Think robots that help take vital signs and connect patients with practitioners, virtual video conferencing, and cloud-based consultations and training sessions.

 

This may sound futuristic and more fantastic than functional, but telemedicine is coming front and center in efforts to streamline costs, reduce transfers and avoidable hospitalizations, and enable experts to care for patients across town and around the country. It’s here, it’s now, and what’s more, it’s practical, efficient, and more cost-effective than one might think. It is making diabetes, cardiac, and psychiatric care, as well as chronic disease management, advance care planning, and communication across settings, easier and better for practitioners and patients alike.

 

“Be open to the possibilities, and you might be surprised,” says Natasa Sokolovich, executive director of telehealth at UPMC (the University of Pittsburgh Medical Center) in Pittsburgh.

 

There is “never a great time to implement change,” Sokolovich admits, “but there are ways to do things better.” She adds that, putting it all in perspective, telemedicine “isn’t a heavy lift in comparison to what you’ve already done with EHRs [Electronic Health Records] or e-prescribing.”

According to the American Telemedicine Association, “telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status.” It includes a variety of applications such as two-way video, smart phones, wireless tools, and other telecommunications technology.

Telemedicine is not a separate medical specialty; instead, it involves products and services used for the delivery of clinical care—including patient consultations via video conferencing, transmission of still images, remote monitoring of vital signs, continuing education, nursing call centers, and other applications.

In skilled nursing and assisted living settings, telemedicine is most commonly associated with video consultations for patients and facilities in rural settings. However, the uses are expanding rapidly. Currently, facilities are using telemedicine to manage acute changes of condition, chronic disease management, wound care, family/patient conferences, and staff education, as well as specialist consultations with psychiatrists, neurologists, and other practitioners.

What is driving the advancement of telemedicine? Why should people care about it?

“The drivers include the creation of alternative payment models and next-generation ACOs [Accountable Care Organizations] liberalizing the use of telemedicine. They’re doing away with rural restrictions for its use, and it’s taking off with initiatives such as CCJR [Comprehensive Care for Joint Replacement],” says Steven Handler, MD, PhD, associate professor of geriatric medicine and director of geriatric telemedicine programs at the University of Pittsburgh, in Pittsburgh.

“We’re seeing networks narrow, with hospitals selecting preferred nursing home partners based on their low rates of hospitalizations and readmissions. We think that telemedicine is a tool to help with this.” He adds that there are hospitals working with skilled nursing care centers to establish telemedicine programs to manage acute and chronic conditions. These efforts, he says, can help prevent unnecessary hospitalizations, the cost of which will quickly eat up bundling costs.

“If you reduce what CMS [the Centers for Medicare & Medicaid Services] defines as potentially avoidable hospitalizations, you can improve care and outcomes, while reducing cost,” Handler says. “Telemedicine is a new tool that can help nursing centers develop and sustain new hospital relationships, receive additional sources of funding by participating in some alternative payment models, and provide a new care delivery model.”

For the most part, long term/post-acute care practitioners are ready for telemedicine, according to Handler. He has conducted two surveys at AMDA—The Society of Post-Acute and Long-Term Care Medicine—conferences, and he says, “What we’ve heard was strong agreement that telemedicine has real potential to improve clinical care both for acute changes of condition to reduce potentially avoidable hospitalizations and speciality care to improve the management of chronic disease.”

The first study involved 435 attendees at the 2015 AMDA annual conference. “Respondents overwhelmingly agreed that telemedicine has potential to improve timeliness of care, as well as fill existing service gaps,” says Handler. At the same time, the physicians disagreed that telemedicine would hurt care effectiveness or jeopardize resident privacy.

When using telemedicine, respondents stressed the importance of technical characteristics such as high-quality audio and video hardware and the inclusion of a high-end electronic stethoscope. The survey results generally proved the hypothesis that practitioners see telemedicine as a useful tool to improve access to clinicians and eliminate the distance between people.

The second survey, conducted earlier this year at the AMDA conference, was designed to determine the perceived utility of providing specialty telemedicine in skilled nursing centers from the perspectives of physicians and advanced practice providers.

“This latest survey was designed to query about the types of services that should be provided as part of telemedicine,” Handler says. “Based on the volume of responses, a lot of people seem to care about this.” He notes that the majority of respondents he spoke with said that they don’t have a telemedicine program but want to learn more about it.

The few who said they currently use telemedicine “love it.”

Wound care nurses are valuable resources, but it’s impractical if not impossible to have one in every facility. However, thanks to telemedicine, it is possible to have that level of expertise.

“We started building our case on this concept. Then we started studying the technology and the telepresence utilized in the industry for wound care,” says Sheri Easton-Garrett, MSN, RN, vice president of clinical programming at Brookdale Senior Living in Brentwood, Tenn. She and other team members then selected equipment to use for a pilot.

“We chose the technology we did for several reasons. It was easy to control remotely, and there were other possibilities to use it beyond the wound care pilot. It had a scope to be applicable across multiple levels of care.”

Easton-Garrett and her team have several goals for the pilot. “We are looking at being able to do telewound care and consults with our wound care nurse to determine: Are we using the right product? How is the wound progressing? Are we training staff right?” To do this, Easton-Garrett and her team are using a model of telepresence robot, a sort of skype on wheels, only more sophisticated. The users can zoom in and out and direct the camera in specific directions.

“Sometimes people want to jump to technology because they think it solves everything,” says Easton-Garrett, but she stresses, “To get the most out of it, you have to go through a planning process. Our pre-process took about a year. Not only did we go through legal and information technology security issues, we conducted a complete analysis of what we wanted to look at and where you are starting,” she says.

“You can learn a great deal by doing what I call ‘shadow visits’—walking around, observing what is happening, what staff are doing, what types of dressing they’re using, and how they’re applying them,” Easton-Garrett adds. “You really have to do your due diligence. You have to narrow down the scope of what you want to accomplish—at least initially—then partner and conduct pilots. You need to be realistic about the resources you have, who will be using the technology, and how.”

The true success of any type of technology program, she says, “is the planning and effective introduction of the processes with staff and residents.”

Handler agrees that planning is essential. “We believe that to get consistent results, you have to go in and assess the facility and its infrastructure and supports, match it to the technology, and implement and test it.” This assessment and testing can help identify important gaps.

For instance, he says, “Some facilities say that they have robust Wi-Fi, but some facilities may have dead zones or insufficient bandwidth to support telemedicine consultations. Once you identify these issues, you can fix them before you get started.”

Chronic disease management is a key use for telemedicine, and Ryan Kelly, executive director of the Mississippi Rural Health Association, gives a powerful example of how this can work. Diabetes telemedicine was piloted in one of the poorest, least-educated counties in the country. Through the program, physicians consult with nurse practitioners who are monitoring patients, taking blood sugars, making sure patients are eating right and complying with their medications, and so on.

“Nearly all patients saw remarkable reductions in A1C levels; many aren’t even on insulin anymore,” Kelly says. “The ability to monitor these patients on a daily basis is key, and particularly in rural areas, telemedicine is the best—sometimes the only—way to do this.” He adds, “We now have a chronic disease management billing code that can be used” to cover diabetes telemedicine costs.

Moving forward, Kelly suggests, expect to see more telemedicine programs involving diabetes management, as well as telepsychiatry. He urges facilities across the continuum to get on board. “The worst thing you can do is to get the equipment and not use it. You need to train people and have protocols for its use.” There are barriers, he admits, but says that they aren’t insurmountable.

Neurology consults are another promising use for telemedicine. Amber Humphrey, assistant director of Vanderbilt Telemedicine at Vanderbilt University Medical Center, talks about her organization’s use of hand-held video conferencing with neurologists via iPad.

“When a patient has a stroke or neurological issue at a partner hospital and a neurologist isn’t available on-site, having something mobile and easy to use—a device that everyone is familiar with and can grab and use—is critical,” she says.

“We’ve had good results with this. Overall patient response to talking to the physician via iPad is positive. The immediate access to the neurologist makes them feel more comfortable,” she says.

Vanderbilt uses a Health Insurance Portability and Accountability Act (HIPAA)-compliant, cloud-based platform. The partner hospital uploads information that physicians get in minutes and can review before they are connected with a patient.

“Our goal isn’t to triage patients [to get them admitted to our hospital], but to keep them in the community at the most appropriate level of care,” Humphrey says. “Using this technology, we’ve found that our partner facilities can retain 85 percent of the patients.”

The University of Pittsburgh Medical Center has a robust telemedicine program that started with a problem and the desire for a solution.

“The chair of UPMC’s Department of Neurology, Dr. Lawrence Wechsler, was a stroke specialist, and he recognized that community hospitals often couldn’t treat stroke patients, which resulted in patients being transported to urban facilities, thus delaying treatment and resulting in progressive neurological damage,” Sokolovich says. “He believed that if patients could be treated sooner, their clinical outcomes would be better.”

Enter, telemedicine. The program has been so successful that UPMC has expanded its telemedicine efforts far beyond stroke. For example, Sokolovich says, “Our behavioral health leadership recognized the shortage and lack of access to behavioral health and began our telepsychiatry program. From there, we had additional physician specialists who saw opportunities to use telemedicine for things such as virtual rounding at community hospitals for post-surgical follow-up.”

Even though telemedicine increasingly is shown to have clinical value and cost-effectiveness, reimbursement still remains somewhat elusive. Traditionally, reimbursement for telemedicine in long term care was only eligible for use in rural settings. Handler says, “Physicians may be reimbursed for some subsequent care services in nursing homes. Specifically, CPT E&M codes 99307-99310 can be used with limitations of one telemedicine visit every 30 days per resident in a rural/nonmetropolitan area,” he says.

Telemedicine also may be reimbursable if used as part of certain ACOs, or other alternative payment models such as the Comprehensive Care for Joint Replacements bundled payment program.

Phase 2 of the CMS Innovation Awards includes funding up to $1 billion in awards to organizations that are implementing the most compelling new ideas to deliver better health, improved care, and lower costs to people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program. It allows participating facilities, regardless of their location, to use telemedicine to diagnose the qualifying conditions for keeping residents in the skilled nursing care center for an additional $218 per patient day.

“This is an incentive to the facility to keep residents in the facility and not send them to the hospital, and it eliminates the three-day qualifying hospital stay,” says Handler.

Skilled nursing centers that are involved in Phase 2 of the CMS Innovation Awards may receive money for managing a limited set of qualifying conditions in the care center instead of the hospital. Phase 2 allows for the use of telemedicine in addition to in-person visits to confirm the presence of a qualifying medical condition.

“On the private insurance side, they’re more embracing of telehealth, so there might be some reimbursement opportunities there,” says Easton-Garrett.

No matter how much planning goes into telemedicine programs or how much is invested in the technology, it won’t be effective if patients aren’t energized and engaged.

To get elders involved, according to Easton-Garrett, “you need technology that is easy to understand and use. Make sure that the contrast of the screen is appropriate for aging eyes; have the ability to change the font size. Some items may need Braille or voice prompts.”

To help residents embrace telemedicine, she suggests having focus groups and involving resident leaders in the community. Take the intimidation out of the technology.

“Have someone who can introduce it in a way they will understand. Be prepared to address their objections. For example, if they say that they’re too old to learn something new, remind them about what changes they’ve been able to manage. Make them feel empowered.”

Part of the reason the wound care telemedicine program works, says Easton-Garrett, is that the screen is at “conversational height” for people who are seated or in wheelchairs. Because they are comfortable and can easily engage and make eye contact with the nurse, they respond and interact easily.

Easton-Garrett and her team also worked to build excitement about the telemedicine program. “We had posters at the nurses’ stations and in the hallways—‘VGo [the name of the telemedine technology] Is Coming.’” And they asked for suggestions on names for the robot.”

As Handler’s survey suggests, practitioners generally are on board with telemedicine. However, he warns that there is bound to be some resistance for those who see this as just one more burden or responsibility.

“You have to create a telemedicine software interface for physicians and nurses that allows them to integrate this new clinical work flow and exceeds their current solution of using phones when providers aren’t available to see residents in person,” he says.

“We have learned that certain technologies are particularly important, such as high-quality audio, video, and an electronic stethoscope that is as good as listening to the heart, lungs, and abdomen as if you were in the same room as the resident. If you provide this functionality and demonstrate it for them, they will understand the value of telemedicine.”

Having a physician leader who also is a telemedicine champion also can make a difference, says Humphrey. “We have a neurologic telemedicine medical director, and he works on building partnerships with his colleagues in the field. It’s good to have physician leadership on board who are comfortable with telemedicine; they then socialize among their peers and get them to try it.”

“You can’t ask people to do something for nothing,” says Sokolovich. “For example, if you’re still reimbursing physicians on a fee-for-service basis, this needs to be included in their contract. You need to integrate telemedicine as something they get credit for and enables them to achieve the minimum standards required of them.” She adds, “As you build momentum with clinicians, it becomes viral and exciting. And before you know it, more people want to leverage the technology.”

Leveraged effectively, telemedicine “absolutely will make you a more desired player in the new world of health care,” says Easton-Garrett. However, she cautions, “It’s never just about the technology. You need to make it high-touch as well as high-tech. It’s about the ability to provide a higher level of clinical resources and services to support acuity and provide quality, cost-effective population health management.” That, she says, is what ACOs and hospitals will be seeking in their partners.

Sokolovich agrees. “CMS is toward more to bundled payments and looking at outcomes. Facilities and organizations that successfully leverage technology will be rewarded and will thrive.” At the same time, she predicts that consumers increasingly will expect this technology.

“It’s a competitive marketplace, and as consumers have more skin in the game with out-of-pocket expenses, they will shop for health care as they do for other products. Facilities that have innovative programs such as telemedicine are more likely to be attractive.”

“This type of technology is compelling. It shouldn’t and can’t replace hands-on care. However, it can be useful when a practitioner can’t get to the facility or when the resident has an acute change of condition, and it’s viable to avoid a hospital transfer,” says Handler.

Implementing telemedicine may not be easy, but it doesn’t have to be hard. “Facilities have implemented EHRs and other changes. They can do this,” says Sokolovich. “Waiting around won’t make it go away. The train has left the station, and it’s moving rapidly. Get on board, or you will be left behind.”