Jan. 3, 2012
A fundamental change in the way healthcare is delivered is rapidly gaining ground in the United States.
A fundamental change in the way healthcare is delivered is rapidly gaining ground in the United States. Telehealth (or telemedicine) is connecting patients and providers — or providers and providers — in ways that don't rely on face-to-face contact. In remote or underserved areas, it can be a way to deliver specialty services and education by optimizing the use of available professionals. And even in large urban areas, the rise of e-ICUs and other telehealth specialties like e-pharmacy, e-dermatology and even e-psychiatry makes the sting of specialty shortages less acute.
Marc Holland
In what many say will be the most far-reaching consequence of this trend, patients, through remote monitoring at home, can begin to take charge of their disease — with chronic conditions managed effectively in a home setting, conserving valuable hospital resources for the most critical cases. With the costs of treating chronic conditions at a staggering 75 percent of the $2 trillion health expenditure, according to Health Industry Insights, a consulting company based in Framingham, Mass., remote patient monitoring (RPM) technology will be an effective way to address that cost. “There are many drivers that will feed growth in this area,” says Marc Holland, research director of the company. Those drivers, he says, are the increasing prevalence of chronic conditions, the aging of baby boomers, the escalating shortages of medical professionals, and the spiraling cost of care.
Ken Lawonn
Source: HCI Online Poll, December 2008

Two legislative acts passed in July of 2008 may also spur growth: the approval of Medicare reimbursement for telemedicine-enabled follow-up inpatient consultations, and the expansion of the list of qualifying sites authorized to bill Medicare for telemedicine services.

In addition, millions of dollars in government funding have recently become available to states that will support telemedicine expansion, often through broadband and connectivity initiatives. For example, six hospitals in rural Maryland will implement Baltimore-based Visicu's eICU, thanks to a $3 million grant from CareFirst BlueCross BlueShield (Owings Mill, Md.). And in November, the USDA awarded more than $1.5 million in Rural Utility Service grants to hospitals around the country to fund expansion of e-ICU services to rural communities.

The solutions

One recipient of that grant is Alegent Health, a nine-hospital system in Omaha, Neb., which according to CIO Ken Lawonn, will use the grant money to expand the telemedicine program it already has in place. Alegent will be growing the program to its four rural hospitals, along with another four that are part of a critical access network. “The grant can help us offset the cost of expanding the service to the rural hospitals,” he says.

The grant will be used to fund the e-ICU start-up costs — equipment licenses, integration and connectivity for the small facilities and, for those that need it, new patient monitoring equipment to connect to the e-ICU equipment. Lawonn says his telemedicine program was driven by patient safety. There was a shortage of intensivists and clinicians to support the ICUs in his hospital system. “Being able to provide the effective level of coverage was impossible, so we're really driven around how do we ensure a high level of quality and safety in our ICU without having to transfer patients around.”
Joseph Kvedar, M.D.

Though the rural applications like e-ICU and specialty visits are exciting, some of the most cutting-edge work is being done in urban environments like Boston-based Partners Healthcare. Its Center for Connected Health, operational since 1994, has been a pioneer in many areas of telemedicine, including the growth area of home-based monitoring.

Founder and Director of the Center, Joseph C. Kvedar, M.D., says the program has continued to evolve in ways no one could have predicted. “The biggest lesson learned is that we thought the big story was going to be that we were able to empower our clinicians with a richer data stream to make a thoughtful decision about care,” he says. “What we found was that the patients themselves become their own provider.” Kvedar says patients using home monitoring became very involved in their own care and started making decisions about how to manage their lifestyle, and stay out of the hospital. “That's why we've continued to design it more and more patient-focused.”

At Partners, the telemedicine program has expanded its specialty visits to include e-visits for dermatology, cardiac and more. And at Alegent, Lawonn is also planning to expand the telehealth program. “We have a strategy called the e-hospital that looks at those very scarce and high specialist services that are difficult to staff and recruit to. We're looking to see whether we can extend this model to provide coverage from a central location,” says Lawonn, who is already using an e-pharmacy model with a pharmacist around the clock in his central location.

In November, both Intel and Microsoft announced RPM pilot projects with major healthcare organizations. Intel's Health Guide, an FDA-cleared medical device that connects patients with chronic conditions to their providers, will pilot at 26-hospital Providence Health, which spans five states in the Pacific Northwest. And at the Cleveland Clinic in Ohio, Microsoft is partnering on a study that will involve a combination of commercially available home health monitoring devices, Microsoft HealthVault and Cleveland Clinic's MyChart personal health record system.

“The technical challenge is first getting that data into the patient record,” says Jonathan Edwards, research vice president at Stamford, Conn.-based Gartner, noting that CIOs need to consider where the data generated by remote devices will reside. “Where do you put that data, and how do you bring it all together so the physician doesn't have to look at several different Web sites?” he asks.

And, as with any new technology, culture change is important. “The stumbling block is whether the organization is willing to make a serious commitment to re-thinking the way they treat chronically ill patients, and to develop programs of chronic care management,” says Edwards, adding that they he often hears, “Oh, and by the way, should we use IT for this?”

In light of the current economy

Most agree that the rate of market growth for RPM will be predicated on demonstrated clinical efficacy and healthcare cost reductions; however, it will also depend upon the willingness of payers. According to Holland, though progress is being made, there is a limited degree of current third-party reimbursement. And while Medicare has reimbursed for telemedicine-enabled services for almost 10 years, its expansion of the list of approved services and qualifying providers has been spotty and slow.

Lawonn says he looked at ROI carefully, even though Alegent's drivers for the e-ICU program were principally about quality and patient safety. “We looked at what we were paying for pulmonologists and intensivists to provide coverage 24/7, the cost of back-staffing and e-ICU nurses. Then we looked at the financial perspective of keeping people out of the ICU.” He also analyzed the effects of optimizing the ICU on LOS with an e-ICU. “If you've got a bottleneck in the ICU, you can turn those beds around.”

Kvedar agrees that there is value in keeping some patients out of the hospital, because that helps with throughput. “When you start to look at things as a system, it's okay to keep patients out of the hospital, as long as there's excess demand and the beds are full.” This is particularly true, he adds, now that Medicare will no longer pay for readmissions one month later. “When you look at, for example, heart failure cases, typically they're money losers, and when you look at the 30-day readmission rate, you've got a pretty compelling business case. Even if you are a hospital and your primary revenue source is having sick patients in beds, it may make some sense to keep patients out of the hospital.”

Edwards says the cost of a telemedicine program can be offset by leveraging another cutting-edge application of the technology: the use of video for administrative purposes. “The use of video is clearly a great opportunity for cost savings on administrative and team meetings,” he says. He's seen hospitals use the cost savings they get in implementing video for reducing travel costs as a means of justifying the use of video for patient care. According to Edwards, CFOs may be reluctant to commit dollars to a video program for patient care. “They'll quite rightly say, ‘Where's the revenue generation?’ But you can prove that it reduces travel costs for clinicians and improves the patient experience and improves the brand of the organization.”

There are ways to help ensure success for a telemedicine program. Lawonn found the key was getting active involvement from the medical staff — and by that, he means not just having intensive care on board, but getting internal medicine and primary care involved early on to help find the appropriate places for telemedicine.

“There are still challenges in the effective coordination of that care and who is responsible for what,” he says. “Get the nurses and physicians engaged up front to walk through that process. Some physicians don't like the thought of it and it can be a little threatening, so you have to open up the lines of communication and really have people understand what it is, what it isn't, and what the options are.”

Healthcare Informatics 2009 February;25(14):42-44

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