At ATA 2015 (American Telemedicine Association), held in Los Angeles, a milestone was achieved as over 5,000 attendees from around the world stormed the LA Convention Center. The content of the symposium keeps getting better, ranging from lightening rounds to superb plenary sessions. What particularly struck me was that the keynote speakers, both physicians in different areas of medicine both understood and support telemedicine as an integral part of healthcare delivery. Dr. Sanjay Gupta, chief CNN medical correspondent, had previously done a story on telemedicine featuring Yulun Wang, CEO of InTouch Health. Dr. Patrick Soon-Shiong, an entrepreneur and brilliant visionary, has already embarked upon ways to treat cancer utilizing mobile health. The exhibit hall allowed one to roam a roomy exhibit hall to see new and established medical product and software companies display and explain their technology. Based upon the opinion of those in attendance, the ATA is striving toward increasing the content experience. Looking optimistically to another high level meeting in Minnesota for ATA 2016.
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.
A group of pediatric intensivists at the duPont Hospital for Children in Wilmington Delaware published the results of evaluating telephone versus telemedicine evaluation of pediatric patients with moderate to severe critical illness being transported between hospitals. Findings were as follows based upon the opinions of the medical command center physicians:
- Connection and audio quality were equivalent and there were no dropped calls.
- Average call duration in the phone group was 186 versus 139 seconds in the video group (P = 0.055).
- The MCO survey results were the following: 100% found video intuitive, 92% felt that disposition based on phone report was difficult, 80% felt that video provided better understanding of patient condition, 70% felt that video assisted disposition, and 80% believe that video should be used for transport.
- The iPad system offers a significant savings when compared with conventional telemedicine.
This was a prospective randomized study of a total of 50 patients divided between call only versus video conferencing. An iPad tablet was the technology used which the authors conclude is much more cost effective than other technologies.
In the just released issue of Telemedicine and e-Health, Doan and Merrell’s editorial addresses robotics in telemedicine. The editors write “Telemedicine, telehealth, and robotics are a few innovative approaches to alleviating the stress on an overburdened system. While technology continues its march forward, often unabated, the culture of medicine has not changed as rapidly. There are many individuals and health systems across the United States and the world that are reticent to change. Perhaps it is a lack of understanding or a fear of change or even a level of trust in the technology. Clearly a robot in a nursing facility that is driven by a remotely located physician who is in contact with the on-site nursing staff can add tremendous value. Robots have added value both in clinical settings and in the educational setting.”
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.
In the Wall Street Journal Opinion page on August 3, 2015 , Dr. Richard Boxer who is chief telehealth officer of Well Via and former CMO for TelaDoc discusses the efficiency of getting a doctor on the phone within minutes, all courtesy of the utilization of telemedicine. He stresses a new found efficiency in a highly inefficient healthcare system. Emphasizing that over 100 million people are living in under served areas where major shortages of primary care physicians leave this population vulnerable, telemedicine helps to lessen the severity.
Economically, Boxer reports that 136 million ER visits could have been replaced by a $50 telemedicine consultation. Coupled with the anticipated 52,000 primary-care physician shortage by 2025 the crisis has already begun. Looking to train more physicians won’t do it. Advanced practice nurses helps but is not the solution. Anticipated health workers graduating from community colleges is a feel good thought without real power.
While no one is stating or hoping telemedicine will replace the live physician encounter, states and the federal government need to address how to engage and incorporate telemedicine into main stream medicine today, not tomorrow. How? Dramatic and commonsense inter-state licensure approval. Just as we have one drivers license good in all 50 states, with proper oversight why shouldn’t a California license be recognized in New York or any other state? After all, the European Union is light years ahead by recognizing other country medical licenses.
It is up to the public to jump on their legislatures to help move this along if they wish to avoid long waits or even worse, no access for their primary medical needs. Telemedicine is certainly a solution.
Lancet Psychiatry. 2015 Aug;2(8):693-701. doi: 10.1016/S2215-0366(15)00122-4. Epub 2015 Jul 16.
Many older adults with major depression, particularly veterans, do not have access to evidence-based psychotherapy. TelePsychotherapy could increase access to best-practice care for older adults facing barriers of mobility, stigma, and geographical isolation. We aimed to establish non-inferiority of behavioural activation therapy for major depression delivered via telemedicine to same-room care in largely male, older adult veterans.
In this randomised, controlled, open-label, non-inferiority trial, we recruited veterans (aged ≥58 years) meeting DSM-IV criteria for major depressive disorder from the Ralph H Johnson Veterans Affairs Medical Center and four associated community outpatient-based clinics in the USA.
- Between April 1, 2007, and July 31, 2011, we screened 780 patients,
- Treatment response according to GDS did not differ significantly between the telemedicine and same-room groups.
- Response on the Structured Clinical Interview for DSM-IV, clinician version, also did not differ significantly
- Results showed that no significant differences existed between treatment trajectories over time for BDI and GDS. The criteria for non-inferiority were met. We did not note any adverse events.
TelePsychotherapy for older adults with major depression is not inferior to same-room treatment.
This finding shows that evidence-based telepsychotherapy can be delivered, without modification, via home-based telemedicine, and that this method can be used to overcome barriers to care associated with distance from and difficulty with attendance at in-person sessions in older adults.
US Department of Veterans Affairs.
The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents.
MATERIAL AND METHODS:
- We performed a prospective cohort study over 3.5 years.
- Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls.
- Consenting patients at intervention facilities could access telemedicine for acute illness care.
- Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses.
- The primary outcome was the rate of ED use.
- We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group;
- 1,058 subjects served as controls.
- Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home.
- Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction).
- Primary care use and mortality were not significantly different.
High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.
COMMENT: A very nice introductory cohort study on a very pertinent topic. Hopefully to follow will be a prospective randomized study looking at both outcomes and financial data. Additionally, for those seen through telemedicine, following the ED admission course would be important.