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Congressional Leaders Exploring Use of Digital Health to Improve Federal Healthcare Programs

September 16, 2016
by Heather Landi
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During a U.S. House of Representatives Ways and Means subcommittee on Health hearing Wednesday, Congressional leaders sought insights from the digital health industry and leading healthcare providers on how to use digital health solutions to cut costs, increase efficiency and access and improve quality in the healthcare system.

Specifically, the Health subcommittee members were keenly focused on how digital health technology and innovation could be applied to federal healthcare programs such as Medicare.

According to Health subcommittee Chairman Rep. Pat Tiberi (R-Ohio), while there are a myriad of companies in the commercial sector inventing and developing groundbreaking products, those innovations are not yet seen in federal programs like Medicare.

“The commercial sector is utilizing these innovations to improve systems, beneficiary care and collaborative care efforts. To date, Medicare has fallen significantly behind these efforts,” he said.

The focus of the hearing likely signals that the Ways and Means subcommittee on Health will continue examining the uses of digital health into 2017. In fact, at the conclusion of the hearing, Tiberi said the subcommittee planned to dig deeper into the issues of improving efficiency and quality in healthcare through digital health.

“This hearing kicks off discussion about the innovative aspects of healthcare and emerging technology to enhance efficiencies, reduce waste, improve outcomes and create greater access to care for beneficiaries in the Medicare space. It’s about using existing dollars in the program more efficiently,” Tiberi said.

“We have clinician shortages jeopardizing access for Medicare beneficiaries who need access to care, and that is unacceptable and untenable. We need to lift the barriers and incentivize greater efficiency,” he said.

Tiberi also said Congress should learn lessons from steps that have already been taken, such as the Health Information Technology for Economic and Clinical Health (HITECH) Act, and continue to build on payment reform efforts such as the Medicare Access and CHIP Reauthorization Act (MACRA), “rather than create more bureaucratic layers.”

During the hearing, Rep. Jim McDermott (D-WA) said innovation will be central to efforts to address rising healthcare costs. “Innovation through electronic health records (EHRs), telemedicine, payment reform must be part of the discussion,” he said.

McDermott mentioned the challenges faced by many accountable care organizations (ACOs) as one example of healthcare innovation, specifically recent news that Dartmouth College was dropping out of the ACO model it helped to develop. “This doesn’t mean ACOs are failures, but there are questions we need to ask. Where are we going as a country and how can we turn investments in innovation into sustainable models moving forward?”

“I’m looking forward to hearing about what works, what hasn’t worked and where we are heading. We can all agree that without meaningful action on cost containment we will continue down an unsustainable path for healthcare in this country,” McDermott said.

The Health subcommittee members heard from Michael Gallup, president of Pittsburgh-based TeleTracking Technologies; Jared Short, chief operating officer at Portland, Ore.-based Cambia Health Solutions; Paul Black, Allscripts’ chief executive officer and Greg Long, chief medical officer, senior vice president, Systems of Care at ThedaCare, a health system in Wisconsin.

Long shared with subcommittee members a pilot project that ThedaCare began in 2014 to identify the health system’s most complex patients, or “super utilizers,” using data and a team-based care approach. ThedaCare is a health system in northeastern Wisconsin consisting of seven hospitals and 34 clinics serving eight counties. The system cover more than 240,000 patients annually.

ThedaCare leaders were able to identify high-risk patients using a risk calculator program developed in its EHR system and based on clinical factors, utilization of services and psychosocial needs, Long said. The pilot project involved 282 high-risk patients being enrolled in a new, decentralized, team-based model. The model was comprised of three care coordinators, one registered nurse, one clinical pharmacist, one behavioral health clinician, one nurse practitioner and one medical assistant, Long said.

Long further explained that care plans were developed for patients in the model with each patient receiving supportive services and intensive case management including chronic disease monitoring and management skills, behavioral health screening, psychotherapy and other behavioral health care, medication consultation and counseling and life skills classes. Patients also received assistance with obtaining housing and other basic needs, Long said. And, the care teams have begun exploring the use of technology with some patients uploading blood sugar results to a smartphone or iPad and submitting the results to clinics.

As a result of the pilot project, the percentage of patients with uncontrolled diabetes decreased from 12 percent to 3.8 percent. The percentage of patients who visited the emergency department more than three times in a six-month period fell from 11.8 percent to 2.6 percent, he said. The program saw a number of other positive results as well.

Long also shared other technology projects at ThedaCare, such as an e-visit platform to enables patients to consult with primary care physicians through a web-based portal, which has achieved a 98 percent satisfaction rate from patients. The health system has a telepsychiatry program and has plans to implement a tele-stroke program, funded by a grant award, in the next six months. The health system also is exploring alternative payment models and is participating in the Next Generation ACO model.

When Rep. Mike Kelly (R-PA) asked how the government can learn from the private sector to improve health care without adding to the deficit, Gallup with TeleTracking responded, There’s enough money in the system to get the patients through and give them the care that they need if we cut out the inefficiencies. We have a doctor shortage, a nurse shortage, we have all these shortages out there. How do we fix that? Well, let’s make them more productive. If we can take labor and help them get more productive, we can get more patients through at the same price. If we can get more through at the same price, we can solve many of our problems.”

TeleTracking Technologies developed automated patient solutions to improve hospital patient flow, and during the hearing Gallup provided examples of how TeleTracking's real-time enterprise visibility and automation solutions had improved efficiency and operatiosn at a number of hospitals.

“Each year nearly two million people walk into hospital ERs and walk back out because they are frustrated with waiting. Millions more wait more than six hours to get a hospital bed and every minute of every day, an ambulance is diverted from its intended hospital, yet there are seven open beds for every two admitted patients, and why? Because little innovation or attention has been given to the logistical flow of patients, caregivers, assets, and materials,” he said.

Cambia’s Short highlighted the company’s HealthSparq solution, a transparency tool that allows people to shop for healthcare services by showing price and quality of healthcare services, and GNS Healthcare, which collects patient data, analyzes it and determines which treatment is the best match for patients. According to Short, GNS Healthcare solutions also can predict which patients are most likely to stop taking medications. “This process helps people have more success with care plans and helps organizations lower costs,” he said.

During the hearing, Black detailed Allscripts’ interoperability platform, db Motion, delivers a single patient record view across multiple systems and settings with a focus on workflow and adaptability. Black also mentioned Allscripts’ 2BPrecise solution for genomic sequencing. The platform makes genomic sequencing data available and actionable at the point of care. The National Institutes of Health is an early adopter of 2BPrecise as part of the Cancer Moonshot efforts, Black said.

Black said “despite bumps in the road,” there has been substantial progress in healthcare technology. “It wouldn't have happened if Congress hadn’t provided the impetus for ubiquitous adoption of EHRs. These changes disrupted paper records and created a new digital ecosystem of caregivers and software developers and patients. Following disruption there is innovation and opportunity,” he said.

The subcommittee asked the digital health leaders and Long what Congress should be doing to increase adoption of information exchange solutions and tools to support interoperability.

With regard to data blocking, Allscripts’ Black said that while data blocking has occurred in the past, “those issued have been removed.” “Whether behaviorally, economically or because someone can call a hotline and report somebody for data blocking, a lot of reports suggest that the problem has been solved.”

The subcommittee members appeared keenly interested in gaining insights about incentivizing innovation and how Medicare can better collaborate with the private sector.

Short pointed to payment reforms that have passed to date and urged Congressional leaders to “continue to see those through.” “The next two to three years, look at ACOs and how they perform, what works or doesn’t work, and see through the current innovation and then deploy and scale some of them. There’s tremendous innovations on interoperability to come,” Short said.

Long said, “I think if you piece together the great work by organizations, the road map is out there. We all see the waste and are trying to improve it. The ones doing the best work can create the road map. The information is out there if we can piece it together.”

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Research: Trends Point to Positive Increase in Telehealth Acceptance, Access

December 17, 2018
by Rajiv Leventhal, Managing Editor
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Current events and issues, such as the opioid epidemic, are increasing the need to provide telehealth services

Stakeholders’ recognition of telehealth benefits has continually increased, as doors are now opening for various subsets of medicine, including tele-mental health, according to new research from law firm Epstein Becker Green (EBG).

The 2018 Tele-mental Health Laws survey provides an update to state telehealth laws, regulations, and policies for mental and behavioral health practitioners and stakeholders across all 50 states and the District of Columbia. The survey’s researchers said that in the last few years, “the public’s and the healthcare industry’s recognition of the benefits of telehealth has continually increased. While the shortage of behavioral health providers has long been acknowledged, the use of telehealth technologies, including practice management systems and online patient portals, to provide greater access to behavioral health professionals has increasingly gained traction and continues to gain validation as an alternative model of care delivery.”

What’s more, EBG also found that current events and issues, such as the opioid epidemic, have put more pressure than ever before on federal and state legislators to pass laws that promote access to, and provide guidance for, providers seeking to utilize telehealth services.

The survey revealed various reasons for the increase of access to tele-mental health services, and telehealth services overall, including:

Bipartisan support: The Bipartisan Budget Act of 2018 signed into law in February expanded Medicare coverage for certain telehealth services to beneficiaries who are being treated by practitioners participating in accountable care organizations (ACOs).

Greater advocacy from Medicare & Medicaid: In June 2018, the Centers for Medicare & Medicaid Services (CMS) publicly encouraged states to utilize telemedicine and telepsychiatry to facilitate coordinated care for Medicaid recipients. As of August 2018, 49 states and the District of Columbia provide reimbursement for live video telehealth services through Medicaid fee-for-service programs.  Massachusetts is the only state not yet participating.

The opioid epidemic: Several states, including Indiana, Michigan, and Missouri, have introduced and/or passed legislation that expands remote prescribing of controlled substances for treatment of substance use disorders (SUDs). In October 2018, President Trump signed into law H.R. 6, the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (“SUPPORT”) for Patients and Communities Act.

This year’s survey also looked at positive trends in telehealth adoption and usage models, including: school sites and pediatric care; the Department of Veterans Affairs’ expanded telehealth programs (since its rollout, the VA’s telehealth program has onboarded approximately 20,000 new patients and hosts more than 6,000 virtual visits each week); and the promotion of care models for growing aging-in-place populations.

Despite the continued telehealth momentum, several barriers and policy variances do remain, the researchers stated. Some of these include: limited federal guidance on coverage and reimbursement and the lack of meaningful coverage by third-party payors, the report said. To this end, A recent MedPAC survey noted that coverage of telehealth services continues to vary widely across commercial health plans, with most covering only one or two types of telehealth-based services.

“While telehealth parity laws are currently in effect in 39 states and the District of Columbia and are intended to ensure the same coverage of (and in some cases, reimbursement for) telehealth services, there is more work ahead to achieve comprehensive coverage and access. States must continue to enact new parity laws or expand existing ones,” the researchers stated.

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KLAS: EHR Integration, Enterprise Scalability Key Challenges Facing Telehealth Vendors

December 11, 2018
by Heather Landi, Associate Editor
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Healthcare organizations report high satisfaction with their telehealth virtual care platforms (VCPs), however there are significant differences in how broad the various platforms are and in the quality of the vendors’ service. What’s more, integration with electronic health record (EHR) systems is a key challenge facing every telehealth vendor, according to a KLAS report.

In its report, “Telehealth Virtual Care Platforms 2019: Which Telehealth Vendors Have the Scalability Customers Need?,” KLAS evaluates some of the top telehealth companies including American Well, MDLive and Epic, and analyzes what capabilities will set vendors apart as more healthcare organizations adopt virtual health technology solutions.

Most virtual care platform vendors receive positive performance ratings, but the depth and breadth of their capabilities vary, and this can impact scalability for organizations looking to grow, according to KLAS. No two vendors are alike in their capabilities, offering different combinations of functionality and experience.

Of the companies KLAS evaluated, the most common type of visit varied—most of American Well’s visits were on-demand urgent care, while the majority of Epic’s visits were associated with virtual clinic visits.

A key factor of scalability is the ability to support multiple visit types, KLAS researchers note. While multiple vendors offer support for all three visit types (on-demand or urgent care, virtual clinic visits and telespecialty consultations) no single vendor has a large proportion of customers using all three (only 12 respondents across all vendors said they were doing so).

American Well, a market share and mindshare leader, and MDLIVE, two of the vendors used most frequently for multiple visit types, receive generally positive—but lower than average—performance scores. Vendors more specialized in specific visit types or component layers (e.g., Vidyo and Zipnosis) have high scores but narrower expectations from customers.

No one vendor meets all needs equally well, but several are reaching for “all-purpose” status with internal development and/or recent acquisitions (American Well acquired Avizia; InTouch acquired TruClinic), according to the report.

KLAS’ analysis also uncovered a general trend of poor integration. In most cases, the addition of a virtual care platform also means the introduction of a second EHR into the clinician workflow.

“Although integration between EMRs is generally understood to be important for care quality, patient safety, efficiency, and productivity, few interviewed VCP customers have full bidirectional transfer in place. Most say that they are too early in their virtual care programs to pursue integration or that it simply costs too much,” KLAS researchers wrote.

Only American Well, Epic, and MDLIVE have more than half of interviewed customers currently on an integrated path, KLAS found. Epic has placed virtual care capabilities directly into their top-rated MyChart patient portal, which many patients already use. Epic integration means clinicians are able to stay within their existing workflow environment as well.

Many provider organizations are in the early phases of their virtual care programs where showing an ROI is an important milestone and one that organizations want to achieve as soon as possible, KLAS notes. “A key promise from vendors is that their technology and accumulated expertise will result in a fast start and continuous acceleration. When this comes at significant cost or progress is slower than expected, provider organizations can experience disappointment,” the KLAS researchers wrote.

When it comes to getting their money’s worth and achieving desired outcomes, Epic and InTouch are rated highest among fully rated vendors, and swyMed and Vidyo perform well among their smaller groups of respondents, KLAS researchers note.

“For each vendor, the current value proposition is somewhat narrow but well understood: Epic’s use is limited to existing patients of Epic EMR customers; InTouch is used primarily for consults; swyMed is used by respondents primarily for mobile, first responder needs; Vidyo delivers video-conferencing tools,

which are typically combined with other VCP solutions. SnapMD is seen as a low-cost option, but some customers say the impact has been limited. Commentary from VSee customers suggests a similar experience,” KLAS researchers wrote in the report.

Many healthcare organizations are early on in their virtual care journeys, and their ability to achieve desired results depends on guidance from vendors. According to KLAS’ analysis, swyMed and InTouch receive the most praise for taking initiative in proactively guiding customers and also in quickly responding to support problems.

While respondents praise American Well’s platform scalability, some customers blame the vendor’s “exponentialgrowth for staffing shortages that have led to implementation holdups and backlogged service requests. Some SnapMD customers say hard-to-beat pricing comes with a support model that is spare in terms of providing tailored guidance, according to the KLAS report.

Most vendors offer two additional options that can help accelerate customers’ expansion and growth—supplemental services, including added-cost advisory and outsourced services, and tools that automate patient-facing tasks that traditionally require additional staff. I

KLAS found that few customers mentioned these options in top-of-mind conversations. “Respondents who spoke of their vendor’s supplemental services most often referred to marketing support or strategic planning services from vendors American Well, MDLIVE, or Zipnosis. Those who referred to task automation report patient-self-service capabilities around check-in, scheduling, surveys, and/or patient flow from InTouch Health (TruClinic), Epic, MDLIVE, or Zipnosis,” the KLAS researchers wrote.



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Study: Neonatal Telehealth Reduces Hospital Transfers, Saves Money

December 11, 2018
by Heather Landi, Associate Editor
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Neonatal video-assisted resuscitation reduces transfers from hospitals without newborn intensive care units and provides significant cost savings, according to study published in the November issue of Health Affairs.

The study authors, led by Jordan Albritton of Intermountain Healthcare, examined a newborn telehealth program implemented at eight Intermountain Healthcare community hospitals in November 2014–December 2015 and the impact on the transfer of newborns from those eight hospitals to level 3 newborn intensive care units.

Studies show that 10 percent of newborns require assistance breathing at birth, and 1 percent require extensive resuscitation. At Intermountain Healthcare, approximately 1–2 percent of all babies born in suburban and rural hospitals are transferred to newborn intensive care units (NICUs) for higher-level care, according to the study.

In response to the need to improve outcomes for complex newborn patients, an innovative telehealth program was established at Intermountain Healthcare in 2013 to provide synchronous, video-assisted resuscitation (VAR), bringing a neonatologist to the bedside. As a result, access to specialized neonatal services in rural and suburban settings is no longer limited to telephone calls or the arrival of a neonatal transport team, the study authors wrote.

While telehealth can facilitate video connections between neonatologists at tertiary care centers and providers at smaller hospitals, there is little empirical evidence about the benefits of telehealth programs for neonatal resuscitation, according to the study authors.

Although Intermountain Healthcare began using telehealth technologies in 2013, the current VAR program was implemented in the period November 2014–December 2015. Today, neonatologists from four level 3 NICUs provide VAR support for nineteen referring hospitals.

As part of the study, the researchers evaluated eight hospitals that contained either well-baby (level 1) or special care (level 2) nurseries staffed by physicians, advanced practice clinicians, nurses, respiratory therapists, and other health care professionals. T

The study found that video-assisted resuscitation was associated with a reduction of 0.70 transfers per facility-month and a 29.4 percent reduction in a newborn’s odds of being transferred. Annually, this resulted in 67.2 fewer transfers and an estimated cost savings of $1.2 million per year.

The study authors conclude that reducing transfers keeps families closer to home, increases community hospital revenue, and reduces risk associated with transfers.

“This program helps keep newborns in level 1 or 2 nurseries, which in turn allows families to stay closer to home, improves social support, and increases the revenue of community hospitals while reducing costs and risks associated with transfers,” the study authors wrote. “Payers should consider reimbursement for pediatric subspecialty telehealth consults for neonates in level 1 and 2 nurseries. Through improvements in care quality and cost savings, this service would likely pay for itself many times over.

However, the authors also note that lack of reimbursement for telehealth services limits widespread implementation.

“Policy changes are necessary to align payment incentives and promote the use of telehealth services,” the study authors wrote.

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