As Seen on TV

Edition: July 2010 - Vol 18 Number 07
Article#: 3502
Author: Repertoire

Healthcare reform, physician shortages, technology advancements and acceptance by patients just might be converging to make telemedicine a real factor in healthcare delivery.

Imagine your doctor examining a patient in Exam Room 3, then moving to Exam Room 1 where, instead of a patient, there hangs a flat, high-definition screen with a patient’s image on it. The doctor reviews the patient’s medical history on her laptop, looks at the vital signs readings from the remote monitor, and then begins the consultation.

“We’re not there today because of the complexities involved,” says Jim Woodburn, M.D., vice president and medical director for clinical initiatives at OptumHealth, a UnitedHealth Group company. But we will be, he says.

Indeed, telemedicine might be on the verge of becoming mainstream.

“I’ve been doing this 20 years, and every year, it’s ‘This is the year,’” says Steve Normandin, president of AMD Global Telemedicine, Chelmsford, Mass. “But the industry has made more progress in the last 18 months than in the previous 18 years. You have a new generation of doctors who are much more exposed to technology. All the technology we’re using, 20 years ago was bleeding edge. Now we’re using Skype with our kids.”

Even the government has gotten involved. When it released its National Broadband Plan in March 2010, the Federal Communications Commission predicted that electronic health records and remote monitoring technology alone could create more than $700 billion in savings over the next 15 to 25 years. One month later, U.S. Senator Ron Wyden (D-Ore.) chaired a hearing of the U.S. Senate Special Committee on Aging to review the barriers that limit the adoption of telehealth and remote patient monitoring.

But when telemedicine ads start appearing on TV, well, you know the technology must have made it. “Fifteen or 18 years ago, I never thought we’d see telemedicine advertisements on TV,” says Normandin. “But look at the recent Cisco ads – for its HealthPresence [platform]. It’s on ESPN, Fox and CNN; and there’s a Welch Allyn vital signs monitor sitting right there.” (To view the Cisco ads, which feature Canadian actress Ellen Page, go to http://videolounge.cisco.com/video/the-doctor-is-in/)

“Are we gearing up for telemedicine?” says Steve Meyer, president, USA/Canada, and executive vice president, Welch Allyn. “We’re in it. Everything we have in product development right now has some digital aspect with varying communication capabilities. To that extent, that positions us to be able to deal with what we know is increased decentralization of healthcare, where clinicians, patients and hospitals will all have to communicate more effectively in ways that are not typical face-to-face encounters.”

Differences are only skin deep

Some have a tendency to think of telemedicine as a separate branch of medicine, according to experts. Indeed, Welch Allyn aside, Repertoire readers are probably unfamiliar with many of the names associated with it, such as American Well, Continua Health Alliance, OptumHealth, AMD Global Telemedicine, Polycom and Tandberg.

But according to the American Telemedicine Association, telemedicine is not a separate medical specialty. “Products and services related to

telemedicine are often part of a larger investment by healthcare institutions in either information technology or the delivery of clinical care,” says the association. “Even in the reimbursement fee structure, there is usually no distinction made between services provided onsite and those provided through telemedicine, and often no separate coding [is] required for billing of remote services.”

Still, the term “telemedicine” is broad. “Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth,” says the telemedicine association.

“It’s a developing or evolving space in clinical medicine, where medical information is transferred through the phone or Internet or other network for the purposes of consulting and, in some cases, [the performance of] remote medical procedures or monitoring,” says Meyer. “The whole notion is to improve patient outcomes.”

Models

Several models exist. The American Medical Telemedicine Association refers to the following:

• Specialist referral services, in which a specialist assists a general practitioner in rendering a diagnosis. Radiology is the most popular application. Others include dermatology, ophthalmology, mental health, cardiology and pathology.

• Patient consultations, in which audio, still or live images are exchanged between a patient and a health professional for use in rendering a diagnosis and treatment plan.

• Remote patient monitoring, in which medical devices are used to remotely collect and send data to a monitoring station for interpretation. Applications include blood glucose and ECG.

• Medical education, whereby health professionals can gain CEUs.

• Consumer medical and health information.

Delivery mechanisms include:

• Networked programs, which link tertiary care hospitals and clinics with outlying clinics and community health centers.

• Point-to-point connections, which are private networks over which hospitals and clinics can deliver services directly or contract out specialty services to independent medical providers at ambulatory care sites.

• Connections between primary or specialty care and the home, which link providers with patients over single-line phone/video systems.

• Home-to-monitoring-center links, which are used for cardiac, pulmonary or fetal monitoring, home care and related services. Most of these connections use normal phone lines, though some use the Internet.

• Web-based e-health patient-service sites, which provide direct consumer outreach and services over the Internet.

In Hawaii, patients can access a physician by phone or Web for 10-minute consultations any time of day or night. Sponsored by HMSA, an independent licensee of the Blue Cross and Blue Shield Association, the program uses a network created by Boston-based American Well to conduct the sessions. For HMSA members, the physician has access to the members’ health summary (if the patient has given his or her permission). Non-HMSA members who use the Microsoft HealthVault system to collect and store their medical information may forward that information to the physician during the call. Patients pay for the session with a credit (or prepaid debit) card. Weekly payments go directly to physicians’ bank accounts.

Home monitoring

Home monitoring could generate savings of $200 billion over 25 years from just four chronic conditions, said Mohit Kaushal, M.D., healthcare director for the FCC, at the Senate Aging Committee hearings in April. Already, the Veterans Hospital System has implemented a Care Coordination/Home Telehealth Program (CCHT) for 32,000 veteran patients with chronic conditions, he said. The program has resulted in a 19 percent reduction in hospital admissions and a 25 percent reduction in bed days for those who are admitted.

“There is also a significant cost saving associated with these improved clinical outcomes,” said Kaushal. “The CCHT Program, at $1,600 per patient per year, costs far less than the VHA’s home-based primary care services, at $13,121 per patient per year, and nursing home care rates, at $77,745 per patient per year.”

Hospitals’ role

A more traditional application of telemedicine is that in which a tertiary care hospital or hospital system is connected with outlying providers, such as rural hospitals, clinics or other ambulatory care settings. In July 2009, Tammy Cress, RN, MSN, FAHA, was appointed director of telehealth for Swedish Medical Center in Seattle, Wash., an integrated delivery network comprising four acute-care hospitals, a network of clinics and other care sites.

Prior to becoming director of telehealth, Cress was the director of the Swedish Stroke Program, a component of which is TeleStroke, a system that connects Swedish Medical stroke specialists with outlying facilities. When a patient at one of the facilities presents in the emergency room with stroke symptoms, the facility notifies the Swedish stroke center, which connects a stroke team with the facility. The team can log in on their home or office computers, complete a remote examination and determine what steps – including administration of tissue plasminogen activator, or tPA – should be taken.

Even prior to TeleStroke, Swedish Medical had implemented a tele-ICU, in which its intensivists or ICU doctors monitor patients in remote ICUs. “They conduct rounds virtually by video conferencing,” explains Cress, speaking with Repertoire. “They have access to medical records, imaging studies and medications the patients are taking,” as well as vital signs. A newer program, tele-EEG, calls for technicians at outlying facilities to attach electrodes to patients, and specialists at Swedish Medical to interpret the tests.

“Where we’re heading,” she says, “is to understand the needs in our region, state and community, and to figure out what types of programs we can develop as we move forward.”

The physician’s office

Although TeleStroke, tele-ICU and tele-EEG do not call for the involvement of the physician office, Cress sees many telemedicine applications for physicians in their offices. Some of them are already up and running. “Many send their chest X-rays outside their walls via telemedicine technology for someone else to interpret,” she says.

Another potential application would find the primary care doctor establishing a telemedicine relationship with a specialist for consultation. One example: A patient presents with skin lesions. Rather than send the patient to a dermatologist, who might be some distance away, the primary care doctor may share images (or conduct a teleconference) with the dermatologist.

And rather than drive (or even, for remote clinics, fly) to outlying clinics for regular visits, medical-center-based specialists could visit those clinics via telemedicine. At the remote site or clinic, a telemedicine coordinator would greet the patient, establish the telemedicine connection, and, with electronic instruments, conduct an exam under the specialist’s instructions. Medical assistants, nurse practitioners and physician assistants might serve as telemedicine coordinators, says Cress.

Insurer’s backing

Already, one national insurer has begun building what it hopes will be a national telemedicine network. The insurer, United HealthCare Group, through its OptumHealth division, already has networks set up in several locations around the country, including its home base in Minnesota, as well as Colorado. The company also started a telehealth mobile unit in New Mexico, as part of a philanthropic partnership with Project HOPE.

OptumHealth’s system, called Connected Care, uses videoconferencing technology developed by Cisco. “The picture, quality and audio is the best in the world,” says Woodburn. (In April 2010, Cisco acquired Tandberg, a Norwegian videoconferencing firm, for $3.3 billion. The other big videoconferencing players are LifeSize, which was acquired in December 2009 by Logitech International; and Polycom.)

“We’re a one-stop shop for telemedicine,” says Woodburn. For a monthly service fee, OptumHealth sets up participating physicians with videoconferencing equipment, training, support and electronic connections. “We get the wiring set up, set up the equipment in the exam room, train the staff and doctors, and manage the scheduling,” he says.

OptumHealth’s newest and largest implementation to date is in Colorado, in which seven locations will be connected by the end of the summer. Meanwhile, in Minnesota, OptumHealth’s employee health clinic is connected to Park Nicolett Health Services, a Twin Cities integrated delivery network. A Park Nicolett employee – an RN – is stationed at the clinic. “He or she becomes the hands and physical presence [for Park Nicolett-based specialists] to handle diagnostic equipment, so the physician can listen to the heart or lungs, or look at the patient’s eyes and ears,” says Woodburn.

Employer campuses

Indeed, says Woodburn, the employer campus is a good application for telemedicine. Busy downtown workers, for example, find it tough to schedule appointments with their doctors in the suburbs. “[Telemedicine is] convenient and it improves the quality of healthcare, because many times, illnesses get worse over time,” says Woodburn. “So from the employee standpoint, the speed to treatment and convenience is great. And employers like that too.”

For elderly or near-homebound patients, the ability to check in at an urban health center, which is electronically connected to primary care doctors and specialists in another part of town, make it easier for people to get the care they need, points out Woodburn.

Cisco is not in the business of manufacturing the diagnostic equipment needed for telemedicine visits, points out Woodburn. For that, OptumHealth relies on Welch Allyn and AMD Global Telemedicine for automated blood pressure monitors, pulse oximeters, electronic stethoscopes, otoscopes, dermascopes, etc. Data from these instruments are imported into OptumHealth’s IT platform, explains Woodburn.

“Connected Care is one of the fastest growing segments of UnitedHealth Group, as we … help patients manage illness and maintain wellness, and help physicians improve their accuracy,” says Woodburn. Ultimately, the company intends to introduce telemedicine into all 50 states. “We’ve been very pleasantly surprised at the interest on the part of providers we’ve talked to,” he says.

Driving forces

Physicians may be receptive to the idea, but the truth is, most have plenty of things besides telemedicine on their plates. “Right now, I don’t think it’s a primary focus,” says Cindy Dunn, RN, FACMPE, senior consultant with the healthcare consulting group of the Medical Group Management Association. The implementation of electronic medical records, revenue cycle management, the pending implementation of the new ICD-10 coding system, and new claims transmission protocols are far more pressing and immediate concerns, she says.

That said, the aging of the population and expected shortage of primary-care doctors would seem to favor telemedicine in the years ahead. Certainly the federal government seems to see it that way.

The FCC’s National Broadband Plan, for example, calls for better funding of what it calls a “mass market broadband infrastructure” for rural clinics and small physician offices. The Plan also supports an incentive plan (similar to that for electronic medical records) for e-care technologies, as well as a revision of existing licensing, privileging and credentialing standards “which currently slow down physicians from practicing medicine remotely and across state lines.”

Healthcare reform’s impact

The recently passed Patient Protection and Affordable Care Act (healthcare reform law) contains several provisions favoring telemedicine, points out the American Telemedicine Association. For example, it:

• Directs the Center for Medicare and Medicaid Innovation to explore electronic monitoring of patients at local hospitals by integrated health systems.

• Requires newly created “accountable care organizations” to coordinate care through the use of telehealth and remote patient monitoring.

• Allows physicians to use telehealth to certify the need for home health services or durable medical equipment.

• Includes use of remote monitoring for eligible medical practices in the Independence at Home Demonstration Program.



“If you look at the various elements of the reform package, you’ll find all kinds of elements that start bringing to life the whole [telemedicine] concept,” says Meyer. “It’s pretty exciting when you think about the potential. The question is, how rapidly will it get implemented?

“Payers are going to demand that clinicians manage their patients in different ways going forward,” he continues. And if predictions about physician shortages pan out, clinicians won’t be able to continue to take on more patients, at least if they must conduct traditional face-to-face visits.

One answer to MD shortages

Do patients necessarily need to visit the doctor’s office to have their blood pressure and weight taken? asks Meyer. “If physicians were incentivized to manage patients on a remote basis, they could take on more acute patients. It would be a way to increase the capacity of the healthcare system. But it requires utilization that’s a little different.”

Adds Normandin, if projections are to be believed, the United States will have a shortfall of thousands of physicians by 2025. “That means that doctors will have to have further reach,” he says. “Using technology, they can get better data from their patients. They can get better heart sounds, and they can save and store them. They can look in their eyes and ears and get better images. The reach of the individual physician may be expanded.”

A question of cost

Telemedicine’s future has its share of clouds, not the least of which are the other priorities physicians face today, point out many who spoke with

Repertoire. Other stumbling blocks include cost, reimbursement, credentialing, broadband availability, and various “cultural” factors, such as the degree to which the doctor’s office can change its routine to accommodate telehealth patients, and the reluctance on the part of patients and doctors to give up traditional face-to-face encounters.

Telemedicine is a combination of video, medical technology and networking, says Dunn. “The connection piece, the transmission mode, is expensive, whether you’re using a T1 line, digital network, DSL or whatever. The ability to look at data and images online is fabulous, but there’s a cost to it, and right now, doctors in private practice are absorbing that cost.”

“The problem with pricing over the years has been the fact that [telemedicine] has been a niche business,” says Normandin. “Manufacturing has been done in the hundreds, not the thousands.” That makes digital equipment, including cameras and telemedicine-ready medical instruments, more expensive. But as large companies such as Cisco and UnitedHealth get into the business, “those are game-changers,” he says.

Reimbursement

“What we would like to see happen is for telemedicine to be accepted as a standard way of providing care, and that it be reimbursed irrespective of where the patient is located,” says Cress. “If there’s a connection and a willing provider, they would be reimbursed, as long as they do the same things they would do in person.”

Says Woodburn, “Telemedicine has been around 42 years. One of the major barriers to its mass application has been lack of reimbursement.” In March, UnitedHealth made the decision to pay for telemedicine – through its Connected Care model – at the same rate as a face-to-face visit. “We believe it was an important stake in the ground, and a way to challenge other insurance companies, and Medicare and Medicaid plans, to be more universally covered.”

In April 2010, Virginia Governor Bob McDonnell signed into law legislation expanding telemedicine coverage for Virginians. The measure ensures that health insurers will cover and reimburse for healthcare services provided through telemedicine. “Telemedicine brings the best doctors into every clinic and hospital in our Commonwealth at the click of a mouse,” said McDonnell at the time of the signing. “These are tough economic times. We must look for every opportunity to use technology to improve the lives of our citizens, while keeping costs down.”

According to the American Medical News, Virginia became the 12th state to require health plans to pay for telemedicine services. The others are California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, New Hampshire, Oklahoma, Oregon and Texas.

Other challenges

Today, state physician licensing laws and malpractice contract requirements can inhibit a doctor’s ability to consult with an out-of-state patient. The issue has been a sticking point for telemedicine proponents, but that could be changing. Speaking at the recent American Telemedicine Association national convention in San Antonio, Texas, Aneesh Chopra, chief technology officer in the U.S. Office of Science and Technology Policy, announced that the Centers for Medicare and Medicaid Services is working with the Joint Commission on its standards for credentialing and privileging to address the issue.

Another stumbling block has been the lack of affordable broadband connectivity. At last April’s Senate hearing, Kaushal pointed out that 93 million Americans are not connected to broadband. Furthermore, the FCC believes that many citizens over age 65 are poor adopters of broadband, even if they have access to it. “This is due to multiple reasons, such as cost, digital literacy and perceived lack of relevant digital content delivered over the Internet,” Kaushal said.

What’s more, approximately 3,600 small physicians’ offices lack service by an existing “mass market” broadband infrastructure, added Kaushal. Larger providers must purchase “Dedicated Internet Access” to meet their quality of service requirements, “but those are often four times or greater in price than mass market solutions,” he said.

To boost consumers’ access to broadband, the FCC in its National Broadband Plan “sets the ambitious goal of providing access for every American to robust and affordable broadband service,” said Kaushal. It plans to do so by creating a “Connect America Fund” and expanding existing programs, including “Lifeline Assistance” and “Link-Up America.” Meanwhile, to help providers get onboard, the FCC has proposed creating a permanent infrastructure fund as well as continuing to subsidize monthly Internet charges.

But not all the stumbling blocks are technological or economic. Some are very human. “It’s that whole paradigm shift,” points out Dunn. “Patients need to get their arms around it. It’s hard to say, ‘I’m going to look at my doctor in a camera, and he’s going to look at me.’” In addition, any telemedicine site – including the patient’s home – will need people who can work the tools and fix them, if necessary. Another issue that doctors will have to resolve is how to carve out time in their day for telemedicine visits, she says.

Supply side

Repertoire readers have an important role to play in telemedicine, particularly in the medical-home model, in which the physician and patient collaborate closely on disease management, says Meyer. “Compliance is the big issue,” he points out. “If you have a patient at home with a device, they have to be compliant. But if the device isn’t easy to use, or doesn’t allow for levels of compliance beyond what we see today, we’ll continue to see the problems we have today.”

For physicians, telemedicine may be a way to reassert their influence in home care, he adds. But they need technology that can get them there, including technology that is EMR-ready. “Distribution is in a position to be a resource to enable that to happen.”

Telemedicine today is delivered on a very ad hoc basis, says Meyer. “It’s disconnected; the incentives aren’t very well aligned; and reimbursement is pretty spotty.” Just as problematic is the fact that much of medicine today is delivered on a fee-for-service basis. But, he says, as the system turns around to one that is more performance- or outcomes-based, telemedicine will find an increasingly bigger role in U.S. healthcare.