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At the Health IT Summit in Nashville, Next-Door Neighbor Georgia Offers Lessons in Rural Telemedicine Advances

June 28, 2018
by Mark Hagland
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Suleima Salgado shared with attendees insights on the advances in telemedicine being made on behalf of rural Georgians

For every challenge in healthcare delivery, there is some potential approach for improvement; that was a broad theme underlying the message delivered by Suleima Salgado, of the Office of the Chief of Staff of the Georgia Department of Health, on Thursday morning at the Health IT Summit in Nashville, sponsored by Healthcare Informatics. Speaking to an audience at the Sheraton Nashville Downtown, Salgado delivered a presentation entitled “Telemedicine: Improving Population Health through Collaboration and Partnerships.”

The Atlanta-based Salgado sketched a portrait of the state of Georgia that many in Tennessee and throughout the Southeast and Appalachia would find relatable, of a state with vast rural areas that remain underserved for their residents, and in dire need of the benefits of telehealth/telemedicine solutions and strategies. “We have 159 counties in Georgia, and 110 of those are rural,” Salgado noted. “Meanwhile, here in Tennessee, you have 89 rural counties and only six urban counties, according to your state office of rural health. We need to find ways to provide access to quality care for a huge percentage of the residents of our states,” she said. And that involves facing up to daunting challenges of all kinds, from funding to staffing to data and information infrastructure challenges. “The reality at the end of the day is that most of our rural health partners are facing severe data issues,” she said, noting that, just to take one smallish example, “Clinics tell us that they have to schedule their participation in webinars around potential data crashes.” Many rural clinics have fragile Internet connections; what’s more, some have only one active nurse on staff, so if that nurse drives to a live educational session, that particular clinic has to shut its doors for a day.

Suleima Salgado

Of course, every state has its own peculiarities in terms of addressing rural health issues, as well. Salgado pointed out that, while the Georgia Department of Public Health is overseen by one commissioner and one board of public health, and that one commissioner appoints the 18 district health directors who oversee the state’s 18 public health districts, its 159 county governments each have their own county health departments and county boards of health, which are managed independently and which independently implement broad statewide policies. “Our state health commissioner employs the health directors, but has no control over policies implemented at a local level,” she noted. Still, that fact in itself is not necessarily negative, she pointed out. “I’ve worked in a state office and in a county office. And to me, the work happens at the county level. At the end of the day, most of the work and effort come from those county organizations,” she said. So the independence of county health organizations is not in itself a problem; it just adds to the complexity of addressing broad rural healthcare policies, she emphasized.

One positive in the landscape around rural health in Georgia has been around funding, Salgado said. “In Georgia, we’re always looking towards the federal, state, and local organizations that can help us. And Georgia [health] has undergone a dramatic change in the last ten years as a result of increased federal funding, state legislative support and intra-state collaboration.”

The Georgia Telehealth Network

That increased funding has been absolutely necessary to address some disparities around access to quality healthcare in Georgia. “About 60 of our 159 counties don’t even have specialists in certain specialties; people are having to drive four to five hours to see a specialist,” Salgado noted. “So we established a telemedicine network through the state,” she reported, with an initial funding grant of $2.3 million to establish the Department of Health-led network. But, she quickly added that, though that figure sounded large in the abstract, in practice, “when you start figuring in technology, data, and other costs, it wasn’t a lot. Still, it provided a strong start. “The goal of the Department of Health,” she continued, “is to connect patients to providers in their local communities and not extract business/medical services from the local economy. We’re trying to help those counties without specialists in specific specialties. We want to help those counties so that people don’t have to drive to Atlanta or Jacksonville or across the state line to Alabama. It’s not a replacement, and we’re not using it as a medical home.” Indeed, she said, she and her colleagues have emphasized to the local communities they’ve reached out to, that providing adequate telemedicine medical specialty services actually helps local communities, and does not take resources out of communities. In that regard, she said, “Significant inroads have been made with private physicians, local hospitals and other telehealth entities within Georgia to advance towards a cross-collaborative network,” with the goal of the telehealth network “as a means to better communicate between each other and most importantly as a way to provide access to specialty care for our patients.”

Among the key points made in her presentation, which included a slide presentation, were the following:

  • It is the goal of DPH to connect patients to providers in their local community and not extract business/medical services from local economy.
  • In situations where a provider is not available within the community or through existing DPH referral services, DPH will look to surrounding counties and then eventually to metropolitan areas to find services.  
  • DPH also has an agreement with the Georgia Partnership for Telehealth, for access to their telemedicine network, when needed.
  • The Georgia Partnership for TeleHealth is a non-profit, Open Access Network, with over 200 specialists and providers that represent more than 30 medical specialties.
  • In addition, DPH contracts directly with local, specialty providers to meet the healthcare needs of our patients. 

Meanwhile, the list of clinical areas involved is wide. Salgado noted the following areas:

  • Administration
  • Asthma/Allergy—pediatric
  • Audiology—pediatric
  • Behavioral Health counseling—pediatric
  • Dermatology—pediatric
  • Diabetes Education—adult and pediatric
  • Dental Services (School Based)—pediatric
  • Emergency Preparedness-
  • Endocrinology—pediatric
  • Genetics/Developmental—pediatric
  • Infectious Disease—specialty clinical care for HIV/AIDS patients
  • Interpreter Services—health department clinical services
  • Lactation Support/WIC—adult
  • Maternal Fetal Medicine—adult
  • Nephrology—pediatric
  • Neurosurgery—pediatric
  • Nutrition/WIC—adult and pediatric
  • Sickle Cell —adult & pediatric


“What does telemedicine look like in Georgia?” Salgado asked. “Private providers use their own platforms, but we’re Cisco-based with a Cisco suite, and a full telemedicine backup,” in terms of telecommunications and medical equipment. Often, the telehealth applications involved are not necessarily purely medical in the strictest sense; in fact, she noted, nutritional counseling and behavioral health services are two key telehealth services that have been broadly helpful. For example, she noted, “In many cases, there is one nutritionist serving four rural counties. In the past, that single nutritionist might have been driving across four counties to deliver health-related services. Now, she can see people everywhere.” The same goes for the expanded access to behavioral health afforded by the state’s statewide network.

Among other strategies to maximize resources, Salgado reported, “We realized and leveraged the fact that the FCC [Federal Communications Commission] has telecommunications funding to give you reduced cost per circuit for these kinds of projects. So we decided to put our hub in the third most rural county in Georgia, Waycross County, to get that discount. And we leveraged existing teams that had already created and were maintaining technology in various places. And now we’re running our network.” She cited a cost of $800,000 so far in terms of the cost of running the network. “But we did well,” she said. Initially, at least, she noted, “We couldn’t do a cloud-based infrastructure, we had to do traditional T1 lines. And everything coming back to the hub” in Waycross County. “We’re changing the model over time, and eventually moving to cloud-based. But keep in mind that five rural counties still have no Internet connectivity.”

One very concrete example of resource savings and gains over past dislocation has been around clinician education, Salgado noted. “The Department of Health had been offering a two-day refresher course in Macon for nurses who treat STDs. IN the past, that involved local healthcare provider organizations having to pay for lodging and travel costs, which figured out to about $500 per nurse. And some of those clinics are so rural that they have only one nurse on staff, so they would have to shut down their local clinic to send their nurse to that course.” Providing the educational course via weblink eliminated those costs and dislocative elements.

Meanwhile, the need for ongoing development of telemedicine and telehealth services remains absolutely crucial, Salgado emphasized. “Fifty-two counties in Georgia do not have OB/gyns who can support high-risk pregnancies. That means that for many pregnant women in rural areas, it requires a four-hour drive each way in order to be seen by a physician who can meet their medical needs.” Telemedicine offers an incredible advantage for those women in terms of accessing the specialized medical care they need.

Similarly, she reported, there is a huge need for teledermatology and teledentistry. In the case of teledentistry, the statewide telemedicine program has sent dental hygienists into schools to provide cleaning, fluoride treatment, x-rays, and dental education in schools. Dentists can remotely view the x-rays that the hygienists administer, and can communicate with them regarding potential treatment for the children. That program has been very popular with schoolchildren, she added.

The work will continue to evolve forward in this program, Salgado said, but the advances already made are proving heartening for all involved, and demonstrate what can be done collaboratively to improve healthcare access and quality to rural residents.

Among the many partner organizations in this program include the Georgia Partnership for TeleHealth, the Georgia Department of Behavioral Health and Developmental Disabilities, the Georgia Department of Community Health, the U.S. Department of Agriculture, the Georgia Department of Juvenile Justice,  Voices for Georgia’s Children, Children’s Healthcare of Atlanta, Georgia Regents University, the Augusta University Medical College of Georgia, and the University of Florida College of Medicine-Jacksonville.




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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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Can Telehealth Slow the Traffic Between Nursing Homes, Emergency Departments?

December 6, 2018
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The RUSH Act seeks to reduce the 1.3 million transfers from skilled nursing facilities to emergency rooms each year

There are 1.3 million transfers from skilled nursing facilities (SNFs) to emergency rooms each year, and CMS estimates that two-thirds of those are avoidable. The result is as much as $40 billion in unnecessary spending. Could telehealth be part of the solution?

That question led Timothy Peck, M.D., formerly chief resident in the Emergency Department at Beth Israel Deaconess/Harvard, to co-found a startup company, Call9, and become an advocate for legislation, the RUSH (Reducing Unnecessary Senior Hospitalizations) Act of 2018, to support reimbursement for connecting emergency physicians and SNFs.

Peck has spent considerable time studying the issue. “I didn’t know much about nursing homes when I started,” he said.  “I went and lived in one for three months. I wound up sleeping on a cot in a conference room.”

Peck was trying to understand nursing home finances and operations and why the patients are being transferred. They usually have things like urinary tract infections or pneumonia, which could be treated in the outpatient setting, but the SNFs aren’t equipped with the right tools to be able to treat these patients. Those patients come in without their families and 43 percent have dementia, he said. “Most become delirious upon transfer. We don’t have much information about them so we order every test under the rainbow, driving up the bill unnecessarily. We put them in hallways. They get bedsores. We inevitably admit these patients for an average of $15,000 to $20,000 per admission.”

The two-thirds of transfers that are avoidable represent about $40 billion in unnecessary spending for something that harms patients,” he said. “We are spending money on hurting patients.”

Peck zeroed in on three operational issues:

• First, on average, nurse to patient ratios in nursing homes are 1 to 36. If one patient becomes acutely ill and spikes a fever, that nurse does not have time to take care of that patient when they have 35 other patients to take care of. Also, most nursing home nurses are trained to handle chronic care, not emergency or acute care. It is a mismatch of skills, not a people problem in any way, he said.  

• Second, diagnostic equipment is sparse, and EKGs and lab tests take 24 hours to 48 hours to come back. That doesn’t work well for acute care.

• Third, physicians are not present in nursing homes. “When I was living in that nursing home and walking the halls weekends and nights, I never once saw another physician. Long-term care patients are seen once a month by their primary care doctors.”

Peck described the Call9 service: They embed 24x7 a paramedic or EMT or a nurse with emergency experience in the SNF. They go to the patient’s bedside and connect to a remote emergency physician who is available 24x7 and working from home. They can see a patient in nursing home A with a paramedic by the bedside and then jump to nursing home B and see a patient there with a first responder with them. “It makes the physician a scalable resource,” Peck said. “Believe it or not, they are our least expensive resource because they get scaled.”

Call9 has full integration with the three most commonly used EHRs in the SNF world. The solution also deploys a suite of mobile diagnostics and can return lab test results in a few minutes. It offers real-time telemetry and real-time ultrasound.

After treating a few thousand Medicare Advantage patients, he said the model has shown that it can save payers more than $8 million per nursing home per year. That allowed Call9 to get involved with Medicare shared savings value-based contracts with several payers nationally. But he notes that 60 percent of patients in nursing homes are Medicare patients. “We took that data to CMS and showed it to them,” Peck said. “The Ways and Means Committee in the House of Representatives got ahold of the data and got excited and started writing the Rush Act.”  He stressed that Call9 is not the only organization creating a program like this. There are others working on similar solutions.

Peck said CMS is interested in using telehealth in this way, he said. “But they don’t have any way to change payment mechanisms in a quick manner. They would have to ask CMMI to run demos, which takes years. But Congress could pass new legislation.” He described the RUSH Act as creating a value-based shared savings arrangement with Medicare where 50 percent of the savings goes back to Medicare, and 37.5 percent goes to a company like Call9 or a physician group or medical staffing group that administers the program and 12.5 percent goes to the nursing home, aligning all stakeholders, he said. “The bill has been introduced by a bipartisan group, because it is a nonpartisan issue.” With time running out in this session, he said, the bill still has strong support among Democrats set to take over House leadership in 2019.

Besides bipartisan sponsors in Congress, the bill also has support from patient advocacy groups such as the Alzheimer’s Association, Michael J. Fox Foundation for Parkinson’s Research, American Heart Association, the National Alliance on Mental Illness, and the American Telemedicine Association. “They are saying that the patients need it; the taxpayers benefit; why are we not doing this?” Peck said.

As someone who has seen family members and friends make that repeated, disruptive round trip from nursing home to emergency room, I concur.  



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