Dynamic duo a triple threat in research, patient care and leadership in telehealth

You should not die in South Carolina because of where you live. That’s the belief of pediatrician Katie Cristaldi, M.D, one of two leading MUSC researchers in a landmark grant establishing MUSC as one of only two Telehealth Centers of Excellence in the nation.

On Sept.22, Dee Ford, M.D., and Cristaldi, principal investigators on a grant submitted to the Health Resources and Service Administration, learned that their team’s bid to develop the center had been funded.

MUSC Health CEO Patrick Cawley, M.D., said, “I am extraordinarily proud of our exceptional telehealth team, which now, through this Center of Excellence designation, has been acknowledged at the federal level. I offer my congratulations to all involved in bringing this grant to fruition. The leadership of Drs. Dee Ford and Katie Cristaldi will undoubtedly propel this to success and add tremendous value to the national health care system.”

Ford and Cristaldi, who will serve as the COE’s director and associate director respectively, were responsible for leading the herculean effort to pull together the federal grant application in just a month’s time. Their painstaking efforts paid off: The grant awarded $600,000 the first year and up to $2 million more over an additional two years.

The COE team, which has been integrally involved with MUSC telehealth initiatives, will continue to work hand in hand with the existing MUSC Center for Telehealth as it expands the scope of its delivery of clinical care throughout the state, in addition to the guidance and resources it provides at the regional and national levels. In a collaborative multidisciplinary team approach, the COE, applying rigorous scientific evaluation, will assess the effectiveness of MUSC’s telehealth services in rural and urban areas in an effort to achieve “next level” telehealth.

If that sounds like a tall order, it is.

Being that South Carolina is largely a rural state, the task of ensuring all South Carolinians have equitable access to quality health care and providers, regardless of where they live, has long been a challenge. Health equity means that everyone has an equal opportunity to achieve optimal health —even when considering such obstacles as poverty, health disparities, little or no access to health care providers and lack of health insurance or transportation. And while that pursuit is tackled, further quantifying the success of those endeavors adds yet another layer of complexity.

Bearing all that in mind, the South Carolina Legislature made improving access to health care a priority policy issue. In 2013, MUSC received $12.4 million of state appropriated funds to advance telehealth initiatives throughout the state. The legislature has appropriated funds each year since.

Telehealth is an innovative, convenient and effective way for health care providers to deliver acute, primary and specialty medical care and support to patients located in all areas of the state — even rural areas, where often, meeting those needs can be nearly impossible. But now, in seconds, through the use of high-tech videoconferencing equipment, doctors miles away can be virtually at the bedside of a patient with end–stage kidney disease, in the ER with an ischemic stroke victim or at the school nurse’s office assessing a child suffering with asthma. 

Both Ford and Cristaldi credit legislators for being forward thinking.

“The South Carolina Legislature wanted to see telehealth rolled out intelligently,” Cristaldi said. “A lot of thought was put into planning — not how to replicate care but how to be more efficient. That could only be achieved by determining what is good for the population as a whole.” 

Fortunately, legislators recognized MUSC’s valuable track record of being able to deliver that type of specialized care to South Carolinians, particularly in those rural areas with no access to care.

Ford explained that early on, even before state telehealth funds were available, MUSC clinicians had a desire to help underserved patients in meaningful ways.

“Our first telehealth programs at MUSC were entirely grassroots-driven,” she said. “Dr. Robert Adams started our telestroke program in 2008, but even before that, Dr. Donna Johnson started maternal-fetal medicine telehealth in 2005, which allowed women with high risk pregnancies living in rural areas to benefit from specialty care. She really wanted to help those babies.”

Directly following those nascent efforts, and before legislators took notice, a cluster of other telehealth programs soon emerged. Pioneers in telehealth, Ford received one of the first NIH telehealth grants, which enabled her to start a tele-ICU program; James McElligott, M.D., established the school-based telehealth program; and David McSwain, M.D., launched pediatric critical care telehealth services.

“It was really the impetus of MUSC providers who saw this need in our state that wasn’t being met and couldn’t realistically be met by local resources alone,” Ford said. “So they said to themselves, ‘We need to do this.’ As a result, we had demonstrated success in getting external funding to support telehealth efforts, but more importantly, in trying to help people in South Carolina.”

And it was these efforts, coupled with meteoric growth, that helped garner MUSC the Center of Excellence designation.

Since the program’s humble beginnings, it has flourished in ways the teams could not have predicted. For instance, MUSC’s number of annual telehealth interactions has grown from 1,078 in 2013 to a projected 232,424 in 2017. Today, MUSC provides telehealth services to more than 200 sites in 27 counties at 28 hospitals, more than 100 community clinics and 50 schools, as well as alternative sites such as nursing facilities, prisons and patients’ homes. Seventy-eight percent of sites are located in completely or partially medically underserved areas of the state.

Commitment, Heart, Passion

Care from a distance. Specialized technology carts. Virtual stethoscopes. Telehealth could well sound sterile and impersonal. But that couldn’t be further from the truth, say Ford and Cristaldi. It’s the commitment, heart and passion of the clinicians and their teams that drive their mission — striving to improve access to quality health care.

“We’re not doing this to compete with other systems or to increase market share,” Ford explained. “We feel this is a mission-based effort. It’s a passion.”

Still, how do clinicians personally make the leap from high-tech to high-touch when they aren’t in the room?

Ford shared an experience that transformed her thinking on this subject. Clinicians interact with patients through audio-visual communication, so no matter how good the equipment is, there is still a level of separation.

“I was doing a tele-ICU shift, and it was really chaotic. This hospital’s ICU was falling apart. There were multiple people crashing at the same time. I was dealing with all of that, but there was one particular woman who had many end-stage advanced illnesses. She was dying, and as sad as it was, because of how advanced all her problems were, there just was no good future ahead of her. There were no doctors there, and the nurses were understandably overwhelmed with all that was happening in their space.”

Ford talked to the woman’s daughter and son-in-law through a two-way camera. She explained that the team at their hospital had done everything they possibly could to help her mother. Ford assured them they had done a valiant job, but unfortunately, at that point, they just needed to make her comfortable.

“And to have to tell them that… through a camera… They were crying. The nurses were crying.” Ford paused, recalling the range of emotions experienced by many that night. “At the end of that shift, I felt so empty — because I couldn’t be there. So much of communication is nonverbal — how do you communicate the nonverbal through a camera? I walked out the door and just hoped those people felt supported. I hoped they could feel the empathy I had for them. It just all felt so hollow to me.”

But what happened the next day was the very thing she needed to realize she could indeed touch people — right through the video screen.

Ford received a note from that hospital’s chief nursing officer who shared the family’s gratitude with her. The couple, she explained, felt her caring compassion during their very difficult time, and while they’d lost their mother, they were incredibly grateful to her. Further, the CNO added, her team felt very supported by her, because Ford had validated their hard work that night.

“I knew clinical care could be replicated,” she said, “but it was the people part that I wondered about — if it could be the same. The answer is yes. Even though it’s through a camera, it’s still powerful.”

Turning-point moments like this fuel the team’s commitment to telehealth, she said. And it’s the tangible experiences they’ve lived through with patients that marked them as valuable experts at the national level.

Ford also credits McElligott, medical director for MUSC’s Center for Telehealth, with the visionary approach that led them to this accomplishment.

“Dr. McElligott said, ‘We are not going to build competitive telehealth programs in South Carolina —instead, we are going to be collaborative and inclusive, and we’re going to have the South Carolina Telehealth Alliance.’ He’s really stuck to a value-based approach to thinking about collaboration across traditionally competing organizations in South Carolina, and that type of approach stood out to HRSA,” Ford recounted.

COE - the brass ring

HRSA was looking for high-volume telehealth programs that were focused on the medically–underserved in rural areas and could demonstrate a financially sustainable telehealth business model. MUSC hit the telehealth trifecta.

“HRSA now wants to see how telehealth can be embedded in traditional clinical practice — not an add-on,” Ford said. They want it interwoven and integrated, and they want to see financial feasibility.”

HRSA has a long commitment to rural health, and telemedicine is one essential tool it uses to meet the needs of people in those areas. Through its Regional Telehealth Resource Centers, HRSA helps telehealth programs get off the ground.

But that’s just a start.

“Where we come in,” Ford explained, “is at MUSC, we have a lived experience of telehealth successes and failures. Most of the regional centers don’t. They are not wedded to clinical operations or universities, and they are not clinical providers or IT specialists, so they don’t have that tangible experience. The regional centers can help an organization get started, but at MUSC, we have a lived telehealth experience and can help organizations that have gotten started and hit the inevitable stumbling blocks get to that next level.”

While the MUSC Center for Telehealth will continue its clinical efforts under the leadership of McElligott, medical director, and Shawn Valenta, director of the center, the COE will fill important gaps in the national telehealth landscape, focusing on three priority areas: the impact of telehealth on federal and local health care spending, provider and patient engagement in telehealth and open access network evaluation and best practice dissemination. MUSC will also develop and offer at a national level teams devoted to consultation, evaluation, technical support and collaboration.