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10/4/2015
1
TeleMedicine (TeleHealth)
Scope, Current State and
Application
Nadir Abdelrahman, MD
Pankaj Jandwani, MD MMM
Disclosure
Both presenters have no relevant financial
relationships to disclose.
Outline
Definition
Modalities
Benefits and Challenges
Current Applications
Application in Post Acute Area
Recommendations
3
10/4/2015
2
“It is an amazing invention, but who would
ever want to use one”
Rutherford Hayes 1882 - On the using
telephone for the first time
History...
History...
Boston Logan Airport to
Massachusetts General
Hospital 1967
10/4/2015
3
Overview - Models
• Store and Forward
• Dermatology, Pathology, Radiology
• Remote Monitoring
• Cardiac Telemetry, Health kits, e-ICU
• For COPD, CHF
• Real Time Video Consultations
• Video conferencing with remote provider
• Psychiatry, Neurology, post surgical follow ups
Courtesy – Advisory Board
Use
Ca
se
sM
od
alit
ies
Telehealth Use Cases, Relevant Modalities, and Investment Required
Videoconference Asynchronous
Store-and-
Forward
Remote
Device
Telephone
Professional
Consultation
Diagnosis &
Treatment
Education &
Engagement
Ongoing
Monitoring
& Care
Coordination
Patient
PortalMobile App
• Need software,
secure internet
access for
patients
• Home and
hospital-based
technology
• Need additional
bandwidth,
storage space
• Can replace
non-urgent
phone calls and
visits
• More expensive
hardware
investment
• Used for high-
risk patients in
non-hospital site
• Little tech
investment,
requires proper
staffing
• Used for pre-
visit triage
• High security
needs require
significant
investment
• Must integrate
EHR
• Minimal
hardware
investment for
providers
• Complex
security and
data storage
issues
Models and Medium
10/4/2015
4
Extending Access to Providers for High-Risk, Rural, and
Wellness Visits
Industry Overview
Source: Hirst, E. J., “Walgreens App Makes Virtual Doctor Visits a Reality,” Chicago Tribune, December 2014, http://www.chicagotribune.com/business/ct-walgreen-virtual-doctor-app-1209-biz-20141208-story.html
Industry Snapshot: Video Platforms
Use Cases
Chronic
disease
management
Behavioral
health video
consults
Rural
access to
care
24/7 coverage
“I think [virtual visits]
will become a normal
part of health care in
three to five years.”
Dr. Harry Leider
Walgreens CMO
Low-Cost Alternative to Traditional Primary Care
Cost of Walgreens virtual visit, most
of which goes to physician
$49Interactions per week via
Walgreens’ Pharmacy Chat virtual
visit platform
9,000Estimated new patients added per
day for MDLive following
partnership with Walgreens
2M
Major Vendors
• MDLive
• Teladoc
• American Well
• Zipnosis
• CampusMD
• Stat Doctors
• Sentara
Consumer Price Sensitivity Drives Decision-making
Purchasers Patients to Shop Based on Price
Source: Consumer Oriented Competition, Marketing and Planning Leadership Council 2014; Riffkin, R. “Cost Still a Barrier Between Americans and Medical Care,” Gallup, December 2014, http://www.gallup.com/poll/179774/cost-barrier-americans-medical-care.aspx.
Consumer Needs & Preferences: Cost
1) Consumer Directed Health Plan.
33%
Patients who put off medical treatment because of cost in 2014
9%
Increase in privately insured patients putting off care due to cost from 2013 to
2014
Price Sensitivity in Action
Consumers’ Utility Ratings of Clinic Attributes1
4.26
4.09
2.59
2.73
3.87
3.80
2.87
2.94The visit will cost me
$20
I will know the exact
price before visit
I can get lab tests or
x-rays done at the
clinic if needed
I can walk in without
an appt and am
guaranteed to be seen
within 30 min
Non-HDHP HDHP
By Health Plan Type
Consumers Increasingly Prefer “On-Demand” Care
Survey Finds Email Visits Preferred to Clinic Near Errands or Work
Source: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis.
Consumer Needs & Preferences: Convenience
1) Based on proportions of respondents interested in teleheatlh.
Increasing Consumer Preference
Emailing provider
with symptoms
Preference for Location of Services
Clinic location
near work
Clinic located
near errands
Clinic located
near the home
Young, Wealthy, Busy—Strongest Potential Telehealth Targets1
Of 18-29 years olds
54%Of those making >$71K per year
49%Of those working >35 hours per week
53%
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5
Industry Snapshot: Mobile Apps
Big Market in Early Stages of Development
Source: McCann, E. “mHealth Market Scales to New Heights,” Healthcare IT News, March 4, 2014, http://www.healthcareitnews.com/news/mhealth-market-growth-trajectory
Common Applications
EHR Access in
and out of care
site
Biometric data
collection and
transmission
Fitness/activity
tracking
Remote
communication
with providers
“Similar to the internet
revolution, mHealth is
revolutionizing the way of
patients receiving their care.”
Mary Annecharico
CIO at Henry Ford Health Systems
Mobile Health Market Rapidly Expanding
Estimated global mHealth
market size by 2020
$49.1BAmericans using mhealth
technologies in 2013
95MUS population covered by
mobile network
100%
Major Vendors
• Qualcomm
• Apple
• IBM
• GE
• Individuals and small start-
ups to large hospital
systems and payers
Mobile Apps, Cont.
Apple, Others Entering the Health Care Market
Source: Global eHealth Executive Council interviews and analysis.
• Integration: With hubs, providers will not
have to do as much work to make sure third-
party devices are operable with their existing
platforms
• Coordination: Other providers and caregivers
can access more data securely
• Messaging: Patients will be able to send
data directly to providers
Impact on Providers
• IBM – to combine Apple’s leadership in
customer experience and mobile devices with
IBM’s extensive experience in enterprise
mobility management, analytics, and
knowledge management (e.g., Watson)
• Epic – integration of MyChart with Apple
Health; Other vendors working with HealthKit
include Cerner Wellness (HealthyNow),
athenahealth and Allscripts
• Mayo – and other emerging partnerships with
leading provider organizations (Mount Sinai,
The Cleveland Clinic, Johns Hopkins) to
develop health applications
Partnerships
• Apple HealthKit
• Microsoft HealthVault
• Google Fit
• Samsung S Health
Major Players
Keeping Providers and Patients Connected Regardless of Location
Source: Baum, S. “Report: 19 Million Will use Remote Patient Monitoring by 2018,” MedCity News, June 2014. http://medcitynews.com/2014/06/biggest-market-remote-patient-monitoring/
Industry Snapshot: Remote Monitoring Devices
Clinical Benefits
Reduced
readmissions
Reduced ED
visits
Improved chronic
disease-related
mortality
Improved care
coordination
“Patient monitoring is becoming a
necessary measure for hospitals
and doctors to measure their
business. The focus is shifting
whether they like it or not.”
Jack Young
Head of Qualcomm Life Fund
Remote Monitoring has Wide Reach
Estimated patients connected
to remote monitoring devices
by 2018
19MTotal remote patient
monitoring market in 2013
$5.85BMarket share of connected
medical device manufacturers
76.7%
Major Vendors
• Noninvasive Medical
Technologies
• Corventis
• Pharos Innovations
• Honeywell HomMed
• McKesson
10/4/2015
6
Enables Growth in Telehealth
Technological Advances
Sources: “mHealth in an mWorld: How mobile technology is transforming health care,” Deloitte, available at http://www.deloitte.com/; Health Care IT Advisor research and analysis
Technology Getting Faster, More Widespread
4,160 4,848 5,791
10,381
20,804
32,702
36,100
2005 2006 2007 2008 2009 2010 2011
Medicare-Billed Telehealth Encounters
• Remote monitoring devices with cellular or fixed-line modems enabling data transmission without computer or smartphone
• Expanded memory and processing capabilities
• Geospatial tracking
• Movement tracking
• Touch-screen technologies
• 100% US population covered by mobile network
• Health information fastest-growing content accessed by US mobile users, up 134% between 2010-2011
Advancements in
TechnologyIncreased Population
Mobile Communication Saves Clinicians Time17
Preventing Wasted Time from ‘Phone-Tag’ with Specialists, Care Team
Benefit #3: Cost Management
1) Messages often replace unpaid patient encounters such as post-ops, prescriptions, discussion of lab results, etc.2) Not required; mean response time for MD-to-patient is 60 min.
55%PINGMD messages
replace office visits1
30 minMedian response time
from physician to patient on PINGMD2
50%Physicians saving
15-60+ minutes/daywith application
More Streamlined Care Coordination Across Networks
• Providers conduct case consults or referrals virtually using group chat
• Improves communication and efficiency between providers
• Prevents readmissions through collaborative care follow-ups
• Automatic documentation ready for export to medical record
Case Consult
Screen Shot
10 minMedian response
time between care partners
on PINGMD2
Source: PINGMD, available at: www.PINGMD.com, accessed October 1, 2013; Health Care Advisory Board interviews and analysis.
Proposed Rule Adds Procedures to List of Covered Telehealth Services
Source: Center for Medicare and Medicaid Services CY2015 Physician Fee Schedule Proposed Rule, 42 CFR 410.
CMS CY2015 Reimbursement Updates
Services Affected by Rule
Wellness Visits
Behavioral Health Visits
Geographic Service Area
Expansion of Service Impact on Providers
Wellness visits are covered as long as
there is an existing relationship between
the patient and physician; the
relationship can be initiated via a virtual
visit
Psychoanalysis, family psychotherapy
(both with and without the patient
present), and prolonged service
Payments allowed for patients in rural
census tracts even if those tracks are
within metropolitan statistical areas
Because the Medicare definition of
telehealth involves two-way audio and
video coverage, providers can have and
be paid for meaningful, ongoing patient
relationships
The ability to offer behavioral health
visits remotely can be a new source of
patient volume for providers who
previously did not have the capacity to
offer these services in-house
More sites will now be eligible as
telehealth originating sites, opening up
business opportunities for more
providers
Chronic Care Management CMS will reimburse providers for
furnishing specific non-face-to-face
services to qualified beneficiaries over a
calendar month
While not specific to telehealth, these
payments will cover medication
reconciliation, care coordination among
providers, and RPM
10/4/2015
7
Case in Brief: Medical
Associates Clinic
Telehealth Pilot Shows Early Adopters Now Recruiting Early Majority
Benefit #1: New Patient Recruitment
Source: 2014 Primary Care Consumer Choice Survey; Teledoc, available at http://www.teladoc.com/healthplans/how-it-works-for-your-members/, accessed July 2014; “The Virtual Primary Healthcare Revolution,” Becker’s Hospital Review, available at http://www.beckershospitalreview.com/strategic-planning/the-virtual-primary-healthcare-revolution-what-health-systems-need-to-know.html, accessed July 2014; “Just how far in usage and savings can telemedicine take US healthcare?” mHealthNews, available at http://www.mhealthnews.com/news/just-how-far-usage-and-savings-can-telemedicine-take-us-healthcare, accessed August 2014; Marketing and Planning Leadership Council interviews and analysis.
Following Trial, Strong Preference for Virtual Care
71%Of midsized to large U.S.
employers anticipate
offering employees
telehealth services within
three years
92%Of a virtual visit
provider’s patients said
they would use the
service again
91%Of Zipnosis users would
recommend the service
to at least three friends
• Four-physician practice in Kentucky
• Piloted the Me-Visit mobile app to offer online care for primary care and chronic condition follow up needs
• In 30-month pilot, 20% of patients used the app, and 97% of users preferred the service to in-person care
Real Time Video -Risk Based approach
Source: Marketing and Planning Leadership Council interviews and
analysis.
Courtesy – Advisory Board
Emerging Areas for Virtual Care
Remote In-Person
• Diagnoses, treatments
follow reliable standard
protocols based on
evidence-based
medicine
• Suggested therapies are
nearly always effective
• Physical exam not
required, visual exam
adds nominal value
• Diagnoses, treatments
more complex, may vary
within disease category
• Therapies may need careful
selection and monitoring
• Physical exam or diagnostic
test required to correctly
identify issue and select
treatment
• Intervention required
(i.e., immunization)
Management, Maintenance
• Chronic disease checkups,
follow-ups
• Care plan updates
• Specialist consults
Diagnosis, Treatment
• Remote diagnostics
• Self-guided interventions
LOW RISK HIGH RISK – FOLLOW UP
How likely are you to keep referrals/transfers within our health
system if this TELE-CONSULT was available?
MidMichigan Provider Survey of over 400 providers
10/4/2015
8
MidMichigan Provider Survey of over 400 providers
How Would TeleMedicine affect
Telemedicine and Post Acute
and long Term Care Medicine
In the news:
Modern Doctors’
House Calls: Skype
Chat and Fast
Diagnosis
By ABBY GOODNOUGHJULY 11, 2015
10/4/2015
9
In the news:
“Telemedicine can help —and we should streamline licensing and explore how to make that reimbursable under Medicare.”
Democratic presidential candidate and former U.S. Secretary of State Hillary Clinton speaks to guests gathered for a campaign event on the campus of Des Moines Area Community College on August 26, 2015 in Ankeny, Iowa.
Telemedicine Use in SNFs
A recent systematic review identified 22 studies.
Most studies employed interactive services (17)
Focused on economic, feasibility, satisfaction,
reliability, and service implementation.
Edirippulige S, et al. J Telemed Telecare 2013.
Teledermatology
Teledermatology consults may replace some onsite consultations
by offering quality care in a cost effective manner.
1997 2007
Use
10/4/2015
10
Dementia
Case-based video-consultation program can be successful in improving
the care of elders with dementia and/or delirium related behavioral
issues by linking specialists with long-term care providers. 2014
Use
University of Nebraska Medical Center
Department of Psychiatry
Services for Geriatric Patients in Nursing Homes
Long-term care/telemedicine
Correctional telemedicine as a model
Similar scenarios
Desire to not transport patients off site
Limited on-site primary care
No on-site specialty care
Must maintain certain level of staff on-site at all times
Have stringent rules and regulations to follow
Use
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11
Grabowski and O’Malley, Health Aff February 2014 vol. 33 no. 2 244-250
Benefits in Post Acute and Long Term
Medicine
Enhance and increase on-site primary care
Enhance and increase on-site specialty care
Reduce ambulance transportation for off-site care
Reduce unnecessary ER visits
Reduce risk of injury associated with transports
Reduce loss of revenue to nursing homes
Allow better community ambulance coverage with less
nursing home transports
Provider Perspective
Communication/Collaboration with other teams
Addressing issues, answering questions raised by
patient/family
Patient/Family education
Better evaluation of urgent cases
Follow up on different patients with stable chronic conditions
Saves time, travel to different facilities
Benefits
10/4/2015
12
Patient Perspective
Access: in a timely manner
Health Provider Collaboration
Enhanced Communications with provider and
family
Increase patient satisfaction with care
Benefits
Payment
Will Medicare Part B pay for initial and subsequent
nursing facility visits furnished by telehealth?
• In 2011, CMS approved the addition of subsequent visits (99307–99310) to the
list of Medicare telehealth services with the limitation of:
– One telehealth subsequent nursing facility care service every 30
days.
• The initial visit and Federally-mandated periodic visits should be conducted in-
person. It may not be furnished through telehealth.
• Medicare beneficiaries are in an originating site (SNFs are an authorized
originating site) located in a rural health professional shortage area or in a
county outside of a Metropolitan Statistical Area.
• As a condition of payment, an interactive audio and video telecommunications
system must be used that permits real-time communication between a
physician or practitioner at the distant site and the beneficiary at the originating
site.
Payment
Patients seen at two SNFs in 2014
0
2
4
6
8
10
12
14
16
18
Apr May Jul Aug Sep Oct Nov Dec
0
5
10
15
20
25
30
35
40
99308 GT 99309 GT 99310 GT
CPT Codes Telemedicine visits per month
Num
ber
of
patients
10/4/2015
13
37
Real-Time Videoconferencing between
a Physician and critically-ill resident
Tools
Rollabout with Electronic
Equipment• Telemedicine Carts
• Video Conferencing
• Exam Cameras
• ENT Digital Otoscopes
• Electronic Stethoscopes
• Dermascopes
• Ophthalmoscopes
• 12 lead EKG
Tools
Adoption
• Consumer Needs & Preferences
• Technological Advancements
Regulations: Privacy, security, and
confidentiality. Licensing and
Credentialing issues / Liability
Provider Concerns: Reimbursement
Infrastructure: IT
Cost
Driver of
Adoption
Barrier to
Adoption
10/4/2015
14
Summary
Telemedicine is coming to Post Acute and Long Term Care Facilities
Simply making it available does not guarantee its use by nursing home
staff.
Engagement is the key to the use of telemedicine.
Additional steps needed to encourage buy-in among nursing home
administrators, front-line staff members, and physicians.
Health care providers and governments should work together for the
best results
We should get ready and plan to take an action.
Mere Vehicles - Mere Tools
Telemedicine is just a vehicle that permits the delivery of health care
services but it has no greater impact on healthcare than the truck that
delivers our groceries has on our nutrition.
It is the content of the vehicle that permits effective health care, not the
vehicle.
Thank you!
Questions