Long-Distance Medicine 2.0

by Matthew Greseth

Telemedicine has enabled physicians to reach their patients at home. This is especially important here in South Carolina, one of the more rural states in the country. The legislature has invested heavily in the development of telemedicine across the state, and MUSC’s Center for Telehealth coordinates and facilitates access to specialized expert care for people in remote rural areas of South Carolina that don’t have a large hospital nearby.

Targeting pediatric and maternal health care

MUSC’s telehealth program has seen exponential growth, going from 12 programs to more than 70, and has identified several innovative strategies for delivering health care.

“One of the ways in which MUSC has really distinguished ourselves is we have one of the broadest varieties of pediatric telehealth services either in operation or in development anywhere in the country,” says S. David McSwain, M.D., MPH, FAAP, MUSC’s chief medical information officer and medical director for the South Carolina Children’s Telehealth Collaborative.

MUSC has more than 20 different services that utilize telemedicine to improve pediatric and maternal health care. Some of the programs focused on children include behavioral health, psychological advice, nutritional advice, school-based telehealth and pediatric critical care. For maternal medicine, MUSC offers obstetric help for maternal fetal medicine, genetic counseling, diabetes management and behavioral health — MUSC has the only specialist in the state that works with addiction in pregnant women.

MUSC continues to grow its presence across the state and maintains a network of partnerships, especially with children’s hospitals. One of the near-term goals is to strengthen the internal connections of these partnerships. This is particularly true of the new MUSC Shawn Jenkins Children’s Hospital and Pearl Tourville Women’s Pavilion. Most of the rooms are equipped with cameras so that specialists can link in to talk with patients. The emergency room and neonatal intensive care unit (NICU) will be equipped with carts that enable specialists to see their patients from distant locations. Furthermore, video conferencing will allow families who are unable to visit to be part of the case discussions, especially for babies who must spend long periods in the NICU

Reducing emergency room admissions for asthma

The school-based health program is one of the founding telemedicine programs at MUSC. It began in three schools (in Charleston, Kingstree and Hemingway) and has grown to more than 100 across the state as legislators, with public support from their communities, funded and built the infrastructure needed to expand the program.

“What’s wonderful about the program is that it is designed to be a partnership with local communities,” says James T. McElligott, M.D., MSCR, telehealth executive medical director and founder of the school-based telehealth program, now led by Kathryn K. Cristaldi, M.D., MHS, assistant professor of pediatrics in the College of Medicine at MUSC. “In some ways, that’s done by us delivering the care here at MUSC, in other ways we can have local practitioners do it.”

The school-based system functions like Uber. The school nurse activates the system, which alerts one of the local providers to get on the platform and see the child. If the first call goes unanswered, a second local physician is contacted. If the call still remains unanswered, MUSC takes the call. This system allows MUSC to partner with local physicians and be a critical resource for the state.

Each school is provided with a cart that is capable of video conferencing for visual examination of the student. The cart is also equipped with a stethoscope and a camera with various lenses to examine the skin, ears and teeth. With these capabilities, 90% of consultations, ranging from acute conditions such as a rash or earache to chronic conditions like asthma or ADHD, can be managed in partnership with local physicians.

“We have been doing this program for a while, and we believe in it,” says McElligott. “Anecdotally, kid by kid, we can see the success of it, but until recently we didn’t have true empiric data to support it. In Williamsburg County, where I started the program and where we have 100% school coverage, we saw, over a three-year period, a steady decline — more than 20% — in the use of the emergency room for kids with asthma.”

These data were recently published in JAMA Pediatrics and highlight the success of telehealth when it is fully integrated into the community. Coverage of the entire county increases utilization of the program and avoids any stigma associated with it. Over the next few years, McElligott and Cristaldi want to replicate the success of Williamsburg County in other counties across the state.

Consulting for pediatric critical care

Another one of the earliest telehealth programs at MUSC focuses on pediatric critical care. Pediatric ICUs specialize in the care of critically ill infants, children and teenagers. Children who visit the PICU often require complex care. Many hospitals lack the technical expertise for these complex cases, so pediatric telemedicine allows physicians at MUSC to share their knowledge and expertise across the state.

MUSC has active relationships with five different community hospitals that have telehealth capabilities in their emergency departments and pediatric floors, and the South Carolina Children’s Telehealth Collaborative supports the development of pediatric critical care programs at children’s hospitals across the state.

“The community hospitals we currently partner with do not have PICUs, so we are their only resource for that type of care,” says Whitney E. Marvin, M.D., assistant professor of pediatric critical care at MUSC Children’s Hospital and medical director for pediatric critical care telemedicine. “A few hospitals have small pediatric wards with pediatricians on staff, but they are not as well versed on managing critical care cases as our training allows us to be.”

Oftentimes, MUSC plays a consultative role, providing 24-hour access to experienced physicians. MUSC physicians can visually monitor patients remotely through video conferencing, and a stethoscope attachment allows them to examine the heart and lungs. In some cases, MUSC physicians may assist in acutely managing certain traumas, septic patients or patients with obstructed airways. Thanks to these interactions, there has been a noticeable impact on the health of children.

“We did a study on the pediatric critical care program a couple of years ago that demonstrated that kids who get a pediatric critical care telemedicine consult are 2.6 times less likely to be admitted to the intensive care unit than kids who get the traditional telephone consultation,” explains McSwain. “That’s a huge outcome and something that we didn’t really expect.”

This improvement likely comes from intervention in acute conditions, having relationships with patients and knowing the health status of the children well enough to feel comfortable admitting them less often or admitting them to lower intensive centers.

One of the major goals of the pediatric telehealth program is to see and treat patients at home as much as possible, and remote patient monitoring is helping make this a reality. Not only does this save families time and money, but it allows physicians to monitor patients over time and have a better sense of their history. To facilitate at-home monitoring, families can use the mobile, patient-facing software Epic MyChart to set up a video conference appointment, access their medical records and upload data; however, these features do require a smartphone.

“One of the key barriers is the simple fact that broadband network access might be difficult to come by for patients in rural areas,” says McSwain. “That’s a challenge that still needs to be addressed.”

Interestingly, telemedicine offers the unique ability to help with disaster preparedness, and MUSC is looking to pioneer a program focused on responding to a disaster quickly and efficiently,

“We already have many established relationships with other emergency departments,” says Marvin. “In the event of a major disaster or some type of infectious pandemic outbreak, I think there is a potential use for telehealth to help triage patient care across large areas.”

In the future, McSwain and Marvin hope to expand the improvement they’ve seen in South Carolina throughout the country.

“This is one of the premier pediatric critical care telemedicine programs in the country, and in fact, our program was used as a model for the development of a pediatric critical care telemedicine service in British Columbia, Canada,” says McSwain. “So we’ve had an international impact as well.”

Growing pediatric health care safely

Telemedicine is improving the lives of patients across South Carolina and the nation. Concurrently, pediatric telehealth is growing rapidly, and it is imperative that doctors assess their progress to ensure that children are receiving the best care. One of the biggest challenges facing pediatric telehealth is identifying which practices offer the best care for children and which practices can be improved upon. This is a critical part of developing and growing programs that will have the greatest impact on improving our health care system, and over the past few years, MUSC has been tackling this challenge.

“One of the areas where we are leading nationally in pediatrics is in research around telehealth,” says McSwain, who is also a cofounder of the SPROUT Pediatric Telehealth Research Collaborative.

The SPROUT (Supporting Pediatric Research on Outcomes and Utilization of Telehealth) initiative has several goals. One goal focuses on identifying and addressing barriers to telehealth access through multicenter research. Another important goal centers on evaluating state and federal telehealth policies and linking those to research priorities and best practices. Ultimately, SPROUT aims to demonstrate how telehealth fits into value-based health care across the country.

MUSC is the main investigative site for the NIH-funded SPROUT-CTSA (Clinical and Translational Science Awards) Collaborative Telehealth Research Network. This collaborative partners with health systems across the country and allows McSwain and his colleagues to centralize data collection and research. The findings are then disseminated to other institutions to improve their telehealth programs and help them develop their own research strategies.

The telehealth programs at MUSC are generously supported by the state, and McSwain feels strongly that we should help other states, providers and communities that don’t have that support. SPROUT has helped implement best practices for vulnerable populations such as children, but McSwain sees the success of pediatric telehealth research expanding.

“SPROUT is growing rapidly,” says McSwain. “The goal is to establish a model for the approach to telehealth research that can be expanded beyond pediatrics. We want to be the standard bearer for telehealth research across all disciplines.”

Realizing the promise of telehealth

Many doctors are still hesitant about utilizing telehealth services; however, as more data accumulates, it will become harder to ignore the benefits of these unique programs, especially in more rural areas. One of the big advantages of telemedicine services is that the families are really engaged in their health care. Each engagement centered around an immediate concern, like a runny nose, can become a broader conversation — reminding parents about vaccination schedules, informing parents about other health concerns, and prompting parents to look after their own health.

The many telehealth programs at MUSC have laid the foundation across South Carolina and the country to deliver on the promise of improving health care administration

Read part 1 of the Progressnotes series on telehealth, published in Summer 2019, at MUSChealth.org/pn/telehealthpart1.