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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

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TelehealthOpportunities to enhance access, lower costs, and improve quality

Karen S. Rheuban MD

Professor of Pediatrics

University of Virginia

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  • The use of advanced telecommunications and other technologies for:

    • Medical diagnosis

    • Ongoing patient care

    • Health-related distance learning

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Telemedicine: History

  • Alexander Graham Bell

  • Hugo Gernsback (vision)

  • Massachusetts General

  • University of Nebraska

  • NASA

  • Dept of Defense

  • Medical College of Georgia

  • University of Virginia

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Facilitate the Health System’s missions of

  • Clinical Care

  • Teaching

  • Research

  • Public Service

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  • Videoconferencing for patient care

  • Store and forward applications

  • Distance learning

    health professionals



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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

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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

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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

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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

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  • 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

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Broadband Technologies

  • Network Virginia (statewide ATM network)

  • Telco broadband (N’Telos)

  • Wireless

  • ISDN

  • Satellite

  • Cable modem

  • Bristol Virginia Utilities

  • Mecklenburg Electric Cooperative

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Specialty/Subspecialty Division Participants



Developmental Pediatrics


Emergency Medicine








Infectious Disease



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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

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More than technology and numbers:Facilitating expert care

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Enhancing accessRemote area medical clinic

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Educational programs

  • Broadcast continuing health professional education

  • Patient education

  • School Health Projects

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More than technology and numbers: Saving lives: Infant with Interrupted aortic arch

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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)

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UVA Pediatric tele-echo program >3000 studies

  • Reduced unnecessary transfers

  • Provided timely interventions Improved case management

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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

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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.

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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

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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

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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

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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

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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)

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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

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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)

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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)

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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

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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

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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

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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

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Facilitating expert care: DiabetesTele-ophthalmology

  • Tele-ophthalmology technologies:

    • JPEG compression algorithms did not impact examiner accuracy

  • ATA: Tele-ophthalmology standards

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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

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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.

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Other pediatric applications

  • Sexual abuse assessments

  • Obesity clinics

  • Comprehensive case management of diabetes

  • Remote access to clinical trials

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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

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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

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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

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Changing patient care needs:Remote monitoring andHome telehealth

  • Remote monitoring

    • CHF

    • Hypertension

    • Diabetes

    • COPD/ Asthma

    • post NICU care

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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.


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  • 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)

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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

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Grant/Foundation fundingOther funding sources

Department of Homeland Security

State office of Emergency Preparedness



Department of Defense

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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

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Challenges: Licensure

  • Primarily serve Virginians

  • Primarily provide consultations

  • International patients

  • Discussion surrounding model of nurse compact

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Challenges: Confidentiality


  • Encrypted data

  • Virtual private networks

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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

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Challenges: Telecommunications

  • Telecommunications venue/costs

  • FCC: Universal service fund,

  • FCC Pilot - Internet 2

  • Quality of service, bandwidth sensitive

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Challenges: Integration of telehealth with EMRS/RHIOs

  • Interoperability

  • Common standards

  • Funding of EMRS

  • Electronic claims processing

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  • Serve Virginians

  • Informed consent

  • New local standard of care?

  • Equipment manufacturers

  • Limited precedents in case law

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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

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Congressman Rick Boucher, Mrs. Lisa Hubbard, Alexandra Bartley

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Governor (now Senator-elect) Mark Warner

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State Senator William Wampler

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Special thanks to Pat Finnerty and Jeff Nelson

Virginia Department of Medical Assistance Services