**Transcript of Cyberseminar**

**VIReC Clinical Informatics Series**

**Promoting Patient-Centered Care by Home Automated Telemanagement in Multiple Sclerosis**

**Presenters: Mitchell Wallin, MD, MPH, and Joseph Finkelstein, MD, PhD**

**February 19, 2013**

**Promoting Patient-Centered Care by Home Automated Telemanagement in Multiple Sclerosis**

**February 19, 2013**

Moderator: Welcome this session is part of the VA Information Resource Center’s ongoing Clinical Informatics Cyber Seminar Series. The series’ aims are to provide information about research and quality improvement applications in clinical informatics and also information about approaches for evaluating clinical informatics applications. Thanks to CIDER for providing technical and promotional support for this series. Questions as Heidi said will be monitored during the talk in the Q&A portion of Go to Webinar and VIReC will present them to the speakers at the end of the session. A brief evaluation questionnaire will appear when you close Go To Webinar, please take a few moments to complete it. Let us know if there is a specific topic area or suggested speaker that you would like us to consider for a future session. At this time I would like to introduce our speakers for today, Mitchell Wallin MD, MPH, and Joseph Finkelstein MD, PhD. Dr. Wallin is Clinical Associate Director of the VA and that Center of Excellence East and Associate Professor of Neurology at Georgetown University and the University of Maryland’s School of Medicine. Dr. Finkelstein is Informatics Associate Director of the VA MS Center of Excellence East and Associate Professor of Medicine Division of Geriatric Medicine and Gerontology, Department of Medicine Johns Hopkins School of Medicine. Without further ado may I present Dr.’s Wallin and Finkelstein.

Dr. Mitchell Wallin:Thank you Margaret for that nice introduction and it is a pleasure to talk to the audience. Our talk will be divided, I will start out, my name is Mitch and Joseph will follow about halfway through and then we will have some time at the end for questions. The topic is promoting patient centered care by home-automated telemanagement in multiple sclerosis. Hopefully this is a model that can be used for other chronic disease and we are going to share a little bit about what our work is and what we have been doing. So by way of disclosure I have listed our grant support and I have no conflicts otherwise to declare. I would like to start with just an overview of Telehealth, talk about how Telehealth is used in neurology and then how we have used it within multiple sclerosis to try to improve care. So we have come a long way, the past two decades have seen the preinternet era, we have gone to e-records in the development of CPRS in the 90’s now we have gone full bore into Telehealth visits and even Telemanagement so a lot of things have been happening within healthcare as far as IT developments. 

So Telehealth really is taking charge of your healthcare when and where you need it and it is using technology to provide care remotely essentially and there are a few different buzz words that have been flying around different directives of the VA. One of the main ones is CVT or Clinical Video Telehealth that really stands for realtime video conferencing to provide care to patients that are at remote sites. By and large this is mainly clinic to clinic or clinic to hospital but over the last even year several VA’s have used CVT into the home. The other major type of Telehealth is defined within VA directives is Store and Forward and that is use of technology to either acquire stored clinical information like images or other data that can be forwarded to another provider at another location. Now home Telehealth can combined both of these things and it is really using technology in various forms to care for patients in the home setting. So My Healthy Vet has seen a lot of progress over the last three or four years, it is really has gotten enhancements over the last year or two, it is a free online health record as many of you know. It is secure which is very important and behind a few firewalls and it is HIPPA compliant and it is also integrated into the system.

So the Patient Protection and Affordability Care Act sometimes called Obama Care was approved in 2010, within that act there were a number of provisions to try to promote care in patient centered medical homes. These are homes comprised of a team of health professionals that would provide comprehensive care and this concept really started in the 60’s in the United States in pediatric clinics especially with complex cases like pediatric cancer patients and it evolved from their but I think it has taken on new breath with this new initiative. And also in 2011 as part of the Honoring America’s Veterans Act, there was money and funds set aside for IT capabilities to improved healthcare delivery. This scene within VA with the medical home has also caught a lot of attention including the Secretary as part of his mandate for improving care.

So there is a group of primary care physicians and leaders that got together in 2007 and defined what was meant by the patient centered medical home and these are the joint principles that are sometimes throw out in various forms and literature that every person would have a personal physician. There is a whole person orientation, in other words that the care is to take into account the physical, mental health and social aspects of the individual patient. The care is integrated from the ER to operating room to chronic visits. There is quality and safety, in other words benchmarking, there is use of evidenced based tools and there is enhanced access which rally means IT tools such as the internet and some of the things we have talked about with CVT and Store and Forward. So not only primary care groups but an 18 specialty societies including the American Academy of Neurology that have bought into this concept of the Patient Centered Medical Home. These groups often care for patients with complex chronic conditions and there has really been the promise that by using this model of improved coordination, improved quality and efficiency but there are also a number of concerns, some of the ones I have listed here, unrealistic expectations as far ass how far you can go. How will these services be reimbursed which is a big roadblock in implementing these things outside the VA system at least, and implementation challenges for those small groups or individual practitioners that may find it hard to do this.

So what are the implementation challenges of Telehealth in general? Well first of all there is variability and unpredictability of symptoms in somebody that has a chronic condition. How do you validate these changes and how do you make sure that data is secure. Obviously patients want to make sure they are diagnoses or confidential information is not going to float over the internet and there also are patients out there that still do not use a computer or they may have disabilities that may interfere with this use. Reimbursement is still a major issue and we need IT support to maintain these systems and we need to know if docs using these or other healthcare providers using these systems are able to evaluate them and be able to use them confidently. 

So switching towards Teleneurology, which really is neurology at a distance, there have been a number of initiatives that have gotten underway. The biggest boom in studies and assessments is in stroke and this was initiated in the 1990’s and really geared toward acute stroke management. So these hospitals that maybe are not aligned with a stroke center have used Telehealth to evaluate patients to deem is they are candidates for Pharmalytics and the American Heart Association has given Class I evidence for the reliability of the remote NIH Stoke scale exam. And so this has been through a number of studies and a number of reliability checks to show this is a valid way to evaluate patients. There have been a number of pilots in Teleneurology for other chronic diseases including Parkinson’s, Epilepsy and general neural rehab and MS but they have been small. Everybody wants to know does this really saved money, there really has not been a lot of broad studies but there have been a few that I will mention here. There was roughly just using Telehealth visits site to site there was a saving of ten percent in epilepsy patients that was published a few years back. Critical care using robotics in ICU produces savings of a million dollars in one major ICU over a year’s period and there are some reduced costs to patients in the Parkinson’s Cohort that was studied over a short period of time, Samii and colleagues in 2006.

So there was a survey published just this past year about how telemedicine is used in a leading US Neurology departments, this is a survey of 30 top neurology departments as published by US New and World Report and they really surveyed the neurology faculty or department chairs to get this information. So sixty percent overall response rate and there was a major use in stroke as well as critical care neurology. Most of the programs were started between 08 and 2010 and you can see here the biggest challenge in this little graphic was reimbursement, eighty-four percent said that we cannot be reimbursed for this so that was a huge drawback. For the figure it says provider lack of interest so over half the docs surveyed said they were not that interested in doing this. On the other hand almost six percent of patients said that same so it is interesting to see just in this basic survey data out there why people are avoiding or not using these technologies that are out there and available.

So integrated multiple sclerosis care, multiple sclerosis is a chronic disease, it is the most common progressive neurologic disease in adults and there have been a number of surveys that said there are a lot of unmet needs out there in cure delivery and there is a lot of fragmentation and discontinuity of care. There were few teams that tried to do something about that in these studies. One group used a multi disciplinary community team to work with them, as specialists to try to integrate some of the social and rehab issues in with the primary neurologist and it seemed to improve. Outcomes another group uses a home based cure team to intervene and try to also improve quality outcomes which had some success. But even if we look at all the approaches we are using now, even within VA, many of these approaches do not utilize evidence-based models of chronic care. The current technology even though it is very nice is not very cost effective, it is often time provided with big IT contracts that may not be cost effective to integrate into other systems. We currently do not have a great system in use that really fully integrates into Vista. So this is PACT system, many of you are familiar with the VA’s version of the primary care medical home or the patient aligned care team and at least we have been promoting ourselves within the MS centers as a primary care medical home neighbor. So in essence that we co-manage patients with the PACT groups, the primary care groups and I think working out the details in how this would work is what we are trying to do right now. And how does Telehealth integrate with all this is another question that I think hopefully can try to answer with some of our various projects.

So the VA MS center of excellence has been around for about ten years, and we started a number of initiatives. One of our mandates is actually to back up a little bit was to use Telehealth to improve care within the VA system and we have done a number of pilots including a Viterian system, but we needed a system survey questionnaire that was really helpful in trying to understand MULTIPLE SCLEROSIS patients. However, we found that the platform was a little bit hard to be integrated within Vista and it was hard to change and modify according to patients that had issues with plugging into the standard form line. But we wrote that up and it is going to be published this year. We have done a tele pilot with USB cameras modeling clinic to home visits and found a very high degree of reliability and accuracy between the live visits that we do with the neurologic exam and the remote visits. We have several other projects that are under development including a MULTIPLE SCLEROSIS  HAT demonstration project. We have a physical telerehabilitation trial that is going to start soon, adherence pilot using HAT and a cognitive rehab pilot. We have been doing a number of thins in clinical and video Telehealth including a remote exam between two VA’s that was published a few years back and we are also doing rural CBT pilot project that is looking at how we use a remote exam within day to day management. And then we have a Store and Forward kind of assessment using multiple sclerosis HAT to remotely assess cognitive function.

So I think that there are a number of things that we would like to show directly and Joseph will talk about things but this is from a thirty thousand foot view, the studies we have done, the data showing that the remote exam is similar to the live exam in almost every respect. There are a few things that we cannot assess to a great degree but I think it is fairly comparable and patient satisfaction is high when we use these tools. We know we have been able to save money in terms of getting patients to the VA versus just doing the visit from home or CVT and also we have been able to enhance multi discipline care through these procedures. So to just give a highlight into HAT and what it is and HAT is a platform, a research bed developed by collaboration between Hopkins group that has been using it for other chronic diseases and we basically integrated multiple sclerosis into the system. It is really designed to help patients follow their self-care plans, healthcare practitioners to follow that plan and then facilitate the multi component disease management. 

So this a technical design of HAT, there is a patient unit, there is a HAT server and a clinical unit. The patient unit can be anything from a smart phone or the WII or just a regular traditional computer but any kind of internet connection can be potentially used as a patient unit and a HAT server processes data and then it presents it to clinicians. Here is an overall picture of the HAT system, it \is a very flexible internet based platform that can work with mobile devices, with serial connected computers, smart phones or a desktop. And what we tried to do through a project that uses, central offices has given us some funding for us to integrate this into Vista, into their Austin automation center and try to have it integrate with the data that we get from this system. So it has taken us a year and a half, we have slowly been climbing up this mountain. Those of you that deal with this stuff or IT issues in VA know this is not an easy task but we have been able to get through the security issues  and Joseph’s team has been working regularly with the Austin people to try to connect our system with this secure firewall. So without further ado I am going to let Joseph take the next several slides here and then we will come back together at the end.

Dr. Joseph Finkelstein:Thank you Mitch, I am Joseph Finkelstein and I am delighted to be here and thank you so much for joining our webinar. The conceptual design of home Telemanagement system, which Dr. Wallin discussed, is based on consecutive, iterative, and step wise implementation process which was employed by multiple sclerosis center of excellence during the last decade. Over these years, we started the right of care components, which potentially can be delivered to Veterans with multiple sclerosis by different telecommunication, or computer assisted modalities. And in a slide, I would like to present four major components, which we evaluated for, and we put together a full-scale home telemanagement system, which is now being implemented, at Austin Automation Center. So four components which we analyzed were interactive patient education and counseling, telerehabilitation, remote neurological examination and patient home care management, next slide. So the first project which started about ten years ago when we recognized that patient education and counseling is a crucial component of patient engagement and empowerment and is required to deliver truly patient-centered care. So we develop then an interactive web based education portal, which can remotely educate and inform patients with multiple sclerosis about their condition. And it was developed using certain concepts of adult learning theories so that it would be able to match patient comprehension rate and keep them involved and excited about this so they do not get bored or discouraged by very complex components. 

So it was about ten years ago where widespread use of this kind of technology was not still available and one more  major question is how well multiple sclerosis would patients accept this and whether it would result in any changes in their knowledge score and what would their suggestion be. Next slide. In the next slide you can see the results of this initial evaluation and what we found was very exciting that even then there was a very high uptake from multiple sclerosis patients in using these interactive technology. One hundred percent of them claimed that they would advise other multiple sclerosis patients to use these kinds of interactive education co-modality. They felt that the way the material was structured an interactive way where each fact is delivered in a tailored way with constant feedback in allowing them to understand what they answered correctly, what is not. And in a very simple kind of screen design resulted in a high support and approval and moreover there was twenty-two percent improvement in knowledge score. So it was very encouraging for us, we got also very interesting feedback from multiple sclerosis patients. For example many of them are very concerned about their cognitive level and they received their negative feedback from this program which included feedback when they answered incorrectly. They did not receive it well so we had to restructure this to deliver it in a way which multiple sclerosis patients felt more appropriate. Some multiple sclerosis patients had certain visual impairment, blocked vision or some of them were legally blind but still they were able to use this because the interface was developed in the way which was very simple, did not require even using a mouse.

So this was our initial teaching moment and one of the issues, which were discussed with multiple sclerosis with these interactions, was that they want to be actually involved in their care, they want to be in constant communication with their care management team and they want to be involved in ongoing rehabilitation process. So next slide, so this point that is the next component that we evaluated which was physical telerehabilitation in multiple sclerosis. As we know, the lifelong rehabilitation measures together with medication treatment are major components in multiple sclerosis patients. Management and physical exercise and particularly certain physical therapy programs were found very effective in multiple sclerosis patients both immediately after the (inaud.) and also as a long-term maintenance program. However current improvement structure does not support fully continuous physical telerehabilitation so computer interactive web based system may facilitate rehabilitation, next slide. 

So our objective in this study was to assess disability of supporting structured physical rehabilitation program in patient’s homes, next slide. So the system again the design was the same as Dr. Wallin just discussed, it consisted of patient unit which was actually a touch screen tablet which allowed the patient to go through their exercise program. It consisted of a server, which was more toward the patient exercise log, and clinician unit, which allowed physical therapy team to setup individualized treatment program. What you see right now with this slide, it is a clinician unit, and patients do not have access to this particular site. This is basically a web based prescription pad for physical therapists who evaluates patients on both their visits and based on individualized relation and identifies particular deficiencies in the patient status including muscle weakness or gate and balance deficiencies etc. they choose particular exercises from this prescription pad and they prescribe it in an individual way, setting up for each patient an individualized number of repetition sets and etc. also they train patients during this visit how to carry out this exercises. So once it is setup and approved, this exercise program is sent to a patients unit, next slide. Patients are following the exercise program on a daily basis in a guided way and I will show you in a second. The exercise logs, daily exercise logs are automatically sent to a system support sorter and are analyzed in terms of patient adherence to exercise program, any side effects from exercise, any complaints or just patient requests to be contacted by physical therapy team. And this screen just represents also the clinician’s unit screen where results of particular exercise is presented, next slide.

So this is what patients actually see, as you see it is an extremely simple design, patients do not need to know actually Windows or Internet Explorer or any other. There is no requirements for various computer experiences. Once the computer is turned on they immediately see the screen, they start their exercise and then they see utilized exercise prescription, next screen. And then the screen is presented where detailed information about each particular exercise is provided in terms of what particular steps are involved in carrying out this exercise. It states several cues how to conduct this exercise correctly, safely, including the image of exercise and also a video clip which they can run while performing the exercise. So after that patients report, actually immediately after each exercise, how well they completed the exercise and whether they are experiencing side effect after each exercise. So patients also constantly are kept aware about the importance of self-care in multiple sclerosis and each day they receive the message of the day and the next day they will get multiple choice question about the message that they had yesterday. If they answer correctly they get encouragement, the next message is  answering correct and they get the same message again. So this slide shows the patient also correct and they get congratulations screen and they move on to the next message. Messages are sequenced from very basic notions to more complex, kind of a story, which is cut into tiny tiny consecutive pieces so it is not random messages, it is ongoing education and delivery of occupation activation  as a part of  telerehabilitation experience. 

So we started this modality in 12 patients with multiple sclerosis who had multiple sclerosis for an average of 13 years, next slide. So our major outcome was Berg Balance Scale and Six Minute Walk. So patients were evaluated as a baseline and after 12 weeks of using this telerehabilitation program, so what we found that there was a statistically significant improvement in Six Minute Walk, Distance, and next slide. And also improvement in Berg Balance Scale which was really very significant, next slide. So we felt that providing patients at home individualized self care tools was very, very important and met real support from all multiple sclerosis patients. One of the issues which they suggested also was the ability to communicate remotely with their provider not only in terms of their immediate self management issues but overall to participate in remote examination and we decided then to evaluate whether it was currently cost effective way of utilizing web based conferencing to facilitate remote neurological examinations. So one of the solutions that we implemented here is that we used low cost web cams, which currently are just imbedded in your table or laptop, and the average price was about twenty dollars. And our question was is it possible to utilize these cost-effective and widely available technologies to get some assessment, some neurological status of these patients and how well it compared to in person evaluation, next slide. 

So we used digital conferencing complication which utilized low cost web cams and we also wanted to evaluate acceptance of this kind of technology both by patients and providers, next slide. So this is an example how you see there is a huge red button, it was based on multiple requests from patients, they consider this as a direct visit to their home and they wanted to make sure that they can connect and disconnect immediately at their volition and have full control of video conference session, next slide. So we did a evaluation in 20 patients in which we implemented a cross over study where the same patients that were evaluated both in person and remotely and that the order of remote or in person relation was chosen at random, next slide. So what we found this slide represents our most important outcome that the... overall, the user of this technology allows remote evaluation of EDSS in multiple sclerosis patients. One thing, which I want to mention, is that in our evaluation the patients also had a caregiver, proxy caregiver who assisted them to carry out certain tests as a part of EDSS. So and what we found is that particularly in higher level of neurological disability the evaluation is very precise, less neurological impairment they have, less precise it is because it requires much more in-depth review and more interaction with neurologists. But overall, we concluded that this matter of modality could be at least a useful proxy to evaluate remotely in a very cost effective way, the neurological deficiencies in these patients, next slide. 

We also were very concerned about how patients responded, how well they accepted because previously in our experience some patients express concern about video visit by being concerned that this video visit would replace their direct contact to their providers. However in our experience and we did an in-depth semi structured qualitative interviews the majority of patients really embraced this kind of modality of Telecare. And they felt particularly in multiple sclerosis patients who’s mobility is limited and that Veterans that maybe are located in a remote location and have challenges in getting to a hospital, this was really a modality which they fully supported, next slide. So what we learned just to summarize in terms of success factors of four applications which deliver telecare at home and support self management in multiple sclerosis patients that interface and the way the quantity is delivered very important. So this slide represents certain requirements, which we embedded in following versions of home telemanagement systems before that the screen uses large forms it includes color markers. There is only one task per screen; there is a prompt on each screen so there is no way to get lost. Each screen clearly indicates where to go. It provides some adaptation to various disabilities like vision, lack of motion, audio cognition and allows incorporating using remote control audio and voice. 

It is very important to be persistent and respectful when training patients, some patients it may take a little bit longer for them to grasp all requirements but after they get this into a routine, it works very well. There should be a clear statement of individual advantages for each patient, they need to understand why it is being done and what particular advantages that they may get in terms of improving their quality of life and care and one of the most prominent articles for patients which was repeatedly indicated to all our telemedicine endeavors was knowledge that information which patients provide to our telemedicine systems is delivered and reviewed on a timely basis by care management teams. Many patients also voiced interest in [getting] tailored content because the symptom part is so different in different multiple sclerosis patients so they really want content which is tailored to their individual symptoms. They want also to utilize multiple heath communication channels meaning that when they access it though the web, through cell phone and other modalities and our goal overall to improve self-care self-efficacy meaning that  patients are so confident in caring for their condition.

So based on all of these accumulative studies, we were fortunate to obtain funding from [inaud.] Innovation Project which was followed by support provided by The Veteran Health Administration Office of Specialty Care. And we were able then to implement a fully web based and interactive home telemanagement system for multiple sclerosis patients and this screen represents a screen, which is delivered by via web-based or other channels and you see it is very simple. Everything can be just used as a touch screen, as a touch button and they immediately can access their individual diaries and carry out their exercises, do education and also communicate with providers. And the screen on the bottom show that how simple here it is for patients to enter their diary and this is actually is an interesting question on coordination and dexterity so the clinician sees their dexterity is limited is very important to provide interface which would allow to report about that, next slide. So this screen shows actually that the clinician part of the telemanagement system, which allows a very detailed and tailored way to prescribe individual exercises to prescribe individual patients to prescribe individual surveys. To actually come out with individualized calendar when surveys of diaries or questionnaires are administered come up with reminders and allow implementing and tailoring decision support coupled with individualized treatment plan, next slide.

So we evaluated this approach in 40 Veterans and we found that there was overwhelming support of this kind of technology, the majority of them felt it is not complicated. They felt that it is very easy to report their data and they felt that they can use it in the future, next slide. So they also expressed interest in communicating with their provider via this system and overall eighty percent of them rated this kind of system as excellent or good, next slide. So we also monitor their adherence to self-testing, meaning in each new system there is a lull affect where interest gradually wears off. So here with their adherence to self testing over four weeks and you can see that initially their first week one hundred percent of patient used the system and up to sixty percent in the next week. However our system implements a closed feedback loop where it monitors patient up here and it informs care management team if patients do not do the test on time or [inaud.] strength is detected based on symptom reports and other parameters. So here you see that actually our feedback loop worked were patient were  contacted to do their self testing and actually explain in some cases by phone why it was important and the adherence to self testing increased to seventy five percent and continues at seventy percent level, next slide. We also studied what are the factors that will affect successful acceptance of this kind of system. What was interesting and this was the result of linear logistic regression where the primary dependent variable but was acceptance score, and so it is a sum of an answer of particular options on the actual survey and their independent [inaud.]. Where how long they had multiple sclerosis, age, computer use, English proficiency, education, race, what we found that age, education and race did not affect acceptance. What affected acceptance how long they had multiple sclerosis, patients who just recently were diagnosed with multiple sclerosis were much more likely to embrace this kind of system and maybe reflected their kind of quest for more comprehensive ongoing support. Previous history of using computers at home was highly significant factor and also English proficiency, next slide. 

So patients also provided us very valuable feedback about what they think about these kinds of technologies and how would they like to use them in the future. So here are the results of our semi structured quality interviews and this was enormously valuable feedback. So most of them as you see from the citations from patient testimonials really embraced the concept of self-testing. They said I like the whole concept of self testing using the computer. They also believe that using the computer was easier than using the remote control. One very characteristic feedback was following, my symptoms may disappear, and my symptoms might disappear by the time I meet my doctor. Multiple sclerosis patients have memory problems too, if I do not record it I will forget to tell my doctor, it keeps you mindful and aware of your condition. Another patient said I thought it would give a better sense of how patients are feeling on a daily basis. So what they say is that they would like also to follow the trends on their home unit and it gives them more awareness about their condition. And the notion that their doctor can review it when needed is also crucial as was stated at the phone call, it is very important to me that my doctors can review my results from the diary, I would only review them occasionally, next slide.

So also we wanted to find out how frequently these patients would be able to enter their data and the consensus was that overwhelming that at least once a week they are ready to report their information even if they feel very well and their condition is very well controlled. So they would prefer to enter it more frequently when they feel that the symptoms that they need to communicate with providers. Many of them were interested to document their side effects so the one patient stated that I also want to document side effects from medication. I may get flu like symptoms from the medication. All of them stated that the education component which continuously provided them awareness and empowerment using interactive patient education module was very useful. So one patient stated the education was good, it is a good part of the program, and it helps to reinforce the knowledge. Another patient stated I like how there was a question after each message and the quiz is a good way to help with memory and get you to remember the information that you read, next slide. So as we found previously the webcam and the remote Televisits with providers may a very powerful component for delivering future care for these patients. So one patient said the webcam would be good for me to talk with my doctor and if I have any problems, the doctor would be able to see what is wrong and I would not have to try to remember any problems that I had between doctor visits. Another patient stated that web based access is particularly important for him because I can access it any time according to my schedule and it makes me more confident to report how I feel. I think the computer is the best way to digitize the symptoms and see the trend because it is a positive thing that they use to manage their disease.

So one of the very exciting messages from patients was that using this kind of technology made them more confident and self aware about their condition. Another patient stated I feel more confident with managing my multiple sclerosis while being monitored by a computer. It was very convenient that I can do it at home, no driving involved, next slide. So these findings allowed us to build an overall conceptual design over comprehensive daily care support for patients with multiple sclerosis, which Dr. Wallin would describe. 

Dr. Mitchell Wallin:So I think Joseph nicely talked about some of our programs and the iterative process we are gong through to develop multiple sclerosis HAT from a variety of conditions within multiple sclerosis and this slide is a summary and then the last few here I will just quickly go through so we can get to questions. We are doing an adherence trial with MS HAT looking at one of the major medicines used to treat multiple sclerosis, interferon beta and doing a followup of the parental-based injection which is once a week with also an oral based medicine. And trying to see if we can improve compliance and in the group, that gets the HAT and this would be a major step forward for both parental drugs and oral drugs that could be applied to other diseases if it works. And we talked about the physical Telerehab trial, we are have launched the Merit review with 100 patients, we will be starting to recruit shortly and in three to six months we will look at outcomes in the HAT group versus routine care.

So conclusions telehealth can improve access and integration of care in patients with multiple sclerosis. MS HAT can be a very efficient platform for our management with a variety of different modalities and issues that multiple sclerosis patients face and I think it is important that we try to emphasis these tools must be tested in the clinical setting and by patients and providers for them to be effective. I think all of us have looked at products that we get from the shelf that never have the  testing with patients and providers and they really are challenging I think like CPRS was developed in the VA for clinicians and I think that system has been fairly robust and easy to use. So the rest of our team who has been working on some of these projects, we have had both multiple sclerosis centers in the east, Baltimore DC and Hopkins and questions, thank you.

Moderator: Thank you both very much, there are a few questions already and I think probably more will be typed in as we go along. First one, are patients able to print out the report after each session to review with family members or other concerned individuals?

Dr. Joseph Finkelstein:The system provides actually monthly reports which are generated and potentially can be sent directly to providers plus on the home unit there is a functionality where they can review trends for each particular question or survey. Or their symptoms which are collected in the disease diary and they can then print out through just regular printer connected to their computer.

Moderator: Next question, do you think these tools are better for certain conditions or disease populations?

Yes, go Joseph.

Dr. Joseph Finkelstein:We think that the content and frequency may differ but the overwhelming agreement right now is that care management, care coordination and disease management in prevention is crucial for promoting health and quality care. The overall design of this kind of telemedicine technology, which supports continued self-testing, individualized symptom diary and communication with providers, awareness and empowerment by interactive education and social support is actually a part of Wagner’s model of quality care management, which is applicable to any disease.

Moderator: At the moment I do not have any additional questions, a few may come in let me just say what I would like to say at the end which is to thank you both very much for taking the time to develop and present this talk. And let the audience know that our next scheduled session is for Tuesday, March 19, Jody Trafton will be presenting on Creation of a Mental Health Information System to support VA Office of Mental Health Operations Quality Important Initiative. Let us see if there are more questions, there are none at the moment, if people have further questions they can submit them to VIReC at our help desk, virec@va.gov. I believe our speakers email addresses are on the slides which you can get copies of or have gotten copies of and people could contact both of you directly is that okay?

Dr. Mitchell Wallin:Fine

Moderator: There are no more questions coming in so I guess we will bring this session to a close. Thank you both Dr. Wallin and Dr. Finkelstein, thank you for presenting and hopefully we will see you all in a month, bye bye.

Dr. Joseph Finkelstein:Bye.

Dr. Mitchell Wallin:Thank you.

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