Are we at an inflection point in terms of telehealth in U.S. healthcare? The policy, business, operational, clinical, technological, and IT aspects of telehealth’s moment were discussed broadly in a panel discussion on July 22 at the Sheraton Downtown Denver, during a session at the Health IT Summit in Denver, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics under the Vendome Group LLC corporate umbrella.
The session entitled “Telehealth: Colorado and Beyond,” was moderated by Heather Haugen, PhD., Instructor and Co-Director of Health Information Technology, University of Colorado, and its additional participants were Peter Kung, system vice president, virtual Health, SCL Health (Broomfield, Colo.); Samantha Lippolis, telehealth manager, Centura Health (Denver); Kate Kiefert, state HIT coordinator for the State of Colorado; and Debbie Voyles, director of clinical operations, telehealth, at Colorado Access (a Denver-based health plan serving the Medicaid and underserved populations).
“Let’s start with some of the changes in opportunities in legislation that have come our way,” Haugen said. “Legislation was passed in May expanding access to telehealth in Colorado. Can you tell us about that?”
Lippolis of Centura Health said, “We had been working for legislation matching federal reimbursement. If a patient is located in a rural area, then commercial payers were required to reimburse for that. Working this year in the legislature, we were able to get that updated. So as of Jan. 1 2017, all commercial payers will be required to reimburse for telehealth services, and the definition has been broadened beyond the historical understanding of it. It’s opened up to urban telehealth, so you can say, would you like to come back here to see your cardiologist, our primary care office, or drive through traffic to see the cardiologist in person? That makes a huge difference for us. It’s very difficult to roll out telehealth in very segmented, rural locations only. We still have the carve-out of Medicare, but this makes a huge difference.”
“This is a really significant breakthrough. What does it mean for patients?” she asked.
SCL Health’s Kung, noting a show of hands of audience members polled on whether they were involved in expanding telehealth in their organizations, said, “It was very encouraging that 40 percent of this audience raised their hands saying that they were involved in this. Kaufman Hall has said this would grow from $20 billion to $40-50 billion a year. We’re moving away from proof of concept and piloting, around telehealth and virtual care. We’re reducing readmissions. And hospitals are going to say, this is actually a growth initiative, strategic to objectives. Sustainable, scalable model will be based on if it’s good for the patient, good for the organization, and good for the community. And I think many hospital organizations will be willing to take the risk and provide better quality at lower cost.”
Kiefert, of the state of Colorado, noted that “The 1029 legislation removed the barriers of location and specific provider and cost—and at Children’s Hospital, which is a significant referral center from several states—a pediatrician can see the patient in Montana and the surgeon can see the incisions from a surgery remotely, without having to bring that child patient back, 10 hours away. So it’s really modernizing and broadening what telehealth can do.”
“Yes, that parity in payment is something we’ve been looking for,” said Haugen. “Now, nationally… a lot of us have been frustrated by a lack of reciprocity across state lines. Nationally, what things are going on?”
Colorado Access’s Voyles said, “You reference cross-state licensing—if you think about the impact that that can have—the VA has that now, and it’s huge. If you look at the analogy of having a driver’s license, and you’re licensed in a particular state, but you’re allowed to drive in other states, if you know the rules. I learned the hard way that in Hawaii, you can’t make a u-turn unless there’s a sign posted saying you can. I was driving there on a Texas license. So I think cross-state licensing will give patients access to the best care possible anywhere.”
Kiefert explained to the audience that Colorado’s Department of Regulatory Affairs (DORA) is in the process of preparing to change rules and guidelines that had been “in conflict with each other,” and that had been barriers to expanding telehealth efforts. DORA as an agency holds a majority of the professional boards in healthcare in Colorado, she noted; it supports the 29 medical professional boards, of which five are mental health medical professional boards. “There are rules and guidelines for all healthcare professionals, and they had rules that were in conflict with each other,” she added. “So you can have legislation removing barriers and providing for payment parity, but they’ve been working through establishing the provider-patient relationship—can you do that remotely? And how can you establish the protocols for telehealth. Some of the language in the rules had been interpreted very conservatively. So they’ve been working on this, and receiving open comments, so they’ll be providing recommendations on this.” In fact, she reported, DORA is expected to produce a set of recommendations in this area in August.
So what are some of the biggest challenges going forward right now in terms of expanding telehealth access, on a nationwide level? “We know that healthcare is very fragmented,” said Voyles. “And across the U.S., it’s estimated that we need 40,000 child psychologists to meet all the needs out there. And right now, we have about 7,000. And know that it’s not that people don’t care about this, when you’re frustrated in getting your child into see a psychiatrist, but rather, that there aren’t enough of them. We have to integrate behavioral healthcare into that primary care setting.”
What’s more, Voyles said, “We need to work with primary care providers on how to better manage those cases. Primary care providers—I applaud them—they have to know about a lot of things. They’re expected to know a little about a lot of things. But especially when it comes to dealing with kids—by bringing in a mental healthcare provider in to consult with them, and to help that primary care provider make sure of their diagnosis, that’s huge. And then only the kids who need to be assessed or access to a psychiatrist—most kids only need access to counseling—but we’re trying to figure out a better mechanism and a better plan, to help those providers reach out and provide care for more kids. But it’s a challenge because we don’t get paid for that physician-to-physician consult, and that’s a barrier. But that’s an area of challenge, and where chose to make a difference.”
“Per fragmentation,” Kung offered, “the future of virtual health could really make a difference. I’ll start operationally. Sometimes, even within our own organizations, we’re siloed within our own organizations. And not only do you need the technology—you need the operations people and the clinicians, all coming together. And all boats rise on this tide, and sharing is one of the key, really interesting parts of this. But if we’re talking about fragmentation in healthcare, we have to not create a virtual care network disconnected from the main healthcare system. We want to be available to patients, absolutely. But we need to have that tie-in of virtual to a physical health system, and we have to provide that continuity of care. That’s where virtual health could really add value to healthcare systems.”
“And we know that it would be possible to create silos of care,” Haugen said. “So how do we ensure—and I’m watching organizations, including the University of Colorado, partnering with those clinics. Are we making some connections?”
Lippolis noted that “A traditional challenge for us in telehealth has been all these pilots, based on grant money. And so it’s very difficult for leadership to understand that this is just one more tool to deliver healthcare. And so just as organizations have developed strategies around ambulatory care and so on, we need to integrate this into everything we do, so that a physician’s normal daily practice is, patient #1 is in room 5; patient #2 is on my video screen; and patient #3 is in room 6. And if you provide a half-day a month endocrinology clinic, how is that really improving access? You need to think about how you provide telehealth as part of a [normalized] full range of healthcare services.”
Haugen asked panelists what the impact of the development of accountable care organizations (ACOs) will be on efforts to expand telehealth access going forward.
“It’s going to be a challenge,” Voyles said, “and part of the challenge is that the technology is the easy part overall, but there is a challenge in the technology in how you’re going to reach into a person’s home.” Now, as care delivery actually moves literally into patients’ homes, using Internet- and cloud-based solutions, she said, “You have to make sure the patient has adequate bandwidth and a computer, to bring in virtual providers. And that’s a challenge, and it’s a challenge to CIOs, because how do you secure that connection? And there are firewall issues, etc. So all the IT folks have to work together—we have to figure this out. There’s not going to be one solution; we have to work towards interoperability among all telemedicine systems, so it doesn’t matter what [technology] the patient has, or the physician has. We’ve got to figure that out. And you’ve got to make sure that whatever you go with is interoperable with other systems. So that’s a challenge. But you know, patients are going to demand access. My kids’ generation, they want immediate access to information. “
And, on a very broad level, Kung said, “We are seeing the consumerization of healthcare in certain segments. I want to be sensitive to securing data; we’ve got to do that right. On the other hand, I look at the other companies that are driving the consumerization, the Amazons, the Apples, the Googles—they’re coming into the space. And venture capital is on track to provide $4 billion in healthcare in 2015--$2 billion has been spent already. And if healthcare doesn’t choose to disrupt ourselves, someone else will do it for us. So we’re seeing what our patients want and need. So yes, we do need to keep it safe and follow regulations, but I would look at leveraging knowledge from other industries, such as the banking industry,” to find solutions to some of the challenges facing telehealth going forward.
