Getting Rural Care There with Telehealth
Living in a rural community poses unique challenges to maintain one’s health. The realities of living far from primary care physicians or having a lack of access to medical specialties can elevate already complex care situations. However, the application and promise of telehealth can help patients, regardless of location, get timely care.
The concept of telehealth or telemedicine is nothing new. Since the explosion of wireless technologies, hospitals and healthcare providers have been testing the waters of telehealth. U.S. rural communities stand much to gain with appropriate application of telehealth services, including real-time, face-to-face videoconferencing and the ability to send digital images to specialists for evaluation. The federal government recognizes this. For one, the U.S. Department of Agriculture Rural Development provided $30.2 million to 34 states through its Distance Learning and Telemedicine program last December to improve healthcare access to rural areas.
Notably, outcomes research is showing a positive trend in treating the rural population with telehealth services. For example, a three-year study conducted at the 272-bed Billings Clinic in Billings, Mont., has helped to demonstrate a case for telehealth services to rural communities. The study, published October 2011 in Telemedicine and e-Health, compared diabetes care with and without videoconferencing. The 225-physician regional multispecialty group practice found that one year post-intervention, a comparison of telehealth with face-to-face patients resulted in increased self-reported blood glucose monitoring as instructed (97 vs. 89 percent) and increased dietary adherence (244 vs. 159 percent).
Since the study’s conclusion in 2009, technologies at the Billings Clinic have been integrated into regular care to fuel a diabetes prevention program to identify people who don’t have diabetes but have risk factors that indicate the potential. Patient groups gather and have videoconference discussions on physical activity and diet, and their lab work is tracked by physicians, says Elizabeth L. Ciemins, PhD, MPH, research director at the Center for Clinical Translational Research at Billings Clinic.
At Saint Francis University’s (SFU) Center of Excellence for Remote and Medically Under-Served Areas (CERMUSA) in Loretto, Pa., researchers have been studying the effects of using telehealth services to facilitate the care of in-home patients in need of a certified wound care nurse. The care is not cheap: the average cost of healing wounds at home is approximately $13,000 per treatment episode according to published reports (Health Manage Technol 2002;23(4):22-24). Therefore, establishing beneficial and cost-efficient wound care strategies is imperative.
The wound care study involves a visiting nurse using an iPhone to take photos of a patient’s wounds during a routine home visit, says Brenda L. Guzic, MA, RN, assistant director for telehealth at CERMUSA. These are immediately sent to a certified wound care nurse who is centrally located at the visiting nurse organization’s main office. The wound care nurse then evaluates the wound and instructs the visiting nurse on any necessary care changes. “By using this format, the wound care nurse has the ability to see patients more often, enabling more timely changes to the wound care treatment regimen,” says Guzic
Using cellular technology has saved approximately $17,500, according to Guzic. Most of those savings came from streamlining a suitcase full of accessories (tripod [$25], power strip [$12], video cable [$30], light for camera [$56], HandyCam [$797], etc.) totaling $22,605 into one hand-held smartphone. “The old camera system weighed approximately 19 pounds, with all of the add-ons. An additional 19-pound suitcase can be rather cumbersome and nurses may not want or be able to carry everything,” says Guzic. The iPhone approach costs $5,175. Also, the photos now are becoming a permanent part of the patient’s EHR. As a result, the wound care specialist can monitor the healing of the wound on an ongoing basis and does not have to rely solely on written documentation.
The camera also cut down on driving time for the wound care nurse since, says Guzic, he or she no longer has to travel around 13 Pennsylvania counties to visit patients. And yet, travel time is in the eye of the telehealth beholder. For example, 75 percent of Alaskan communities are not connected by road, says Cheryl Moon, MS, acting-director of Alaska Federal Health Care Access Network (AFHCAN) under the Alaska Native Tribal Health Consortium (ANTHC) in Anchorage. The lack of access to roads, coupled with expensive airfares and great distances, justifies telehealth services for many Alaskan communities.
The ANTHC telehealth program, begun in 1998, seeks to improve access to health services for federal beneficiaries in Alaska to improve access to health services for federal beneficiaries. Last year alone, statewide providers generated more than 33,000 cases using telehealth services, and over the past 10 years, more than 125,500 cases were created.
“Our main focus is to improve access to quality healthcare for patients living in remote areas,” says Moon. “We often manage to keep patients in their home community.” Almost 75 percent of their specialty consultations prevent the need for patients to travel to see a specialist. “Without telehealth, the patient would need to fly into Anchorage to be seen at the Alaska Native Medical Center (ANMC) for a specialty appointment,” she says. “For pediatric cases, for example, an adult would need to take off work, take the child out of school and potentially travel a great distance to see a specialist.” A roundtrip plane ticket from a outlying village to Anchorage can cost up to $1,200, and AFHCAN estimates that the use of telehealth now saves more than $9 million annually in travel costs for specialty and primary care.
Connectivity is not the only challenge though. In a December 2011 IDC Health Insights report, the Framingham, Mass.-based research firm found 32 percent of respondents cited data security as an obstacle to telehealth, in addition to cost, which again, 32 percent stated cited as an obstacle. However, as the value of telehealth is demonstrated to a community, organizations may be more willing to foot some of the bill. Of the 108 counties serviced by Texas Tech University Health Sciences Center (TTUHSC), 22 have no physicians, 32 no hospitals and 75 percent of the region lives more than 90 miles from a comprehensive trauma hospital.
“Ninety-eight of those counties are considered rural and more than 50 percent are considered ‘frontier,’ meaning they have less than seven people per square mile,” says Debbie Voyles, MBA, director of telemedicine program at TTUHSC. With more than 400 patients per month treated for different specialties, including pulmonology, mental health and dermatology services, she says cutting driving time in favor of more frequent care proves value.
After grant funds ran out from a 2009 Children’s Healthcare Access for Rural Texas project, nine of the community clinics decided to take on the cost of DSL line connections and lease the telehealth equipment from TTUHSC. Also, it doesn’t hurt that the cost of technology is decreasing. When TTUHSC began their telehealth services in 1990, capabilities cost upwards of $100,000, but now, a high-definition videoconferencing unit costs approximately $35,000, says Voyles.
Costs vary with medical carts depending on the included equipment and their respective manufacturers. In Voyles’ $35,000 range, the peripheral devices make up most of the costs. The digital otoscope that TTUHSC uses comes with a price tag of $11,000, for example.
Lack of reimbursement amplifies telehealth’s cost barrier. However, the Centers for Medicare & Medicaid Services (CMS) is slowly changing the Physician Fee Schedule to reflect modern mobile clinical settings. The 2012 Physician Fee Schedule addressed changes to payment policies to ensure payment systems are updated to reflect changes in medical practice and the relative value of services. According to the final rule, CMS requires that telehealth services be equipped with an interactive telecommunications system, defined as a multimedia communications device which includes, at minimum, audio and visual equipment permitting two-way, real-time interactive communications between a patient and a practitioner at a distance site.
Currently, “Medicare telehealth services may be provided to an eligible telehealth individual notwithstanding the fact that the individual practitioner providing the telehealth service is not at the same location as the beneficiary,” reads the published rule. “An eligible telehealth individual means an individual enrolled under Part B who receives a telehealth service furnished at an originating site.”
According to the rule, certain services commonly furnished remotely using telecommunications are covered and paid the same as services delivered in person. The patient is not required to be in the same place as the practitioner.
However, a large part of who pays for telehealth services varies by region, and third-party payors are beginning to enter into the reimbursement game. David Guggenbuehl, RN, MBA, director of regional services at Gundersen Lutheran Health System (GLHS) in La Crosse, Wis., says GLHS is “fortunate” that payors like Blue Cross Blue Shield of Wisconsin are reimbursing for telehealth services. GLHS provides telehealth specialty services—including endocrinology, cardiology, medical oncology and radiology services—across 22 regional sites via a medical cart with capabilities including videoconferencing and digital cameras.
Additionally, Medicaid regulations vary by state and not all state programs, such as Wisconsin, pay for telehealth services. In Texas, eligible areas including rural counties (less than 50,000 population) and medically underserved areas are eligible for Medicaid telehealth service payments. Eligible medical services include consultations, office or other outpatient visits, pharmacologic management and psychotherapy. Texas insurance code generally requires health coverage providers to treat telemedicine consults as if they had occurred in a face-to-face environment, says Voyles.
But even if cost is overcome, other problems persist. “The No. 1 challenge is changing the culture of the way physicians practice,” says Guggenbuehl. Serving a half million people within a 100-mile radius around La Crosse, he notes that change management can be difficult as physicians put aside their traditional training. “There’s a learning curve on the clinical side when you don’t have your hands on the patient. Physicians have to be willing, able, interested and somewhat energetic to participate in these services.”
In addition to culture change, executives need to plan out their IT infrastructure before jumping into a telehealth initiative. “The rural environment is challenged in getting broadband circuits to supply the infrastructure needed,” says Brock A. Slabach, MPH, senior vice president of member services at the National Rural Healthcare Association, who adds that infrastructure foundation is critical and advises a 1GB circuit as the ultimate goal.
As adoption increases and cost goes down, more citizens in rural communities may soon be the beneficiaries of modern technology and telehealth services. Seemingly, there ain’t no mountain high enough; ain’t no valley low enough and ain’t no river wide enough to keep telehealth from getting to quality care.
The concept of telehealth or telemedicine is nothing new. Since the explosion of wireless technologies, hospitals and healthcare providers have been testing the waters of telehealth. U.S. rural communities stand much to gain with appropriate application of telehealth services, including real-time, face-to-face videoconferencing and the ability to send digital images to specialists for evaluation. The federal government recognizes this. For one, the U.S. Department of Agriculture Rural Development provided $30.2 million to 34 states through its Distance Learning and Telemedicine program last December to improve healthcare access to rural areas.
Notably, outcomes research is showing a positive trend in treating the rural population with telehealth services. For example, a three-year study conducted at the 272-bed Billings Clinic in Billings, Mont., has helped to demonstrate a case for telehealth services to rural communities. The study, published October 2011 in Telemedicine and e-Health, compared diabetes care with and without videoconferencing. The 225-physician regional multispecialty group practice found that one year post-intervention, a comparison of telehealth with face-to-face patients resulted in increased self-reported blood glucose monitoring as instructed (97 vs. 89 percent) and increased dietary adherence (244 vs. 159 percent).
Since the study’s conclusion in 2009, technologies at the Billings Clinic have been integrated into regular care to fuel a diabetes prevention program to identify people who don’t have diabetes but have risk factors that indicate the potential. Patient groups gather and have videoconference discussions on physical activity and diet, and their lab work is tracked by physicians, says Elizabeth L. Ciemins, PhD, MPH, research director at the Center for Clinical Translational Research at Billings Clinic.
Driving down drive times
The utilization of telehealth services is largely dependent upon the unmet healthcare needs of a community and the presence of a technology infrastructure to support those services. For rural and medically underserved communities, low doctor-to-patient ratio and lack of access to medical specialists are major impedances to care.At Saint Francis University’s (SFU) Center of Excellence for Remote and Medically Under-Served Areas (CERMUSA) in Loretto, Pa., researchers have been studying the effects of using telehealth services to facilitate the care of in-home patients in need of a certified wound care nurse. The care is not cheap: the average cost of healing wounds at home is approximately $13,000 per treatment episode according to published reports (Health Manage Technol 2002;23(4):22-24). Therefore, establishing beneficial and cost-efficient wound care strategies is imperative.
The wound care study involves a visiting nurse using an iPhone to take photos of a patient’s wounds during a routine home visit, says Brenda L. Guzic, MA, RN, assistant director for telehealth at CERMUSA. These are immediately sent to a certified wound care nurse who is centrally located at the visiting nurse organization’s main office. The wound care nurse then evaluates the wound and instructs the visiting nurse on any necessary care changes. “By using this format, the wound care nurse has the ability to see patients more often, enabling more timely changes to the wound care treatment regimen,” says Guzic
Using cellular technology has saved approximately $17,500, according to Guzic. Most of those savings came from streamlining a suitcase full of accessories (tripod [$25], power strip [$12], video cable [$30], light for camera [$56], HandyCam [$797], etc.) totaling $22,605 into one hand-held smartphone. “The old camera system weighed approximately 19 pounds, with all of the add-ons. An additional 19-pound suitcase can be rather cumbersome and nurses may not want or be able to carry everything,” says Guzic. The iPhone approach costs $5,175. Also, the photos now are becoming a permanent part of the patient’s EHR. As a result, the wound care specialist can monitor the healing of the wound on an ongoing basis and does not have to rely solely on written documentation.
The camera also cut down on driving time for the wound care nurse since, says Guzic, he or she no longer has to travel around 13 Pennsylvania counties to visit patients. And yet, travel time is in the eye of the telehealth beholder. For example, 75 percent of Alaskan communities are not connected by road, says Cheryl Moon, MS, acting-director of Alaska Federal Health Care Access Network (AFHCAN) under the Alaska Native Tribal Health Consortium (ANTHC) in Anchorage. The lack of access to roads, coupled with expensive airfares and great distances, justifies telehealth services for many Alaskan communities.
The ANTHC telehealth program, begun in 1998, seeks to improve access to health services for federal beneficiaries in Alaska to improve access to health services for federal beneficiaries. Last year alone, statewide providers generated more than 33,000 cases using telehealth services, and over the past 10 years, more than 125,500 cases were created.
“Our main focus is to improve access to quality healthcare for patients living in remote areas,” says Moon. “We often manage to keep patients in their home community.” Almost 75 percent of their specialty consultations prevent the need for patients to travel to see a specialist. “Without telehealth, the patient would need to fly into Anchorage to be seen at the Alaska Native Medical Center (ANMC) for a specialty appointment,” she says. “For pediatric cases, for example, an adult would need to take off work, take the child out of school and potentially travel a great distance to see a specialist.” A roundtrip plane ticket from a outlying village to Anchorage can cost up to $1,200, and AFHCAN estimates that the use of telehealth now saves more than $9 million annually in travel costs for specialty and primary care.
Challenging times
Although telehealth has seen its fair share of success stories, there are still barriers to its adoption and use. For example, the growing demand for videoconferencing throughout Alaska presents challenges for AFHCAN and its partners when making connections between separate organizations and their networks, Moon says. While AFHCAN initially rolled out a “network of networks” for inter-organizational connectivity, the current focus is to develop a unified solution for naming conventions, addressing schemes and scheduling across organizations.Connectivity is not the only challenge though. In a December 2011 IDC Health Insights report, the Framingham, Mass.-based research firm found 32 percent of respondents cited data security as an obstacle to telehealth, in addition to cost, which again, 32 percent stated cited as an obstacle. However, as the value of telehealth is demonstrated to a community, organizations may be more willing to foot some of the bill. Of the 108 counties serviced by Texas Tech University Health Sciences Center (TTUHSC), 22 have no physicians, 32 no hospitals and 75 percent of the region lives more than 90 miles from a comprehensive trauma hospital.
“Ninety-eight of those counties are considered rural and more than 50 percent are considered ‘frontier,’ meaning they have less than seven people per square mile,” says Debbie Voyles, MBA, director of telemedicine program at TTUHSC. With more than 400 patients per month treated for different specialties, including pulmonology, mental health and dermatology services, she says cutting driving time in favor of more frequent care proves value.
After grant funds ran out from a 2009 Children’s Healthcare Access for Rural Texas project, nine of the community clinics decided to take on the cost of DSL line connections and lease the telehealth equipment from TTUHSC. Also, it doesn’t hurt that the cost of technology is decreasing. When TTUHSC began their telehealth services in 1990, capabilities cost upwards of $100,000, but now, a high-definition videoconferencing unit costs approximately $35,000, says Voyles.
Costs vary with medical carts depending on the included equipment and their respective manufacturers. In Voyles’ $35,000 range, the peripheral devices make up most of the costs. The digital otoscope that TTUHSC uses comes with a price tag of $11,000, for example.
Lack of reimbursement amplifies telehealth’s cost barrier. However, the Centers for Medicare & Medicaid Services (CMS) is slowly changing the Physician Fee Schedule to reflect modern mobile clinical settings. The 2012 Physician Fee Schedule addressed changes to payment policies to ensure payment systems are updated to reflect changes in medical practice and the relative value of services. According to the final rule, CMS requires that telehealth services be equipped with an interactive telecommunications system, defined as a multimedia communications device which includes, at minimum, audio and visual equipment permitting two-way, real-time interactive communications between a patient and a practitioner at a distance site.
Currently, “Medicare telehealth services may be provided to an eligible telehealth individual notwithstanding the fact that the individual practitioner providing the telehealth service is not at the same location as the beneficiary,” reads the published rule. “An eligible telehealth individual means an individual enrolled under Part B who receives a telehealth service furnished at an originating site.”
According to the rule, certain services commonly furnished remotely using telecommunications are covered and paid the same as services delivered in person. The patient is not required to be in the same place as the practitioner.
However, a large part of who pays for telehealth services varies by region, and third-party payors are beginning to enter into the reimbursement game. David Guggenbuehl, RN, MBA, director of regional services at Gundersen Lutheran Health System (GLHS) in La Crosse, Wis., says GLHS is “fortunate” that payors like Blue Cross Blue Shield of Wisconsin are reimbursing for telehealth services. GLHS provides telehealth specialty services—including endocrinology, cardiology, medical oncology and radiology services—across 22 regional sites via a medical cart with capabilities including videoconferencing and digital cameras.
Additionally, Medicaid regulations vary by state and not all state programs, such as Wisconsin, pay for telehealth services. In Texas, eligible areas including rural counties (less than 50,000 population) and medically underserved areas are eligible for Medicaid telehealth service payments. Eligible medical services include consultations, office or other outpatient visits, pharmacologic management and psychotherapy. Texas insurance code generally requires health coverage providers to treat telemedicine consults as if they had occurred in a face-to-face environment, says Voyles.
But even if cost is overcome, other problems persist. “The No. 1 challenge is changing the culture of the way physicians practice,” says Guggenbuehl. Serving a half million people within a 100-mile radius around La Crosse, he notes that change management can be difficult as physicians put aside their traditional training. “There’s a learning curve on the clinical side when you don’t have your hands on the patient. Physicians have to be willing, able, interested and somewhat energetic to participate in these services.”
In addition to culture change, executives need to plan out their IT infrastructure before jumping into a telehealth initiative. “The rural environment is challenged in getting broadband circuits to supply the infrastructure needed,” says Brock A. Slabach, MPH, senior vice president of member services at the National Rural Healthcare Association, who adds that infrastructure foundation is critical and advises a 1GB circuit as the ultimate goal.
As adoption increases and cost goes down, more citizens in rural communities may soon be the beneficiaries of modern technology and telehealth services. Seemingly, there ain’t no mountain high enough; ain’t no valley low enough and ain’t no river wide enough to keep telehealth from getting to quality care.
| What goes into a telehealth cart? | ||
|
