Telehealth models in 21st Century healthcare

Karen S. Rheuban, MDUniversity of Virginia Center for Telehealth

The Teledactyl (Tele, far; Dactyl, finger — from the Greek) is a future instrument by which it will be possible for us to “feel at a distance.” Gernsback, Science and Invention Magazine, 1925

The delivery of healthcare and health related education over a distance using telecommunications technologies.

Live interactive videoconferencing Store and forward technologies Remote patient monitoring Virtual care, e-care, m-Health

Not a specialty in and of itself!

Definition: Telehealth

• We are an aging populationBy 2030, more than 71.5 million Americans will be older than 65

• We suffer from high rates of chronic illnessNearly 50% of American adults have at least one chronic illness

• Chronic disease is expensive More than 75% of healthcare costs are spent on chronic disease25% of spending is on inpatient costs

• There are serious workforce shortages and geographic mal-distributions of providers

• There remain serious barriers to access to care nationwide

The need, the opportunity and why telehealth?

• PatientsTimely access to locally unavailable servicesImproves chronic disease managementReduces the burden and cost of transportation for care

• Health professionals (workforce shortages)Access to consultative servicesSupports collaborative care delivery models

• Hospital systemsDecreases readmissionsImproves triage, keeps patients local when appropriate

• Communities Increased broadband deployment, hospital viability

Benefits of telehealth

UVA Center for Telehealth • Integrated program across the service lines and schools

within the University that facilitate our missions of:Clinical CareTeaching across the continuumResearch and innovationPublic service/Public policy

• Centralized coordinated program within Health System• HRSA funded Mid Atlantic Telehealth Resource Center (MATRC)• Academic partner with Specialists on Call

UVA Telemedicine Partner Network (132 sites)

CharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesvilleCharlottesville

Scale LegendMile(s)

0 20 40

* Includes emergency preparedness only sites.

Community HospitalsHealth SystemsRural Clinics (FQHCs, Free Clinics)Virginia Department of HealthVirginia Department of CorrectionsCommunity Service BoardsSchool HealthNursing Facilities (2014 USDA grant)Dialysis Facilities (2014 USDA grant)PACE programsHome Telehealth

• >41,000 patient encounters in VirginiaAdditional international outreachAdditional remote patient monitoring

• Partner with teleradiology • Spared Virginians > 14.5 million miles of travel• Services in >45 different sub-specialties

EmergencySingle consults/follow up visitsBlock scheduled clinicsScreenings with store forward technologiesCare coordination/remote patient monitoring program

Patients served

Metrics tracked: clinical, technical and operationalContinuous process improvement to allow us to support expansion

Technologies: secure, interoperable, FDA approved

Tele-stroke

Need: High morbidity, high mortality, high cost condition – when every second counts

Low utilization of TPA nationwide Telemedicine improves access to stroke and other neurology services

Tele-mental health• Shortage of mental health providers• Consultations, medication management, emergency

telepsychiatry Improve access, shorter wait timesFewer no showsControlled studies show efficacy comparable to face to face psychiatry

• NUMBER ONE request for services at UVA (> 18,000 encounters)

High risk obstetrics

• Governor’s productivity investment fund and HRSA grant• 363 patients saved 162,126 miles of driving from 5 sites

Parameters Before HROB Program After HROB I mplementation

Gestational Age at First Visit 13.6 weeks 13.8 weeks Missed 1 or more appointments 57.1% 21.3%

NICU admission rate 12.0% 10.8%

NICU days 22.11 13.42

Tele-ophthalmology

• Conditions requiring screening and/or annual examinations (diabetic retinopathy)

• Practice guidelines

• UVA program > 1800 diabetic patients screened18% patients diagnosed with diabetic retinopathy

• Launched in 2013 to address readmissions challenges• Enrolled 688 patients discharged with CHF, AMI,

Pneumonia, COPD, now added TJR• Care coordination model with remote patient

monitoring for 60 days• Results: 688 patients, 41.5 % reduction in all cause

hospital readmissions

Remote Patient Monitoring/Home telehealthUVA-BroadAxe Care Coordination Center (“C3”)

2012 IOM Workshop

Actions to further the use of telehealth to improve health care outcomes while controlling costs

Improve Federal Payment Mechanisms

Medicare reimbursement of telehealth services remains low• 2012: CMS reported <$12 million dollars in

reimbursements nationwide to distant site providers• Rural requirement for originating site including for ACOs• Non-MSA definition of rural limits sustainability models

and more importantly, access to care for our seniors• Rural definition is poorly aligned with specialty workforce

shortages

Federal actions regarding telehealth• Waiver requested for ACOs under Medicare • Rep. Thompson (D-CA) introduced H.R.5380 , Medicare

Telehealth Parity Act of 2014 • Sen. Thad Cochran (R-MS) introduced S.2662 the Telehealth

Enhancement Act of 2014• Senate Aging Committee held a telemedicine roundtable in

September• House Energy and Commerce Committee has indicated that

the committee's 21st Century Cures legislation• Veterans' Access to Care through Choice, Accountability and

Transparency Act of 2014.

Improve State Policies and Payment Mechanisms

• Medicaid coverage of telehealthExpansion opportunity>45 state Medicaid programs currently cover telehealth No two states are exactly alikeMost state programs pay for transportation

• Private pay mandates (21 states plus DC) • Varying state regulations – BOM, Health Departments• Correctional telehealth opportunities• State health information exchanges • NOBEL women – national champions for telehealth

States with Parity Legislation for Telehealth (ATA)

Other important actions in 2014

• AMA policy document on telehealth

• FSMB “SMART Working Group” recommendations

• FSMB Interstate Licensure Compact

• Safe, secure, sustainable care delivery models• Collaboration with the AMA, the specialty societies,

FSMB, consumers and industry • Improve access to care and care coordination• Encourage greater federal inter-agency alignment• Encourage state actions • Integrate with health information exchanges• True integration into mainstream healthcare

The future of telehealth