Telehealth Gets Connected

Telehealth may not be a cure-all for what ails U.S. healthcare, but this is an area where health IT is already answering the call for increased access and lower-cost care delivery, powered by federal money and technology initiatives, and by improvements in wireless networks, data compression and remote patient monitoring.

Converging demographics—more patients with harder-to-treat conditions and a continuing decline in the number of primary care physicians—are also factors. By 2020, according to the American Academy of Family Physicians, about 140,000 PCPs will be needed to meet the needs of the aging U.S. population, but trends indicate there might be only 100,000.

Vendors are taking the telehealth bet. Research firm Pike & Fischer predicts telemedicine devices and services will generate nearly $3.6 billion in annual revenue within the next five years, according to a 2009 report. Wireless applications, devices and services will account for more than 70 percent of market spending within five years, according to the report. In addition, Juniper Research predicts that revenues from remote patient monitoring via mobile networks will be close to $1.9 billion globally by 2014. Heart-based monitoring in the U.S. will account for the bulk of early mobile monitoring rollouts, Juniper predicts.

There’s a lot left to do: Many states are taking action to address reimbursement and credentialing—two of the biggest challenges for telehealth programs. A dozen states now have laws on the book requiring insurers to reimburse for services provided via telemedicine. Several states are working to enable physicians credentialed to practice telemedicine in one state to do so across state lines. Meanwhile, telehealth programs are helping physicians deliver care to patients who otherwise might face delays and complications, or might not get it at all.  

Timely intervention saves hearing

Medical care in Alaska, the most rural state in the nation, presents special challenges: Getting a specialist to a remote town or a patient to a hospital often means a costly, potentially risky plane ride, says Stewart Ferguson, PhD, Director of Telehealth at the Alaska Native Tribal Health Consortium (ANTHC), in Anchorage. ANTHC co-manages the Alaska Native Medical Center (ANMC), which provides statewide services in specialty medical care.

The Consortium’s Alaska Federal Health Care Access Network (AFHCAN) telehealth program started providing clinical care in 2001 as an initiative of the Alaska Federal Health Care Partnership. The vision for AFHCAN was to deploy sustainable telehealth solutions at every site in Alaska that serves Federal health beneficiaries (including Alaska Natives, active military personnel and veterans), says Ferguson. Approximately 250 sites, including 162 village clinics, now use the AFHCAN telemedicine system. Most sites are equipped with a portable cart containing a power system, computer, video otoscope, ECG, stethoscope, scanner, digital camera, and possibly other devices (such as dental camera, vital signs monitor). The system uses broadband and satellite links to connect patients and healthcare providers.

AFHCAN’s platform uses a store-and-forward model that allows separate organizations to manage and control all health information, Ferguson says. A PC in a remote community captures patient data from a variety of medical devices, and stores the data if the PC is offline. When the PC has connectivity, the data is transmitted to the organization’s server. At that time, providers are notified to look at the data, he says.

“For most of our partners in Alaska, each organizational server communicates with servers at other organizations to share data… That’s the way we’re able to help the Tribal partners in Alaska that manage clinics, to send cases to Anchorage to the tertiary care facility [ANMC],” Ferguson says. AFHCAN servers use a Microsoft SQL Server database platform on the back end; clinicians and consultants have a web-based front end where they log in, look at cases and respond.

Ear infections and hearing loss, especially in very young children, are a problem in Alaska’s Native community, says Ferguson, and telemedicine has enabled faster access to care. Phil Hofstetter, an audiologist in Nome, conducted a study that demonstrated prior to telemedicine almost 50 percent of new referrals waited more than four months to see a specialist in Nome because specialists (and many patients) had to fly in for the visits, says Ferguson.

After the agency started using telemedicine to obtain consults and triage those patients in 2001, Hofstetter found the percentage of patients who had to wait more than four months to see a specialist dropped from 50 percent down to 3 percent today, according to Ferguson.

“At the same time, the number of patients who are actually seeing a specialist went from 200 to 600 [per year], so more people are seeing a specialist through telehealth,” he says.

“We have anecdotal data from specialists that we have saved hearing in children … [because] we’ve been able to intervene in a timely manner,” he says. “Thanks to the commitment of providers such as Dr. John Kokesh, Chair of the Ear-Nose-Throat Department at ANMC, telehealth has been able to make a significant impact on the treatment and care for patients with ear disease in Alaska.”
“Now the cardiology department is starting to do post-surgery follow-up on their heart patients. They can actually follow up through videoconferencing and have live stethoscopy so they can listen to heart and lung sounds live all the way from the village to Anchorage,” Ferguson says.

The AFHCAN telehealth system saves about $3 million in travel costs for patients annually, according to Ferguson. And “when you save travel for patients, you’re saving hardship and reducing the risks associated with travel in Alaska’s inhospitable weather and terrain,” he says.

“We’ve looked at all the patients [for whom] we received Alaska State Medicaid reimbursements. The Alaska Native Medical Center billed about $250,000 to Medicaid over five years, but when we look at all the patients who were served, we estimate that for every $1 Medicaid spent on reimbursing for professional fees, they saved somewhere between $8.80 to $12 in travel costs,” says Ferguson. “The cost savings just for Medicaid patients are about $2 million to $2.5 million in travel savings for $250,000 payments in professional fees.”

The AFHCAN system has been deployed to several states in the lower 48 through the Indian Health Service, according to Ferguson. AFHCAN also is working with AMD Global Telemedicine to distribute its technology internationally to sites in the Caribbean, Greenland, school-based clinics in Ohio and U.S. prison systems, he says.

Getting the picture in Maine

In the past five years, Eastern Maine Medical Center (EMMC) has developed a nationally recognized tele-ED trauma program and pediatric intensive care network that links 11 regional hospitals in Northern and Eastern Maine, mostly small rural critical access hospitals, to EMMC, says Robert Holmberg, MD, MPH, pediatrician, director of Clinical Outreach and Telemedicine  at EMMC, in Bangor.

Mobile wireless Tandberg videoconference units in these regional rural hospital EDs link via IP connection to EMMC’s trauma surgeons and pediatric intensive care services, who are on call 24/7 for tele-trauma or PICU consultation service.

The tele-ED program now provides five to 10 consults a month, according to Holmberg, and it has been an invaluable specialty service to the ER teams in the very small critical access hospitals in the EMMC telemedicine network. Some of these hospitals average no more than 15 patients per day, have small staffs and usually no specialty staff, and do not provide 24/7 coverage.

“The anecdotal evaluation data are really what’s most remarkable—[they’ve] been so effective in supporting the rural hospital ED staff, who oftentimes may be a PA, nurse practitioner, or a community family physician who’s cross-covering the ED and their practice,” says Holmberg. “These are people who are not living in an ED with high volumes of trauma and pediatric emergencies every day, so it’s been tremendous professional support mechanism for them.”

The system has been most helpful in several areas, including support of the initial triage management and decision on whether a patient should be transferred and how. “[For] that kind of decision-making, it’s been tremendous. And from the professional support, we’ve actually done pediatric codes with the assistance of the pediatrics ICU doc in the middle of the night, connected from [his or her] home,” Holmberg says.

“I’m a true believer that the connection via telemedicine of a rural hospital to a regional tertiary care referral medical center like ours is really the answer to providing good quality, updated emergency care in rural areas and recruitment [and] retention of staff,” says Holmberg. “One of the biggest difficulties in getting providers to practice in rural hospitals is the professional support isolation, and their skills can atrophy so fast when they don’t see the volume [of patients]. I see real-time telemedicine consultation as having a major role in ongoing training and skills maintenance in rural medicine.”
EMMC plans to implement a dedicated telemedicine unit in the ambulatory care facility for telemedicine post-surgery follow-up, enabling patients to check in by video as needed. “Instead of driving three hours for a 15-minute visit, they can be connected by telemedicine,” says Holmberg.

‘High-flyers’ head home

A general lack of implementation guidelines for home-based telehealth care systems is not stopping vendors or practitioners from deploying systems. “We’re doing a lot of things with the goal of keeping patients out of our ED,” including home-based telehealth, says George Conklin, senior vice president and CIO of Christus Health, a faith-based healthcare network with headquarters in Dallas that has hospitals in Texas, Lousiana, Arkansas, Georgia, Missouri and New Mexico, and seven facilities in Mexico.

Christus Medical Group is establishing a virtual clinic environment that will focus initially on Louisiana and will eventually be deployed to other areas, says Conklin. If physicians are licensed to practice in Louisiana, they would be able to deliver service remotely through Christus’ telemedicine networks, says Conklin.

In the San Antonio area, Christus’ home health organization has been using remote monitoring capabilities on patients, “which would generically fall into the class of telemedicine,” Conklin says. “They’re not using videoconferencing, but they have devices in the patient’s home [so] patients could put information into it themselves. In addition, medical devices—for example, a cardiac monitor—could connect to a hub in the patient’s house, and transmit data back for the service to be able to manage, and they contact our home health people if it looked like a patient might have a problem.”

Christus has used some telehealth techniques to develop a medical home initiative jointly with a number of other organizations for Corpus Christi, Texas, to keep “ED high flyers” out of Christus Spohn Memorial Hospital, the City Receiving Hospital emergency room, says Conklin.

Memorial’s ED was “packed with people whose [chronic conditions] had gone wild,” he says. “We did a study, found the ED high fliers as our target population” and created a community-health-worker-based medical home program. In this pilot program, community health workers met with the patients, put them on treatment protocols, looked at the broader family issues and social constructs around the patient, and then followed them.”

Medicity’s iNexx app development platform enabled Christus to build a medical home application for its EMR, a web-based system carried across the Medicity Novo Grid Health Information Exchange [HIE], says Conklin.

Community health workers have been using that app to monitor and record information about their patients. “We’ve seen a significant reduction in ED volumes among that high-flyer population and we are now pushing that down into any kind of chronic disease exacerbation that appears in the ED, so that we can more effectively manage those populations in the community,” Conklin says.

The EMR-medical home connection

Some of the technology driving telehealth is also driving new modes of service delivery in less remote areas. The patient-centered medical home care model enlists EMRs, remote monitoring equipment and high-speed connectivity to deliver better care to patients living with chronic conditions such as diabetes and congestive heart failure.

Potomac Physicians P.A., a seven-office, 38-physician group in Maryland, leveraged internet connectivity and its Aprima EMR to become the nation’s first National Committee for Quality Assurance (NCQA)-designated medical home practice, says Carol Reynolds-Freeman, MD, Medical Director, Potomac Physicians P.A. “Once we implemented our EMR … we were able to consider services that our patients needed based on best practice guidelines that we had incorporated into our EMR,” says Reynolds-Freeman.

Potomac Physicians reviewed the NCQA Medical Home tool as a way to provide more in-depth, comprehensive patient care, says Reynolds-Freeman. The NCQA tool is a list of requirements, “but these requirements can be very hard to meet—they’re requirements about organization, provision of care in very specific ways,” she says. NCQA requirements include a way to track populations, to track referrals, medication profiles, prescriptions, and to organize that information. “Being a medical home is not static, it’s a very dynamic process, and it’s hard to maintain,” says Reynolds-Freeman. “It takes some time to get your practice going in that direction.”

Potomac Physicians implemented the Aprima (formerly Imedica) EMR in 2006 and 2007; the practice was recognized as the first NCQA-certified Medical Home group in April 2008.

When a patient with a chronic condition such as diabetes makes an appointment, a care coordinator accesses the patient’s EMR and checks whether the patient may be due or overdue for care. For example, the patient may be due for [ahemoglobin Alc test] because he or she has diabetes, or may be due for pneumococcal vaccine or flu shot. The care coordinator notes that in the EMR.

“When the patient checks in, the nursing staff can see this as well,” says Reynolds-Freeman. The EMR organizes this information in summary form in some places, and in another place, “it’s something that can flash at the top or side of your screen, called Health Maintenance Reminders, which prompts clinicians: ‘We want to be sure these things are evaluated,’ ” she says.

The physician designates which remarks are actionable by the nurse and which require physician input. “The physician will have already said to the nurse, ‘when you see these remarks, act on all of them except X. Always ask me about X before you act on it for the patient or these particular patients.’ Because everything is not just an assembly line, there are personal things and individual patient-specific items that often need to be evaluated,” Reynolds-Freeman says.

“So this patient who’s 65 with diabetes, [is] coming in because her shoulder hurts. We have information that suggests we can do more, better, than just evaluating the shoulder—so let’s do it.”

Designated office staff manage the referral process within the EMR, tracking key referrals. At Potomac Physicians, the referral coordinator tracks all first cardiology appointment referrals and makes sure appointments are completed within a defined time frame. “That may mean periodic calls to the patient and confirming the appointment and visit with the cardiology office,” Reynolds-Freeman says.

“The application sits on servers and we can log in and authenticate to the servers from wherever we are. It didn’t reduce work at all, but [now] we can, in a secure fashion, be at home and reviewing more [information] about our patients” Reynolds-Freeman says.

The Potomac Physicians system was put to the test last winter. “We had four feet of snow in the course of a couple of weeks,” says Reynolds. “Even if we couldn’t make it into the office, we were still able to get refill requests on medications from the pharmacies, we were able to send those refills to the pharmacies so our patients could still get their medicine. If we didn’t have the EMR, we couldn’t do that.”

“Patient-centered medical home is not so much a transformation of care; more of a rejuvenation,” says Reynolds-Freeman. However, “technology is not a panacea. Sometimes it can make things so easy it can become less personal, and we have to continue to struggle to keep it all personal.”