Patients, providers embrace telehealth while payers drag their feet
Telehealth already plays an important role in rural areas, primarily driven by the nationwide shortage of specialist physicians. Now, soaring gas prices could make the technology all the more attractive to hospitals, patients and even payers. But take note: hospitals engaged in telehealth warn that even under favorable conditions, this care model requires considerable nurturing. Knowledgeable remote site coordinators are needed to manage scheduling, ensure forms are completed and assist physicians with the technology.
Reimbursement also continues to be a challenge in many areas. Medicare recognizes the service in rural settings, but Medicaid coverage is variable, and the situation with private payers is even dicier. Yet even when payers balk, telehealth can be a worthwhile investment through productivity gains, cost avoidance in chronically ill patients, and time savings for scarce specialists. It also can be a vehicle to strengthen relations among isolated management teams and to educate staff members without the hassle and expense of travel. For those reasons, the Most Wired hospitals featured here say their telehealth programs are a success.
Avera Health, Sioux Falls, S.D.
If ever there was a case for telehealth, Avera Health in Sioux Falls, S.D., has it. The system operates a network of 231 primarily rural facilities and clinics in five upper Midwest states. Harsh winters replete with inhospitable driving conditions would, on the surface, make telehealth a must from the perspective of its patients, physicians and administrators. Avera does have a strong telehealth presence, which has grown especially during the past three years, but the system has realized that gaining acceptance of telehealth is a long-term proposition. “We’ve learned and relearned that we need to be patient,” says Mary DeVany, director of telehealth. “People are ready to learn about telehealth when they’re ready to learn about telehealth.”
Starting in 1993 with “very small and very expensive” equipment, Avera has built the case for telehealth one provider at a time. In 2007, physicians representing 16 specialties provided approximately 3,500 teleconsults. In addition, Avera sponsored about 900 educational and administrative sessions. In total, the system’s telehealth network has around 100 endpoints at 50 facilities in 28 communities, according to DeVany.
A key to winning over physicians was to make telehealth as turnkey as possible. “You have to be sensitive to efficiency and productivity and integrate it into the natural workflow of the practice,” notes James Veline, senior vice president and CIO.
DeVany relies on a network of site coordinators who work individually with physicians to establish their telehealth practices. “It’s different for each one,” she says. Some practices have enough volume to justify having equipment in their offices with dedicated telehealth rooms. They may have a face-to-face consult with one patient, then step next door for a telehealth visit, then return for another face-to-face session. Other practices may schedule blocks of time for telehealth visits using Avera facilities and equipment.
Site coordinators ensure that all forms and procedures, such as taking vital signs, are completed for each telehealth visit just as they would be in face-to-face circumstances.
“Our goal is to make a telehealth visit as similar to in-person as possible,” DeVany says. “It helps physicians feel comfortable with telehealth so it’s not some big different thing they have to do, but just a tool.” Avera also helps physicians make their way through the maze of credentialing and licensure issues so that they can participate in telehealth sessions, sometimes across state lines.
An early convert was Naomi Wahl, M.D., a perinatologist at Avera McKennan Hospital and University Health Center in Sioux Falls. Wahl conducts obstetrical ultrasounds via a telehealth connection at seven Avera sites. A sonographer at the remote hospital performs the ultrasound under Wahl’s supervision. At her end, Wahl can see the patient and the ultrasound screen in real-time, and she can direct the sonographer to focus on areas of interest. The sonographer and patient can see and interact with Wahl. The arrangement works to the advantage of all involved. Patients benefit through time savings, and the process “clarifies when specialty care is needed and helps local facilities know what they need to do to properly care for the patient,” Wahl says.
Support of local facilities is one of the reasons Avera offers telehealth. “It helps them be viewed by the community as a health center rather than just a hospital, and it raises the perception of their already good quality of care,” DeVany says.
Kootenai Medical Center, Coeur D’alene, Idaho
Support of a network of critical access and rural hospitals was the main impetus for Kootenai Medical Center’s foray into telehealth in 2000. At 246 beds and in a county of more than 130,000 people, Kootenai is the anchor member of the North Idaho Rural Health Consortium. The other four NIRHC hospitals range in size from 19 to 48 beds and are in small towns 45 miles to 100 miles from Coeur d’Alene. “Both we and the referring hospitals agree that this is the best way to take care of patients,” explains Thomas Legel, Kootenai’s vice president of finance and information services. “Often [the larger hospital] will say, you need to send the patient to my facility so I can take care of him, and what may be unsaid is they will have the revenue, too. But we have taken the long-term view so the other hospitals feel comfortable sending us patients that really need to come here.”
Collectively, NIRHC has invested about $3.5 million over eight years in equipment and a wide area network that supports telehealth and other applications like electronic medical records. The consortium received several grants from the U.S. Department of Agriculture Distance Learning and Telemedicine Program and from the Office for the Advancement of Telehealth, part of the Health Resources and Services Administration.
In 2007, NIRHC held 427 telehealth sessions, most for continuing education and administrative meetings for physicians and hospital personnel. Kootenai sponsors tumor boards that are broadcast to all NIRHC members, and a variety of managers from the five facilities hold monthly or quarterly meetings via videoconference. “It makes a significant difference in the way we relate to each other in the care we provide,” Legel says. “It also saves productive time in driving here, especially when the weather’s bad.”
In the patient care realm, telehealth enables the rural NIRHC members to provide certain services that otherwise would be difficult because of a shortage of health care professionals. For example, with approval of the Idaho Board of Pharmacy, Kootenai supports the pharmacy at Benewah Community Hospital in St. Maries, about 55 miles from Coeur d’Alene. Pharmacists at Kootenai have access to patient records at Benewah and can consult with its pharmacy techs and nurses as needed. Nearly 24,000 prescriptions were filled through this arrangement in 2007, according to Tom Hauer, Kootenai’s telehealth director.
Kootenai also has arrangements with two NIRHC hospitals to provide remote pathology diagnosis using a robotic microscopy system. A pathologist at Kootenai uses a remote-controlled microscope to view tissue specimens in real time, aided by a technician at the participating hospital. “It allows our smaller hospitals that have surgeons but not enough volume to keep a pathologist on staff to offer more complete services in their own communities,” Hauer explains.
For all its pluses, the Kootenai-NIRHC telehealth network continues to struggle with reimbursement issues. While the program meets Medicare telehealth criteria and recently received approval from Idaho Medicaid for mental health consultations, commercial payers in the state largely do not recognize the service, creating a hindrance to further adoption, according to William H. Miller, M.D., a psychiatrist at Kootenai. “When we get the reimbursement issues worked out, I think there will be more participation,” he predicts.
University Health Systems of Eastern Carolina, Greenville, N.C.
The telehealth network sponsored by University Health Systems of Eastern Carolina and the Brody School of Medicine at East Carolina University in Greenville is a perfect marriage of the strengths of each organization to extend the reach and capabilities of telehealth in eastern North Carolina. UHS has provided support to the telehealth infrastructure, investing more than $1 million in a high-speed fiber-optic network that connects hospitals in a 29-county region. In November 2007, it received a three-year, $960,000 grant from the Federal Communications Commission to participate in a pilot program to expand the high-speed data network as a means of improving health care delivery in the region.
“It will enable us to bring non-UHS facilities into the network and connect the last mile of providers in the eastern part of the state,” says Stuart James, CIO at UHS. “It will enable the rural facilities to share information, including but not exclusive to telehealth.”
Meanwhile, the medical school has been involved in telehealth since 1992, making it one of the oldest telehealth services in the country. Clinicians from more than 30 specialties and services participate in the program, mostly through distributed networks that enable live teleconferences between patients and providers. The network also offers store-and-forward services for radiology, pathology and cardiology. In addition, it is a hub for distance learning for health care professionals in the region.
A beneficiary of the expanded network will be Roanoke Chowan Community Health Center in Ahoskie. The center currently provides home monitoring of patients with cardiovascular disease, diabetes and other chronic conditions. When the UHS-supported broadband network reaches Ahoskie, these patients will be able to come to the center for telehealth consultations with Brody faculty members, who will have access to their daily home monitoring records. “It will allow the patients to have a specialty consult that they don’t have access to now,” says Bonnie Britton, R.N., chief nursing officer for the center. Britton also expects the telehealth connection to the medical school to boost already impressive outcomes from the home monitoring program, which cut hospitalizations among 40 enrollees by more than 70 percent.
Back at Brody, there are four teleconference rooms where physicians can conduct telehealth sessions with patients in at least 17 remote sites. The service also features intra-hospital mobile units. One, known as Hello Mommy, enables new but ill mothers to view their babies in the neonatal intensive care unit at Pitt County Memorial Hospital, Greenville, either from within the hospital or a remote facility.
The medical school also has a policy of carefully selecting and training remote site coordinators. “There may be a very qualified nurse [at the remote site], but he or she may not know anything about the specialty being seen through telehealth,” explains Gloria Jones, clinical operations manager and assistant director of the Telemedicine Center at Brody.
Perhaps owing to its status as a telehealth pioneer, reimbursement has not been a particular challenge for the UHS-Brody network. It participated in a demonstration project for Medicare to determine how it would reimburse telehealth visits. The program also has been recognized by North Carolina Medicaid since 1995 and by Blue Cross plans in the state for about 10 years.
Gina Rollins is a freelance writer based in Silver Spring, Md.
Vital Statistics
Avera Health, Sioux Falls, S.D.
President and CEO: John Porter
Senior vice president and CIO: James Veline
Number of Beds: 1,605
Number of Employees: 11,000
Number of IT Employees: 125
IT Operating Budget as a Percentage of Total Operating Budget: 3.1%
IT Capital Budget as a Percentage of Total Capital Budget: 12%
Mary DeVany
BIO: Director of telehealth, Avera Health, Sioux Falls, S.D.; B.S., University of South Dakota.
Rewards of the job: The service we provide to patients, giving them access to care that otherwise would be difficult for them to obtain.
Biggest challenges: Change management, and encouraging people to try something new.
IT Philosophy: Telehealth has not been fully embraced by IT, but the understanding of telehealth is critical to further the development of health care IT.
E-Mail: mary.devany@mckennan.org
Vital Statistics
Kootenai Medical Center, Coeur d’Alene, Idaho
President and CEO: Joseph Morris
Vice president, finance and information services: Thomas Legel
Number of Beds: 246
Number of Employees: 1,762
Number of IT Employees: 10
IT Operating Budget as a Percentage of Total Operating Budget: 2%
IT Capital Budget as a Percentage of Total Capital Budget: 20%
Thomas Legel
BIO: Vice president, finance and information services, Kootenai Medical Center, Coeur d’Alene, Idaho; B.B.A. and M.B.A., Gonzaga University.
Rewards of the job: Providing quality, cost-effective health care for our community and bringing technology to our caregivers to accomplish that.
Biggest challenges: Change management—getting buy-in on needed changes.
IT Philosophy: Telehealth is a technology that needs to be used more. It’s a way to provide better, more efficient care in rural areas.
E-Mail: tlegel@kmc.org
Vital Statistics
University Health Systems of Eastern Carolina, Greenville, N.C.
President and CEO: Dave McRae
CIO: Stuart James
Number of Beds: 1,116
Number of Employees: 8,977
Number of IT Employees: 181
IT Operating Budget as a Percentage of Total Operating Budget: 2.2%
IT Capital Budget as a Percentage of Total Capital Budget: 16.2%
Stuart James
BIO: CIO, University Health Systems of Eastern Carolina, Greenville, N.C.; M.B.A., Oklahoma City University; B.S., Cameron University.
Rewards of the job: Being part of the IT revolution in health care. IT is the key enabler of a critical transformation in the way health care is delivered, and it’s a very exciting and rewarding time to be a health care IT professional.
Biggest challenges: Prioritizing the many strategic projects and coordinating the needs of the various clinical disciplines that we support.
IT Philosophy: Our business is health care, not IT. Technology only adds value when it supports and enables the organization’s business needs.
E-Mail: bddunn@pcmh.com
Toolkit resources
The American Telemedicine Association is a membership organization that promotes access to care through telemedicine by providing information on telehealth services, practice guidelines, networking opportunities and research. Available at www.americantelemed.org.
The Center for Telehealth and E-Health Law serves as the National Telehealth Resource Center, which was created through a grant from the Health Resources and Services Administration to advise, educate and inform telehealth stakeholders and interested parties about relevant legal and regulatory issues. Available at www.telehealthlawcenter.org.
A directory of regional telehealth resource centers, supported by the Office for the Advancement of Telehealth, provides assistance to organizations that are interested in telehealth. Available at www.telehealthlawcenter.org/content/?page=16.
The Telemedicine Information Exchange provides news and updates, meetings, articles, policy issues and research on telehealth from the Association of Telehealth Service Providers. Available at http://tie.telemed.org.
Tracy, Joseph, ed. Telemedicine Technical Assistance Documents: A Guide to Getting Started. Missouri Telehealth Network. Available at http://telehealth.muhealth.org/general%20information/TAD.html.
Dos & Don’ts
For an effective telehealth program
DO:
- Be persistent. Telehealth represents a change in the status quo, and providers may be reluctant to try it. But they can be won over with repeated education and reminders about its benefits.
- Invest in human resources to support telehealth at the remote site. On-site coordinators who work out scheduling, physician-requested procedures and paperwork related to telehealth sessions and troubleshoot any problems are essential.
- Have a firm understanding of how telehealth fits with the mission of your organization and your philosophy about supporting services at remote facilities that also are potential referral sources.
- Find champions to promote telehealth. Physicians with telehealth experience who influence their peers will have a bigger impact on adoption than anything else.
- Seek federal and state grant funding to support the development and expansion of telehealth and other forms of health care information exchange.
DON’T:
- Build it and think they will come. Technology is the backbone of telehealth, but it’s the people who make it work. Support and participation from clinicians and management is a must.
- Neglect equipment and infrastructure maintenance. Telehealth operates on a stable platform, but the equipment needs periodic checkups. It takes only one malfunction to turn off providers and patients.
- Fail to document time and cost savings, hospitalizations avoided and specific case studies that demonstrate the value of telehealth. Such data may help win over payers reluctant to cover telehealth.
- Think of telehealth only as a patient care resource. It can be a time- and cost-saver and a means of keeping communications open in far-flung health care systems.
- Fail to consult with others who have established telehealth programs. Learn from their experiences, triumphs and challenges.