Telemed’s Legacy as Connected Care

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Judd Hollander dishes on the distant service actually providing a superior care delivery mechanism.

Judy Tintinalli recently spoke with Judd Hollander, the senior vice president for healthcare delivery innovation at Thomas Jefferson University, to discuss his telemedicine fellowship, his institutional telemed activities and why he telemedicine is more a state of being than destination.


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JUDITH TINTINALLI:  I was in Michigan giving a lecture to their statewide osteopathic residency group. Part of my talk is on the importance of telemedicine and how this is a cool thing for the future of ER. Two residents came up and say they’re going to be in your program. What motivated you to switch to the innovation concept you’re doing?

JUDD HOLLANDER:  It’s really seeing: Where is there an unmet need and how can I solve the problem? After spending the better part of my career of doing that within the emergency department, it became clear to me that at the end of the day, it would be new and different and a more broad-based legacy and a bigger challenge if I tried to take it outside of the emergency department and do things that were more scalable rather than develop new tests for subsets of patients with different diseases.

TINTINALLI: You can really affect the population base in your telemedicine method. Can you define telemedicine?


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 HOLLANDER:  I prefer to think of it more as connected care. To me telemedicine is anything that let’s say a physician or an advanced practice provider takes care of a patient when they’re not physically located in the same situation or same room.

TINTINALLI:  So are you using physicians and advanced care providers? Tell us a little bit about what you set up.

HOLLANDER:  When I went over to Jefferson, I was very fortunate. There were multiple spots and so I was able to choose a whole bunch of really good people to come with me; many of whom were then or are now household names in emergency medicine, which is rare. We got started at a time when Jefferson hired a new president, Steve Klasko.

Steve actually charged me with beginning a telemedicine program. After we did the focus groups and the exploration, I said: Okay, here’s some semblance of a strategic plan. How would you like me to proceed? He says: Judd…I want you to assume you have $100 million. I don’t [care] if you fail, just do something that’s cool.


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Judd Hollander, MD

For most people beginning a telemedicine program it’s like this: Judd or Judy sitting in the back hallway with a cool idea begging for dollars to do it. That wasn’t my situation. There was major institutional support to grow out an initiative. We didn’t pilot a little program here and pilot a little program there and see what worked. We went all in with an enterprise-wide program, which at its simplest level was doing direct-to-consumer on demand platform with telemedicine. At the same time, we took everybody in the institution and trained them to do telemedicine with their patients.

TINTINALLI:  So you’re doing this within the institution or also outside of the institution?

HOLLANDER:  For the on demand program, it’s staffed all by ER docs. I believe we’re the only program in the country that has all of our own ER docs taking all of the on demand calls 24/7/365. Most programs will have somebody covering it 9 to 5 who works at the institution. And then it gets kicked out to what I’ll refer to as the provider network; sort of a large commercial telemedicine program to handle the after-hours calls.

We just said: If you’re a Jefferson patient or you’re a Jefferson employee, you’re going to want to see your Jefferson doctor. At the end of the day, we thought why not provide care with ER docs to everybody who thinks they need to see an ER doc, whether or not they need all of the resources of the emergency department? In essence, we deliver our intellectual knowhow to everybody, but we don’t need to do it in the expensive environment of an emergency department.

TINTINALLI:  So there are lots of benefits for the patients, the physician and the institution. What is the risk of this, as opposed to in-person care as you see it?

HOLLANDER: We know that even when appointments are made across the US, 20 to 30 percent of patients cancel their appointments, but we actually know the telemedicine case cancellation rate is considerably lower. Out of every hundred people that have an appointment, only 70 are going to get care and in telemedicine that 90-plus are going to get care. Even if telemedicine was slightly worse, it would be better for those hundred patients overall as a whole.

I like to say is telemedicine is just a care delivery mechanism. It’s the same care. If you have a cough, you should get the same thing done. If you have cellulitis on your leg, you should get the same thing done. The question becomes: Can you get enough information via telemedicine via video to get to the right next actionable step? In the emergency department, I don’t always know your diagnosis right away. Sometimes I need a CAT scan. Sometimes I need lab. Sometimes I need somebody with more expertise than the typical emergency department and I need a consult. The same exact thing is true in telemedicine. Sometimes I could see them on video and I can solve their whole problem. Sometimes I need to send them somewhere for an X-ray. Sometimes I need to send them somewhere for more expertise, which sometimes might be a better physical exam.

TINTINALLI:  So how do we get emergency medicine to be the nationally recognized experts in telemedicine?

HOLLANDER:  We got to do it. We have to do it. And we have to do it better than everybody else. I’d say our biggest competition is ourselves. What we’re really good at is being available. Our core value in emergency medicine is that 24/7/365 with or without insurance, we’re there for you. We got you covered.

Our value to the world, the health system is going to be: Can we do it in a less expensive place than an emergency department? But we are the people with the right knowledge base to know whether or not somebody can be taken care of at home or somebody needs the emergency department.

TINTINALLI:  Let’s move onto your fellowship, which I think is so exciting. What’s it about? What’s the structure?

HOLLANDER:  We decided that if you’re going to teach people to do telehealth, you need two things: telehealth training and recognition that telehealth needs to be built into training for everything else. It’s like we don’t figure out if it’s the third floor care or fifth floor care; you’re just getting cardiology care. We started at the level, even before premed. The first program we developed was a telehealth certificate program for telehealth coordinators so that we could train staff on how to do telehealth.

At the same time, we created an elective for med students and an elective for residents and a one-year physician fellowship program. And they have evolved over time as we’ve had more people come through them. But we also built telemedicine into the med school curriculum; so that it’s not telemedicine, it’s just there.

For the physician fellowship, that is a full one-year fellowship that we embed people in everything. So they can do different concentrations during the time. They all participate in the operational components of running the telemedicine programs of the enterprise.

My hope at the end of the day is that we make everybody a better clinician. But what they really get out of the program is learning how to manage, run, coordinate and grow a telemedicine program. Within that, one woman wanted to concentrate on marketing and learning new things. She works as a provider for multiple telemedicine companies doing care and is involved with some startups. And our fellow now is a first year out of an ER residency, but has an MBA. When he finishes up with us, he’s going to go start a telemedicine program at another academic medical center.

TINTINALLI:  That is I think so exciting and you’re making such a great impact. What’s the limit in terms of where telemedicine can go?

HOLLANDER:  Emergency medicine has to not be about the emergency department. We spent a lot of years worrying about whether people call us the emergency room or emergency department. We should be neither. We’re not a location. We’re emergency physicians and we have a special expertise and that expertise is both our content knowledge of disease and our willingness to be there anytime, anywhere for people who need it. And we can’t say we’re there anytime, anywhere if we’re only in the emergency department. We need to be where our patients want us.

TINTINALLI:  Hurray, hurray. That is such visionary thinking. I mean, we’re a system and this is part of the system for sure. It’s well outside of the box of the ED.

HOLLANDER:  Think about it, nobody ever said: I’m going to go see my cardiology office.

ABOUT THE AUTHOR

Dr. Tintinalli is currently a professor and Chair Emeritus of Emergency Medicine at the University of North Carolina. In addition to teaching in the emergency medicine department, she is an adjunct professor at the UNC Gillings School of Global Public, and a frequent lecturer in the School of Journalism and Mass Communication. Dr. Tintinalli is double boarded in emergency medicine and internal medicine. She was the founder and first president of the Council of Emergency Medicine Residency Directors. She is a former president of ABEM as well as the Association of Academic Chairs in Emergency Medicine. She is a past winner of ACEP's James Mills award as well as ACEP's National Education Award. And of course, she is the Editor-in-Chief of 7 editions of her eponymous textbook, which is arguably the best-known EM text in the world.

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