Rural Telehealth A Rising Star

The healthcare industry is transforming at a brisk pace. There are many unknowns but rural telehealth is a sure bet as organizations seek to improve access to care and better manage their patients.

Some 42 percent of U.S. hospitals have implemented telehealth platforms—with the highest levels of adoption occurring in rural areas, according to research published in Health Affairs. In the study, The Center for Connected Health, University of Michigan and Brigham and Women’s Hospital researchers found that state reimbursement policies and local competition directly impact adoption rates.

“I thought we were going to have a flood, but we have a tsunami in telemedicine this year,” says Jonathan Linkous, CEO of the American Telemedicine Association. “It’s happening so fast, we’re running to keep up with it.”

Focus on children

Tift Regional Health System in Tifton, Ga., is a telehealth frontrunner, operating several rural telehealth programs including programs providing telehealth at schools, an ADD and autism clinic, an emergency department stroke program, a program for patients undergoing kidney transplants, a geriatric psychiatric program and a program where patients can reach a provider 24 hours a day.

“We believe in telehealth. We believe it’s the future,” says Jeff Robbins, director of the organization’s telehealth effort.

Tift Regional completely funds and operates telehealth services at two schools, with another school system soon to join. On an on-demand basis, five physicians see students and provide remote wellness visits for both students and teachers, which keeps them in school, he says.

“We’re connecting families for the very first time with doctors who know the child. Then you start to deal with issues like obesity and diabetes, which all can be incorporated into telehealth,” he says.

A telemedicine unit allows physicians to remotely control scopes to peer inside a child’s throat, magnify a wound, look into an ear or nose, or listen to the heart—all from thousands of miles away, Robbins says. “Except for touching, there is nothing that the units can’t do.”

The units typically cost about $10,000, but Tift Regional owns more sophisticated units that run close to $40,000, he says.

In the health center’s five-year old stroke program, patients who present in the emergency room are connected to neurologists in the Medical College of Georgia in Augusta, who determine whether tissue plasminogen activator needs to be administered. “That changes lives right there,” he says. “That’s determining whether someone leaves the hospital walking or not walking. Instead of going to the nursing home, they go back to work.”

The ADD and autism clinic annually works for 600 children who often don’t have access to psychiatrists, endocrinologists, geneticists and other specialists. Some live more than three hours away, making monthly appointments challenging in terms of finding quality transportation and taking time off for caregivers. The program especially has impacted children from families with limited means, Robbins says.

Finding & Training Physicians

Telehealth is not a money maker for Tift Regional. But, if providers do not buy into it now, they will struggle down the road when patients seeking telehealth will prioritize organizations that already have the units, providers and connections in place, Robbins says.

In the meantime, the great stumbling block for telehealth is access to physicians, especially ones who will act as telehealth champions. The average salaried doctor already is so busy, it’s tough to convince him or her to add to their workload, he says. “We try to find doctors who want a new challenge and see that telehealth is the future.”

A program at the University of California at Davis (UC Davis) School of Medicine successfully leveraged telehealth to train rural clinicians to deliver better care to their own pediatric obesity patients.

The Center for Health and Technology, the UC Davis Children’s Hospital, and the faculty from the UC Davis School of Medicine’s pediatric telemedicine program has provided more than 5,500 telemedicine consultations to children across California.

UC Davis was grappling with a flood of rural pediatric patients seeking telemedicine services. Patients were waiting two to three months for a telemedicine visit, according to Ulfat Shaikh, MD, MPH, MS, associate professor of pediatrics and director of healthcare quality at UC Davis School of Medicine.

To address demand, UC Davis launched a nine-month pilot, HEALTH-COP (the Healthy Eating Active Living TeleHealth Community of Practice)—a virtual learning and quality improvement network that utilized video conferencing and other methods to train clinicians at seven rural clinics on pediatric obesity care. The pilot not only resulted in measurable improvements in care delivery but patient outcomes as well.

In the pilot, rural clinicians learned how to better assess patients’ weight; provide counseling on nutrition and physical activity; reorganize clinics to provide better care; screen for risk factors; and implement strategies to effectively discuss body weight. Every month, for 90 minutes, clinicians from the seven clinics signed onto the network to discuss best practices and exchange strategies for improvement, according to Shaikh.

During the pilot, researchers contacted parents or guardians of the 228 children seen for well-child care visits both two to three days after their clinic visit and after the HEALTH-COP program ended. From these surveys, the researchers determined that the children both improved their diets and increased their physical activity.

Also, clinical materials, education and peer support significantly impacted care, with clinicians receiving higher scores on their abilities to document their patient’s BMI and other weight measures, counsel patients and families and provide family-centered care.

“I was not surprised by results that clinics changed practices when screening for obesity but I was cautiously optimistic about behavioral change,” says Shaikh.

Telehealth Resources

Indiana Rural Telehealth Association’s Upper Midwest Telehealth Resource Center (UMTRC)—which oversees Indiana, Illinois, Michigan and Ohio—is among 14 telehealth resource centers funded by the Health Resources and Services Administration’s Office of Rural Health Policy to provide technical assistance to providers.

The most common inquiries involve locating a provider, equipment advice and questions on policy and reimbursement, according to Becky Sanders, UMTRC director of operations.

While Medicare is nationwide, Medicaid differs state-to-state and varies depending on where the patient resides and the type of facility. Private payers most often will pay for telehealth, she says.

Reimbursement between states varies so significantly, it is challenging for providers to keep up.

So far in 2014, 30 states have introduced legislation to expand telemedicine either by allowing or requiring private payers to reimburse such services, or expanding Medicaid to include telemedicine. In the meantime, several bills are circulating in Congress to ease physician licensure requirements and expand reimbursement, according to Linkous.

As this issue went to press, Congress was slated to act on a physician payment reform bill that would expand the geographic footprint of rural areas eligible for reimbursement.

“States are moving faster than the federal government on this,” Linkous says. With so many newly enrolling in Medicaid under the Affordable Care Act, he says many states are looking for cost-effective ways to deliver care.

The complexity of telehealth also is spurring a need to better define a quality program. ATA soon will unveil an accreditation program to help payers, consumers, regulators and providers better identify which telehealth programs meet certain criteria.

With the regulatory space ripe for change, and pilots showing that effective, cost-effective ways to better deliver care are within reach, the momentum for rural telehealth has just begun.