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Night-Shift Solutions


 

Karim Godamunne, MD, watched the moving images on the computer screen as he maneuvered the joystick with his hand. Using the computer screen as a guide, he traversed hallways, entered rooms, and zoomed the camera lens in on patients and equipment—all with a slight flick of the controller.

Sounds like a doc playing video games in the back office, right? But entertainment wasn’t what Dr. Godamunne, a hospitalist medical director with Eagle Hospital Physicians in Atlanta, was after. He was busy overseeing a study on admitting ED patients to St. Joseph’s Hospital in Atlanta, but he and the other participating physicians weren’t physically in the ED: With the help of a robot, a computer, and a secure high-speed Internet connection, the physicians obtained patients’ medical histories, performed physical exams, and admitted them in about the same time it normally takes on-site doctors.

“It’s like a video game, but much more. That’s how I describe it to people,” Dr. Godamunne says of the technology used in the study. “You have to be able to visualize what you’re doing.”

About 10 Eagle hospitalists participated in a pilot program last year that aimed to determine whether ED patients could be admitted by remote hospitalists using the RP-7 robot, which was developed by Santa Barbara, Calif.-based InTouch Health. Eagle was so pleased with the small study’s results that it began offering its remote-robot program to hospitals last October and anticipates deploying the first robot for HM work this spring. Eagle CEO Robert Young, MD, MPH, conceived the study and considers his company’s fledgling telemedicine program a solution to the hospitalist shortage, particularly for covering night shifts.

The Future of Round-the-Clock Rounds

Is telemedicine the right fit for your HM group? Consider the following pros and cons before you make a decision:

BENEFITS

  • Less burnout for hospitalists, leading to higher productivity and longevity;
  • Easier hospitalist recruitment, because applicants know they are less likely to work nights;
  • Ability to cover multiple hospitals at one time, mitigating the hospitalist shortage that many areas face;
  • Enhanced access for hospitalists and their patients to medical specialists;
  • Higher technology comfort level among many patients; and
  • Ability to expand hospital market area by employing telemedicine technology at outlying medical clinics and offices.

BARRIERS

  • Reimbursement obstacles for Medicare and some private health insurers;
  • Medical licensing can be time-consuming for telemedicine doctors who serve patients in multiple states;
  • Difficulty getting buy-in from on-site doctors and primary-care physicians who are worried about liability and telemedicine doctors’ competence;
  • Fear of lawsuits by patients treated via telemedicine;
  • Startup technology and training costs; and
  • Potential patient resistance to telemedicine.

“Eagle’s experience is that many hospitalists will be skeptical at first, but once they see it in action, not only does much of the resistance go away, but some become champions for its use,” Dr. Young says. “It is largely a matter of exposure to and experience in using the technology.”

While increasingly common in hospital ICUs and radiology departments, telemedicine is catching on more slowly in HM. Experts and practicing hospitalists cite reimbursement hiccups, a laborious medical licensing process, technology costs, physician and patient resistance, and risk aversion as the main reasons telemedicine isn’t embraced throughout HM. Some think it will take a concerted government effort to nudge hospitals and HM groups to buy into the technology.

Nevertheless, a growing number of physicians and administrators think telemedicine is inevitable, especially as the demand for HM services outpaces the supply. As in within the Eagle system, some hospitalists are positioning themselves to capitalize on the advancing technology.

The Future Isn’t Far

photo courtesy of The Night Hospitalist Co.

Robots and mobile carts offer hospitalists remote access to multiple patients at multiple facilities.

“I think it’s going to explode,” says Yomi Olusanya, MD, a hospitalist in rural Rolla, Mo., and founder of The Night Hospitalist Co., LLC, a startup that is busy developing a business model to provide nighttime hospital coverage via telemedicine. “I think with increased costs and the shortage of physicians, hospitalist groups are not going to have any choice but to find alternative ways of doing business. I really believe that.”

Dr. Olusanya envisions establishing a team of about 10 telehospitalists who would handle cross-coverage calls at multiple hospitals in multiple states. The hospitalists would use a mobile cart fashioned with a high-resolution, dual-focus video screen; a video camera; and diagnostic equipment, such as a digital stethoscope, to aid in physical exams. Hospital clients would be given a toll-free number to call to connect with a telehospitalist between

7 p.m. and 7 a.m., and on-site nurses would simply wheel the mobile cart into a patient’s room to begin the care. All overnight changes in medical management would be transmitted to the correct hospital floors for insertion into patients’ medical records. The Night Hospitalist plans to cover malpractice insurance for its physicians and charge a nightly rate, which would vary depending on the length of the contract.

The mobile cart costs between $20,000 and $30,000, and Dr. Olusanya is contemplating absorbing that expense just to get groups interested. At this point, he’s not promising prospective clients cost savings. Instead, he’s offering them a way to lighten the physician workload in order to increase productivity, job satisfaction and career longevity.

“We’re trying to sell the idea to hospitalists,” he says. “This is so new that I’m trying to figure out the best model.” After originally including hospital admissions in his business model, he ultimately decided to focus exclusively on cross-coverage calls and leave the admissions to an on-site physician. “At this point, I don’t see the telemed machine in the ED doing an admission of a new patient, because it becomes less efficient,” he explains.

Conversely, Eagle Hospital Physicians’ remote-robot program is designed to do hospital admissions. The RP-7 robot is mobile enough to aid in cross-coverage, but hospitals must be careful not to overburden the machine with floor calls because it takes the robot longer to travel around the hospital than it does for an on-site physician, says Betty Abbott, Eagle’s chief operating officer.

Doctors have to be good at using the robot to act like a human being rather than simply a stationary screen in a room.


—Betty Abbott, COO, Eagle Hospital Physicians, Atlanta

Through the robot, which stands 5 feet 6 inches tall, a remote hospitalist can interact with a patient, the patient’s family, and the physician or nurse through a live, two-way audio and video system. The remote hospitalist can move the robot’s head to view charts and vital signs on monitors, zoom in to look at a patient’s pupils, and use several diagnostic tools with the help of an on-site health provider to conduct a patient exam, Abbott says. The remote hospitalist also can split the robot’s screen to show a patient X-rays, test results, videos, or other multimedia imaging.

“Certainly, using a robot to interact with patients takes some thought,” Abbott says. “Doctors have to be good at using the robot to act like a human being rather than simply a stationary screen in a room.”

The robot received high marks from patients, hospitalists, ED staff, and healthcare providers who participated in the pilot program at St. Joseph’s Hospital, according to the results of Eagle’s unpublished study. The technology is user-friendly enough that all types of healthcare providers can be trained to use it, says Dr. Godamunne. He designed and helped implement the study, and he found patients quickly adapted to the robot once they focused on the physicians’ faces on the screen.

Financial, Philosophical Hurdles

Hospitalists like Suman Narumanchi, MD, who leads the HM team at Resurrection Medical Center in Chicago, surmise most patients and their primary-care physicians expect doctors—not a robot or telemed cart—to physically be at the bedside in the hospital. As a result, if something goes wrong, the patient and their primary-care physician might respond with lawsuits. For that reason, “there has to be consistency in telemedicine,” Dr. Narumanchi says. “I just think at this point, it is probably a different level of care based on pure luck, because you don’t know who is going to be working that particular night.”

The concept raises interesting questions, says Eric Samson, DO, HM director for IN Compass Health Inc. in Greensboro, N.C. “Such as that of accountability and ownership of outcomes. On the other hand, it seems enticing to limit the multitude of distractions that occur through nighttime floor calls by implementing a cross-cover specialist fielding floor calls from a more-humane time zone—‘Hey, I’m working night call, but during bankers’ hours.’ ”

photo courtesy of The Night Hospitalist Co.

The Night Hospitalist Co.’s mobile cart costs between $20,000 and $30,000.

Protocols vary from hospital to hospital, and it will be difficult for telehospitalists who cover multiple facilities to learn the differences, says John Nelson, MD, FACP, co-founder and past president of SHM, and principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm in La Quinta, Calif. The job becomes even harder if one or more of the hospitals does not have electronic medical records (EMRs) and instead has to fax patient records to the telehospitalist, he says. Before hospitals invest in this expensive technology, a better solution might be to invent another way to address night coverage, such as allowing nonphysician providers (e.g., nurses) sign off on routine items that now require a doctor’s signature, he says.

Robert Cimasi, president of Health Capital Consultants, a St. Louis-based healthcare financial and economic consulting firm, says telemedicine’s ability to connect patients with distant specialists and allow hospitals to share doctors is tremendous, but agrees the technology is expensive and shouldn’t be entered into without a solid game plan, staff buy-in, and a long-term outlook. Although telemedicine proponents insist EMRs aren’t necessary, Cimasi advises hospitals serious about telemedicine to invest in EMRs, along with electronic order entry for their pharmacies and a secure computer network.

“A lot of hospitals aren’t going to have the capital capacity to do this without government help,” Cimasi explains. “The question is whether the political will is there to have a sustained period of investment.”

Eagle’s remote-robot program is less expensive than hiring a nocturnist or using a locum tenens physician, Dr. Young says. He predicts rural hospitals will benefit the most from his company’s program and other telemedicine services in the market because rural hospitals are most affected by the shortage of inpatient physicians. That might be the case, but if telemedicine is to ever make inroads among hospitalists, it will happen at urban hospitals first because they have the patient populations to support it, Dr. Nelson says.

“At larger hospitals where hospitalists are very busy admitting patients and busy checking patients already admitted, I could see using telemedicine to do the cross-coverage,” he says. “But in a small hospital, that wouldn’t make much sense, because there’s not enough patient volume.” TH

Lisa Ryan is a freelance writer based in New Jersey.

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