Telemedicine Breakthroughs in Pittsburgh

At the 20-hospital University of Pittsburgh Medical Center (UPMC) integrated health system in western Pennsylvania, clinician leaders are moving forward on multiple fronts to make leading-edge telemedicine a reality. Leveraging a variety of information and medical technologies, UPMC clinicians are broadening their existing telehealth footprint, and are in the process learning what works best in an integrated health system in terms of optimally connecting the right physicians with the right patients at the right time.

One of the health system’s key leaders in this overall effort is Lawrence Wechsler, M.D., vice president for telemedicine, Physician Services Division, and chair of the Department of Neurology, both at UPMC. Dr. Wechsler works with six physicians involved specifically in the telestroke part of the program, while between 40 and 50 physicians are involved in telemedicine-delivered care at any one time. Wechsler spoke recently with HCI Editor-in-Chief Mark Hagland regarding telemedicine at UPMC. Below are excerpts from that interview.

What is your overall perspective on telemedicine and on the advances you and your colleagues are making at UPMC?
We see telemedicine as being part of the integration of technology into the care of patients. Right now, we’re working on how this technology can enhance patient care from a number of standpoints, how it can make physicians more efficient, how it can enhance the patient-physician relationship, and how it can improve care across the community. And in the future, we expect that telemedicine won’t exist as a separate entity; it will simply be part of the way physicians practice medicine. You’ll have an office in the city, one in the suburbs, and a telemedicine practice, for example.
And from a systems point of view—and UPMC is a very large system—there are many ways in which telemedicine can fit into the system. And because we’re such a large system, and spread out across such a large area, obviously, telemedicine has a large attraction for people at UPMC. And one element is the integration of smart technology into patient care; telemedicine is certainly one aspect of that. We’re looking at how it can enhance care, but also where it can provide more affordable and cost-effective care as well.

Lawrence Wechsler, M.D.

What elements have you and your colleagues deployed so far?
We have a number of different telemedicine applications that are currently active. Telestroke is one that we’ve been doing since 2006, while telepsychiatry has been going on for about 10 years already. Psychiatry is one area in which there just aren’t a lot of rural providers, and there’s tremendous need. We’re providing dermatology services to hospitals where there’s no inpatient dermatology consultation service available. And we’re hoping to integrate dermatology into our urgent care center practices, so that, say, if a patient comes into one of the urgent care centers, they can see a dermatologist right away via telemedicine.

And we’re doing consultations via telemedicine. We have a neurologist, for example, who sees Parkinson’s patients at a site about 100 miles away. Obviously, it’s hard to see Parkinson’s patients in person; someone has to bring them in, and they’re fragile. So the neurologist is here at UPMC-Presbyterian, and the outlying hospital is in Franklin, Pennsylvania, a two-hour drive away, and is a part of UPMC-Northwest. She sees five or six patients once a month.

We’re also in trauma—we’re an acute service in the emergency department, where our trauma service can evaluate patients at outlying hospitals, in terms of potential transfer, etc. On the stroke side, we have 16 hospitals involved in the program, with Presbyterian as the hub hospital. ICU is another one we’re developing; it provides consultation services to enhance the ICU care. A lot of times, they don’t have real, card-carrying intensivists [at outlying community hospitals]; they might have generalist hospitalists or pulmonologists covering the ICU, but they’re not full intensivists.

And we’re doing some post-op consultations, so that patients who have surgery and come a long distance into the medical center here for surgery, rather than coming all the way back here for wound care and follow-up, their post-op visits can be done via telemedicine. We’re doing that in GI surgery and liver surgery. That, too, is operated out of Presbyterian. We’ve set up those post-op evaluations in two or three outlying hospitals.

What’s needed to be successful with telemedicine, from an IT and technology management standpoint?
You need a dedicated team, and almost full-time support for this. Particularly for the emergency services like stroke, if the equipment doesn’t work when you’re need it, you’re sunk. So you have to work to be proactive around equipment and connectivity reliability.

How big is the team supporting this, then?
Well, we currently have two pretty much full-time dedicated people from our IT group. But we’re planning on expanding that out, so that we can provide true 24/7/365 coverage for this.

How many people might that look like, then?
The IT group is putting together a plan for that at the present time.

What have the broad clinical management lessons learned been?
First, that telemedicine definitely has a place in the care of patients; it can’t do everything, but it definitely has a place. Second, you might think that patients might be reluctant to have a telemedicine-facilitated consultation rather than a face-to-face one with a specialist, but the patients love it, and sometimes they love it even more than the doctors do. Also, the more experienced physicians are, the more comfortable they seem to feel with telemedicine.  Lawrence Wechsler, M.D. (on screen) demonstrates the use of the telemedicine system at UPMC Presbyterian, as Ravi Vajjhala, M.D., and William Kristan, M.D., of UPMC-Passavant look on.

What do you see as the potential for improvement in stroke care outcomes?
We don’t expect the outcomes to be better in telestroke than in face-to-face caregiving, but we expect them to be the same. There are a lot of patients in rural areas who aren’t getting treated at the highest level now, because of a lack of specialists; and we want to make sure that the correct patients get the tPA [tissue plasminogen activator, a drug given to stroke patients to restore brain function] medicine, the ones who can benefit from it. And where we’ve instituted telestroke, we do in general treat many more patients: the number of patients treated with tPA goes up dramatically, even if there has been a neurologist on site. And just because of the awareness of the EMTs and the community around the fact that that stroke treatment is available.

And the outcomes of the patients treated remotely with TPA are the same as for those whom we treat in person. The good outcomes are the same, and the number of complications due to hemorrhage are comparable. And this is one of those situations that’s a win-win for everybody, and one of the reasons it seems to be working so well.

What advice would you give to our audience around potentially developing telemedicine programs?
I would say that, from the technical and connectivity point of view, don’t underestimate the complexity. It sounds simple enough, but in practice, there are lots of issues that have to be solved, particularly when you go across firewalls. And not everyone can have access to everything, and you have to worry about security, and you’re dealing with equipment that generally wasn’t designed specifically for telemedicine, but rather for audioconferencing. Those are all solvable issues. And it turns out that most of the issues that turn out to be roadblocks turn out to be political, not technical; there are hospital politics issues, physician politics issues, licensing, credentialing, reimbursement, and legal issues.

Can you give our readers a sense of timeframes around development and go-live?
We generally think about 90 days from when we sign a contract until we start service. But in that period of time, you can do all the technical issues; sometimes, the political issues take a little bit longer, but you can be ready to be up and running in 90 days.