Telehealth in an evolving healthcare environment

Karen S. Rheuban MDProfessor of Pediatrics

Senior Associate Dean for CME and External AffairsDirector, Center for Telehealth

University of Virginia

No COI to discloseVerizon Foundation grant

Objectives

• Understand the landscape of telehealth across the healthcare continuum

• Identify opportunities to advance telehealth through favorable public policy collaborations

DefinitionThe use of technology to enhance access to health care, to improve public health, and to support health-related education using communications services• Live interactive videoconferencing• Store and forward technologies • Remote patient monitoring• Health related distance learning

• Telehealth is not a specialty in and of itself!

Benefits of telehealth• Patients:

Timely access to locally unavailable servicesEnhances patient choiceSpared burden and cost of transportation

• Hospital systemsReduce readmissionsImprove triage, keep patients localImprove quality indicators

• Health professionals (workforce shortages)Access to consultative services and CMEEvidence based models of care

• Public healthEmergency preparednessDisease surveillance

UVA Center for Telehealth • Integrated program across the service lines and

schools within the University that facilitate our missions of:

Clinical CareTeaching across the continuumResearch and innovationPublic service/Public policy

• HRSA funded Mid Atlantic Telehealth Resource Center • Academic partner with Specialists on Call

UVA Telemedicine Partner Network (113 sites)

Community Hospitals Health Systems Rural Clinics (FQHCs, Free Clinics) Virginia Department of Health Virginia Department of Corrections Community Service Boards School Health Nursing Facilities PACE programs Home Telehealth

Patients served• >33,000 patient encounters in Virginia

Additional international outreach• > 30,000 teleradiology services/year• Spared Virginians > 8.6 million miles of travel• Services in >40 different sub-specialties

EmergencySingle consults/follow up visitsBlock scheduled clinicsScreenings with store forward technologies

Mobile digital mammography Retinopathy

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Technologies:HIPAA compliant, interoperable

o Cancer Centero Cardiology o Dentistry o Dermatology o Diabetes Educationo Endocrinology o ENT o Emergency Medicine o Gastroenterology o Genetic Counseling o Geriatrics o Gynecology o Hematology o Infectious Disease

o Mammographyo Neonatologyo Nephrology o Neurology - generalo Neurology - strokeo Neurosurgery o Nutrition o Obstetrics – High Risko Ophthalmologyo Orthopedics o Ostomyo Pain Managemento Patient Monitoringo Pediatric specialtiesPediatric Specialties Pediatric Specialties

o Pediatric Critical Care

o Plastic Surgery

o Psychiatry – Adult

o Psychiatry – Child & Family

o Psychiatry – Emergency

o Pulmonology – Cystic Fibrosis

o Radiology

o Rheumatology

o Surgery

o Thoracic Cardiovascular Surgery

o Toxicology / Poison Control

o Transplant

o Urology

o Wound Care

Clinical services

Tele-stroke Need: High morbidity, high mortality, high cost condition –

when every second counts Low utilization of TPA nationwide Telestroke programs improve access to stroke neurology

services UVA: TPA use increased from 0% to 25% of rural stroke

patients

The evidence

Pediatric Cardiology• High incidence of congenital heart disease (1:100

births)• Newborn O2 saturation monitoring standard of care• Tele-echocardiography: Emergency and routine

Digital store and forward imagesImmediate diagnosisLife saving case management (triage)

Pediatric opportunities • Geographic disparities in pediatric emergency services

• 92% of children seen in non CH emergency rooms• Rural EDs and providers have limited access to pediatric

specialists

High risk obstetrics

• UVA High Risk Obstetrics Telemedicine Program6 sites with state and federal funding

• Modeled after Arkansas ANGELS

I ssues Before HROB Program After HROB Implementation

Gestational Age at First Visit 17 weeks 13 weeks

Entry into Care 25% after 20 weeks All before 20 weeks

Missed Appointments 11% of visits 4.4% of visits

Rate of pre-term birth 16.5% 12.5 %

Emergency telemedicine• Serious staffing challenges in rural (and urban) EDs • Provides access to specialty care• Transfer avoidance when appropriate• Improved triage when transfer needed‒ University of Mississippi >500,000 ED tele-services!!!‒ UC Davis: Pediatric emergency telemedicine‒ Dartmouth: Tele-trauma training and care‒ UVA: Medical Toxicology, telestroke, emergency

telepsychiatry, pediatrics and other emergency consults as requested

Tele-mental health• Shortage of mental health providers in rural areas• Consultations, medication management

Improve access, shorter wait timesHigh rates of patient satisfaction in all age groupsControlled studies show efficacy comparable to face to face psychiatry

• NUMBER ONE request for services• Adult, Child and adolescent services• Emergency telepsychiatry *Terry Rabinowitz – “Think inside the box”

e-ICU /Critical care• Continuous monitoring model

Hospital mortality decreased ICU length of stay shorter

• Consultation model using VTCNICU Inpatient and ICU consults

Cancer outreach and care

• Screenings• Second opinions• Tele-colposcopy training and

support• Follow up care• Collaborative tumor boards• Remote access to clinical trials

Chronic Disease Management: RPM

• ACA: Incentives and penalties Hospital penalties for readmissionsMedicare shared savings programsModels of capitated care

• Examples: Vidant Health (North Carolina)Sentara Home health (Virginia)VA Care Coordination and Home TelehealthUVA C3 – initial focus on CHF, COPD, AMI, Pneum

8% readmission rate (76% reduction)

Public policyAlignment with State and Federal Goals

• Improves access to care• Improves quality• Lowers costs • Improves population health • Mitigates specialty workforce shortages• Facilitates disease surveillance/emergency

preparedness• Increases broadband deployment/adoption

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Issues for consideration• Reimbursement • Funding of telehealth (Stark, Anti-kickback)• Informed consent• Ensure privacy and confidentiality (HIPAA)• Credentialing and privileging – CMS, Joint Commission• Licensure• Malpractice • Practice guidelines and technical standards• Telecommunications venue/costs• Integration with EMRS/HIE• Interagency malalignment related to policies

2012 IOM Workshop

• Evolution of telehealth • Telehealth evidence base• Technological developments • Actions to further the use of

telehealth to improve health care outcomes while controlling costs

Key Findings• Improve payment mechanisms• Streamline licensure and credentialing processes• Develop a trained workforce in the practice and

delivery of telehealth services• Explore the role of telehealth in new care delivery

models• Conduct more research to improve the evidence

base for telehealth

Federal payment mechanisms

• Centers for Medicare and Medicaid Services• Department of Veterans Affairs• Department of Defense• Indian Health Service• Federal employee benefit plans

Improve Federal Payment Mechanisms

Medicare reimbursement of telehealth services remains low• 2011: CMS reported <$6 million dollars in

reimbursements nationwide to distant site providers• Rural requirement for originating site including for ACOs• Non-MSA definition of rural limits sustainability models

and more importantly, access to care for our seniors• Rural definition is poorly aligned with specialty workforce

shortages

Urban areas under Medicare

• The Grand Canyon, Arizona

Other Federal Roles in Telehealth:16 federal agencies

• HHS: HRSA, NIH, AHRQ, CMMI, ONC• USDA, Commerce• Rural healthcare support mechanism (FCC)• NASA• Department of Defense• FDA

Improve State Policies and Payment Mechanisms

• Medicaid expansion opportunity>40 state Medicaid programs currently cover telehealth Most state programs pay for transportation

• Private pay mandates (19 states plus DC) • No prior in-person requirement• Health insurance exchanges

Benchmark plans that include telehealth

• Correctional telehealth opportunities• State health information exchanges• NOBEL women

State Commitments to Telehealth

• Virginia Department of Health • State Rural Health Plan• State Stroke Systems of Care Task Force• Joint Commission on Health Care• Tobacco Indemnification Commission• Medical Society of Virginia• Virginia Health Reform Initiative• HBE Benchmark plan• Workforce Development Authority• State Board of Medicine

Virginia Medicaid• Began coverage in 1995 • Broadened statewide in 2003 as non-statutory

administrative decision• Covers store forward for ophthalmology • School as originating site for speech and language• State-wide managed care networks• 2013 Dual enrollee contract with CMS

– 77,000 Virginians covered– Urban telemedicine for Medicare enrollees– Remote patient monitoring

Credentialing and Privileging

• CMS 2011 rule change allows for a proxy credentialing and privileging process in the revised Conditions of Participation standards

• Must hold an accepted license within the state• Must be bound by a legal agreement between

entities• Must share quality data

Licensure

• Movement towards licensure portability• FSMB compact model• HRSA licensure grant program• Consider malpractice coverage implications!

Develop the Telehealth Workforce• Prepare the next generation of healthcare

professionals to integrate telehealth into models of practice

• Training programs developed – ATA, VA, HRSA funded projects

• Integration into medical and nursing school curricula• Create innovative workforce development models, to

include physician extenders

Recent federal legislation/actions

• Harper - Telehealth Enhancement Act of 2013 (HR 3306)*– Add incentive to reduce Medicare hospital readmissions– Create new Medicaid optional package for high-risk OB– Expands originating sites to include the home– Allow Medicare accountable care organizations (ACOs) to use telehealth

• Nunes – Medicare Telemedicine Enhancement Act of 2013 (HR 3077) – Licensure portability to serve Medicare beneficiaries

• Rangel – VETS Act (HR 2001)– Licensure portability for VA providers

• 2014 CMS physician payment schedule*• FDA guidance document on mobile medical applications

The future of telehealth

• Outcomes• Practice guidelines• Standards of interoperability • Demonstration projects including with FSMB• Collaboration amongst providers, policymakers• Collaboration with AMA and state medical societies• Telehealth resource centers• Champions at all levels • Integration into mainstream medicine

Telemedicine - for the patient.....