Will “Telehealth” Soon Become, Simply, “Health?” | Mark Hagland | Healthcare Blogs Skip to content Skip to navigation

Will “Telehealth” Soon Become, Simply, “Health?”

October 2, 2016
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A Health IT Summit-New York panel discussion probed exciting healthcare delivery potentialities

It was my privilege and pleasure last week to moderate a panel discussion on telehealth and population health at the Health IT Summit in New York, sponsored by our publication, Healthcare Informatics. Our panel discussion, under the title “Telehealth: New Platform for Population Health,” was privileged to have with us Rahul Sharma, M.D., emergency physician-in-chief in the Division of Emergency Medicine, New York Presbyterian-Weill Cornell Medical Center; Mony Weschler, chief and senior director, applications and innovations strategy, at Montefiore Health Systems; and Todd D. Ellis, a managing director at KPMG.

We looked at a broad range of issues, including payment, industry, clinical practice, and technological developments that have been dramatically expanding the concept and implementation of telehealth. For example, as noted in the report on the session published by our Assistant Editor Heather Landi, Dr. Sharma shared extensively with our audience about a telehealth initiative that has been very successful at New York Presbyterian-Weil Cornell, involving efforts to reduce waiting times in that organization’s emergency department by offering patients waiting in the ED the opportunity to move next door in the facility to a space where they can immediately be seen by a physician via a telehealth connection. “We launched a pilot telehealth program so when a patient comes into the ER, they have the option of a virtual visit through real-time video interactions with a clinician after having an initial triage and medical screening exam. So they go to a private room and see a clinician via a telehealth monitor,” Sharma noted. “The analogy we use is that years ago there were banks going up on every single street corner, and then the banks all put in ATMs. And people said that’s crazy, why go to ATM when can go to the teller? It’s the same concept. We’re allowing patients a choice in how they get healthcare.”

This was just one example of newer initiatives that are using telehealth strategies to improve care delivery, efficiency, and the patient experience, that have nothing to do with the initial types of telehealth efforts, involving linking rural primary care physicians with specialists at large urban hospitals.

That initial concept, which led to initially rather smallish-scale telehealth efforts, was sincere and meaningful at the time. But as all of my panelists noted, U.S. healthcare is changing very rapidly now, and all the shifts taking place are fueling a reassessment of what telehealth should be. We all know that exploding costs across the U.S. healthcare system, driven by the aging of the population and an explosion in chronic illness, are leading the purchasers and payers of healthcare to demand that providers come up with solutions to the cost juggernaut.

And certainly, care delivered in the emergency department is being delivered in one of the most expensive venues available. So Dr. Sharma’s solution at New York Presbyterian-Weil Cornell makes sense from multiple standpoints—not only in terms of patient satisfaction and outcomes, but also in terms of cost-effectiveness and efficiency.

What is interesting is how the policy, cost/reimbursement, operational, clinical care and outcomes, technological, and patient satisfaction/experiences elements in this situation are all aligning towards the inevitable expansion of the telehealth concept. Indeed, that was the point behind the concept of our panel discussion in New York last week, as the concepts “telehealth” and “population health” are inevitably beginning to draw together and align. And all of that makes eminent sense.

The fact is that, as the leaders of patient care organizations take on risk-based contracting, whether it be through accountable care organization (ACO) formation, broad population health initiatives, patient-centered medical home (PCMH) development, or outcomes measurement and value-based payment generally, they will need to expand attributed patients’ access to healthcare, via the most patient-friendly, patient-satisfying, family-satisfying, time-efficient, and cost-effective means and venues possible, all the while assuring the correct clinical care parameters and safeguards. As Dr. Sharma noted in our panel, patients with serious symptoms such as chest pain or bleeding, are never offered a telehealth redirect. The telehealth option is for those with simple symptoms like colds, coughs, and low-grade fevers.

Data and information systems seen as crucial

Meanwhile, Wechsler noted in our discussion that, when it comes to Montefiore’s population health efforts and its telehealth technology platform, his organization’s leaders have learned important lessons about using data and developing data analytics. “It’s all about the data, so the more data you have on a patient, the more you can have a longitudinal view, the better you can treat that patient,” he told the audience. “If a patient stays in our system, then we have data and we do very well. But if the patient leaves our system, then we need to fill in the gaps as there are holes in the data, and we don’t do as well, so we learned from that.”

Instead, providing physicians and nurses at the point of care with key data points they need to treat patients, will naturally help to expand population health and telehealth capabilities across numerous dimensions and venues.

Indeed, Wechsler said, the core electronic health record is going to be a vital element in expanding all these concepts. “We’ve also learned that we need to make this easy and very seamless for the physician,” he said. “While most of these technologies can interface with the electronic medical record, he called on EMR vendors to “step up to the plate and make it seamless.”

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

What’s particularly exciting going forward, and is something that Wechsler noted, is the prospect of technology, including home-based technologies and wearable technologies, to combine the concepts of telehealth, consumer-based/consumer-facing health and fitness engagement, home-based health, and care management, in new and exciting ways. “This is the future, to use sensors, wearables and implantables, and the technology is being developed right now to enable continuous monitoring of the patient and to be able to do vitals and get real data from the patient, as that’s one of the last obstructions to telehealth,” he said.

I agree. Looking at the current landscape and the potential landscape of five years from now, the U.S. healthcare system (and also potentially the healthcare systems of many advanced nations) could be on the verge of a true breakthrough, in which policy, reimbursement, technological, and clinical practice changes and advances align in such a way that individuals with chronic illnesses and other health conditions could be both broadly and deeply connected to the patient care delivery system on a moment-to-moment basis, allowing for rapid, highly effective interventions, at the earliest appropriate moment, and often in the home or even as patients navigate their daily lives. Getting there will require not only ongoing investments in still-evolving technologies; it will also require a commitment to population health at the highest conceptual level; and an acceptance and indeed, an embrace, of a fundamental shift away from inpatient care wherever possible, towards and through outpatient care, into the home and into patient’s mobile daily lives.

But the end result could be amazing: a new world of healthcare and health, one no longer circumscribed by many of the physical, technological, payment and policy limitations that we all now face—and one that could make our society both healthier and less financially burdened.

So yes—one day, “telehealth” really will simply be “health.” And that is a vision of the future that patient care leaders need to plan for.

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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.

Related Insights For: Telehealth

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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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