Telehealth heads toward the mainstream (July/August 2011)

By Eric Wicklund
08:28 AM

From the July/August issue of Government Health IT.

When the Ford Motor Company announced plans in mid-May to partner with at least three companies to develop healthcare apps for the company's car-based platform, telemedicine experts around the country offered a hesitant smile. Could this be the big break they've been waiting for?

Could telemedicine finally gain mainstream attention?

Long thought to be stuck in the realm of academic medical universities and small-scale pilot projects, telemedicine – and telehealth, and mHealth, and all the other names being used for this wide-ranging healthcare field – may be turning a corner, thanks to some high-profile implementations.

Everybody's Talking

Telehealth has become a favorite topic of conversation for, among others, the nation's chief technology officer, Aneesh Chopra, who spoke at last year's American Telemedicine Association (ATA) conference. This year, ATA's 16th international meeting and exposition, held May 1-3 in Tampa, Fla., drew close to 5,000 attendees, placing it among the top 10 healthcare-related conferences in the nation. And telehealth has attracted the attention of the Centers for Medicare & Medicaid Services (CMS), which recently relaxed its rules on credentialing to allow hospitals to engage in telemedicine-based consults with physicians in other parts of the country.

"CMS' new rules will truly help patients receive the care they need, no matter where they live or where their doctor is located," said Dale Alverson, MD, former ATA president and medical director of the Center for Telehealth and Cybermedicine Research at the University of New Mexico's Health Sciences Center. "By eliminating the overly-burdensome credentialing and privileging rules in Medicare, CMS has shown its growing support of telemedicine."

The CMS ruling is expected to boost a program overseen by the Department of Health and Human Services' Health Resources and Service Administration, which has awarded grants to the Federation of State Medical Boards to help states set criteria to allow physicians to practice across state lines. According to an HRSA report issued to Congress, cross-state licensing "is seen as one element in the panoply of strategies needed to improve access to quality care services through the deployment of telehealth and other electronic practice strategies." To date, eight states have established licensing criteria.

Add to that separate projects by UPMC, Kaiser Permanente, the Mayo Clinic, the University of Miami and the Ford announcement (Toyota and GM are expected to announce similar projects soon), and telemedicine may finally be finding the spotlight.

Missing: Monetary Incentive

Ironically, while the ATA was trumpeting CMS' decision, a panel discussion at the May conference was taking the federal government to task for not including telemedicine or telehealth in the meaningful use program – thus depriving healthcare providers of valuable financial incentives contained in the HITECH Act.

There's "no real inclusion for telemedicine and telehealth" in the incentives designated by the American Recovery and Reinvestment Act for adoption of healthcare IT, said Neal Neuberger, executive director of the Institute for e-Health Policy and president of Health Tech Strategies.

Neuberger called on the Office of the National Coordinator for Health IT (ONC), headed by Farzad Mostashari, MD, to set the stage for increased acceptance of telemedicine.

"I think we need a grand vision that takes the long view as far as transforming healthcare outcomes, quality, efficiency, cost, and access," he said.

To be fair, the HITECH Act did include some consideration for telemedicine in the Beacon Community Program. According to Yael Harris, director of the HRSA's Office of Health IT and Quality, four community-based collaboratives in San Diego, Indiana, Utah and North Carolina, have received funding to incorporate telemedicine technology into programs.

The question of cost – not only of paying for telemedicine projects, but finding the reimbursement value – continues to plague the industry. Some vendors, like Arizona's Stat Health, are targeting businesses with an online doctor service in hopes of convincing them that paying a telemedicine fee will reduce employee health insurance and lost productivity costs over the long run. Others are exploring "pay-per-consult" plans, in which physicians set a price for their services, whether they're delivered online, by text message, or in person.



Care Without Technological Borders

Telemedicine might be the next version of the electronic health record. In a nation moving toward accountable care and outcomes-based reimbursement, the pressure may be on the providers to adopt telemedicine, Joseph Kvedar, of the Massachusetts-based Partners HealthCare System and director of the Center for Connected Health, told attendees at the "Health IT: Improving Healthcare and the Economy" conference, held May 10 in Worcester, Mass.

"There are ways to look globally at economics around this," he said. "One is, as we prepare for a world where we're paid for outcomes and quality, it will be up to us to interact with patients in whatever way we think will add the most value. That could be via e-mail, or via Skype. It doesn't have to be in the office."

The issue isn't specific to the United States. European healthcare leaders at the recent eHealth Week 2011 conference in Budapest, Hungary, urged government leaders to invest in telemedicine even as they wondered where the ROI would be found.

"Telemedicine is part of a complex healthcare process with different actors, factors and devices," said Francisca Garcia Lizana, policy officer at Spain's DG Infso and a spokesperson for the European Commission. "The change of any parameter in the process affects the total outcome. It is therefore difficult to measure the benefits of telemedicine on its own."

World leaders need to "evaluate the process and not the technology," she said. "We need more research but we should learn from the past and not repeat the same mistakes."

More Than Physician-to-Patient

Kaveh Safavi, vice president and global leader for Cisco's healthcare business, sees an immediate benefit to telehealth in linking physicians to each other to foster better collaboration and problem-solving, rather than linking patients to the physicians. And at a time when reimbursement for telemedicine services is murky, the effort to gain physician buy-in may be better served by focusing on the improvement in clinical outcomes through access to resources.

While Cisco is advancing the telemedicine platform on the West Coast, working with Kaiser Permanente and other providers, UPMC is taking the reins on the East Coast. The Pittsburgh-based healthcare network recently announced a partnership with Alcatel-Lucent to create a virtual "exam room" linking real-time audio and video communications with mobile devices.

"The challenge involved in creating this next-generation telemedicine system is designing a true multi-point communication platform that allows everyone involved in the medical case to securely view the same data and medical records at the same time regardless of the communication device used," said Sid Ahuja, vice president of Alcatel-Lucent Ventures/Bell Labs, who will co-manage the initiative. "With cloud-based technologies, services and software applications are delivered from the Internet rather than a dedicated enterprise network in a single location, enabling a new level of medical collaboration and information sharing via secure real-time audio, video, and data links."

The Department of Veterans Affairs, which cares for more than 43,000 servicemen and –women through its home telehealth program, is also taking a step forward. In April, the VA awarded contracts to six vendors: Authentidate, American Telecare, cardiocom, HealthHero Network, Visual Telecommunication Network/ViTelCare and Viterion TeleHealthcare. The contracts run between $150 million and $372 million and could cumulatively total $1.38 billion if all the contracts are renewed for the full five years.



Remarkable Implications

Meanwhile, surveys continue to paint a rosy picture for the future of telemedicine.

Recently, Manhattan Research reported that 7 percent of physicians in a recent study (2,041 U.S.-based physicians answered the call) use online video conferencing to communicate with patients.

"Telemedicine has the potential to open up consultations with top specialists, regardless of your location," said Meredith Ressi, Manhattan's president. "Combined with the impending shortage of primary care physicians, the implications of these technologies for how healthcare is delivered in our country are remarkable."

In addition, a recent study conducted by the University of Massachusetts Medical School in Worcester, Mass., and reported in the Journal of the American Medical Association reported that intensive care units that implemented a telemedicine program saw lower mortality rates, lower rates of preventable complications, and shorter hospital and ICU stays.

So while the Ford announcement is certain to spur a new round of mobile healthcare interest, only time will tell if it makes any headway on the long-standing issue of federal support.

Sidebar: The 4 Pillars of Telemedicine

Telemedicine's potential to improve care delivery and outcomes stands to benefit doctors and patients alike. The advantages have been called remarkable, and a number of requisite technologies are already in place. Questions linger, however, most notably about funding and incentives. Nonetheless, the push to make telemedicine a part of accepted mainstream healthcare seems to focus on four areas:
    (1)    Chronic disease management – With diabetes, high blood pressure and heart disease (among many conditions) on the increase, the ability to monitor people in their homes – or anywhere outside the doctor's office or hospital – is seen as an important step in reducing unnecessary healthcare costs.
    (2)    Wellness/preventive health – Health plans are pushing telehealth resources on such issues as smoking cessation, exercise and weight loss programs, while psychiatrists, schools and prisons are all exploring the benefits of remote consults.
    (3)    Replacing the ER trip or non-acute visit to the doctor's office – Hospital emergency rooms are closing down, and those left open are often overcrowded. Providing online contact between a physician and a patient is seen as a way of reducing unnecessary trips to the ER, as well as giving busy families an easy alternative to the time-consuming trip to the doctor.
    (4)    Emergency care – Accident victims, as well as those suffering a stroke or heart attack, need quick access to healthcare. Giving physicians a means to diagnose a patient in the field – either through a video connection or by receiving vital signs – could mean the difference between life and death.