21 August 2012

More than a fad, telehealth can save lives, reduce costs, improve patient access to care and increase market share for participating organizations. Remote consults dramatically expand the range of services available to patients in rural parts of the country. “Telehealth reduces mortality, hospitalizations, duration of stay and improves drug adherence. If you had any drug that had the outcome measures demonstrated by telehealth, you would have a blockbuster,” Chris Wasden, global health innovation leader for the consultancy PwC, tells FierceHealthIT in an interview for this eBook.

Still, there are challenges: Reimbursement and sustainability most notable among them.

In this eBook, FierceHealthIT interviewed healthcare leaders and industry experts from around the country on how they overcame those challenges and reaped the rewards of successful, profitable and sustainable telehealth programs.Read on to learn:

• How to ensure rapid adoption of telehealth across departments and how to marshal physician champions to the cause.

• How telemedicine supports some of the nation’s most seriously injured warriors and military physicians in remote locations.

• How to operationalize telehealth so it is just one more way to provide excellent care to patients, no matter where they are.

• How to devise sustainable programs—and which telehealth services experts say will see the most growth.

• How to take advantage of recent reimbursement changes and why operating at a loss today may actually be a good strategy to prepare for future success

3Across the Country,

Telehealth Reimbursement Grows

5How to Create a

Sustainable Telehealth Program

6Telehealth and Mobile

Technology

*Sponsored Content*

7Q&A: with Peter Kung, UCLA Health System’s Director of Innovative

Technologies

9Case Study: Children’s

Healthcare of Atlanta and Coffee Regional Medical Center

�Thank you To our SponSor:

september 2013

by gienna shaw editor-in-chief /// Fiercehealthit

FierceHealthIT.com FierceHealthIT

TelehealTh MoniToring: Creating Profitable, SuStainable ProgramS

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Reimbursement—or lack thereof—remains one of the sticking points for providers that want to expand telemedicine services. But there’s been more progress in the last year than in the previous decade,” says Chris Wasden, global healthcare innovation leader for PwC, the New York City-based consultancy.

In mid-July, the Centers for Medicare & Medicaid Services (CMS) proposed a change to the 2014 Medicare Physician Fee Schedule that would expand payment for telehealth services. CMS currently covers telemedicine visits for residents outside of a metropolitan statistical area at the same rate as in-person visits. The proposed change would extend coverage to anyone living in a rural census tract, as defined by the Office of Rural Health Policy, and would review that coverage on an annual basis, providing continuity of care for areas that lose rural status during the calendar year, according to the National Telehealth Policy

Resource Center. In addition, CMS proposed coverage for transitional care management services in selected cases.

states that payAlso in July, Missouri passed legislation requiring private insurers to cover any services provided remotely that they would cover for in-person visits. Previously, patients had to live more than 50 miles away from providers to qualify for telemedicine coverage.

Kentucky also expanded Medicaid telemedicine coverage to include a wide range of therapies and monitoring as well as evaluation or management consultations by physicians, advanced practice nurses, optometrists and chiropractors.

Earlier in the year, Arizona mandated coverage of remotely provided services starting in 2015 for trauma, burn, cardiology, infectious diseases, dermatology and neurology in the state’s rural areas.

According to the American Telemedicine Association, 20 states require private insurers to cover telemedicine services and 10 mandate Medicaid coverage for at least some services.

But in states that do provide payment through Medicaid, the reimbursement rates still pose financial challenges, according to Michael McConnell, medical director of the telemedicine program at Children’s Healthcare of Atlanta (CHOA). “State of Georgia Medicaid reimburses at about 15 cents on the dollar,” he said. “That’s not sustainable if you have a fully Medicaid population served by telemedicine.”

Debra Lister, M.D., medical

Across the Country, Telehealth Reimbursement Growsby Annet te m. boyle And brendA l . mooney

director at the Coffee Regional Medical Center Telemedicine Program in Douglas, Ga., notes that reimbursement differs between

presentation and consulting sites. “Don’t expect to start off making a bundle of money at presentation sites. Specialists are supposed to

be reimbursed by Georgia law what they would be paid for seeing a patient in the office. With private insurance and Medicare, they do pretty well. Medicaid has historically paid poorly, but it has improved a great deal in recent years. Unfortunately, that’s where most of the need is.”

service lines that paySome services get high reimbursement rates across the board. “If you include radiologists reading chest x-rays from remote sites as telemedicine, that’s very efficient and there is no issue with reimbursement.” says McConnell. Across the country, teleradiology is one of the most commonly provided telehealth services and has little incremental cost.

“Most radiology imaging equipment has digital capability and embedded picture archiving and communication systems,” says Jon Linkous, chief executive officer of the American Telemedicine Association. “The cost for technology is minor compared to what it used to be.”

Pressure to reduce healthcare costs and the move away from fee-for-service payment bode well for telemedicine, says Wasden. These trends “create pressure on legislatures and healthcare organizations to change the system and focus on delivering care in space instead of place.”

CHOA has built out its telemedicine program based on the expectation that the reimbursement model will change. “Right now, it’s a labor of love,” says McConnell. “We’re planning for a future state, where we’re rewarded for delivering healthcare more efficiently and get paid for keeping people healthy.” l

“There’s been more progress in the last year than in the previous decade.”

ChriS WaSden, global healThCare innovaTion leader, pWC, neW york CiTy

“We’re planning for a future state, where we’re rewarded for delivering healthcare more efficiently and get paid for keeping people healthy.”

MiChael MCConnell, MediCal direCTor, Children’S healThCare of aTlanTa TeleMediCine prograM

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The secret to success? Keep it simple.

Telehealth works, but how do you maintain a profitable program over the long run? Chris Wasden, global health innovation leader for PwC, says he thinks he knows the answer: Make the telehealth model as easy for physicians as prescribing a drug.

“Telehealth reduces mortality, hospitalizations, duration of stay and improves drug adherence. If you had any drug that had the outcome measures demonstrated by telehealth, you would have a blockbuster,” he says. “To make telehealth more successful and sustainable, it needs to mimic the prescription model. We’re seeing movement in this direction with health monitoring solutions, where a physician has been able to order the product, send the patient home” and arrange for in-home training. “And the physician sets the frequency at which updates are received.”

video creates unnecessary barriersTelehealth, or remote care without video, notes Wasden, offers much greater opportunities than telemedicine, which requires video consults. “Over half of

the practice of medicine can be done remotely without video,” he says. “Telemedicine can be additive. Most organizations that provide remote monitoring use tablets that also have video capability, so that’s available if necessary.”

Eliminating video circumvents the challenges posed by the absence of broadband capability in many rural areas. “Telehealth data is collected in kilobytes,” says Wasden. “In rural situations, you’re fine using

GSM connectivity [Global System for Mobile communications], which telehealth companies can buy at a wholesale rate of about $5 per month.”

strategy drives successful programsFor the more intensive telemedicine programs, sustainability starts with integrating the service into physician workflow and organization strategy, says Jon Linkous, chief executive officer of the American Telemedicine Association (ATA). “Many telemedicine programs start as pilots, funded by grants. That’s a good beginning, but not

How to Create a Sustainable Telehealth Programby Annet te m. boyle And brendA l . mooney

“If you had any drug that had the outcome measures demonstrated by telehealth, you would have a blockbuster.”

ChriS WaSden, global healThCare innovaTion leader, pWC, neW york CiTy

continued on page 11

monitor patients. Patients can transmit information, such as blood pressure or blood glucose levels, via

smartphone app or web portal. Based on this data, caregivers can quickly and knowledgeably make recommendations, or change the patient’s care regimen.

increasing access to health servicesMobile technologies, such as videoconferencing, store-and-forward imaging and streaming media help healthcare providers meet the needs of underserved people—including disabled, elderly and rural patients—who cannot easily access medical care facilities. Mobile networks help support the two-way communication necessary for patients and providers to exchange information over the Internet, when meeting in person isn’t possible.

improving self-care managementThe proliferation of mobile applications and connected devices helps patients help themselves. For example, telehealth programs can result in significant improvement in self-care behaviors, like daily weighing, medication management, exercise adherence, fluid and alcohol restriction, salt restriction or stress reduction, for the intervention of

heart failure patients.iv

providing timely access to a patient’s medical historiesThe secure, online storage of medical records facilitates prompt data-driven decisions by providing up-to-date patient health information at the point of care. By accessing centralized data, providers can validate drug interactions and help protect patients from medical errors.v

developing solutions for a health-conscious futureTechnology helps medical professionals provide treatment services and empowers patients to become engaged in their health care. Reliable, secure broadband connections make telehealth possible. With our 3G, 4G LTE and fiber-optic networks; cloud computing and enterprise-level security, Verizon provides the infrastructure that connects patients to the care they need and healthcare providers to the patients they serve.

To discover more, contact your Verizon business specialist, or visit us at verizonenterprise.com/healthcare.l

Bringing patients closer to care

Healthcare providers are investing time and resources into remote health monitoring. By 2017, telehealth is projected to reach 1.8 million patients worldwidei and the number of remote monitoring devices with integrated communication capabilities is projected to grow to 9.4 million connections globally.ii

There are several reasons why the practice of telehealth is gaining such momentum. The rising cost of in-facility care is only part of the story.

reducing patient readmission ratesReadmissions are among the leading problems facing the U.S. health care system. Research shows that 15-25% of people who are discharged from the hospital will be readmitted to the hospital within 30 days or less.iii In fact, The Centers for Medicare & Medicaid Services is now penalizing hospitals with high rates of readmission for patients with certain conditions. Telehealth can help.

streamlining patient careA telehealth practice helps doctors

Telehealth and Mobile Technologyby michelle bruno

Sponsored Content

i The World Market for Telehealth, an Analysis of Demand Dynamics. InMedica. 2012.

ii mHealth and Home Monitoring. Berg Insight. 2013.

iii Center for Healthcare Quality and Payment Reform. http://www.chqpr.org/readmissions.html

iv Impact of Telehealth on Patient Self-Management of Heart Failure: a review of literature. Journal of Cardiovascular Nursing. 2012.

v http://www.healthit.gov/providers-professionals/improved-diagnostics-patient-outcomes

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and must be able to integrate telehealth into clinical workflow. At the enterprise level, if you tie telehealth to technology, you will always be behind. You need to create a telehealth service platform that has the right contracting and right payers in place, so you can deliver sustainable service and incentivize physicians to embrace technology from an operational point of view.

fhiT: A recent study in Telemedicine and e-Health found that University of California-Davis Children’s Hospital doubled its referrals and saw a 60 percent increase in revenue from patient transfers after implementing a telemedicine network. Are you seeing a similar return on investment (ROI) for UCLA?pk: I absolutely agree that we see that kind of increase in referrals. The main ROI we see now, however, is a halo effect. We are expanding our reach, partnering with organizations outside our community, and achieving our three missions as an academic medical center of research and teaching as well as treatment. If you look at ROI today just from a fee for service model driven by volume, there’s tremendous variability by state and by service. Within our departments, different specialties require different equipment. We didn’t want them to worry about taking on the financial risk. Leadership secured funding and supported the program, so our physicians felt comfortable diving into telehealth, regardless of the short-term ROI.

fhiT: What’s next?pk: We have two goals for the coming year: Put the platform in place to sustain the program

and develop a hybrid model for telehealth. The platform will move us from focusing on the next great gizmo to honing in on the right technology, payers, contracts and workflow across our departments so we can continue to offer telehealth programs to patients for years to come.

The hybrid model will leverage our current system and extensive capabilities and enable us to better coordinate our programs, reduce costs and streamline management. This new structure will position us to respond to the movement toward reimbursement for improving

population health and away from pure volume and fee for service.

The telehealth program will expand in response to those new financial incentives and to achieve our vision of providing quality healthcare regardless of geography. Already, we are building out our network in rural California. We support military service members nationally through Operation Mend. We provide pathology consultations and training in China and we’re also expanding programs elsewhere in Asia, into South America, and starting to do cancer education in Africa. l

fiercehealthiT: UCLA has telemedicine and telehealth embedded in nearly all of its departments. What drove the widespread adoption?peter kung: Initially, various departments received individual grants that allowed them to start to provide services. In 2006 and 2007 telemedicine really took hold, as funding from California’s Proposition 1D provided financing for the equipment and networks needed to carry out our value of delivering quality healthcare regardless of geographic location. We took a different approach than most other large health systems,

how a hybrid model paves the way for value-based payments

A leader in the use of telemedicine, the University of California at Los Angeles (UCLA) Health System offers remote consultation and monitoring in nearly every service line. With more than 2,000 physicians and 800 beds in four hospitals on two campuses, the organization’s telemedicine services include neurology and stroke care, radiology, neonatal intensive care, family medicine, surgery and a variety of pediatric specialties. FierceHealthIT spoke to Peter Kung, director of innovative technologies at UCLA Health System, about the key decisions that make telemedicine an integral part of the organization’s service delivery system and what must change so it can succeed long-term.

which start with a centralized telehealth office and a single service and expand from there.

Executive leadership here knew telehealth could be very disruptive and that a massive pivot in delivery can be difficult. Instead of a top-down approach, we implemented a decentralized model that enabled telemedicine to spread through various departments quickly, based on the interest and ability of physicians who wanted to take on

the responsibility and find new ways to deliver care.

fhiT: What’s the difference between telehealth and telemedicine?pk: While we frequently use the terms interchangeably, telemedicine refers to diagnosis and treatment using remote technology. Telehealth is the larger umbrella term; it includes telemedicine as well as prevention and disease management.

fhiT: What steps must an organization take to make telehealth services work?pk: At the department level, you have to have the right technology

Q&A: with Peter Kung, UCLA Health System’s Director of Innovative Technologiesby Annet te m. boyle

If you tie telehealth to technology, you will always be behind.

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Organizations create a telemedicine partnership to improve pediatric care in rural Georgia

For years, physicians in rural Douglas, Ga. struggled to find nearby specialists to whom they could refer patients, particularly children. The closest pediatric cardiologist practiced in Macon, more than two hours away. To see other specialists, children had to travel 200 miles to Atlanta. Poverty further compounded lack of access.

“We frequently have people cancel clinic appointments because the car is out of gas and they can’t afford to buy enough to get the 10 miles to see us,” says Debra Lister, M.D., medical director of the telemedicine program at Coffee Regional Medical Center (CRMC), the only hospital in Douglas and surrounding Coffee County.

connecting specialists and patients To improve access to specialists, in 2007 CRMC joined the Georgia Partnership for TeleHealth (GPT), a statewide network initially funded by an $11.5 million grant from WellPoint, Inc. and $100 million in rural capital

bonds. Early on, the hospital’s telemedicine program enabled neurologists at the Medical College of Georgia in Augusta and cardiologists in Atlanta to examine patients with strokes or heart attacks in the emergency department through a teleconferencing link; pulmonologists could evaluate patients using the telemedicine suite in the hospital’s walk-in clinic. Consistent access to pediatric specialists, however, remained elusive.

In 2009, Children’s Healthcare of Atlanta (CHOA) launched a pilot program to offer subspecialty services outside the Atlanta metropolitan area through GPT. Over the next three years, the three-hospital, 529-bed organization expanded its telemedicine program to include 25 physicians in 14 pediatric subspecialties, including autism, cardiology, child protection, endocrinology, fetal

echocardiography, nephrology, neurosurgery, orthopedics and pulmonology. CHOA provides consultations to 43 sites, including hospitals, public health departments, schools and department of family and children’s services offices.

“Now specialists can see children who otherwise would

never have been able to come to their offices,” says Lister. Local physicians like the program, too, not only because their patients receive appropriate care but also because they can better manage the care patients receive.

Keeping care in the community“Our families are very grateful not to have to travel far and our local doctors like that they have more control of their patients’ care. When we referred patients out of town for consultations, often the physician would refer the child to other specialists close to them—even if we had that specialty in Douglas,” Lister says. “We are very conscientious about sending reports from consults to primary care physicians. We act as a go-between

Case Study: Children’s Healthcare of Atlanta and Coffee Regional Medical Center by Annet te m. boyle And brendA l . mooney

continued on page 12

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sustainable,” he says. For telemedicine to work well,

Linkous says “it must be integrated into care; part of the standard procedures for the organization.” With more than 200 telehealth networks connecting more than 3,000 healthcare organizations, according to the ATA, knowing what makes programs successful could profoundly affect healthcare across the country.

Healthcare organizations provide telemedicine services for many different reasons, says Linkous. “A hospital may look at telemedicine as a way to boost visibility of clinics and eventually raise the number of referrals. They may do it to reduce readmissions, related to upcoming

financial penalties or to increase market footprint.”

equipment costs create few barriersFor organizations interested in telehealth programs, the cost of equipment is no longer a barrier. “Reimbursements don’t cover equipment, but these days technology costs are relatively minor,” says Linkous. “Unless you’re talking about assisted surgery, you don’t need bells and whistles. Monitoring and conferencing equipment are not expensive systems. The decision to offer telemedicine services shouldn’t be based on cost of the technology or software today.”

Presenting sites providing therapies that do not require scopes

or other examination equipment can get by with a laptop and $1,500 in software. A fully loaded cart with a variety of scopes and full video capability runs about $27,000, says Sherrie Williams, director of state projects for the Georgia Partnership for TeleHealth.

Equipment requirements vary by service offerings. “Different diseases need different technology,” says Wasden. “Programs fail when they lack a level of sensitivity and specificity. One size does not fit all.”

Teleradiology, the most common telemedicine service, uses images transmitted through communication lines built into most equipment. Teleneurology for stroke patients requires full video conferencing. Remote monitoring of intensive care beds, a rapidly growing field, relies more on ongoing data transmission rather than episodic video consults.

chronic disease monitoring poised for growthOnline consultation and web-based monitoring of chronic health conditions offer the greatest opportunities for growth, says Linkous. “Hospitals may provide 1,000 or 2,000 consults to rural areas each year; with web-based programs, they can provide that many in a week,” he says.

A new source of funding may speed widespread adoption of telehealth initiatives, adds Linkous. “About 20% of large employers say that they are looking at offering web-based programs in the workplace or through employer-sponsored plans. Factories or large office buildings could make telehealth services available through a nursing office or you may see companies allowing employees to use their desktop computers to obtain services.” l

continued from page 5

to keep everything going smoothly during and after a telemedicine visit.”

For CHOA, keeping care local achieves multiple goals. “We rarely ask families to bring a child to Atlanta; our goal is to support the healthcare professionals in the community. If we were seeing a patient in Coffee County, for example, who needed multiple tests, the labs there would do the work and get the revenue,” says D.D. Fritch-Levens, R.N., director of the contact center for CHOA. In other instances, CHOA has proactively identified patients who travel significant distances and asked them whether they would prefer a telemedicine consult at a more convenient presenting site.

“We can’t put bricks and mortar everywhere in the state. With telemedicine we don’t need to. We can partner with communities and local physicians to increase pediatric medical knowledge,” adds Fritch-Levens. In keeping with that objective, CHOA recently completed a three-part series on pediatric cardiology offered to physicians and mid-level practitioners through telemedicine links and plans sessions on pediatric nursing and pulmonology.

getting startedLister advises healthcare organizations considering adding or expanding telemedicine services to find someone within their practice or hospital who thinks it is a good idea and is willing to promote it. Presenting sites should “canvas local doctors and find out what they need, what services they have trouble getting patients into.” Expect the service to evolve, she adds.

“Initially, we had more requests for dermatology consults than anything else.” Now, pediatric subspecialties comprise three of the top four most requested services.

Fritch-Levens echoes the importance of finding internal champions. “The will to do this must come from the clinic side. The organization may plan to offer one service, but if that specialty or department is not interested in doing it, and doesn’t have someone with passion to spearhead it, it simply won’t succeed,” she says. “There are too many competing priorities.”

maKing it worKTo make it easy for physicians to work telemedicine consults into their daily schedule, Fritch-Levens advocates putting telemedicine facilities inside clinics or bringing wireless capability to the bedside.

Making remote consults part of the regular workflow also helps. Initially physicians would set aside available time and wait in the telemedicine suite for presenting sites to initiate visits, but for most practices, that led to underutilization. “On a typical clinic day, a physician sees 15-18 patients; on a busy telemedicine day, he might see four,” says Michael McConnell, medical director, CHOA telemedicine. “We’re trying to work telemedicine into the daily workflow of the clinic now. A doctor might have patients scheduled at 9:00, 9:30 and 10:00 for in-person visits

and at 10:30 talk to someone via a telemedicine link and be back in the clinic for an 11:00 appointment.”

Fritch-Levens notes that some sites queue all their patients who need a particular type of consultation on one day, and the specialist books the entire day in the telemedicine suite. This structure works especially well to continue care for patients when a specialist closes a practice in a rural location.

measuring successIncreasing efficiency improves the economics of the program, but ultimately, CRMC and CHOA each consider the work part of their missions. For both hospitals, reimbursement, while steadily improving, does not fully cover the costs of the service.

“The program gives Children’s a voice in communities that we didn’t have before. It allows us to intervene in children’s health in a positive, impactful way,” says Fritch-Levens. “Recently, we did a consult with a teenage girl who had severe shortness of breath. She’d been treated for asthma and wasn’t improving. A pulmonologist remotely diagnosed her with pulmonary hypertension and she was in the ICU that night. She has a long road ahead, but now she’s getting the right treatment.”

“Improving care, saving lives—that’s really the whole point of the system,” says Lister. l

continued from page 9

“Unless you’re talking about assisted surgery, you don’t need bells and whistles.”

Jon linkouS, Chief exeCuTive offiCer, aMeriCan TeleMediCine aSSoCiaTion

“Our families are very grateful not to have to travel far and our local doctors like that they have more control of their patients’ care.”

debra liSTer, M.d., MediCal direCTor, Coffee regional MediCal CenTer TeleMediCine prograM