PROPOSED USE CASE: STORE AND-FORWARD TELEMEDICINE

A. Summary:

The American Health Information Community Chronic Care Workgroup, after extensive discussion within the workgroup and extensive consultation on the part of several workgroup members with industry experts, proposes a store-and-forward telemedicine provider-to-provider tele-consultation use case. We believe that this recommendation is of considerable utility to payers, providers and patients alike and, if adopted and acted upon by AHIC, is fully consistent with its mandate to help achieve the President’s goal for most Americans to have access to secure electronic health records by 2014.

B. Rationale and Scope:

Store-and-forward telemedicine provider-to-provider tele-consultations offer great potential to ameliorate the specialty shortage/ mal-distribution challenges that we face across the nation. We propose this use case in order to: (i) attain greater access to quality care, (ii) increase patient convenience and value for their healthcare interactions, and (iii) reduce overall costs of certain healthcare encounters and visits. Given the aftermath of Hurricane Katerina, the events of 9/11 and the ongoing bio-terrorism threat, it is the feeling of this workgroup that several compelling national security interests can be advanced through the adoption of this use case. It is urged that this store-and-forward use case be advanced as important priority for our national healthcare agenda. In proposing this use case, the Chronic Care Workgroup expects that store-and-forward activities will integrate into the electronic health record and personal health record systems and that this integration, in turn, will spark further healthcare product and service innovation to help meet the challenges ahead.

C. Background:

Store-and-forward is a type of telehealth encounter or consult that involves the use of digital images (still and/or motion) and/or audio recordings of a patient for the purpose of rendering a medical opinion or diagnosis. While already in use extensively for healthcare services requiring a simple reading and interpretation of images such as radiology, the use of store-and-forward for physician-to-physician clinical consultations that include both a diagnosis and treatment plan is in use in various geographies and sectors of the US healthcare system.

Technology advancements and results from years of evaluative research have made the use of store-and-forward technology an important and viable option in the delivery of care. The evaluative research has documented: (i) important savings in time and money, (ii) improved clinically efficacious outcomes and (iii) in several specialty areas, no difference in diagnosis and treatment plans between face-to- face consultations and store-and-forward telemedicine. Over the past few years, there have also been significant advances in telemedicine to include development of standards. These developments have come at a critical time. There are well-documented shortages of medical specialists and mal-distribution of said specialists, and this trend is not expected to change. At the same time, there is a growing population of aging Americans who are hitting the healthcare system en-mass and will need care that our present system will be unable to meet. Thus, this store-and-forward telemedicine provider-to-provider tele-consultation use case represents a critical capacity builder to enable efficacious, high quality rapid care in the years ahead.

Store-and-forward is a proven method of speeding care, diagnosis and treatment plan in a cost effective, efficient and convenient way. It has been shown to scale and address the specialty shortage in the Veterans Administration, Department of Defense and correctional healthcare. Further, in isolated geographies such as Alaska and Hawaii, store-and-forward has been used extensively and a sustainable economic model has developed. To date, store-and-forward telemedicine has been most widely used in otolaryngology (ear-nose-throat), ophthalmology, pulmonary, cardiology, dermatology (including wound care), and others.

Store-and-forward will become an important part of how healthcare. The advent of the electronic health record and health information exchanges will help to accelerate this phenomenon. AHIC's selection of this use case for further development will ensure the adoption and integration of existing HITSP standards into EHR, PHR and HIE store-and-forward features.

D. Standards proposed: HL7, CCD, CDA, CCOW, DICOM, JPEG and other HITSP recommended standards

E. Recommendations:

1. Proposed Process Flow for Recommended Use Case

a. A referring provider or a designated representative sees a patient and determines that a patient needs a consultation to a specialist.

b. The referring provider, a designated representative or a telemedicine coordinator/presenter captures the appropriate history and images based on a standard protocol. This can be done at the time of referral or by an appointment at a later time. The patient may be sent to a separate location (telemedicine center) for the history and image capture.

c. The referral history and appropriate multimedia are saved, uploaded, and sent to the designated specialist. This may be done as a stand-alone web-based application, secure email, or as part of an EHR system. Multimedia types may include still digital images, recorded videos or audio, and waveforms and will vary among specialties.

d. The specialist reviews the referral history and multimedia then renders a diagnosis and/or management recommendation in a report format.

e. The referring provider reviews the recommendation from the specialist and manages the patient with appropriate follow up.

f. The specialist recommendation along with the patient’s final management and disposition from the referring provider is recorded as part of the record system.

2. Requested Next Steps

1. AHIC review and approve the above use case

2. Appropriate existing AHIC/ HITSP standards for interoperability should be identified and leveraged for this use case and any additional communication and interoperability standards for store-and-forward telemedicine be developed in collaboration with appropriate entities.

F. Impact if recommendation is not accepted:

AHIC in 2006 made several recommendations to HHSincluding the recommendation to “allow the widespread use of secure messaging, as appropriate, as a means of communication between doctors and patients about care delivery.” Our proposed store-and-forward recommendation coupled with AHIC’s previous recommendation presents a fuller suite of asynchronous clinical interactions and closes a gap in the existing recommendations. If this store-and-forward use case is not accepted the gap will remain. This will result in the lack of clearly defined and comprehensive use case scenarios and associated interoperability standards. This, in turn, will result in the continued development and deployment of separate, disparate, proprietary systems for store-and-forward telemedicine. These systems will be inherently less efficient, more expensive, and poorly integrated into clinical information systems and workflow.

G. Acknowledgement:

This use case proposal was prepared as a collaborative effort of AHIC Chronic Care Workgroup members Jonathan D. Linkous, Jay H. Sanders, MD and Joseph L. Ternullo, JD. The development of this use case included discussions with Dena S. Puskin, Sc.D, Director of the Office for the Advancement of Telehealth, and Michael B. Robkin, Principal Enterprise Architect in Care Delivery for Kaiser Permanente Information Technology. LtC. Hon S. Pak, MD, Director Advanced Information Technology Group, Telemedicine and Advanced Technology Research Center and Scott C. Simmons, MS, Director of Telemedicine, University of Miami Miller School of Medicine prepared the initial draft of this use case and remained involved in its edits and refinements, working collaboratively with Mr. Linkous, Dr. Sanders and Attorney Ternullo. Joseph C. Kvedar, MD, Director, of the Center for Connected Health at Partners HealthCare System and Vice Chair of Dermatology at Harvard Medical School participated in the final review of this use case proposal prior to its submission.