COMMENTARY

How Telemedicine Can Improve Our Disaster Response

Robert Glatter, MD; Shari L. Platt, MD; Nancy Pagan, RPA-C, MPA-S

Disclosures

February 09, 2018

Robert Glatter, MD: Hi and welcome. I am Dr Robert Glatter, assistant professor of emergency medicine at Northwell Health and attending physician at Lenox Hill Hospital in New York City.

When Hurricane Maria struck Puerto Rico on September 20, 2017, it upended the island's infrastructure.[1] Almost a month after the storm, Kaiser Health News reported that many of the island's 3.4 million residents were still unable to get nutritious food to eat, let alone medication or treatment for chronic conditions such as heart disease or diabetes.[2]

To help with the situation, on October 26, 2017, NewYork-Presbyterian (NYP)/Weill Cornell Medical Center (WCMC) in New York City began to offer free telemedicine and peer-to-peer consults between New York physicians and a New York–based disaster response team stationed in Puerto Rico. Physicians used live conferencing to treat four patients through an effort coordinated by the Greater New York Hospital Association and the Health Care Association of New York State, under the auspices of the US Department of Health and Human Services, the state of New York, and the Puerto Rico Department of Health.

Dr Shari Platt, chief of pediatric emergency medicine at NYP/WCMC, and Nancy Pagan, emergency medicine physician assistant, are here to talk about the program. I want to welcome you both and thank you for taking the time to talk about this effort.

Dr Platt, can you tell me about the mechanics of the program, exactly how it was set up, and why you needed such a program?

Shari L. Platt, MD: After the disaster, it became obvious that NYP was likely to send a team. We had sent teams after Hurricane Katrina and after the earthquake in Haiti, and we realized that there would be a need in Puerto Rico.

Under the leadership of Jeff Bokser, vice president of safety, security, and emergency services at NYP/WCMC, emergency medicine physicians at Columbia and Cornell, physician assistants, and emergency medicine nurses gathered together and determined that they were going to go to Puerto Rico. Unfortunately, there was no way that every service could possibly be represented on the response team. After the first 2 weeks, we recognized the need for subspecialty expertise on the ground in Puerto Rico and particularly for pediatric support for our colleagues.

Dr Rahul Sharma, who is the chief of the emergency department at NYP/WCMC, proposed using telemedicine as a resource for the providers on the ground in Puerto Rico. That would essentially bring all of the resources of NYP/WCMC to our providers in Puerto Rico and allow us to deliver that kind of broad care for the patients in Puerto Rico.

Dr Glatter: Was telemedicine an initial part of the plan or was that something that developed secondarily after the team was already on the ground?

Dr Shari Platt
Credit: NewYork-Presbyterian/Weill Cornell Medical Center

Dr Platt: I do not know that it was initially part of the relief plan. We have a very robust telemedicine program at NYP/WCMC. We have already cared for more than 10,000 patients, either in the emergency department or from home. I believe that using it as a resource is always at the forefront of our minds. Most likely, it happened simultaneously; of course, the priority was to send a direct mission team.

Dr Glatter: What kinds of patients were cared for and how many patients did you treat using telemedicine?

Dr Platt: Ultimately, we only cared for four patients, but this was essentially a proof-of-concept mission where we were able to show the utility of telemedicine in this scenario. It took time to develop the infrastructure. We had to get approvals from many regulatory agencies, including the Federal Emergency Management Agency (FEMA) and New York State. Even the process of getting approval took time.

By the time we ultimately activated the telemedicine program, we sent our second team, with all of the technology that was needed to set up the telemedicine. That included laptops, cell phones, and all of the technical equipment. That was supported by our innovation team at NYP/WCMC, which helped to make the connection and provide the telemedicine resources. This allowed us to do the peer-to-peer consultations for the second 2 weeks, when Nancy's team was there.

Dr Glatter: It's almost like having a virtual emergency room at your fingertips.

Dr Platt: Exactly. We essentially provided subspecialty consultation. Once we finally got the green light to go, Dr Sharma and I reached out to our colleagues in all of the subspecialties at NYP/WCMC. We had an incredible response, with basically everyone (from cardiology, dermatology, pulmonary medicine, endocrinology, infectious disease) saying, yes, of course we'll be available.

Dr Glatter: Nancy, how did this work on the ground when you were there? Did you interact with the doctors and other consultants by telemedicine to carry out their orders or discuss what they wanted to do, and would you use it to transmit the status of the patient?

Nancy Pagan, RPA-C, MPA-S: First, I want to mention that there was a satellite when I arrived with the second team on October 24, and that helped with access to the telecommunication. My understanding is that team one was unable to use telemedicine because they did not have it available to them. Dr Sharma sent the second response team to Puerto Rico with laptops and the Mobile Heartbeat–enabled phones—smartphones that give us secure access to each other.

Credit: Erika P. Rodriguez for NewYork-Presbyterian's HealthMatters.nyp.org.

Once on the ground in Manati, Puerto Rico, we had an internal medicine physician and an orthopedic surgeon at the family medical shelter and at the acute and nonacute emergency medicine tents, where we would see patients. The first case I saw required the expertise of a pediatric endocrinologist. Our internal medicine physician practices adult medicine and did not feel comfortable managing this 2-year-old. I work in adult emergency medicine and was also uncomfortable. I thought it was a perfect case for the physicians at NYP/WCMC to provide their consultation.

Dr Glatter: What was wrong with the patient?

Ms Pagan: The mom brought in her 2-year-old, who appeared well except that his glucose was extremely elevated. The insulin the mom had could not be appropriately refrigerated, for obvious reasons—there was no electrical power—and the insulin went bad. We did not know how to manage the toddler's type 1 diabetes. We wanted to do the right thing and get the appropriate medication prescription to care for him appropriately. That's when Dr Platt took over.

Dr Glatter: Having that connection really helped to facilitate care. How did the child do after you had the telemedicine consultation?

Ms Pagan: He came back for follow-up 2 or 3 days later and he was doing well.

Dr Platt: From my end, we had a connection from Mobile Heartbeat and received a text from Nancy that said, "I'm in Puerto Rico, and I need a pediatric endocrinologist. We have a 2-year-old with uncontrolled diabetes." I reached out to our chief of pediatric endocrinology, Dr Zoltan Antal, and within about 30 minutes, he and I were on the telemedicine screen with Nancy.

We were doing a peer-to-peer consultation, but what was particularly amazing for me was that we were able to physically see the child and speak with the mother directly. This allowed us to become part of the care team in Puerto Rico. More than for us, it enabled the mom to realize that she was talking to real people. I don't know how much familiarity you have with telemedicine, but you quickly lose the concept of being on a screen and quickly feel as though you are having a regular face-to-face conversation. It becomes a very intimate relationship where you are free of distraction, and you are able to communicate and feel as if you are this patient's provider.

Dr Antal spoke with the mom and Nancy and guided them. This mom was amazing. She really understood her son's diabetes. She knew his calorie counts, his insulin doses. Unfortunately, she did not have access to appropriate refrigeration for the insulin and she also did not have access to her own providers. She could not reach her physicians because of the hurricane.

Dr Antal was able to guide the mom, changing her child's insulin doses, modifying his diet, and then we made a plan for her to return in 2 days. She was checking his glucose levels all along, but we were also able to watch the little boy. He was playing with our paramedics, and I felt that it was a very successful encounter.

Dr Glatter: That brings us to the notion of telemedicine. Can we really establish connections with patients? You are saying yes. That's good to hear because some have argued that it does not provide that warmth, that connection you make at the bedside.

Dr Platt: I believe that there is a tremendous utility to telemedicine. The emergency department is an important environment of care for patients. Many patients do not want to come into the emergency department and do not necessarily need to.

Telemedicine allows us to have a close relationship with our patients. When you are communicating this way, you are free of distractions, it is generally quiet, and you are having a one-on-one conversation. You are able to make eye contact. You can do a lot of clinical medicine with telemedicine. I would have shared your doubts, but I am a big believer right now. I think it's great.

Credit: Erika P. Rodriguez for NewYork-Presbyterian's HealthMatters.nyp.org.

In the setting of a disaster, it was priceless. We obviously cannot send our entire subspecialty team to a disaster site. This provided the opportunity for every single subspecialist at NYP/WCMC to provide care with our colleagues on the ground.

Dr Glatter: Do you see any other uses for telehealth or telemedicine, even more locally rather than only during disasters?

Dr Platt: There are countless uses for telemedicine. We are expanding the program at NYP/WCMC. We already use it to expedite the care of patients who are arriving in the emergency department. Some research shows that it actually improves the delivery of care, the time to see a patient, and their length of stay. Patient satisfaction is very high with it. Also, for geriatric patients who may not want to come in in the middle of the night, or for little babies who may not need to come in in the middle of the night, it gives reassurance.

You are able to see the patient. This is not a mere phone call; I would not rely on a phone call. But I do rely on my clinical acumen when I am able to see the patient. We are reaching out to many different venues in Manhattan and parts of New York to provide telemedicine to patients.

Dr Glatter: Do you believe that patients at NYP/WCMC will benefit from this type of relationship with their providers in the future?

Dr Platt: They already do. Many of those resources already exist. We have a second-opinion program through which patients who want a second opinion are able to access that through telemedicine. There are probably countless other opportunities for telemedicine to provide care.

Ms Pagan: I am a firm believer in telemedicine. Since 2006, our emergency department has implemented this for nonurgent, appropriate cases. Yesterday and today, I worked in the waiting room of the emergency department. I offer a telemedicine visit to anyone who is appropriate for it. For example, if a patient comes in for suture removal, I will remove the sutures and then the attending physician speaks to the patient via telescreen, gives them instructions, prints out their exit care, and hopefully, the patient is out within 20 minutes. They are very happy and very pleased.

When the patient comes into triage and tells the nurse, "I'm here for suture removal," I am the mid-level provider there. When I hear the patient say this, I offer them the opportunity to see an attending physician via a telescreen, and 99% of the time they say yes.

Dr Glatter: They don't enter the department physically?

Ms Pagan: They will follow me into a room that is designated for this. It avoids wait time, which is one of the reasons patients love it. They will come in and if no one else is in the telemedicine room, it may take less than 30 minutes, from start to finish, for something like a suture removal.

Dr Glatter: Could this be accomplished in the home or another remote setting without a patient physically coming to the hospital?

Dr Platt: We have started that. NYP/WCMC offers an app (NYP OnDemand app) that is available on demand and provides telemedicine to the community. Patients just need to download the app, and they can access an emergency medicine attending physician at NYP/WMC 16 hours a day, every day. For 6 hours in the evenings, a pediatric emergency medicine physician is available for this. The physician assigned to this is one of our own doctors who, on another day, may be working in the emergency department. We are not outsourcing the physician staffing; patients are really being seen by Weill Cornell Medicine physicians, and they love it. Having access to good care is important to patients; most of the time, honestly, we're offering peace of mind.

Some of the adult patients have been complicated and needed to come in. And a few pediatric patients have been seen via telemedicine. Most of the time these are patients who do not want to come in to the hospital, and they just want a doctor to tell them that everything is okay. A handful, a very small handful, have been advised to come in because they needed to come in. I believe that this is important because those are patients who would have chosen not to come in, had they not had that service.

Dr Glatter: We are often reminded of patients who call the emergency department asking whether it is safe to take a certain medicine when they do not feel well. This is the perfect solution.

Dr Platt: You are actually seeing the patient. You are seeing their child. You can watch them breathe, you can watch them walk, you can assess their mental status, you can check their hydration status. There is quite a lot that you can do through the screen.

Dr Glatter: The medical-legal aspects of this are interesting too, because once you commit to visualizing the patient, having that encounter, do you have to bring that patient into the department? Can you adequately and safely treat them in the home setting? That is something to think about.

Dr Platt: All of this has been vetted through our legal department, so we are 100% medically and legally responsible for those patients.

Dr Glatter: Thank you both for such a good conversation. It has been a pleasure to hear about your efforts. This is all very worthwhile.

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