Patients requiring upper or lower gastrointestinal diagnostics normally have to present to a hospital or clinic for a tube-based endoscopy. The capacities for these procedures are constrained by infrastructure (rooms, endoscopes, etc.) and expert personnel (doctors, nurses, technicians and administrators).

THE PROBLEM

Even without the unparalleled pressure from the pandemic, meeting demand can be costly and is often not available locally at all – especially in rural environments and places serving underprivileged communities.

"Video capsule endoscopy offers an alternative test that can be delivered in an outpatient setting, is minimally invasive, and can principally be scaled up and down rather seamlessly," said Dr. Rome Jutabha, professor of clinical medicine in the division of gastroenterology and hepatology at Keck Hospital, and director of clinical outreach and development for the Keck School of Medicine of USC in Los Angeles.

"However, in the standard set-up, like at USC or neighboring Los Angeles County Hospital, after a GI consultation, patients are still required to present at the GI unit with a nurse present when swallowing the video capsule, and sometimes even have to stay at the hospital until the capsule has been excreted to return the equipment – belts and recorders," he continued.

Then technicians need to download, compile and store the videos, which then have to be analyzed by doctors in a session that can take as long as 90 minutes.

"Furthermore, rural health centers and community hospitals from California, Arizona, Nevada and beyond had reached out to USC to ask for help with GI diagnostics, where they either don't have any GI facilities, no capsule endoscopy equipment or no experts able to conduct the procedure," Jutabha explained.

"USC turned to GI Digital, a company with a long history in providing capsule endoscopy services and related technologies through its sister companies in Europe and Southeast Asia, to create a USC platform for GI via telehealth, or 'Tele-GI,'" he said.

"This solution is about establishing a platform that can bring other imaging technologies online. Capsule endoscopy was the most straightforward one for GI."

Dr. Rome Jutabha, Keck Hospital and School of Medicine of USC

The goal was to leverage the general change in acceptance of telehealth while deploying the technology in GI. Before the pandemic, there was real resistance by physicians, patients and insurers to adopt telehealth. Then with COVID, suddenly almost everyone accepted it.

"What we quickly learned was that patients liked it for various well-known reasons – stay at home, avoid travel efforts, limit exposure to pathogens, less wait time, etc.," Jutabha recalled. "Physicians had to start doing telehealth, but felt constrained that they couldn't see the patient in person and – especially during the height of the pandemic – couldn't do any procedures.

"This created a mounting backlog of GI diagnostics, forcing them to act," he continued. "When then also the payers agreed to pay for these telehealth diagnostics, we finally embraced capsule endoscopy via telehealth – or tele-GI."

Now, the technology underlying the tele-GI platform keeps improving, he added. Also, telehealth visits are widely accepted, so it will certainly expand further from here, he said.

PROPOSAL

During the pandemic, Keck Hospital and School of Medicine of USC was not able to do GI screening for Barret's, varices, cirrhosis, colon polyps and cancer.

"We couldn't perform screening procedures without exposing staff to COVID," Jutabha explained. "What we wanted to do is to do all data acquisition, reporting, etc., remotely, followed by a telehealth visit.

"Those outcomes would then prioritize procedures for those patients that require them the most and tailor interventions accordingly," he added.

Keck turned to GI Digital's telehealth service for GI diagnostics, or tele-GI, which is combined with what the vendor calls its Tele-GI Smartbox, to support the four main components of the capsule endoscopy procedure with telehealth: pre-procedure, procedure, post-procedure and reporting.

"While the Smartbox directly enables the procedure-related tasks with patients and patient-facing medical staff with telehealth, the video analysis and reporting uses software called Tele-GI PEARL to facilitate remote work for the experts," Jutabha explained.

"All technology and services are capsule vendor agnostic to make sure any choice our physicians, partners or patients make can be supported," he continued. "Furthermore, the whole tele-GI workflow has to be aligned with the existing telemedicine program at USC, such USC tele-care – with vendor Teladoc Health – and Powercharts."

A virtual-care committee oversees the compliance with legal and other procedural requirements, and Biomedical Engineering ensures new capsule technology is introduced in a coordinated way.

MARKETPLACE

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MEETING THE CHALLENGE

Many administrative aspects had to be resolved before the system could be fully operational at Keck Hospital and School of Medicine of USC. This severely delayed the implementation.

"We opted for a process that leads straight into standard care to avoid the pitfalls of abandoned telehealth projects," Jutabha noted. "However, that also meant many more stakeholders are involved, more processes need to followed and some newly created, and approvals be received.

"With the lack of availability of many of them due to the pressures of the pandemic, that means we have only just initiated the first patient pathway expecting to conclude our phase 1, which runs at the USC campus in L.A., as well as the neighboring LA County Hospital, early this year, and then to rapidly connect the partner sites in Bear Valley, California, and in Arizona, to conduct up to 400 procedures before the summer of 2023."

The core tele-GI team at USC and GI Digital has taken the lead since the first days of the project.

"It's comprised of gastroenterologist professors, residents and interns; administrators; and nurses at USC, as well as business and technical leadership at GI Digital, including their service delivery manager," Jutabha said. "The project is sponsored by the head of the GI division.

"While the current capsule endoscopy delivery teams get appraised of the progress, we intentionally start by making this solution complementary, to avoid any disruption to the standard process, before everything has proven successful," he added.

Also, the technology is what staff call "loosely coupled," meaning any integration with existing systems is minimized in the first two of three phases, opting for manual steps, for example, to upload a report or archive a video to avoid the added complexity of an IT project.

However, the data flows will already be standardized to specify all requirements and be able to seamlessly start the IT integration work and be ready for an efficient standard-care delivery, Jutabha said.

"Furthermore, we are looking to use the 'reader pool' infrastructure to train more experts and give young doctors the opportunity to learn about the procedure and step into the role of a 'pre-reader,'" he explained.

RESULTS

Telemedicine visits for patients with obscure GI bleeding have become common practice for Keck Hospital and School of Medicine of USC. Staff members have started with small bowel investigations, where capsule endoscopy is the gold standard, and are planning to move to esophageal, gastric and colorectal diagnostic tests.

Throughout the first quarter of 2023, we will the organization will be seeing about 100 patients via the new tele-GI infrastructure.

USING FCC AWARD FUNDS

The FCC's telehealth grant program awarded Keck Hospital and School of Medicine of USC $895,102.

"The existing telehealth solutions for radiology have already been successfully used for many years, and we are finally able to adopt this innovation in GI," Jutabha summed up. "This solution is about establishing a platform that can bring other imaging technologies online. Capsule endoscopy was the most straightforward one for GI.

"The majority of FCC funds has been allocated to acquire all the infrastructure, software and equipment, the set-up and training both for the delivery staff as well as the experts – in line with the defined scope of the project," he concluded. "Normal reimbursement will initially supplement the rollout and then become the standard funding once the project has moved tele-GI into standard care."

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Email the writer: bsiwicki@himss.org
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