Strategies, goals key to telehealth success

BOSTON—Healthcare delivery organizations across the country have varied experience with telehealth and varying levels of success, according to a panel discussion during mHealth + Telehealth World 2014.

Boston Children’s Hospital (BCH) first launched telehealth three-and-a-half years ago, said Naomi Fried, PhD, chief innovation officer. The hospital has run several pilot projects including tele-concussion, teleretinology and teledermatology.

The University of Virginia (UVA) Health System connects to more than 100 sites and offers clinical services remotely in 45 specialties, said Karen Rheuban, MD, medical director of the organization’s Office of Telemedicine. They’ve also had remote patient monitoring in effect for almost a year. Working with other state agencies, Rheuban said she and her team have worked hard to get equal reimbursement for telemedicine services. “We try to make it sustainable every day.”

CHRISTUS Health, headquartered in Irving, Texas, has a team responsible for connected care, according to Luke Webster, MD, CMIO. The organization does a fair amount of telestroke work and is working on teleconsultative arrangements with pediatric subspecialties. They also conducted a remote patient monitoring pilot, which was met with skepticism until they saw the return on investment. Based on that, CHRISTUS leadership is more engaged in expanding that effort.

The panel was asked how important it is to have a strategy when launching telehealth services. Webster said “it’s more important what we say no to than what we say yes to. Now that there’s a great deal of interest, there is the temptation to try to do everything and do it quickly.” Instead, they pulled back and brought in outside help to develop an overall strategy for connected care. The primary tenet of the strategy is that any service be self-sustainable.

“My position has always been that access through telemedicine should be the same as a phone call or entry to the emergency department,” said Rheuban. UVA’s CEO wants more of a strategy but she said she doesn’t ever want to say no to a patient. Seven-eighth of telemedicine patients have a payer source, which makes it sustainable.

“Strategy is absolutely vital,” said Fried. “It’s your game plan. You need to know where you’re going and why and how you’re going to get there.” By engaging physicians, BCH was able to build a consensus around its strategy. But that’s not enough. “How you implement the strategy is vital. It was important to have clinical champions. Doctors are the thought leaders so we needed to connect with a clinical champion every time because they understood what it would take to move forward.”

Fried also said clear goals are helpful. That led to targeted apps designed to improve clinical efficiency. Leadership liked knowing that efforts were meeting goals and planning for the future, she said. “It’s so important to engage leadership. Without their support, we could not have moved forward on executing our strategy.”

Webster said CHRISTUS has tried to partner with state advocacy organizations and the Texas Medicaid group “now enables us to reimburse for remote monitoring for two conditions.”

“It’s so important to advocate,” said Rheuban. She said organizations should work with a wide variety of stakeholders because “when you want to get legislation passed, you don’t want to just be a band of telehealth providers.”

Reimbursement and payment are the biggest challenges in telehealth implementation, said Fried. But, because medicine is a regional activity, “the environment in your state really determines your telehealth experience.” BCH has taken the discussion directly to payers and got the whole gamut of responses, she said. “It’s challenging to deal with that kind of environment but we don’t have a choice. We’re working on all fronts with all possible partners on payment.”

When asked about the importance of return on investment, Webster said, “no margin, no mission.” However, “evaluating an ROI can be exceedingly complex.” There’s also concern that if CHRISTUS does a great job but isn’t aware of it in advance, they could negotiate contracts in which the payers reap the financial rewards instead. Going forward, their strategy will include robust methodology for ROI assessment, he said.

Fried said once hospitals think about total cost of care, “they’re very interested in engaging in telehealth.” Changing care models are serving as major motivators, she said. With providers taking on financial risk, they need to consider lower cost methods of delivering care. You want to start building telehealth programs now.”

Rheuban recommended keeping track of miles saved. Virginia spent $70 million on emergency transports last year and its corrections department spends a lot of money on security when transporting inmates for healthcare.

Aside from hard numbers, Freid said many telehealth programs result in better quality and better outcomes for patients. Many concussion patients weren’t coming back for their six-week follow-up appointment to ensure that they could safely return to sports and other activities. Physicians asked for telehealth visits at the six-week mark to better engage patients. “Now we have a much higher rate of compliance. This is an example where a telehealth program can lead to long-term better quality of care because of better patient convenience and compliance.”

Fried also cited an incident when a child in a community hospital aspirated a pretzel. The care team there didn’t know how to care for him so they were able to get advice from BCH doctors. “I’m not sure that child would have made it had we not been able to provide that guidance.” They sent out their specialty care ambulance and brought the child back to BCH where an operating room was ready. “Having a success like that was catalytic for the rest of the clinicians. They saw the impact of their consultations to clinicians at another hospital. That carried that whole department over and made people really appreciate the benefit and opportunity of telehealth.”

"These technologies are fantastic,” said Webster. “We’ve seen absolute improvements in quality and efficiency with positive ROI. They’re here and it’s our job to do them well. We need to continue to step up.”

“The future is about telehealth,” said Fried. She said other providers should not feel like they’ve missed out if they haven’t started yet. “Look toward the future and think about how telehealth can empower your organization.”