Enhancing the medical service delivery system

1. Enhancing the medical service delivery system Innovation Challenge Project Improving the patient experience

2. Problem statements • Many patients do not have transportation to visit health provider’s office. (Sonoma County Paratransit provided 34,442 rides in Fiscal Year 2010). • People in rural area do not have local access points to health care. • Lack of easy access to health care creates last minute visit to emergency department. (PHP avoidable ED utilization rate PMPY was nearly 50% in 2010). WCHC - Innovation Challenge Project

3. Solution Face-to-face encounter with providers remotely • Nurse visits patient’s home for consultation • Real-time video conferencing with provider Benefits • Improve patient’s access to health care provider without making a trip to office • Provide face-to-face encounters between patient/nurse and provider to make decisions WCHC - Innovation Challenge Project

4. Business model Nurse visits patient’s home Care team & provider $ Video Conf. Target population: Patients aged 65 and older with chronicle illness, isolated geography and circumstances. WCHC - Innovation Challenge Project

5. Business process Steps • Qualify the patients who needs nurse visits • Nurse visits patient’s home with communication device • Nurse makes video conference request to provider • Provider makes video call to nurse • Provider talk to patient face-to-face on video conference • Provider sends bill to Medicare for the medical service delivery HIPPA requires security of patient’s health information. MediCare reimburse for face-to-face medical delivery. WCHC - Innovation Challenge Project

6. Underline Magic • Use of technology • Health care delivery service with use of video conferencing technology. • Billing (financial) • Provider can bill Medi-Cal for face-to-face encounter with patient as medical service delivery to patient. • Billable services enable nurse to make home visits. WCHC - Innovation Challenge Project

7. Competition & alternatives House call doctors Ambulance service Phone, email, texting, web portal WCHC - Innovation Challenge Project

8. Scenario case - A Medical staff & patient in remote site calling in to provider: • Transition home from hospital after surgery, RN wants to ask the provider if the incision is OK or needs to be seen in the ER. • Transition home, RN wants to review new medication with the provider and discuss a number of questions. • Transition home, RN wants to have a conference with the provider and social worker. Such as unstable housing, need to apply for disability, addiction issues, etc. • Home visits with high risk patients with many medical concerns. RN wants to conference with provider and Care Team members to communicate the plan and get approval from the provider. WCHC - Innovation Challenge Project

9. Scenario case - B Provider & patient in exam room communicate with other Care Team members during office visit: • Provider wants to discuss the status of a prior authorization for a critical medication and convey new information to the pharmacy technician in charge of this task. • Provider wants to do warm hand-off with mental health staff for identified depression prior to referral for consulting. • Provider wants to discuss a number of critical items with the RN. Such as need for home health referral, new durable medical equipment, when the patient is being seen for the first time after hospitalization. WCHC - Innovation Challenge Project

10. Scenario case - C Provider & patient in exam room wanting “decision support” from a specialist during an office visit: • Patient in the office for a pre-op appointment. The ECG in the office has abnormalities. The provider calls in the cardiologist to review the patient’s symptom prior to the surgery. • Patient has a new diagnosis of and endocrine condition that needs treatment. Asking the endocrinologist what he can do. • Provider is interviewing a patient and concerned about a psychiatric condition. The provider wants to have the Psychiatric Nurse at the county interview the patient. • Provider is interviewing a child. The provider wants to conference with North Bay Regional Center to talk about next step. WCHC - Innovation Challenge Project

11. Requirements • Infrastructure • Broadband communication at patient home • Video conference capability at provider’s office • Medical process and procedure • Medical provider & care team scheduling • HIPAA compliant • Billable record • Communication device • Portability, video conference capability and Wi-Fi connectivity • Accessible to eCW application WCHC - Innovation Challenge Project

12. Value proposition For a Medicare patient with chronic illness Who can not come to our clinical facility We provide face-to-face encounter with a provider That can be done remotely Unlike telephone call or email We have ability to view vital signs and facial expressions Which are critical to proper diagnostic and medical decision WCHC served 10564 Medicare cases (1514 patients) in 2011. WCHC - Innovation Challenge Project

13. Project Categories • Technology verification • Video communication platform • Video communication devices • Remote location connection • Wireless coverage • Communication point environment Underlining requirements: HIPAA compliance and financially billable. WCHC - WebEx Connect

14. A-1: Communication platformTechnology verification • Be able to run on existing WCHC computers • Platform available beyond West County Health System • Real-time connectivity with other party • Interactive features • Calling and receiving video conference calls • Simultaneous multiple site participation • Recording (HIPAA compliant) • Desktop and file sharing • IM • Invite new contact immediately to join a video conference WCHC - Innovation Challenge Project

15. A-1: Communication platformPlan-Do • Plan • Determine video communication platform functions and limitations. • Do • Test for on-demand calling, and receiving video communication instantly. • Test for desktop sharing. • Test for file sharing. • Test for multiple people in multiple site simultaneous conference. • Test for ease of sign-in, and be able to identify the availability. • Test for running on multiple computer devices. WCHC - Innovation Challenge Project

16. A-1: Communication platformStudy-Act • Study • Act • Standardize to use WebEx Connect. WCHC - Innovation Challenge Project

17. A-2: Video communication devicesTechnology verification • eCW application • Ease of navigating eCW • Ease of entering information in real-time • Video communication • Ease of making video call • Sound & video quality • Local data storage • Rugged and easily cleanable after each use WCHC - Innovation Challenge Project

18. A-2: Communication devicesPlan-Do • Plan • Determine the usability of the device (endpoint). • Do • Test for ease of making Wi-Fi or LAN connection. • Test for ease of reading the screen in various environment. • Test for clarity of sound and visual image. • Test for video communication latency. • Test for ease of navigating eCW at remote site. • Test for eCW interactivity on the device. • Test for local storage and security of stored data. WCHC - Innovation Challenge Project

19. A-2: Communication devicesStudy-Act • Study • Act • Standardize on Apple iPad. WCHC - Innovation Challenge Project

20. B-1: Network coverageRemote location connection • Wired communication • LAN • Wireless communication • Wi-Fi • 3G/4G cellular data communication • External accessories • Speaker (for multiple people audience) • Headset (for conversation privacy) WCHC - Innovation Challenge Project

21. B-1: Network coveragePlan-Do • Plan • Determine wireless communication connectivity in remote area, and connectivity to external peripheral accessories. • Do • Test for wire line (LAN) and wireless within WCHC facility. • Test for 4G/3G cellular coverage in remote west county. • Test for Real-time connection without delay. • Test for security of the connection. • Test for external accessory connect ports (such as USB ports) and printers. WCHC - Innovation Challenge Project

22. B-1: Network coverageStudy-Act • Study • Act • Standardize on LAN for Windows PC. • Standardize on Wi-Fi for iPad. WCHC - Innovation Challenge Project

23. B-2: Endpoint environmentRemote location connection • Introduction of provider to patient • Before the video conference • During & after the video conference • Patient consent • Privacy to comply with HIPAA • Consent for video conferencing • Procedure • Proof of consent WCHC - Innovation Challenge Project

24. B-2: Endpoint environmentPlan-Do • Plan • Determine the need for patient’s consent to engage provider via video conference call. • Do • Test for privacy. • Test for security. • Survey patient’s ease and comfort of video communication. WCHC - Innovation Challenge Project

25. B-2: Endpoint environmentStudy-Act • Study • Act • Standardize on protocol check list WCHC - Innovation Challenge Project