Quality and Outcome Measures
From the suggested CMS measure list, we selected the following quality measures: Imaging results for acute stroke patients within 45 minutes, follow-up after hospitalization, timeliness of Emergency Medicine Care, National-Caregiving Alliance survey, and Hospital-Wide-All-Cause Unplanned-Readmission measure, which is also an outcome and process measure. We also chose the following outcome measure called Participants-All-Cause-Mortality. For more information about how these measures will help to evaluate and measure the success of our program, please see our Operational Plan.
We selected the following individual validated measures unique to our program to assess quality and outcome:
(1) Time to written and verbal treatment recommendation in the ER to evaluate timeliness of emergency medicine care and the effectiveness of THS improved ER patient care quality.
We define time to treatment as the first treatment decision made by the neurological or neurosurgical specialist contacted by the referring physician. This treatment decision can be as simple as starting steroids for brain tumors, administering seizure medication, or as complex as flying a patient who needs emergency neurosurgical intervention to UNMH, or discharging a patient home for a local follow-up with the telehealth clinics. The time from ER check-in to the first treatment decision will be measured in the control group and the usual-care group. In some cases the first treatment decision by the neurosurgical specialist will not be carried out in the usual-care group until the patient is seen in clinic or transported to UNMH. Our onsite research team will be sure to track this measure once the patient is enrolled in the NMXS database, which happens any time a telehealth consultation is initiated. The limitation of this measure is that there might be a delay between the time of the treatment recommendation (that the HCP in the spoke hospital receives) and the HCPs ability to note it in the records. The PALS records at UNMH and the telehealth system will store the exam time the consult report was generated. Overall we think this is an important measure that may also lead to better outcome because timely treatment recommendations and triage decisions are especially important in neuro-emergent conditions where time is brain.
(2) Proportion of patients transported from the spoke hospital to UNMH or other tertiary referral center.
Our preliminary data(9,10,14) has shown that implementing telehealth for neuro-emergent patient care in the Indian Health Services system and in some high volume hospitals in NM could decrease transport to UNMH by 45% and save $1,484,700 in transport costs alone. Therefore we will collect the disposition status in all patients so we can calculate the proportion of patients transported. The limitation of this measure is that patients may be transported to another tertiary referral center. However, UNMH is the only Level 1 trauma center in the state and the only hospital taking emergency neurology and neurosurgery calls, so transport to another center would be rare. To account for this, our local THAs at spoke hospitals will record any disposition of all enrolled patients to also capture those transported outside NM. Decreasing the number of unnecessary transports will contribute to major cost savings.
(3) Patient experience and (4) Patient satisfaction with telehealth are measures to assess the patient clinical encounter experience and patients' satisfaction with telehealth encounters.
These two measures fall into the CMS domain category of general and population specific satisfaction. We selected two validated measures to assess as such in our enrolled patients: Patient experience questionnaire (PEQ)(19) and the Telemedicine Satisfaction Questionnaire (TSQ).(20) Both questionnaires are available in Spanish and English. The limitation of any survey is the low response rate. Following CHAPS' recommendation of mixed mode (mail, telephone, and email), we anticipate a 40% response rate. The feedback we will gather from these surveys will help us to maintain or improve quality of care and make necessary changes to our procedures. We will also assess, via self-assessment, the confidence of hub and spoke HCPs to make treatment decisions and care for neuro-emergent patients. This will be a means for us to evaluate our education program and identify possible knowledge gaps, which can be covered in our ongoing webinars.