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N.C. School-Based Telehealth Program Grows Into National Model

February 1, 2017
by David Raths
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What started as a pilot in three rural schools has grown to 33 schools in four counties
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In its sixth year of providing school-based care via telehealth in four counties of North Carolina, the nonprofit Center for Rural Health Innovation’s Health-e-Schools program has grown into a national model. What started as a pilot in three rural schools in the Appalachian Mountains has grown to 33 schools in four counties.

The program’s founder and medical director, Steve North, M.D., made the transition from schoolteacher to primary care physician to telehealth program executive. Here is his story: In the 1990s North was a Teach for America corps member in rural North Carolina. He remembers seeing a student who had come to school after stepping on a nail. He couldn’t concentrate on his schoolwork, and the parents had trouble getting him to a provider because they had one car and both worked two jobs.  At about the same time he read a book by Joy Dryfoos called “Full Service Schools,” about the idea of school-based healthcare.

“It just made sense to me that we should be providing care to kids where they spend the majority of their days,” he said. Later he went to medical school at the University of North Carolina and then did a family medicine residency and an adolescent medicine fellowship at the University of Rochester, with a focus on school-based healthcare. It was there in 2005 that he met providers who were working on school-based telehealth programs, a concept he took back to rural western North Carolina.

Even though they had grant funding, starting up a telehealth program was full of challenges for North and his colleague Amanda Martin, the executive director.  

“School-based health centers were not known in our region. We were looking at providing care at a new place and by new means,” North said. “When I started shopping this idea around to the school systems in 2009, no one had really heard of telehealth.” He said one preliminary issue was the technology. “We got our first three carts but they were put together by a videoconferencing company that didn’t really know telehealth. In our next rollout we went to a specifically designed telehealth cart.”

Another challenge was that the program relies on school nurses who present the patients to providers. “Without their support we wouldn’t see any kids. They are our eyes and ears in the school,” North said. “In our first three schools, two of the nurses were not enthusiastic about the program. Because we didn’t have buy-in from them, it was a challenge. But we now have three excellent nurses in that district, and they are our busiest of our three districts.” He said maintaining good relationships with those school nurses and supporting them is key. “It doesn’t always have to be a telehealth visit, but if they are trying to figure out a new way to improve care for kids with allergic reactions, they often call me or one of our other providers to talk it through.”

In the first few years, they didn’t have funding for a full-time provider and that resulted in slower uptake. “Once we were able to have a full-time provider, that was a huge benefit for us. We have two nurse practitioners who job-share.

“We have a centralized scheduling person and an e-mail address. We have found that is the best way for nurses to contact us. A parent or the nurse can e-mail and set up an appointment.” North does a lot of behavioral health work such as medication management for ADHD. “Those are typically scheduled appointments. The rashes, coughs and colds, UTIs, strep throat, those are more on-demand. Depending on the season, we can see 14 patients in a day or we can see none. That is the hit-or-miss nature of what we do.”

At first they only had a pediatric nurse practitioner. Once they started seeing teachers with a family nurse practitioner, uptake really improved. “Now the teachers could be seen as well as part of a workplace health offering. That in turn makes them advocates for the program.”

The program bills and gets reimbursed by private insurance companies and by Medicaid in North Carolina.

It requires parental consent, and students are enrolled at the beginning of the year, or on demand. “We use Athenahealth as our EHR and send records over to the primary care provider after we see the patient," North said. "That is one of the areas that has been slowly growing — working with the students' regular providers.”

North mentioned several ways the program is currently expanding or plans to. “This year we have partnered with Mission Children’s Hospital in Asheville, working with the pediatric pulmonologist and asthma educator. We have rolled out a comprehensive asthma management program focused on education and on how to treat an acute asthma exacerbation at school,” he explained. “At what point does the nurse does engage the telehealth providers or the child needs to go to the emergency room? We are making sure there is a rescue inhaler at school and at home.”

The center also wants to establish partnerships with ACOs. “When we see a child via telehealth, the quality indicators get sent to their primary care provider’s EHR, and they get credit for that — and they can refer out to us. It would be great if that provider could say to a patient, ‘I would like you to be seen by the nurse practitioner through Health-e-Schools and she will report back to me on how you are doing.’”

The program also partners with the statewide Community Care of North Carolina, which offers enhanced case management. “We partner with them to identify at-risk children and high emergency room utilizers, especially for things like asthma, and try to get them into more regular care and on more appropriate medications.”

As far as expansion goes, North said, they are already talking to six schools in an adjacent county in Appalachia. But in other areas of the state, he suggested that it might be better for local groups to actually build and run the programs with consultation from the center.

Last year the federal Health Resources & Services Administration awarded a series of telehealth grant focused on school-based telehealth. North and Martin, who are on the board of the Mid-Atlantic Telehealth Resource Center, are consulting with many of the groups that got funded.



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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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



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Study: Neonatal Telehealth Reduces Hospital Transfers, Saves Money

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

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

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

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

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

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

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

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

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

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

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

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

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