State-by-State Telemedicine Report Card Indicates Progress, and Ongoing Barriers | Healthcare Informatics Magazine | Health IT | Information Technology Skip to content Skip to navigation

State-by-State Telemedicine Report Card Indicates Progress, and Ongoing Barriers

February 13, 2017
by Heather Landi
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The telemedicine policy landscape continues to be complex, as decades of evidence-based research highlighting positive patient compliance, clinical outcomes and increasing telemedicine utilization have been met with a mix of strides and stagnation in state-based telemedicine policy, according to a state-by-state gaps analysis by the American Telemedicine Association (ATA).

The ATA recently released two reports titled 50 State Telemedicine Gaps Analysis, with one focused on coverage and reimbursement and another focused on physician practice standards and licensure.

The Physician Practice Standards and Licensure report takes a look at the complex policy landscape of 50 states with 50 different telemedicine policies, extracts and compares physician practice standards for telemedicine for every state in the U.S. and ultimately assigns a grade which indicates existing policy barriers that inhibit the use of telemedicine that would enable patient and provider choice to quality health care services.

The ATA contends that since the first version of the report in 2014, medical boards have moved towards a trend of developing different regulations or guidance for medical practice via telemedicine when compared to in-person practice. Further, states are removing telepresenter requirements, while also becoming more prescriptive in the types of modalities permitted for appropriate clinical practice when using telemedicine. As a result of changing guidance and regulation for telemedicine when compared to in-person practice, more states have improved a letter grade since the report in 2016, according the 2017 report.

In all, 21 states received an A in this latest report, compared to 20 in December 2015, suggesting a supportive policy landscape that accommodates telemedicine adoption and usage.

Since the January 2016 update of this report three states (Arkansas, Florida, and Louisiana) have earned higher scores suggesting a supportive policy landscape that accommodates telemedicine. “Arkansas made the most significant improvement with the adoption of rules which allow licensed physicians to use interactive audio-video to establish a provider-patient relationship,” the report authors wrote. Twenty-nine states received a B (the same as last year) and only one state, Texas, received a C grade, which suggests many barriers for telemedicine advancement.

The report notes that with regard to physician practice standards and licensure, only Michigan saw a drop in its composite grade. Last year, Michigan lawmakers enacted legislation which creates a new definition of telemedicine and requires an additional informed consent, according to the report.

The report focused on coverage and reimbursement painted a better picture as all Medicaid agencies, since the ATA’s initial report in 2014, have adopted some type of coverage for telemedicine. Additionally, seven states have adopted policies that improved coverage and reimbursement of telemedicine-provided services, thus improving their standing since the 2016 report, while two states and the District of Columbia have either lowered telemedicine coverage or adopted policies further restricting telemedicine coverage, and thus, received lower grades.

States have made significant efforts to improve their grades through the removal of arbitrary restrictions and adoption of laws ensuring coverage parity under private insurance, state employee health plans, and/or Medicaid plans, the report authors found. Overall, no states have failing composite grades, and there are more states now with above average grades, “A” or “B”, including Connecticut and Rhode Island which improved from an “F” to “B”, compared to last year’s report.

Connecticut, Florida, Hawaii, Idaho, Rhode Island, Utah, and West Virginia have higher scores suggesting a supportive policy landscape that accommodates telemedicine adoption while D.C., Delaware, and South Carolina saw a drop in their composite grade. “South Carolina dropped from an “B” to “C” because the Home and Community-Based Service waiver allowing remote patient monitoring expired,” the report authors wrote.

Breaking down the scores by the 13 indicates, the state-by-state comparisons reveal large disparities in telemedicine coverage and reimbursement. With regard to telemedicine party laws, 10 states have enacted telemedicine parity laws since the ATA’s initial report in 2014. Of the 31 states that have telemedicine parity laws for private insurance, 24 of them and D.C. scored the highest grades indicating policies that authorize state-wide coverage, without any provider or technology restrictions. Less than half the country, 20 states, ranked the lowest with failing scores for having either no parity law in place or numerous artificial barriers to party, the ATA report, which represents a significant improvement as more states adopt parity laws. Arkansas maintains a failing grade because it is the only state that requires an in-person visit in its parity law.

The report also highlights that telemedicine in Medicaid in working, as all 50 state Medicaid programs have some type of coverage for telemedicine. “Eleven states scored the highest grades by offering some comprehensive coverage, with few barriers to for telemedicine-provided services. Connecticut, Florida, Hawaii and Iowa passed reforms that ensure parity coverage with little or no restrictions, while Rhode Island has included some coverage of telehealth-provided services in their Medicaid fee schedule,” the report authors wrote.

According to the 2017 report, the state-by-state comparisons of physician practice standards and licensure still reveal great disparities in the ways licensing boards regulate clinical practice.

Regarding physician-patient encounters, Arkansas was the only state to improve their score to a “B” in this area. The state adopted rules which allow licensed physicians to use interactive audio-video to establish a provider-patient relationship. Texas is the only state ranked the lowest with failing scores mainly because they create the most stringent clinical practice rules for telemedicine providers when compared to in-person practice.

Regarding telepresenter requirements, Texas ranks the lowest with a “B.”  Alaska and Hawaii improved their low ranking scores from the last report with enacted legislation which removed telepresenter requirements. Both states now receive an “A”. All states except for Texas do not require the presence of a health professional during a telemedicine encounter.

Twenty states and D.C. require physicians to obtain patient informed consent. According to the report, this growing trend is largely due to states adopting language developed by the Federation of State Medical Boards (FSMB) and the American Medical Association (AMA) which promotes a regulatory environment for patient informed consent for telemedicine encounters.

Further, the report authors note that no state achieved a top score (A) for their licensure policies. “However, states are addressing the issue of licensure portability by establishing out-of-state registries or joining the FSMB Compact. Thus, adopting policies to uncomplicated the process of practicing medicine across state lines regardless of whether or not telemedicine is used,” the report authors wrote.

Health care providers have seen a considerable amount of state policy activity to improve coverage and reimbursement of telemedicine-provided services by various payers. However, despite improvements to address the payment challenges, health care providers are encountering conflicting and sometimes confusing policies from their own colleagues,” the report authors wrote.

The report authors note that a few state medical boards are adopting practice standards with different, and sometimes higher, specifications for telemedicine than in-person care. “Specifically, these boards have considered legal guidelines requiring an initial examination be conducted in-person and a physician-patient relationship be established in-person. Boards have also considered other telemedicine barriers including requirements for a telepresenter, in-person follow up exam, and additional patient informed consent. These decisions leave telemedicine providers no choice but to navigate the medical practice laws in their state or risk punitive action by their board,” the report authors 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.

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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