In this chapter, we explore the concept of a system of care for telemedicine through three cases that illustrate the challenges of expansion. Whether virtual or traditional, a system of care is necessary to provide comprehensive services throughout a health care setting. But what is a system of care? A system of care is the whole environment of individuals and resources that surround a patient and the processes that coordinate those individuals and resources. A useful example is that of a patient with a seizure. We can see how a system of care begins when the patient collapses at home and 911 is called. The system of care for this patient would include the county 911 dispatcher who alerts EMS (emergency medical services) that a seizure patient needs help, and the EMS personnel who arrive and transport the patient to a local emergency department (ED) capable of handling an unstable, possibly intubated patient. From there, the system of care includes the ED physician, who may be concerned enough about status epilepticus that he or she contacts an affiliated tertiary facility with 24/7 neurophysiology to take the patient in transfer. Once stable, the tertiary facility may further expand the system by involving a subspecialty epileptologist for clinic follow-up and possibly even a neurosurgeon who specializes in epilepsy surgery. In this example, the patient simply called 911 and depended on the health care system to be responsive and efficient in coordinating the best care. From the system standpoint, protocols and properly trained personnel had to be developed, updated, and coordinated to ensure the patient received the care.
While neurological patients may enter a health care system through a hospital admission, they are often seen by family doctors and referred to specialty care. This too is a system of care, but one that often has fewer protocols and less coordination. In many parts of the US and the world, neurology appointments can be difficult to schedule due to limited availability. Even some hospitals may not have full-time neurology coverage, and even fewer have routine access to subspecialists, such as an epileptologist, as in the example above.
A major strength of telemedicine is its utility across many different care settings to bridge gaps that are apparent in more traditional models. New clinic visits, emergency department encounters, follow-up visits, and subspecialty opinion visits allow expertise to reach patients through telemedicine despite geographic and resource barriers. Some counties are even implementing telemedicine services in ambulances. Realizing this strength of telemedicine, many institutions are seeking ways to cooperate among members of their own organization and leverage expertise where it is needed and when it is needed. The specific example of telestroke coverage to deliver vascular neurology care to the ED is only the beginning of a spectrum of possibilities for connecting the right patient to the right doctor. For physicians, the appeal of such arrangements is that they allow the practice both to grow and to become more focused.
Before exploring the case studies, it is worthwhile first considering the conceptual arrangement for a system. Often it is suggested that systems have spokes and one or more hubs. While this is familiar and a simple, useful arrangement for some systems, it often does not capture the real-world needs of most institutions. Furthermore, in neurology the spokes may evoke the image of a general neurologist, and while a true “general neurologist” may occasionally exist, even a generalist typically has a practice focus or prior training that makes him or her better suited for a subset of patients that is distinct from another colleague who also practices general neurology.
More problematic, a spoke and hub arrangement evokes a sense of superior-inferior, which can undercut system progress and collegiality. Most systems of care have a wide variety of clinics, freestanding facilities, and hospitals that do not neatly fit into a spoke or a hub. They may not even fit into the same umbrella institution. A clinic on the east side of town may have an autonomic testing lab, while a facility on the west side of town may perform muscle biopsies, and yet another may share space with a private neuro-ophthalmologist. Are these spokes or hubs? How then should we consider such a system? The better analogy is a wide array of various-sized gears. Gears depend on each other to move and when one moves the others react; unfortunately, if one breaks, the whole system becomes vulnerable. Some gears may be small, others large, but the cooperative nature of this arrangement better illustrates the true variety of facilities and physician practices that combine to form a system.
Core values should guide decisions
On the surface, systems of care may share a logo or a balance sheet, but what really unites a system is its shared values. If a system values excellence in neurosciences, it will be more likely to invest in teleneurology services, but regardless of any system’s priority for neuroscience excellence, there are two core values that must be in place for a system:
- (1)
a commitment to cooperative growth; and
- (2)
recognition of the fiduciary role to patients.
A commitment to cooperative growth is a fundamental feature of a successful system of care. Actions that undercut trust, ignore stakeholders, or direct services for purely financial gain will ultimately lead to inefficient systems.
The fiduciary role of the health care professional is to put the patient’s needs ahead of their own. Such clear principles are easy to discern when one considers a single patient, but may become less clear when a collective, future group of patients are considered. Nonetheless, the obligation to put the patient first does not change and must also remain a core feature of the system of care.
In the next three sections, we will examine actual challenges or outright conflicts that arose in developing a system of care for telemedicine in a mixed urban, suburban, and rural environment. In each case, the scenario may seem familiar or may differ from those encountered in your own environment, but they were chosen to highlight pitfalls that can be avoided with strategic, thoughtful planning. As a reader, consider taking a moment after each case to jot down the source of the problem and potential solutions—the more the better. In considering the various solutions, be mindful of the fiduciary role of the system as well as the need for cooperative growth. Are these core principles served? How is the conflict a reflection of misguided actions? After each case, a discussion will follow that explores how things went wrong and then how solutions came to be. No one answer is correct and the most important takeaway is the process of planning itself.
Case 1: Dr. Garcia needs help at the hospital
Dr. Garcia is a general neurologist who practices in a rural clinic that is part of the St. Elizabeth System of Hospitals (StESH). Adjacent to the clinic is a 75-bed hospital that is a primary stroke center and serves a population of about 25,000 people. The clinic and hospital where Dr. Garcia works was previously part of Unity Healthcare and was purchased 2 years ago by StESH, which now owns eight regional hospitals and employees a group of 700 physicians. The StESH Main Campus has 15 neurologists and a new teleneurology service that is currently operating at two of the eight hospitals in the StESH system but not at Dr. Garcia’s hospital. Dr. Garcia joined the employed practice with an agreement to do five night/weekend calls per month. The remainder of the hospital calls would be covered by a private group of physicians who are paid a per diem rate and were part of the Unity Hospital but opted not to join StESH. The typical neurology census at the hospital is about 5–10 patients, with two or three new consults per day.
Dr. Garcia has an interest in expanding her hospital consults. She feels that she could see all of the hospital patients every weekday and at least one weekend per month. Although she did not do a fellowship in vascular neurology, she enjoys caring for stroke patients and has kept up with the latest advancements in thrombectomy and imaging for stroke patients.
In addition to building her practice, she has some concerns that the private group rotates providers too frequently and the lack of continuity of care for patients has caused some lapses in quality. The hospital CEO supports her decision and would also like to hire more StESH neurologists, but his neuroscience budget is limited due to the per diem he is paying the private group.
Dr. Garcia asks the CEO to come up with a plan to cover after hours and weekend call with teleneurology and she will provide in person rounds on the patients. The CEO discusses teleneurology with Dr. Randolph, a provider at StESH Main Campus who coordinates teleneurology. Dr. Randolph and the CEO negotiate a plan that costs the CEO 50% of his prior per diem budget and allows him to invest in another neurologist for the practice in time. The CEO informs Dr. Garcia that she can see the patients during the day and Dr. Randolph’s team will cover acute issues after hours and weekend.
Questions to consider for Case 1
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Who are the stakeholders in the plan to add teleneurology to the call schedule?
- 2.
What pitfalls might exist with the plan?
- 3.
Are the goals of patient care and growth presently aligned, and does the current plan improve or worsen the alignment of these goals?
Discussion
One of the most common mistakes made in putting together a system of care is inadvertently forgetting important stakeholders. In this case, an accommodating CEO, an ambitious local neurologist, and a well-organized telemedicine team made a plan without the input of many other members of the system of care. A critical first step in planning a system of care for telemedicine is identifying stakeholders. The list in this case might include the emergency department physicians and nurses, the county EMS chief, hospitalist physicians, the nursing director for the stroke center, the other system hospitals that are still not served by the teleneurology service, and the private practice that has long served the hospital before it was part of StESH and continues to provide call coverage 25 out of 30 days.
An alienated stakeholder can derail a well-intentioned plan. In this case, the CEO informed the private group that he would be ending the per diem pay but welcomed their ongoing presence at the hospital. Feeling left out of the decision-making process, they informed the CEO that they would not see patients at the hospital any longer and would no longer provide coverage as part of a call pool, leaving the hospital with Dr. Garcia as the lone neurologist on staff.
The emergency department physicians initially liked the idea of a teleneurology service, but became concerned when the hospitalist physicians did not want to admit unstable neurological patients without a plan from a staff neurologist whom they could easily contact. The floor nurses were unsure who to call with questions overnight and did not have any setups for video visits like the ED had. The hospitalists requested significantly more patients with neurological complaints transfer to Main Campus. Patients and their families who were accustomed to care at the local hospital found themselves transferred 30 miles and having to drive an hour to Main Campus to see their family. Recognizing this trend, EMS started diverting more stroke and seizure calls to other hospitals and bypassing the StESH campus. With a shrinking neuroscience patient population, the CEO no longer had the budget available to hire a second employed neurologist. Dr. Garcia also felt left out of the call pool for teleneurology and had expected Dr. Randolph to include her in the rotation of telemedicine providers.
Solutions and realignment
In reality, the plan did not unravel as spectacularly as described, mostly because the hospital CEO was astute enough to recognize the stakeholders during a soft introduction and series of meetings where many of these issues came to light.
Dr. Randolph met with Dr. Garcia and explained that the budget for the current year of teleneurology service had already been allocated, but that he welcomed her interest and offered to have her shadow a few nights of call to see if it was something she would like to join in the future.
The ED medical director took the lead in working with his providers and the hospitalists to ensure that unstable patients would be given extra scrutiny before transferring to a floor bed and that they would utilize more intermediate units and intensive care unit (ICU) beds when there was any lingering concern about a patient’s stability. Dr. Randolph also met with the ICU team and hospitalists and reassured them that the teleneurology physician would be available throughout the initial hospital course to manage any issues even outside the ED until the in-person neurologist saw the patient. The teleneurologists provided the nursing staff with a single hotline to reach the on-call teleneurologist and a set of iPads for video encounters. Dr. Randolph and the ED medical director also met with the local EMS chief and explained that in similar rollouts, the utilization of tPA (tissue plasminogen activator) increased, and shared literature that showed how a successful prehospital notification of the teleneurology team would further shrink door-to-needle times. This partnership was well received by the EMS, which had been interested in enhancing prehospital stroke scores.
As for the private group, the CEO recognized that they would be taking a financial loss and decided a phased approach would be better than a cold break. He offered the private team a 50% reduction in per diem rates, recognizing that their services would still be needed but their afterhours responsibilities were significantly less. They agreed to this plan for 1 year. The total amount the hospital was paying for neurology call was the same for 1 year but would be split between teleneurology and in-person call pay. While there were ultimately no call pay savings in the first year, the volume of patients grew, and the CEO was able to justify a new hire.
Takeaways
When treating patients, physicians are well attuned to the downstream effects of their therapies. An antiplatelet medication reduces stroke risk but may cause a gastrointestinal bleed. An antiseizure medicine may stop seizures but cause excessive sleepiness and imbalance. While the physician is accustomed to the chess game of thinking two steps ahead physiologically, the same planning and careful consideration must apply to make changes within a system. In almost every telemedicine system of care, change will result in collateral effects. Change itself can be a source of resistance for no other reason than it is different from how things have always been done.
When facing these challenges, it can be disheartening to hear a barrage of complaints about a well-intentioned plan. The remedy for such criticism is to listen early and often and to plan over time based on this feedback. To engage stakeholders, start with any point of stress in the system and hold listening sessions. In this case, Dr. Garcia meeting with the ED medical director would be a sensible early contact. For these meetings, it is best not to have a specific plan or even agenda. By listening and addressing concerns, one can turn stakeholders into champions. These champions may be formal leaders, but in any department there are also informal leaders who may not have a specific leadership title in the organization, but who play an outsized role in the organization’s morale. These may be long-tenured staff, or personal friends of the leaders, or just very vocal individuals whose disagreement can sink a plan. These individuals are key allies to bring into the fold early to avoid demoralizing backchannel criticism.
When facing difficult changes, such as the CEO informing the private team of a pay cut, make a point of holding in-person meetings that emphasize the values of the organization and frankly address how the environment is changing. While email may be efficient, it is the worst possible vehicle for introducing difficult changes. The CEO should find out how important the per diem call pay is for the private practice, and point out that as fewer and fewer neurologists want to take overnight acute calls, he must make forward-looking and patient-centered plans that are appropriate for the future.
Many courses and lectures exist on change management, and the details are outside the scope of this chapter but included as references at the end. Experienced health care executives are well-versed in change management and can be valuable colleagues in navigating a plan through resistance.
Finally, it is important to remember the core values of putting the patient first and cooperative growth. While these values may seem simple, they increase dramatically in complexity as more and more stakeholders face a change to the status quo.
Case 2: The call volume is increasing
Dr. Randolph has started a successful teleneurology program at StESH. For the first 6 months, he covered all the calls himself from just one campus. He now has three of the eight campuses participating and has received enough funding to recruit a full-time faculty member and cover half of their salary with telemedicine revenue. He has also been able to fund call pay for two more of his colleagues to participate. The panel of teleneurologists taking acute calls now includes four faculty members with experience in acute neurological care.
The program has been very well received by the ED providers, who appreciate the rapid response and video evaluations. As a result, the program has had an increase in calls over the last 24 months, as shown in Fig. 14.1 .
