The Landscape: As the U.S. population ages and the number of patients with chronic conditions continues to rise, hospitals are beginning to leverage remote technology to improve care post-discharge and cut down on avoidable hospital readmissions. In addition, rural areas with increasingly limited access to specialists are using telemedicine to provide care without transporting patients from small, critical care hospitals into the larger cities.
The Future: As healthcare reform begins to change the payment structure, episode of care reimbursement will provide the push for hospitals to increase their chronic care management programs. The cost of technology for in-home monitoring is rapidly dropping, and patients will begin to play a greater role in managing their own care. In addition, Washington's pledge to increase the national network infrastructure means that rural areas will have better, faster connections to link specialty services to the cities, and the use of telemedicine for specialty services like telepsychiatry, telestroke and wound care may rise.
Changes from Washington are coming. Though many areas of telehealth, like e-ICUs, have seen steady growth in recent years, many believe a slew of different initiatives lumped under ARRA are going to provide the push to make these technologies more mainstream.
In rural areas, for example, Rural TECH (Telemedicine Enhancing Community Health) Act of 2009 aimed to increase the use of telehealth technologies like video conferencing to connect medical experts with providers, facilities and patients, and provide critical health services and education. The Act created three telehealth pilot projects to analyze clinical health outcomes and the cost-effectiveness of telehealth systems in medically underserved communities.
“We do not have a shortage of specialists, we have a disproportionate distribution of specialists,” says Gregg Malkary, founder of Menlo Park, Calif.-based Spyglass Consulting Group. “They're all in the cities.” Today, telemedicine systems such as Netherlands-based Phillips Visicu e-ICU - already in use in many small critical care hospitals - are linking city-based specialists to rural areas and allowing patients to receive care without leaving their communities. And most say that as infrastructure improvements abound, the trend will continue to grow.
According to Marc Holland, principal in the New City, N.Y.-based System Research Services consulting firm, ARRA provisions state that by 2011, the National Coordinator for Health IT (currently David Blumenthal, M.D.) is obliged to present recommendations to the Senate in this area. “There's a billion dollars for improving the broadband infrastructure in this country,” says Holland, “and telemedicine was cited as part of that push.”
In total, the USDA has awarded more than $1.5 million in Rural Utility Service (RUS) grants to hospitals around the country to fund expansion of e-ICU critical care services to rural communities. ICU telemonitoring programs are closing the coverage gap as physicians and critical care nurses, staffed 24/7 at an e-ICU hub, can now assist bedside caregivers in the diagnosis, treatment and management of critically ill and trauma patients.
“We're seeing an increased demand for specialists and certainly not a growing supply,” says Ken Lawonn, senior vice president and CIO at Alegent Health in Omaha, Neb. “What we're seeing is building out a better network infrastructure for higher speed connections between the smaller communities so we can do some things that are above and beyond what you can do on low speed connections.”
Alegent is currently using Visicu's e-ICU technology to monitor 120 beds in eight locations, and Lawonn says the plan is to expand further. “We're working on a plan to offer it to non-Alegent small critical care hospitals,” he says. “We think it would provide not only better care and some revenue, but also provide a connection with the community and help with referrals - we do have some competition in the area.”
While e-ICUs have experienced early popularity, the scarcity of rural specialists is having an effect on other telemedicine initiatives as well. The Atlanta-based Centers for Disease Control, for example, recently awarded a three-year grant to the Louisiana Department of Health and Hospitals Heart Disease and Stroke Prevention Program to build a telestroke network in collaboration with Ochsner Health System and the American Heart Association.
Ochsner, a seven-hospital system based in New Orleans, plans to utilize Reach Call's (Augusta, Ga.) telestroke and telehealth services to improve stroke care in urban and rural areas throughout the state by connecting neurologists with patients. The aim? To develop a regional TeleStroke Network in southeastern Louisiana that will address the lack of access to stroke neurologists and availability of stroke-treating hospitals in the state.
It starts at home
And while telemedicine solutions geared toward specialty services continue to grow, many feel that chronic disease monitoring in the home will see some of the most explosive growth in the years to come. Many say broadband penetration into homes, coupled with the emergence of more sophisticated portable medical devices, will push the point of healthcare delivery to the home. According to a report from New York-based PricewaterhouseCoopers, the remote medical care market for telehealth services is expected to top $1.8 billion by 2013, up from $77 million in 1995. Broadband expansion has also caused telecommunications giants like ATandT and Verizon to enter the market with home health offerings (see sidebar).
And as legislation changes transform the reimbursement model with bundling and preventable readmissions penalties, many expect home monitoring for patient management to spike.
Warm and Fuzzy Data
Telecommunications companies are rushing to get a piece of the telehealth pie by developing wearable health devices that connect with home health networks. Dallas-based ATandT, for example, recently unveiled a prototype for foot-signature telemetry in the in-sole of slippers to detect or even prevent falls. These “smart slippers” have embedded pressure sensors to help prevent falls in elderly patients by relaying messages to a doctor if the wearer starts walking erratically. ATandT hasn't yet set costs for either the product itself, or the accompanying wireless service needed to deliver notifications.
Another research project is a networked pill-minder that provides a voice reminder to take a pill when required, and also sends information on which pill was taken and when, to a database that can be examined by physicians.
Currently, however, most agree that reimbursement presents a knotty situation. According to Malkary, the real return is for IDNs that are both payer and provider, such as Oakland, Calif.-based Kaiser Permanente and Rochester, Minn.'s Mayo Clinic. “When a hospital is part of an IDN, the goal is to keep the diabetic patient out of the hospital,” he says. “For the non-IDN hospitals, they want the diabetic who needs his leg removed.”
Holland agrees that changes in the reimbursement model will drive change. “If you can perform all the services and meet the quality, you get to keep the difference,” he says. “There will be a restructuring of the reimbursement system first with Medicare - which will require validation through pilots - and all the private insurers will follow suit.”
And regardless of how things play out with Medicare, Holland says the price of the technology itself is decreasing, which is enabling hospitals - and patients - to purchase it more easily. “That is going to drive this market even absent a change in reimbursement,” he says.
Alegent, like many health systems, is using in-home monitors for its home health division, says Lawonn. “We have some pretty crude ones that connect to the telephone, but there are exciting new technologies coming out. It's an increasing area but hasn't gotten critical mass yet.” He believes changes and incentives in reimbursements to keep patients healthy will drive the change. “It's the right thing to do anyway.”
Many of the newer home monitoring technologies are also less invasive, and can include devices like GPS tracking for Alzheimer's patients and even medication compliance tools.
But the biggest problem with home monitoring is managing the data. “It's like home security monitoring - home security is like the burglar alarm in the house, and the physician is like the police that's only notified if the situation warrants it,” says Holland. “The question is ‘who is going to be ADT?’”
“When a hospital is part of an IDN, the goal is to keep the diabetic patient out of the hospital,” he says. “For the hospitals, they want the diabetic who needs his leg removed.”
A sound strategy, believes Malkary, is a call center that would monitor the data transmitted from the home-based patient. “The care is only as good as the data you have,” he says. “If the home health nurse only takes vitals when they're there for a visit, you're operating in the dark.”
Though call centers may be on the horizon, they are not commonly used today. At University of Illinois Medical Center, for example, CIO Rose Ann Laureto says the home telemanagement model includes an advanced-practice nurse who works with a cardiology fellow and an attending cardiology physician. Clinical goals are set as desired ranges for blood pressure, heart rate, weight, and laboratory values specified in each patient's individual medical plan. The advanced-practice nurse evaluates the data transmitted by the patient, conducts telephone assessments, titrates medication therapy, and conducts patient education as needed to achieve the goals of the medical plan. Patients with heart failure use trans-telephonic home monitoring devices to measure their weight, blood pressure, heart rate, and oxygen saturation level, says Laureto.
But many say the missing link is getting all that telemedicine information into the patient's EMR. “What would be ideal is when it connects into the clinical system so the alert goes right into the patient's chart and a nurse responsible for the patient is notified,” says Lawonn. “That way you don't need a separate monitoring system.”
Many believe the missing links may fill up fast due to the shortage of caregivers with the right skill sets. “As Medicare approves more and more telemedicine modalities, the floodgates are going to open,” says Holland. “It will be a trickle in the beginning but it's going to be a pretty steady flow.”
Healthcare Informatics 2010 February;27(2):28-58
