the devices that is outside of the predefined Health Plan standards signals an alert, which is directed by Health Plan staff. That program has reduced total cost-of-care by $880 and unplanned cost of care by $952, and has decreased 30-day readmissions from 24% to 21%. UPMC Health Plan intends to expand and improve its RPM. The Health Plan continues to support and expand this program, including a systematic review of the program in FY15 with expected programmatic improvements (including a change in vendor) to be implemented in FY16.

The Mobile Wound Care program is a mobile-based application that has been constructed to facilitate the documentation and image-sharing needs between Health Plan Home Health Nursing agencies and the UPMC Department of Vascular Surgery.

Users of UPMC Telemedicine are clear that one of the major benefit of the program is the greatly increased convenience with no diminishment in the doctor-patient relationship.


The application allows nurses to complete treatment plan details and take pictures of a patient’s wound(s) during each home visit. Vascular surgery physicians have access to the data and images, and are able to consult with the nurse regarding treatment plans and advise on the best course of action for the patient. The Health Plan has been working closely with UPMC Telehealth leadership to determine the implementation and expansion plans for the mobile platform. There is potential to leverage the technology to address clinical needs on skilled nursing, outpatient clinic, and inpatient modalities.

The CHF SimCoach Payor/Provider Initiative is a collaborative project with the Donald D. Wolff, Jr. Center for Quality, Safety, and Innovation, that utilizes gaming technology as a method of education in disease management. It offers an innovative method to educate congestive heart failure (CHF) patients during an inpatient hospital stay — teaching the skills patients need to manage their condition after discharge.

This project delivers value through the use of an educational monitoring application delivered on an iPad. The target population is patients admitted to a UPMC hospital with a primary diagnosis or history of CHF.

Finally, the Health Plan has been enhancing the Employer On-Site Clinics at MyHealth@Work. This initiative provides a service to UPMC staff that allows them to interact virtually with a Certified Registered Nurse Practitioner (CRNP). Employee telehealth clinics at UPMC Passavant, UPMC Altoona, UPMC Northwest, and UPMC Shadyside hospitals have been equipped with mobile carts that have the ability to capture patient vitals and images, which are shared with the CRNP. He or she can then determine a diagnosis, establish a treatment plan, and prescribe medication. In FY14 and FY15, more than 1,400 telemedicine visits were conducted. When combined with the additional 21,000 acute visits performed at the MyHealth@Work centers, a total savings of more than $3 million was achieved through improvements in productivity, operations, and avoided acute care costs since inception. The Health Plan will continue to expand, adapt, and market these clinics both internally and externally.


Hospital and Community Services DivisionSteven M. Handler, MD, PhD, CMDChief Medical Informatics Officer, UPMC Community Provider Services Director, Geriatric Telemedicine Programs

Deborah BrodinePresident, UPMC Community Provider Services

During FY15, the Hospital and Community Services Division continued to expand its use of telemedicine in the skilled nursing facility (SNF) setting. UPMC Senior Communities entered its fourth year of cooperative agreement funding from the Centers for Medicare and Medicaid Services (CMS) to reduce the number of potentially avoidable hospitalizations from SNFs.

One of the major components of the RAVEN (Reduce Avoidable hospitalizations using Evidence-based interventions for Nursing facilities) cooperative agreement is to use telemedicine in the 19 partner non-UPMC SNFs. Since January 2014, when we began the RAVEN telemedicine program, we have successfully trained more than 450 partner nursing staff, conducted 90 telemedicine consults, and handled 745 telephone consults related to acute change in condition and/or palliative needs assessments.

The telemedicine consults completed by nurse practitioners resulted in a 42 percent perceived reduction in ED/hospitalizations, while the telephone consults resulted in a 19 percent perceived reduction in ED/hospitalizations. At the end of October 2015, the RAVEN program submitted to CMS for a second round of competitive funding that, if awarded, will include an additional four years of funding to evaluate a payment model for SNFs and participating practitioners.


This payment model will provide financial incentives for SNFs and providers to use telemedicine as a way to assess and treat the six most common causes of potentially avoidable hospitalizations (pneumonia, dehydration, congestive heart failure (CHF), urinary tract infection, skin ulcers/cellulitis, and chronic obstructive pulmonary disease (COPD)/asthma) within the SNF, instead of sending residents to the hospital.

During 2015, we implemented telemedicine in four UPMC-owned SNFs, and the final two were scheduled for December 2015. University of Pittsburgh Physicians (UPP) geriatricians are providing consultations during nights and weekends, when clinical staff are less available, with the goal of reducing the number of potentially avoidable hospitalizations through the standardization of order sets and pathways. As of November 2015, we have completed 70 on-demand urgent consultations. The telemedicine geriatricians have reported a 43 percent avoidance of ED/hospitalizations. We have been able to capture patient stories throughout our implementation. Telemedicine is transforming the way we provide after-hours care in our SNFs and enabling the patient and family to have a voice, as 80 percent of telemedicine consultations discuss goals of care.

We continue to focus our energy on well-defined, potentially avoidable diagnoses since CMS has announced the value-based purchasing program. Starting in 2018, this program will tie Medicare payment rates to the performance of SNFs’ risk-adjusted potentially preventable hospital readmission rates. A new development is the expansion of telemedicine in UPMC SNFs to support orthopedic consultations. A protocol is under review to support the hip/knee bundle through the provision of 90-day urgent postoperative consultations by telemedicine.

In 2015, Home Health continued to provide remote monitoring to patients within their homes, with a focus on CHF, to reduce the cost of care and provide enhanced care coordination. The organization utilizes both ATI (American TeleCare)-owned equipment and AMC-leased equipment. On a continuous basis, there were 40-50 ATI monitors and 60-70 AMC monitors in operation, providing 612 remote-monitoring patient interventions during the past year. The call center and alerting activities were handled by UPMC Visiting Nurses Association (VNA) staff members during daylight hours through a carefully structured process.

Home Health has been participating and helping to lead a new telemonitoring initiative under the Chief Medical Scientific Office to create a centralized, scalable, clinical, operational, and technical remote-monitoring platform. The goals for this platform are to enable and drive new models of care; enable better and more cost-effective chronic disease management; and provide a solution as a single point of reference for post-acute care, long distance care management, and transitional care. We anticipate launching this new initiative in 2016, with the VNA actively involved with the key tactical and strategic components.

In the meantime, Home Health has been working with remote monitoring leadership for the development of the two Go-Live use cases: CHF and Advanced Illness Care (AIC). There has been continued development of heart failure protocols that include home remote monitoring and a standing medication titration protocol. In November, the first patients were admitted under this newly launched pathway. Currently, we are in the process of evaluation to finalize the utilization of an internal call center; the VNA role in this operational and business decision is central. At this time, the UPMC Visiting Nurses Association Call Center is providing the triaging of potential patients for remote monitoring.


MyUPMC and UPMC AnywhereCare Report In 2014, Deloitte predicted that there would be 100 million eVisits globally, potentially saving more than $5 billion when compared

to the cost of in-person doctor visits and representing a healthy 200 percent growth rate when compared with 2012 volumes.


(1) Deloitte. eVisits: The 21st Century Housecall. Technology, Media, & Telecommunications Predictions 2014. http://www2.deloitte.com/content/dam/Deloitte/global/Documents/Technology-Media-Telecommunications/gx-tmt-predictions-2014.pdf

(2) Centers for Disease Control and Prevention. Ambulatory Care Use and Physician Visits. May 30, 2013. www.cdc.gov/nchs/fastats/docvisit.htm

(3) In early FY16, UPMC AnywhereCare expanded services to include eDermatology visits, which are available to patients in Pennsylvania.

In 2010, there were 1.2 billion patient visits to physician offices, emergency departments, and hospital outpatient clinics; this is equal to 3.3 visits per U.S. citizen1. A little more than half of these visits were to primary care doctors. Coughs, stomach pain, sore throat, earache, skin rash, and prescription refills accounted for more than 110 million office visits. Most of these could have been diagnosed and treated via an online eVisit2.

It is anticipated that future health care delivery will involve a seamless blend of virtual and brick and mortar experiences, depending on patients’ needs at certain points during their lifetime. The new model will assimilate comprehensive care coordination and will include virtual preoperative and postoperative follow-up visits, as well as chronic disease monitoring and wellness management. By incorporating recent technological advancements, including synchronous live audio and video interactive or asynchronous store-and-forward communication, as well as the use of mobile apps and remote monitoring tools, patients will have convenient, high-quality access to optimize their health and well-being.

On November 4, 2013, UPMC launched both its new patient portal — termed MyUPMC — and its first online convenience care platform — branded as UPMC AnywhereCare, which offers both traditional eVisits and the option for live, interactive audio-and video-enabled visits. The successful deployment of both platforms was the result of combined efforts across multiple teams, including the Technology Development Center, the Epic team, the Office of Physician Relations, the Physician Services Division’s Revenue Cycle team, Legal, Compliance, Quality, Audit, Community Provider Services, and the UPMC Health Plan, with oversight by Telehealth leadership across the UPMC system.

At right is an image of the new UPMC AnywhereCare dedicated landing page3.


http://www2.deloitte.com/content/dam/Deloitte/global/Documents/Technology-Media-Telecommunications/

450K

400K

350K

300K

250K

200K

150K

100K

50K

0KJan

— 2015— 2014— 2013— 2012— 2011— 2010— 2009— 2008— 2007— 2006— 2005

Feb Mar Apr May June July Aug Sept Oct Nov Dec

MyUPMC Cumulative Registrations

MyUPMC patient portal was established to serve as a common front door for all of a patient’s remote virtual health care needs. Building on the prior success of HealthTrak, the original UPMC patient portal which was launched in 2005, MyUPMC incorporates additional features and benefits. There are currently more than 450,000 patients enrolled in the MyUPMC patient portal. Through MyUPMC, patients have convenient access to their own and their family members’ health information4, including lab results, prescription information, previous visit summaries, and the ability to communicate with their providers and schedule appointments online via a HIPAA-secure platform.

In response to the evolving market opportunity and anticipated consumer demand for low-cost, high-quality access to care for simple acute conditions, UPMC Telehealth leadership launched the creation of UPMC AnywhereCare. UPMC AnywhereCare provides services to patients across Pennsylvania, regardless of health insurance, with 24/7 and 365-day-per-year online convenient access to high quality care. By accessing UPMC AnywhereCare, patients can complete a quick questionnaire about their clinical symptoms and receive a diagnosis and treatment plan, including a prescription when appropriate for a simple primary care-type diagnosis.

(4) Access to family member health records is only available if a Patient Proxy relationship is established.


473.9: Sinusitus

461.9: Acute Sinusitus

465.9: URI (Upper Respiratory Infection)

461.9: Acute Sinusitus Infection

450: UTI (Lower Urinary Tract Infection)

490: Bronchitis

786.2: Cough


465.9: Acute URI

461.9: Acute Sinusitus, Unspecified

Top 10 Continuity Care Diagnoses Treated Through UPMC AnywhereCare

0 10 20 30 40 50 60 70 80 90 100


465.9: Acute Upper Respiratory Infection of Unspecified Site

599: Urinary Tract Infection, Site Not Specified

461.9: Acute Sinusitus, Unspecified

490: Bronchitis, Not Specified as Acute or Chronic

462: Acute Pharyngitis

616.10: Vaginitis and Vulvovaginitis, Unspecified

372: Acute Conjunctivitis

366: Acute Bronchitis, Viral

788.1: Dysuria

Top 10 Convenience Care Diagnoses Treated Through UPMC AnywhereCare

0 100 200 300 400 500 600 700 800 90 1,000

Top 10 Convenience Care Diagnoses Treated Through UPMC AnywhereCare Top 10 Continuity Care Diagnoses Treated Through UPMC AnywhereCare

Through UPMC AnywhereCare, patients have the choice to either select a Convenience Care or Continuity Care visit. The adult Convenience Care visits are treated by an Advanced Practice Provider (APP) between 6 a.m. and 9 p.m. and by a physician between 9 p.m. and 6 a.m., with a usual turnaround of less than 30 minutes. The Convenience Care visits also provide patients with the option to choose a video visit between 6 a.m. and 9 p.m. In addition, patients who prefer to send their visit request to their primary care provider have the option to choose a Continuity Care visit and select from a group of participating primary care practices to submit their visit and receive a response within one business day. The Continuity Care visits do not have a video option.

Some of the most common symptoms treated via UPMC AnywhereCare include cough, cold, sinus infection, bronchitis, and urinary tract infections. UPMC AnywhereCare adult visits are completed by Pennsylvania licensed APP physicians (Emergency/Urgent Care/UPMC Command Center) and PCPs. UPMC AnywhereCare pediatric visits are completed by a Children’s Community Pediatrician. The retail price for a UPMC AnywhereCare visit is $38.00/visit; our UPMC Health Plan has negotiated reduced rates for certain members.

In FY15, UPMC AnywhereCare visits were expanded to patients living in Maryland. The UPMC Telehealth leadership team, in partnership with UPMC Legal Counsel, is continuing

to pursue additional expansion opportunities to neighboring states. In addition, there are plans to expand clinical services to include subspecialty virtual visits. The first subspecialty

services added were virtual asynchronous (store-and-forward) dermatology visits, which launched in July 2015.

UPMC ANYWHERECARE/ADULT AND PEDIATRIC SYMPTOMS TREATED

Adult Symptoms

Back pain Birth control Bronchitis Burn

Cold Cold and flu symptoms Cough Diarrhea

Flu Genital herpes Pink eye Pneumonia

Poison ivy Rash Red eye Scabies

Seasonal allergies

Shingles Sinus/cold symptoms

Sinus infection

Sore throat Strep throat Urinary symptoms

Vaginal irritation/ discharge

Pediatric Symptoms

Cold Cough Diarrhea

Pink Eye Rash Vomiting


Cumulative Counts

AnywhereCare Cumulative Visit Report – 11/4/2013 - 6/30/2015

Total Visits

Total Adult Visits

Adult Video Visits

Requested

Adult Video Visits

Completed

Adult Visits

Completed

Total Pediatric

VisitsSubmitted

PediatricVisits

Completed

Total Visits

Completed(Excludes

NONEVISITS)

ClinicallyInappropriate(NONEVISITS)

Total Health Plan

Visits Completed*

AnywhereCare Convenience (24/7/365 On-Demand, Virtual Visits and up to 30 minute response time)

5,381 5,333 118 83 4,385 48 26 4,411 961 3,809

AnywhereCare Continuity (PCP w/established Patient-Provider relationship and up to 1 business day response time)

544 538 0 0 481 6 6 487 50 338

Total 5,925 5,871 118 83 4,866 54 32 4,898 1,011 4,147

1,000

800

600

400

200

0

Convenience/ContinuityAnywhereCare by Weekday

—— Convenience —— Continuity

Co

unt

of

Vis

its

Mon Tue Wed Thur Fri Sat Sun

Thursday14.77%

Tuesday16.74%

Saturday10.94%

Sunday9.37%

Monday17.0%

Wednesday15.93%

Friday15.26%

AnywhereCare by Day of the week

2,000

1,800

1,600

1,400

1,200

1,000

800

600

400

200

012 a.m.

to 3 a.m.

AnywhereCare Submitted Across Various Time Intervals

Co

unt

of

Vis

its

3 a.m.to 6 a.m.

6 a.m.to 9 a.m.

9 a.m.to 12 p.m.

12 p.m.to 3 p.m.

3 p.m.to 6 p.m.

6 p.m.to 9 p.m.

9 p.m.to 12 a.m.

Time Interval

Below is a summary of the total number of UPMC AnywhereCare visits submitted and completed for both adult and pediatric patients.

The charts below display the breakdown of visits submitted across each day of the week and across various time periods.


Telehealth Subcommittee Reports

Finance Subcommittee Donald C. RiefnerVice President, Finance, and Payer Provider Programs

Andrew R. Watson, MD, MLitt, FACSDepartment of Surgery, Division of Colorectal Surgery Vice-President, International Division Medical Director, Telemedicine

The overall goals of the Finance Subcommittee are:

1) To provide support and guidance to the UPMC Telehealth Oversight Committee for finance-related issues;

2) To support the value proposition for telehealth development at UPMC through the definition, measurement, reporting, and analysis of volume, financial, performance, and other necessary metrics; and

3) To coordinate the interaction of appropriate UPMC Health Plan and Provider representatives through regular meetings as means of performing prioritized tasks.

The FY15 objectives centered on providing continuous centralized and standardized revenue reporting to monitor telehealth activities, as well as billing and reimbursement; and on the development of financial models, value proposition, and projections for all telehealth activities. The subcommittee set the following priority actions:

• Provide monthly consolidated volume and net revenue reports to monitor the financial impact of all telehealth activities across UPMC

• Monitor insurance billing and reimbursement activities for currently reimbursable telemedicine services, and aid in development of new billing policies to help expand current reimbursement

• Assist in development of teleconsult financial models and summaries to monitor and assess financial impact and value proposition

• Assist in the development of the new Remote Monitoring Program, and provide financial models/return on investment (ROI) to assess vendors and return on investment for certain case studies

The Finance Subcommittee has worked with multiple areas and established a standardized, consolidated, and ongoing reporting process that includes all business units and allows for monthly/quarterly updates to the Oversight Committee. This allows for tracking and trending of insurance and contract revenue across all telemedicine services on a year-to-date basis. The subcommittee has worked with operational leads to also track billing and reimbursement activities, mainly around telestroke services, to ensure proper compensation by insurance companies and to set the foundation for expanded reimbursement.

Finally, the subcommittee assisted operational leads with streamlining and improvement of financial reporting for the Teleconsult Centers to understand the value impact on the organization. The team developed financial analysis/ROI for remote monitoring for CHF and AIC to show the benefits of establishing the new program and to aid in the approval process.

Looking forward to FY16, the Finance Subcommittee will focus on continuous monitoring of existing activities, assisting in review of billing policies to drive reimbursement expansion to additional services, and expanding the value proposition and financial modeling to all telehealth activities.

The Finance Subcommittee continues to build the best practice financial model for past, present, and future telehealth services. By maintaining the evaluation and analysis strategies for budgeting, billing, reimbursement, and return on investment, the UPMC Telehealth initiative can continue to grow through a centralized financial model proven for success.


Grants Subcommittee

Barbara Barnes, MDVice President, SponsoredPrograms, Research Support, and CME

Rural hospitals and community health centers that are struggling in the midst of a national shortage of available specialists now have immediate access to UPMC specialists with the UPMC Telehealth Program and services.

During FY14, the Grants Subcommittee determined that the provision of behavioral health services to adult and pediatric rural populations would be one of its major priorities. At the present time, concept statements are being refined. We have also analyzed the alignment of UPMC facilities with state and federal legislative districts and identified legislators who might be advocates for our initiatives. Staff attended the Johnstown Showcase for Commerce in May 2014 and spoke with U.S. Senator Bob Casey and U.S. Senator Pat Toomey about our potential projects. Although the Congressional delegation was invited to visit UPMC, there was no significant follow-up.

In 2015, the Grants and Government Relations subcommittees were combined, given that there was significant overlap in the activities of the two committees. Drs. Ronald Poropatich and Barbara Barnes are the co-chairs.

The University of Pittsburgh is joining a Department of Defense (DoD) contracting consortium led by Engility, which will provide the opportunity for us to respond to a large variety of RFPs for work of interest to the DoD. It is likely that many of these will involve a telehealth component, providing a very streamlined mechanism for identifying projects of interest to UPMC.

Government Relations Subcommittee Ellen MazoDirector, Government Affairs Children’s Hospital of Pittsburgh of UPMC Western Psychiatric Institute and Clinic of UMPC

Michelle Fisher ReyesDirector, Advocacy and External Relations

Ryan Yuhas Director, Federal Government Relations

The Government Relations Subcommittee, established to provide awareness and understanding of the UPMC Telehealth Program’s direction of virtual health care with state and federal elected officials, was successful in FY15 in securing sponsorship in the Pennsylvania House of Representatives to establish across-state-lines licensing for physicians’ telemedicine consults. Representative Jesse Topper of Bedford introduced Pennsylvania House Bill 1619 in October 2015.

The subcommittee continued to educate elected officials about the importance of expansion of government reimbursement and reimbursement from private payers for telemedicine consults, as well as funding for equipment in rural/underserved hospitals.

Members of the subcommittee helped educate members of the new administration on progress being made in telehealth at UPMC, which is now part of working groups established by the state Department of Health to advance telehealth in Pennsylvania.

The subcommittee also continued to build on relationships with the Mid-Atlantic Telehealth Resource Center (MATRC) and the American Telemedicine Association (ATA), provide comments for public hearings, and host elected officials at telehealth-related events.

The subcommittee continues to work with U.S. Senator Brian Schatz of Hawaii, who is preparing legislation to lift Medicare restrictions on telehealth.

Looking forward to FY16, the Government Relations Subcommittee will provide updates on the legislative progress, including progress of the legislation for across-state-lines medical licensure. The subcommittee will continue to work closely with the Grants and Legal subcommittees on key policies and tactics for developing funding, awareness, and a global recognition for the entire process of advancing telehealth to ensure that UPMC stays in the forefront of this exciting market of health care.


IT Support SubcommitteeMichael KistlerTelemedicine IT Manager, UPMC Information Services Division

The dedicated members of UPMC’s IT team have earned numerous awards for their work in building virtual-physician-visit capabilities. UPMC’s Technology Development Center has won the prestigious Innovator Award from Hospitals & Health Networks, the journal of the American Hospital Association (AHA), and for the 17th consecutive year, designation as one of the “Most Wired” health systems in the country — the only one in the nation to achieve that distinction.

The IT Support Subcommittee continues to play a critical role in the expansion and development of UPMC’s Telehealth program and services. The IT Support Subcommittee is the central point of IT oversight and support across all areas of UPMC that offer telehealth services. This includes the entire UPMC hospital network — Western Psychiatric Institute and Clinic, Children’s Hospital of Pittsburgh, Magee-Women’s Hospital, and all other UPMC-owned hospitals — as well as the Physician Services Division and the UPMC Health Plan. The IT Support Subcommittee is responsible for vetting and deploying ongoing advances in technology in support of the ongoing expansion of UPMC’s Telehealth services. UPMC is fortunate to have an experienced, dedicated Telemedicine IT team focused on supporting current operations and planning for future developments.

The UPMC Telehealth community has grown accustomed to having a dedicated 24/7 and 365-day-per-year IT support team, which is accessed by dialing 1-855-4TELMED. This service line assists telemedicine providers with any and all problems faced before, during, and after their activities. The team also proactively tests and provides recommendations on telemedicine equipment, identifying potential areas of risk in order to minimize technical disruption and facilitate successful visits. The Telehealth IT team maintains a detailed log of all IT support and help desk calls to monitor trends and ensure continuous quality improvement.

In addition, the team is responsible for the ongoing development of telemedicine user training and customizing UPMC’s telemedicine equipment training manuals and reference materials. Having a metric-driven evaluation and assessment process has helped ensure that the Telemedicine IT team provides the most effective instruction and educational materials possible.As new doctors, nurses, and other clinical staff become involved with telemedicine, their feedback and suggestions are incorporated to improve the existing manuals and the training process. By continually evaluating key performance indicators, the Telehealth IT team is dedicated to high-quality customer satisfaction.

The 1-855-4TELMED 24/7 and 365-day-per-year live support service assists both internal and external telemedicine providers with ongoing assistance in support of each telemedicine visit. By providing end-user assurance that any technical issues are quickly managed, the Telehealth IT Support team fosters ongoing user acceptance, satisfaction, and trust in the program. The team records and analyzes the details of each call to determine ways that UPMC can improve the telemedicine visit process and overcome end-user challenges. The support line has assisted with over 1,900 calls since its inception in 2013. The average rate is approximately 3 to 4 calls per day which reinforces the fact that existing IT training and technology standards, as well as internal networks are appropriate and functioning as intended. The data is reported regularly and shared with UPMC’s Telehealth leadership in order to ensure transparency and provide ongoing support of UPMC’s rapidly expanding Telehealth program needs.


http://possible.as/

The key performance indicators for UPMC Telehealth IT Support include the following:

• The number of completed visits versus those lost to IT problems

• Answer time for support call resolution

• Availability of technical support

• Frequency of downtime as measured by support incidents

• Audio/video quality and utilization measures

• Total number of telemedicine sessions completed (and without incident)

The IT Support Subcommittee members oversee the review of telemedicine equipment utilized across UPMC. In FY15, the Telehealth IT Support team supported the transition from the Virtual Care Collaboration to the Vidyo platform as the main audio/video solution used throughout the enterprise. This transition entailed working closely with local IT groups at all locations, as well as with the providers directly, to ensure a smooth transition was accomplished. This extensive training effort facilitated greater cooperation and communication among IT groups and has resulted in a much higher level of overall understanding of telehealth enterprise-wide. With the increased volumes and utilization for Vidyo, additional infrastructure components have been added to the UPMC data center, with high availability/disaster recovery now in place. The Telehealth IT Support team oversees the training, support, and documentation in support of the Vidyo application. As other new telemedicine technology comes to market, the Telehealth IT Support team engages in ongoing testing and analysis of various telemedicine equipment and platform options to ensure that the highest quality and level of service is maintained, and the most efficient and affordable telemedicine options are available.

Currently, the Telehealth IT Support team is leading the effort to identify a telemedicine provider platform that will further enhance and simplify the telehealth experience. A working group was formed to help guide the process and identify the specific areas for improvement through the new platform. A comprehensive product and vendor review is currently underway, with representation from all technical and clinical areas involved with telemedicine. This enterprise-wide group of representatives is in the final phases of selecting a vendor, with the planned last steps of the contracting process occurring during the second and third quarters of FY15.

The IT Support Subcommittee will continue to improve and further develop the standard UPMC Telehealth Cart, as well as identify and test new peripherals as they become available. This process has been very beneficial to our organization, as vetting these devices through this group has identified needs and clarified requirements. The IT Support Subcommittee has been an instrumental component of the ongoing expansion and success of the UPMC Telehealth Program.

100

50

0

Telehealth Provider Support Calls per Month (1,311 Total)

April 2

013

May 2

013

June

2013

July

2013

Augus

t 2013

Septe

mber

2013

October

2013

Novem

ber 2

013

Decem

ber 2

013

Janu

ary 2

014

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ary 2

014

March

2014

April 2

014

May 2

014

June

2014

July

2014

Augus

t 2014

Septe

mber

2014

October

2014

Novem

ber 2

014

Decem

ber 2

014

Janu

ary 2

015

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ary 2

015

March

2015

April 2

015

May 2

015

June

2015

July

2015

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t 2015

Septe

mber

2015

October

2015

17 13 1636

23 26 28

5343 45 49 45 46

61 5748

2244 47 39 36

5031

67

41

6954 57

36 40

72

Telehealth Provider Support Calls per Month (1,311 Total)


Marketing and External Relations SubcommitteeDoug LucasSr. Director, Digital Marketing and Interactive Engagement

The Marketing and External Relations Subcommittee successfully brought together representatives from across UPMC to share information and the coordination of marketing and external relations needs to support telehealth activities across the UPMC health system. Monthly meetings have been established among the subcommittee to ensure information is shared across all business units. During these sessions, representatives have the opportunity to share recent telehealth developments from their respective departments and request marketing support.

In 2014, the subcommittee collaborated to develop a “Telemedicine at UPMC” brochure that highlights UPMC as a leader in virtual care and illustrates UPMC’s commitment to extending world-class clinical services and access to hospitals, clinics, specialists, and primary care providers throughout our community. In addition, the subcommittee managed the initial development and design of this extensive Annual Report. Furthermore, 2014 saw the launch of a targeted, consumer-focused digital marketing campaign for the online medical visit platform, UPMC AnywhereCare. This new campaign, driven by the UPMC Digital Marketing and Interactive Engagement team, served to increase the total number of AnywhereCare visits, as well as increase brand awareness. As part of the new campaign message platform, the UPMC AnywhereCare Web page was completely redesigned and analytics tools were added to allow for thorough tracking of user behavior on the site.

The digital marketing campaign was launched in October 2014, running heaviest during the cold and flu season before tapering off at the end of the FY15. The three key audiences targeted were college students, working professionals, and on-the-go moms, which proved to be the strongest performing of the three audiences. Research showed that Facebook was the strongest performing medium across the board, followed closely by Pandora and display ads. No previous data or benchmarks for comparison were available outside of industry benchmarks for engagement during the initial launch of the UPMC AnywhereCare digital campaign.

Over the course of the campaign, many key findings were uncovered, as many strategies were tested that led to an overall increase in engagement rates of the digital ads, and a better understanding of how consumers were interacting with the UPMC AnywhereCare platform. Not every target audience is created equal, thus trends changed over the course of the campaign.

The campaign was re-launched in October of 2015, focusing on the key takeaways from the first time around and applying those to the media mix for this fiscal year. Those changes were made and will continue to be made moving forward in order to optimize performance not only as a whole, but from a year-over-year monthly standpoint.

In July 2015, Clinical Marketing — in conjunction with Internal Communications — began promoting UPMC’s new eDermatology program. Marketing objectives included:

• Raising awareness of the new eDermatology service

• Driving utilization of the service to increase patient volumes

• Mitigating the threat to dermatology volumes by promoting our competitive advantage over other competing products, includ-ing the expert care, convenience, and value of eDermatology

The roll out included messaging to employees of UPMC and UPMC Health Plan, as well as UPMC’s current dermatology patients, as capitalizing on employees and existing patients was a quick and low-cost way to share the message about eDermatology and reach potential users. A public-facing digital campaign for eDermatology launched in October 2015 to coincide with the start of UPMC AnywhereCare’s fall/winter advertising. These highly targeted ads continue to run, targeting conditions that patients are already searching for, such as acne psoriasis, and rosacea.

Also in fall 2015, UPMC Health Plan began promoting eDermatology to its members via online and print tactics.


Telemedicine Evaluation CenterJames HendersonSystems Analyst Lead, Donald D. Wolff Jr. Center for Quality Improvement and Innovation, UPMC

Andrew BilderbackClinical Outcomes Analyst, Donald D. Wolff Jr. Center for Quality Improvement and Innovation, UPMC

Natasa Sokolovich, JD, MSHCPMExecutive Director, Telehealth, UPMC

• Colorectal

• Maternal Fetal

• Rheumatology

• Infectious Disease

• Stroke

• Endocrinology

• Dermatology

• Psychiatry

More than 10 years ago, UPMC launched its Telehealth Program with telepsychiatry and telestroke services, providing patients with access to a specialist without burdensome travel. Cameras, monitors, and audio were coordinated to allow patients and physicians to meet face-to-face, as if sitting in the same room. Since then, the UPMC Telehealth Program has grown exponentially.

The UPMC Telemedicine Evaluation Center (TEC) is focused on establishing core clinical measures across specialties in order to collect data and evaluate outcomes across each telemedicine service, as well as to facilitate the comparison of telemedicine outcomes with outcomes for similar encounters delivered through traditional, in-person encounters. In collaboration with the Wolff Center at UPMC, a core group of clinical and administrative telehealth leaders comprise the UPMC TEC.

The clinical outcome measures for each telemedicine specialty service are established by the UPP physician specialist delivering care (as the clinical expert for a specialty service). The Wolff Center team works with each of the physicians to identify the core clinical outcomes to measure. The clinical outcome measures are shared and reviewed in collaboration with the UPMC TEC analytic team, who provide ongoing feedback on initial analyses. Outcome measures vary based on specialty; for example, the Maternal Fetal outcome of the Caesarean section rate is not relevant to other specialties. While acknowledging the specialty-specific nature of each quality outcome, the TEC team has also made efforts to consider outcomes that are relevant across specialties, such as patient satisfaction, physician satisfaction, and access to care. Working with individualized outcomes, the TEC team must often access data in different systems, depending on specialty, and has met this challenge by remaining system neutral and building an infrastructure to generate reports across various systems.

In 2014 and 2015, the TEC established a reporting infrastructure to allow the analytic team to update reports with additional patient visit and outcome data on a regular, semi-annual basis across several key subspecialty areas, which were prioritized based on volumes. The ongoing goal is to expand the reporting infrastructure across additional clinical subspecialty areas and to ultimately provide analytical reporting across all specialty services. As UPMC’s telehealth services continue to expand, the TEC is structured to provide key analytical data in support of UPMC’s mission of expanding high quality, world-class care through new, innovative models of care delivery.

The following pages provide summaries of the TEC’s progress in evaluating the quality outcomes across several prioritized clinical subspecialty telemedicine services.


Colorectal

Wolff Center, in collaboration with the TEC, collected data from various sources and combined this data into a single data source to provide an advanced analytics review of colorectal surgeries where the preoperative consultation was done via telemedicine to compare telemedicine outcomes with outcomes from traditional, in-person encounters. The data included a rigorous testing and statistical comparison of clinically relevant metrics, including length of stay, readmission rates, returns to operating room, procedure times, complications, and emergency department visits within 12 months of surgery, between telemedicine and in-person encounters. Findings concluded that there were no significant differences between the two groups. This initial analysis suggests that patients evaluated via telemedicine do as well as patients evaluated in-person across several key data measures, including resource utilization, cost, and patient safety outcomes.

These findings have been submitted by Dr. Andrew Watson, who is planning to present the information at the 2016 ATA (American Telemedicine Association) Annual Conference and Trade Show with the intention of publishing the results. In addition to the preoperative data that is shared in the table below, the TEC has begun reviewing outcomes for postoperative colorectal telemedicine consultations.

Maternal Fetal

The TEC gathered data from Epic and the Medipac Corporate Data Base (CDB), which was combined to allow a single source for data analysis purposes. Comparisons were made from clinically relevant outcomes, including delivery type, birth weight, gestational age, NICU level of stay, and infant mortality, between telemedicine and in-person encounters, and found no significant differences between both groups. This initial analysis suggests that mothers who are evaluated via telemedicine deliver infants who thrive as well as infants of mothers who receive in-person evaluations. Dr. Hyagriv Simhan is currently writing a paper for publication with these results.

Maternal Fetal Medicine Outcomes In-person N=5853

Telemedicine N=221 p

Delivery type [n=6042] 0.633

C-section, n (%) 2390 (41) 93 (43)

Vaginal, n (%) 3434 (59) 125 (57)

Underweight (Birth weight <2500 grams), n (%) [n=5941]

1013 (18) 36 (17) 0.649

Nursery LOS in days, mean (SD) [n=5989] 5.5 (11.2) 4.6 (8.4) 0.269

NICU, n (%) [n=5989] 1613 (28) 54 (25) 0.262

NICU LOS ≥ 1 day, n (%) [n=1627] 1155 (72) 21 (81) 0.312

Baby mortality postdelivery, n (%) 77 (1) 1 (0) 0.192

Pre/Intraoperative variables In-person N=308

Telemedicine N=30 P

Set up time, median [p25, p75] 78 [48,131] 99 [56,140] 0.16

Procedure time, median [p25, p75] 375 [202,713] 469[270,740] 0.391

Total case time, median [p25, p75] 497 [260,909] 543[342,912] 0.392

Number of procedures, mean (SD) 2.0 (1.1) 2.2 (1.1) 0.343

Postoperative variables

Return to OR, n (%) 8 (3) 3 (10) 0.07

Any complications, n (%) 72 (23) 6 (20) 0.671

DRG weight, mean (SD) 2.55 (1.38) 2.49 (0.95) 0.824

Length of stay, mean (SD) 6.4 (3.9) 7.3 (5.2) 0.215

Readmission, n (%) 28 (9) 3 (10) 0.871

ED visit in the following year (n=322), n (%)

103 (35) 10 (40) 0.596

Number of ED visits in the following year (n=322), median [min, max]

0 [0,46] 0 [0,4] 0.865


Rheumatology

Dr. Christine Peoples, UPP Department of Medicine clinician, converted her clinical practice exclusively to telemedicine visits in November 2014. The Wolff Center and TEC team focused on the collection of data for rheumatoid arthritis patients from various sources, including Medipac CDB and Epic. The analysis compared outcomes of clinical disease activity index (CDAI) scores, patient global scores, and physician global scores between patients seen in telemedicine and in-person encounters. While the current data sample of rheumatoid arthritis patients is limited, the goal is to continue to expand the database with additional visit results and to update the analyses on a regular basis. In addition to CDAI, patient global scores, and physician global scores, the TEC plans to measure outcomes across follow-up return rates and the length of telerheumatology visits (in minutes).

Infectious Disease

Data was collected to identify patients who had either an inpatient or outpatient teleID (Infectious Disease) consultation initiated at either UPMC Northwest or the UPMC Teleconsult Center at UPMC Northwest. The teleID consultations were completed via synchronous, live, interactive audio-and video-enabled telemedicine visits by a UPP infectious disease specialist located at UPMC Presbyterian. Charts were pulled manually for 69 sepsis patients, and a standardized abstraction form was developed to collect outcome data from each chart.

Outcomes measured included: antibiotic course changes (i.e., change in either the antibiotic prescribed or the antibiotic frequency or dose), new diagnostic tests ordered, and clearance of S. aureus bacteremia. The process-of-care outcome measures (i.e., antibiotic change, new tests) were selected to demonstrate that the teleID consult resulted in a change in patient management plan, which was also measured by assessing whether telemedicine recommendations were followed by the UPMC Northwest attending physician. An ID-specific clinical outcome was also selected and included S. aureus clearance to complement process outcomes.

The results demonstrated that the majority of teleID consults resulted in a change in process outcomes and clinical management. The results did not demonstrate clearance of S. aureus bacteremia in any of the patient samples, which may be due to lengthy testing requirements that often take up to three weeks to complete prior to a determination that the patient is officially “cleared.”

Telerheumatology Non-telemedicine Telemedicine P

Rheumatology Outcomes N Mean N Mean

CDAI change 3716 -1.11 5 -9.5 0.06

Patient global change 1607 -0.45 3 -0.67 0.89

Physician global change 1608 -0.44 3 -0.17 0.82

Infectious Disease OutcomesNumber of

Recommendations (n=69)

Recommendation followed by attending

Medication change 54 (78%) 54 (100%)

Frequency change 0 (0%) —

Medication duration change 1 (1%) 1 (100%)

Additional test 65 (94%) 61 (94%)


Stroke

Telestroke and teleneurology continue to expand and currently serve 20 acute care hospitals in the region. Process Measures are continuously measured; this includes door-to-needle time for IV tPA (tissue plasminogen activator), time from call to initiation of telemedicine, onset to treatment times, tPA treatment rates and transfer rates. Functional outcomes at 90 days and hemorrhage rates for all patients treated with IV tPA by telemedicine are also recorded.

TEC committee member Dr. Parthasarathy Thirumala, with the help of Dr. Lawrence Wechsler, recently evaluated the morbidity and mortality in patients who received tPA by telemedicine for treatment of acute ischemic stroke (AIS). A previous study, published in the journal Stroke, found similar mortality rates, rates of symptomatic intracranial hemorrhage, and 90-day outcomes based on the modified Rankin Scale in patients who were administered tPA for AIS and treated at local hospitals via telemedicine consultation compared to patients administered tPA at a comprehensive stroke center. The aim of the new study was to examine characteristics of care, including length of stay and overall adjusted mortality, during hospitalization after IV tPA treatment at UPMC spoke hospitals in a telestroke network. Analysis included the retrospective examination of 134 consecutive medical records of patients treated after telemedicine consultation at five UPMC spoke hospitals who then remained at the spoke hospitals for treatment, and 272 consecutive patients treated at UPMC Presbyterian, a tertiary care comprehensive stroke center.

Multivariate analysis of spoke hospital patients compared to hub hospital patients

Parameter Odds Ratio95% CI

Lower Upper

Demographics

AGE >65 2.140 1.060 4.322

MALE 0.714 0.394 1.295

Prior CVA 1.174 0.637 2.162

Atrial Fibrillation 1.284 0.665 2.479

Diabetes 0.646 0.329 1.270

Treatment

NIHSS score 0.307 0.150 0.629

SBP>160 0.638 0.354 1.149

Large vessel occlusion 0.292 0.136 0.624

Onset-needle >180 0.581 0.269 1.258

Complications

Length of stay >6 days 4.696 2.428 9.083

mRS = 6 1.542 .635 3.746

Fever 0.288 0.116 0.712

Intubated 0.043 0.007 0.256

Seizure 0.821 0.142 4.752

In-hospital Mortality 11.046 2.785 43.810

CVA = Cerebrovascular accident, SBP = systolic blood pressure, mRS = modified Rankin Scale

Mean NHISS

mRS 0-1

mRS 0-2

Asx Hem

Sx Hem

UPMC NINDS (Benchmark)

0 10 20 30 40 50 60

Comparison of outcomes on the modified Rankin Scale between 677 patients treated in our telestroke network and the NINDS tPA trial that established the efficacy of IV tPA.

n UPMC n NINDS (Benchmark)

A summary of the study results is included below:


Stroke (continued)

The patients were treated within the same time frame. Complications recorded included: mortality, length of stay, symptomatic intracranial hemorrhage, pneumonia, urinary tract infections, gastrointestinal bleeding, myocardial infarction, new-onset atrial fibrillation, fevers, falls, and constipation. Multivariate analysis was completed using Bayesian shrinkage to control for risk factors and identify complications that are independently increased or decreased in the spoke hospital population. In addition, long-term survival was compared using a Cox proportional hazards regression, with age and NIH Stroke Scale Score as covariates. Main outcome measure: Whether length of stay and medical complication rates differed between tPA patients who remained at community hospitals after treatment via telemedicine and those who were treated at a comprehensive stroke center at UPMC Presbyterian. Results demonstrated that patients who received intravenous tPA via telemedicine had an increased risk of in-hospital mortality and longer length of stay, after adjusting for lower stroke severity and fewer large vessel occlusions. This data has been published in the journal Stroke. The results of this study demonstrate that, in addition to the initial telestroke consult, patients at community hospitals may benefit from follow-up general teleneurology consults, which may facilitate better overall care coordination and clinical management.

Endocrinology

The tele-endocrine visit quality analysis included a review of subsequent data records as a follow-up to a study conducted in 2012 by Dr. Frederico Toledo at UPMC that focused on hemoglobin A1c (HbA1c) levels, a universally well-accepted measure of diabetes control and quality of diabetes care in patients who received synchronous telemedicine visits. Ideal diabetes control is represented by HbA1c < 7%, while HbA1c values > 9% suggest poor diabetes control. Dr. Toledo’s original study demonstrated that patients who completed a telemedicine consultation had improvement in their mean HbA1c levels from 9.6% (SD 0.4%) to 8.5% (SD 0.4%) (P < .001). Similarly, recent analysis showed a trend toward decreased HbA1c scores after a telemedicine consultation (although the sample size was limited and included 21 patients and resulted in a nonsignificant p-value of .24). The TEC plans to work with UPP endocrinologists to expand the endocrinology database, recognizing that HbA1c data is typically collected every 3-6 months, as this measure reflects blood glucose values over the past 90 days, and obtaining the data is challenging because patients’ results are often collected across multiple locations with disparate database systems.

The analyses is further limited by lack of access to HbA1c data collected outside of the UPMC system. The goal is to continue working with the UPP Division of Endocrinology to attempt to collect additional HbA1c data across the UPMC system (or at accessible outside labs, such as Quest Diagnostics™), as well as to broaden the number of clinically relevant outcomes collected in patients with diabetes and other endocrine conditions.

25.0

20.0

15.0

10.0

5.0

0.0

90 Day mRSError Bars: 95% CI

Modified Rankin Scale (mRS) and NIHSS Score

0.0 1.0 2.0 3.0 4.0 5.0 6.0

Mea

n N

IHSS Legend:

NIHSS = NIH stroke scale Purple = Telemedicine Green = Non-telemedicine

Endocrinology OutcomesBefore

telemedicine consult

After telemedicine

consultP

N Mean N Mean

HbA1c % 21 8.74 21 8.28 0.24

Modified Rankin Scale (mRS) and NIHSS score


Dermatology

Dr. Stephanie Snyder, a fellow in the UPP Department of Dermatology, together with Dr. Joseph English, UPP Dermatology attending physician, collected data to review the impact of asynchronous, store-and-forward teledermatology visits. Teledermatology incorporates the use of store-and-forward technology, where-by a requesting PCP clinician or patient takes several images of the suspicious dermatologic area and uploads them to the consulting teledermatologist via Epic. During 2014 and 2015, the TEC and Wolff Center team completed a comparative analysis of outcomes from virtual teledermatology visits with the same outcomes from in-person dermatology visits. The key quality outcome data elements identified include diagnostic accuracy, preventable referrals, time to recovery, and patient/physician satisfaction.

A significant advantage of teledermatology is that it facilitates care coordination by incorporating a teledermatology consult as part of a general PCP visit. The teledermatology consult is utilized when a general PCP visit results in the observation of an unusual dermatologic condition. By allowing PCPs or their mid-level provider to upload several images of the skin condition to the UPP dermatologist, patients have same-day access to a board-certified dermatologist (including access to traditional, in-person consultations within 48 hours), if needed.

The table below outlines the results across a number of teledermatology quality indicators.

Access to Care

Average wait from the time the consult was placed to the time the consult was completed

15.11 minutesMax: 73 minutes Minimum: 1 minutes

Average time from consult to obtaining biopsy

11.54 days

Accuracy of Diagnosis

For patients where follow up and/or biopsy was recommended, the average number of final diagnoses (from either simple, in-person observation of condition or biopsy) that matched the consult diagnoses

83.41% overall82.61% accuracy compared to biopsy84.21% concordance with clinical diagnosis

Preventable Referrals

Consults with diagnoses that did not require in-person dermatology follow-up, representing the amount of consults avoided utilizing the service’s triaging effect

63.21%

Patient Satisfaction

Percent of patients who agreed/strongly agreed with the statement: “I liked being able to have questions about my skin problem answered without another appointment”

81%

Internal Medicine Attendings’ Satisfaction

Overall rating of High or Very High for telemedicine by internal medicine attending physicians who have used UPMC’s Teledermatology service

90%

Psychiatry

Wolff Center members met with Frank Ghinassi, MD, WPIC and Jack Cahalane, PhD, MPH, Director of Telepsychiatry, WPIC to identify appropriate outcome measures. In addition, the Wolff Center members met with Dr. James Shuster, who oversees the clinical management of UPMC’s telepsychiatric services, which have expanded access to patients residing in underserved areas across Pennsylvania. The Community Care Behavioral Health (CCBH) data team is leading both data pull and analysis of desired quality outcome measurements across telepsychiatric visits. The Wolff Center team will continue to assist the CCBH and will support the progress toward analyzing the key quality outcomes. The potential outcomes identified include: engagement retention rates, pharmacological intervention, and ED visit rates. The TEC anticipates that the ongoing work to analyze key quality telepsychiatric outcomes will demonstrate the potential clinical impact of telehealth on public health across behavioral and mental health services.


About UPMCA world-renowned health care provider and insurer, Pittsburgh-based UPMC is inventing new models of patient-centered, cost-effective, accountable care. It provides nearly $900 million a year in benefits to its communities, including more care to the region’s most vulnerable citizens than any other health care institution. The largest nongovernmental employer in Pennsylvania, UPMC integrates 60,000 employees, more than 20 hospitals, more than 500 doctors’ offices and outpatient sites, and a more than 3 million-member Insurance Services Division, the largest medical and behavioral health services insurer in western Pennsylvania. Affiliated with the University of Pittsburgh Schools of the Health Sciences, UPMC ranks No. 12 in the prestigious U.S. News & World Report annual Honor Roll of America’s Best Hospitals. UPMC Enterprises functions as the innovation and commercialization arm of UPMC, while UPMC International provides hands-on health care and management services with partners in 12 countries on four continents. For more information, go to UPMC.com.

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Telehealth FY14 -FY15 Annual Report · (1) This growth trend played out across our nation in 2015...

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