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UC Riverside Launches Telemedicine Pilot Project to Treat MS Patients

March 16, 2017
by Heather Landi
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Researchers at the School of Medicine at the University of California, Riverside have received a grant from Genetech, a biotechnology company, to develop and pilot-test a new home-based telemedicine program geared toward treating multiple sclerosis (MS) patients.

According to a press release from UC Riverside, Elizabeth Morrison-Banks, M.D., a health sciences clinical professor who studies MS, is leading the one-year project, titled “Clinicians’ Online Neurology Network Empowering Communities through Telemedicine – Multiple Sclerosis (CONNECT-MS).” The pilot program aims to determine whether virtual visits are equivalent to in-person appointments for people with MS.

MS clinicians face continued challenges in optimizing neurological care, especially for people with advanced MS living in medically underserved communities.  Because of insurmountable geographical and physical challenges, patients cannot always travel to neurology office appointments, according to the UC Riverside press release. Morrison-Bank and her research team aim to examine whether telemedicine – the use of telecommunication and information technology to provide clinical health care from a distance –can be effectively used to address this problem.

MS is an autoimmune disease of the brain and spinal cord, impacting about 2.3 million people worldwide (400,000 in the United States). Early disease-modifying therapy has been found to slow the progression of this unpredictable disease and lessen long-term disability, according to the UC Riverside press release.

The pilot project builds off an earlier telemedicine program Morrison-Banks and her research team conducted in collaboration with the Landon Pediatric Foundation for MS care funded by a previous Genentech research grant.

In this current pilot, Morrison-Banks said her research group will randomly assign participating adults with MS to an intervention group that will receive telemedicine intervention versus a control group that will be offered the usual care. For the intervention group, a nurse practitioner will visit patients in their homes, review the history and perform a neurological examination in collaboration with a neuro-immunologist at UC Riverside who will participate through a telemedicine connection.

The CONNECT-MS project’s nurse practitioner will visit each patient at home within three to four weeks after study enrollment to coordinate a HIPAA-protected telemedicine visit with Morrison-Banks. Together, the nurse practitioner and neuro-immunologist will conduct an intake visit, reviewing the patient’s history, performing a neurological examination and going over laboratory results and neuro-imaging before discussing decisions about work-up and management with the patient and family.

The research group will compare the intervention versus control groups for a number of variables, including quality of life, pain levels, fatigue, visual impairment, and mental health.

“The goal is to determine whether the home telemedicine approach works as well as usual care—that is, office visits with the neuro-immunologist,” Morrison-Banks said. “This is a pilot study and it may not be able to show whether MS telemedicine in patients’ homes is better than usual care, but if it appears to be equivalent – and if patients and families like it better because of its convenience and comfort – then the pilot study will provide useful preliminary data to guide larger research studies in the future.”

“Tele-neurology” is now a popular approach for stroke care because it allows rural communities rapid access to a qualified neurologist. Morrison-Banks said that telemedicine is newer in MS care and the focus is different from acute stroke care. People living with MS in rural areas can access a fellowship-trained MS specialist through telemedicine in a way that may never be possible for them if they had to travel long distances to get to the neuro-immunologist’s office, according to the press release.

“People with advanced MS face additional barriers to traveling to an MS center, even if it is located nearby, because if they have a lot of disability, over time it tends to become increasingly difficult for them to leave their homes,” she said. “So if we can bring the ‘medical home’ into people’s actual homes, we can meet multiple needs at the same time while allowing a safe and comfortable environment for the medical visit.”

She noted that caveats include the challenges of implementing any new technological solution.

“Some people may miss the face-to-face experience with the MS specialist,” she said. “In our current telemedicine clinic for teens with MS, as one might expect, the teens adapt to the technology without missing a beat.  I think these young people are going to lead the way for the rest of us in blending technological solutions into our everyday lives.”


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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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Telehealth, Interoperability Recommendations Outlined in Administration’s Health Reform Report

December 5, 2018
by Rajiv Leventhal, Managing Editor
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Various health IT recommendations related to telehealth and interoperability were made on the part of the Trump administration as part of its report on reforming the nation's healthcare delivery system.

The 119-page report, "Reforming America's Healthcare System Through Choice and Competition”—authored by Labor Secretary Alexander Acosta, Treasury Secretary Steven Mnuchin, and Health and Human Services Secretary (HHS) Alex Azar—includes more than 50 recommendations that Congress, the administration, and states can take to improve healthcare choice and competition, including several recommendations related to telehealth services and improving the exchange of health data.

The report mostly reinforces comments that the administration has made several times before, and among the administration's telehealth suggestions included: improving license portability to create additional opportunities for telehealth practice and modifying reimbursement policies that impede telehealth coverage in federal health programs, such as Medicare's originating site requirements.  The report’s authors write, “For example, Medicare fee-for-service pays for telehealth services only when patients are located at certain types of healthcare facilities (“originating sites”) in rural areas with a shortage of health professionals. Another barrier is that states may require practitioners to have first provided services in person before caring for a patient by telehealth.”

Catherine Pugh, senior director of government affairs at Health IT now, a coalition that supports the use of data and IT to improve healthcare,  said in a statement following the release of the report, “Health IT Now endorses the recommendations in this report related to expanding telehealth services because we cannot allow this critical model of care delivery to be impeded by bureaucratic rules or geographic boundaries.” The statement continued, “We support the adoption of mutual recognition compacts among physicians—like those widely adopted in the nursing profession—to create additional opportunities for telehealth practice, as the Interstate Medical Licensure Compact is not broad enough on its own to improve license portability…”

Meanwhile, in regard to the need for greater interoperability, the report noted various barriers that exist in the market today, such as: medical complexity (a given diagnosis, treatment or procedure in medical records can be recorded in many different ways); lack of business drivers (the fee-for-service model provides little incentive to connect with other clinicians  or  service  providers  and  leads  to  significant  disconnects  across  the  care continuum); lack of accessible APIs (typically, EHR developers have either not published their APIs,  charged  prohibitively  high  fees,  or  set  onerous  contractual  conditions  to  use  their APIs); and lack of network exchange (most systems simply do not or cannot communicate with one another).

As such, the report mentioned the 21st Century Cures Act and recommended that “the administration should expeditiously implement [its] provisions to prevent information blocking, make it easier for patients anywhere to get  their  core  health  information,  support  “open  application  programming interfaces”  to  allow  patients  to  get  data  on  their  smart  phones,  and  encourage support of population-level data queries to allow payers electronic access to clinical data.”

The report further recommended that agencies such as CMS (the Centers for Medicare & Medicaid Services) and ONC (the Office of the National Coordinator for Health IT) should continue to work on ways to reduce the documentation burden that currently plagues clinicians.

What’s more, the report suggested that CMS should continue its efforts to make data available to patients through efforts such as “MyHealthEData” and Blue Button 2.0, and that “ONC should continue making standards more comprehensive and robust.”

Related Insights For: Telehealth


Study: Physicians’ Use of Telemedicine Still the Exception, not the Rule

December 4, 2018
by Rajiv Leventhal, Managing Editor
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In 2016, 15 percent of physicians worked in practices that used telemedicine for patient interactions, such as diagnosing or treating patients, following up with patients, or managing patients with chronic conditions, according to an AMA (American Medical Association) study on telemedicine.

The research, published in the December issue of Health Affairs, which covers telemedicine trends in an array of different ways, gauges the emergence of telemedicine and its integration into healthcare delivery.

Regarding the overall use of telemedicine, the findings showed that 15 percent of physicians worked in practices that used telemedicine for patient interactions, such as diagnosing or treating patients, following up with patients, or managing patients with chronic conditions. Meanwhile, 11 percent of physicians worked in practices that used telemedicine for interactions with healthcare professionals, such as having a specialty consultation, or getting a second opinion.

When it comes to telemedicine use by specialty, radiologists (40 percent), psychiatrists (29 percent), and cardiologists (24 percent) had the highest use of telemedicine for patient interactions. In other specialties, the use of telemedicine for patient interactions ranged from 6 percent to 23 percent, according to the research.

Emergency medicine physicians (39 percent), pathologists (30 percent), and radiologists (26 percent) had the highest use of telemedicine for interactions with healthcare professionals. In other specialties, the use of telemedicine for interactions with healthcare professionals ranged from 3 percent to 15 percent.

What’s more, videoconferencing was the telemedicine modality with the most widespread use, as it was used in the practices of 13 percent of physicians. Use of videoconferencing was most common among emergency medicine physicians, psychiatrists and pathologists. Remote patient monitoring (RPM) was used in the practices of 7 percent of physicians.

Breaking it down further by practice size, physicians in smaller medical practices and physician-owned medical practices had a lower rate of telemedicine use than physicians in larger medical practices and ones that were not physician-owned. The findings suggest the financial burden of implementing telemedicine may be a continuing barrier, especially for that segment of practices, researchers said.

The researchers concluded, “Our work suggests that despite regulatory and legislative changes designed to encourage the use of telemedicine, the financial burden of implementing it may be a continuing barrier, especially for small practices. Even after we controlled for specialty differences, we found that physicians in larger practices and ones that were not physician owned were more likely to report that their practices used telemedicine for interactions with both patients and healthcare professionals.”

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