International Telemedicine: Developing a Model for a Global Pediatric Practice

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International Telemedicine Developing a Model
for a Global Pediatric Practice

• Molly Reyna, BA, Oussama El-Baba, MHA,
• Gerard Martin, MD, Philip Hopkins, Craig Sable,
  MD
• Childrens National Medical Center, Washington,
  DC

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International Health Partnership Models for
Patient Care

• Patients travel to United States
• Medical teams travel internationally
• Consultation
• Patient Care
• Education
• Advance state of care
• Physicians provide consultation for international
  physicians after record review

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Goals of International Outreach

• Improve health care
• Increase educational opportunities
• Didactic
• Hands on patient care
• Build sustainable business model
• Patient care
• Education

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Our Experience

• Over view of international program at Childrens
  National Medical Center
• Utilization of telemedicine to complement and
  enhance our international program

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International Referrals to DC 2006

• Service Line
• Cardiovascular surgery 46
• Cardiology 17
• Orthopedic surgery 7
• Gastroenterology 4
• General surgery 4
• Pediatric medicine 2
• Urology 2
• Oncology 1
• Physical medicine 1
• Neurosurgery 1
• Otolaryngology 1

• Country
• Kuwait 43
• Saudi Arabia 11
• Uganda 8
• United Arab Emirates 6
• Qatar 4
• Brazil 3
• Netherlands 1
• Barbados 1
• Greece 1
• Chile 1
• Afghanistan 1
• Honduras 1
• Argentina 1

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Countries Visited 2006

• Middle East
• Saudi Arabia
• Kuwait
• United Arab Emirates
• Qatar
• Europe
• Belarus
• Ukraine
• Russia

• Africa
• Uganda
• Morocco
• Latin America
• Dominican Republic
• Asia
• China
• Sri Lanka

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Financial Impact Direct Patient Care

• Inpatient admissions
• N 67
• Hospital charges 6,280,000
• Outpatient encounters
• N 286
• Hospital charges 372,000
• Same day surgery/cardiac catheterization
• N 12
• Hospital charges 195,000
• Total charges (hospital and professional)
• 9,020,000

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Telemedicine/Distance Education

• Telemedicine
• Germany
• Saudi Arabia
• Iraq
• Morocco
• Qatar
• Distance Education Live Lectures
• Bosnia
• Iraq
• Morocco
• Ukraine

• Potential sites for 2007 08
• Egypt
• Eritrea
• Uganda
• Kuwait
• United Arab Emirates
• Belarus

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Telemedicine

• Specialties
• Cardiology
• Nephrology
• Pulmonary medicine
• Infectious disease
• Gastroenterology
• Emergency medicine
• Models
• Electronic data transfer
• Live case presentation
• Discussion of transferred data

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Cardiology Case Study 1

• 24 hour old baby born at Landstuhl Regional Army
  Medical Center in Germany
• Trisomy 21/mild cyanosis
• Referring army cardiologist suspected coarctation
  of the aorta
• Initial plan
• Start prostaglandin E
• Arrange for medical transport to Washington, DC
• Plan for expedited discharge of father from Army

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Cardiology Case Study 1

• Referral call received at 9 AM EDT (3 PM GMT 1)
• Three way telemedicine call to view live
  echocardiogram established within 1 hour
• Physician home (IP to hospital/bridged via
  Gateway to Germany)
• Our hospital in DC (ISDN 384 kbps to Germany)
• Patient and physician in Germany
• Telemedicine diagnoses
• Patent ductus arteriosus/normal transitional
  circulation
• No coarctation of aorta
• Recommendations/outcome
• Oxygen therapy for 24 hours
• Normal newborn care
• Repeat echocardiogram (also by telemedicine) at
  DOL 3 was normal
• No disruption of service for father

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Cardiology Case Study 2

• 1 month old blue baby in Saudi Arabia
• CNMC cardiologist in Saudi Arabia with local
  physicians 6 AM EDT (2 PM GMT 3)
• Live videoconference (ISDN 384 kbps) 8 AM EDT
• Cardiologist and cardiac surgeon in Washington
  reviewed and discussed case with Saudi team
• Outcome
• Complex congenital heart disease
• Surgical plan agreed upon
• Patient transferred to Washington for surgery

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Nephrology Case Study

• 5 year old boy in Iraq with severe hypertension,
  headaches, stroke, and hyperpigmented lesions
• Data sent in advance via email (PowerPoint) and
  reviewed by nephrologist
• Live case discussion (IP 256 kbps)
• Satellite from Baghdad to New York
• IP from New York to Washington
• Recommendations
• Medication
• Renal artery angioplasty

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Telemedicine Business Model

• Sustainability is critical
• Direct reimbursement/contractual agreement
• Telemedicine installation/maintenance
• Lectures
• Patient consultation
• Direct revenue from test interpretation
• Customization from menu of services
• Downstream revenue
• Grant/external funding
• Support poorer countries with revenue from
  wealthier countries

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Outcome measures

• Patient care outcomes
• Direct patient care statistics mortality,
  morbidity, length of stay
• Public health initiatives
• Physician satisfaction
• Academic productivity
• Public relations/media coverage
• Financial

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Challenges

• Language barriers
• Time zone difference
• Computer technology compatibility
• IT staff communication
• Band width availability
• Medical practice variability
• Ongoing funding
• Sustainability
• Travel time/insurance/safety

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Lessons Learned

• Strong incentive to move forward with
  international telemedicine
• Good business in wealthy countries
• Can fill critical need in poor countries
• Need to be very cognizant of each countrys
  needs, resources, customs, and politics
• Relationship building is vital
• Multiple visits necessary for success
• Ongoing communication with technical, medical,
  administrative and political staff
• Involvement of embassys on both ends is very
  helpful

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Next Steps

• Continue to build international program
• Open up CNMC office in United Arab Emirates
• Partner with adult hospitals
• Schedule routine international visits
• Expand telemedicine reach
• Build networks in existing countries
• Look for new partners
• Advance the concept of combined international
  programs/telemedicine service line

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