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At MIT Conference, Economists and Healthcare Leaders Take a Deep Dive into Health IT

October 24, 2016
by Heather landi
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The U.S. healthcare industry is in the process of major transformation and during a health innovation conference at the Massachusetts Institute of Technology (MIT) on Oct. 21, faculty, researchers, clinicians and practitioners addressed the challenges confronting the industry and the tools being brought to bear to address those challenges.

MIT’s Sloan School of Management’s Initiative for Health Systems Innovation (HSI) sponsored the “Technology, Analytics and Systems” conference at the Cambridge, Mass.-based campus with a specific focus on three major challenges—the management of chronic illness, the role of telemedicine and intra-system payment and reward plans for providers.

To kick off the day-long conference, Jay Levine, retired principal of ECG Management Consultants, drew parallels between the ongoing transformation in healthcare to transitions in other industries in which there were dramatic federal realignment of regulations, such as the banking and airlines industries. “There was dramatic disruption in those industries, characterized by new entrants into the industry, low cost entrants, and consolidation among players to attain scale and market. This transition is now happening and it’s ripe for the innovation and application of technology and analytics and other tools that are bringing to bear in the healthcare industry,” Levine said.

MIT Sloan Professor Retsef Levi, Ph.D., co-chair of the conference and the HSI, said, “The health system is under significant pressure to change, to transform itself, and to articulate what this transformation is about, the current health system is designed to provide discrete, reactive care for sick patients, in specified locations, and it’s physician-focused with providers paid based on the volume of activities performed.”

He continued, “What it needs to transform to is very different. The idea of health is going to be broader, more comprehensive—what do patients eat, do they smoke, where do they live? It’s going to require us to think deeply about what we do for every patient, and how we think about the welfare of the population. It’s going to be team-based, patient-centric, and data-driven personalized care. And providers will be paid based on risk managed, health outcomes and efficiency.”

Retsef also said market incentives and payment schemes will not be enough to drive the transformation. “There is a lot of evidence in the last 50 years that tweaking market incentives is not enough,” he said, noting the development of accountable care organizations (ACOs). “There is growing concern that just merely changing the incentives is not sufficient as some organizations are seriously struggling and it’s an ambitious task.”

“We really need to fundamentally rethink how health systems are structured and what organizational capabilities they should have in terms of analytics, technology, workforce, processes and resource allocation. We need to think deeply about behavioral and cultural considerations—the humans that are patients and the humans that are providing the care. And, of course, we need to continue to leverage advancements in clinical innovation and how use that to create effective systems with better outcomes at sustainable cost.”

Retsef also said MIT’s Sloan School of Management’s HSI program is working to bridge different stakeholders across disciplines to address these healthcare challenges. “Most health systems, even the pioneering systems, struggle with the stream of ideas and technologies and how to take these ideas and technologies and do something that is sustainable economically. There is very little infrastructure to allow these systems to think and experiment rigorously to learn what works. We can be facilitators with data-driven experimentation and system cost-benefits analysis,” he said.

The Role of Telemedicine

During a panel discussion, healthcare industry leaders and an economist discussed the current and future state of telemedicine and the challenges to more widespread use of telemedicine technologies.

On the panel were Kevin Galpin, M.D., acting chief consultant of Veterans Health Administration (VHA) Telehealth Services; Michael Hodgkins, M.D., vice president, chief medical information officer at the American Medical Association (AMA); Mary Modahl, chief marketing officer and senior vice president, American Well Corporation and Joseph Doyle, Erwin H. Schell professor of management and a professor of applied economics, MIT Sloan School of Management.

Looking at the current state of telehealth and what it encompasses, Galpin, whose agency, the VHA, has been progressive in this space with two million telehealth visits in 2014, said, “We break it down into three things. There’s accessibility to the system, so a patient has an appointment over at this location and how do I make it easier for the patient to get access to care, whether that’s bringing something from a main medical center to a local clinic, or even to their home. Second, there’s the capability to increase capacity, so in underserved areas, in rural areas where it’s hard to recruit, we go to areas that I can recruit and deliver services through digital technology. And then quality and looking at areas where we want to improve outcomes. In our ICUs, we added telemedicine as an additional layer of providers and systems on top of what we already have and we get better outcomes. Those three things can blur and great programs will improve all three, but you can focus on one and you can have different goals for different programs.”

Modahl with telehealth vendor American Well, said, from a technology point of view, telemedicine is moving rapidly forward. “You hear about technology such as remote monitoring, two-way video visits and those technologies, and we have individual silos of innovations, but when they come together, the applications become truly exciting.”

She continued, “We’re working on how to bring data from remote monitoring systems in, so the data is in front of clinicians and healthcare providers can see how they need to do interventions. I’m not saying we’re there yet, but that’s at the forefront of innovation. Is it video, or is it store and forward technology? I think it’s all of those things and it’s evolving from individual silos to a digital delivery system with a range of capabilities, and it needs to integrate back into systems of records such as electronic health records (EHRs) from companies like Epic, Cerner and Allscripts. Another area of research is developing APIs [application program interfaces] to make sure integrations happen, because if we make telemedicine a little thing on the side, it’ll just be a little thing on the side. We believe that every clinical relationship will have some element of telemedicine and some element of in-person care.”

Doyle, a professor of management and applied economics at the MIT Sloan School of Management, outlined his current research on telehealth comprised of two randomized, control trials. One telehealth trial is focused on a suicide prevention program. “It starts with a predictive model and uses a lot of variables, big data, and machine learning type tools to identify which patients might be at risk of attempting suicide.” As part of the program, physicians at some clinics receive notifications that their patients are scoring high in the risk assessment tool. For large organizations, researchers are sending hundreds of thousands of text messages to patients asking them how they are feeling and supplemented with phone outreach. “We’re hoping to move the needle on this, with big data tools coupled with casual analysis through randomized control trials,” Doyle said.

The second project involves a community paramedic program through a large healthcare provider in New York, he said. “They use data tools to identify super utilizers, and then provide home visits with a paramedic and a virtual visit with a critical care physician there on-site to help prevent this revolving door with emergency room visits with this population. This a way to improve the quality of the care these patients are getting, as it’s more timely, at their home so they don’t have to make a trip to the ED and it saves money at the same time.”

The Technical Challenges

When discussing current technical challenges to using telemedicine technologies, such as video conferencing, Galpin made a plea to digital technology developers and engineers to make improvements to the patient experience by focusing on what he called “low-hanging fruit.”

“With video conferencing, for example, with the person you’re talking to, their eyes are here toward the top of the screen, and the camera is here at the bottom of your screen. I think the technology exists to correct that so I can look at my patient’s eyes and they look at my eyes. We’re doing care from a distance and being able to look somebody in the eyes is a critical piece.”

Galpin noted that there is the opportunity to improve quality and access to care, but the "tools are missing."

“I’ll use the stethoscope as an example," he said. "When I was training, we used written records, I’d listen to the patient with a stethoscope and then translate that information into a visual picture of heart sounds. And now with EHRs, I have to describe the sound. So we’re now digitizing but I’m still describing the sound. Why can’t we see a visual of the heart sounds? If I could digitize that and put it into a picture, I could do better care through a stethoscope remotely than I do in person without a digital stethoscope.”

Modahl agreed with Galpin about the need for better tools for clinicians. “We’re training clinicians to deliver healthcare over telemedicine systems and they are learning to look into the camera a certain percentage of the time so the patient feels that they are being looked at. There are challenges of reimbursement and human factors and both are critical on the patient side and the clinician side. We need to figure out protocols, what is the evidence for how we treat various conditions remotely? Clinicians have a different relationship with patients in that the patient has to assist with the examination, it’s 'feel here, do this,' so it’s a different kind of examination emerging, and it’s not defined yet.”

Hodgkins sees the management of healthcare data as one of the biggest challenges to harnessing the potential of telemedicine. “I think we’re in a challenging stage in the use of technology to enhance care. Some of you may be familiar with the Gartner hype curve and some people think we’re heading into the trough in this space. That’s not a bad thing. It means we have a challenge figuring out how all this works at a system level. The big challenge is the data we created With EHRs, we’ve moved analog to technical stores of information that don’t talk to each other, or don’t talk to each other very well, for the most part, even though that was the promise. And with the introduction of digital technologies, apps, we’ve created more data. The biggest challenge is how do you create a system that makes sense to deliver the best care at the best time for each individual?”

Evaluating Telemedicine’s Effectiveness and Reimbursement Challenges

According to the panelists, a significant challenge facing the healthcare industry in the use of telemedicine is a lack of peer-reviewed, academic studies focusing on the efficacy of telemedicine to improve care and the potential for cost savings.

The panelists cited a report from The Agency for Healthcare Research and Quality (AHRQ) released in July. In that report, AHRQ concluded that the use of telehealth is vast and varied, yet there is evidence to support its effectiveness for specific uses, such as remote patient monitoring for patients with chronic conditions and psychotherapy as part of behavioral health.

“One thing the report focused on was the need to focus on the practice,” Hodgkins said. “There is very little literature on how best to execute digital health in clinical practices and how to integrate it into workflow, and they also said there isn’t enough metric data to see the financial impact of digital health.”

While Modahl agreed that there is a lack of research, she noted that American Well works with 45 major health plans. “With the health plans, the actuary teams do their estimates, and the fact is that we are moving from 50 million covered lives to 75 million covered lives. The actuaries have concluded it’s beneficial in terms of payment and that it’s saving money. I think the studies will come out over time. Observationally, we see the people who estimate cost, the commercial insurers, are fast to cover it.”

Galpin with VHA said, “We certainly study this and have our own data and have seen fantastic outcomes, with a 50 percent reduction in admissions or readmissions. I think this is a challenging area for telemedicine, what do you study? Am I testing the providers’ ability, the patients’ adherence, or the technology? We know the technology works. We need to design studies to measure the type of outcome we are trying to achieve.”

Hodgkins said an AMA survey of 1,300 physicians indicated that physicians are ready to embrace telemedicine. “The good news is, the vast majority, 75 to 80 percent, are excited about the possibilities and opportunities created by virtual health. The expectation is that these tools have to integrate with their work. To get to the state of disruption, you have to accept technology, and it must fit into the work life of physicians and staff. Physicians want to know it won’t disrupt their work, or disrupt their relationship with patients.”

“If you make it easy to use, people will use it,” Galpin said. “We have a far way to go to make it fully integrated.”

The discussion among the panelists turned to current payment models and reimbursement for telemedicine services. “It’s a challenge, and we have to live within those [limitations] right now,” Modahl said. “With regard to reimbursement, there’s also integration with EMRs, which are these old systems, so there are huge technology challenges for sure. Ultimately, telemedicine will be for payers who are in it for the long haul and make the commitment and there might be a five to 10 year period of doing integration.”


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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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