Why is Healthcare Broken?
Why is healthcare broken? There is a multitude of reasons, but the poor delivery of care is often the result of ignorance. Yes, for years quality experts and specialists from all medical specialties have worked on guidelines that are based on scientific evidence. The problem is will physicians adapt them? Will hospital and hospital systems ensure compliance with the guidelines?
Let me give an illustration that recently appeared in DHealthcare Daily where the CEO of Methodist Health System was interviewed. The CEO is quoted as saying “So last year we spent a lot of hours working on a condition called sepsis, which has a very high mortality. It’s lethal in many cases, and it’s lethal not only in the elderly but the young as well. So our learning in that, learning the early symptoms and the early interventions that need to take place, and how the key is early intervention, and the impact that has had on the way we practice across Methodist as it relates to sepsis is dramatically different today than it was 12 months ago. And the impact, well, it’s a life saver. There’s no question about it. We were average in that area, I would say, among hospitals in America. Today I would say we’re in the top decile.”
What is disturbing is that sepsis had been around for years. The fact that the Society of Critical Care Medicine along with other professional societies published scientific guidelines on the recognition and treatment of sepsis back in 2002. Why 14 years later are healthcare professionals suddenly realizing this is a major problem that affects almost 800,000 patients a year? Why is the dissemination and utilization of sound medical evidence not being implemented immediately?
The above example is one of many that may be attributed of hospitals not having the expertise of quality programs or specialists in certain areas of medicine. It may also be the result of physicians either not accepting guidelines or not paying attention. Telemedicine may have a very significant impact on improving quality. Telemedicine may very well be the conduit to provide intensivist and infectious disease expertise to hospitals that lack these specialties. The same services may enhance both accessibility and speed to obtain highly efficient treatment modalities. There is growing evidence to suggest that remote care by distant intensivists and infectious disease physicians provide a significant quality benefit to patients often unable, because of geography, not have access to these providers.
Certain diseases that affect larger portions of our population often have associated evidence-based guidelines for physicians. It is up to hospital leadership to ensure compliance. When expertise is needed for patients that are complex, then telemedicine is certainly an alternative that must be utilized.
Inconsistencies with brain death criteria: telemedicine to help?
Is there a role for telemedicine in the determination of brain death? An article in JAMA Neurology December 28th included 52 organ-procurement organizations obtaining brain death policies from 492 qualified hospitals across the United States. The researchers evaluated the policies based upon:
- who is qualified to perform the determination of brain death,
- what are the necessary prerequisites for testing,
- details of the clinical examination,
- details of apnea testing, and
- details of ancillary testing.
There remained significant variability across all 5 categories of data, such as excluding the absence of hypotension (276 of 491 policies [56.2%]) and hypothermia (181 of 228 policies [79.4%]), specifying all aspects of the clinical examination and apnea testing, and specifying appropriate ancillary tests and how they were to be performed.
Additionally the study revealed:
33.1% required specific expertise in neurology or neurosurgery for the health care professional who determines brain death,
- 43.1% stipulated that an attending physician determine brain death;
- 150 policies did not mention who could perform such determination.
CONCLUSION: Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters. Hospitals should be encouraged to implement the 2010 AAN guidelines to ensure 100% accurate and appropriate determination of brain death.
COMMENT: ROLE OF TELEMEDICINE?
The issue is what is the role of telemedicine, if any, in the determination of brain death? At first glance, one would think that the determination of brain death is such an emotionally challenging procedure that the presence of a physician would be expected. Working closely with families which at times requires the holding of the hand, the provision of a tissue or reassurance is an important aspect of providing care by both physicians and nurses. Can this be achieved remotely? One might easily agree that in hospitals that do not have a physician available, telemedicine as a proxy might be better than no physician presence. On the other hand, an Emergency Medicine physician who is trained in this evaluation could serve in the capacity of providing the proper assessment. The telemedicine neurologist or intensivist promote the utilization of the AAN guidelines. Most importantly as the study has shown, there is no reason why all hospital brain death policies should not be in compliance with the 2010 AAN guidelines. In the end, telemedicine should serve as a clinical service that augments on site physicians and brain death procedures might be the alternative and not the preferred solution.
In 2003, Geisinger Health System formed a new group, Geisinger Ventures (GV), to accelerate the growth of new lines of business, such as telemedicine, that were extensions of the core mission of the organization. Careworks, the convenient care clinic line of business, began in early 2006 as one of the early components of the GV portfolio. Over the past nine years, Geisinger has tested several retail and walk-in models, including in-store clinics, separate retail sites, and models colocated with primary care practices and emergency departments. Each site and model presents different benefits and challenges with respect to patient care, marketing, staffing, and clinical integration. With the implementation of healthcare reform and a decision to participate in Medicaid’managed care, Geisinger’s strategic need for convenient care options has intensified, and new models, including e-visits and telemedicine specialty consultations, are being actively explored. Geisinger’s view is that healthcare is rapidly changing, being affected by demographic shifts, diagnostic and treatment options, payment changes, and communication technologies. Healthcare delivery must flex to adjust to these and other trends, and retail clinics are part of that response. Careful examination of the critical elements necessary for optimal care (including wellness, prevention, and management of chronic disease and severe multimorbid disease) and then matching those elements to the optimal mode and site of care will lead to a streamlined healthcare system. The historical–and still most prevalent–methodology of traditional office, emergency department, and inpatient care options are not ideal for all patients’ care needs in the twenty-first century. A thoughtful, deliberate extension of those options will be necessary. Rather than simply adding a static retail or virtual offering, medical professionals should develop a process to continually assess patients, technology, payment, and disease changes so that they are constantly adding exciting new options to the clinical delivery model. The ability to assess and respond to the changes that these varied inputs drive will be the most important element of success for the future.
U.S. Senators Joni Ernst (R-IA) and Mazie Hirono (D-HI), led eight co-sponsors, in introducing the bipartisan Veterans E-Health & Telemedicine Support Act of 2015 (VETS Act), legislation to improve health care access for disabled or rural veterans by expanding telehealth services provided by the Department of Veterans Affairs (VA).
As defined by the Department of Health and Human Services telehealth is, “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.”
Under current law, the VA may only waive the state license requirement for telehealth services if both the patient and physician are located in a federally owned facility. In addition, the VA may only perform at-home telehealth care when the patient and physician are located in the same state. These barriers are a deterrent for disabled or rural veterans who are seeking treatment from a physician in another state, in some cases forcing veterans to travel great lengths to a federal facility before receiving telehealth services by camera or phone.
The VETS Act would address these deficiencies by allowing qualified VA health professionals to operate across state lines and conduct telehealth services, including mental health care treatment, for veterans from the comfort and privacy of their own homes.
Telehealth is one of the VA’s major transformational initiatives, and the number of veterans utilizing telehealth services continues to climb. In fact, VA telehealth care grew by 18 percent among veterans in Fiscal Year 2014 and in turn more than 12 percent of veterans received elements of their care through telehealth services. According to the VA, 88 percent of veterans who utilized the VA’s telehealth services were satisfied with the care they received. Telehealth services are effective and affordable as veterans save on average $2,000 per year in health care related costs, including travel to a VA medical facility.
“The bipartisan Veterans E-Health & Telemedicine Support Act moves us one step closer to achieving more affordable, patient-centered health care that our veterans deserve by embracing telehealth services to offer physician care and health treatment beyond the walls of a VA facility,” said Senator Ernst. “Telehealth care is an innovative and important means to meet the wide-ranging needs of veterans in Iowa and nationwide, including the invisible struggles of mental health care.”
“Our nation has a moral obligation to provide the best care for all veterans,” said Senator Hirono. “This legislation would eliminate the added burden of traveling long distances, or even to different states, in order to see a doctor. The VETS Act will build on a VA telemedicine program that is proven to work and removes barriers to accessing care particularly for veterans in rural areas like Hawaii’s Neighbor Islands.”
Additional cosponsors to the bipartisan VETS Act include: Senators Kelly Ayotte (R-NH), John Boozman (R-AR), John Cornyn (R-TX), Chuck Grassley (R-IA), Mike Rounds (R-SD), Jeff Sessions (R-AL), Thom Tillis (R-NC), and Tom Udall (D-NM).
The VETS Act is widely endorsed by the Veterans of Foreign Wars, Paralyzed Veterans of America, the American Legion, Concerned Veterans for America, and the American Telemedicine Association.
The companion bill in the U.S. House of Representatives was introduced by Congressmen Charles Rangel (D-NY) and Glen Thompson (R-PA).
Click here to read the full text of the VETS Act.
- Allows VA health professionals to practice telemedicine across state lines if they are qualified and practice within the scope of their authorized federal duties.
- Ensures the VA and Congress provide oversight of the VA’s telehealth program by requiring the VA to measure program effectiveness.
Benefits of VA Telehealth Services in Fiscal Year 2014:
- Provided veterans telehealth care from more than 150 VA Medical Centers and over 750 Community Based Outpatient Clinics.
- More than 12 percent of veterans received elements of their care through telehealth services.
- More than 717,000 veterans participated in over 2.1 million telehealth care interactions.
- 45 percent of veterans who used telehealth services lived in rural areas.
- Reduced hospital bed days of care by 54 percent.
- Reduced hospital admissions by 32 percent.
- VA telehealth care grew by 18 percent among veterans in Fiscal Year 2014.
- Patient satisfaction for clinical video telehealth averaged 94 percent.
- Patient satisfaction for overall home telehealth services averaged 88 percent.
- Home telehealth services save veterans on average $2,000 per year.
Researchers from Boston Childrens/Harvard reported:
- Higher confidence in clinical care with telemedicine compared to telephone.
- They also reported that the videoconferencing was high-quality, easy to use, and did not increase their telecommunication costs.
- The telemedicine encounters supported clinical decision-making, especially in patients with active clinical problems or when the patient was acutely ill.
- The telemedicine encounters prevented the need for 23 clinic visits, three emergency room visits, and probably one hospital admission.
Although the study was small, videoconferencing appears useful in the management of medically fragile patients on home ventilator support, producing high levels of family confidence in clinical management and value to clinicians in their decision-making.
The AMA is pleased to announce the formation of a CPT® Telehealth Services Workgroup, which will be chaired by members of the CPT Editorial Panel. The workgroup will be comprised of relevant medical specialties/organizations and industry stakeholders. The workgroup will recommend additions and changes to the CPT code set related to medical services utilizing telehealth technology. The charge of this ad-hoc workgroup is to:
- Recommend solutions for the reporting of current non-telehealth services when using remote telehealth technology (to include but not limited to E/M services). Considerations will include potential new codes, use of current codes without or with modifier, add-on code(s).
- Address the accuracy of current code set in describing the services provided when telehealth data is reviewed and analyzed, including potential code set revisions and/or education for:
- Appropriate code use (e.g., E/M versus data analysis codes);
- Potential code development to report analysis of transmitted data;
- Definition of data types whose interpretation will require differentiation and consideration of separate reporting of current E/M services/codes
- Potential new E/M services codes based on emerging new patterns for sites of service.
- Recommend whether any other telehealth service codes should be developed based upon services currently being provided.
- Develop new introductory language or modify existing introductory language to guide coding of telehealth services.
The workgroup will also help facilitate discussions with key stakeholders who may wish to bring forward telehealth services applications for consideration. According to the CPT Editorial Panel AdHoc Workgroup Organizational Structure and Processesguidance, all workgroup recommendations will be presented in a Code Change Application(s) for consideration by the CPT Editorial Panel. Participation in the Telehealth Services Workgroup does not preclude the submission of a separately developed code change application for consideration by the Editorial Panel.
(PRWEB) May 14, 2015 — WASHINGTON- Thursday, May 14, 2015— The American Telemedicine Association (ATA) recently elected Reed V. Tuckson, MD, as President of the Association’s Board of Directors. Dr, Tuckson has been recognized among the 50 most influential physician executives and top 25 minority executives in healthcare. With a distinguished career that has spanned over 35 years, Tuckson has served in a variety of senior posts including the Senior Vice President for Professional Standards of the American Medical Association and the Executive Vice President and Chief of Medical Affairs for UnitedHealth Group. He is currently the Managing Director of Tuckson Health Connections.
Tuckson is joined by the following members of the Board’s executive committee: – President-Elect, LTG (Ret.) James Peake, MD, Senior Vice President, CGI Federal, former U.S. Secretary of Veterans Affairs and Surgeon General of the United States Army – Vice President, Peter Yellowlees, MD, MBBS, Professor of Clinical Psychiatry, Department of Psychiatry and Behavioral Sciences, UC Davis Health System – Secretary and Treasurer, Herb Rogove, DO, FCCM, FACP, President & CEO, C3O Telemedicine – Immediate Past President, Yulun Wang, PhD, Chairman & CEO, InTouch Health In addition, two other individuals recently joined the Board of Directors: – Amnon Gavish, ScD, Senior Vice President of Vertical Solutions, Vidyo, Inc.; Chair of ATA’s Industry Council – Kristi Henderson, DNP, NP-BC, FAEN, Chief Telehealth and Innovation Officer, the University of Mississippi Medical Center; Past Chair of ATA’s Institutional Council “We are pleased to announce the addition of this group of prestigious individuals to the Board and officers of this Association,” said Jonathan Linkous, CEO of ATA. “This reflects ATA intention to work with a balance of leaders from both the ranks of healthcare providers and industry in order to fulfil our goal to improve healthcare delivery through the use of telecommunications technology.” Other current at-large Board members include Ellen R. Cohn, PhD; Naomi Fried, PhD; Alexis Gilroy, JD; John Glaser, PhD; Julia L. Johnson, JD; Roy Schoenberg, MD; and Andrew R. Watson, MD.
About the American Telemedicine Association The American Telemedicine Association is the leading international resource and advocate promoting the use of advanced remote medical technologies. ATA and its diverse membership work to fully integrate telemedicine into healthcare systems to improve quality, equity and affordability of healthcare throughout the world. Established in 1993, ATA is headquartered in Washington, DC. For more information, visit www.americantelemed.org
For the study, researchers sent a 30-question survey to health professionals across the U.S. who process medical licensure applications (Rogove, C3O Telemedicine study, 2/11).
More than half of respondents said they process more than 100 applications annually (C3O Telemedicine release, 2/25). Of those:
- 54% said the application process takes longer than 12 hours; and
- 17% said the process takes four hours to nine hours (FierceHealthIT, 2/26).
After the application process is complete, the amount of time it took to acquire licenses varied among states. For example, it took one to three months to obtain licenses in Indiana, Arizona and Virginia, while it took at least 10 months in California, Illinois and Texas (C3O Telemedicine release, 2/25).
Just 8.3% if respondents said all states were “reasonable in processing the applications,” according to the study.
The authors concluded that state medical license portability “continues … to remain elusive for a solution that will allow for the exponential and timely growth of telemedicine.”
They added, “If there were ever a time for the mission of state medical licensure boards to rally in support of shaping the future of health care delivery by finding a solution for removing a most significant barrier to telemedicine, the time is now” (FierceHealthIT, 2/26).
According to Jonathan Linkous of ATA in todays Inside ATA:
“It’s only February, but telehealth is clearly a priority to state lawmakers. One hundred telemedicine-related bills have been introduced to define telehealth and telemedicine, redefine licensed provider practice standards, remove artificial barriers or improve coverage and payment options. Some bills seek to improve the telemedicine policy landscape while others risk to severely limit health providers’ clinical decision making and patient choice. ATA members are monitoring state activity using the ATA legislative and regulatory trackers, and seizing the opportunity to educate lawmakers about the clinical application of telemedicine and the unintended consequences of over regulation. Join the ATA State Policy webinar this Thursday, Feb. 26, at 1 p.m. EST, to hear about legislative proposals and possibilities for engagement.”
According to Christopher Cheney of HealthMedai Leaders: “Since the model Compact legislation was finalized by state medical board representatives and released to the states for their consideration at the end of 2014, it has been introduced in 12 state legislatures and endorsed by 26 state medical and osteopathic boards. We expect both counts to continue to grow,” Humayun Chaudhry, DO, president and CEO of theFederation of State Medical Boards, said last week.
So far, the draft has been introduced at statehouses in Iowa, Maryland, Minnesota, Montana, Nebraska, Oklahoma, South Dakota, Texas, Utah, Vermont, West Virginia and Wyoming. The FSMB is tracking the legislation’s progress on the organization’s website.
The Compact also has the support of the American Medical Association, the Council of Medical Specialty Societies, the Society of Hospital Medicine, and many other national and state provider, hospital, and specialty organizations. Consumer and patient advocacy organizations like the South Dakota AARP chapter have also been very supportive of the Compact and its potential for improving access to care.”
Critics of the Compact
The FSMB has lashed out at critics of the Compact, among them Independent Physicians for Patient Independence (IP4PI) and the Association of American Physicians and Surgeons (AAPS). In a letter to the US Senate dated Jan. 26, AAPS called the Compact “little more than a pretext for transferring state sovereignty to out-of-state, private, wealthy organizations” and called for “an investigation of the FSMB to “[evaluate] the very reason for their existence on top of state licensure boards and specialty boards.”
Critical Mass of States Needed to Launch Compact
Several states will have to enact laws codifying the model legislation before the Compact can seat commissioners and launch.
“The model Compact sets a minimum of at least seven states to enact the legislation in order to enable functionality and the creation of an interstate commission. The commission would be charged with the administrative functions of the Compact and be led exclusively by members of participating state medical boards,” Chaudhry says.