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Healthcare Leaders Tout Telehealth as “The Future of Medicine” at New York HIT Summit

September 29, 2016
by Heather Landi
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The consensus among physician and healthcare IT leaders who met at the New York Health IT Summit to discuss the newly emerging telehealth paradigm was pretty clear—telehealth will change how physicians practice medicine, and healthcare organizations beginning to test the waters now will have a competitive advantage in the future.

The panel discussion, held at the Convene conference center in New York City's downtown financial district, was part of the New York Health IT Summit, sponsored by Healthcare Informatics, and included industry leaders familiar with telehealth platforms: Rahul Sharma, M.D., emergency physician-in-chief, division of emergency medicine, New York Presbyterian-Weill Cornell Medical Center; Mony Weschler, chief and senior director, applications and innovations strategy, Montefiore-Information Technology, Montefiore Health Systems and Todd Ellis, managing director at consulting firm KPMG. The panel discussion was moderated by Healthcare Informatics Editor-in-Chief Mark Hagland. 

Framing the current telehealth landscape, Hagland said in contrast to 20 years ago when telemedicine was primarily considered a technology to connect rural physicians to urban specialists, today telehealth has not only matured but is becoming integral to care and wellness for managing population health across regions and the community.

“We have had this emerging population health concept, and, at the same time, we’re also seeing an explosion in the evolution of consumer-facing devices and we’re also moving inexorably from inpatient to outpatient care, even into the home, so now we have an interesting convergence of all these concepts and now we are no longer talking about telehealth just for rural physicians,” Hagland said. “How do you see this landscape evolving and all these different concepts coming together?”

“It’s interesting when you look at the healthcare landscape and you take a closer look at CVS, Walgreens and Walmart as they are getting into the healthcare business. The demand is there on all fronts, from the physician perspective, from a patient perspective and from payers,” Ellis said.

There is a lot of research indicating the benefits to telehealth and telemedicine, Ellis said, and he cautioned that “those organizations taking the ‘wait and see approach’ need to re-look at telehealth and see how it can help them.”

Sharma with New York Presbyterian-Weill Cornell Medical Center said despite the passage of the Affordable Care Act which has enabled more people to get insurance and has resulted in a greater demand for primary care services, there also continues to be tremendous demand for emergency care services as well.

“Last quarter, we had the highest number of visits ever to our ER,” he said. “One thing that has changed dramatically in healthcare is that the government now is really focused on the patient experience and what patients say about their healthcare, and then linking it to financial reimbursements for hospitals. It matters what experience patients have.”

In order to provide patients who visit the emergency room more options for how they receive care, New York-Presbyterian health system launched, just two months ago, a digital health platform, called NYP On Demand, providing virtual emergency room visits with the goal of reducing wait times in the emergency department and providing patients more convenient care options.

“We launched a pilot telehealth program so when a patient comes into the ER, they have the option of a virtual visit through real-time video interactions with a clinician after having an initial triage and medical screening exam. So they go to a private room and see a clinician via a telehealth monitor,” Sharma said.

He continued, “The analogy we use is that years ago there were banks going up on every single street corner, and then the banks all put in ATMs. And people said that’s crazy, why go to ATM when can go to the teller? It’s the same concept. We’re allowing patients a choice in how they get healthcare.”

To date, there have been 160 patients enrolled in the ER telehealth pilot with average wait times of 30 minutes, from the time patients come in to discharge, Sharma said.

“Patients love it and we’ve gotten great feedback. We’re responding to what patients want and we’ll soon have an app,” he said. “In order to be competitive, if you’re not doing it, the competitor down the block is doing it as consumers are driving how they are seeking healthcare.”

Health systems also are partnering with pharmacy retail companies, such as CVS and Walgreens, to provide virtual care with a health system clinician when the on-site pharmacist is not able to provide appropriate care, Ellis noted. “The leading healthcare organizations are talking about access to care, and how do you get a patient into an organization. There are unique things that healthcare systems are doing now with those access points to get that patient into their respective organization.”

Regarding the policy landscape, Sharma said there is work going on behind the scenes at the legislative level to provide reimbursement for telehealth visits. “Under fee-for-service, telehealth is only covered if it’s in a rural area, or it’s a participating Medicare facility, but I think that’s going to change in the next several years or even in the next several months as more people are embracing telehealth because it’s cost effective and also it’s really about quality of care. If a patient goes to the ER, the minute they get admitted they have an increased risk for hospital-acquired infection. Telehealth is a great way to help prevent these costly hospitalizations.”

IT and Data Challenges

At the Bronx, N.Y.-based Montefiore Health Systems, Weschler leads IT innovations and applications strategy for the health system and Montefiore has developed a telehealth program for its home care patients with congestive heart failure and diabetes.

Speaking to Montefiore’s population health efforts and its telehealth technology platform, Weschler says healthcare leaders have learned important lessons about using data and developing data analytics.

“It’s all about the data, so the more data you have on a patient, the more you can have a longitudinal view, the better you can treat that patient. If a patient stays in our system, then we have data and we do very well. But if the patient leaves our system, then we need to fill in the gaps as there are holes in the data, and we don’t do as well, so we learned from that,” he said.

He continued, “We also learned to be very good gatherers. The presentation layer was lacking and the decision support machine learning behind the data also is lacking. So, for providers who spend 15 minutes with patients, how much can they consume from all that data gathering? Very little of it is consumed. At this point, we’re not good at percolating to the top the data that says, 'this is what you need to do, this what is actionable for you with this visit,' and that’s where we need to do more work on how we present the data.”

“We’ve also learned that we need to make this easy and very seamless for the physician,” he said. While most of these technologies can interface with the electronic medical record, he called on EMR vendors to “step up to the plate and make it seamless.”

“This has to become a seamless operation for patient and provider, and there’s an ability to improve on that. If those things doesn’t fall into place, then there’s going to be a lack of adoption both from the patient side and provider side,” he said.

The Future Telehealth Landscape

Weschler sees the promising potential for telehealth to disrupt healthcare and improve how care is delivered.

“This is the future, to use sensors, wearables and implantables, and the technology is being developed right now to enable continuous monitoring of the patient and to be able to do vitals and get real data from the patient, as that’s one of the last obstructions to telehealth,” he said.

He noted current developments on a medical device that will enable imaging of a patient’s ear so physicians can virtually diagnosis an ear infection. “That device will provide the physician the same quality of imaging as in the office and the physician will feel comfortable legally prescribing antibiotics. It’s coming and it’s here and it’s already being used in other countries. That’s the potential and the future we’re starting to see.”

And, echoing Sharma’s comments, Weschler says, “Organizations like ours, if we don’t step up to the plate, others will. And I agree with the bank analogy. And, with future generations, they might be never be inside a hospital, only the sickest patients will be seen inside a hospital, others will not.”

When panelists were asked for predictions regarding telehealth, Ellis said healthcare organizations testing the waters now will be better prepared to expand their telehealth programs. “You need to start thinking about how to use telehealth and your organization will be more mature and have a competitive advantage.”

“Telehealth and telemedicine is the future and the present of medicine,” Weschler said. “The military performs robotic surgeries on aircraft carriers and that’s happening on a daily basis. Being able to have a telehealth consult with a physician, having the right devices, a clinically validated device, that’s happening, and it’s what medicine is turning into. It’s not a technology issue, the technology is right here, it’s a cultural challenge.”

Ellis recommended that hospital and health system leaders need to develop a strategy to evaluate the value of telehealth at their specific organizations. “When understanding and starting a telehealth program, you need to ask where you want to be five years or 10 years from now as telehealth is going to be a critical part of value-based payment,” he said.

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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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