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Telemedicine Success Linked to Workflow, Rather Than Technology

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A telemedicine-based diabetic retinopathy screening program in Los Angeles proves that the digital health platform saves time and improves outcomes - primarily because it improves collaboration between primary care and specialty care providers.

 

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A telemedicine-based diabetic retinopathy screening program in Los Angeles proves that the digital health platform saves time and improves outcomes - primarily because it improves collaboration between primary care and specialty care providers.

Telemedicine is proving its value not because of new technology, but because of better workflows and collaboration.

A program that placed telemedicine platforms into 15 primary care clinics at the Los Angeles County Department of Health Services found that wait times for diabetic retinopathy screening were reduced by almost 90 percent – from 158 days to just 17 days. It also greatly improved screening rates for the more than 21,000 patients who were tested between September 2013 and December 2015.

More importantly, researchers said, the project proved that a telemedicine platform that splits that workflow between primary care and specialty care providers can achieve greater efficiency and outcomes if done right.

“Although these implementation solutions seem straightforward and clear, they actually represent cultural shifts in work responsibilities, as well as expectations on the part of both primary care and specialty professionals and staff,” Courtney Lyles, PhD, of the University of California, San Francisco, and Urmimala Sarkar, MD. MPH, of UCSF and Zuckerberg San Francisco General Hospital, wrote in a commentary piece attached to the study in JAMA Internal Medicine.

“This finding suggests that much of the innovation in this telemedicine DR screening program is not limited to the new fundus camera technology but can be found in the use of such technology in the context of several new team-based clinical workflows to create more efficient outcomes,” they added.

The project, led by Lauren Daskivich, MD, MSHS, of the Los Angeles County Department of Health Services – the largest safety net healthcare system in the country – placed telemedicine platforms in various clinics around Los Angeles. Licensed vocational nurses and medical assistants were trained to operate the screening cameras, so that the clinics could screen patients during their primary care visit and upload the photos to the cloud, for review by staff optometrists.

"I was very happy to find that a program like this could work in the safety-net setting,” Daskivich said in an audio interview accompanying the JAMA article, noting that these patients are both urban and rural and have many different types of insurance coverage. "[It] gave me hope that this project could spread to other resource-limited settings, where the need for services like this is really critical.”

Daskivich credited that success to a streamlined approach that gave the primary care providers a standard workflow for each patient, and used the telemedicine platform’s collaborative qualities to improve the interaction between the clinic and the optometrist.

In their commentary, Lyle and Sarkar agreed – adding that a safety net healthcare system is the ideal location for this type of telemedicine success.

“This investment in clinician and staff education and buy-in from the beginning allowed the telemedicine DR screening program to be deployed using existing staff without outsourcing or hiring, which represents improved healthcare value (i.e., better quality at the same or reduced cost),” they wrote.  In doing so, [the study provides] a clear example of how safety net healthcare systems can be leaders in innovation.”

“Although the mainstream view is that innovation often starts within more well-resourced systems and then is adapted and disseminated to other systems once the evidence base is sufficiently deep, it is not uncommon for safety net settings to be better positioned to develop and implement innovations first,” they added. “The fragmentation within the U.S. healthcare system and its often lopsided financial incentives across healthcare systems can create particularly challenging external drivers against efficiency and team-based care. Although safety net healthcare systems are rarely fully integrated, their longstanding history of considering population-based health outcomes and their ability to align team-based approaches for the greatest clinical effect can foster greater innovation.”

The program, which has been expanded to three more clinics since the study was completed, proves that telemedicine can work in a large population health context, Lyles and Sarkar said.

“Private and other types of healthcare systems can learn a lot from how this project was implemented and from the results, which are becoming increasingly relevant across different types of healthcare systems," Sarkar said in the audio interview.

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