Urban Telehealth: Ready to Fly?
Despite promising results from pilot programs among underserved populations in urban areas, telehealth hasn't taken off. The barriers aren't always technical: for example, telehealth has been something of a regulatory afterthought until quite recently. What will it take to get from promising pilot programs to widespread use?
A January 2009 report from California Telemedicine and eHealth Center (CTEC), a nonprofit telehealth/telemedicine resource center in Sacramento, found that:
All of these beg the question: "If telemedicine is so great, why isn't it more widely available?" asks CTEC Executive Director Christine Martin. One piece of the answer is reimbursement. "Reimbursement needs to be available for a broad spectrum of telehealth services," Martin says.
Telehealth has the potential to significantly change the way healthcare services are provided and received, according to Martin. "CTEC found that estimates of a full deployment of telemedicine nationally would create savings of $4.2 billion annually," she adds.
However, telehealth will not achieve maximum financial benefit until it is fully deployed across all levels and settings of the U.S. healthcare continuum, says Martin. Yet deployment is hindered by, among things, a higher burden of proof for clinical efficacy and cost effectiveness than more conventional care delivery, the center notes. Although this burden limits telehealth implementations today, CTEC predicts consumer demand will drive full deployment of telehealth in the near future.
"It's been my passion that telemedicine is about access, not geography," says Alexander M. Nason, program director of Johns Hopkins Medicine Interactive and director of telehealth at Johns Hopkins Medicine in Baltimore.
Johns Hopkins Medicine has been expanding its telehealth presence in Maryland. For example, the organization has merged with Suburban Hospital in Bethesda and has fully integrated telehealth services with Johns Hopkins' Bayview Hospital in Baltimore.
By expanding services beyond the Beltway, Johns Hopkins Medicine is poised to harness telehealth services to support its growing market share. For example, the Bayview emergency department (ED) can access Johns Hopkins' pediatric intensive care unit (PICU) for consultation, education and training, Nason reports. Johns Hopkins has been running mock codes over videoconferencing and remote capabilities to the PICU, he says. "It's a small initiative, giving a taste of services within a small city's limits."
Johns Hopkins Medicine, like other organizations, is motivated at least in part by the Centers for Medicare & Medicaid Services (CMS) decision not to reimburse for patient readmissions within 30 days of discharge—as happens with conditions such as congestive heart failure (CHF). However, Nason also is excited about the possibility of using smartphones and smart scales to track and trend patients, harnessing chronic disease management to prevent readmissions. "That would ultimately be more beneficial to patients and a cost-savings to the healthcare system," says Nason.
One uniquely urban care issue that telehealth can assist in solving is provision of translation services to walk-in patients, according to Nason. In a small pilot program at Johns Hopkins in Baltimore, an interpreter was available all day via RP-7 robots (InTouch Health). In that program, an interpreter used a laptop with a joystick to drive a robot topped with a 17-inch monitor around the ED. The pilot program provided 24-by-7 translating services to patients, and interpreters could work from their homes.
"It was a great success and cut interpretation services time down by 65 percent," says Nason, who laments that Johns Hopkins stopped using the robots when the pilot program ended. Lack of funding to support the technology forced the program to cease. However, "as urban environments are becoming ethnically diverse, you're [going to be] seeing more need for this type of service," he predicts.
The lack of reimbursement also is hindering telehealth at Detroit Medical Center (DMC), says Leland A. Babitch, MD, MBA, CMIO at DMC, a 2,000-bed provider serving metropolitan Detroit and southeast Michigan. "The Michigan laws around telehealth, unless you're in a rural area, states that there's not a billable interaction," says Babitch. "You can charge a flat service fee to provide services and generate downstream revenue when they get sent for care. That's the best we can do in terms of payor recognition for reimbursements of telehealth."
One arena of telehealth market growth could be in prison systems, Babitch says. "It's expensive to move prisoners back and forth for [minor ailments] a lot of the time. If a prisoner complains of something that's deemed medically necessary to be seen, they get transported," he says. "Many medical conditions could be consulted over telehealth screen without the need to have two officers to escort the prisoner and risking injuries to multiple people."
DMC is exploring expanding its telehealth services now for Wayne County and its jail system, according to Babitch.
Getting these recommendations to the national level will be key to greater telehealth use, wither urban or rural. "Telehealth should be focused on access, whether it's getting healthcare access to a patient one or 100 miles away. There are still individuals with no access to care in an urban environment—for example, because they might have to take public transportation, and there might be a snowstorm or another unintended barrier," Johns Hopkins' Nason says.
A January 2009 report from California Telemedicine and eHealth Center (CTEC), a nonprofit telehealth/telemedicine resource center in Sacramento, found that:
- Home monitoring of chronic diseases is reducing hospital visits by as much as 50 percent by keeping patients stable through daily monitoring.
- The national average for readmission to hospitals within 30 days following a heart failure episode is 20 percent—yet some telehealth monitoring programs have reduced that rate to less than 4 percent.
- Timely provision of treatments that effectively reverse the consequences of stroke have risen from 15 to 85 percent due to the availability of telestroke programs.
All of these beg the question: "If telemedicine is so great, why isn't it more widely available?" asks CTEC Executive Director Christine Martin. One piece of the answer is reimbursement. "Reimbursement needs to be available for a broad spectrum of telehealth services," Martin says.
Telehealth has the potential to significantly change the way healthcare services are provided and received, according to Martin. "CTEC found that estimates of a full deployment of telemedicine nationally would create savings of $4.2 billion annually," she adds.
However, telehealth will not achieve maximum financial benefit until it is fully deployed across all levels and settings of the U.S. healthcare continuum, says Martin. Yet deployment is hindered by, among things, a higher burden of proof for clinical efficacy and cost effectiveness than more conventional care delivery, the center notes. Although this burden limits telehealth implementations today, CTEC predicts consumer demand will drive full deployment of telehealth in the near future.
'Access, not geography'
Nevertheless, researchers and CMIOs in urban, underserved areas are forging ahead with telehealth programs that will be ready to go if and when regulators deliver funding."It's been my passion that telemedicine is about access, not geography," says Alexander M. Nason, program director of Johns Hopkins Medicine Interactive and director of telehealth at Johns Hopkins Medicine in Baltimore.
Johns Hopkins Medicine has been expanding its telehealth presence in Maryland. For example, the organization has merged with Suburban Hospital in Bethesda and has fully integrated telehealth services with Johns Hopkins' Bayview Hospital in Baltimore.
By expanding services beyond the Beltway, Johns Hopkins Medicine is poised to harness telehealth services to support its growing market share. For example, the Bayview emergency department (ED) can access Johns Hopkins' pediatric intensive care unit (PICU) for consultation, education and training, Nason reports. Johns Hopkins has been running mock codes over videoconferencing and remote capabilities to the PICU, he says. "It's a small initiative, giving a taste of services within a small city's limits."
Johns Hopkins Medicine, like other organizations, is motivated at least in part by the Centers for Medicare & Medicaid Services (CMS) decision not to reimburse for patient readmissions within 30 days of discharge—as happens with conditions such as congestive heart failure (CHF). However, Nason also is excited about the possibility of using smartphones and smart scales to track and trend patients, harnessing chronic disease management to prevent readmissions. "That would ultimately be more beneficial to patients and a cost-savings to the healthcare system," says Nason.
One uniquely urban care issue that telehealth can assist in solving is provision of translation services to walk-in patients, according to Nason. In a small pilot program at Johns Hopkins in Baltimore, an interpreter was available all day via RP-7 robots (InTouch Health). In that program, an interpreter used a laptop with a joystick to drive a robot topped with a 17-inch monitor around the ED. The pilot program provided 24-by-7 translating services to patients, and interpreters could work from their homes.
"It was a great success and cut interpretation services time down by 65 percent," says Nason, who laments that Johns Hopkins stopped using the robots when the pilot program ended. Lack of funding to support the technology forced the program to cease. However, "as urban environments are becoming ethnically diverse, you're [going to be] seeing more need for this type of service," he predicts.
The lack of reimbursement also is hindering telehealth at Detroit Medical Center (DMC), says Leland A. Babitch, MD, MBA, CMIO at DMC, a 2,000-bed provider serving metropolitan Detroit and southeast Michigan. "The Michigan laws around telehealth, unless you're in a rural area, states that there's not a billable interaction," says Babitch. "You can charge a flat service fee to provide services and generate downstream revenue when they get sent for care. That's the best we can do in terms of payor recognition for reimbursements of telehealth."
One arena of telehealth market growth could be in prison systems, Babitch says. "It's expensive to move prisoners back and forth for [minor ailments] a lot of the time. If a prisoner complains of something that's deemed medically necessary to be seen, they get transported," he says. "Many medical conditions could be consulted over telehealth screen without the need to have two officers to escort the prisoner and risking injuries to multiple people."
DMC is exploring expanding its telehealth services now for Wayne County and its jail system, according to Babitch.
State by state
The expansion of reimbursement for telehealth began when Congress passed the Balanced Budget Act of 1997, which mandated that Medicare reimburse telehealth care and fund telehealth demonstration projects. However, state organizations are now doing much of the work of advocating for telehealth. For example, the Center for Connected Health Policy in February released a telehealth model statute for California, recommending ways to modernize state telemedicine and workforce laws and encourage adoption of telehealth technologies. The model statute proposed 13 recommendations in four categories:- Revisions to California's Telemedicine Development Act of 1996 (TDA), focusing primarily on financial incentives and informed consent: "Update the term 'telemedicine' used in current law to 'telehealth' to reflect changes in technologies, settings and applications, for medical and other purposes," the document read. Another recommendation was to remove restrictions in current telemedicine definition that prohibit telehealth-delivered service provided by email and telephone.
- Recommendations to incorporate telehealth into state workforce law: For example, "[r]equire the Office of Statewide Health Planning and Development (OSHPD) to develop and implement a plan to provide greater visibility for the State Health Workforce Pilot Project (HWPP) and require that OSHPD prioritize HWPP projects that utilize telehealth."
- Statutory recommendations to promote interoperability of technology and consumer education: Require telehealth equipment and software vendors who seek to contract with the state of California to show that their products comply with current telehealth industry interoperability standards.
- Recommendations on increasing research and education efforts in telehealth technologies: Require state activities related to health IT/HIE to explicitly include telehealth representation, for example.
Getting these recommendations to the national level will be key to greater telehealth use, wither urban or rural. "Telehealth should be focused on access, whether it's getting healthcare access to a patient one or 100 miles away. There are still individuals with no access to care in an urban environment—for example, because they might have to take public transportation, and there might be a snowstorm or another unintended barrier," Johns Hopkins' Nason says.