Earlier this spring, Cleveland Clinic announced that its providers will be available to patients for online and mobile visits for nonemergency urgent care needs via CVS MinuteClinics in Ohio. The move is just the latest in a string of Cleveland Clinic distance health initiatives in recent years (see sidebar below), and its Neurological Institute has been at the forefront of many of those efforts.
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The case for distance health
“We are responding to patients’ needs for better care, greater convenience and improved access to our services,” says Peter Rasmussen, MD, Cleveland Clinic’s Medical Director of Distance Health and Director of its Cerebrovascular Center. He adds that using distance health technologies for the right patients in the right place at the right time can maintain or enhance the quality of care while reducing healthcare costs, such as by curbing unnecessary ER visits.
“Virtualizing the practice of medicine drives value where it makes clinical and economic sense,” Dr. Rasmussen notes. He points out that telemedicine-enabled virtual visits can increase providers’ efficiency in the era of bundled payments while providing a lower-cost care option for many patients, especially if they have to travel to see a provider.
|Sampling of Cleveland Clinic Distance Health Initiatives
|Express Care Online, a HIPAA-compliant Skype®-like app that connects patients directly with Cleveland Clinic providers for face-to-face visits
MyConsult Online, a secure web platform that allows patients to obtain a written second opinion from a Cleveland Clinic specialist
Remote Image Upload, which enables digital transfer of images from multiple vendor sources into a patient’s EMR and subsequent access from any point of care
A coordinated collection of neurological apps (the “Orchard of Neurological Apps”) and related remote management tools that allow monitoring of patient data in real time and/or interaction with patients to monitor their condition
Telestroke Network, which provides outside hospitals 24/7 access to enhanced stroke consultation services from specialists in Cleveland Clinic’s Cerebrovascular Center via a mobile two-way videoconferencing system and linked imaging systems
A mobile stroke treatment unit that brings the essential tools of stroke diagnosis and treatment right to the site of stroke onset via a specially equipped and staffed ambulance
Making a difference in acute stroke
Beyond efficiencies and convenience, Neurological Institute caregivers are finding that distance health can be a lifesaver in acute stroke care. In addition to Cleveland Clinic’s pioneering use of its mobile stroke treatment unit, which is trimming intervention times, Cerebrovascular Center specialists now provide consults via videoconference to many patients with suspected stroke who arrive in the ER of a Cleveland Clinic regional hospital or an outside hospital participating in Cleveland Clinic’s Telestroke Network.
Such patients receive specialist consults in an average of less than five minutes. “That’s faster than most neurologists can walk to the ER,” Dr. Rasmussen says. “Having a stroke neurologist present virtually with a patient is 98 percent as accurate as having a stroke specialist there in person, and diagnosis is 30 percent more accurate than if the patient were assessed by an emergency physician or general neurologist.”
Expanding the use of teleconsults
The stroke experience has shown that distance is not a deterrent to diagnosis. In 2015, Neurological Institute physicians began providing general neurology consults to one Cleveland Clinic regional hospital with no neurologist on staff. Similarly, they offer neurocritical care consultation services via telemedicine at Cleveland Clinic Florida’s hospital in Weston, Florida. “This can be a valuable super-specialty augmentation to the bedside intensive care team,” Dr. Rasmussen notes.
Similar expansion is being seen in online second opinions from Neurological Institute staff, which grew substantially from 2014 to 2015. And Cleveland Clinic is in the process of expanding options to include a video appointment with the specialist who provides the second opinion.
Popular with patients everywhere…
In noncritical situations, teleconsults and virtual visits have become a convenient way of conducting outpatient visits for patients in various subspecialty areas, such as pediatric neurology, sleep disorders, neuromuscular disease, behavioral health and post-acute stroke care.
“It works very well for routine follow-ups, including postop checkups, medication checks, screenings and general issues,” Dr. Rasmussen says. “Patients love the system because it’s so convenient. And the interactions are generally shorter for providers, which increases efficiency.”
Cleveland Clinic’s Express Care Online app helps make these interactions happen. Patients simply open the app on their Apple or Android device, log in and enter an electronic waiting room. After reviewing the patient’s chart or test results, the physician “enters” the room and chats face to face with the patient through a secure connection with Skype®-like access.
…including rural Nevada
The same principles are used by Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas to bring neurological expertise to remote areas of Nevada with few or no neurologists. In a teleconference room in Elko, Nevada, a nurse coordinator helps Cleveland Clinic neurologists in Las Vegas follow outpatients with chronic neurological conditions.
“We’re able to provide the same examination we offer in Las Vegas,” says Lou Ruvo Center for Brain Health neurologist Charles Bernick, MD, MPH.
…and the NFL Players Association
Perhaps the most intriguing use of virtual visits involves longitudinal monitoring of retired NFL players through The Trust, a collaborative program with the NFL Players Association designed to help address these players’ elevated risk of neurological disease.
Retired players’ brain health is assessed at Cleveland Clinic to obtain baseline measures, after which follow-up can be conducted via virtual visits. The goal is to identify changes likely to lead to cognitive impairment, decreased motor function, intractable pain, depression, suicide or other potentially predictable outcomes of repeated brain trauma.
“The program allows us to facilitate personalized guidance for proper follow-up care,” says Jay Alberts, PhD, the Neurological Institute’s Vice Chair for Health Technology Enablement and Director of the Concussion Center.
App-enabled patient empowerment
Neurological Institute specialists have similarly tapped into the public’s mobile device fascination to develop interactive apps promoting greater self-management of stroke recovery, spinal conditions, epilepsy and multiple sclerosis (MS).
“Most of the apps we’ve developed enhance self-management by patient participation in remote assessments that allow more frequent monitoring,” says Matt Stanton, Senior Director of Distance Health. “This lets us track patients’ health more closely and know, for example, whether they are following medication instructions.”
The jewel in the crown is the C3Logix™ app. Developed by Dr. Alberts’ team to facilitate concussion assessment in student athletes, the app is now used by more than 150 schools in 32 states. It utilizes iPad functionality to collect data on postural stability, and includes programs to assess cognitive and motor function relative to an athlete’s pre-injury baseline measures. In Alaska, the C3Logix app has reduced the need for specialized medical personnel to visit remote schools by bush plane in some cases where assessment can be handled by iPad-equipped providers.
Only the beginning
As the benefits of distance health become apparent, the Neurological Institute is working to find new ways to exploit relevant technologies. Among the efforts underway:
- Integrating data from the C3Logix app and a similar app for MS into the patient’s electronic medical record (EMR)
- Installing telemedicine monitoring stations at skilled nursing facilities to increase communication with patients’ providers
- Developing an aggregator that collects data obtained through various consumer apps into a common format that can be entered in Express Care Online and the patient’s EMR
“Pooling data into large data sets will make it possible to do powerful predictive analyses around elements of cognitive and motor function in patients with various neurological diseases,” Dr. Alberts notes.