Instant Access Cooley Dickinson, Mass General Make Strides in Telemedicine

When Cooley Dickinson Hospital made its affiliation with Massachusetts General Hospital official last month, respective presidents Craig Melin and Dr. Peter Slavin signed off on the partnership together — yet, more than 100 miles apart.

It was telemedicine technology that brought them into the same room, and there was meaning behind the gesture — specifically, to promote the system that, for the past two and a half years, has allowed emergency physicians at CDH to speak, face to face, with Mass General neurologists regarding complicated stroke cases and other issues.

“If someone presents with some form of neurologic emergency, the doctor in the hospital can consult with someone at Mass General,” Dan Barrieau, administrative director of Clinical Services at Cooley Dickinson, told HCN.

Dr. Tor Krogius, Emergency Department physician and medical director of the CDH Stroke Program, explained that telemedicine isn’t exactly new at the hospital, but has improved over the years — with promise of more expansion in the future.

“Six or seven years ago, we originally had a contract with a private company that provided neurology specialty care primarily for the evaluation of patients who seemed to be having stroke symptoms or were candidates for thrombolytic treatment for stroke,” he said, referring to the use of drugs to break up or dissolve blood clots.

“That was the birth of telemedicine at Cooley Dickinson,” he continued. “The technology consisted of a TV set that had a camera on top, sort of like Skyping, so the neurologist at the other end could see the patient in bed, and the patient in bed could see the neurologist, in whatever milieu they happened to be sitting in. Then, about two and a half years ago, we switched our provider of telemedicine services to Mass General, and we’ve had them ever since.”

Barrieau noted that the Mass General affiliation — finalized last year after a long search by CDH for a larger partner hospital — partly grew out of the relationship the two institutions already had, including the telemedicine service. While particularly helpful in emergency situations, that’s not the only use of the technology. If the patient is not in any urgent, life-threatening condition but we still want to sit down with a neurologist, we’re able to do that. The equipment has advanced to high-definition stuff and better security.”

Telemedicine is not unique to the hospital setting — far from it. The technology has been used for decades for purposes ranging from medical education to remote patient monitoring at home-care agencies.

Mass General, however, has been at the forefront of its use in hospitals, said Barrieau, who characterized the Boston institution as the hub of a wheel, and CDH one of many ‘spoke’ hospitals that access its specialists through telemedicine. “Their intent is to spread this expertise where it’s needed, so that patients can be treated in a community hospital instead of going to a big center in Boston if their needs can be met here.”

One reason, said Krogius, is that neurology is an under-represented specialty in Massachusetts.

“Neurologists are very thin on the ground,” he explained. “If we didn’t have telemedicine and didn’t have neurologists, it would be unfathomably difficult to figure out how to do things. We’d have emergency-room doctors practicing far beyond their capacity or having to turn patients away.”

And clearly, Barrieau said, it’s usually more convenient for patients to receive the care they need close to where they live, and a face-to-face consultation with a specialist in Boston could help determine whether that’s necessary. “If my mother could be treated here and get everything she needs here, it’s way better for the family and everyone who needs to visit her, her whole support system. And if she needs to go 100 miles away, she should go.”

Krogius noted that most telemedicine calls from the CDH emergency room center around patients who seem to be having strokes, but some are those presenting with complex seizures or more bizarre neurological presentations.

Mass General is so committed to its telemedicine partnerships, he said, that calls are typically answered immediately; Cooley Dickinson uses the resource virtually every day. Sometimes the neurologist leads the evaluation, and sometimes he or she observes while emergency physicians conduct tests.

“Consultation with a Mass General neurologist will generate a document that is accessible through a security-protected website that we can access at this hospital,” he added. “Commonly, patients will be admitted to the ER or admitted to the hospitalist service, and the hospitalist will rely on that advice from the neurologist.”

If doctors determine that a patient would be better treated in Boston after stabilization, Barrieau said, “the physician who did the consultation would meet that patient at Mass General. If they weren’t going to be the one taking care of the patient, they would make sure there was a good handoff so the doctor taking care of that situation knew everything that transpired. It’s a good situation.”

The technology has been so effective, in fact, that CDH has piloted its use in doctors’ offices and plans to introduce telemedicine in some of its affiliated practices.

That could be a benefit for patients who need to see a specialist. “If your doctor thinks you should have a consultation with a neurologist, it might take some time to get a flesh-and-blood appointment because of how few of them there are,” Barrieau said, adding that the hospital’s telemedicine service can often speed up the process.

“One of our inpatients actually had an appointment [with a neurologist] three months out, but he did it before he left the hospital,” he noted. “That particular patient was scheduled in Boston, and we were able to do a same-day appointment for them. They didn’t need to drive to Boston or wait three months to find out what was going on.”

The American Telemedicine Assoc. has identified three key benefits to this still-evolving technology:

• Improved access, which is important, considering the provider shortages in some areas, both urban and rural;

• Cost efficiencies, through better management of chronic diseases, shared staffing, reduced travel times, and fewer or shorter hospital stays; and

• Improved quality, because patients are able to see the specialist they need instead of a doctor with less expertise with their particular issue; and

 For these reasons, the ATA argues that patients are increasingly demanding this technology. “Over the past 15 years, study after study has documented patient satisfaction and support for telemedical services. Such services offer patients the access to providers that might not be available otherwise, as well as medical services without the need to travel long distances.

“They might soon get more such services,” Krogius said. “Particularly for stroke, the use of telemedicine at small hospitals might become ubiquitous because the protocols required to administer thrombolytics for stroke more or less require there be a neurologist involved. I think just about all small community hospitals that wish to receive patients by ambulance who might have a stroke will have to come up with telemedicine services.

“Ours is a little more comprehensive,” he noted. “I think many services are limited only to stroke patients. We have an arrangement with Mass General that’s broader in terms related to neurology. But this is not unique to this hospital; it’s going to be everywhere soon, and we’re also considering other services. We recently had a presentation from the surgeon who runs the burn center at Mass General, and we’re probably going to set up an arrangement, particularly with significantly burned patients, to be evaluated with the telemedicine model. They’ll make recommendations for patients to be transferred to Mass General or be cared for here.”

In the meantime, CDH uses telemedicine in its emergency department, critical-care units, and the childbirth center, and is looking to expand its use in the ICU. In addition, when patients have CT scans or other imaging work, those images can be sent electronically to a neurologist in Boston, Krogius said. “That’s another way in which information is transferred.”

Barrieau also sees potential for the technology’s expanding use. “There’s more opportunity now for our physicians to link up with other physicians,” he said, “and we’re finding out what else is available.”