Executive Summary

 This is the third annual status report on telemedicine activities at the UMHS. The report describes the basic activities and progress achieved by the Telemedicine Resource Center (TRC) in terms of meeting the objectives it set out for itself, in consultation with senior leadership, in 2003.  As in previous years, the TRC continued to focus on three major target areas that constitute concentric circles of priority areas.  The first and highest priority relates to activities within the Health System, including services and benefits to providers and patients.  The second priority relates to services beyond the institutional boundaries to providers and patients within the State of Michigan.  The third relates to services that are international in scope.

Overall, some accomplishments across the three priority areas include:

• Clinical telemedicine applications are underway or in development in Dermatology (MOHS), Plastic Surgery/Michigan Visiting Nurses, Trauma/Burn, Psychiatry, Pediatric Surgery, Pediatric Cardiology, the Cancer Center, and Pediatric Dentistry.
• Distance educational applications were initiated or given continued support include Thoracic Surgery, Urology, Neurology, Rheumatology, General Surgery, Trauma Burn, MFit, Multicultural Health, Psychiatry, DNA Repair and Psychiatry.    
• The number of internal and external participants in TRC supported educational events has increased from 2,275 in 2003 to over 8,000 in 2004.
• The number of clinical, educational/CME and administrative events increased from 146 in 2003 to 341 in 2004.
• The TRC hosted an international symposium on telemedicine which brought together leading experts from the US and several other countries.  The symposium was officially introduced by President Mary Sue Coleman.

The TRC continues to pursue emerging opportunities within the UMHS to leverage information technology to improve outpatient and inpatient clinical productivity and efficiency; enhance quality and safety; and contain cost.  Since third-party reimbursement for either live (synchronous) or “store and forward” (asynchronous) telemedicine service remains limited and subject to categorical eligibility requirements, the volume of teleconsultations and telediagnosis remains low nationally, and the situation in Michigan is no exception.  Hence, the TRC has focused its attention on supporting clinicians with appropriate technology to enhance their productivity and efficiency wherever there is expressed interest, thereby making better use of their valuable time.  Moreover, current capacity and resource constraints across the outpatient and inpatient care continuum are creating pressures to increase productivity and efficiency of clinical staff at all levels.  Hence, the TRC has focused its efforts on promoting a variety of technological applications to enhance the delivery of care to patients in an effective, efficient, and timely manner.  This report will highlight the various projects that were supported by the TRC in 2004, including remote wound care and the MOHS clinic.  These programs serve as concrete examples of the vital contributions of information technology in optimizing the effective use of available clinical resources in a constrained environment.

 There is already concrete evidence of substantial and growing interest in various applications of information technology in health on the part of several clinical departments and units at the UMHS.  This interest has led to several significant initiatives with potentially overlapping functions and activities.  It is time to review these initiatives from a broad institutional perspective for the purpose of coordinating and streamlining their functions and activities to create synergy and to enhance overall system effectiveness, efficiency and performance.  In 2005, the Federal government is expected to promote wider adoption of information technology in various aspects of health care delivery, including clinical decision support, electronic information systems, and coordinated delivery systems.

Introduction

 This is the third annual status report on telemedicine activities at the UMHS.   It was prepared specifically to inform senior leadership of achievements, plans, and impediments in utilizing information technology to support patient care, education, and research at the UMHS.   Whereas the 2003 report focused on actual achievements and the diversification of telemedicine activity throughout the Health System, the 2004 report will expand this focus to include opportunities and plans for leveraging information technology to promote the efficient use of available clinical resources, quality and safety of patient care, and clinical decision support.   However, we start this report with a restatement of the basic priorities or target areas that have guided our activities to date.

I.    Telemedicine priorities or target areas

 The following priorities were identified in 2002 as a basic guide for allocating resources and effort on our part.  These priorities were established on the basis of discussions with senior leadership at the Health System.  In descending order of strategic importance, these areas are as follows:

1)   Health System – The first priority area is serving our patients and their families.  Hence, telemedicine applications should be promoted within and across Health System sites as a means of enhancing quality of care and safety, patient and provider satisfaction, as well as improving efficiency and productivity of clinicians and staff.  Such improvements can be achieved by reducing the need for travel between sites (for both patients and providers); and by providing technological solutions for more effective triage, scheduling, referral, decision support and follow-up.  Patient satisfaction may be achieved through improved access and provider satisfaction may result from improved triage, and enhanced efficiency and productivity. 

2)   Intra-State – The second priority area is the State of Michigan.  Hence, telemedicine should be utilized to the extent possible to enhance the role of the UMHS as a tertiary care center for referring physicians and hospitals in Michigan through strategic partnerships in clinical care, education and research.  This is consistent with the broader mission of the UMHS to serve the health care needs of the people of Michigan.

3)   National and International  - The third priority area is to extend the reach of the Health System’s clinical and scientific expertise throughout the United States and other countries on the basis of collaborative agreements with appropriate partners in the US and in other countries.  This serves the broader educational, clinical, scientific and humanitarian goals of this institution.

It may be appreciated that telemedicine constitutes an effective electronic tool that can be utilized by clinicians, administrators, and support staff to enhance the basic mission of the UMHS in patient care, education and research.  It does so by

·         Extending the reach of clinicians beyond geographic and time barriers

·         Providing remote patients and providers with virtual access to UMHS resources

·         Enhancing productivity and efficiency of staff at various levels

·         Providing clinical decision support to assure quality of care and patient safety

II.    2004 Telemedicine Resource Center Activities

 It should be noted from the outset that the TRC is engaged in a variety of activities including clinical, educational, and administrative functions that rely on videoconferencing and other aspects of information technology.  These activities continue to be diversified and decentralized within the UMHS, but they are essentially of three types:

(1) Project Support and Management: The TRC provides technical assistance to clinical departments and administrative and service units to advance the efficient use of telemedicine technology in patient care, education, and research. This includes serving as a central point of contact for all internal and external inquiries regarding telemedicine issues and initiatives, assisting with proposal preparation for extramural funding, negotiating business terms and agreements, and linking external partners with appropriate departments and faculty at the UMHS.

(2) Research and Design: The TRC responds to various requests from clinical departments and service units regarding the design and implementation of innovative information delivery systems. It provides technical assistance in the design, development and deployment of such systems. These approaches include clinical workflow analysis and the design of prototype telemedicine models together with educational/training components.

(3) Capital and Infrastructure Deployment: This consists of supporting the deployment of the appropriate infrastructure and meeting the operational needs of faculty and staff throughout the Health System. As indicated in (2) above, this includes serving as a source for information, technical design, installation, coordination and trouble shooting in the deployment of telemedicine in clinical, educational, research and service activities.

In 2002 and 2003, we proposed that a reasonable assessment of performance of this program be based on “process” variables, namely progress in significant activity areas aimed at the objectives identified above.  As in previous years, we provide the same kind of information in 2004 that may be used to assess the TRC’s performance.  These are stated as criteria and results. 

Criterion 1.  The extent to which the telemedicine program allocated its resources within the institutional priority areas.  Is there evidence of a proper emphasis on serving institutional needs, service within the state, and international initiatives?

Results

 In order to give a clear idea of the scope of services provided by the TRC staff during this past year, we describe these activities within the context of the institutional priorities.  For simplicity, this information is provided in tabular form here, as was done in the 2003 report.

Table 1 describes the variety of internal and external activities the TRC supported during the 2004 fiscal year.  Where appropriate, links are provided to web pages that offer more detailed information on the activities described.  When viewing the document electronically, “right click” and select “open hyperlink” to view more information about the project of interest. 

Table 1:   Telemedicine Activities by Target Area

Table 2:  Summary of Educational and Outreach Activities

The deployment of infrastructure or technical equipment may be considered successful if it encourages broad use by faculty and staff within and outside the Health System.  Decisions on providing and/or supporting the deployment of infrastructure or technical equipment were based on the following functions, listed by order or priority.  Nonetheless, we have not denied any reasonable request for support or assistance in this regard.

     a)    Consultation – clinical consultations between UM clinicians and internal or external patients. 

b)   Distance Education / CME – educational events within and outside the Health System.

c)   Administrative Applications – meetings, interviews, depositions and other administrative functions. 

TRC support for these activities continued to increase during this past year.  Each of these events presented an opportunity to enhance institutional awareness of telemedicine’s utility in providing clinical care and education.  Based on average attendance or participation, we estimated the total number of faculty, staff, patients and referring physicians who participated in each of these events, including internal and external participants. 

Table 3:  Participants in Telemedicine Supported Applications

Criterion Two: The extent to which the challenges and implementation obstacles are addressed, the appropriateness and effectiveness of the steps taken, and the flexibility and adaptability to find new ways to address the problems.

 Results

The most significant internal challenge has to do with the coordination of related projects and programs that relate to telemedicine, patient/provider portal, disease management and clinical decision support.  While all these projects are important and are designed to enhance the efficiency, effectiveness, quality and safety of care at this institution, they share some common attributes that must be streamlined and coordinated to minimize redundancy and waste of resources.  We have already started discussions with project managers and other concerned stakeholders to establish a common agenda for addressing the major issues of coordination and collaboration. 

The most significant external challenge continues to be reimbursement and appropriate credit for clinicians engaged in telemedicine.  The overall trend in reimbursement is encouraging, but the basic issue is far from resolved. Consequently, the TRC is trying to do what it can to pursue any opportunity that presents itself within the UMHS to leverage information technology to improve outpatient and inpatient clinical productivity, efficiency, and quality.  The TRC is supporting approaches to equip clinicians with technology that would allow them to make better use of their clinical time.    We are focusing our efforts on a variety of technological applications aimed at promoting efficiency and effectiveness. 

Criterion 3. Evidence of initiatives pursued in clinical care, education, and research.

Results

In addition to the three primary telemedicine activities described above, the TRC supported numerous training and technical support activities in 2004, including the delivery and installation of videoconferencing equipment; technical training for clinicians to support clinical care, education and research; service calls for department-based equipment; and technical assistance during telemedicine consultations and video conferencing.

The total number of TRC supported activities increased from 169 in 2003 to 380 in 2004. 

 Table 4:  Telemedicine Activity 2001-2004

The final criterion is evidence of progress in the installation of the infrastructure and the technical and supportive services.

 Results

Videoconferencing Station Deployment

 Access to convenient and reliable telemedicine/videoconferencing technology facilitates actual use by clinicians and staff.  During 2004, the TRC purchased new video conferencing units and deployed them across the hospitals and health centers.  Table 4 lists the number of functional and reliable video conferencing stations available to faculty and staff, from 2002 through 2004.  It includes medical campus and off-site locations. 

Table 4.  The Expansion of Videoconferencing Facilities 

MCIT Infrastructure Installation 

In 2003, MCIT completed the installation of the information technology infrastructure to facilitate access to videoconferencing stations across the institution.  The networking, a Multiway Conferencing Unit (MCU) and Gateway, allows users to connect to videoconferencing stations within and outside the UMHS system through nearly any computer networking site (i.e., networking “jack.”).  It also provides “firewall” protection for the security of the UMHS information systems. 

MCIT and TRC staff have utilized this infrastructure to support internal and external videoconferencing and telemedicine applications.  They are also developing protocols and processes for broader use of the MCU and Gateway across UMHS.  A model of this infrastructure is provided in the Appendix. 

III. Short and Long Term Plans

 The short-term plans consist of specific measures and steps aimed at promoting and supporting current and emerging initiatives and opportunities in telemedicine and related projects in information technology throughout the system.  To date, the TRC has not differentiated between revenue generating activities and non-revenue generating ones since we are still at a formative stage.  Its services are provided without charges. As faculty and staff become more familiar and comfortable with this technology, more emphasis must be placed on revenue or other tangible benefits. 

 Short term plan can be described in specific terms.  Indeed, some are underway and some will be underway within the next two years. True long-term plans, however, can only be described in general terms.

1. Health System

 Current Fiscal Year:

• Integrate and coordinate the interests of key stakeholders in telemedicine and e-health including:  the Patient/Provider Portal Project, Medical Management Center, Clinical Decision Support, and e-Learning teams. 
• Broaden implementation of Wound Care project with Michigan Visiting Nurses as well as other home-based applications. 
• Explore the potential for Plastic Surgery to offer Tele-wound services to other home care companies, based on interest and human resource availability. 
• Utilize findings of IOE Student Project to develop new wound care processes across inpatient units that utilize Tele-wound technologies and standardize wound management throughout the system.
• Implement e-MOHS system in Dermatology.  Link electronic referral system with Plastic Surgery, Otolaryngology and Ophthalmology. 
• Continue to utilize telemedicine available capital and residual FGP funds to support projects that promise to become self-sustaining, if not revenue enhancing.

FY 2006-2007:

*       Promote Health Center use of telemedicine technology for Grand Rounds as well as graduate and continuing medical education.

*       Encourage use of videoconferencing technology in various administrative areas to diminish commuting between sites.  In the long run, videoconferencing should substitute for, and may possibly eliminate, unnecessary travel between sites, especially for clinicians and administrative staff.

*       Promote the use of telemedicine and related IT applications in clinical departments, wherever there is interest and potential for improving patient access, enhancing efficiency, quality, safety and cost savings.

*       Provide technical assistance for faculty and staff in proposal preparation for extramural funding.

*       Develop protocols (in consultation with clinical departments and units) for telemedicine encounters, if not done sooner.

*       Pursue opportunities for home-based systems for monitoring and assisting home-bound, chronically ill, and post-surgical patients.

*       Develop training manuals in the use of technology for specific clinical applications and education, if not done sooner.

2. Intra-State

 Current Fiscal Year:

*       Continue to support initiatives in Pediatric Subspecialty care in the following services:  Pediatric Nephrology, Pediatric Surgery and Pediatric Pulmonary Medicine.

*       Support implementation of Trauma/Burn’s outreach efforts with hospitals across Michigan. 

*       Support implementation of ESRD telemedicine program with Marquette General Hospital.

*       Explore opportunities to collaborate with Medical Management Center and specific Clinical Departments in supporting remote monitoring and care across a variety of conditions including: 

*       Congestive Heart Failure

*       Diabetes

*       High Risk Pregnancies

*       Asthma

*       Depression

*       Promote greater use of MCHC and Ford Auditoriums for external CME, other educational activities and nursing education broadcasts. 

FY 2006-2007: 

*       Identify and pursue opportunities to provide UMHS specialty telemedicine clinics to hospitals and providers throughout Michigan.

*       Explore the development of shared patient information systems on a regional basis in Michigan.

3. International

 Current Fiscal Year:

*       Publish and distribute the second International Telemedicine Symposium in Ann Arbor, 2004. 

 FY 2006-2007: 

*       Evaluate international contracts and relationships; pursue additional relationships wherever there are mutual interests and shared benefits.