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MultiCare’s Telehealth Journey to Improve Post-Acute Care

July 6, 2017
by Heather Landi
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Clinical leaders are finding the use of video visits, combined with biometric data, is key to engaging patients in their own care management
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Clinical leaders at the Tacoma, Wash.-based MultiCare Health System, a six-hospital integrated healthcare delivery system, have been utilizing remote monitoring and telehealth technologies for more than a decade, with a focus on improving outcomes and reducing readmissions among patients with chronic conditions. As digital health technologies have advanced from basic vital-sign data collection, to Bluetooth-enabled mobile platforms and video interfaces, the MultiCare team has been able to expand its telehealth program, and is seeing significant results with reducing readmission rates.

Lynnell Hornbeck, home health manager at MultiCare, says the health system initiated its telehealth program more than a decade ago, primarily focusing on heart failure patients, and working with Honeywell Life Care Solutions, a Brookfield, Wis.-based telehealth software vendor.

“At the time, there were reasons to start remote monitoring and telehealth, and one of the reasons was to look at alternative ways to deliver care rather than in-home visits. For home health, the reimbursement model had changed and was more of a capitated or bundled payment-type approach, rather than per visit, particularly for nursing visits,” Hornbeck says. “But another large reason was from an outcome perspective; there was some information coming out about the benefits of telemonitoring with improving outcomes and reducing readmissions. It was early back then, 15 years ago, and with our initial project, the equipment we used was older technology; it wasn’t wireless, it had the basic vital sign capacity, and there was no video or face-to-face capability with that equipment.”

Fast-forward to today, and MultiCare’s Telehealth Chronic Disease Management program for Home Health patients has grown from 10 remote monitors to 100, and has expanded to include patients with pulmonary conditions, mostly chronic pulmonary obstructive disorder (COPD), as well as pneumonia, in addition to the heart disease patients. MultiCare continues to work with Honeywell and leverages the vendor’s telemonitoring and video conferencing capabilities through its LifeStream 5.2 telehealth software.

With a census of 80-90 patients per registered nurse, patients participating in the program report their blood pressure, respirations, weight and oximetry on a daily basis using a tablet, called the Honeywell Genesis Touch, and this tablet transmits the biometrics to Honeywell’s LifeStream Management Suite.

The software alerts the nurse to abnormal values, resulting in a staff intervention, Hornbeck says. This may include medication education, enactment of physician ordered action plan, or coordinating patient appointments with providers. Interventions are provided telephonically or via video visit.

Hornbeck reports that the telehealth program for home health patients has helped to reduce 30-day readmissions rates for heart failure and COPD patients. “That’s our key metric, our readmission rate. Year-to-date data, 30-day readmission rates for heart failure patients is 4 percent, and 30-day readmissions for COPD patients is 2 percent. So, it’s very successful,” she says, adding, “What I would highlight, in particular with COPD patients, is a lot of articles and literature for tele-monitoring have not been supportive of the use of it for COPD patients. With our program, we use a lot of medical protocols, and with addition of the video and the engagement and the unique interventions, we feel it’s been quite successful. We’re proud of the fact that we’ve been able to use this with that COPD population as well.”

Kelly Gariando, R.N., telehealth registered nurse at MultiCare, says that the remote monitoring technology is a valuable tool, but the technology alone doesn’t achieve those results.  “We have about 80 to 90 patients active at any one time, and our monthly interventions to achieve that is over 700 interventions. So, it is a lot of work; it is not just the vitals coming in, and then, once in a while, we call patients. There’s a lot of calls and a lot of coordinating with physicians and reviewing physicians’ notes after a patient sees a doctor. We’re on Epic, so we can see the physicians’ notes, and then we call the patient and say, ‘I see you saw the doctor and your meds were changed, did you pick up your antibiotics or your medications?’ It’s a very interactive type of monitoring. And, I would say a full 50 percent of the time those patients needed those follow ups for a variety of reasons, such as they had not yet picked up their medications or they left the doctor’s office with questions about the meds and didn’t understand why the doctor was changing things, and didn’t want to ask.”

Hornbeck adds, “When we speak to others about this program, we really emphasize that a tool is wonderful but if you just put it in the home and don’t have any protocols around it, if you don’t have the intensive tools that have been developed, along with the willingness to respond and be proactive and have the clinical aspect of it, all of that is very important. It is all of that together that makes this program successful.”

The Engagement Piece

Many clinical leaders at hospitals and health systems talk about “high-tech, high-touch,” and that concept seems to be driving the success of the remote monitoring program for MultiCare’s home health patients. Hornbeck says implementing the video interface capability as part of the remote monitoring program as an alternative to nurses conducting at-home visits has been a critical factor. “The video aspect of it is, from an engagement perspective, is huge,” she says.

She elaborates, “We use it to further assess the patient, or ‘eyes’ on a patient, but also from an ability to engage the patient and coach them through different treatments. So, it’s responsive, such as responding to abnormal information that the patient is having an issue, but we also do some proactive video interactions with these patients. I would say in particular with the COPD pulmonary population, I think what’s different is that video component and, in combination with the biometric data and other assessment data, we’re actually able to see them, that’s a large difference.”

The video interactions enable the telehealth nurses to virtually “reach” into the home talk to patients in real-time when they are experiencing a problem. For instance, if a COPD patient is experiencing shortness of breath, Gariando says she can talk the patient through using their pulse oximetry to measure oxygen saturation and to use their spirometry and then coach the patient through the proper technique of using their nebulizer. “Then we re-check them so they can see the real-time biometrics and they’ll see their oxygen levels come up and they can see that for themselves in the home. That is all done with a video visit.”

Gariando stresses the importance of walking the patients through those treatments. “It shows the patient how effective their equipment can be because there is a chronic problem with the COPD population, even though they have the nebulizer, they don’t use them very often. That’s an example of a video visit where we can actually show them, in real time, actual improvements.”

As another example of how the video capabilities combined with the biometric data enables effective patient coaching, Gariando says telehealth nurses can demonstrate to a heart failure patient how compliance with their treatments, such as taking an extra water pill, has helped to keep their vitals at the right levels that day, and compare that biometric data to a previous day’s data when the patient wasn’t compliant and their vitals fell out of parameter.

The video visits and coaching also might focus on diet education. “Generally speaking, I would say at least 80 percent of the patients who have COPD also have heart failure, and a lot of the teaching is getting them to understand that when you can’t breathe that symptom starts with diet non-compliance. So, if a patient’s weight goes up or they have more shortness of breath, I will say, ‘Okay, tell me what you had to eat yesterday.’ And, if they went to a particular restaurant and we can pull up a menu and we’ll screen share with them and show them that this is the amount of sodium you had. And, we also use colored handouts to show them the process that when you eat salt, you hold more fluid in your body, and that fluid builds up and it goes to your lungs and so today you are short of breath,” Gariando says.

Hornbeck and other clinical leaders at MultiCare have learned important lessons on their telehealth journey. “You must have a way to engage the patient very quickly, and have the technology work from the beginning, that’s important to engage the patient. And, I would say the second lesson is that you must have the clinical platform and clinical expertise to go along with the technology. So, work with your partners,” Hornbeck says, adding, “Work with your health system, find a physician or provider to be a champion. When we started with heart failure, we partnered closely with the Pulse Heart Institute, some of the physicians, pharmacists and medical directors, to come up with clinical protocols that were blessed by them. That way, it’s more accepted by other providers when we begin to implement these protocols.”

What’s more, Hornbeck says it’s critical to get senior leadership support for these initiatives. “If you are going to go forward with this to get funding, you want to understand how to speak to that audience. We had some interesting experiences as we presented to different audiences and key stakeholders and the things that we thought would speak to them, and amazingly enough, to some audiences, readmission rates don’t speak to them. They want to hear about something else, they want to hear real stories. You need to know who your audience is when you’re going to put your proposal together so you can present the benefit that speaks to them.”

One ongoing challenge to building support for telehealth and remote monitoring programs is the lack of direct reimbursement, Hornbeck says. “You have to get people to understand what the benefits are; it’s indirect, it’s a cost avoidance, it’s a cost savings model. A lot of people still think about fee-for-service. Certainly, there is virtual medicine out there and a lot of people are very familiar with that, and it’s taking off because it’s provider-driven. With this particular model, it’s still a little early, especially on the West Coast, for payers to jump on board and pay as part of their bundles. I think that’s just on the horizon. That’s the cultural shift, to get people to move from that fee-for-service perspective to a perspective of seeing the cost savings associated with keeping people out of the hospital.”



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MUSC Telehealth Leaders Share Their Roadmap to Success

October 17, 2018
by Heather Landi, Associate Editor
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The Medical University of South Carolina (MUSC), based in Charleston, is widely regarded as an industry leader in telehealth with a robust, high-volume telehealth program that touches not only MUSC’s local community but also impacts patients throughout the state.

In 2017, MUSC was one of two academic health systems recognized by the federal government as a National Telehealth Center of Excellence. The Health Resources and Services Administration (HRSA) gave MUSC this designation in recognition of MUSC’s expansive breadth and depth of telehealth services, most of which are in medically underserved areas of South Carolina, a state with a high burden of chronic disease and health disparities.

The MUSC Health Center for Telehealth brings together resources from across MUSC Health to connect patients and providers across South Carolina. The Center provides 77 unique telehealth services to more than 200 sites in 27 South Carolina counties, which includes hospital-based programs, such as tele-stroke and tele-ICU, as well as outpatient programs, where urgent, primary and specialty care is delivered directly to patients. The Center also operates school-based telehealth and provides telehealth services for skilled nursing facilities and institutional facilities.

Three key leaders of MUSC’s telehealth program will be presenting at the Convege2Xcelerate conference taking place Oct. 22 at Columbia University in New Yok City. The conference is sponsored by Partners in Digital Health, publisher of Blockchain in Healthcare Today and Telehealth and Medicine Today, and will feature sessions on transformational technologies including blockchain, telehealth and artificial intelligence (AI).

The MUSC speakers include James McElligott, M.D., who is the medical director for telehealth at the MUSC and an assistant professor in the division of general pediatrics at MUSC Children’s Hospital. McElligott oversees the Center for Telehealth at MUSC. Kathryn King Cristaldi, M.D., the medical director for School Based Health and an assistant professor in the division of general pediatrics at MUSC Children’s Hospital, also will be presenting, along with Dee Ford, M.D., a professor of medicine in MUSC’s division of pulmonary and critical care medicine.  

Leading up to the conference next week, Healthcare Informatics Associate Editor Heather Landi recently spoke with Drs. McElligott, Ford and Cristaldi about their innovative work in telehealth services, what they plan to share with the Converge2Xcelerate audience and their vision for the future of telehealth delivery and its potential to transform healthcare. Below are excerpts of those interviews.

What do you plan to share with the Converge2Xcelerate audience during your presentation?

McElligott: We’re not doing as much on telehealth 101, but more on innovation and how telehealth leads to innovations in healthcare business models.

Ford: We will focus on two major initiatives within our Center of Telehealth. We will share the structured, guiding framework that MUSC applies to telehealth service development, which includes strategy, development, implementation and continuous quality improvement, and how we were able to develop that. We’ll talk about how you can develop and refine that to help ensure that you are able to successfully deploy a telehealth solution and sustain that solution. And the second part will focus on telehealth finance, and we’ll talk about the value proposition framework for telehealth services, as financial performance is integral to sustaining and scaling telehealth services. How does the value proposition inform how you structure and quantify your different telehealth services when you have a diverse portfolio of telehealth services, such as we do? Those two things, the structured framework for implementation and sustainment and the value analysis strategy for telehealth, will be the bulk of the session.

McElligott: When organizations are developing telehealth programs by using these distance technologies to enhance healthcare, what many folks struggle with is that they are specifically trying to take what they do with in-person care and extend it. Looking at the value proposition means you flip that a little and say, maybe the way we do it now is because it’s practical for what it means for a patient to walk into your office. What you find is that as you develop these services and as they morph a little bit, you have to ask yourself, what I am doing this for again? Some of the services that we have developed are directly to support a need, like another hospital contracts with us for a certain service, such as tele-stroke, because they have a lack of it.

James McElligott, M.D.

The other telehealth services are focused on a population health perspective or trying to solve a problem in another way. If you remain focused on why you set out to do what you do, it keeps you guided towards that value proposition, rather than reinventing the wheel of what in-person care is like. It’s a way of giving yourself a trajectory of what we’re trying to get done and breaking out of the mold of traditional healthcare. You have to give yourself a trajectory and then design your telehealth service from that perspective.

Your organization has been able to scale its telehealth program to a full suite of modalities. What has been your roadmap to success?

Ford: I think it is a couple of things. One is the people—early on, we had physician engagement and strong physician leadership buttressed with an excellent administrative team who were collaborative and recognized that building some small siloed thing would not allow us to achieve scale. We had a really great team of dedicated people, both from a leadership level down to the front line, administrative support team. We also have very strong executive buy-in as far as telehealth being a key strategy. Our most senior leadership were very bought-in to the importance of telehealth and to MUSC using it in order to meet the healthcare needs of our state. That combination of talent and passion and leadership endorsement was integral. And, frankly, we were well-supported financially in terms of pursuing these efforts through a combination of funding sources, including some legislation allocation grant funding. We had the right people, leadership buy-in and enough financial resources to be able to grow and build.

Dee Ford, M.D.

Looking ahead, many people believe “telehealth” will become, simply, health, and a seamless part of healthcare. What is your view of the future of telehealth delivery?

Cristaldi: I think there is that thought that eventually we won’t be telehealth experts and we won’t work within the Center for Telehealth, but rather, we’ll be healthcare experts, and this will just be a part of what we do and part of the healthcare landscape. I think that’s everyone’s goal—how do we integrate this into healthcare as we know it. The thought behind it is—how do we address health, wellness, disease and the whole spectrum and continuum of care, when we can have more access to our patients and/or are patients have more access to us, and in different ways? Looking at how to directly connect to patients, that will be the future.

McElligott: That kind of conversation happens a lot over the past half-decade or so. It still seems to be going in the opposite direction, as the term itself [telehealth] is not going away as quickly as some of us thought it would be. It’s certainly is getting integrated and some of it is getting normalized and absorbed into healthcare.

You can look at it from two perspectives; one, it will be normalized, and just be a part of care. On the other hand, I think that it will be powerful enough that it will really change the way we do care, enough that it will be distinct. What I mean by that is, if you are using your cellphone to access care enough in multiple different ways, the whole healthcare relationship with the population might be enough to change that we will be accessing preventive care in a totally different way than we are now, where we go to a doctor and they tell us all the things to do to be healthy. So, yes, it may very well be absorbed into healthcare over time, but I think it will be different than what people think; it will be patient-driven in a way that’s even hard to predict now. It’ll be absorbed, but it will also transform healthcare at the same time.

Ford: I agree with that perception. The guiding vision for our Center for Telehealth is efficient and effective care. There isn’t another dollar in the healthcare system to pay for add-on services. But, you can clearly use technology to either make it more effective in some way, so more timely access to the right specialist, or, also, to make healthcare more efficient. And, there’s some work that you see in chronic disease management; there’s been good success in those areas to increase efficiencies in the systems. I think those two things combined—using technology to make the health system more effective and/more efficient, from the perspective of the patient, the provider, the payer, and the system—is going to be the thing that drives it forward and transforms the healthcare system.

What are some of the telehealth success stories for patient populations in South Carolina?

Cristaldi: Certainly, one of the most profound example is tele-stroke. In South Carolina, only a handful years ago, the majority of the population did not live within driving distance of a stroke specialist. That meant that, for most patients, if they needed tPA, the clot-busting drug that saves the lives of people who are having ischemic stroke, they didn’t live close enough to a hospital that had a stroke specialist to provide that kind of care. To me, that is so profound. You can’t physically get to lifesaving care, even though it’s well established in the medical community. To me, that was how I felt living in East Africa [where she completed some of her pediatric training].

Kathryn King Cristaldi, M.D.

Through the tele-stroke program, we connect stroke specialists out to the majority of hospitals in South Carolina and every South Carolinian now lives within an hour of expert stroke care. At a large population level, we’ve changed the ability to address a deadly disease. And, in our school-based programs, we’ve been able to increase access to care for children, particularly in counties where residents have no access to pediatricians. We have evidence that our quality metrics in dealing with chronic disease, like asthma, can even be better than those of in-person care, because we are able to see patients more often and really monitor their symptoms.

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Seven Companies, Four Individuals Indicted in Billion-Dollar Telemedicine Fraud Conspiracy

October 16, 2018
by Rajiv Leventhal, Managing Editor
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Four individuals and seven companies have been indicted in a $1 billion telemedicine fraud scheme, the Department of Justice announced this week.

The District Court for the Eastern District of Tennessee unsealed a 32-count indictment on the individuals and companies. The indictment stated that HealthRight LLC, a telemedicine company with locations in Pennsylvania and Florida, and Scott Roix, 52, of Seminole, Fla., and the CEO of HealthRight, pleaded guilty to felony conspiracy for their roles in the telemedicine healthcare fraud scheme in a criminal information. Roix and HealthRight also pleaded guilty to conspiring to commit wire fraud in a separate scheme for fraudulently telemarketing dietary supplements, skin creams, and testosterone, according to DOJ officials.

In addition, three other individuals were indicted along with their compounding pharmacies, Synergy Pharmacy Services, located in Palm Harbor, Fla. and Precision Pharmacy Management, located in Clearwater, Fla.. Another co-conspirator, Larry Everett Smith, of Pinellas Park, Fla. also a pharmacy compounder, and his companies Tanith Enterprises, ULD Wholesale Group, Alpha-Omega Pharmacy, all located in Clearwater, Germaine Pharmacy located in Tampa, Fla., and Zoetic Pharmacy located in Houston, Texas, were all also named as defendants. All the defendants were charged with conspiracy to commit healthcare fraud, mail fraud, and introducing misbranded drugs into interstate commerce, per the indictment.

The indictment alleges that from June 2015 through April 2018, these individuals and companies, together with others, “conspired to deceive tens of thousands of patients and more than 100 doctors” located in Tennessee and elsewhere across the country “for the purpose of defrauding private healthcare benefit programs such as Blue Cross Blue Shield of Tennessee out of approximately $174 million. The indictment further alleges that the defendants submitted not less than $931 million in fraudulent claims for payment,” according to the indictment.

More specifically, according to the indictment, the defendants “set up an elaborate telemedicine scheme in which HealthRight fraudulently solicited insurance coverage information and prescriptions from consumers across the country for prescription pain creams and other similar products.” The indictment states that doctors approved the prescriptions without knowing that the defendants were massively marking up the prices of the invalidly prescribed drugs, which the defendants then billed to private insurance carriers.

In addition to their roles in the healthcare fraud conspiracy, Roix and HealthRight were also charged with conspiring to commit wire fraud as part of a scheme to use HealthRight’s telemarketing facilities to fraudulently sell millions of dollars’ worth of products such as weight loss pills, skin creams, and testosterone supplements through concocted claims of efficacy and intentionally deficient customer service designed to stall consumer complaints, according to the indictment.

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With $6.3M PCORI Contract, UPMC Health Plan to Study Tech-Based Approach to Chronic Disease

September 25, 2018
by Heather Landi, Associate Editor
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The UPMC Center for High-Value Health Care was recently awarded a $6.3 million contract from the Patient-Centered Outcomes Research Institute (PCORI) to study different care delivery models to improve outcomes for patients with chronic disease and a co-existing behavioral health condition.

The multi-year study will highlight payer-provider collaboration to support individuals with both physical and behavioral health conditions. The UPMC Center for High-Value Health Care is housed within the UPMC Insurance Services Division, which includes UPMC Health Plan, and is part of Pittsburgh-based UPMC health system.

The focus of the study is to better understand how to design systems to manage chronic disease and will compare a technology-centric approach with a team-based, high-touch intervention, according to UPMC.

PCORI awarded the UPMC Center for High-Value Health Care support for a five-year study with a long-term objective to enhance the ability of health care systems to better support individuals with chronic diseases like inflammatory bowel disease (IBD) and behavioral health conditions, reduce variations in practice, connect patients with care that is best for them, and improve meaningful, patient-centered health outcomes.

This PCORI study is related to a recently completed one-year pilot study, which showed that participation in an IBD specialty medical home, a care delivery model that is uniquely designed to provide comprehensive and well-coordinated health services, increases patients' quality of life while decreasing levels of disease activity and use of unplanned care. In fact, the pilot study demonstrated a 50 percent decline in emergency room visits and a 30 percent decline in hospitalizations among participants.

“The early successes of the pilot study are encouraging and now this multi-year PCORI study will allow us to further align the payer and provider to develop long-term benefits and applications in a variety of clinical settings," William Shrank, M.D., chief medical officer for UPMC Insurance Services Division, said in a statement. "The use of technology as a key component of the study underscores the role that emerging trends will play in the future of health care."

Participants who enroll in the study will receive IBD specialty medical home care through either a team-based or tech-based approach.

The team-based approach is a personalized service design that includes gastroenterologists, behavioral health specialists, registered nurses, and health coaches who provide intensive, in-person support and resources. The tech-based approach leverages a digital platform using remote monitoring, digital behavioral interventions, and telehealth to deliver team-based care at the patient's convenience, at home and in the community, with the guidance of health coaches.

“By examining the effectiveness of a 'team vs. tech' approach, we expect that this research will provide insight on the most effective methods to provide both physical and behavioral health care to individuals with IBD and most importantly, a better quality of life for patients both now and into the future,"  principal investigator for the study, Dr. Eva Szigethy, professor of psychiatry at the University of Pittsburgh and senior faculty at the UPMC Center for High-Value Health Care, said in a statement.

Co-investigators of the study include clinical experts from the UPMC Center for High-Value Health Care, the University of Pittsburgh, Mount Sinai Health System in New York, and Brigham and Women's Hospital in Boston.

This marks the fifth PCORI contract awarded to the UPMC Center for High-Value Health Care over the past five years.


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