REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges
Deborah A. Randall, JD & Consultant
www.deborahrandallconsulting.com
Kathy Duckett, RN,BSN, Director
Clinical Services Partners Homecare
Moving Towards Electronically Enabled Care Delivery@Home
HIT = Health Information Technology HIE = Health Information Exchange EHR = Electronic Health Record EMR = Electronic Medical Record PHR = Personal Health Record ONC = Office of the National
Coordinator for HIT [DHHS]
Survey 2010: eHealth Initiative
61% of respondents agree or strongly agree that significant progress has been made in the successful adoption and use of HIT since 2007.
BUT 54.9% disagree or strongly disagree the value of HIE is clearly understood &
66.6% disagree or strongly disagree outreach on value of EHR/HIE is effective
55.5% of respondents disagree or strongly disagree that differences between federal and state privacy laws are not a barrier to consumer’s rights to healthcare privacy.
56% agree or strongly agree that HIT and HIE have had a positive effects on care delivery.
Evolving Definitions
Telemedicine vs. telehealth Doctor to doctor d2d Doctor to patient d2p Distance learning Remote monitoring eCare eHealth “Smart” homes
Developments & Trends
New Medicare Reimbursement Possibilities: SNFs; kidney, nutritional, diabetes self-management; mental health services
Devices as diagnosis-enhancers Infrastructure for Telemedicine and
Telehealth Legislation
LEGISLATION 2009-2010
HITECH ACT 2009- Stimulus Bill
HIT Policy Committee of ONC
Infrastructure got first funding
Aging Services Technology Study
PPACA – Health Reform Act 2010
Independence@Home; Medicaid Medical Home; Chronic Care; Innovation Cntr
TELEHEALTH IMPACT
A. $2 billion in direct funding for health IT efforts, channeled through the Office of the National Coordinator [ONC]– $300 million reserved for supporting regional health information exchange efforts and the state-based “extension centers"– $20 million reserved for NIST for work on health careinformation enterprise integration- BEACON GRANTS
B. Incentives Medicare and Medicaid to providers and hospitals adopt and use health IT systems =AND THESE PHYSICIANS CAN BE WORKING WITH HHAs and HOSPICES
HIGHTECH, cont.
– $85 million for the Indian Health Service to use on health IT
– $1.5 billion for community health centers, a sum thatcan be used toward health IT acquisition
– $500 million for the Social Security Administration forprocessing disability and retirement workloads, of whichup to $40 million may be used for health IT researchand adoption
– $1.1 billion to AHRQ, HHS, and the NIH for comparativeeffectiveness research
BEACON: $16+Million Buffalo
Western NY Info.Exchange, Buffalo clinical decision support –
registries ;point-of-care alerts/reminders innovative telemedicine =improve
primary/specialty care for diabetics, ↓preventable ER visits, hospitalizations re-admissions for diabetes, CHF, pneumonia; ↑immunization of diabetics
Patient Protection and Accountable Care Act of 2010
“PPACA” --This is where the expansion will continue to be.
PPACA drives the process towards management of chronic disease.
Health information technology is finally showing, with reliable data, that telehealth can integrate with traditional care and use staffing innovations.
PPACA Promises? Promises!
Post-hospitalization bundling pilot Independence at Home demonstration Innovation Center at DHHS; chief
policy person in place;telehealth focus ACOs Medical Home-Medicaid and Pilots Face2face HHA provision w telehealth
Blue Cross/Blue Shield WNY
Blue Cross/Blue Shield Western New York in May 2010 initiated online physician-patient communication as a compensated service; encouraging telehealth communications and webcam visits; measuring quality of care and patient compliance factors
Technology-enabled Care: Where are we now?
Satellite health facilities In situ care w medical devices Remote monitoring and sensors Awareness and acceptance European efforts in ambient care The VA system –the Vanguard
Where is Telehealth in Use
Care coordination and Chronic Disease
Patient self-management Ambulatory care and safety Palliative care Rehabilitative services Behavioral & mental health services
VA Chronic Care Coordination via Telehealth Study
CONDITION # % DECREASE UTILIZATION
Diabetes 8,954 20.4
Hypertension 7,447 30.3
CHF 4,089 25.9
[congestive heart failure]
COPD 1,963 20.7
[chronic pulmonary obstruction]
VA Chronic Care Coordination via Telehealth Study
Posttraumatic stress disorder 45.1% Depression 56.4% Other mental health condition 40.9% Single condition 10,885 patients;24.8% Multiple “ “ 6,140 patients;26.0% Interventions “just in time”; “air traffic
control”
VA Chronic Care Coordination via Telehealth Study
The cost ($1,600.24 pp/yr compares favorably)
direct cost of VHA’s home-based primary care services of $13,121.25 per annum and
market nursing home care rates that average $77,745.26 per patient per annum”.
Conclusion: a flexible and cost-effective adjunct to VHA’s existing services. Darkins et al., Telemedicine & EHealth, 12/2008.
Telehealth and chronic illness
St. Vincent Health System's Visiting Nurse Association [Arkansas] has used telehealth computers to monitor patients in their homes for several years, and in its 11 county region had only about 4.5% of heart attack patients re-hospitalized compared with a national rate of 37%. [National Assn for Home Care report]
Telehealth and Aging in Place
University of Missouri :sensors, computers and communication systems, along with supportive health care services monitor the health of older adults who are living at home.
Motion sensor networks installed in seniors’ homes can detect changes in behavior and physical activity, including walking and sleeping patterns. Early identification of these changes can prompt health care interventions that can delay or prevent serious health events.
HMSA: Ambulatory MD/Home
Hawai’i Medical Service Ass’n Jan 09 Online Care connects, 24/7, patients
and physicians via the Internet or telephone;1st in the nation.
$10/45 for 10 minutes interaction Physicians can be “anywhere”; service
is across all islands
Telehealth: Dementia Patients
Residential facilities designed to allow movement of individuals through facility and grounds; Families can track on computer/internet based systems
Sensoring systems; Intel research; TRILL; diagnostic sensoring for fall prevention yielding data on Alzheimer specific movement differentials
Telehealth:Dementia Patients
AlarmTouch GPS is a personal safety phone with GPS location in Europe. The telecare device includes a ‘Geofencing’ feature, enabling accurate location of users in need. When the wearer wanders outside a specified zone – such as home or school area - the system can send a short message (SMS) alert to a monitoring centre or to a relative or caregiver.
Home Care Association of New York State 24
Home Telehealth - NY State
93 providers approved to bill Daily rates as of 1/1/2010 Tier I – 62 $8.88/day/patient Tier II – 31 $10.20/day/patient Tier III – to be tied to regional connectivity Medicaid Managed Care covered service
Electronic Medical Records Approximately 50% - 60% utilization – generally
medium & large sized agencies Multiple other “pieces”
Referral software, physician portals, med management hardware etc.
Home Care Association of New York State 25
Length of Experience - Home Telehealth
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2-3 years
3-4 years
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More than 5
Multipleprograms withdifferent lengthsof operation
Home Care Association of New York State 26
CURRENT TECHNOLOGY UTILIZATION
#Providers
Home Care Association of New York State 27
Disease Management
Ambient Assisted Living Programme - EU
23 EU member states with support of European Community [EC]
-Enhance quality of life of older people-Strengthen industrial base by use of Information and
Communication Technologies [ICT]-Aging well at home, community and work-Coherent framework for research into solutions which
are compatible with varying social preferenceswww.aal-europe.eu
American Telemedicine Assn
Home telehealth and remote monitoring practice group
Working group exploring opportunity for, and prevalence of telehospice; I chair this group.
www.americantelemed.org
Stats and Facts175 Towns and Cities2,500 Average Daily Census24,000 Admissions Annually360,000 Visits/Year46% of Admissions are from non-
Partners Healthcare System Sources4 Hospitals: Massachusetts
General Hospital, Brigham and Women’s Hospital, North Shore Medical Center, Newton Wellesley Hospital are the core hospitals for PHS
Technology
383 Clinicians on POC305 Telemonitoring devices –
remote monitoring3800 Personal Emergency Response
units
Clinicians and Staff
700 Full, Part-time, Per-visit244 Registered Nurses 25 Licensed Practical Nurses131 Therapists: physical,
occupational, speech7 Social Workers
61 Home Health Aides 32 Liaisons 11 Intake Nurses 4 Nutritionists 185 Other managers, clinical, admin
Partners Home Care
9 Essential Steps for Sustainability1. Set Program Goals2. Gain Insight of Stakeholders3. Get Buy-in 4. Patient Selection – choose wisely5. Care Coordination – 5 “Ws” 1 “H”6. Establish Clinical Standards7. Equipment Management – DME matters8. IS Infrastructure - IS is your friend9. Quality Improvement – implement soon,
evaluate often
Success Follows
1. Set Program Goals What is the problem you want to solve? Set goals based on measureable outcomes
Why telemedicine? Improved care
decrease number of emergency room visits
decrease number of hospital re-admissions
Increase patient involvement in care
Decrease home visits
Improved outcome and access/decreased costs
You’ve decided to choose to start a telemedicine program
What’s Next?
Recognize the Nature of a Paradigm Shift
Telemonitoring changes traditional notions of care delivery
Incredible opportunity to improve care and increase access
It builds careers and new skill-sets and improves peoples lives …..BUT……
People resist change Doing it “right” requires set up and
perseverance The 1st time takes longer than one would
think
2. Gain Insight of Stakeholders
Patient
Nurses &Allied Health
Physicians
Quality &Compliance
InformationSystems
Finance
Senior Leadership
Operations
3. Get Buy – In 4 Main Groups
Senior Organizational Leadership CEO Field Staff
Patient Getting equipment in
MD/nurse confidence Clinicians/Allied Health Professionals
Champions Touch and Play sessions Manager accountability/feedback loop Prizes
Physicians Education “Just in time” reports Promised decreased calls from patients d/t triage
by TM staff
4. Patient Selection – Choose Wisely Determine Patient Population
Based on program goals
Partners Telemonitoring criteria: Moderate to high risk for re-hospitalization Will benefit from telemonitoring Can be managed with decreased nursing visit
frequency Patient or caregiver is able/willing to assume
responsibility for monitoring Working phone line in patient’s home Home is safe environment for equipment
5. Care Coordination – 5Ws, 1HDetermine process flow SN evaluations for program
admission By Whom?
Referrals Who refers? Where do referrals go? Who processes them?
Telemonitoring of patients Centralized – requires
dedicated TM staff Decentralized – integrated
into primary clinician work flow
Reporting – Why? Who What When Where How
6. Establish Clinical Standards Best practice, evidence based standards Must be able to individualize standards Use clinical experts that clinicians will
accept to set standards Educate clinicians regarding standards Give clinicians autonomy to modify
standards as they deem necessary Give clinicians algorithms/guidelines for
further autonomy in practice
7. Equipment Management – DME Matters Rent vs. purchase Identify who will manage Establish responsibility and accountability for
electronic inventory control system set- up and provisioning installation/testing/break-fix equipment recovery, sanitizing, storage and
redeployment Training, retraining, written protocols Begin with decentralized process (greater buy-in at
local level), migrate to centralized process (efficiency & consistency) over time, selecting best of breed processes
Cultivate leadership
9. Quality Improvement Implement Soon – Evaluate Often Establish QI program at beginning of process Establish planned review periods
Initially weekly Include stakeholders as appropriate Include all 8 essential elements as part of
formal QI program Establish database for statistics at start of
program If you think you might need it, get it Build mechanisms for gathering data if not
inherent in EMR program Excel, Access databases
Telemonitoring at PHC PHC Telemonitoring Program - 2006
Patient Selection Criteria Available for Medicare pts currently receiving PHC
Connected Cardiac Care Program - 2007 4 month home telemonitoring program Patient Criteria Strong educational component –
1 Nurse visit to establish clinical status and knowledge deficits, then no further nursing
Bi-weekly telephonic educational phone calls Encourage direct patient/PCP relationship
Patient Choice Program Private Pay
Hospice Telehospice Pilot
CMS Pilot program
Positive Patient Outcomes > 2100 patients cared for 2006-
present Average LOS 70 days Average LOS with no rehospitalizations
– 53 days Average LOS with > 1 hospitalzation –
103 days Average rehospitalization
PHC program – 25% CCCP – 30% decrease year over year
1.3% - 1st 30 days 3% -program completion
MD Acceptance - CCCP
Clinician Response Decrease average SNV to 10
visits/episode with improved outcomes for rehospitalization
Consistent referrals to programs
Clinician comments: “I love it. I feel like I have
a better handle on my fragile heart failure patients using telemonitoring – they look at them every day and let me know if there is a problem I need to be aware of.”
“I think it’s great – it’s made a huge difference for my patients.”
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Admissions by Region FY10
South
Central
North
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October December February April J une August
Combined Program Census FY10
What are the New Directions?
Tele-rehabilitation; Falls prevention Tele-mental and behavioral health Continuous monitoring: diabetes;
cardiac Impaired; Alzheimer’s & dementias “Wellness”
Telehealth and Rehabilitation
Distanced assessments Robots in SNFs Telestroke => telerehab Wii units in senior living facilities Remote monitoring for falls anticipation Traumatic brain injury;wounded warrior
Behavioral & Mental telehealth
On-going research Post traumatic stress disorder Tele-psychiatry Distanced mental health services
under new Medicare reimbursement provisions for community mental health centers
Telehealth and Palliative Care
Telehealth and pain management TeleHospice care
•bringing patient and family into the interdisciplinary group [IDG]
•counseling to patients and family when social workers are scarce resources
Palliative Care
Pain and symptom management Outreach and crisis management Triage without transporting to facility Psychological pain and suffering Diagnostic opportunities; family
interactions Ethical principles= autonomy enhanced
Prevalence of Telehospice
Informal survey CIMIT Grant to review Methodology Findings Follow-on research Canadian telehealth research in
palliative area
Research on Telehospice
Initial research papers Work in Missouri and Washington State Directions –
IDG involvement patients and families Education and emotional support to
caregivers Reactions of patients to use of health
information technology Preferences of video versus audio only
Opportunities and Challenges
Medical Director and other physicians Demonstrating cost savings, &/or
quality of care/life improvements- to justify expense of equipment and staff
Training and staffing. Maintenance of depth of field/bench so turnover is not a problem. Need for a "champion".
Leading nurses to embrace technology
Telehealth: Government Impediments
Reimbursement under Medicare Medicaid Grants Outcomes, cost savings and Disease
Management concerns Licensure and interstate barriers Standards lacking:Interoperability
among devices/software/infrastructure
Legal Barriers and Concerns
Licensure Liability Consent Reimbursement Management of the Case Privacy and confidentiality Security of Communication Fraud and Abuse
Licensure
Many states –New York is one--bar physicians from practicing via telehealth without a full or partial new license=quality; control as issues
Some states now licensing the entity which arranges for and participates in telehealth services
Nurses—not surprisingly—more sane
Liability--Consent--Managment
Medical device or simply a conduit of information
Manufacturer; Software vendors will seek total immunity from exposure
Patients need to hear from physicians and health entity about conditions, errors and backup response
Insurers reluctant or ignorant
Telehealth: Privacy Laws and Impediments to Data Exchange
State privacy laws HIPAA Congressional opposition on the HITECH
and other HIT bills –Strong language extending privacy protections including business assoc’s
Is ARRA destined to slow eHealth progress
Fraud and Abuse
Coordination of telehealth services vs.Impermissible incentive to referral source, including patient herself
and If it is a new “service“ is it subject to
Stark law concerning physician financial interests
Discussion – Are you involved
Audience experience in telehealth Reluctance….and reasons Board reactions…have they been
educated Can our society afford not to bring
telehealth into our long term care situations?
Contact Information Deborah A. Randall [email protected] www.deborahrandallconsulting.com 202-257-7073
Kathy Duckett, RN, BSN, Director Clinical Programs Partners Home Care [email protected] 781-290-4058