Specialty Telemedicine

To extend its geographic reach to enable patient tele-visits and physician tele-consults, the five-surgeon Dallas Neurosurgical and Spine Associates (DNS) recently implemented a communication platform, Lync (from the Redmond, Wash.-based Microsoft). DNS, which has five office locations, is preparing to offer consultations to patients in rural areas around Dallas-Fort Worth, and to as far away as Saudi Arabia and Peru. Adding a new communication layer is just one step in this practice’s IT journey, as it recently moved to an electronic practice management system and will soon adopt an electronic medical record (EMR) (both systems from the Carrollton, Ga.-based Greenway Medical) come July 7. Stephen Cracknell, managing partner at US Medical IT and lead IT coordinator for DNS, spoke to Associate Editor Jennifer Prestigiacomo about DNS’s telemedicine vision for the future and the challenges so far with making these connections.

What was the impetus for using a communication platform like Lync to start this telemedicine project?

A while back the doctors experienced a burst pipe in their main office, and that actually shut down the office and their IT infrastructure for a number of weeks. This was the primary driver for them to move their infrastructure offsite and into data centers.

The specific scenarios we’re trying to address here is with rural patients. For example, when [doctors] have a rural patient coming in with a benign tumor that needs follow up on a regular basis. The doctors want to be able to provide the patient the ability to go into their primary care provider (PCP)’s office on a regular basis for follow-up visits. The PCP [will have] to retrofit their exam rooms with this technology so that the follow-up visits can be done from the PCP’s office in their rural community, rather than have patients travel back into [Dallas Neurosurgical & Spine Associates].

I am excited about continuing to explore this around international patients. One of the doctors has a practice over in Saudi Arabia, and they’re looking forward to using this technology to allow these patients to have more frequent interactions with doctor. He goes over there about six times a year. Two of the other doctors go on mission trips to Peru. They’re planning a two-week trip this year in September. I want to be able to connect them with the neurologist in Lima, so they can start to vet out which of the patients are good candidates for surgery when they’re down there. Currently, when they’re down there, they’ll spend a good chunk of their time determining which of these patients should have surgery. It would be much better if they had a full surgery schedule when they got down there. I would say this year we’ll go down with them and figure out all the logistics, and so the following year they will have the opportunity to interact with the doctors [remotely].

Can you tell me more about how Lync has been leveraged as the foundation of DNS’s telemedicine program?

When we tried to [share] the MRI images over the older technology it didn’t provide the fidelity that the doctors felt comfortable with. So I reached out to Microsoft to see if there were any plans to improve the fidelity and if there was anything we could do within the current infrastructure to make that work. Once we got our hands on the Lync software, we ran a test and it was a much better experience than before from a fidelity standpoint.

We’re still in pilot mode, so we haven’t made the shift to see patients with the software yet. We still have some paperwork to get over from a HIPAA standpoint, and we hope in the next month or two we’ll be able to put patients in front of it.

Will physician-patient tele-visits be saved and flowed back into the EMR?

In the first phase we probably won’t record them. Ultimately, we’ll give the option for the physician to enable that. As we plan right now, US Medical IT will be responsible for the IT infrastructure. We’re probably not going to house those recordings on our servers. In the future if a doctor wants to record and save those files and link them as part of the electronic medical record, they will certainly have that capability.

How are the connections to the PCPs going to be established?

The DNS doctors consider themselves a boutique firm, and they provide a higher level of service. To them, this [communication platform] allows them to continue their mission of premium neurosurgical services in North Texas. For years they’ve been receiving referrals from these rural physicians, and they plan to reach out to the PCPs they already have relationships with and say, ‘we’d like to extend this service to you.’ Historically, they’ve been shipping those DVDs and finding time when those two doctors can reengage, so the nurse can get a consult on that image. What they want to be able to do when they get one of those CDs in—the doctor can go into the exam room, pop a CD into the tray, and the two of them can talk about it at that very moment. It will speed up those diagnoses.

Have there been any challenges so far?

The biggest challenge is having network connectivity. Having enough bandwidth and making sure the right ports are open between the doctors so that experience is a good one. That is part of the reason we’re going with a VPLS [Virtual Private LAN Service] or a MPLS [Multi-Protocol Label Switching] network that allows us to control the experience from the quality of service standpoint. The Lync software has been pretty seamless.

For me, the trickier part is scheduling doctor to doctor consults, and find out how we make that experience happen—that is something that will fall into the telemedicine project. Especially in a case where a doctor doesn’t take Medicare or a particular type of insurance, but a PCP wants a consult with them. That’s the trickier piece to all this, figuring out which doctors want to talk to which doctors, and how do you find the time to get together to do one of these consults.