PROJECT MANAGEMENT OFFICE
World University of Florida Maternal-Fetal Medicine Telemedicine Pilot Project
Version – 1.0
Last Updated – 9/25/2010
Date
Version
Description
Author
9/26/2010
1.0 Draft
Initial Project Management Plan
Group 1 Consulting
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Table of Contents
Project Overview
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Estimated Costs and Funding
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Stakeholders
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Project Scope
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Workflow and Process Integration
Management of Vendor Solution Implementation
Regulatory Compliance
Staff Augmentation
Training
EHR Modification to Manage Telemedicine Patient Records
Community Outreach
Project Management
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Organizational Goals & Objectives
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Project Overview
The World University of Florida Hospital (WUFH) Division of Obstetrics and Maternal-Fetal
Medicine (DOMFM) has partnered with regional health departments to expand access to
prenatal care and improve birth outcomes in underserved counties in Florida. The initiative is
modeled on a successful program at the University of Arkansas Medical Center called
ANGELS (Antenatal and Neonatal Guidelines, Education and Learning System).
The DOMFM provides obstetric care to patients with high-risk pregnancies, with the goal of
ensuring the best possible outcome for the mother and infant. One barrier to providing this
service is the distance patients have to travel to the University Hospital. A component of this
project is the creation and implementation of a prenatal telemedicine practice for the purpose
of providing ultrasound screenings to high-risk patients in underserved areas who would not
otherwise have direct access to equipment and specialists able to monitor high-risk
pregnancies. Through telemedicine, the reach of the Department can be expanded to
underserved rural counties in Florida.
This project has the specific aim of developing a working telemedicine pilot program in four of
the eight counties WUFH currently partners with through the counties’ respective health
departments. The health departments will be able to provide a live fetal-maternal medicine
consult with our faculty in the Department of Obstetrics. The first four listed counties
(Columbia, Dixie, Gilchrist, Hamilton) will be in the pilot with the goal of expanding to the latter
four (Lafayette, Levy, Marion and Suwannee) at a later time. Their combined population is
approximately 500,000 with the majority in Marion County (330,000). With an approximate birth
rate of 11/1000, this population produces 5500 live births annually. These counties have been
identified as rural with high infant mortality rates, and a lack of Obstetricians and other
specialists to provide prenatal care.
Other components of the Maternal-Fetal Medicine program outside the scope of the
telemedicine project are: 24 hour patient call center staffed with RNs and NPs who have
access to patient records, development of evidence-based guidelines, grand rounds, and
community education components.
Florida Maternal and Fetal Medicine Data & Statistics
Overall, women in Florida fall short of the Healthy People 2010 National Target of 90% with
only 75.9% of women receiving first trimester prenatal care. 15.7% of women did not have
access to prenatal care due to lack of money or insurance. 48.5% of women in Florida were
uninsured before pregnancy, and 33.6% of women who tried to get Medicaid had difficulty in
getting Medicaid during pregnancy. Florida has 7.2 infant deaths (younger than 28 days) per
1,000 (infant mortality rate). This is 22nd among the 50 states. 49.6% of Florida births are
Medicaid births, which is above the national average of 41%.
In the 8 target counties, the percentage of woman who do not receive early (1st trimester)
prenatal care ranges from a high of 36% to a low of 22%, and the infant mortality rate ranges
from 5.8 to 24.5 per 1000 infants. The rate of underweight births (<2500g) ranges from 10.8%
to 13.3%.
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The CDC has reported that preterm birth is the strongest risk factor for infant mortality. In
addition there is a strong correlation between lack of early prenatal care and preterm birth.
Consequently, one of the best strategies to lower infant mortality is to improve access to early
prenatal care. The infant mortality rate for those who do not receive early prenatal care is 40%
higher than in those who do (Mathews, T.J.; Macdorman, M.F., 2008).
Project Goals
This program will enhance the existing outreach programs by the county health departments.
This pilot will provide the means to identify high-risk pregnancies early, provide appropriate
interventions in the most convenient location and determine which patients require a higher
level of care. It will allow for early planning for the most appropriate place for delivery and what
services the infant may require at birth (e.g level 1 NICU, Pediatric Surgery etc.) Some patients
are expected to need delivery at our University Hospital, and thus the project should expand
the referral base of the University Hospital. However, the telemedicine consults will also allow
for deliveries by local obstetricians supported by our subspecialists which otherwise would
have required emergent transfer of the expectant high-risk patient. Thus, the program may
lead to lower overall healthcare costs as well as more convenience to patients.
The overall goal of this pilot will be to improve the quality of early prenatal care and improve
the birth outcomes in the areas served. We are hopeful that telemedicine will prove to be a
cost effective method to expand access to underserved populations. The success of the pilot
project will prompt state officials and private insurers to offer appropriate reimbursement for
telemedicine opening up the opportunity to expand the concept to all underserved areas.
Specifically, we will measure improvements by the:
 Number of prenatal telemedicine MFM and MD (non-MFM) consultations
 Increase in telemedicine consults from Year 0 to Year 5.
 Number of telemedicine consultations as a percentage of total high-risk consultations
from rural counties
 Number of referrals from pilot health departments
 Increase in number of successful high-risk deliveries from rural counties
Estimated Costs and Funding
This pilot project is an ideal candidate for a federal grant in that it addresses clearly identified
health care goals currently emphasized by the federal government. The program is an ideal
candidate for comparative effectiveness research as prenatal care and infant mortality both
show wide disparities among ethnic groups. In addition, it is an example of leveraging
information technology to improve health outcomes and improve efficiency in delivery of care.
There is considerable federal funding available for both comparative effectiveness research
and IT pilot programs. The program is also an example of patient-centered care, and focuses
on population health.
The full costs of the program are yet to be determined at this time. The intent is to apply for
and receive federal grant funding to cover the cost of the equipment and training. State health
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department funding will cover the ongoing clinical costs for the individual health departments.
An application to the state for a waiver to provide reimbursement for Medicaid patients is
underway. Negotiations with private insurers have also been started. The University Hospital
will receive reimbursement for professional services from these efforts.
Stakeholders
The internal stakeholders for the telemedicine project include:
 WUF Hospital Board of Directors
 WUF College of Medicine
 WUFH Department of Obstetrics and Maternal-Fetal Medicine
 WUFH Department of Pediatrics
 WUFH CIO
 WUFH CMIO
 WUFH CFO
 Chief of Maternal-Fetal Medicine
 Director of information Technology
 CNP
 Rural Outreach Coordinator
 Department of Medical Informatics and Biostatistics
 Director of Health Information Management
External stakeholders include:
 Patients and medical community from rural counties
 Florida Department of Health
 Medical Directors for Columbia, Dixie, Gilchrist, and Hamilton county health
departments
 Florida Medicaid
 Community representatives
Project Scope
Workflow and Process Integration
The pilot project will require careful consideration of existing workflows and processes before
the introduction of new workflows to accommodate the telemedicine component.
The planned telemedicine workflow will allow all health care providers in the region to make a
referral to the program by contacting the University Hospital. This will include patients cared for
at the health departments themselves as well as private physicians offices.
Accepted patients will be scheduled for a preliminary visit to the appropriate health department
where additional clinical and demographic information will be collected and sent electronically
to WUFH, where a patient record will be created in the EMR. Additional clinical records will be
collected by the RN associate coordinator including all relevant old medical records and
ultrasounds, laboratory tests etc. and added to the patient’s EMR record.
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The Clinical Coordinator will review the records and set up an appointment with the
appropriate physician. Additional instructions for preparation for the consult will be
communicated directly to the patient from the University Hospital.
Reminder notices will be sent to the patient by the University Hospital. The University Hospital
will notify the referring physician of the pending consult. A phone call the day prior to the
appointment will be made by the health department clinical coordinator.
The patient will be greeted on the appointment day by the clinical coordinator and prepped for
the consult.
At the time of the consult, two–way video conferencing will start between the specialist at the
University Hospital and the patient, who will be accompanied by the health department
physician/midwife and/or the referring private doctor (at their request only).
A physical exam, ultrasound, fetal tracings and colposcopy exam will be performed as
indicated by the local provider with real time electronic transfer of images/tracing to the
specialist. The specialist will then communicate orders for any additional lab studies to be
completed. The local clinical coordinator will arrange for any lab studies at the conclusion of
the visit.
Two way video-conferencing will again take place for the specialist to provide any initial
assessments and recommendations to the patient. A comprehensive treatment plan will be
completed after the consult and sent to the patient’s provider. If the consult recommendations
include additional telemedicine visits or travel to the main campus arrangements will be made.
Management of Vendor Solution Implementation
The telemedicine component of the project is involved with the vendor relations for
telemedicine equipment and connectivity, system installation at the University of Florida
hospital and health departments in the four pilot counties, as well as training and staff
augmentation.
Cisco HealthPresence has been chosen as a suitable vendor for telemedicine equipment
through grant funding for antenatal and neonatal screenings and consultations. Cisco
HealthPresence combines high-definition video and advanced audio for almost as real face-toface experience over the network. Cisco also provides fixed-price planning, design, and
optimization services to help increase business value and return on investment. The vendor
also promises the affordable maintenance and upgrade on their equipment and communication
systems.
The project involves managing the relationship with Cisco and oversight of telemedicine
equipment selection and installation, including:
 Documenting technological and bandwidth requirements for selected equipment
 Allocating staff and resources for vendor relationship management
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Placing orders for equipment
Assuring site preparedness including availability of utilities and facilities (power,
broadband connectivity, telephony, generator back-up, telemedicine consult room
availability, etc.)
Applying for required permissions for connectivity and other allied requirements
Monitoring progress of readiness at site
Carrying out any necessary software customizations
Carrying out testing, integration and fitness certification of hardware and software
Integrating and 'Hot' testing the complete application through connectivity available in
the central office
Ensuring the availability and adequacy of connectivity between WUF and county health
departments
Debugging any issues that may arise
Testing security protocols
Dismantling and packing equipment for transportation after initial testing
Stationing one team member at site during implementation phase to assist and advice
the client, and certify readiness of the TMC
Certifying that each site is ready for implementation
Collecting necessary documents and permissions for delivery of material to the client
site
Determining availability and delivery schedule of hardware
Transporting equipment to each health department location
Regulatory Compliance
Medicaid
The Medicaid guidelines state that reimbursement must meet standards of improved
“efficiency, economy, and quality of care”. States are given flexibility in determining a
reimbursement rate for services via telemedicine. At the present time, most states with
established Medicaid reimbursement for telemedicine reimburse a consultation fee for the hub
site while reimbursing for an office visit for the spoke site. States may also reimburse for
technical costs (i.e. tech support, on-line costs) if they can show it meets the requirements for
improved “efficiency, economy, and quality of care”. Private payer insurance tends to
reimburse fully for consultations, however a little over half do not reimbursement a facility fee.
BCBS of Georgia has developed a joint program with the state of Georgia to provide grants to
rural areas to buy and implement telemedicine technology with the belief that it will provide
better healthcare at a lower cost, and it is possible that we could use this project as a model.
So far the number of HMOs that provide telemedicine is extremely small. HMOs could be
encouraged to develop telehealth with tax breaks or block grants from the state.
Telemedicine
Telemedicine guidelines are still very broad. The main issues today are licensure of clinicians
and privacy. Each clinician at a facility must have the proper license and certification to
conduct telemedicine consults according to state law. Furthermore, guidelines must be
established to make sure only those clinicians who are authorized are viewing the telemedicine
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presentation. The state of Florida statute indicates that “physicians who order, perform, or
interpret diagnostic imaging tests or procedures are responsible for the appropriateness and
quality of the non-invasive diagnostic procedure, interpretation of the results, diagnosis, and
either maintenance of medical records or provision of the results of the test to the referring
physician.”
Staff Augmentation
This project will require additional staff or new roles and responsibilities for existing staff, or a
combination of both.
Information Technology Staff
 Full-time telemedicine IT Director plus 1-2 additional help desk staff for support and
maintenance. The IT Department will further evaluate staffing needs as part of this
project)
 Available technical support on site during telemedicine consult days (2 days/week)
 One IT liaison at each health department who with central IT backup can provide local
support during consults.
Clinical Staff at WUFH
 Obstetrics and Maternal-Fetal Medicine Faculty (4) and one fellow. These staff
members will be chosen from existing faculty.
 Clinical Coordinator: an RN or Nurse Practitioner at WUF full-time for the duration of the
initiative. Fifty percent of the Clinical Coordinator’s time will be for the telemedicine
component and fifty percent for the other components of the program, such as training,
development of evidence-based guidelines, coordination of community outreach, etc.
 Associate clinical coordinator (RN): one full-time employee for the telemedicine project.
This person’s role will involve travel to the health departments to assist with program
development and publicity in early phases.
 Pediatric cardiologist, Neonatologist, and Geneticist as needed for specialty consults
and weekly case review
Clinical Staff at County Health Departments
 Health Department Medical Directors and Clinical Staff
 Health Department Clinical Liaisons: a current health department employee (medical
assistant or other staff) utilized at twenty-five percent to schedule bi-weekly clinics for
each health department, including appointment scheduling and assistance during
consults.
Administrative Staff
 Secretary/Billing personnel: 4 full-time employees at University Hospital
 Patient records and documentation assistant at the University Hospital: 1 full-time
employee utilized at fifty percent
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Training
Training for WUF staff as well as health department staff will be essential for the initiative to
run smoothly. Training tasks include:
 Training WUF telemedicine staff on Cisco HealthPresence.
 Planning and preparing training materials including lesson plans, manuals, and the
creation of a staff-accessible training web site with library to how-to videos, forum, and
live technical support chat.
 Training health department staff in the field on telemedicine, advising patients on the
use of telemedicine, and Cisco HealthPresence software and hardware.
 Training health department staff on the use of the WUF EMR.
EHR Modification to Manage Telemedicine Patient Records
WUF’s EMR system will contain a patient record for each telemedicine consult patient, even if
the patient has never been to WUF before. Considerations must be made for
 Providing a mechanism for initial assessment and patient history as it pertains to
telemedicine, as well as a vehicle for importing CCDs and scanning paper records from
rural facilities.
 Providing the ability for health departments to access patient records in the WUF EMR
remotely through a web interface
Community Outreach
The telemedicine project seeks to expand its reach outside the realm of WUF and the pilot
health departments by conducting grand rounds and providing continuing education
opportunities to providers in the greater community. Video artifacts of teleconsults can be used
for educational purposes as well as for weekly case reviews.
Measurement of Patient Satisfaction
The telemedicine project will design and field patient satisfaction surveys at all participating
health departments to better understand patient feedback and gauge the success of the
project from a patient standpoint.
Project Management
Overall project management needs for the telemedicine project are:
 Creating and communicating with the project team on a regular basis
 Establishing a steering committee
 Providing a document repository for information for all project stakeholders
 Documenting the responsibilities of WUF, Cisco, and each county health department
and communicating those responsibilities to interested parties
 Creating a project work breakdown structure and Gantt chart, and sharing that
document in such a way that the latest version is always available
 Creating a risk mitigation plan
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Determining project governance and planning accordingly
Create a human resources plan
Finalizing the project budget and specific hardware and software deliverables from
Cisco
Planning for delays and exigencies
Testing equipment, connectivity, software, workflow, and processes
Planning for training of staff (users)
Planning for operational management where necessary
Backup planning for system outages, failures, etc.
Organizational Goals & Objectives
The pilot is consistent with the mission statement to be on the leading edge of health care
delivery. Academic Medical Centers have the advantage of having the most highly specialized
physicians but the disadvantage of relatively high costs. As the market share has shrunk due
to restrictions by insurance companies, the survival of such centers is contingent upon patient
referrals. Any model that would expand our referral base and provide more cost effective and
patient centered care will maintain our position as a leader in health care.
Moreover, while telemedicine reimbursement is limited now it is expected that changes are
rapidly approaching and positioning ourselves as leaders in telemedicine early will be a
strategic advantage consistent with our strategic business and clinical goals. This pilot covers
a single clinical need but the lessons learned and equipment purchased will lay the foundation
for expansion of telemedicine into virtually all clinical subspecialties.
We have a number of negative perceptions to overcome in the implementation of the
telemedicine project. First is an internal concern over acceptance of telemedicine technology
and workflow changes by Florida rural providers and patients. There is also concern by
providers who have practiced face-to-face consults for many years that it will be difficult to
adapt to teleconsult and new technology. We have heard from providers at local health
departments that there is a fear that the telemedicine project will divert patients from rural
hospitals and practices to University Hospital, resulting in closure or loss of revenue to these
facilities. In addition, there is concern about legal risk in treating high-risk pregnancies from
rural provider perspective. Finally, we face resistance from Florida Medicaid to reimburse for
teleconsults.
However, a number of positive factors exist. The WUF medical and IT staff are dedicated to
using technology to improve care. The project has a clear vision and leadership stakeholders
who are passionate about the project and potential benefits. These staff members have a
desire for outreach within Florida and beyond, as well as a desire to build a model program
including evidence-based practices to share both within the state and with other states. The
WUF staff also wishes to expand the telemedicine network to clinical areas outside Obstetrics
and Gynecology.
From an infrastructure standpoint, we have the ability to use the existing Florida Department of
Health bioterrorism network (T1) for broadband connectivity with every acute care and critical
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access hospital in the state, as well as every health department. We feel confident about the
availability of grant funds to purchase telemedicine equipment. In addition, WUF possesses a
seasoned technology and training team equipped to simplify the use of technology and provide
technical support to remote teams.
Our existing IT infrastructure includes an EMR system that can be extended to include
telemedicine records including video files of consults. We also have the ability and expertise to
create a web interface to allow health departments to view these records.
WUF stands to benefit from the telemedicine project in ways that extend beyond improved
outcomes. These include:
 The ability to provide evidence-based guidelines and build upon these as a public
resource
 The ability to conduct grand rounds and continuing education courses through the
teleconference equipment
 The creation of a video library of case studies for educational purposes
 The ability to conduct a telemedicine forum with interested parties around the state and
later, around the US
 The ability to assist other states in replicating telemedicine projects
 The prospect of state and national recognition and press
 The ability to deploy telemedicine programs for other specialties
 The potential to become thought leaders and industry experts in telemedicine care
References
Florida Commission on the Status of Women and the Florida Department of Health (2009).
Florida Department of Health Women's Health Data Report (pp. 90-96).
Lavanian, D., Indian Space Research Organization: How to setup a Telemedicine center &
Telemedicine Devices and Equipment . Retrieved on 20 September 26, 2010 from:
http://laico.org/v2020resource/files/setup_tele_center_devices.htm
Mathews, T.J.; Macdorman, M.F. (2008, 30-July). National Vital Statistics Reports: Infant
Mortality Statistics from the 2005 Period Linked Birth/death data set. National Vital Statistics
Data Report , 57 (2), p. 5.
The Henry J. Kaiser Family Foundation (2010). Medicaid/CCHIP Eligibility. Retrieved on 23
September, 2010 from http://www.statehealthfacts.org/profileind.jsp?cat=4&rgn=11
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