Telehealth/Virtual House Calls
What exactly is Telehealth? The Federal Government’s Health Resources Services Administration (HRSA) website defines Telehealth as the “use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. Technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications”.
Telehealth encompasses not only the clinical (actual healthcare given to a patient, also known as Telemedicine) but the non-clinical (patient or provider education, administrative meeting, etc). That’s a pretty broad definition and it has some very broad implications for healthcare – from healthcare providers to patients and insurers to the State and Federal governments who direct the rules and regulations for healthcare in this country.
One of our consultants wants to tell a story about her mother and telehealth to give you an idea of its capabilities. A few years ago, her mother was diagnosed with pneumonia and spent several days in the hospital. On admission, it was discovered that she had a rapid heartbeat (atrial fibrillation) caused by a deteriorating aortic valve that was going to have to be replaced. But first, her medical team wanted her pneumonia cured and for her to gain some strength back before that valve replacement surgery.
Her mom was placed on some powerful medications to help control the rapid heart rate and she had been on blood pressure medication for years. Her doctor needed daily monitoring of her vital signs so he’d know how well those medications were working – or if they needed adjusting. Getting her mom to his office every day so that his staff could monitor her vital signs wouldn’t have been very convenient; it also would have cost quite a bit to get her back and forth to the doctor’s office every day. And it wouldn’t have been very restful for Mom. Not to mention the extra strain it would have put on the doctor’s office staff.
So when her mom was discharged home from the hospital, Home Health visits were set up, with a nurse visiting twice a week; but that still wouldn’t have been often enough to appropriately monitor her medical status given the medications that she was now on.
So a new “nurse” came to stay with her mom. This nurse was about 6 inches tall and about 8 inches wide and 12 inches long, dressed in black plastic with a blue LED display and she was connected to weight scale, a blood pressure cuff, a pulse oximeter AND the telephone.
We called her “Nurse Nancy”. And Nancy talked! Every morning at 9:00am sharp, Nancy would call out to the mother, reminding her that it was time for her to get her morning vital signs taken. Nancy would instruct her through each phase: to stand on the scale for her morning weigh in, to place the blood pressure cuff on her arm for blood pressure and heart rate readings, to put the pulse oximeter on her finger for blood oxygen levels. Nancy even reminded her mom to take her morning medications. Then Nancy dialed the Home Health office and relayed all that information to the Home Health staff via the phone.
Her mother’s condition could be tracked on a daily basis – without someone actually having to come to the house. It was less stressful for her mother, because, like many seniors, she disliked having strangers coming to her house. And she didn’t like having to wait on the home health nurse to show up sometime between 9am and noon, either. It worked well for the Home Health agency too; they didn’t have to have a nurse waste an hour’s worth of travel just to spend 15 minutes recording her mom’s medical information. And her doctor got the timely information that he needed to treat her mom’s condition.
Nurse Nancy did her job beautifully. One morning, her mother’s blood pressure was too low and her heart rate too slow; a trend that had started a couple of days earlier and gradually got worse; information that the Home Health agency was tracking. When her mom’s blood pressure and heart rate reached a certain threshold, the Home Health agency called to follow up. They instructed her to hold off on certain medications until they could get in touch with her doctor and would have called the doctor if our consultant hadn’t already. The doctor modified her medication dosages so that the medicine kept her heart rate and blood pressure in line without allowing them to get too low and causing even more medical problems for an already sick woman.
Since our consultant travels for business and her siblings live out of town, there wasn’t always someone able to be there for her mom. Knowing that the Nurse Nancy was monitoring the situation was not only a big relief for the family, it was crucial to her mom’s safety. About a month later, her mom was strong enough to have the valve replacement surgery which resolved the atrial fibrillation problem.
So for our consultant’s mother, family and her health care providers, even her insurers – both Medicare and a private supplement, Telehealth, specifically Telemedicine, was a win/win situation. Convenience, peace of mind, AND cost savings all around.
Telehealth includes Telemedicine but it also includes a non-clinical side as well. A hospital system can use a teleconference to train staff in all its hospitals across the country on the latest policy for NG tube placement via video or teleconferences. Patients can use their home computer to get on-line and access the latest results of blood tests drawn at their doctor’s office via a web portal. An ER doctor can dial into the radiology department of a hospital 500 miles away to see the last chest x-ray of a COPD patient on vacation who presents to the ER complaining of increased chest pain and difficulty breathing. You can call your local pharmacy and re-order a refill of your asthma medication without having to wait for available pharmacy staff using a phone line – and arrange for it to be ready so you can pick it up on your way home after work. A nurse can type patient information onto a computer screen rather than writing it down in the patient’s chart and the patient’s doctor can access it from 3 floors away.
Telehealth encompasses all of that and more. Electronic Health Records are an integral part of just why Telehealth is so important. Portability of a patient’s healthcare records depends on telecommunications technology, and as we become a more global society, moving not just across the country but across the world, the ability to “take” our medical records with us, becomes more important. So does the ability of healthcare providers, from hospitals to private practitioners, to be able to access the latest, most relevant information and education to care for their patients with the most effective treatments possible.
Studies from the US, as well as Canada, the UK and Australia have shown that Telehealth options can reduce costs and conserve important staff and financial resources. Rural populations especially can benefit from medical care and education that previously was unavailable to them.
But, while Telehealth can help reduce costs and conserve resources, it can also have some significant upfront costs as well as maintenance costs associated with it. A fax machine may only cost a couple of hundred dollars but designing and maintaining a web portal and capabilities can cost more than a few hundred-thousand dollars. So how do you pay for Telehealth? Which Telehealth options offer a good return value for the money spent and which don’t?
And like anything new, there may be resistance to utilizing Telehealth technologies. Healthcare providers as well as patients may be unfamiliar with the technologies used and become easily frustrated by them. This is especially true for older patients and providers who didn’t grow up in the age of video games, cell phones, and the internet.
While Medicare, Medicaid and other insurers may reimburse a health provider for Telemedicine, Telehealth applications may be not be directly reimbursed. They may, however, be reimbursed as part of a covered service. For example, under Section 1905(a) of the Social Security Act, Telehealth technologies such as telephones fax machines, e-mail systems and remote patient monitoring devices may be covered as part of a Medicaid coverable service such as lab, x-ray or physician services.
And then there are the myriad rules and regulations that apply to Telehealth. In addition to the Federal Government, State governments also have to be considered. For example, some state governments have laws on the books that impede the portability of a patient’s healthcare information, making it illegal for example, to transmit certain patient information across state lines. HRSA provides competitive grant programs for Licensure Portability, Telehealth Network and Telehealth Resource Centers to help deal with some of these issues.
Federal and State governments are also working to help solve other problems associated with Telehealth, including its cost. For instance, the Federal Communication Commission (FCC) sponsors the Rural Health Care Program which provides funding and discounts to rural healthcare providers for the purchase of telecommunications services, as well as launching the Rural Health Care Pilot Program to provide broadband services in rural areas where such services are lacking. The Program pays up to 85% of the costs associated with construction of state or regional broadband networks, including connecting to Internet 2 or National LambdaRail or the public internet. In 2013, Missouri became the 19th state to pass a state-wide parity law for private insurance coverage of Telehealth.
The common goals of Federal and State governments, healthcare providers, insurers and patients are state of the art healthcare, decreased healthcare expenditures, cost effectiveness and good health. Telehealth can help make that possible.
Consideration of several factors must be examined by any healthcare provider planning to utilize Telehealth technologies:
1. Legality issues, including patient confidentiality and Federal and State government rules and regulations.
2. Patient benefits, including ease and likelihood of use, fewer missed doctors appointments, less travel, as well as good health outcomes.
3. Provider benefits, including reducing the cost of providing patient care and services as well as providing optimal patient care.
4. Upfront and maintenance costs, including reimbursement issues from insurers.
5. Long term goals and the constantly changing technology and healthcare landscapes. What technologies do you currently use? Will those technologies still be relevant 5 years from now?
Telemedicine technology has been around for many years. Now the concept has expanded with technology to include providers doing Virtual House calls.
There is no data to prove that virtual calls help more patients - whether the patient is seen virtually or in person, the care seemed to be the same. The thing it did improve was the number of times a patient was seen by the provider. Some patients do not have access to transportation to consistently make it to a doctor's appointment, but they almost always were available in their home via technology. It saved the patients time and money in terms of travel and wait periods. Cases have also shown patients visited the ER less when they were able to see a provider virtually - especially if the service was available 24 hours a day 7 days a week.
Currently some of these services are not reimbursable to providers with current Medicare rules, and there are licensing issues that need addressed as well. Licensing issues are due to the fact that providers may not be licensed to treat patients in another state, so they cannot see patients that do not live in the state they are licensed to practice even if that patient sees them as the primary care provider. Many changes have been made since the emergence of telemedicine, but many more need to come to help the providers want to use this technology.
There are three ways providers can "see" patients virtually:
1) Store Forward - the patient is videotaped and a provider reviews it at a later time and date. This method is best for Dermatologists, Radiologists, and Pathologists.
2) Remote Monitoring is best for patients with chronic diseases or issues such as heart disease, diabetes mellitus, or asthma.
3) Interactive telemedicine is for most visits where the provider needs to interact with the patient by looking at body parts and/or getting answers from the patient to help in the diagnosis and treatment.
This technology has also improved the lives of many people living in third world countries who didn't have access to doctors as well as those living in the US who have transportation issues.