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Top Ten Tech Trends 2017: Telehealth Reaches the Tipping Point

March 22, 2017
by Heather Landi
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In a recent survey conducted by Harris Poll and commissioned by American Well, a telemedicine technology provider, 20 percent of consumers said they would switch their current primary care provider (PCP) if another PCP in their area offered telehealth visits. Among the 4,000 respondents to the survey who have a primary care physician, 65 percent said they were interested in seeing their PCP over video. Parents with children under 18 are even more likely to say they’re interested, with 74 percent interested in seeing their PCP through telehealth, according to the survey.

Telemedicine is not a new technology; in fact, it’s about 40 years old, according to Jonathan Linkous, CEO of the American Telemedicine Association (ATA). All the same, the use of telemedicine is accelerating very rapidly. “After decades of experimentation and pilot projects, we’re over the point of no return. I think we’re over the tipping point and we’re now at the point where it’s starting to transform health delivery.”

There is ongoing discussion about the consumerization of healthcare, and that impact is being felt now at healthcare organizations across the country, as consumer demand for the convenience of virtual visits and digital services is driving this acceleration of telehealth services.

“Consumers are very aware of the technology that is available. They see it on their smartphones every day. There is a growing expectation, then, that their healthcare providers are going to make use of this technology to advance the way that care is delivered,” Alan Perkins, principal at The Chartis Group, a Chicago-based healthcare consulting firm, says. The healthcare industry is hitting an inflection point where patient care organizations are now essentially competing with retailers, such as Walgreens and CVS, that are now offering telehealth services.

Alan Perkins

And while there continue to be barriers to telemedicine adoption, Perkins cautions, “Providers can’t wait for all the reimbursement or technical issues to be resolved, or they will be left behind as this consumer-driven change alters the healthcare landscape.” He adds, “So the providers that have been taking a wait-and-see approach, they need to start working now on an enterprise telemedicine strategy. A robust telehealth capability takes time, and as consumers increasingly come to expect these services, health systems need to be ready, and they need to be planning now.”

At the same time, there are rapid technological advancements as electronic medical record (EMR) vendors are building telehealth capabilities into their current EMR applications and into their native workflow designs, says Carl Dolezal, associate principal at The Chartis Group. “We have changed the landscape to the point where technology is no longer the barrier, but the enabler. Historically, we have struggled with stitching together networks and applications, and integrating devices with EMRs in the provider space. Developing telehealth through these systems that were, for the large part, not intuitive. But now with improved telehealth application capabilities and integration, some of which have actually been developed and supported by the EMR vendors, information is available with telehealth tools within their standard workflows, and that’s very important.”

For many patient care organizations, telehealth and RPM technologies are becoming just another tool in the toolbox for providing patient care. Health systems and providers using telehealth and RPM technologies are reporting significant benefits, in terms of improving patient care and lowering costs. Tele-ICU is now widely implemented, with about 30 percent of ICU beds in the U.S. connected to remote monitoring technology, Linkous says, and studies have shown that tele-ICU helps to reduce length of stay and improve patient outcomes.

At the Phoenix-based Banner Health, a 28-hospital health system, healthcare leaders built an in-home telehealth program targeting a subset of patients with complex chronic conditions following a successful tele-ICU program. The in-home telehealth pilot program, called the Intensive Ambulatory Care (IAC) program, focuses on the system’s most complex population, those diagnosed with five or more chronic diseases, according to Deb Dahl, vice president of patient care innovation at Banner Health.

Banner Health and its vendor partner, Royal Philips, studied the impact of the IAC telehealth initiative on patient outcomes, and the results showed significant decreases in patient healthcare costs and hospitalization rates. Specifically, an analysis of patient results over the first full year of the in-home AIC program revealed that the program helped to reduce overall costs of care by 34 percent, reduced hospitalizations by 49 percent and reduced the number of days in the hospital by 50 percent. Prior the program, there were 10.9 hospitalizations per 100 patients per month; after enrollment in the program, the acute and long-term hospitalization rate dropped to 5.5 hospitalizations per 100 patients per month. Additionally, Banner Health saw the 30-day readmission rate for that patient population drop by 75 percent—from 20 percent prior to enrollment to 5 percent after program enrollment.

Deb Dahl

Dahl says the average age of the patient in the program is 82—the very first patient had 20 chronic conditions and was taking 17 medications—and the real-time in-home monitoring is critical, as it provides clinicians with data on adverse trends, “so you can intervene before the adverse trend becomes an adverse event.” More broadly, telehealth can play a significant role in care coordination and care management, which is critical to a population health strategy.

“When you start your population health journey, you can say ‘I’m going to do wellness’ and that’s a pretty long payback period. Or, you can say ‘I’m going to focus on the more expensive group of folks and use those savings to bring in the next layer and the next layer,’” Dahl says. “So we looked at this complex chronic population and one criteria is that they have to have a $20,000 prior 12-month spend to get into the program. If we can reduce their total cost of care by 34 percent, then you can improve quality of life, reduce the number of hospitalizations, reduce the costs to them and to the plan. So we’ve done that quality of life and cost reduction and that allows us to move into another space, like diabetic patients.”

Building a Telehealth Strategy

While many in the industry still cite barriers to telehealth and RPM adoption, the drive to value, cost reduction and improved patient experience are all going to continue, industry stakeholders say. So as telehealth demonstrates that it advances those goals, reimbursement is expected to follow, Perkins says. “Regardless of what happens in the short term, providers need to be developing a clear telehealth strategy now.”

Perkins adds that reimbursement, in general, is a rapidly evolving area. According to the ATA, 31 states currently have telemedicine parity laws for private insurance and all state Medicaid agencies have adopted some type of coverage for telemedicine. “As for CMS [the Centers for Medicare & Medicaid Services], reimbursements are already changing as more and more telehealth services continue to be added to the list of reimbursable CPT codes,” Perkins says.

The more significant limitation on Medicare reimbursement is the requirement that the patient has to located in a health professional shortage area and must be physically present in the clinical setting. “This is changing, as a waiver to this rule is now available to participants in a Next Generation ACO [accountable care organization],” Perkins says. “So a patient participating in the Next Generation ACO can receive telehealth services in their home, and not be required to be in a rural area. So we’re seeing an openness to change there and those changes will likely accelerate.”

Carl Dolezal

Executive leaders at health systems need to be identifying and then acting upon opportunities to serve patients with telehealth. “There are some questions to consider, Perkins says, such as ‘What approaches would providers prefer? What are my payers covering or planning to cover? What is my competition doing?’” Additionally, healthcare executive leaders need to think about where the ball is headed to get a sense of what services the organization should develop and align strategy with reimbursement opportunities.

As telehealth use accelerates, Perkins says patients’ focus may move away from the provider of healthcare and more towards the service that’s being purchased, and that has a few implications for providers. “First of all, providers need to ensure that the care they are delivering is not perceived as a commodity, they need to differentiate themselves, and that differentiation can focus on superior quality, convenience, access to specialists, and outstanding patient experience. But they need to ensure that patients have a reason to choose them over the alternatives, other than simple geographic convenience.” And, he adds, “Providers need to offer telemedicine options to those that want them, so that their business model isn’t disrupted by those who are more adept at this new digital delivery of care.”

Many healthcare CIOs have a lot of work to do in developing and launching an enterprise telehealth and digital technology strategy, according to a recent survey by KPMG and the College of Healthcare Information Management Executives (CHIME). That survey found that only half of hospital CIOs have a clear digital business strategy and vision and only 39 percent of CIOs are currently working on a digital healthcare strategy. In that same survey, 38 percent of CIOs ranked EMR system optimization as their top priority for capital investment over the next three years, and 13 percent cited virtual/telehealth technology enhancements as a top priority.

“As the barriers to telehealth come down, whether those are technical or regulatory or reimbursement-related, patients are going to come to expect this as a normal part of healthcare delivery.” Perkins notes. “We are moving toward a future in which telehealth is not seen as something unique and different, but simply another option for healthcare delivery. For some types of patient-to-physician interactions, such as the ongoing management of chronic conditions, telehealth will be the natural choice.”

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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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