The Dignity Health Telemedicine Network is one of the nation’s pacesetters in establishing – and continuously improving – quality and outcomes benchmarks. The network is based in Sacramento, California and now has 39 partner sites across the state (plus one in Hawaii).
In surveying the network’s recent achievements, you can almost hear the voice of quality guru William Edwards Deming saying, “Well done.” Here’s a quick look at some of those accomplishments, as reported at ATA 2015 by Dignity’s program director Jim Roxburgh, RN, MPA:
- 15 specialties and growing, ranging from teleICU, teleneurology and telecardiology to telepediatric critical care, telemental health and remote wound care
- Twice-a-day remote ICU rounding that provides greater continuity across shifts and gives families greater access to specialty providers
- Response time of 5 minutes or less for critical care physicians
- Teleneurologist response time of 2 minutes or less – and ability to screen all patients for tPA and ERT within 30 minutes, which enables Dignity to administer tPA about four times more often than most health systems
- Target response of 30 minutes or less for initial telepsychiatric consultation – and under one hour for psych team evaluation by LCSW and registered nurse
While some health systems may view these quality benchmarks as unreachable as running a mile in 3 minutes and 43 seconds (the current world record), Dignity sees them as measurements that can be continuously improved.
The Dignity Health Telemedicine Network is a bit like Morocco’s Hicham El Guerrouj, the runner who holds the current record for the mile run. Dignity’s successes encourage other networks to push quality and outcomes beyond what they ever thought was possible.
Telehealth and Telestroke
The pundits at leading tech publications like Wired and Information Week are now confirming what industry insiders have long known: telehealth is going mainstream.
Two recent stories in Wired prove that telehealth has indeed crossed the Rubicon. The magazine noted that UnitedHealthcare’s decision to cover virtual doctor visits is an undeniable tipping point. This year, the virtual coverage extends only to the insurer’s self-funded clients, but it’s slated to roll out to all members by 2016.
Wired also gave some love to the pediatric telemedicine innovations at Oregon Health & Science University (OHSU). Viewers of the TV comedy Portlandia might mistakenly think that most of Oregon is trendy and urban, but there are plenty of rural communities that don’t have a wide variety of service lines. In fact, there are only three pediatric intensive care units in the entire state – and all of them are in Portland.
The Wired story recounts how OHSU pediatrician (and telehealth medical director) Miles Ellenby was able to help guide the resuscitation of a newborn baby in a rural hospital from the OHSU network hub in Portland. It’s not a simple procedure, but now it’s becoming almost commonplace because specialists can walk local caregivers through the entire process.
This type of guidance is also essential in stroke treatment. The Wired piece notes that most rural providers don’t have the expertise to determine whether tPA administration will help or hurt the patient. But via telehealth, they can let a stroke specialist decide – and that’s why successful tPA administration rates are increasing dramatically throughout the U.S.
In recent decades, strokes have claimed the lives of many famous people (like Richard Nixon and Cary Grant), plus thousands of non-celebrities worldwide. Now telestroke networks are greatly improving outcomes by enabling timely, informed tPA administration. The fact that it’s becoming “commonplace” is extraordinary.
The Advisory Board recently released a report on the changing roles and responsibilities of Chief Medical Information Officers – and it predicted that these folks will play a vital role in the rollout and maturation of telehealth systems.
For the past five years, CMIOs have primarily dealt with the herculean task of implementing and fine-tuning EHRs. As more organizations enter Meaningful Use Stage 3, CMIOs can now turn their attention to things like telehealth, population health management and analytics (all of which are intertwined).
The report concludes that CMIOs are ideal candidates for overseeing the design and implementation of innovative projects like telehealth networks. Most CMIOs are seasoned practitioners, not computer nerds. They have the clinical, operational and strategic experience to ensure that telehealth systems will be easy for physicians to use – and will complement what’s being done in population health management and predictive analytics.
In the Advisory Board study, none of the CMIOs interviewed were computer scientists – and almost all of them had backgrounds in physician leadership. They shared a passion for process design and improvement, which means that we’ll see steady yet significant enhancements in the telehealth networks they oversee.
There are three things that every organization should do to help their CMIOs succeed:
- Offload some of their current EHR work (especially optimization) to other members of their team so they have more time to focus on telehealth.
- Send them to clinical informatics conferences – Most CMIOs are self-taught and relish opportunities for ongoing education.
- Give them a greater voice in strategic planning for telehealth, population health management and predictive analytics.
Fortunately, tomorrow’s telehealth networks will be shaped in large part by CMIOs who have years of clinical and operational experience, not by techies who don’t understand that world.
The Texas Two-Step is a popular dance, but when it comes to telehealth, Texans are taking one step forward, one step back.
Let’s start with the backward step: last month the Texas Medical Board voted to ban doctors from doing even the basics (making routine diagnoses, prescribing medications) for patients they’ve never physically seen before.
The ruling marked the end of a long battle between the state board and Teladoc, which is based in Dallas but does nationwide teleconsults for routine things like sore throats, flu, etc. The board was acting on behalf of the many Texas physicians who feel that telehealth “takes work away” from them.
But a recent study by the Rand Corporation refutes that argument. Their researchers found that Teladoc availability in California had actually struck a chord with many people who don’t like going to brick-and-mortar physician offices. In fact, 20 percent of those who used Teladoc in California hadn’t physically visited a doctor in the previous year.
Now for the step forward: the Texas business community was highly critical of the board’s decision on telehealth. In their view, the convenience of telehealth increases the likelihood that people will seek treatment faster, which reduces lost work time and increases business productivity.
While the Texas board voted to go back to business-as-usual, the Texas House of Representatives moved forward on three new telehealth bills aimed at improving care for children covered by Medicaid. The bills are sponsored by legislators who normally wouldn’t agree on anything: two liberal Democrats and two conservative Republicans (including a former neurosurgeon).
Is the Texas Medical Board’s decision an attempt to protect doctors’ financial interests while posing as a high-minded effort to prevent “second class” care via telehealth? Legislators on both sides of the aisle are taking matters into their own hands. The bottom line is that Texans of all ages deserve to enjoy the many benefits of telehealth – especially the children.
Apple and Google will undoubtedly grow a lot by 2020, but nothing like the pace forecast for telehealth. The American Medical Association predicts that the telehealth market will expand from about $1 billion next year to $6 billion by 2020.
This astonishing growth is being fueled by a number of converging trends. Because of the expanded coverage under the Affordable Care Act, millions more patients are needing treatment – and a significant number of them live in either remote or underserved areas where MDs (particularly specialists) are in short supply. Meanwhile, the use of telehealth for chronic disease management is going through the roof. According to IHS Technology, the number of people being remotely monitored for congestive heart failure in the U.S. will increase 68 percent to 578,000 cases in the next year alone – and remote monitoring of diabetes patients will rise about 73 percent to 236,000 cases.
Many health systems are already starting virtual health departments, like the Virtual Urgent Care recently introduced by CHI Franciscan Health in the Tacoma, Washington area. The program enables area residents – not just existing patients – to receive care 24/7 via phone or video chat on smartphones, tablets and PCs.
Franciscan’s Virtual Urgent Care program is already receiving rave reviews from community members. In fact, it’s achieving a 96 percent satisfaction score from patients – a higher rating than many brick-and-mortar facilities get. There have been unexpected benefits, too. Since the program began, the number of pages to on-call doctors has decreased by 50 percent.
When describing the pace of growth in telehealth, you almost need terms like “warp speed” and “turbo-charge.” Get set for the most exciting – and fastest moving – chapter in telehealth history.
Telehealth Goes Turbo
For decades, TV ads have been promoting the “next generation” of products, whether it’s a soft drink or smartphone or laundry detergent. The phrase has been so overused that we’re wary of it.
But now there’s a “next generation” announcement that’s the real deal: the Next Generation ACOs (Accountable Care Organization) unveiled last month by CMS (Centers for Medicare and Medicaid Services). There’s much to applaud about this announcement because it offers many things that are indeed “new and improved” – especially when it comes to telehealth.
A Next Generation ACO must have at least 10,000 aligned members – or 7,500 if it’s in a rural area. To qualify for next-gen status, an organization must provide access to both telehealth services and home visits. The new model also has more sensible financial metrics and goals than the preceding Pioneer ACO model.
Next Generation ACOs are now allowed to cover and reimburse for telehealth services just like Medicare Advantage plans do today. The new model lifts the longstanding requirement that beneficiaries must live in a rural community. That’s great news for the 80 percent of Medicare beneficiaries who live in large metropolitan areas.
It didn’t take long for telehealth advocacy groups to sing the praises of the new ACO structure. “This is an important change in CMS policy and attitude,” said Jonathan Linkous, chairman of the American Telemedicine Association. “We hope it will encourage CMS and Congress to further open up all value-based payment plans to telehealth.”
His comments were echoed by leaders of the Alliance for Connected Care. “This policy is a critical step forward in expanding the use of telehealth services in Medicare, which will allow for greater care coordination and improved quality of care,” said Alliance chairman Joe Peterson, M.D. “It represents a major victory for patients and the broader telehealth community, which has been gathering evidence of telehealth’s benefits for decades.”
For years, many telehealth proponents have been patiently waiting for the CMS to take this long overdue step. Now it’s time to pinch ourselves because it’s not a dream any more. The Next Generation ACO model will help bring telehealth services to nearly 40 million Americans who previously didn’t qualify. It’s a bold innovation that truly lives up to its name.
The ATA’s Home Telehealth special interest group was launched 16 years ago – and the progress made in that field has been spectacular.
Telehealth was originally envisioned as a way for rural patients to get access to specialists, but now it’s widely used in many other ways:
Remote patient monitoring has really come of age. For example, the University of Arizona health system uses telehealth technology to provide at-home monitoring of prospective heart transplant patients who are waiting for a donor match.
Remote medication management helps ensure that patients adhere to the appropriate dosages and schedules. Research shows that medication non-adherence is a factor in more than half of hospital readmissions – and nearly twenty-five percent of all nursing home admissions.
Telehealth for care transitions reduces errors as patients move to different care settings: hospital, skilled nursing facility, home care, etc.
The bottom line is that thousands of patients are getting expert care without having to physically visit a specialist or PCP. As they grow comfortable with the benefits of at-home monitoring, they’re much more receptive to acute care consultations when the need arises.
The laws governing home health vary widely from state to state, and that’s why there are efforts underway to create standards and protocols for remote home care.
Without telehealth, most communities will fall short of their population health management goals. Patients with multiple chronic conditions need ongoing education and observation where they matter most: in their own homes.
In recent years, there have been more articles written about population health management than about the entire Kardashian clan.
The first version of population health management had a lot of good intentions but few measurable results. Now comes the hard part: turning mission statements into successful programs. And it’s becoming increasingly obvious that telehealth is an essential ingredient for success.
In a recent article in Executive Insight, Dr. Yulun Wang noted that one of the six pillars in the AHA’s population health roadmap is “seamless care across all settings,” which is practically a Webster’s definition of telehealth. If the population you’re managing happens to be Bear River, Wyoming (population: 521), there are probably not enough locally based primary care physicians, much less specialists, to handle the job. An enterprise telehealth platform is the force multiplier that can solve the problem, while also improving quality and lowering costs.
Dr. Wang’s article also made it clear that many telehealth solutions fall far short of being enterprise platforms, which need to provide:
- Scope to accommodate sub-acute services (clinics, SNFs) in addition to high-acuity service lines like ICU, neurology, etc.
- Scalability to make it easy and cost effective to add new service lines and organizations
- Ease of use in capturing and viewing clinical data across a wide range of environments and applications
- High quality and reliability because high-acuity cases often involve life-or-death decisions
- Access controls to safeguard data integrity across multiple time zones
- Superior analytics and reporting, both historical and real-time
Any organization that’s serious about population health management must also be willing to implement – or be affiliated with – an enterprise telehealth platform that meets these criteria.
Most health systems grow through mergers and acquisitions, which is a costly and complex process. Merging the existing operations and cultures of healthcare organizations can be an overwhelming task.
Mayo Clinic thinks there’s a smarter way: reaching millions of new patients through technology. In just four years, the Mayo Clinic Care Network (MCCN) has grown to include dozens of affiliated facilities in 18 states, Mexico and Puerto Rico. Bear in mind that Mayo doesn’t own any of these partner organizations. It’s a relationship that’s based primarily on information sharing – and telemedicine plays an important role.
A great example is the Altru Health System in Grand Forks, North Dakota. Neurologists there conduct frequent e-consultations with Mayo specialists. This allows many more patients to be treated close to home, without requiring a trip to Mayo’s headquarters in Rochester, Minnesota.
Last year, MCCN reached seven million patients, which means that Mayo’s clinical footprint has increased threefold to about 63 million people. Mayo CEO Dr. John Noseworthy has set an organizational goal for that number to reach 200 million people by 2020. That’s nearly two-thirds of the U.S. population.
Mayo isn’t alone when it comes to adopting this “growth through technology” approach. The new Memorial Sloan-Kettering Cancer Alliance has found a pioneering partner in the Hartford Healthcare system in central Connecticut. Just like the Mayo network, the Sloan-Kettering alliance will allow cancer patients to get expert care without having to go to New York City for weeks or months of treatment.
Mayo and Sloan-Kettering are two of the biggest “brands” in healthcare. By demonstrating telemedicine’s many clinical and financial benefits, they’re setting the stage for similar partnerships in the near future.
For decades, the entry point in healthcare was the primary care physician’s office. That’s changing rapidly as retailers like Walgreens and Walmart ramp up their efforts. The first wave of retail medicine has been described as a “nurse practitioner in a closet.” But in 2015, we’ll be seeing many retail locations that offer everything a traditional PCP does…and often a whole lot more.
This trend is great news for telehealth providers. Most retail medicine operations are just barely beginning to make a profit. They can become more successful by partnering with telehealth companies that don’t have a comparable investment in brick-and-mortar offices and can leverage scalable, cloud-based technologies.
For example, if nurse practitioners at a retail site wants a quick second opinion, they can get one via telehealth without having to send the patient to a nearby primary care doctor. That keeps more money in the system, both for the retail provider and the telehealth partner.
The rapid growth in both retail medicine and telemedicine is fueled by patients’ desire for greater convenience and faster access to care. A recent Advisory Board story highlighted some of the reasons why Americans have so quickly warmed to retail medicine:
Easy online scheduling – The appointment portals at places like CVS and Walgreens are simple to use – and provide far greater convenience than what most urgent care clinics and EDs currently offer.
Extended hours – Unlike most PCPs, the caregivers at retail clinics work evenings and weekends.
Monitoring chronic conditions – Retail clinics are already adept at helping patients manage and monitor ongoing health problems like diabetes and hypertension.
Deep pockets for clinic upgrades – Retail giants have far more cash than your local PCP for things like the newest medical devices and EMR enhancements.
This will be the year when the synergy between retail medicine and telehealth becomes mutually profitable. The public has made it very clear: give us greater access and more convenience beyond the 9-to-5 limitations of traditional medicine.