Telehealth Approaches to Integrated Multiple Sclerosis Care. May 30, 2013 CMSC Annual Meeting, Dallas, TX

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1 Telehealth Approaches to Integrated Multiple Sclerosis Care May 30, 2013 CMSC Annual Meeting, Dallas, TX Mitchell T. Wallin, MD, MPH Clinical Associate Director VA MS Center of Excellence East-Baltimore Associate Professor of Neurology Georgetown University School of Medicine University of Maryland School of Medicine Disclosures M. Wallin, MD, MPH has the following disclosures: Biogen-Idec, Inc. Investigator Initiated Grant Support

Learning Objectives: Telehealth & MS health care Using telehealth for remote assessments: Remote neurological examinations (EDSS) Remote cognitive assessments (ANAM) MS Surveillance Registry

2 Learning Objectives: Telehealth & MS health care Using telehealth for remote assessments: Remote neurological examinations (EDSS) Remote cognitive assessments (ANAM) MS Surveillance Registry Discuss optimal models of care for MS Patient-Centered Medical Home Joint Principles (Kirschner, 2010) Personal physician Whole-person orientation Integrated care Quality and Safety Enhanced Access

3 Patient-Centered Medical Home Joint Principle Endorsement 18 Specialty Medical Societies: including Am Acad Neurology, Am College Cardiology, Am College Chest Physicians, Am Soc Clin Oncology, Infec Dis Soc America, Soc of Critical Care Medicine Promise of improved coordination, quality & efficiency Concerns: Unrealistic expectations How will new services be reimbursed Implementation challenges for small practices Telehealth & Neurology (Agarwal S. J Neurol 2011) Telestroke: initiated in 1990s for acute stroke thrombolysis consultation, AHA Class I evidence for reliability of remote NIH Stroke Scale exam Teleneurology Pilots: Parkinson s Disease Epilepsy Neurorehabilitation Multiple Sclerosis

Telemedicine in Leading US Neurology Departments (George B.

telemedicine services Stroke Movement disorders Neurology critical

Taking Charge of Your Health Care When and Where you Need it

providers can communicate remotely, enabling patients to receive

4 Telemedicine in Leading US Neurology Departments (George B. Neurohospitalist 2012) 60% of respondents provide limited telemedicine services Stroke Movement disorders Neurology critical care Most programs started External funding sources Taking Charge of Your Health Care When and Where you Need it Telehealth: a means of utilizing technology so that patients and providers can communicate remotely, enabling patients to receive health care through telecommunications Clinical Video Telehealth Home Telehealth Store & Forward 4 8

E-Medicine in the VA Health Care System VHA is largest integrated health care system in US Common electronic medical

make appts, rxs, surveys, secure messaging Tablets, smart phones being used to access CPRS & Telehealth platforms

gov Integrated MS Care Comprehensive & coordinated care between health and social sectors Many unmet needs found in

5 E-Medicine in the VA Health Care System VHA is largest integrated health care system in US Common electronic medical record (CPRS) across all sites with links to utilization My HealtheVet is patient portal for access to their record, make appts, rxs, surveys, secure messaging Tablets, smart phones being used to access CPRS & Telehealth platforms Integrated MS Care Comprehensive & coordinated care between health and social sectors Many unmet needs found in review of MS care delivery in part due to fragmentation and discontinuity of the health care system Multidisciplinary community team worked with MS specialists Home-based care interdisciplinary team intervention

6 Clinical & Demographic Predictors of Progressive Disability in MS Favorable Risk Factors Young age at onset Female Sex Race: White Onset sx: optic neuritis, sensory RR disease onset Unfavorable Risk Factors Older age at onset Male sex Race: African American Onset sxs: motor, cerebellar, sphincter Severe disability after first attack Short interval between first-second attack High frequency of attacks in first 5 yrs Progressive disease from onset Age and Disability Progression (Confavreux, Brain 2006)

7 Clinical Features of the GW-Era MS Cohort (n=2,478) Onset subtype: relapsing (94%), progressive (6%) with no single presenting DSS functional system being significantly different between groups Significantly more males and AA had progressive onset MS Optico-spinal MS presentation: Asian > NA/Alaska native > Hispanic > AA>Whites NMO confirmed cases: n=6 (AA: 66%, White: 33%) Percentage of Patients White (n=1,833) Black (n=656) Hispanic (n=153) Asian/Hawaiin/Pacific Islander (n=26) Am In/Alk Nat (n = 7) Unknown (n = 14) Visual Brainstem Pyramidal Cerebellar Sensory Bladder/Bowel Mental Spinal Cord Multiple OTH Clinical Features of the GW-Era MS Cohort White (n = 1,684) Percentage of Patients Male (n = 1,603) Female (n = 845) Total (N = 2,448) Percentage of Patients Black (n = 600) Hispanic (n = 135) Asian/Hawaiin/Pac Isl (n = 20) Am In / Alk Nat (n = 5) Unknown (n = 4) DSS Score DSS Score

8 National MS Society Expert Consensus Statement (2007) Initiate therapy as soon as possible following diagnosis of active-relapsing disease with an FDA approved DMT Access to medications should not be limited by age, level of disability, or frequency of relapses Continue treatment indefinitely unless lack of benefit, intolerant adverse effects, or better treatment becomes available Ensure adequate accessibility of all FDA-approved drugs for MS Change treatments only for medically appropriate reasons MS System of Care Handbook VA MS Center or Excellence Network ( Access to multidisciplinary MS care, home care, long-term care via hub and spoke system All FDA approved MS DMTs available Annual exam and MS Assessment Tool required Telehealth used to enhance clinical access and follow-up (Clinical Video Telehealth intrafacility, CVT-Home, Store-forward)

Existing approaches of care using telehealth do not

care which were shown to successfully improve quality of

IT tools are not fully integrated into the health

9 Existing approaches of care using telehealth do not utilize constructs from evidence-based models for chronic care which were shown to successfully improve quality of care; current technology is not cost-effective; existing IT tools are not fully integrated into the health information systems MS Home Automated Telemanagement Information Infrastructure

10 Home Unit MS HAT VA Demonstration Project MSCoE and Johns Hopkins U Home Unit HAT Server (Austin Automation Center) CPRS-VISTA Home Unit MS HAT: Remote Neuro Exam Background Physician care is routinely carried out in doctor s offices and hospitals. Patients with MS are often separated from specialty care due to disability or distance. The value of low-cost webcams as a tool for remote neurological exam has not been systematically evaluated.

MS HAT: Remote Neuro Exam Objective Develop a videoconferencing application utilizing low-cost webcam to assist in examining patients with MS in the home.

11 MS HAT: Remote Neuro Exam Objective Develop a videoconferencing application utilizing low-cost webcam to assist in examining patients with MS in the home. This study evaluated the feasibility of using regular webcam and microphone as a tool to aid in the management of MS. MS HAT Webcam System Design The video chat application was developed in Microsoft Visual Studio

12 MS HAT: Remote Neuro Exam Study Design A total of 20 patients with MS were recruited Trained study asst. played role of patient s caregiver Two MS clinicians examined each patient at the clinic using the Kurtzke Expanded Disability Scale (EDSS). On a single visit, each patient underwent two identical sets of neurological assessment: Traditional in-person evaluation Remote assessment using portable webcams MS HAT: Remote Neuro Exam Kurtzke Expanded Disability Scale Scores (EDSS)

13 MS HAT: Remote Neuro Exam Telemedicine Satisfaction Survey Overall, the remote assessment system received positive ratings from both patients and providers. 100% - Patients felt comfortable with the equipment used. 85% - Patients were satisfied with the telemedicine parts of this examination. 90% - Providers were able to obtain adequate information interviewing the patients via video chat. 95% - Providers felt confident in the final assessment. Remote Cognitive Assessments in MS (n=20) ANAM-ICE Summary Score Symbol Digit Modalities Test

Home Telehealth for MS Home-based teleneurology is just-in-time care When transportation is a challenge What our research has shown: The remote neurological & cognitive exam is similar to the live

14 Home Telehealth for MS Home-based teleneurology is just-in-time care When transportation is a challenge What our research has shown: The remote neurological & cognitive exam is similar to the live exam Patient & provider satisfaction is high Cost of care is less Multidisciplinary care is enhanced MS Assessment Tool & MS Surveillance Registry CPRS-based annual assessment of all VA-users with MS (MS Policy Handbook-2009) Core demographic & clinical information captured/stored Pilot in VISN 5 & 20 (n=500) Goals: Improved real-time surveillance of MS population Efficient monitoring of DMT use & untoward effects Optimize management of patients Data for epidemiology and policy decisions

MS Surveillance Registry Development Big Picture CPRS template Web Application Project Database CPRS template CPRS template Corporate Data

15 MS Surveillance Registry Development Big Picture CPRS template Web Application Project Database CPRS template CPRS template Corporate Data Warehouse CPRS template MSCoE MS Registry Main Page Data updated daily Main page allows for filtered cohort selection based on individual search preferences

16 Expanded Diagnosis & DMT Medication Filter Options Patient Dashboard MS Surveillance Registry

17 Integrated MS Care Conclusions Integrated MS Care is important to define and use to develop goals within a health care system Telehealth can improve access to MS specialty care MSCoE MS Principal Care is critical to optimize outcomes Telehealth (CVT, MS HAT, My HealtheVet) Integrated Neurology Project Demonstration VISN 5, 6 & 20 MS Surveillance Registry for real-time tracking of morbidity & clinical decisions MSCoE Telehealth-Informatics Research Group VA MSCoE Joel Culpepper, PhD Amy Kunce, MA Heidi Maloni, PhD Jodie Haselkorn, MD, MPH Ruth Whitham, MD NW Innovation Center Staff VACO/Office of Specialty Care Glen Graham, MD Cythnia Sundahl Omar Cardenas Clare Mahan, PhD Johns Hopkins University/Welch Ct Joseph Finkelstein, MD, PhD Amy Cha, MPH McKenzie Bedra, MPH Jeff Wood, BS Georgetown University/DoD Robert Kane, PhD Funding: VA Merit Review, VA MSCoE, Biogen-Idec

18 Questions?

Multiple Sclerosis Surveillance Registry: Introduction and Overview

Multiple Sclerosis Surveillance Registry: Introduction and Overview PVA Summit-2016 Orlando, FL Mitchell Wallin, MD, MPH Interim Director, VA MSCoE-East Associate Professor of Neurology Georgetown University