In a recent article about telehealth policy progress, I led off with an anecdote about how families in Delaware struggling with Parkinson’s disease used to have to travel to Baltimore or Philadelphia for care because there are no Parkinson’s specialists in the state. But many of those families got involved with the nonprofit Delaware Telehealth Coalition and this year successfully petitioned the state legislature to pass a bill to require commercial insurers to cover telehealth visits. Yesterday I attended an all-day conference at the University of Delaware, where healthcare leaders from around the state came together to assess how they might take advantage of the changing legal and policy landscape.
In a panel session, four executives described their successes and challenges with telehealth to date. Albert Rizzo, M.D., section chief of pulmonary and critical care medicine for Christiana Care Health System, spoke about how Christiana has several years of experience with a virtual intensive care unit. For several years it provided that service to smaller community hospitals in Maryland, as well as within its own organization.
Rizzo said it was sometimes difficult to find enough physicians to cover the overnight shifts, so eventually Christiana outsourced that service to Adventist Health System in Chicago. Regardless of the reimbursement scenario, the hospital sees value in continuing the eICU, he added. “Our care has improved, mortality is down, as are days in the ICU, so it was a good investment,” he said. The biggest challenge was building trust between one side of the camera and the bedside. Some clinicians may have seen it as ‘big brother’ looking over their shoulder finding mistakes. “We dealt with that by building a collaborative approach in value improvement teams across ICUs, but trust and personnel were challenges.”
Rizzo said Christiana is finding it can expand what it monitors beyond intensive care to other floors to catch early signs of sepsis to save people from going back to the ICU. Other parts of Christiana are looking at home uses for telehealth.
Michael Kurliand, M.S., B.S.N., R.N., is the director of the telehealth program at Nemours Aflred I DuPont Hospital for Children in Wilmington. He said Nemours is aggressively launching programs connecting pediatric clinics and emergency departments at hospitals in southern Delaware to Nemours. It has 11 programs up and running and an aggressive timeline for new ones including cardiology and rheumatology. He said one challenge is finding the right telemedicine tools. “There are a lot of companies out there. Everyone says they can do everything and they can’t, so we have to vet them all,” he said. (Several speakers mentioned the challenges of integrating the data from telemedicine systems with the patient’s record in an EHR.)
Kurliand said that once Delaware gets over the foundational bumps and bruises of getting infrastructure in place, there are many exciting potential uses of telehealth for care coordination and remote monitoring. He described an outpatient clinic in southern Delaware on weight management and nutrition. Once they changed from in-person to telehealth visits, the no-show rate dropped from 35 percent to less than 10 percent, he said. He added that Nemours is looking at programs that would allow for telehealth visits in the patient’s home. “It is early yet, so we don’t know how that is going to be seen. But it may be a good opportunity to be in a patient’s own space.”
Nataleen Villabona, R.N., a behavioral health nurse for Beebe Healthcare in southern Delaware, described her hospital’s use of telepsychiatry. Because there is a shortage of psychiatrists in southern Delaware, Beebe has worked with a company called InSight Telepsychiatry for four years. The company, which has15 psychiatrists licensed in Delaware, does assessments and offers care 24/7. Villabona plays an intermediary role between the patient and the psychiatrist on the screen. She talks to patients and gathers collateral information to share with the provider before the visit. “Some patients might be scared to talk across a computer screen, so the nurse can play the role of buffer between the patient and psychiatrist,” she said.
Ingrid Pretzer-Aboff, Ph.D., R.N., an associate professor at the University of Delaware, School of Nursing, works in the university’s Nurse Managed Health Care Parkinson’s Disease Clinic. The clinic uses telehealth to reach out to specialists for consultations, and to work with nurse practitioners at other locations around the state.
She said the clinic gets many requests to expand to other counties. Even though Newark is closer than Baltimore or Philadelphia, it is still an 80-mile trip for many patients. “We are growing carefully and gradually,” she said. “We are limited by the time we get from physicians.” Pretzer-Aboff said providers should do more with telehealth to reach people in their homes. “We can reach them where we couldn’t before, but we need to do more to get into people’s homes. The population that I deal with is Medicare patients, and telemedicine is not reimbursable for them. That is the huge boulder in front of us.”
In a keynote talk, Karen Rheuban, M.D., director of the University of Virginia Center for Telehealth, said that although there are many opportunities to work at the state level through the Medicaid program, health systems and corrections, getting Medicare to change its reimbursement policy of paying only for rural telehealth is the No. 1 challenge. “Medicare is the nation’s largest payer, and it is discriminating against urban seniors. The policy is misaligned with specialist shortages,” she said, adding that the initial accountable care organizations were not reimbursed for using telemedicine, (although the next-generation ones will be). But she said there are great opportunities to use telehealth for chronic disease management, such as working with home dialysis patients and partnering with the Veterans Administration to better care for veterans.
