Telehealth opportunities to enhance access lower costs and improve quality
Download
1 / 61

Telehealth Opportunities to enhance access, lower costs, and improve quality - PowerPoint PPT Presentation


  • 629 Views
  • Uploaded on

Telehealth Opportunities to enhance access, lower costs, and improve quality Karen S. Rheuban MD Professor of Pediatrics University of Virginia Telemedicine The use of advanced telecommunications and other technologies for: Medical diagnosis Ongoing patient care

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Telehealth Opportunities to enhance access, lower costs, and improve quality' - paul


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Telehealth opportunities to enhance access lower costs and improve quality l.jpg
TelehealthOpportunities to enhance access, lower costs, and improve quality

Karen S. Rheuban MD

Professor of Pediatrics

University of Virginia


Telemedicine l.jpg
Telemedicine

  • The use of advanced telecommunications and other technologies for:

    • Medical diagnosis

    • Ongoing patient care

    • Health-related distance learning


Telemedicine history l.jpg
Telemedicine: History

  • Alexander Graham Bell

  • Hugo Gernsback (vision)

  • Massachusetts General

  • University of Nebraska

  • NASA

  • Dept of Defense

  • Medical College of Georgia

  • University of Virginia


Mission l.jpg
Mission

Facilitate the Health System’s missions of

  • Clinical Care

  • Teaching

  • Research

  • Public Service


Services l.jpg
Services

  • Videoconferencing for patient care

  • Store and forward applications

  • Distance learning

    health professionals

    patients

    students


2004 iom report status of rural healthcare l.jpg
2004 IOM Report: Status of Rural Healthcare

  • Fewer “core based services” in rural areas

    • Emergency medical services

    • Long term care (SNF, Hospice)

    • Mental health and substance abuse services

  • Physician recruitment/retentionchallenges

  • Fewer specialists

  • Generally lower reimbursement rates

  • Slower to adopt new technologies

    • Urban adoption rate of EMR 150% of rural


Barriers to access l.jpg
Barriers to Access

  • Geographic

    • >20% of US population reside in rural areas

    • Burden of transportation to care generally borne by patients

    • Medicaid programs bear the burden of transportation costs

      1999: >$50 million/year in Virginia

  • Financial

    • The uninsured, underinsured (> 40 million uninsured)

    • Delayed access to services for uninsured

    • High cost of travel for locally unavailable specialty care


Barriers to access8 l.jpg
Barriers to Access

  • Societal

    • Societal stigmatization

    • Cultural barriers

    • Language barriers

  • Maldistribution/shortage of providers

    • Predicted shortage of physicians 85,000-200,000 by 2020

    • Urban predominance of specialty providers

    • Isolation of rural health providers

    • Need for continuing health professional education


Benefits of telehealth l.jpg
Benefits of telehealth

  • Patients:

    • Timely access to locally unavailable services

    • Spared burden and cost of transportation

  • Health professionals

    • Access to consultative services

    • Access to CME

    • Primary care oversight of patient care

  • Academic center

    • Improved triage

    • Better utilization of tertiary/quaternary facilities


Partnerships l.jpg
Partnerships

  • Academic-community hospital linkages

  • Academic-academic hospital linkages

  • Rural clinics (FQHCs, Veteran’s clinics)

  • Virginia Department of Health

  • Virginia Department of Corrections

  • School health

  • Nursing home

  • Home telehealth


Broadband technologies l.jpg
Broadband Technologies

  • Network Virginia (statewide ATM network)

  • Telco broadband (N’Telos)

  • Wireless

  • ISDN

  • Satellite

  • Cable modem

  • Bristol Virginia Utilities

  • Mecklenburg Electric Cooperative


Specialty subspecialty division participants l.jpg
Specialty/Subspecialty Division Participants

Cardiology

Dermatology

Developmental Pediatrics

Diabetes

Emergency Medicine

Endocrine

ENT

Gastroenterology

Genetics

Geriatrics

Gynecology

Hematology

Infectious Disease

Nephrology

Neurology


Patients served l.jpg
Patients served

  • >13,100 patient encounters

  • >35,000 teleradiology readings

  • Services in >30 different specialties

    • Emergency

    • Urgent

    • Single consults

    • Block scheduled clinics

    • Screenings with store forward

      • Mobile digital mammography van

      • Retinopathy


More than technology and numbers facilitating expert care l.jpg
More than technology and numbers:Facilitating expert care


Enhancing access remote area medical clinic l.jpg
Enhancing accessRemote area medical clinic



Educational programs l.jpg
Educational programs

  • Broadcast continuing health professional education

  • Patient education

  • School Health Projects


More than technology and numbers saving lives infant with interrupted aortic arch l.jpg
More than technology and numbers: Saving lives: Infant with Interrupted aortic arch


Pediatric tele echocardiography l.jpg
Pediatric tele-echocardiography

  • Primarily linking community hospitals with NICUs with UVa

    - Contracts with 3 community hospitals

    - Digital image transfer (Heartlabs - AGFA)

    - Other sites “as needed” with live support or video link

  • Referrals from neonatologists, general pediatricians, family medicine, ER physicians

  • Mandatory training of echo techs

    - Most sites are in communities with existing UVa field clinics

    -Adjunct to field clinics

    -“An echo is only as good as the echocardiographer”

    (Howard Gutgesell, MD)


Uva pediatric tele echo program 3000 studies l.jpg
UVA Pediatric tele-echo program >3000 studies

  • Reduced unnecessary transfers

  • Provided timely interventions Improved case management


Telecardiology clinical implications l.jpg
Telecardiology: Clinical implications

Children’s National Medical Center

  • 6,300 Studies: 1998 - present

  • No significant diagnostic errors

  • Patient follow up

    • Management affected in 60% cases

    • 100+ patients transported for surgery

    • 75+ transports avoided

Sable, C et al, Pediatric Telehealth Colloquium, 2008


Telecardiology opportunities fetal echocardiography l.jpg
Telecardiology opportunitiesFetal echocardiography

Sharma, S et al (Mt. Sinai)

  • Live fetal ultrasounds transmitted

  • Bandwidth sensitive

  • Patient counseling via VTC

  • Patient acceptance good

Sharma, S, et al, Screening fetal echocardiography by telemedicine: efficacy and

community acceptance, J Amer Soc Echo, 16(3):202-8, 2003.


Perinatal neonatal care l.jpg
Perinatal/neonatal care

  • Premature delivery correlates with late access to obstetrical care

  • High costs often borne by Medicaid programs

  • Cost of neonatal hospitalization (savings to Medicaid)

    • >$27,000 per week gestation in utero for low birth weight infants

    • Additional costs of long term complications of premature delivery

  • UVA community health center pilot

    • Modeled after Arkansas Angels


Arkansas angels l.jpg
Arkansas Angels

  • Medicaid funded statewide perinatal regionalization project

  • Provider education

  • Collaborative high risk ob care

  • Case management

  • Counseling

  • Referral for at risk pregnancies

  • Referral to UAMS for delivery for preterm infants and infants with congenital malformations


Pediatric emergency support l.jpg
Pediatric emergency support

  • IOM: Future of Emergency Care – Key Findings:

    • “Children make up 27% of all ED visits, but only 6% of EDs in the US have all of the necessary supplies for pediatric emergencies

  • CDC report (Feb 2006): 40% of EDs lack 24/7 access to pediatricians

  • 21% of children in the United States live in rural areas

  • 3% of board certified pediatric intensivists practice in rural areas


Pediatric ed and critical care support l.jpg
Pediatric ED and critical care support

  • Access to pediatric critical care services 24/7

    • Expands the reach of pediatric intensive care specialists

    • Decreases discrepancies in quality of care between rural and urban

    • Allows more patients to receive appropriate care locally

    • Better triage

    • Improved clinical outcomes


Visicu model for critical care continuous oversight model l.jpg
VISICU® model for critical care(Continuous oversight model)

Model for support of adult intensive care units1

  • Two adult ICUs in large tertiary care hospital system

  • 2140 patients receiving ICU care; 6 month control period vs intervention period

  • E-ICU services from 12 noon – 7am

  • Program utilized off-site intensivists, physician extenders, electronic data display, VTC, decision support tools

  • Results:

    Hospital mortality decreased from 12.9-9.4%

    ICU length of stay shorter 4.35-3.63 days

    (Breslow et al 2004)


Pediatric critical care support consultation model davis 1 vermont 2 l.jpg
Pediatric critical care support(Consultation model – Davis1, Vermont2)

  • Premise: some “less critically ill” children can be cared for in community hospitals without PICUs and NICUs

  • Remotely located ERS and ICUs connected via VTC

  • 24/7 coverage by on-call team

    1 Marcin et al, Pediatric Telehealth Colloquium 2008

    2 Salerno, et al, Pediatric Telehealth Colloquium2008



Pediatric critical care support ca l.jpg
Pediatric critical care support - CA

Additional revenue to remote site ICU 1

Decreased transportation costs

Fewer helicopter transports

Cost savings of $5,000-$10,000 per case

Lower transportation costs for families of patients

Increased convenience

Reduced absenteeism at work

Marcin et al (2004)


Pediatric critical care support l.jpg
Pediatric critical care support

73 consults from 13 sites in upstate NY and Vt

Patients ranged in age from 2 days to 17 years

69/73 patients were transported to the tertiary care hospital.

Consulting intensivists made a total of specific 261

recommendations (mean 3.6 per consult)

In 3 cases, the patients were triaged to the pediatric ward

In 4 cases, transport was not required after consultation

Salerno et al (2008)


School daycare telehealth l.jpg
School/Daycare Telehealth

  • University of Rochester program

    • 22 urban daycare centers and schools

    • 66% patients Medicaid

    • Trained lay health professionals connected to UR and local practices for primary care pediatric services

    • Reduced ER visits by 22%

      McConnochie, et al 2007


Tele mental health l.jpg
Tele-mental health

  • Shortage of mental health providers in rural areas

  • Consultations, medication management

  • Sign language for hearing impaired

  • Interpreter services

  • UVA tele-psychiatry services

    • Adult - 900

    • Child – 2290

    • Fewer missed appointments


Tele mental health36 l.jpg
Tele-mental health

  • Comprehensive review of the medical literature in telepsychiatry1

    • Technology predominantly interactive videoconferencing

    • Improve access, shorter wait times

    • Fewer missed appts2

    • High rates of patient satisfaction in all age groups

    • Diagnosis change from PC provider diagnosis in 91%, medication changes in 57%

    • Reduced geriatric hospital admissions from long-term care facility by 59%

      1Hilty, D, et al, Can J Psych 2004; 49:12-23

      2 Tucker et al, ATA 2009


Facilitating expert care tele otolaryngology l.jpg
Facilitating expert care:Tele-otolaryngology

  • AFCHAN telehealth project and use of video-otoscopy1

    • 31% decrease in the use of antibiotics when video-otoscopy services added to community health clinic services1

  • 1 Peterson, K et al, Arctic Investigations Program, National Center for Infectious Diseases, CDC


Facilitating expert care diabetes tele ophthalmology l.jpg
Facilitating expert care: DiabetesTele-ophthalmology

  • Tele-ophthalmology technologies:

    • JPEG compression algorithms did not impact examiner accuracy

  • ATA: Tele-ophthalmology standards


Facilitating expert care diabetes tele ophthalmology39 l.jpg
Facilitating expert care: DiabetesTele-ophthalmology

  • Diabetes is the leading cause of blindness in working adults

  • Retinopathy of prematurity is a leading cause of blindness in US children

    • Insufficient numbers of pediatric ophthalmologists

    • Transportation for screening costly

      • NICU screening protocols using telehealth tools demonstrated to be satisfactory and accurate alternative2

        1 Flowers et al, Ophthalmology, 105:8, 1998

        2 Chiang et al, Arch Ophthal 125:1531 2007


Facilitating expert care tele dermatology l.jpg
Facilitating expert care:Tele-dermatology

  • Significant specialty shortages, long (>6month) waits in most rural areas

  • Study of 87 rural patients1

    • Cost of care in 6 months following diagnosis 50% of that of 8 months prior to teledermatology consult

  • Teledermatologists recommended biopsy 10% more frequently than in-clinic dermatologists 2

    • Countered by potential benefit of diagnosis at an earlier stage

1Burgiss, SG et al, Telemed Journal 1997; 3 227-33

2 Pak, HS et al, Cutis. 2003 71(6) 476-80.


Other pediatric applications l.jpg
Other pediatric applications

  • Sexual abuse assessments

  • Obesity clinics

  • Comprehensive case management of diabetes

  • Remote access to clinical trials


Facilitating expert care acute stroke intervention l.jpg
Facilitating expert care:Acute stroke intervention

  • Challenge of lack of access to stroke neurologist in rural areas

  • Time is of the essence (3 hour window for thrombolytic agents

  • ED Support for Thrombolytic Therapy1

    • ED connection to Stroke Neurologist with evaluation/CT

    • 15 pts < 3hrs from onset of sx

    • 10 patients with Acute Ischemic Stroke

    • 8 eligible, 6 received TPA

    • 7/10 had no residual defects at follow up

  • Telehealth supports care throughout the continuum!

    1Schwamm et al Academic Emergency Medicine 2004: 11


Hiv aids l.jpg
HIV/AIDS

Outcomes: UVA Telehealth HIV Program1

  • 213 correctional patients treated with 1812 visits over 5 year period

  • Of patients naïve to therapy:

    • 77% attained undetectable viral load (<50 copies/ml)

    • 50-60% in HIV clinic

    • 40% receiving community based care by non-HIV specialists

      1 Rheuban,KS, Wispelwey B et al HIV/AIDS, HRSA Telemedicine Technical Assistance Documents 2004


Breast and cervical cancer l.jpg
Breast and Cervical cancer

  • CDC grant to Virginia for screenings oflow-income, uninsured or underinsured women

  • Medicaid coverage for select women

  • Real-time tele-colposcopy services by UVA gynecologic-oncologists supporting rural NPs

  • Mobile digital mammography


Changing patient care needs remote monitoring and home telehealth l.jpg
Changing patient care needs:Remote monitoring andHome telehealth

  • Remote monitoring

    • CHF

    • Hypertension

    • Diabetes

    • COPD/ Asthma

    • post NICU care


Changing patient care needs home telehealth remote patient monitoring for chf l.jpg
Changing patient care needs:Home telehealth – remote patient monitoring for CHF

  • Disease management for CHF in HMO population1

    • Daily monitoring using remote biometric device for 12 mos

    • Interactive communications between nurse and patient

    • > 65 yrs of age: Reduced inpt bed days by 53% (0% control); costs by 50%

    • < 65 yrs of age: Reduced inpt bed days by 62% (9% control); costs by 60%

1 Nobel JJ, Norman GK.Disease Management. 2003 Winter;6(4):219-231.

2


Challenges opportunities l.jpg
Challenges/Opportunities

  • Outcomes

  • Funding of telehealth

  • Reimbursement

  • Confidentiality

  • Licensure

  • Malpractice

  • Telecommunications venue/costs

  • Integration with EMRS/RHIOS

  • Interagency alignment related to policies

    • Federal (definition of rural, rural vs urban)

    • State (eligible plans, coverage of store and forward)


Grant foundation funding stark and anti kickback laws l.jpg
Grant/Foundation funding*Stark and anti-kickback laws

  • US Department of Commerce NTIA TOP Program

  • USDA Distance Learning and Telemedicine Grant Program

  • USDA Community Facilities program

  • HRSA Office for the Advancement of Telehealth

  • Medicare Rural Hospital Flexibility Program

  • Department of Housing and Community Development

  • Virginia Healthcare Foundation

  • Verizon, Sprint, nTelos

  • Baxter Foundation

  • WestWind Foundation

  • Anthem Blue-Cross Blue Shield of Virginia


Grant foundation funding other funding sources l.jpg
Grant/Foundation fundingOther funding sources

Department of Homeland Security

State office of Emergency Preparedness

US AID

NASA

Department of Defense


Challenges reimbursement varies by state l.jpg
Challenges: Reimbursement varies by state

  • Reimbursement

    • Medicaid1,2

    • Medicare (rural)

    • Private payers

    • Anthem grant

    • Contracts

      • Peds cardiology

      • Psychiatry

      • Dept of Corrections

    • Pending: State employees

  • Possible legislative approaches

    1 Formal request of Virginia Medicaid 1995, expanded 2003 to include urban and rural

    2 According to CTEL, 27 Medicaid states cover telehealth facilitated services


Challenges licensure l.jpg
Challenges: Licensure

  • Primarily serve Virginians

  • Primarily provide consultations

  • International patients

  • Discussion surrounding model of nurse compact


Challenges confidentiality l.jpg
Challenges: Confidentiality

  • HIPAA

  • Encrypted data

  • Virtual private networks


Challenges jcaho l.jpg
Challenges: JCAHO

Credentialed and privileged at remote sites

if providing direct care

Must be credentialed and privileged at hub site

Remote site medical staff must endorse telehealth in hospital/facility

Evidence for quality monitoring of program


Challenges telecommunications l.jpg
Challenges: Telecommunications

  • Telecommunications venue/costs

  • FCC: Universal service fund,

  • FCC Pilot - Internet 2

  • Quality of service, bandwidth sensitive


Challenges integration of telehealth with emrs rhios l.jpg
Challenges: Integration of telehealth with EMRS/RHIOs

  • Interoperability

  • Common standards

  • Funding of EMRS

  • Electronic claims processing


Challenges malpractice l.jpg
Challenges:Malpractice

  • Serve Virginians

  • Informed consent

  • New local standard of care?

  • Equipment manufacturers

  • Limited precedents in case law


The future of telehealth l.jpg
The future of telehealth

  • Outcomes

  • Standards

  • Demonstration projects

  • Share data – ATA Pediatric Discussion Group

  • Collaboration amongst providers, policymakers, regulators *

  • Champions at all levels

    *Unique and important opportunity to work with legislators


Champions l.jpg
Champions

Congressman Rick Boucher, Mrs. Lisa Hubbard, Alexandra Bartley


Champions59 l.jpg
Champions

Governor (now Senator-elect) Mark Warner


Champions60 l.jpg
Champions

State Senator William Wampler


Slide61 l.jpg

Special thanks to Pat Finnerty and Jeff Nelson

Virginia Department of Medical Assistance Services


ad