the end of telehealth - ashnha · best for patient care. helps me communicate with a doctor. saves...

The End of Telehealth … as we know it

Stewart Ferguson, PhD Chief Information Officer (CIO)

Alaska Native Tribal Health Consortium


Patients Served by Telemedicine in North America

Courtesy of Jon Linkous, ATA

Alaska Native Tribal Health Consortium 3

Massachusetts-based telehealth leader American Well announced the launch of its direct to consumer service in Massachusetts. The service offers a new level of healthcare convenience and affordability for Massachusetts residents, who can now see a doctor without an appointment anytime 24x7x365, using a live video connection over their mobile device or via the web. Online doctor visits at American Well cost just $49, compared with a statewide average of $85 for in-office urgent care visits, according to the Healthcare Blue Book.

Medicaid - State Telemedicine Reimbursement for Physician Services (2014)

Reimbursement for telemedicine-provided physician services

No reimbursement

2014 TELEMEDICINE LEGISLATIVE ACTIVITY

Enacted Telemedicine Bills 2013

* * *

*

*

*

* * *

*

*

States with Parity Laws for Private Insurance Coverage of Telemedicine (2014)

States with the year of enactment: Arizona (2013)*, California (1996), Colorado (2001)*, Georgia (2006), Hawaii (1999), Kentucky (2000), Louisiana (1995), Maine (2009), Maryland (2012), Michigan (2012), Mississippi (2013), Missouri (2013), Montana (2013), New Hampshire (2009), New Mexico (2013), Oklahoma (1997), Oregon (2009), Tennessee (2014), Texas (1997), Vermont (2012), Virginia (2010) and the District of Columbia (2013) States with proposed/pending legislation: In 2014, Connecticut, Florida, Illinois, Iowa, Massachusetts, Nebraska, New York, Ohio, Pennsylvania, Rhode Island, South Carolina, Tennessee (ENACTED), Washington, and West Virginia *No state-wide coverage. Applies to certain health services and/or rural areas only.


Hype Cycle for Telemedicine, 2011 Published: 28 July 2011

Hype Cycle for Telemedicine, 2011


As we know it in Alaska …

• Need is well defined and accepted

• Fairly ubiquitous connectivity

• Payers do pay • Proven technologies • Expanding VtC

• Many successful programs. • Somewhat limited to specifics

orgs, groups or technologies: – AFHCAN – ATHS – API – ASHNHA – VA – Tele ICU – TelePharmacy

• Standalone systems


ATHS (Alaska Tribal Health System) (1/1/2000 to 6/30/2014)

05,000

10,00015,00020,00025,00030,00035,00040,00045,000

Case

s Cre

ated

Cases Created per Year

3-5% of all encounters



05,000

10,00015,00020,00025,00030,00035,000

# Pa

tient

s

Annual Patient Involvement

20% of all patients



$0$1,000,000$2,000,000$3,000,000$4,000,000$5,000,000$6,000,000$7,000,000$8,000,000

Annual Travel Savings (by Case Role)

Primary Care Specialty Care



0%

5%

10%

15%

20%

25%

30%%

Cas

esTravel CAUSED (by Case Role)

Primary Care Specialty Care


Telehealth Impact on Extended Waiting Times (> 4 months)

Data courtesy of Phil Hofstetter

47%

8%

3%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Pre-Telemed1991-2001(n=1216)

With Telemed

2002-2004(n=276)

With Telemed

2005-2007(n=210)

Perc

ent A

ppoi

ntm

ent A

vaila

bilit

y W

ith 5

M

onth

or L

onge

r Wai

t Tim

e

13


Asynchronous Expansion to Primary Care

• Health aids create all non-emergent patient cases and primary care provider (physician or mid-level) will consult less than 24 hrs.

• Development of synchronous and asynchronous systems on handheld applications improved consulting dramatically.

• Able to access dermatologist and primary care provider out of country.


0

2000

4000

6000

8000

10000

12000

14000NSHC Telemed Cases Created 2001 - 2014


1. DROP THE “TELE”

We are already seeing many examples of widespread adoption of “telehealth” in healthcare, that we need to consider this being part of

healthcare and not a unique service or delivery mechanism.

16

WHY DO OUR PROVIDERS USE IT? What will it take to do more telemedicine?

17


0200400600800

1,0001,2001,4001,6001,800

# Pr

ovid

ers

Annual Provider Usage(by Experience)

Return New

Alaska Native Medical Center (ANMC) (1/1/2000 to 6/30/2014)


Original Premise: Survey High Users

• Do we REALLY know what matters to our most important customers?

• Or do we ASSUME

we know?

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Comparing Providers

20

High User

Medium User

Low User

500 or more cases Minimum of 10 in 2010

100-499 cases Minimum of 10 in 2010

10-99 cases Minimum of 10 in 2010

Initiator (22)

Consultant (49)

Initiator (120)

Consultant (112)

Initiator (222)

Consultant (159)


0% 10% 20% 30% 40% 50% 60%

Best for patient care

Helps me communicate with a doctor

Saves my organization money

Most convenient to the patient

Improves patient satisfaction

Makes me more efficient

Gives me confidence in doing the right thing for the patient

Increase access to care

Why do you do Telemedicine?

• Best for patient care • Increased access for care

21


Why do you do Telemedicine?

22

• Initially use telehealth because of clinical uncertainty – Right diagnosis? – Right treatment?

• “Ability to communicate with a doctor” very important to initiators – Many non physicians in AFHCAN system

• With increased use and experience, appreciation for efficiency develops


AFHCAN Product Development


Rate the Importance of New Features

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Voice Recognition 2.4 Patient Education Content 3.3 Image Annotation 3.4 Video Clips 3.3 Instant Messaging 3.0 Live Video on demand 3.1 Forms - structured information 3.8 Training Materials (multimedia from software). 3.5 Portable unit for case intiation 3.3 Use on hand held devices (iPad, iPhone, smart phone). 3.2

1 Not important

2 Somewhat unimportant

3 Somewhat important

4 Very important

5 Extremely important


AFHCAN

Success with eForms • Enterprise sharing • Versioning • User customizable

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

# Ca

ses

Device Utilization - # Cases (by Year)

Electronic Forms

Scanned Images


Rate the importance of EHR Integration

Listing patients from your EHR database (so you can select a name to start a telemed case). 4.0

Providing a patient health summary obtained from the EHR with every telemed case. 4.0

Receiving hospital discharge summaries, sent to you as a telemed case. 3.7

Providing a text summary of the telehealth case in your EHR. 4.1

Providing a link in your EHR that would open the telehealth case. 4.2

Providing the complete telehealth case with text, images and other attachments, in your EHR. 4.1

1 Very unimportant

2 Somewhat unimportant

3 Somewhat important

4 Very important

5 Extremely important


Comments EHR

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“I was very disappointed when I was informed that I have to now begin to use the EHR. The telemed was working very well for me. Now I hardly ever

use the telemed…”

“…using EHR and because of this, I can't use my beloved Telemed as often and I feel this is to the

detriment of my patients.”

“Whatever happens next, it is VITAL that Telemed software be compliant with all versions of EHR.”


AFHCAN

Challenges with “Full EHR Integration” • Unknown Patient – cannot create record • Unknown Provider – cannot create record • No “encounter” or “visit” to attach case • Unclear file format, data standards • Rendering problems

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Meaningful Use Technology

Patient Portals

Two Problems “How” do we communicate

– Secure – disclosure? – Correct destination – Who can access msg? – Who sent it? – Unchanged? – Chain of trust?

“What” do we communicate? – Purpose designed templates? – Required information? – Optional information? – Human readable? – Structured? – Digestable?


Direct Addresses

• Direct Addresses are used to route information – Look like email addresses – Used only for health information exchange

[email protected]

• An individual may have multiple Direct

addresses

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Endpoint Domain

Direct Address

mailto:[email protected]

mailto:[email protected]

Message Center

Auto-populates (defined in XR Configuration Manager) • CCD Instruction • Confidentiality Statement


Update Provided by AeHN

Alaska now has the largest Direct Secure Message network of any state, with 4800 secure mailboxes for Alaska providers. Over 290,000 messages have been sent, about 5,000 per day.


Follow-up Cases • AFHCAN

most recent solution

• EHR first xEHR solution

43

Alaska Native Medical Center (ANMC) (1/1/2000 to 6/30/2014)

05,000

10,00015,00020,00025,00030,00035,00040,000

Case

s Cre

ated

Cases Created per Year


AFHCAN

EHR


2. Move Telehealth into the EHR

The EHR is the business and clinical engine for health care. It is extremely difficult to fully integrate a telehealth solution with an EHR. It NOW may be

easier to provide telehealth capabilities within the EHR with DSM.

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HIE-based S&F Telehealth

• Access to health summaries, notes • Offers an MPI to match patients and MRNs • A single place for shared solutions

– E.g. Case Management

• Future Capabilities – E.g. eVisits (specific to Epic and Siemens portals)

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Clinician Health Coaching: Teaching the Patient how to self-

manage & meet their goals

Patient Empowerment: At home; Sets Personal Goals;

Submits vitals/ health responses

Telehomecare Overview

48 I Telehomecare

Simple Technology in Home: Tablet, BP Cuff, Scale & Pulse oximeter

Efficient MRP Engagement: Clinician provides regular updates,

consults as required

Remote Patient Monitoring: Weekday feeds & Alerts

How do we know it works?

2007 Phase One Pilot Program

8 Family Health Teams (urban and rural) 813 patients with COPD and CHF Patients were enrolled for four months on average Focus on patient self-management: “what matters to you?” External third party evaluation (Price Waterhouse*)

Program Outcomes 64 – 66 % decrease in hospital admissions 72 – 74% reduction in emergency department visits 33% decrease in number of primary care physician visits 95 – 97% reduction in walk-in clinic visits High levels of patient and provider satisfaction Best practices were developed

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Member of Partners HealthCare, founded by Brigham and Women’s Hospital and Massachusetts General Hospital

39.8%

13.3%

100.0%

58.1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

One year prior to CCCP enrollment (point estimate and 95% C.I.) One year following CCCP disenrollment (point estimate and 95% C.I.)

Proportion of enrollees with 1+ HF hospitalization

Proportion of enrollees with 1 all-cause hospitalization

Proportion of CCCP enrollees with one or more Hospitalization

Data Includes 332 CCCP enrollments among 301 unique patients discharged from the CCCP program prior to July 1, 2009. Results are similar within more recent

cohorts of enrollees discharged from the program prior October 1, 2009 and prior to January 1, 2010.

QUANTIFIED benefits

• Reduces first hospitalizations and hospital re-admissions • Saves $20,000/patient diverted from hospital • Reduces emergency department visits • Saves $1,557 (CHF, COPD) - $8,660 (CHF) per patient/year • Saves $940 (diabetes) per patient/year • Reduces health care resource utilization across 6 conditions

DESCRIBED benefits

• High patient satisfaction • More effective and confident self-care • Improves quality of life for carers • Less travel and disruption for routine check-ups • Retains patient’s dignity • Increases degree of independent living

CAVEATS • Not all evidence has been compelling; success depends on

selecting the right chronic disease patients and right intervention

• Not yet proven that all the evaluation outcomes are fully generalizable beyond the short-term projects

A summary of the evidence from other jurisdictions

Sources: Canada Health Infoway 2013I Pare G et al. Home telemonitoring for chronic disease management: an economic assessment (2012) | Commonwealth Fund. Scaling telehealth programs: lessons from early adopters (2013) | Darkins A et al. Care coordination home telehealth (2008) | OTN Phase One Pilot Project 2009 I http://3millionlives.co.uk/about-telehealth-and-telecare#ccg_potential_savings_featured_at_nhs_innovations_expo | http://beat.ottawaheart.ca/2011/02/18/innovative-home-monitoring-initiative-reaches-1000-patient-milestone/#sthash.tws5MYkS.dpuf | http://www.cdnhomecare.ca/media.php?mid=1683

http://1.bp.blogspot.com/_zMBFmRhl7Gw/TD-uUUVK7HI/AAAAAAAAAgE/IgxabQmzNzE/s1600/Qualitative_Surveys-709070.jpg


3. Adopt New Methodologies

Alaska lags the rest of the nation in the adoption of well established practices

such as remote patient monitoring, telestroke, teleICU, teleTraume, and

teleBH/teleMH.

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via S&F only

via VtC (and S&F)

Confidence in Estimates

via S&F only

via VtC (and S&F)

Cardiology 32,000 47 10% 25% Medium 4.7 11.75Dermatology 47,000 32 30% 50% High 9.6 16Infectious Disease 132,000 11 20% 25% Medium 2.2 2.75Ophthalmology 25,000 60 25% 30% Medium 15 18Diabetic Retinopathy 25,000 60 90% 90% High 54 54Otolaryngology/ENT 39,000 38 10% 15% High 3.8 5.7

Total 248 89.3 108.2

Total FTEs Required for

IHS Population

Specialty

FTE Required for Telehealth Needs

% Workload that can be handled through TelemedicinePopulation to

Require One FTE (6)

Notes

(1) User Pop for IHS assumed to be 1,500,044

(2) Family Medicine is used to support primary care given by non physician providers. Not included here as numbers unknown for population served by non physician providers.

(3) ENT telehealth utilization will double with good audiology support.

(6) Approximation for staffing needs based on average from multiple sources (Information compiled by Medicus Partners from GMENAC, Health Manpower Report, Medical Economics, Inforum, Current National Ratio, AMA, Mulhausen Staff Model HMO, Journal of American Medical Association, Hicks & Glenn.)

How much “Telehealth” can be done?


Adopt EHR capabilities and technologies to provide an integrated health care environment accessible across multiple organizations

Explore new modalities and care delivery models to leverage our investment in telehealth technologies

Work collaboratively to share practices, develop standards, and accelerate the adoption of telehealth.

The Challenges • Need to develop standards (e.g. CCDA),

processes, service agreements, testing methodologies, etc. to connect our EHRs.

• Need shared solutions to shared problems: multimedia components, scheduling, marketing/broker service, eVisits.

• Where do we have these discussions?

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The Clinician’s Perspective … the New Limiting Step


Stewart Ferguson, PhD Chief Information Officer

Alaska Native Tribal Health Consortium 4000 Ambassador Drive

Anchorage, AK 99508

(907) 729-2262 [email protected]

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the end of telehealth - ashnha · best for patient care. helps me communicate with a doctor. saves...

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