Supporting Value-based Care: UPMC’s Telehealth Strategy

Can a physician adequately serve multiple patients—in four or more different locations—in the same morning? Andrew R. Watson, MD, MLitt, FACS, knows the answer is yes because he has done it. Executive director of telemedicine for the University of Pittsburgh Medical Center (UPMC), and a practicing colorectal surgeon, Watson has found that his real world experience prepares him well for the naysayers—but patients are not among the skeptics.Because they don’t have to travel, patients love telehealth, Watson reports. The idea of asking patients whether they want to come into the clinic is still anathema, but Watson anticipates that ethos will eventually change. “We assume the face-to-face visit is necessary, but that is an assumption that’s never been scientifically tested,” he says. “If you separate patients and providers using state-of-the-art technology, is that good enough? The early results are a resounding yes about 90% to 95% of the time.” UPMC—with 400 care locations, 22 hospitals, 4,500 physicians, and 1.9 million members in its insurance plan—already has rolled out several remote specialist clinics, emergency services, telepathology, teleradiology, and tele-anesthesiology. As its telehealth strategy unfolds, UPMC is preparing for the next evolutionary step: virtual care for the monitoring of chronic conditions. Underpinning the initiative is a broad—and vital—IT foundation designed to support patient-centered, value-based accountable care. With roughly 20% of the US population residing in rural America and only 11% of specialists choosing to practice there, telehealth can both broaden access for patients and open new markets for providers. “You can take the expertise of specialists—but, more importantly, primary care physicians—and distribute it throughout a very large geography without the inefficiency, time delays, and inherent risks of traveling,” Watson says. Even in a world transformed by the Internet and smart phones, many colleagues in the medical profession still scoff at the idea of telehealth and/or telemedicine, insisting that the cloud is no substitute for hands-on care. “The greatest challenge is provider cultural change,” he says. While the cultural change is a sizable barrier, an equally large hurdle is understanding the financial model behind telemedicine. “People are focused on fee-for-service billing, but what’s actually important is the concept of cost avoidance,” Watson explains. “It requires working with payors and managing patients over time as part of a population, instead of as a single episodic encounter. In the broader sense, it is fairly straightforward.” In his own practice, Watson practices telehealth via telerounding, and pre- and post-surgical teleconsults. He also serves as medical director for UPMC’s Center for Connected Medicine. Rasu Shrestha, MD, MBA, vice president of Medical Information Technology at UPMC, admits that telehealth has not yet emerged as a big win for organizations looking for a sustainable reimbursement model. Since UPMC is both a payor and a provider, its situation is somewhat different than other entities. “Our health plan has been working directly with our provider organizations to pay for more than 100 specific types of conditions that we are leveraging via our e-visit model,” explains Shrestha, medical director for Interoperability and Imaging Informatics at UPMC and a radiologist. “We are able to reimburse directly to the physicians for the remote care we are providing. We’ve been continually increasing the specific types of reimbursements that are being provided for a wide variety of disease processes.”

Telehealth Characteristics

• Patient-centric, not application-centric

• Coordinate care across collaboration teams

• Improve access through ubiquitous information and knowledge reach

• Applied semantics through natural language processing (not just human insight)

• Preventative (rather than corrective)

• Value, not volume, based
—Watson and Shrestha

Patient-centered Accountable Care Overseeing the big picture for UPMC’s telehealth initiatives has motivated Shrestha to focus relentlessly on what actually works, and the cloud is working. “We have the capability of pushing forward with software as a service or platform where entire applications can be pulled up to the cloud and made available to any end user,” he explains. “We also have infrastructure for remote data storage networks. You have dependability in terms of the service across wide geography.” At this point, he is leveraging the Internet and telephones to connect clinicians with patients via three focal points, the first of which is live surgical consults via telemedicine called tele-stroke, a brain saving program that provides real-time feedback. UPMC is putting suspected stroke patients “virtually” in front of a specialist, who in turn could be located in any of UPMC’s care centers. “We can connect directly to any of our rural clinics or hospitals where we have these telemedicine capabilities,” he says. The program is saving lives and brains by starting the treatment process more efficiently than in the past. A second program called “store and forward” acts something like teleradiology, but UPMC insources these services to its own radiology group. “A patient in rural Pennsylvania experiencing a seizure needed an immediate MRI evaluation,” Shrestha explains. “It needed to be read by a neuroradiologist, and they are not available everywhere. The scan was done in the patient’s hometown, and we were able to immediately electronically ship the radiology content to our teleradiology group. In a manner of seconds, our specialist here at Presbyterian Hospital viewed the study, provided full interpretations, and sent a report back to that remote area.” Evolving to Virtual Care The UPMC telehealth also will implement remote ICU monitoring and/or in-home monitoring for a number of different chronic conditions, marking the organization’s progression from telemedicine to what Watson and Shrestha call virtual care. In a presentation at this year’s Health Information Management Systems Society conference in New Orleans, Louisiana, on March 6, Watson and Shrestha reported that remote monitoring at the Ontario Telemedicine Network yielded a 72% decrease in emergency department visits, and a 95% decrease in walk-in visits. Congestive heart failure (CHF) presents the greatest opportunity to leverage telehealth for chronic care—with less emergency department utilization and fewer walk-in visits as two primary benefits. “CHF can be extremely effectively managed using remote monitoring in patients’ homes,” Shrestha enthuses. “Chronic diseases are best managed through coordination, and we need to better understand how to get specialists to sit in the cloud and coordinate between different locations. The VA hospital is trying to put 20,000 primary care visits into patient homes this year; we also are trying to meet our consumers where they are.” The IT Interoperability Challenge To achieve robust virtual care via the telehealth platform, IT interoperability is a must. “The clinical endpoint decision lies specifically in the bits of information hidden away in multiple different EMR platforms,” Shrestha says. “Patients often have records in a number of different EMRs across organizations, perhaps even in multiple states. To make informed decisions, you must have interoperability as a foundation. At UPMC, we connect 45 different clinical source systems to our interoperability platform. We aggregate the data from all of our different source systems, then semantically harmonize the data.” Monitoring medications from different EMR systems, UPMC clinicians are able to look at baseline codes for each medication and match them up, all while checking drug interactions and adverse affects. “We are then able to publish this on the cloud,” Shrestha enthuses. “When you have that interoperability platform, you can handle these challenges.”

What Is Cloud Computing?
The National Institute of Standards and Technology (NIST) summed up cloud computing as “a model for enabling convenient, on-demand network access to a shared pool of configurable computing resources (networks, servers, storage, applications, and services) that can be rapidly provisioned and released with minimal management effort.”

As for the specifics of cloud interaction, Shrestha relies on what he calls location-independent resource pooling to take different applications, put everything on the cloud, and make it instantly available—not just in a specialty environment, but also in a remote area. “As long as there is connectivity, you’re able to give the same level of service, platform, and infrastructure as what you enjoy in any tertiary care center,” he says. “That level of agility, elasticity, and reliability is what cloud computing enables for telemedicine, and that is what we are pushing forward here at UPMC.” For Shrestha, the telehealth phenomenon blends nicely with today’s focus on accountable care. As volume-based health care gives way to value-based care, telehealth can facilitate that transition. “In reality, with accountable care and accountable care organizations, the transition is already happening from volume-based to value-based health care,” he says. “The newer care models are less about pay for performance, and more about shared cost models and revenue sharing between care collaborators—all while ensuring a tight-knit community around patients. These newer care and pricing models reflect the changing times.” Despite UPMC’s success in the telehealth arena, Watson cautions that it will likely still be a while before physicians buy in en masse. “People are concerned that it is not a good form of care,” he laments. “We thought that hand washing was bad in the 1880s. We thought antibiotics were bad in the 1930s. We thought laparoscopy was bad in the 1990s. In 2013, providers need to understand that telehealth innovation is solving problems. We live in a digital society, and society is evolving with the cloud. It just makes sense.”

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Greg Thompson is a contributing writer for Health CXO.