One of the speakers at the 2013 American TeleHealth Association Conference, held in Austin, Texas, May 5-7, was Wesley Valdes, D.O., who is telehealth services medical director at the Salt Lake City-based Intermountain Healthcare. While at the American TeleHealth Association Conference, Dr. Valdes and his colleagues at Intermountain staffed a booth that featured advanced telehealth solutions developed at Intermountain, including a virtual NICU (neonatal intensive care unit) that allows parents 24-7 visual access to their babies, as well as the capability for eVisits with their babies’ care providers.
Intermountain Healthcare’s leaders have committed significant support to establish telehealth technology across the system’s 22 hospitals and 185 clinics. The organization’s telehealth solutions, along with an open source community, are expected to support the organization’s strategy to transform healthcare by delivery high-quality care at sustainable costs, to a widely dispersed population.
Shortly after that presentation, Dr. Valdes spoke with HCI Editor-in-Chief Mark Hagland regarding his and his colleagues’ efforts at Intermountain Healthcare. Below are excerpts from that interview.
When you presented in a session at the American TeleHealth Association Conference, you partnered with another telehealth director, correct?
Yes, I was on a panel with Andrew Watson, M.D., director of telehealth at UPMC [the University of Pittsburgh Medical Center health system].
What are you doing with telehealth at Intermountain these days?
Intermountain Healthcare, as an organization, has responded to the new healthcare rules and regulations that the government has passed, in its own unique way. You’ve familiar with ACOs [accountable care organizations]; Intermountain would consider itself as already having been, in effect, an ACO, for years. If you look at the actual ACO model, it’s quite noticeable that it leaves out a key player in the healthcare process, as far as we’re concerned—the patient. The accountable care model doesn’t really encompass the patient, so we’ve developed our own concept, called shared accountability. The concept has two main phases. During 2013-2014, the focus is on intra-case cost reduction, which is a fancy way of talking about the admission-to-discharge timeframe when someone is an inpatient. It’s looking at making hospital stays more effective, efficient, and cost-effective. Then during 2015-2016, we’ll be focused on population health management.
And in putting this strategy in place, we decided that telehealth and mobile health would need to be a key part of all this. Intermountain had looked at telehealth earlier than that, but it really fit into this strategy well. At the time, I was a subject matter expert on telehealth from Microsoft, while an employee of the University of Illinois, and Microsoft and Intermountain had conversations, because Microsoft wanted to see how their technologies could provide telehealth solutions. So long short, in November 2011, I came out from the University of Illinois to Intermountain to help out with this. And in looking at the shared accountability strategy, we came to the conclusion that telehealth could help with both phases. The majority of Intermountain’s 23 hospitals are actually small, 10-25-bed rural hospitals; then they have seven mid-range hospitals, the 100-200-bed hospitals, and then four large hospitals.
So in talking about intra-case cost reduction and efficiency, we started a conversation about the element of redefining the concept of waste. And so what we were able to present to the organization is that, by taking the telehealth concept, which is usually cameras pointed outside your walls, if you turn those cameras to inside your walls, you create an infrastructure for greater efficiency. So we decided to put telehealth equipment into every single one of our patient rooms. We’ve been rolling that out, and are rolling it out over the next 12-15 months. That’s where the concept of the interactive patient room came in. And by doing that, we were able to look at several other projects, including patient education, patient entertainment, and patient stimulation, and merge all those projects into one. So while the interactive patient room will have a telemedicine/telehealth capability, it will also incorporate patient education and entertainment as well. So we were demo-ing that concept at both the HIMSS Conference and the telehealth association conference as well.
How will the interactive patient room be set up at Intermountain?
There will be a camera in the ceiling, something patients usually don’t see in their rooms. And the pillow speaker will be more of a touch-screen device. We haven’t yet decided what the form factor will be—it might look like an iPhone or iPad, but it will be some kind of touch-screen-driven device that the patient holds and that can access different features and functions—everything from turning the lights on and off to watching movies; but we also realized there are all sorts of other things we could enable it with. For example, if we’re not using the camera to do a remote consult at the moment, we realized we could also use the room to enable the patient to, say, do a Skype call with their grandchildren.
So now that you have a touch-screen-enabled device, taking a very simple concept such as interpreter services, for example, can be transformed in its delivery. Right now, it’s up to the staff to determine when and where you need an interpreter. Typically, the staff has to call for an interpreter and bring them in and have them wait for physician. Now, we can have the capability for the patient to immediately access an interpreter. And my assumption is, the patients have a lot better sense of when they need an interpreter than the staff does. So if you think of the hospital environment as a place where control is taken away from you—we tell you when to eat, we tell you when and where you can use the bathroom, and that you need us to help you do it—by putting this infrastructure in, I can redefine some elements as waste and improve efficiency. Now we can get the interpreter there when the patient wants the interpreter, and eliminate the wasteful aspects of that process.
Tell me about the work you’re planning to do in your health system’s ICUs and NICUs?
When we talk about putting the equipment in every patient’s room, the ICUs are included. And from my perspective, when I think of the baby isolette in a NICU, I see it as no different from a patient’s room; it’s just a tiny little room with a tiny little person in it. And the camera can help the parents see the baby, for example. But we can also create a communication portal between and among the physicians, nurses, and parents. We can connect to the parent on the parent’s iPad, and the doctor can use that as a communication tool as well. And you can see how this comports well with our e-visit strategy. When parents go home with their babies, they still need support. And frankly, all you need there is the capability to access any Web browser; and we’re still able to provide them with a higher level of care in their home environment.
That makes sense in the context of rural health, too, correct?
Oh, sure. In fact, that’s one of the decisions that we’ve recently made. Although we’ll be investing $20-25 million in setting up this infrastructure, we do see this as a powerful set of tools that smaller hospitals around the country could benefit from. So we’ve made the commitment to release at least the parts of what we’ve built as open-source. To see that announcement, go to www.intermountainhealthcare.org/ata13.
What lessons have you and your colleagues learned so far on this journey?
I think the biggest lesson that we’ve been trying to advocate is that the technology has to be designed to follow the clinical workflow. In my personal opinion, the reason that telehealth hasn’t taken off more than it has, is that it’s typically a service designed for businesses (such as videoconferencing) that people take and try to shoehorn into a medical solution and environment. I personally have been trying to get vendors to develop the ability to transfer a video call, put a video on hold, and cue up an incoming call, like a telephone call, and have been told it’s impossible, can’t be done. To me, that’s a critical piece, because that’s how clinical workflow occurs.
What people have typically done is to put this videoconferencing equipment into a conference room, so when someone wants a video consult, they have to schedule a meeting, and people have to gather in that room. But the technology has to start is to mirror the way a phone call or physical patient comes into the workflow. So we have the ability to use our e-signature form tool integrated into the solution so I don’t need to fax or mail you forms; you can just sign the form online. You can’t do that on a Polycom system. You actually have telemedicine with all this fancy equipment still faxing back and forth consent-to-treat forms—ridiculous! So the technology needs to conform to the clinical workflow, and not the reverse. That’s why we’re going to release this entire platform as an open-source solution, because we think that healthcare needs to step up and transform telehealth. And why make others recreate the wheel?
What would your advice be as others begin to set up these kinds of processes?
The same advice I’ve given my colleagues at Intermountain: don’t go out and look at how others have solved this; instead, look to develop solutions for problems that your own organization has. At Intermountain, we found that, while ostensibly, the definition of waste did not include the whole area of interpreters driving around, for example. But it’s simple root cause analysis and process mapping; start with that, and create technology solutions around process problems.
So go through those processes, and then figure out what you need, right?
Exactly. And as Brent James [Brent James, M.D., executive director of the Institute for Health care Delivery Research, at Intermountain Healthcare; Dr. James was the closing keynote speaker at the Healthcare Informatics Executive Summit last month] will say, totally look at your baseline operations and performance, and track and analyze, and figure out whether or not an implementation was of value or not. From an informatics standpoint, it starts to question the validity of how we actually provide care. There are assumptions based on past practice, of how we actually do an office visit or a hospital stay. If you always do what you’ve always done, you’ll always get what you’ve always gotten—it’s that syndrome.
It’s the lack of questioning of routines, in healthcare operations.
Absolutely. And I take that fault all the way back to medical training, which is structured to almost beat the curiosity right out of medical students. And the thing is, medicine is about curiosity and discovery. But once you get into the healthcare system, you get into that whole “just do it the way it’s always been done” syndrome. The questioning has been driven out of the system. Take for example the electronic medical record: of what use, in taking care of a patient, is an electronic medical record? It’s a rhetorical question.
Not many are questioning the form-fit between what we’re doing and what needs to happen.
Yes, I agree. And the large electronic medical record vendors have helped pushed through the requirement of EMR adoption, without requiring innovation. You open up a Cerner EMR, and it looks like an interface design from the 1980s. So why are spending so much time on the medical record, instead of creating software solutions for planning what’s going to happen to you? There’s very little yield forward for project management tools for performance improvement.
That should change with healthcare reform.
Yes. But understand that if you have a primary care physician and five consulting physicians, you easily end up with six care plans for a particular patient. Now in the project management world, you would never have six project plans. But in healthcare, we allow each physician to develop their own individual care plan for the same patient. In any manufacturing plant, they would that ridiculous. And when you listen to Brent James, he’ll refer to Deming, who went to Japan, and who taught them how to do modern manufacturing. And Dr. James is a huge proponent of the Toyota Production System and just-in-time efficiency, and all those things.
Is there anything you’d like to add?
To me, the most exciting thing is this opportunity to build the solution in an open-source manner, because it immediately allows us to collaborate with other organizations, and to crowd-source and allow people to work with us. To me, this is a better way to figure out how to do telehealthcare. The electronic medical record is a good example: I think that healthcare providers have been too silent, in allowing programmers to design everything for them.
