Nina M. Antoniotti, RN, MBA, Ph.D.Marshfield Clinic TeleHealth

Marshfield, Wisconsin

Tying TeleHealth to Quality:

Where is Your Chasm?

American Telemedicine Association Annual MeetingNashville, Tennessee

May 2007

TeleHealth/TelemedicineTelemedicineThe use of medical information exchanged from one

site to another via electronic communications to improve patients’ health status.

“telehealth,” which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services.

Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers. (Retrieved 04-23-07 www.americantelemed.org)

Quality can refer to:1. Technical interpretation - A specific characteristic of an

object (the qualities of ice - i.e. its properties) 2. Philosophical interpretation - The essence of an object (the

quality of ice - i.e. "iceness") 3. Practical interpretation - The achievement or excellence of

an object (good quality ice - i.e. not of inferior grade) 4. Metaphysical interpretation - The meaning of excellence

itself 5. Scientific interpretation – In physics, the range of

frequencies over which something will characteristically respond. (www.wikepedia.com, accessed 5-07)

Quality

• Not limited by sector, form of payment, organizational type, or clinical discipline

• Two fundamental components:– Technical, scientific appropriateness,

competency, and accuracy of care (Five R’s).– Delivered in a safe and technically

competent manner that is acceptable to the patient.

Definition of Health Care QualityThe degree to which

Health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current

professional knowledge (Lohr, 1990)

Evaluation of Quality– Structure

•Provides the setting, credentialing standards and infrastructure to support good care

– Process•Appropriate evidence-based care as a key

component in achieving good outcomes for patients

– Outcome•Considers the appropriateness, efficiency,

and variation of care creating value-added and meaningful care

                                            

      

Determinants of Quality

Characteristics of QualityIOM Six Chasms(2001)

Haddad et al. (1998)

Gooding(1999)

Foundations of

Quality (2000)

President’s Advisory

Commission (1998)

Safe Conduct of health staff

Availability of

specialized care

Technically safe and appropriat

e

Reducing the underlying causes of

illness, injury, and disabilityEffective Technical

care including outcomes

Personal relationship with health

care provider

Acceptable for the patient

Expand research on

new treatments and

evidence on effectivenessPatient-

CenteredConvenience of facility

Technology

  Ensuring the appropriate

use of health care servicesTimely Organizatio

n of careFamiliarity  

Reducing health care

errorsEfficientDrugs

    Addressing oversupply and undersupply of

health care resources

Equitable       Increasing patient’s

participation in their care

ChasmThe Gap between average care…

… and the best care

IOM Six Chasms

• Safe – avoiding injuries to patients from the care that is intended to help them.

• Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse).

Six Chasms

• Patient Centered – providing care that is respectful of and responsible to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

• Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care.

                                                                                

Six Chasms

• Efficient – avoiding waste, in particular, waste of equipment, supplies, ideas, and energy

• Equitable – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status (IOM, 2001, p. 39-40)

“…a health care system that achieved major gains in these six dimensions would be far better at meeting patient needs. Patients would experience care that was safer, more reliable, more responsive, more integrated, and more available. Patients could count on receiving the full array of preventive, acute, and chronic services from which they are likely to benefit. Such a system would also be better for clinicians and others who would experience the satisfaction of

providing care that was more reliable, more responsive to patients,

and more coordinated than is the case today.” (IOM, 2001, p.6)

Where Does TeleHealth Fit?

• Interactive video consultations– Safe, patient-centered, timely, efficient,

effective, equitable

• Store-and-forward– Safe, timely, efficient, effective

• Remote monitoring– Safe, patient-centered, timely, efficient,

effective

IOM’s Six Chasms of Quality

• Patient Centered– Reduces the burden of access to health care– Provides necessary services in underserved,

disparate areas

• Safe– Diagnostic accuracy, technical superiority– Better patient compliance

• Timely– Reduces time from referral to appointment– Introduces specialist earlier in the process of

care– Early symptom management for chronic

conditions

IOM’s Six Chasms of Quality

• Efficient– Time neutral or less time for providers– Patient is better prepared – No duplication of services– Higher productivity for providers –

especially for health professions shortages

– Increased collaboration/communication between providers

– Lower no-show rate

IOM’s Six Chasms of Quality

• Effective– Quality, cost, outcomes studies– Stabilization of rural practices– Reduction in the number of ED visits,

unnecessary physician office visits, unnecessary care

– Reduction in the total number of visits

• Equitable– Reimbursement– Transmission costs

Quality Management

• Training • Operational Systems

– Scheduling and Appointing– Billing and Coding

• Patient Satisfaction• Provider Satisfaction• Monthly Management Reporting• Evidenced-based Practice• Clinical Outcomes

What TeleHealth Can Mean to Strategic

Management• Outpatient Specialty Clinics• In-patient assessment and support• Decision Analysis model for transfers• Disease Management, Remote

Monitoring• Email consultations• Practitioner Support• Practice Support• CME, CEU, ancillary staff education• Collaboration between organizations

Pay-for- Performance

The use of incentives to encourage evidence-based practices that promote better outcomes

and ultimately may result in a

transformation of the healthcare system.

Objectives of Pay-for-Performance

• Align payment and quality

• Facilitate adoption of HIT

• Reduce clinical practice variability

• Creation of infrastructure

Objectives

• Decreased hospitalizations• Decreased re-hospitalizations• Decreased days of stay per episode• Improvement in health status towards

specific indicators• Decreased use of medications,

treatments driven by health status indicators

• Increase in patient/family satisfaction• Quality and patient safety

Combination of:Practice guidelinesDisease managementDecision support

systemsHistorically paid for:

Units of service$ per person

Pay for Performance

• Setting performance expectations

• Measuring performance

• Rewarding results through financial and incentive systems

• Measured expectations

Facets of Pay-for-Performance– Structure

•Provides the setting, credentialing standards and infrastructure to support good care

– Process•Appropriate evidence-based care as a key

component in achieving good outcomes for patients

– Outcome•Considers the appropriateness, efficiency,

and variation of care creating value-added and meaningful care

Is this an Idea of the Week?

• Rising cost of health care• No accountability for outcomes• No payment for higher quality of care• When patients are kept healthy, doctors and

organizations lose money• 66% of persons are served by federal health care

programs• National Academy of Sciences IOM –

study proposing federal gov’t link payments to performance

Where Does TeleHealth Fit?• Improved access• More timely access• More timely introduction of specialist

into the process of care• Early symptom management• Involves the patient in the process of care• Decreased hospitalizations, days of care,

repeat hospitalizations, use of medications

In a pay-for-performance strategy, TeleHealth is not the solution, but a tool that augments the delivery of care and transfer of information in a pay-for-performance strategy. The technology adoption currently present in TeleHealth may facilitate the adoption of other technologies that support pay-for-performance.

Tying the Knots

Tying TeleHealth/Telemedicine – Quality –

Pay for Performance –

together in a strategic management philosophy.

TeleHealth and Rural Health• Improves Access• Provides Accurate and Available Information• Assists in the deployment of Electronic Medical

Records• Provides Necessary Specialty Services • Provides Chronic Disease Management (Care

Management)• Provides Health Services for the Elderly,

Disabled, Home Bound

What TeleHealth Can Mean to Rural Providers

• Outpatient Specialty Clinics• In-patient assessment and support• Decision Analysis model for transfers• Disease Management, Remote Monitoring• Email consultations• Practitioner Support• Practice Support• CME, CEU, ancillary staff education• Collaboration between organizations

TeleHealth and their networks are uniquely positioned for the

assessment, evaluation, implementation, and

deployment of electronic medical records.

Soon, physicians may be looking for something that helps them prepare for a new reimbursement environment, one that requires that they measure and report on quality and safety indicators for their practice.

CCHIT Certified EHRs are tested against criteria that include the

ability to monitor quality indicators. And as CCHIT’s certification criteria

roadmap matures, product testing criteria will likely become more rigorous to keep pace with the

growing requirement for quality monitoring.

With the introduction of future interoperability criteria, certification will help physicians and other providers choose products that have the ability to report across care settings and coordinate care between the patient and the physician.

Centers for Medicare & Medicaid Services

(CMS)Physician Group Practice (PGP)

Demonstration

The first ‘value-based purchasing’ demonstration

applied to providers.

PGP Objectives

• Align reimbursement with quality.

• Promotes using utilization and clinical data for improving quality.

• Encourage coordination of Part A and B services.

• Promote efficiency in administrative structures and care processes.

• Reward for improving health outcomes.

To CMS, Quality =

• The higher of 75% compliance, or the Medicare mean, or …

10 % reduction in gap between administrative baseline and 100% compliance, or…

• 70th percentile of Medicare HEDIS

What were the stated goals?

• Encourage coordination of Part A and Part B services

• Promote efficiency by investment in administrative structures and care processes

• Reward physicians for improving health outcomes

In other words . . . . .

CMS wants to avoid this!

Bottom Lines1. Improving quality without improving

efficiency results in $$$$

2. Improving efficiency without improving quality results in $$$$

3. Our challenge is to improve quality and efficiency, simultaneously and fast.

Starting Points

• Primary Prevention: Avoid disease• Secondary Prevention: Early detection• Tertiary Prevention: Chronic disease

DiabetesAnticoagulationCHFHypertensionCADDementiaDepressionCOPDFrail & Elderly

HIGH HIGH COST COST

CONDITIONSCONDITIONS

Fundamental Truth

“Every system is designed perfectly for the results it

achieves”- Paul Bataldan, IHI

Quality’s Impact on TeleHealth

• Formalizes an informal initiative• Creates expectations for service• Allows wider distribution of

evidence-based practice• Assists in attainment of

benchmarks, goals• Moves TH out of the grant-

funded arena

Quality’s Impact on TeleHealth

• Creates expectations• Demands attention to detail,

performance, satisfaction• Pulls in strategic initiatives• Requires benchmarks• Proof of clinical outcomes, cost savings,

increased value to the customer

Strategic Management for TeleHealth and Quality

• Ensure that Strategic Management is the foundation for TH/TM initiatives

• Identify TH/TM initiatives within the strategic plan

• Culture change to ‘a way of doing business’

• Become a TH/TM organization

Leaving out one small

detail can make all the

difference in the world.

Make TeleHealth a

part of your quality initiatives and

quality a part of TeleHealth!