The Army launched a new program Feb. 2 to measure the impact of technology on providing primary care services in reducing the time non-urgent care patients spend in busy emergency centers.
The six-month telehealth pilot, administered by Regional Health Command-Atlantic (Provisional), is a joint effort of Blanchfield Army Community Hospital (BACH) and Eisenhower Army Medical Center (EAMC) connecting family medicine and primary care physicians from Eisenhower with patients at Blanchfield to provide medical care via a secured video teleconference.
According to Master Sgt. Jason Alexander, RHC-A (P) Clinical Operations NCO, many ill patients use the emergency department after hours due to the unavailability of their primary physician. With the pilot, RHC-A staff are helping the emergency department staff at Blanchfield focus on more serious ill or injured patients.
"If you or your family member is sick, having access to a doctor right away is a priority. This is why some patients present to the ED with low acuity", said Alexander."This pilot aims to identify patients who fit this category and redirect them to a primary care doctor at Eisenhower. Not only will the care provided be focused to their need but it will also help reduce their wait time and allow ED professionals to take care of more urgent cases."
Accessibility involves establishing a"Virtual Patient-Centered Medical Home or PCMH" to redirect non-urgent care patients from BACH's emergency room in Kentucky to an area where they can be screened and evaluated by qualified telehealth physicians working at the EAMC Telehealth Center 445 miles away in Georgia.
A PCMH is a way of organizing primary care that emphasizes care coordination and communication to transform primary care to allow better access to health care, increase satisfaction with care, and improve overall health.
Access to care is a key focus area for Army Medicine. In 2014, then Secretary of Defense Chuck Hagel released the findings of a military health system review, which described the military's ability to meet certain benchmarks for quality, safety and access to care as average.
"Bringing the right care, by the right person, at the right time, and in the right format will enable us to transform our delivery of care and improve patient access to that care," wrote Brig. Gen. Ron Place, RHC-A commanding general, in his February message to regional staff.
"Our whole objective here is really not to just assist wait times but to assist people who leave because they are tired of waiting and leave without being seen," said Alexander."So the 'left without being seen' rate should drop, our wait times should drop, and the quality of the encounter and our handoff back to primary care should improve as we integrate our systems from this redirect process back to into primary care inside of the hospital."
Lt. Col. Kevin Horde, a family medicine physician from Fort Benning's Martin Army Community Hospital supporting the pilot at EAMC, had no telehealth experience before joining the pilot team.
"It's a great opportunity to move our care delivery to the next level," he said.
In order to get ready for his first virtual patient, Horde had to take online classes in the use and application of telehealth and had to be credentialed to practice at both EAMC (his base of operations for the pilot) and BACH. Hours of practical experience followed under the tutelage of Dr. Wood, chief of telehealth at EAMC. Simulated patients and scenarios were used to get Horde, and the nearly dozen RHC-A physicians training to support the pilot, comfortable with the virtual exam process.
"With that very first patient I had a little anxiety despite all of the training," Horde said."Family medicine is hands-on. But the technology actually enabled me to have some great interaction with the patient. I was surprised."
Horde says the patients he has seen during the first weeks of the pilot all seem to enjoy the process and the attention both he and the support team at BACH provide.
"After the nurses in the room with the patient explain the process, I come on the screen," he added."Usually their first reaction is a smile. I think they are curious about being a part of this [pilot] and interested in the entire process because it is new. We are truly working together as a team and that is what the patient-physician relationship should be."
Voluntary surveys given to patients after the exam indicate that they feel their medical problem was adequately addressed and they are satisfied with their telehealth experience.
High-Tech, Right-Touch
Hospitals across the region have used telehealth, mostly tele-behavioral health for years. EAMC is among the leading telehealth centers in the region, its location at Fort Gordon, home of the Army Cyber Center of Excellence, the Army's proponent for communications and information services, provides prime access to the subject matter experts and technology infrastructure.
"Of course, you can do telehealth anywhere with the right resources, but I like to think we are at the right place for this pilot program," said Joseph Wood, chief, Telehealth Service Line, EAMC.
"We have been pro-telehealth for a number of years and with our medical center status, medical specialty expertise, and an interest in trying new things, I am excited that EAMC is a part of the pilot."
Telehealth exams are more complex that the traditional face-to-face exams, according to Wood. Physicians have to be credentialed at every hospital where they see patients and patient appointments must be made at both the hospital and telehealth site.
"We also have to ensure that system access at both locations is available and meets our high standards regarding HIPPA and PII compliance," Wood said."We also have to have point-to-point encryption. This is not like using your computer with some of the popular software on the market."
The peripheral devices used for evaluating ear and throat pain provide high-definition images that the doctor and patient are able to see at the same time, according to Horde. Those high-definition images are then uploaded into the patient permanent medical record for use by their primary care physician or specialist.
"The technology allows me to share what I see immediately with the patient and use those images to help them understand what is happening," Horde said."This actually increases doctor -patient interaction because we can discuss what they see and hear going on in their body."
Getting a team of more than 50 interdisciplinary professionals together was a challenge, according to Alexander, who serves as project lead for the RHC-A Clinical Operations Directorate.
"You need a great team and that is exactly what we have," Alexander said. A lot of the leadership has really brought in to this whole telehealth concept and using it to assist their patients. It creates more capacity in our health system. If you look at it from a regional health perspective, telehealth provides us the opportunity to leverage other resources and other facilities to create what we call an integrated delivery system."
"We have two facilities connected to each other and at least 25 people working to make this happen from different departments--primary care, emergency department, patient administration, resource management, pharmacy, information management/information technology," he said."This has touched almost every major bellybutton in both hospitals to come together to include at the regional level where we have had to tap into those same shops to make this program work."
The team also extends beyond RHC-A to include combat medics and nurses from Fort Campbell's 86th Combat Support Hospital who are training on the equipment to test the feasibility of using telehealth with forward deployed units.
Colonel Telita Crosland, commander, Blanchfield Army Community Hospital said moving health care from within a defined medical structure to wherever the patient is would be a real-game changer for our community and organization.
"We're taking technology and using it to be more accessible to our patients," Crosland said."It [telehealth] has the potential to project capabilities worldwide from a continental United States location allowing us to better support deployed service members."
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