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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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telehealth opportunities to enhance access lower costs and improve quality
TelehealthOpportunities to enhance access, lower costs, and improve quality

Karen S. Rheuban MD

Professor of Pediatrics

University of Virginia

  • The use of advanced telecommunications and other technologies for:
      • Medical diagnosis
      • Ongoing patient care
      • Health-related distance learning
telemedicine history
Telemedicine: History
  • Alexander Graham Bell
  • Hugo Gernsback (vision)
  • Massachusetts General
  • University of Nebraska
  • NASA
  • Dept of Defense
  • Medical College of Georgia
  • University of Virginia

Facilitate the Health System’s missions of

  • Clinical Care
  • Teaching
  • Research
  • Public Service
  • Videoconferencing for patient care
  • Store and forward applications
  • Distance learning

health professionals



2004 iom report status of rural healthcare
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
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
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
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
  • 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
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
Specialty/Subspecialty Division Participants



Developmental Pediatrics


Emergency Medicine








Infectious Disease



patients served
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
educational programs
Educational programs
  • Broadcast continuing health professional education
  • Patient education
  • School Health Projects
pediatric tele echocardiography
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
UVA Pediatric tele-echo program >3000 studies
  • Reduced unnecessary transfers
  • Provided timely interventions Improved case management
telecardiology clinical implications
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Other pediatric applications
  • Sexual abuse assessments
  • Obesity clinics
  • Comprehensive case management of diabetes
  • Remote access to clinical trials
facilitating expert care acute stroke intervention
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

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
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
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
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.


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
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
Grant/Foundation fundingOther funding sources

Department of Homeland Security

State office of Emergency Preparedness



Department of Defense

challenges reimbursement varies by state
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
Challenges: Licensure
  • Primarily serve Virginians
  • Primarily provide consultations
  • International patients
  • Discussion surrounding model of nurse compact
challenges confidentiality
Challenges: Confidentiality
  • Encrypted data
  • Virtual private networks
challenges jcaho
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
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
Challenges: Integration of telehealth with EMRS/RHIOs
  • Interoperability
  • Common standards
  • Funding of EMRS
  • Electronic claims processing
challenges malpractice
  • Serve Virginians
  • Informed consent
  • New local standard of care?
  • Equipment manufacturers
  • Limited precedents in case law
the future of telehealth
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


Congressman Rick Boucher, Mrs. Lisa Hubbard, Alexandra Bartley


Governor (now Senator-elect) Mark Warner


State Senator William Wampler


Special thanks to Pat Finnerty and Jeff Nelson

Virginia Department of Medical Assistance Services