The Health Leader Forge: Mary Lowry Transcript

The following is a transcript of our interview with Mary Lowry. To find links to the audio files and more information about the interview, please click here.

These transcripts are made possible by a gift from the NNEAHE.

Mark Bonica: Welcome to the forge Mary.

Mary Lowry: Thanks very much Mark.

Mark Bonica: We really appreciate you being with us today.

This is kind of a special episode of the health leader forge and that's because I'm preparing to participate in teaching a class in telemedicine and Telehealth here at the University of New Hampshire along with a group of colleagues from across my College of Health and Human Services.

And so I've asked Mary to join us to talk a little bit about the business side of telemedicine and Telehealth.

And in particular as a representative of the largest hospital and the only teaching hospital in the state of New Hampshire.

So Mary you are the administrative director for the connected care center at Dartmouth Hitchcock.

For folks listening who might not be familiar with the geography of northern New England, where is Dartmouth Hitchcock located? And can you briefly discuss, also describe Dartmouth Hitchcock as an organization.

Mary Lowry: Sure so Dartmouth Hitchcock medical center our main campus as we refer to it is located in Lebanon, New Hampshire which is in the upper valley, a region that spans New Hampshire and Vermont.

So we're about an hour north of Concord and directly over the border of Vermont from White River Junction.

And so Dartmouth Hitchcock as an organization is a nonprofit academic health system and our goal is to serve patients in the northern New England community.

So we have more than 1,000 primary care doctors and specialists in almost every area of medicine.

And we also are comprised of a couple of centers which include the Norris Cotton Cancer Center.

That's 1 of 45 comprehensive cancer centers across the nation and the Children's Hospital at Dartmouth I think people all know that as Chad.

We have 4 affiliate hospitals, 24 ambulatory clinics across New England, across New Hampshire and Vermont I'm sorry and we are also affiliated recently with the visiting nurse and hospice for Vermont and New Hampshire.

Mark Bonica: Yeah it's a, it's a big organization that does a lot of amazing stuff.

So let's talk a little bit about your background and kind of how did you come to work at Dartmouth Hitchcock, how long you've been there, and then more specifically how did you come to be working in the connected care center?

Mary Lowry: Sure. I had no previous experience in healthcare when I came to work here at Dartmouth Hitchcock Medical Center in 1995.

I came as the administrative supervisor in the Department of Anesthesiology.

And over the course of my time there I obtained an MBA and I was promoted to a practice manager position and then eventually to the administrative director position in that department.

And I worked in anesthesiology for about 21 years.

So I've only been transferred over here to the Connected Care Center since May 2016. OK.

And the timing was, it was good timing because there were some leadership transitions, the chair of the Anesthesiology Department with whom I had worked was leaving his position.

And so I it was just kind of an opportunity to make some change and I had had some previous experience help, kind of helping out in an administrative role when the Telehealth services were first getting started.

There was a gap there, so I had an exposure to Telehealth services that interested me in following up.

Mark Bonica: Great, well so you're not a clinician.

Mary Lowry: No.

Mark Bonica: OK. So what is your role in the department and for you know people not familiar with this idea of an administrative director what do you do?

Mary Lowry: So I kind of had to, have a broad range of responsibilities overseeing of finances and operations. So it's a mixed bag.

It's a typical structure here in a clinical department at Dartmouth Hitchcock where you have a physician, medical direct person, partnered with an administrative director so that's our structure here as well.

Mark Bonica: OK. So let's talk about the department then, what what is Connected Care?

Mary Lowry: So connect, the Connected Care Center is actually a space it's a very lovely space in the new Williamson building at Dartmouth Hitchcock Medical Center.

Which we inhabit along with the hospital's Transfer Center and the transport team for the dart helicopter.

So there are some nice synergies because some of the services that we're engaged in for telemedicine interacts with both of those areas to help get patients where they need to be after a telemedicine consult for example.

And so my area the connected care department is a collection or a suite of telemedicine services.

OK.

Mark Bonica: So let's talk about that synergy for a second.

So you, you're saying we do you do telemedicine very often, it's in a consultative of kind of role where where you're maybe making a recommendation to, to a treating physician at another location that hey this person should be transferred perhaps to Dartmouth to get a higher level of care is that what you're saying?

Mary Lowry: Exactly.

So we are, in our actual space we have a tele-emergency hub, that's what we call the space where the physicians and nurses are providing the clinical care from our side.

And it's right nearby to the Transfer Center so our tele-emergency team may be talking to a hospital and determining that that patient should be transferred here or even to another location.

It's very easy for our teams to work with the Transfer Center just across the across the other side of the room to coordinate that patient transfer.

Mark Bonica: OK.

Well let's talk a little bit about the history of the department, how did, how long has connected care existed and kind of how long has Dartmouth Hitchcock been doing telemedicine?

Mary Lowry: It was, our Telehealth Organization was officially founded in 2012 and we started with some telemedicine services in the tele specialty space outpatient appointments and tele stroke in 2013.

Although I was recently told that through Dartmouth College we had physicians who were doing telemedicine services back in the 70's, so that predates me and I don't have any more information about that beyond it was happening then.

Mark Bonica: Yeah, OK.

Mary Lowry: We have officially have been doing these services you know face to face, 2-way video, telemedicine services since about 2013.

Mark Bonica: Yeah I can't imagine telemedicine in the 70's, looks anything like what or looked anything like it does today.

Mary Lowry: Right.

Mark Bonica: Yeah we just didn't have the literal bandwidth to do that kind of, that kind of work right.

For our previous convo's, so we've talked before and we talked a little bit about the organization but you said that connected care really kind of evolved out of your telestroke program, is that correct?

So, yes.

So what is telestroke and what's, let's start with tel, you know with let's start with that service.

What is telestroke and to whom does Dartmouth Hitchcock provide these services?

Mary Lowry: So currently our telestroke service has migrated to a broader teleneurology service.

Some other organizations only have telestroke, we have a broader teleneurology service.

And the this is it for a, typically a patient would present to a local emergency room and they would be exhibiting symptoms of stroke and the hospital then would engage with us to have a consultation by a neurologist.

And it's really important for stroke patients to have appropriate treatment within a very short time line to preserve their quality of life.

So if they're going to have a treatment, it's meant to be administered within a very small window of time.

So if, we have a protocol whereby there is a physician on video with the patient within 30 minutes at the most from the time the request is made.

And the Dartmouth Hitchcock physician, the neurologist, I mean we have board certified neurologists who are providing this service and they would do an assessment and provide some treatment recommendations for the patient.

This is in collaboration with hospital bedside staff, there is always a physician on the other side who is actually then executing what is meant to happen for that patient.

So our physician might say yes this patient is having a stroke and it was, it meets all of the parameters for delivery of TPA which is the treatment for stroke.

And then the physician on that side then would execute those orders.

Mark Bonica: OK so we might have what maybe a primary care physician or a emergency room physician perhaps at a small hospital or small emergency room someplace in the north country.

And they would, they would connect in with your, your provider and they would communicate and the provider at Dartmouth would then make the, kind of the diagnosis, or help make the diagnosis.

Mary Lowry: Exactly that's exactly right.

It's so it's usually an emergency room doctor it might be a hospitalist.

Mark Bonica: OK so you on your end have what you said were board certified physicians with a specialty in treating stroke.

So why, why why are hospitals contracting with you to get this kind of service?

Why, why would I don't know I'm trying to think I don't remember which hospitals you have but maybe give an example of one and you know why would they want to contract with you.

Mary Lowry: Sure so I mean Cheshire Hospital is one of our affiliates and so we're providing the service there but we're also providing the service at for example...

I'm blanking out, I'm going to say Weeks hospital OK.

So we're not live there now but we're talking with them about it.

So one of the reasons is that you know again it, because the time is so critical for treating these patients.

If a patient shows up at Week's hospital even if they get in a helicopter to come here, they may not get here in time for the appropriate treatment.

So that's one thing, it's really the ability to take care of those patients the early intervention is going to ensure the best patient outcome.

Mark Bonica: Yeah.

Mary Lowry: Week's hospital for them to have a neurologist on call 24/7 would be quite an expensive proposition.

You don't know when these patients are going to show up, it's an unpredictable occurrence.

So to pay someone to be available only when you need them is very expensive, this way they only pay for the service when they need it.

Mark Bonica: So Weeks' hospital is what's known as a critical access hospital I believe, is that correct?

Mary Lowry: Yep.

Mark Bonica: So what does that mean?

Mary Lowry: So a critical access hospital has fewer than 25 beds and I am not an expert on critical access hospitals but I do, the main thing we think about when we talk about doing business with critical access hospitals is that they have special reimbursement rules.

So there, so they have they are allowed to bill Medicare in certain ways different from we are.

They don't bill really fee for service and there are certain requirements, they have restrictions on how long they can keep patients in their beds.

So there is just a set of operating rules that apply only to critical access hospitals and not larger hospitals.

Mark Bonica: I mean the thing that I think of and I think that's relevant to this service is you know if a hospital is a critical access hospital by definition it's small.

It's, yes, like you said 25 beds it tends to be in a, they tend to be rural, they tend to be you know far from another organization, you know from a larger another hospital or a larger organization by by law.

So I think the benefit of being able to tap into something like telemedicine then would be like you said...

With a 25 bed hospital you're never going to be able to keep a neurologist t busy right for you know to have a meaningful a meaningful practice.

Mary Lowry: Right.

So Cheshire is a larger hospital, it's a PPS hospital we also have teleneurology as SVMC in Bennington Vermont.

And but 1 of them, so you know but who knows maybe they could it would still be expensive but they could potentially support 24/7 neurology support, these hospitals typically have neurology in the daytime.

But it's it's hard really to make the financial case and the other thing is that a lot of the, but they also want to keep as many of their patients local as they can.

And in, in looking at our teleneurology service over the last year and a half, the majority of the patients who are seen actually are not stroke patients.

So we have a situation when we first went live at Bennington we had some great just kind of anecdotal data from them out of the box that they had some patients they had 2 patients on 1 day who came in that prior to having the teleneurology service would have automatically just been transferred to Bennington.

Neither one of the patients was having stroke.

Both of those patients ended up being able to be discharged to home that day.

So the impact for those patients for their family for that hospital and also understanding when we have, oh this this patient is not having a stroke it's something else, you don't have to then ship that patient to another hospital where they have a stroke unit for the patient to be monitored.

So we found that it's fewer than half of the patients are actually having a stroke and the majority of patients are able to stay at the local hospital rather than being transferred.

Mark Bonica: I mean that's an interesting benefit to this to this whole program is it does in fact allow you to rather than sending somebody to say shipping somebody to Dartmouth.

That's an exciting benefit to to having telemedicine is you know if you're trying to rule out stroke you don't have to now ship somebody off to a place where there is a 24/7 coverage by a neurologist you can get that neurologist online, rule out stroke without actually shipping the person off.

And that both reduces the burden on the on the individual, it reduces the burden on the system as well.

Mary Lowry: Right.

Mark Bonica: I think another interesting point you just raised about like using the example of Cheshire which is a is a fairly decent sized community hospital, 150 beds or so.

Mary Lowry: Yes.

Mark Bonica: So it's not, it's not, it is not a critical access hospital it's a, it's a, it's a decent sized community hospital that probably does in fact have staffed neurology I'm assuming.

But your point was you know in order to provide 24/7 coverage now you're burdening that individual or let's say you have just 2 neurologists, I mean you're not going to have, you're not going to have 10 neurolologists at a place like Cheshire you know.

Mary Lowry: Right.

Mark Bonica: So that burden you know.

No one want's to be on call every other night.

Mary Lowry: Right right so I mean that was my experience with telemedicine back when I was a chief financial officer for the you know for a small army hospital was we we're doing radiology and we were down to 2 radiologists and they were having to pull call every other night and we, that's when that was what motivated us to go to telemedicine coverage.

Mark Bonica: So I think that's an interesting point to kind of keep in mind as well.

A point you made a second ago is your telestroke is now evolved to broader teleneurology services.

Can you give an example of what those kinds of services are that are offered beyond kind of stroke rule out and stroke treatment?

Mary Lowry: Yeah it's really about the diagnoses, so it is still mostly an acute, it's an acute service it's for inpatients most of the time they're in the emergency room they may be in the ICU or they may be on an inpatient unit and demonstrating symptoms of stroke.

But some of the other diagnoses include encephalopathy, just altered mental status.

Patient comes in off the street into an emergency room and they don't really know what's what's going on.

Their status, epilepticus patients seizure patients so it's kind of a broad range of neurological acute neurological conditions that need to be treated relatively quickly.

Mark Bonica: OK what's the technology involved with the provision of these services and I'm I'm kind of assuming it's similar for the other services as well, so maybe we can talk about that.

Mary Lowry: Yeah we have a, we have 2 different models and 1 is a cart based model.

Teleneurology is a cart based model.

So there is a cart and you know it's probably about 5 and a half, 6 feet tall where with a big monitor and a camera and we have peripheral devices that can attach to it so that there is, there may be a stethescope that is being used from the cart on the patient's side but the doctor on our side can hear as if he or she is listening directly to that stethescope.

So it's a 2, there's 2 way video by the camera the doctor can remotely move the camera to zoom in and zoom out and see the things that he or she needs to see.

For teleneurology they often need to look at the patient's eyes pretty closely so the fidelity has to be very good and it is.

So it's a relatively robust structure on the physicians side it's just a computer.

It could be a cell phone it could be a tablet, I think for Neurology they are looking at films typically X-ray images also so they want to have a big screen they're typically getting on their laptop computer and they have a second monitor.

Mark Bonica: And this, when you say on the physicians side you mean at Dartmouth Hitchcock?

Mary Lowry: Yes the telemedicine physician.

Mark Bonica: OK and the telemedicine physician is is typically sitting physically in your connected care area when he or she is...

Mary Lowry: Not for neurolology no so they are sitting, they might be in an office in the neurology department or at home.

So the Dartmouth, we actually work in partnership we do not have enough business or scale at this time to cover the service 24/7 with Dartmouth Hitchcock neurologists.

So we're partnered with an organization called specialist on call which is the largest national provider of teleneurology services in the country.

And they, so they cover the days mostly and we have Dartmouth Hitchcock neurologists covering the majority of night shifts and weekends.

So those neurologists at night will be home in bed and they will you know get the call and get up and go over to their computer to do the video consult.

Mark Bonica: And they don't have to physically leave their house?

Mary Lowry: Right.

Mark Bonica: And so that's interesting so, so that reduces the burden.

Mary Lowry: We have to be presentable you know not just show up on video in their pajamas.

Mark Bonica: Throw on, at least throw on a shirt and a jacket real quick.

You might be sitting there in your underwear but if you know at least the upper half looks good right.

Mary Lowry: That's right.

Mark Bonica: And that makes pulling call a lot easier too I assume right.

I mean you don't have to be physically in the hospital to do it.

Mary Lowry: Right.

Mark Bonica: OK neat.

So let's see, talk about compensation for the service.

So normally a physician would charge a professional fee for providing this consult and then you know the.

And then presumably I mean if the patient was being seen at Dartmouth you'd have a facility feed, you'd have a...

How does this all, what does this look like in terms of revenue collected and billing from the patients perspective and then from the organization the participating organizations perspectives.

Mary Lowry: Currently for this service there is no billing for any telemedicine fees, so there is no telemedicine professional bill for the neurologist, there is no technical bill for the telemedicine service.

And the main reason for that is because of our partnership that we have with specialists on call it's you know their doctors are located all over the country.

They are, it would be kind of a logistical nightmare to try to maintain credentialing a payer credentialing in a bunch of different states for those people so that's just the way it's done.

So the from the hospitals perspective there is a cost to them, they are paying Dartmouth Hitchcock teleneurology a per consult fee.

And they are also able though from a professional billing perspective to bill the payer whatever is happening locally at the bedside.

So if the patient is having a stroke and the recommendation is to administer TPA, there is a charge for that that the hospital would collect, would bill and collect.

If there is a hospitalist you know rounding on that patient and taking care of that patient they would have those professional fees and they would have all of their usual technical fees associated with having a patient in a bed.

Mark Bonica: OK but but the patient wouldn't receive a bill for the neurologist?

Mary Lowry: Correct.

Mark Bonica: So what is the interest and we've talked about this but what's the business case that you make as an organization as Dartmouth, what is the business case that Dartmouth makes as a you know to say a Week's hospital or some other facility.

Say hey you should, you should pay us even though you're not going to be able to then flow this bill through to your patient.

Mary Lowry: Yep I mean it really is for them the ability to keep patients.

It's you know aside, it's this is one of the things that's toughest for us is really to be able to provide a super robust financial return on investment because a lot of the things are in the you know soft green dollar kind of areas.

It's about doing the right things for the patients and keeping them closer to home.

But with teleneurology there is an opportunity to keep the patient there locally especially when we understand that the majority of the patients are not stroke patients who need to be cared for somewhere else or need to have stroke unit review or need to be in an ICU.

So that really is the financial case.

And you need to provide this service, this is a lot more economical for you to pay for 5 consults a month than to pay for 24/7 neurologist staffing.

Mark Bonica: OK because a hospital say Cheshire or you know which was, which was our example of kind of a fairly robust community hospital or a critical access a very small critical access hospital.

In order to have, you would still have to compensate your neurologist even if they were, to take call even if they weren't actually seeing patients.

Mary Lowry: Right.

Mark Bonica: OK so there is a cost incurred by the organization regardless.

So this is an alternative method.

Just to talk to kind of wrap up the discussion around stroke, so let's say somebody is in fact having a stroke and they're at a critical access hospital like Week's.

You consult in and you say yup that person is in fact having a stroke.

Your neurologist says administer TPA, do these other things you know here's the here's the treatments, then what happens to the patient?

Mary Lowry: Yeah so they don't have an ICU or they don't really have the internal resources to care for that patient, so that patient's typically going to be transferred.

Mark Bonica: OK and would they likely be transferred to Dartmouth given the relationship or is that...?

Mary Lowry: Yeah probably, I'm assuming that we have capacity and ability to take that patient.

Mark Bonica: OK alright so in addition to teleneurology you offer 4 other 24/7 inpatient services.

Tele-emergency, tele-intensive care, tele-pharmacy, and tele-psychiatry.

Probably the most interesting one or actually probably the most surprising one to me when I first heard about these services was tele-emergency.

Can you describe the kind of services that Dartmouth Hitchcock provides under this offering?

Mary Lowry: Sure, and tele-emergency is different from teleneurology in that we do have as I mentioned before an emergency hub here in our space.

We also have a partner to provide that service it's Vera health it's located out in Sioux Falls, South Dakota and they are huge in the telemedicine space particularly tele-emergency and tele-ICU.

So we provide 24/7 coverage.

We have the video monitoring set up on our side and in the hospital the local hospital they actually have hardwired in an emergency room cameras, monitors, microphones, all of those things.

So that people we don't have to wheel a cart around it's they're able to see the patient that's right in the bed.

We want it to be easy and hands off because as you can imagine in an emergency situation we don't want people to have to worry about messing around with equipment they're just trying to get the patient taken care of.

So the emergency service, we actually offer kind of a whole range of options within the tele-emergency service.

It's all about collaborating with the bedside team, so it really is up to them what they feel they need.

Sometimes it is just a nurse who is maybe not experienced or is seeing a patient in the emergency room who is different from any patient she or he has seen before and will look for some advice from a nurse colleague.

So they, we call it pushing the button there literally is a button on the wall that will connect them to our emergency hub.

And our team here has collected all of the information of oh this is where your you know site right finder is for helping you do IV's you have it in the third cabinet in the second drawer.

Here they have their formulary so they have all the information about the medications that they have.

So they can just give advice to a nurse about dosing recommendations, how to administer drugs or procedure support or any of those things.

Mark Bonica: Wow there's a lot of, there's a lot of kind of research it's not just like oh I'm just randomly calling somebody I mean you you what you're describing is of a lot of kind of pre-work involved in setting the service up.

Mary Lowry: Yes it's a real partnership and we spend, typically the time line for launching a tele-emergency service at a site is you know 70 to 90 days.

And it's a very involved process our teams go onsite to work with the local hospital teams to make sure we understand how they work and you know are really collaborating with them to understand all of their systems and their staff needs.

Another thing that they do we might also, well we offer to do note documentation for them.

So they're very busy and you know the key is wanting the local bedside staff to be able to focus on the patient in the bed and take care of the patient and not being worried about oh I have to document this and that or I'm going to forget it.

So our team can document the care that's being given and then send it over to the hospital without being involved in it.

We also then can provide full team support including a board certified emergency medicine physician who again may be helping out an associate provider without a physician in a regional emergency room or a hospitalist not an emergency medicine physician on the other side to just get that extra level of specialty trained expertise in emergency medicine.

Mark Bonica: So this is a scenario that you might see in again say a critical access hospital or a small rural hospital someplace where the providers who are staffing the emergency room are not board certified emergency medicine physicians.

Mary Lowry: Right.

Mark Bonica: OK and so.

Mary Lowry: And we have the whole gamut I mean the number one reason for our tele-emergency calls are cardiac related, trauma is the second.

But there's been a whole there's been a gamut so we've had a baby delivered with support from tele-emergency.

Yeah and all kinds of things and you know peds is another area where we're very helpful because in some places they don't see very many kids or they don't see kids very often in the emergency room.

So just having kind of that extra set of eyes as we refer to it can provide a level of comfort and support for the local, to feel like they someone's right there to answer questions or even just to say yeah that's right we agree with your treatment plan.

Mark Bonica: OK so again with the goal of a program like this would be of course to provide kind of immediate consult but also are you also looking to kind of reduce transfers and other what are the other benefits kind of to having this kind of like the emergency services?

Mary Lowry: Yeah I mean that's one of the if you do research about tele-emergency services that's just out there that's one of the factors one of the benefits that is stated is the ability to keep patients.

It's been hard for us to quantify that because it's kind of hard to know whether the patients are calling us about are so, are in such rough shape that they were going to come here anyway so we really don't have a good baseline we're still trying to figure out how to quantify that.

But that is one of the things, one of the opportunities.

I mean we definitely have an understanding that the availability of tele-emergency to these local emergency rooms has saved lives.

We know that patients have ended up transferred out of that local hospital and to place where they need to go much more quickly than they would have been otherwise.

That's another one of the service options of the tele-emergency is that our team will coordinate transfer, whether it's to here Dartmouth Hitchcock or somewhere else.

So if we can't take that patient here, our tele-emergency team is looking for the next best bet for that patient whether it's Boston or you know somewhere else.

So all of those things save time and that's really the goal is to save time and to preserve the best patient outcome.

Mark Bonica: So let's talk about the other services you've got tele-intensive care.

So I'm again trying to picture how does that work.

Mary Lowry: Yeah ICU is another one relatively similar to emergency in that the ICU beds are wired they're hard wired and we have tele-ICU physicians here in our connected care center in an ICU hub.

So they have a bank of monitors they're monitoring patients at all different hospitals and the service again it's really a collaboration with the bedside team and related to what they are comfortable asking for or what they feel like they need.

So they might call they also have a button they might push a button and end up calling to speak to the ICU intensivist to ask specific questions.

The other piece of it though is predictive analytics.

So all of the data that is being collected from the patients in those beds through their monitors all of their labs everything that's in their medical records is being fed into our tele-ICU hub.

So while at the local hospital they may or may not have an intensivist usually overnight that's pretty hard to do.

They may only have hospital hospitalist's in house overnight and they have other stuff to do they can't stay at the bedside.

The tele-ICU team is watching these analytics which will tell them a patient is starting to deteriorate and so early intervention can be launched to make sure that we're preserving again the best possible outcome for that patient.

Mark Bonica: OK what you used the phrase wired bed I think or networked bed, is that something specifically put in place for, to, in order to interact with your program or is that something that most hospitals would have in their ICU?

And when you say wired bed what does that mean?

Mary Lowry: It's specific to tele-ICU and it means that all of the patient data that's coming from the monitors that are attached to the patient and their medical record information are all being collected through a software system called Visicu.

It's a Philips product and so that is really creating the reporting and the alerts that the tele-ICU physicians monitor to be able to keep an eye on a bunch of patients in multiple locations at one time.

Mark Bonica: Oh neat, now you've used the phrase hospitalist and intensivist a couple of time.

Some folks listening to this may not know the difference so could you explain what's a hospitalist and what's an intensivist and why is it that you would, wouldn't, you would be less likely to see an intensivist in a smaller organization?

Mary Lowry: Sure so in, and I'll start with the second one an intensive is a critical care doctor so that someone who has special training in critical care medicine.

And those are typically anesthesiologists and pulmonologists who then have done a separate fellowship training in Critical Care Medicine.

Surgeons are also may be critical care physicians and occasionally neurosurgeons and neurologists have critical care training.

In most places and in our tele-ICU world it's right now staffed by anesthesiologists and pulmonologists.

Mark Bonica: So if I can interrupt just for a second, so we're talking about somebody who has done a probably an internal medicine residency, gone on to do a pulmonology fellowship and then done yet again a critical care fellowship for further training.

So this is a fairly high level fairly advanced level of care that we're talking about here.

Mary Lowry: Yes yes absolutely and you know they're expensive and they're rare.

They're I mean one of the big things that's driving the growth of telemedicine is just the scarcity of physicians in general.

So neurologists are very very scarce, critical care intensivits are very very scarce.

So even if you could afford to have enough of them in your hospital they you might not be able to find them or be able to recruit them to come and work there.

And some hospitals don't really have an ICU.

You know they have you know in most of the critical access hospitals or even small regional hospitals what they might call ICU would not be an ICU patient here at Dartmouth Hitchcock they'd be in a step down unit.

But the but, we can still leverage tele-ICU services to help them take care of those patients so they can stay there.

Especially because we don't want to come to our ICU.

We want to preserve those beds for patients who really need them.

So that's the critical care intensivist, hospital medicine is I don't know as much about them because I lived at the anesthesiology department for 20 years I know a lot about critical care.

But it is a separate training discipline so there is a fellowship in hospital medicine, a residency or fellowship in hospital medicine that those physicians would have completed in order to do that work.

And typically, they're utility physicians so they are really taking care of patients in the all kinds of inpatient locations in the hospital.

Mark Bonica: My understanding particularly at the community hospital level is people who are filling those hospitalist role tend to be internal medicine and don't have to necessarily have gone beyond a internal medicine residency.

Mary Lowry: I'm going to suspect that most of the people that we have here have a separate hospital medicine training, but that may be a Dartmouth Hitchcock thing.

Mark Bonica: I suspect maybe because you are, you're a medical center I think but my experience with hospitalists is I think the minimum requirement is internal medicine.

Mary Lowry: Right, but yeah I'm sure that's correct and I think the idea is that you know they really can go everywhere.

So as opposed to we we can't have you know every different surgeon rounding on a couple of patients here and there and we want them to be doing surgery, the hospitalists can take care of those patients and also they you know pneumonia admitted patients.

Mark Bonica: So this certainly, when we talked about this service before you kind of you described this is, this is a compliment not a substitute for services at a local hospital.

Mary Lowry: Yes.

Yeah and that's really where we want to talk about it as a collaboration.

So you know we're not trying to displace anyone, it's really, it again like much like tele-emergency it's that second set of eyes that can provide that extra layer of monitoring and vigilance because the key is early intervention that's the whole key to making sure that we can provide the best possible outcome for patients.

The data on tele-ICU was that it has shown to reduce ICU length of stay.

It has also shown to reduce post ICU length of stay in the hospital because when the patients leave the ICU they're just more stabilized and they don't need to spend as much time in the hospital in general.

They are also more likely to be discharged straight to home versus to a rehab facility so you know we're saving cost to the system we're just the, and it is all because of that early intervention based on the availability of analytic predictive data.

Mark Bonica: You've talked about this analytics and predictive data that, what do you mean when you say that?

Mary Lowry: So the physician who is monitoring the patient information can see lab values or you know heart rate values they just from watching the patient data they can say oh this, this patient looks like he's heading in the wrong direction we should change the meds, we should do a procedure.

They can see early on that something needs to be done to prevent that patient from further deterioration.

Mark Bonica: OK and so you, when a hospital puts someone in one of these networked beds obviously they're intending for you to be aware of that you know individual.

Who is sitting in the, in the connected care center monitoring that, is there are there is it always a critical care physician or is there a nurse kind of doing the continuous monitoring and then alerting a physician when something seems to be going wrong or how does that work?

Mary Lowry: Yeah the tele-ICU team is a nurse and physician team because of our partnership with Avera, they are providing the nursing support right now we only have physicians here and our space in it it's a collaborative service.

I mean we're in partnership with the Avera, so there are Avera critical care physicians also providing some of that service.

Ultimately, if we had our own individual hub that we were staffing ourselves 24/7 with our own physicians, we would have our own nurses here as well.

Mark Bonica: And then again the revenue stream off of this kind of service, is it roughly the same as as what we've described previously with the neurology where it's kind of a subscription service or is it a consulate service, how does that how does that work from from your perspective?

Mary Lowry: Yes it's a little bit of a mixed bag, so we only have services right now at Cheshire and we are going to go live with SVMC next month.

We charge kind of a flat fee that's kind of based on the size of their I.C.U. units but it's done other ways other places, so sometimes it's a per consult fee, not per consult I take that back, its a per admit so the person is admitted into the I.C.U. there may never actually be a conversation for that particular patient but we're still monitoring that patient from the tele-ICU side.

So there are a variety of reimbursement options for tele-I.C.U. for the local hospital there's a lot of data to indicate the financial return on investment for tele-I.C.U..

So there's a as I mentioned there's data about reducing the length of stay which means if you have already have a full I.C.U. you're going to create some new capacity to get some new volume.

If you don't have a full I.C.U. it will allow you to keep some patients, have an increased census, and get some new revenue that way.

There are a lot of quality improvements that happen, so improvement in sepsis bundle compliance, improvement in DVT prophylaxis, improvement in ventilator acquired pneumonia, all of those things have cost savings attached to them.

So there is an opportunity with telehealth for new revenue but also for significant cost savings because of interventions that can be avoided like the stay reductions.

Mark Bonica: So let's switch gears and talk telepharmacy real quick and you've got this listed as an inpatient service.

So some folks who are listening to this because this is going on to support the class may not realize you know that there are their interactions with pharmacists are typically been kind of on the retail outpatient side.

What's the role that the pharmacist plays on the inpatient side and how does your service support that.

Mary Lowry: So our telepharmacist performs the exact same work that the inpatient pharmacist does in a hospital which is to review every medication order to make sure that there are no contraindications or any issues with any errors in the order, any mistakes, inadvertent errors and to make sure that there aren't going to be any complications or coverage occasions or adverse reactions to other medicines the patient is currently being administered.

Mark Bonica: OK what's the benefit of this service to you know, why would an organization want to contract with you to get this service.

Mary Lowry: Yeah it's similar to the some of the other 24/7 services where your volume really isn't enough to justify the cost of having a person in-house.

So in a small hospital where there may only be you know ten patients in overnight and the pharmacist would only have two orders or something to review overnight, it's pretty hard to justify the cost of an in-house 24/7 pharmacist.

And pharmacists are an expensive resource.

They are and also scarce, yeah right and to get one to go up to the north country or to just fill 2 prescriptions over the course of a shift would be an expensive thing to do, you know.

Mark Bonica: Tele-psychiatry, I know that in our previous conversation the military uses a fair amount of of tele-psychiatry, but primarily from my understanding primarily outpatient.

Your service is focused on inpatient so what is the service that tele-psychiatry provides from an inpatient perspective.

Mary Lowry: This is an acute services so it's essentially based in emergency rooms where patients come into an emergency room and have some kind of acute psychiatric need.

And the goal of the service really is to help to get those patients managed, most small hospitals don't have local psychiatrist services.

They may have, you know, a regional community mental health agency who comes into the hospital during the day and may help to do some care management things, but they don't have a psychiatrist to diagnose or make recommendations about involuntary commitment or reverse an involuntary commitment.

So often what happens is patients end up kind of languishing in an emergency room and not being treated while they wait to get a transfer to the New Hampshire State Hospital or Vermont State Hospital.

And this way with an early intervention of a psychiatrist, the patient can be treated and often we can move that patient more quickly out of the emergency room, so they get to where they need to either its they don't need to go to the state hospital, or even if they do and there's not going to be a bed there for a couple of days, at least those patients can be managed and cared for in the interim.

So it's better for the patients, it's a lot better for the emergency room staff who otherwise don't feel well equipped to take care of these patients.

Mark Bonica: That's a significant problem in the state of New Hampshire in particular I don't don't know how it is in other states, I'm sure it's similar in some states where we have very long waits with people with psychiatric diagnoses who who come in through the emergency room are often waiting in the emergency room for extended periods of time to be transferred to an inpatient facility or to get that kind of definitive treatment, so this is an important service that that that could be could be rendered this way.

Mary Lowry: Absolutely and some of our psychiatrists here did a study that I believe was based on our own emergency room and looked at the fact that you know, at least a quarter of the patients don't need to go to the state hospital and being able to determine that and make other arrangements for them so that they're not stuck waiting around is really the key.

So you know if you're waiting for the psychiatrist who comes in every Thursday, what happens with the patient who presents on Sunday night you know, our service allows them to get a call and to have a board-certified psychiatrist make recommendations for that patient.

Mark Bonica: I noticed from your website that you don't have to tele-psych listed under ambulatory services and I want to transition a ambulatory next, so how come?

It seems like that would be oh you know psychiatry doesn't involve the level of laying of hands that other E.R. or I.C.U. would say seems like a natural fit, are you headed that way,what are your thoughts there?

Mary Lowry: We're talking about it, we're trying really hard how to figure it out, we actually there are some child psychiatry services going on via telemedicine.

There's one psychiatrist who's been doing it for a couple years, it's kind of set it up on his own, so it didn't involve under our department.

And one thing that actually over the last couple of years as our department has grown, we've really tried to get a handle on it to make sure that we are the gate through which telemedicine services are delivered because we want to provide standardized, processes, workflows.

We want the patients and the hospital customers on the other side to have the same experience regardless of which kind of service it is so that one just kind of grew, evolved on its own with that physician.

We have another physician who's going to be doing some child psychiatry services within the Dartmouth Hitchcock system down in Concord, but reimbursement is really the big challenge with that, and with psychiatry it's an extra challenge because not only do we have to deal with whatever the telemedicine reimbursement restrictions might be, but behavioral medicine services just are not reimbursed in general.

So the more we add those, the more we're adding to a negative bottom line for the psychiatry department until we can figure out enough arrangements where the people on the other side are willing to create an arrangement where they may pay to make up the difference.

So in our tele-special services the outpatient, typically the way we have it arranged is that our doctor does the professional billing.

So with the psychiatrist doing professional billing for those services they would just lose money.

Mark Bonica: So let's talk about your ambulatory services, you've got a very robust list of specialty services, and I'll list them real quick: gastroenterology, hematology, oncology, nephrology, rheumatology, neurovascular, pediatrics and we're going to talk separately about radiology in a minute.

How are these services delivered, are they are the consultative relationships with physicians or do patients actually see a Dartmouth Hitchcock physician, or is it kind of both, how does that work?

Mary Lowry: And this is the list from our website, it's a little bit of an old list and we have some of these things we're not doing any longer, but we have a much longer list I'm happy to say of more things we are doing.

OK so it's a little bit of a mixed bag so some of the list, like gastroenterology are visits to patients at home; we also have some surgical post-op patients, post-op visits via plastic surgery where the patient is at home and the visiting nurse is on the patient's side.

So for the patients at home, the patient might be on a phone or a computer or a tablet and the doctor is on here in the hospital on the laptop computer.

It's we provide the patient with information about how to log into the system so that they could have their visit; there is not for the gastroenterology, it's a doctor and the patient that's it.

As I mentioned for the plastic surgery, because they will the doctor or it's actually an associate provider who's doing that post-op telemedicine visit wants to see wounds and how those are looking, it's a little easier for them to leverage the visiting nurse who's there seeing the patient also to help position, they use i Pads for that, and so that's who's there on the patients side.

We also have patients who are at another hospital or a clinic and sometimes there's a tele-presenter, sometimes there isn't; the extent and the skill set of that tele-presenter varies depending on what kind of service it is.

So we have a nephrology chronic kidney disease service that is relatively intensive, there's a nurse on the patient's side but for other services there could be an M.A. who really all that person does is room the patient and is there to help you know position things or you know might help report some physical things to the physicians on the other side.

We do also have occasionally arrangements where there is a primary care doctor on one side with the patient and then there's a specialist on the other side, so that tends to be the least frequent it's the most resource-intensive in some occasions both of those positions can bill a service but not always so we haven't done a lot of that.

Mark Bonica: And is the billing, so I'm imagining say that the home visits are they a part of a of a global bill, typically?

Mary Lowry: Yes, because home visits are not currently reimbursed except in very limited situations, so Vermont just passed a law that requires a coverage of home visits.

So Vermont Medicaid will pay for home visits, the commercial insurers in Vermont must cover home visits, Medicare does not.

So if we were over in, I mean we do see some patients from Vermont, we see patients in Vermont, this is where pediatrics comes in.

So we're working with Copley hospital to start providing some services over there and if those patients subsequently we decide it will make sense for them to have home telemedicine visits, and they were Vermont Medicaid patients, we could do it because there'd be reimbursement.

But otherwise it's hard to differentiate by pay or what kind of service we're going to offer to patients so it does restrict us.

Mark Bonica: OK, I typically think of Pediatrics as a primary care service, but I imagine that's not really what you're providing.

Mary Lowry: No, it's a pediatric specialties and I think we may have talked about this that one of the things we're really excited about are the pediatrics specialty services that we're providing to Cedar Crest Children's Rehabilitation Home, so we have nephrology, neurology, urology, G.I. and pulmonary medicine.

All services all being provided to those patients who previously would have to get transported up here to Dartmouth Hitchcock and it's a long ride with one or two attendants to help those kids get here so that's really a big win in our view to have those patients able to get the care where they are.

Mark Bonica: And that seems to be a consistent theme is this telemedicine allows you to you know, or allows the patients to stay where they are and get specialty services, yes.

So we talked previously about radiology and you were saying tele-radiology is actually managed out of the department of radiology and I wanted to kind of raise that as a transitional discussion and going into strategy and thinking about the provision of of telemedicine and organizations getting into the provision of telemedicine.

Tele-radiology was actually a service, as I told you in our prior conversation, that I actually worked with in the past, I was working at the time I was working at what would be the equivalent of a critical access sized hospital.

We had two radiologists and they were working you know, working like crazy and burning out because they were going to going back and forth taking call every night, so we wound up contracting with a tele-radiology organization and at the time I was up I was working in rural Louisiana and we actually wound up contracting with a practice out of Houston, Texas so we're crossing state lines.

It seems like, and we had a number of choices, so it seems like that's an example of a service that's fairly robust, that has or a service that has there's a lot of people competing in that space.

I mean tele-radiology really I think it lends itself to or radiology lends itself to provision through telemedicine because you're focused on you know you're focused on reviewing images anyway.

So I'm imagining you know, I mean if Dartmouth is trying to get into that field and I don't want to use this kind of a jumping off point to think about telemedicine strategically is, you know as you move into tele-medicine, geography stops being a barrier to the provision of services.

I mean and you've mentioned you actually work with a couple of other firms that supplement your services that are not located in New Hampshire, they're not co-located with you, they're someplace else in the country, so I'm curious your thoughts on kind of strategy and marketing from that perspective of you know, as we move into as you move more online and provide more services and as this becomes a more acceptable and commonplace way of delivering care, how do you think about you know how do you think about strategy, how do you think about competition and how much do you guys worry about that at this point?

Mary Lowry: Our region is actually relatively open from the perspective of competition and we for tele-neurology for example and tele-psychiatry, with specialists on call, we partner with them both we negotiated, not compete, OK.

So that was one thing that helps us in that regard.

Mark Bonica: So that means they can't come in and offer they can then offer services independent of you in this area?

Mary Lowry: Correct, yes.

So that was beneficial, but I mean our main concern is really our region right now, and so fortunately there's not a lot of competition.

We have an opportunity, one of the things that we look at for at Dartmouth Hitchcock tele-medicine services as potentially differentiating, is that we have a whole suite of services.

So where there are some vendors or even some other health systems who are providing services within their own system and may start to think about going outside, maybe they have tele-stroke, maybe they have pediatric trauma, maybe they have one or two things and we have a whole suite of services and there really is some synergy among them.

So as an example we might have if a hospital has tele-emergency and tele-neurology, a patient might come into the emergency room with a seizure and the tele-emergency doctor or team can make some recommendations.

They can also say "gee you have tele-neurology, maybe you want to have a tele-neurology consult" and then they can find out you know, we can keep that patient we know how to take care of that patient.

So we've view that as a really differentiating factor, our goal is really to take your patients in our region that's our first priority, OK, and I think it's, I have a nice little list of what our approach is to talk about how we want to work collaboratively with regional facilities.

So our goals are to identify health care needs or gaps in the region where we can help, where can we help to bridge that gap.

We want to bring resources to patients and providers when and where they're needed.

We want to improve patient outcomes and we really want to allow more patients to stay close to home so that's the approach of our services and again really our priority is taking care of the patients in our region.

When we are partnering with other hospitals who are technically our customers, we are their patients are our patients, they typically end up coming here at some point in their patient care journey, so it's we really view them as all our customers and looking out for our shared patients.

Mark Bonica: You know in a previous conversation you'd mentioned that you know, Dartmouth Hitchcock provides connected care really at a loss so why does Dartmouth Hitchcock do this if that's true if it's not a profit center.

Why the investment?

Mary Lowry: It's not our choice, our goal is to get to be self-sustaining.

It's were really this connected care center is technically in year three of having you know like identified specified cost centers for each one of the services.

So and they are expensive to varying degrees so emergency and ICU are tend to be more expensive services, neurology and both from a capital and an operating perspective, neuroology and psychiatry tend to be less expensive services, but as again that whole portfolio of services our goal is to grow adequately and to have enough scale so that we can be self-sustaining.

Mark Bonica: OK so [INAUDIBLE] you're early in the in the game then and really you're still kind of a start up phase so at some point you think with sufficient scale this will be a money maker in the long run.

Mary Lowry: Yeah we don't have any illusions that were, it's not our goal to make buckets of money, we would like to be self-sustaining and it's that we need to provide the services in a way that's affordable to the region as well.

Mark Bonica: Well that's, I mean that it would be great OK.

And that leads me to my next question because you know, most folks know we're in a process in the health care industry, we're in a process of moving from you know the old fee for service model where a physician or a hospital got paid to provide a procedure, provide a visit, right to more of a value-based model where hospitals, providers linking together to kind of will be compensated based on keeping populations healthy.

It seems to me that you know some of the examples you used where you're keeping you know a lot of the focus of your program is keeping patients where they are, so keeping them in their local community and even your examples of like post-operative care in the home, that seems to fit very well with the idea of bundled payments which is coming and other ways of providing care, provide definitive care at a lower cost.

What are the discussions you all have had about how telemedicine fits into that kind of value-based future?

Mary Lowry: Yeah candidly we haven't had very many detailed conversations about it yet, but it really is the population health aspect of telemedicine is really a big piece and the more we have an opportunity to track and quantify the avoided E.D. visits for patients who have for example outpatient tele-psychiatry services or outpatient tele-specialty services, whether it's a local hospital or home that has an impact.

There is a lot of opportunity for cost savings to accrue to the system and I think our challenge is to figure out how best to quantify it and attribute it to the telemedicine.

Mark Bonica: What would you say are the limits on growth for your organization and what is it that makes it difficult to provide these services.

So you've mentioned you know some issues around billing, licensing, so what are the challenges on a kind of day to day basis and is there anything else that's kind of standing in the way of of expanding and getting to that scale you want to get to.

Mary Lowry: Yeah I mean those are really the big hurdles, Medicare reimbursement restrictions in New Hampshire and Vermont are regulations are actually pretty good, especially Vermont is great and the licensure, I mean New Hampshire is part of the interstate medical license compact but that's not really helping us just yet, so that may be something that becomes easier in the future.

Mark Bonica: What does that mean, what is the interstate compact for?

Mary Lowry: So there are something like nineteen states who are participating and New Hampshire is one of them so the idea is if I have a medical license in New Hampshire and I want a medical license in New York State and New York is also part of the compact, it's a lot it's almost like it's like a courtesy license I don't have to go through the whole licensing process independently for the New York Court of medicine, they take my New Hampshire medical license as adequate documentation.

Mark Bonica: OK so it makes it easier to pull.

Mary Lowry: Most of the states that are participating in the compact are out west, so it's and we're not providing services out west, but if Vermont became a compact state, that would be very easy because a lot of our physicians are providing services to Vermont and Vermont is a very onerous medical licensor process so that would be great if they were compact and it would essentially be just reciprocity in terms of medical licensure.

Mark Bonica: OK, how far away are the furthest facilities that you contract with to provide care, do you provide care to anybody outside of kind of Vermont and New Hampshire.

Mary Lowry: We're not outside Vermont, New Hampshire yet we are talking to some facilities in Maine, OK, so that's the next logical extension.

I mean as I mentioned our focus has really been on our region and our patients and the hospitals with whom we interact to take your patients first, but so Maine feels like the next logical extension.

Mark Bonica: Sure, and its the next state over so and given the physical geography of New Hampshire it's probably not that far from physically from where you are to get to Maine, right.

Let me let me ask you to kind of imagine a future where like is there a point where you could imagine small hospitals, critical access hospitals in rural areas being run mostly by nurses and P.A.'s and basically you know, wheeling around carts with cameras on them that you know and that's where the physicians they have, those are the physicians.

Mary Lowry: Yeah, so that's already happening with some services and I think it's not because of telemedicine it certainly is not our goal to try to replace physicians at all, but I think we what we can do is we can provide the physician access when sites are unable to obtain it.

I think it really it depends a lot is going to be specialty by specialty, it will depend on the local patient population you know, we don't feel like there is a substitute for in-person physician care via telemedicine.

Patients have the the feeling that they're, the data that's out there from patients is that they find care they receive by telemedicine to be at least equivalent to in-person care and the outcomes indicate that the care is equivalent to in-person care, but that still doesn't mean that we don't need physicians locally with patients.

Mark Bonica: OK, just a fun speculation so mostly what you described Dartmouth Hitchcock is primarily involved from a tele-medicine perspective in what I would call a business to business, B to B, kind of segment of the telehealth market so you're not at this point offering services where patients could dial up on their iPhone in more of a retail mode or a business to consumer kind of mode which does exist in some you know in some services are out there doing that, where you just kind of you know hit your app and be clicked into to you know Skype or or you know facetime with a physician directly at will kind of.

Do you instead it seems you make contracts with hospitals, rehab facilities, and so forth to provide these services through so through another facility.

Do you guys house a thought on you know going to that kind of next retail level if you will of having your primary care providers doing telemedicine visits.

Mary Lowry: I think it is in our future, that is the area of growth is you know patients having home visits, there are a lot of different things to consider about it.

There are employers who are providing this and so there is certainly an opportunity with all of our own employees internally to have we're self-insured so it could be providing telemedicine to our own employees as patients.

The direct to consumers business that's out there now is typically that primary care stuff that you're talking about it's the patient avoiding a doctor's office visit or visit to an Urgent Care or walk-in clinic where I have a sore throat is it Strep or those kinds of things.

So I think we have an opportunity to improve our access in our in-person clinics by making those kinds of offering, I'm just not sure where we would start.

I don't think we would start with kind of out there for the world where you know any come to Dartmouth Hitchcock.

York Hospital in Maine for example has a direct to consumer like product it's for their own patients, OK, so my sense is and we are in a strategic planning process going forward in looking at where our opportunities are specifically in the tele-specialty, ambulatory space and I just don't know where we might start with that, we might start with our own employees, we might start with our own patients.

So we're working on that.

Mark Bonica: This it's interesting and I imagine that will become a very competitive environment very quickly.

Mary Lowry: Some private payers are paying for those services, I mean right now it's mostly it's a lot of self pay so it's the person who's willing to pay 45 bucks to have that online appointment, but some payers are starting to cover it with some vendors so I think that the more that moves forward there and again reimbursement drives what happens operationally quite a bit.

Mark Bonica: I mean my speculation is I think we'll see you know the value of that go up as we move away from that you know fee for service model and more towards a you know how do we keep you out of the hospital kind of you know where we're not worrying about OK how do we bill for this service.

And instead we're compensated for you know for some sort of global you know capitated rate that you know just, I think with me yeah, I mean I think that to me that seems to be the the main interference for a lot of these kinds of things going forward at this point are really growing at this point.

So let me close up on a couple of you know kind of quick questions for you about kind your thoughts on it and if you are now let's say you're at a cocktail party and you introduce yourself and so and you say well I work in connected care, what are the things that people most, and you say well that means you know I help manage telehealth and telemedicine.

What are the things that most people misunderstand about telehealth, what you find yourself correcting most often.

Mary Lowry: Yeah I think people really if they don't know what it, either they know or they don't know.

It's really two ends of the spectrum so and people who don't have any understanding of it at all are really impressed and surprised about how you can I guess the thing that people don't understand the most is how much actually can be accomplished by telemedicine and the full spectrum of medical care that can be provided, that's probably the thing that people are most surprised about.

Mark Bonica: And if there's one thing you could tell people about how telehealth would it be?

Mary Lowry: It's not hard to do, patients like it, it's not really new anymore and I think our goal is really to help people understand that it's not some shiny, cool technology thing, it's really just another way of delivering care to our patients and we really want to try to integrate it into the entire range of how we provide care to our patients.

Mark Bonica: That's great, thank you so much for your time today this has been really interesting.

Mary Lowry: Thanks Mark, I appreciate it.