Telemedicine as a Tool for Replicating Quality Across Care Sites

For health systems with locations in multiple regions of the U.S. or even other parts of the world, ensuring consistent quality of care across sites is essential, as compromised standards in just one location can give a black eye to the entire system.

As Cleveland Clinic has expanded its geographic reach in recent years, its Neurological Institute has found telemedicine to be invaluable to replicating and maintaining its hallmark quality of care in new locations. This article profiles a few key examples.

Epilepsy care: One program across two states (and beyond)

When epileptologist Camilo Garcia, MD, arrived at Cleveland Clinic Florida in 2015 after completing fellowship training at Cleveland Clinic’s main campus in Cleveland, he viewed the move as a change in geography, not a change in program.

“Our epilepsy program in Florida operates the same way it does in Ohio, and I continue to consult with many of the same expert colleagues I did in Ohio,” says Dr. Garcia, who was initially charged with developing services for epilepsy surgery evaluation at Cleveland Clinic Florida, which has a number of inpatient and outpatient care sites in the southeastern portion of the state. He identifies several telemedicine-enabled practices, outlined below, as central to the continuity of the epilepsy program between Ohio and Florida.

All-inclusive epilepsy patient management conferences. Cleveland Clinic epilepsy specialists convene five multidisciplinary patient management conferences every week, and Dr. Garcia and his Florida epilepsy colleagues are invited to join all of them — and frequently do. “I present my patients whenever I need to, and I join the conferences any time I don’t have a conflict, to share my perspective on how best to manage a challenging case,” Dr. Garcia explains.

He accesses the conferences via the Cisco Webex videoconferencing platform, which allows easy sharing of images and videos. Before the COVID-19 pandemic, he and his Florida epilepsy colleagues — as well as any Cleveland Clinic providers joining from sites outside Cleveland Clinic’s main campus — were videoconferenced into a conference room where in-person meetings took place. Since the pandemic began, the patient management conferences have been attended virtually by all participants.

By presenting patients at these conferences, Dr. Garcia and other Cleveland Clinic Florida staff — including a neurosurgeon who performs epilepsy surgeries — benefit from the deep expertise of staff in The Charles Schor Epilepsy Center on Cleveland Clinic’s main campus, including experts in specialty areas such as image post-processing. Because both sites use the same system for storing images, the imaging scientists in Cleveland can help Dr. Garcia with requests he may have for specialized processing of MRI or SPECT or PET images, and they can present their findings at the conferences.

The same benefits are enjoyed by staff at Cleveland Clinic Abu Dhabi half a world away, who have been regularly videoconferencing into Schor Epilepsy Center patient management conferences since 2015.

Two-way videoconferencing via mobile video cart. Just as Neurological Institute providers in Cleveland have adopted mobile videoconferencing carts in inpatient settings to enhance patient access to subspecialist expertise (as detailed here), Dr. Garcia and his colleagues are using this technology in similar ways at Cleveland Clinic Florida.

One of these mobile video carts — complete with touchscreen interface, adjustable high-definition camera, speaker and microphone — allows Dr. Garcia to see and examine patients when he is at another location, as long as his nurse practitioner is present with the patient and the cart, with Dr. Garcia connecting via video on a computer, phone or tablet. Additionally, the video cart allows epileptologists on Cleveland Clinic’s main campus to provide critical backup support for inpatient epilepsy care in Florida if one of the Cleveland Clinic Florida epileptologists is on vacation and additional coverage is needed for rounding. Again, an epilepsy nurse practitioner is present with the patient and the cart to assist with examination as needed.

Continuous video EEG monitoring. A similar principle applies with Cleveland Clinic Florida’s use of continuous video EEG monitoring, which is available as needed for patients in the ICU and on other hospital units. While EEGs of these patients and those in Cleveland Clinic Florida’s six epilepsy monitoring unit beds are monitored around the clock by technicians in an on-site epilepsy monitoring unit, they are also simultaneously monitored in the epilepsy central monitoring unit on Cleveland Clinic’s main campus, for backup coverage.

Moreover, the live video EEG feeds are accessible to Dr. Garcia and his epileptologist colleagues from anywhere in the world with an internet connection. “I am able to access a patient’s live EEG from my laptop or phone at any time and virtually anywhere, so I can direct management if a patient is having a seizure,” Dr. Garcia says.

“Thanks to these various connections of Cleveland Clinic’s epilepsy program between our Cleveland and Florida locations,” he continues, “we are able to offer the same standard of epilepsy care here at Cleveland Clinic Florida.” The only gaps, he notes, are a current lack of magnetoencephalography (MEG) and 7T MRI capabilities at the Florida site. “We’re working to address those gaps,” he says, “but in the meantime we can rely on our Cleveland colleagues to process raw MEG data that’s obtained elsewhere, and we can always send patients to Cleveland if they require 7T imaging.”

Movement disorders: Taking DBS assessment across borders

Patient management conferences are also the focus of cross-site collaboration in another Neurological Institute specialty area: evaluation of patients with movement disorders for deep brain stimulation (DBS) surgery.

Every other week, a multidisciplinary Neurological Institute team convenes via videoconference to assess roughly 18 to 30 patients with movement disorders for suitability for DBS therapy. While most patients are presented by Cleveland Clinic movement disorders staff in Northeast Ohio, a few are presented by staff at Cleveland Clinic Lou Ruvo Center for Brain Health in Las Vegas and by staff at Cleveland Clinic Abu Dhabi in the United Arab Emirates.

Integrated care with Las Vegas. Patients from the Lou Ruvo Center for Brain Health site in Las Vegas site have been managed by movement disorder neurologists there, including initial patient testing on and off medications, imaging studies, neuropsychological evaluation and more. These patients’ cases are discussed at the shared patient management conference both to benefit from the collective expertise across all Neurological Institute sites and because, if a patient is approved for DBS surgery, he or she will undergo the operation at Cleveland Clinic’s main campus in Cleveland, as the Las Vegas site provides outpatient care only. If cleared for DBS surgery, patients have a virtual visit with their neurosurgeon in Cleveland before traveling to Cleveland for DBS implantation. They return home soon thereafter, where their Lou Ruvo Center for Brain Health neurologist will do initial programming of the DBS device.

“The two locations operate as a single program,” observes neurologist Benjamin Walter, MD, who directs the movement disorders and DBS programs in Cleveland Clinic’s Neurological Institute and leads the patient management conferences out of Cleveland. “The process is designed to be efficient for patients in the Las Vegas area, to minimize their need to travel while ensuring continuity of top-quality care.”

Launch of DBS surgery in Abu Dhabi. More recently, staff from Cleveland Clinic Abu Dhabi have begun presenting patients at the shared conferences, in the lead-up to the recent launch of DBS surgery there. The specialty hospital, whose staff includes a functional neurosurgeon as well as a movement disorder neurologist who trained at Cleveland Clinic’s main campus, already had experience monitoring Parkinson disease patients with DBS devices who had their DBS surgery abroad. Now they are applying that experience to patients in whom they are implanting DBS leads themselves — in close coordination with their colleagues in Cleveland, who draw on more than 20 years’ experience with DBS and perform over 150 DBS surgeries per year.

In addition to the Abu Dhabi team’s regular participation in the enterprisewide DBS patient management conferences, they were joined in November 2020 by Cleveland Clinic neurosurgeon Andre Machado, MD, PhD, who came to assist with the first three DBS surgeries performed at Cleveland Clinic Abu Dhabi.

“Our team in Cleveland has helped Cleveland Clinic Abu Dhabi set up their DBS program so that it mirrors what we’re doing here, with the exact same standards and techniques for the same high-quality approach,” says Dr. Walter. The aim is to harmonize practice in three areas essential to success in DBS therapy: patient selection, surgical placement of the DBS leads and postoperative programming. “This is the three-legged stool of successful DBS outcomes,” Dr. Walter notes.

This approach, adds Dr. Machado, who also serves as Neurological Institute Chair, is emblematic of the institute’s culture of integrated care. “Cleveland Clinic Neurological Institute has some 300 expert physicians with enormous experience,” he says. “Our mission is to provide care for our patients in Ohio and help other parts of our organization, such as Las Vegas and Abu Dhabi, deliver the same standard of care.”

Standardized data collection. Key to the delivery of that uniform standard of care is the Neurological Institute’s comprehensive approach to data collection for DBS patients, which is also standardized across all care locations, including Las Vegas and Abu Dhabi. “We have a highly regimented approach to collection of DBS patients’ preoperative and outcome data,” Dr. Walter says.

Over the past couple of years, Neurological Institute staff have developed a smart form in the Epic electronic health record (EHR) that merges patient data, summary information and imaging studies from all specialists involved in the care and assessment of a DBS candidate, from neurologist to neurosurgeon to neuropsychologist and sometimes psychiatrist. “Everything gets captured in one smart form and presented in a structured format that makes information easy to find,” says Dr. Walter. “This allows us to visualize discrete data elements, track them, extract them for further analysis and create dashboards to help understand how patients are doing.”

Overcoming challenges. Most of a patient’s preoperative data are entered in the EHR prior to discussion at a patient management conference. “We have much of the essential information in one place, which allows us to efficiently review all relevant data during the conference discussion and make sure all criteria are addressed,” Dr. Walter explains. “That helps keep everyone on track during case discussions,” he adds, since time is at a premium as the number of patients discussed at the conferences grows. “The EHR smart forms have made us more organized.”

In addition to keeping the meetings efficient and organized, Dr. Walter notes, the biggest obstacle to overcome when expanding the reach of virtual patient management conferences is the quest for reliable online connections. “When you have so many people joining a meeting at once and you’re reviewing MRIs and patient videos, the quality of the connection is very important, especially when visually assessing something as subtle as tremors,” he says. After trying a couple of online meeting platforms that weren’t quite up to the task, the DBS program team has settled in with one that works quite well and reliably.

“That’s crucial as we look to maintain and grow the reach of these important multisite, multidisciplinary conferences,” Dr. Walter concludes.

Boosting cross-specialty collaboration for brain and pituitary tumors

As a neurosurgeon specializing in skull base surgery and pituitary surgery in Cleveland Clinic’s Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Pablo Recinos, MD, is a frequent participant in both brain tumor boards and pituitary tumor boards. While the geographic reach of these conferences is not as vast as for the DBS patient management conferences profiled above, the boards do typically include participants from the brain tumor and pituitary tumor teams at Cleveland Clinic Florida and at Cleveland Clinic Akron General, a regional hospital about 40 miles from Cleveland Clinic’s main campus.

Dr. Recinos notes that these multidisciplinary tumor boards have a number of factors in common with other Neurological Institute patient management conferences, including a shift to all-virtual attendance in the wake of COVID-19 and a tendency for the Florida and Akron staff to share their most complex patients with Dr. Recinos and his colleagues at Cleveland Clinic’s main campus for consultation on optimal management. What makes these tumor boards notable, Dr. Recinos observes, is how their attendance has skyrocketed as they have gone all virtual within the past year — and how that has enhanced the multidisciplinary, multispecialty nature of care delivered.

“Since providers have been able to participate remotely, we are seeing more pituitary endocrinologists, pituitary surgeons, radiologists and other types of specialists join our boards because it’s much more convenient for them to attend if they don’t practice at our main campus but are instead at one of our Northeast Ohio regional hospitals or ambulatory centers,” says Dr. Recinos.

This increased participation, he adds, means that he and his surgical colleagues are now hearing more perspectives on patients from a broader array of specialists — and patient care is likely to benefit as a result.

He cites the example of Cleveland Clinic’s Center for Facial Reconstruction and Facial Nerve Disorders recently organized by facial plastic and reconstructive surgeon Michael Fritz, MD. The center’s team, of which Dr. Recinos is a member, spans more than a dozen medical and surgical specialties and is designed to treat patients with complex facial deformities and paralysis due to tumors, trauma or developmental causes.

“For patients treated by this center’s team, we have specialists who say, ‘I don’t have a global solution, but I can address this aspect of the patient’s case,’” Dr. Recinos explains. “When we bring together enough specialists who can say that, we may come up with an approach that amounts to a good solution for the patient. That’s exactly the type of creative collaboration that’s happening at our tumor board conferences as a broader array of specialists are able to join virtually. Providers’ disparate locations and schedules wouldn’t allow these types of meaningful exchanges to happen without videoconferencing.”

He adds that the same principles apply to telemedicine-enabled virtual visits, whose use has increased substantially among his multispecialty team of collaborators over the past few years. “I increasingly get calls from, say, a neuro-oncologist colleague with a patient who has a tumor at the skull base,” he says. “They’ll mention that they’re seeing the patient at one of our regional hospitals or outpatient centers and they’ll ask if I can see them as well. I usually can add a virtual visit with the patient to my schedule and allow the patient to avoid staying overnight if they’re from out of town.

“Patients expect a very high level of care from an institution like Cleveland Clinic,” Dr. Recinos concludes, “but it’s not possible for all patients to always get all their care at our main campus or other largest facilities. For leading institutions like ours, success lies in ensuring continuity of care quality across all points of access. Telemedicine and information technology play a key role in enabling that continuity.”