TeleMedicine (TeleHealth)

Transcription

1 TeleMedicine (TeleHealth) Scope, Current State and Application Nadir Abdelrahman, MD Pankaj Jandwani, MD MMM Disclosure Both presenters have no relevant financial relationships to disclose. Outline Definition Modalities Benefits and Challenges Current Applications Application in Post Acute Area Recommendations 3 1

2 History... It is an amazing invention, but who would ever want to use one Rutherford Hayes On the using telephone for the first time History... Boston Logan Airport to Massachusetts General Hospital

3 Use Cases Modalities 10/4/2015 Overview - Models Store and Forward Dermatology, Pathology, Radiology Remote Monitoring Cardiac Telemetry, Health kits, e-icu For COPD, CHF Real Time Video Consultations Video conferencing with remote provider Psychiatry, Neurology, post surgical follow ups Models and Medium Telehealth Use Cases, Relevant Modalities, and Investment Required Professional Consultation Diagnosis & Treatment Education & Engagement Ongoing Monitoring & Care Coordination Videoconference Need software, secure internet access for patients Home and hospital-based technology Asynchronous Store-and- Forward Need additional bandwidth, storage space Can replace non-urgent phone calls and visits Remote Telephone Patient Device Portal More expensive Little tech High security hardware investment, needs require investment requires proper significant staffing investment Used for highrisk patients in Used for previsit triage Must integrate non-hospital site EHR Mobile App Minimal hardware investment for providers Complex security and data storage issues Courtesy Advisory Board 3

4 Industry Overview Industry Snapshot: Video Platforms Extending Access to Providers for High-Risk, Rural, and Wellness Visits Use Cases Major Vendors I think [virtual visits] will become a normal part of health care in three to five years. Dr. Harry Leider Walgreens CMO Chronic disease management Rural access to care Behavioral health video consults 24/7 coverage MDLive Teladoc American Well Zipnosis CampusMD Stat Doctors Sentara Low-Cost Alternative to Traditional Primary Care $49 9,000 2M Cost of Walgreens virtual visit, most Interactions per week via Estimated new patients added per of which goes to physician Walgreens Pharmacy Chat virtual day for MDLive following visit platform partnership with Walgreens Source: Hirst, E. J., Walgreens App Makes Virtual Doctor Visits a Reality, Chicago Tribune, December 2014, Consumer Needs & Preferences: Cost Consumer Price Sensitivity Drives Decision-making Purchasers Patients to Shop Based on Price The visit will cost me $20 I will know the exact price before visit I can get lab tests or x-rays done at the clinic if needed I can walk in without an appt and am guaranteed to be seen within 30 min Consumers Utility Ratings of Clinic Attributes 1 By Health Plan Type Price Sensitivity in Action 33% Patients who put off medical treatment because of cost in % Increase in privately insured patients putting off care due to cost from 2013 to 2014 Non-HDHP HDHP 1) Consumer Directed Health Plan. Source: Consumer Oriented Competition, Marketing and Planning Leadership Council 2014; Riffkin, R. Cost Still a Barrier Between Americans and Medical Care, Gallup, December 2014, Consumer Needs & Preferences: Convenience Consumers Increasingly Prefer On-Demand Care Survey Finds Visits Preferred to Clinic Near Errands or Work Preference for Location of Services Clinic location near work Clinic located near errands ing provider with symptoms Clinic located near the home Increasing Consumer Preference Young, Wealthy, Busy Strongest Potential Telehealth Targets 1 54% Of years olds 49% Of those making >$71K per year 53% Of those working >35 hours per week 1) Based on proportions of respondents interested in teleheatlh. Source: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis. 4

5 Industry Snapshot: Mobile Apps Big Market in Early Stages of Development Common Applications Major Vendors Similar to the internet revolution, mhealth is revolutionizing the way of patients receiving their care. Mary Annecharico CIO at Henry Ford Health Systems EHR Access in and out of care site Fitness/activity tracking Biometric data collection and transmission Remote communication with providers Qualcomm Apple IBM GE Individuals and small startups to large hospital systems and payers Mobile Health Market Rapidly Expanding $49.1B 95M Estimated global mhealth Americans using mhealth market size by 2020 technologies in % US population covered by mobile network Source: McCann, E. mhealth Market Scales to New Heights, Healthcare IT News, March 4, 2014, Mobile Apps, Cont. Apple, Others Entering the Health Care Market Impact on Providers Integration: With hubs, providers will not have to do as much work to make sure thirdparty devices are operable with their existing platforms Coordination: Other providers and caregivers can access more data securely Messaging: Patients will be able to send data directly to providers Major Players Partnerships IBM to combine Apple s leadership in customer experience and mobile devices with IBM s extensive experience in enterprise mobility management, analytics, and knowledge management (e.g., Watson) Epic integration of MyChart with Apple Health; Other vendors working with HealthKit include Cerner Wellness (HealthyNow), athenahealth and Allscripts Mayo and other emerging partnerships with leading provider organizations (Mount Sinai, The Cleveland Clinic, Johns Hopkins) to develop health applications Apple HealthKit Microsoft HealthVault Google Fit Samsung S Health Source: Global ehealth Executive Council interviews and analysis. Industry Snapshot: Remote Monitoring Devices Keeping Providers and Patients Connected Regardless of Location Clinical Benefits Major Vendors Patient monitoring is becoming a necessary measure for hospitals and doctors to measure their business. The focus is shifting whether they like it or not. Reduced readmissions Improved chronic disease-related mortality Reduced ED visits Improved care coordination Noninvasive Medical Technologies Corventis Pharos Innovations Honeywell HomMed McKesson Jack Young Head of Qualcomm Life Fund Remote Monitoring has Wide Reach 19M $5.85B Estimated patients connected Total remote patient to remote monitoring devices monitoring market in 2013 by % Market share of connected medical device manufacturers Source: Baum, S. Report: 19 Million Will use Remote Patient Monitoring by 2018, MedCity News, June

6 Technological Advances Technology Getting Faster, More Widespread Enables Growth in Telehealth Advancements in Technology Remote monitoring devices with cellular or fixed-line modems enabling data transmission without computer or smartphone Expanded memory and processing capabilities Geospatial tracking Movement tracking Touch-screen technologies Increased Population 100% US population covered by mobile network Health information fastest-growing content accessed by US mobile users, up 134% between Medicare-Billed Telehealth Encounters 4,160 4,848 5,791 10,381 20,804 32,702 36, Sources: mhealth in an mworld: How mobile technology is transforming health care, Deloitte, available at Health Care IT Advisor research and analysis Benefit #3: Cost Management Mobile Communication Saves Clinicians Time 17 Preventing Wasted Time from Phone-Tag with Specialists, Care Team More Streamlined Care Coordination Across Networks Case Consult Screen Shot Providers conduct case consults or referrals virtually using group chat Improves communication and efficiency between providers Prevents readmissions through collaborative care follow-ups Automatic documentation ready for export to medical record 55% 30 min 10 min 50% PINGMD messages replace office visits 1 Median response time from physician to patient on PINGMD 2 Median response time between care partners on PINGMD 2 Physicians saving minutes/day with application 1) Messages often replace unpaid patient encounters such as post-ops, prescriptions, discussion of lab results, etc. 2) Not required; mean response time for MD-to-patient is 60 min. Source: PINGMD, available at: accessed October 1, 2013; Health Care Advisory Board interviews and analysis. CMS CY2015 Reimbursement Updates Proposed Rule Adds Procedures to List of Covered Telehealth Services Services Affected by Rule Wellness Visits Expansion of Service Wellness visits are covered as long as there is an existing relationship between the patient and physician; the relationship can be initiated via a virtual visit Impact on Providers Because the Medicare definition of telehealth involves two-way audio and video coverage, providers can have and be paid for meaningful, ongoing patient relationships Behavioral Health Visits Psychoanalysis, family psychotherapy (both with and without the patient present), and prolonged service The ability to offer behavioral health visits remotely can be a new source of patient volume for providers who previously did not have the capacity to offer these services in-house Geographic Service Area Payments allowed for patients in rural census tracts even if those tracks are within metropolitan statistical areas More sites will now be eligible as telehealth originating sites, opening up business opportunities for more providers Chronic Care Management CMS will reimburse providers for furnishing specific non-face-to-face services to qualified beneficiaries over a calendar month While not specific to telehealth, these payments will cover medication reconciliation, care coordination among providers, and RPM Source: Center for Medicare and Medicaid Services CY2015 Physician Fee Schedule Proposed Rule, 42 CFR

7 Benefit #1: New Patient Recruitment Following Trial, Strong Preference for Virtual Care Telehealth Pilot Shows Early Adopters Now Recruiting Early Majority 92% 91% 71% Of a virtual visit provider s patients said they would use the service again Of Zipnosis users would recommend the service to at least three friends Of midsized to large U.S. employers anticipate offering employees telehealth services within three years Case in Brief: Medical Associates Clinic Four-physician practice in Kentucky Piloted the Me-Visit mobile app to offer online care for primary care and chronic condition follow up needs In 30-month pilot, 20% of patients used the app, and 97% of users preferred the service to in-person care Source: 2014 Primary Care Consumer Choice Survey; Teledoc, available at accessed July 2014; The Virtual Primary Healthcare Revolution, Becker s Hospital Review, available at accessed July 2014; Just how far in usage and savings can telemedicine take US healthcare? mhealthnews, available at accessed August 2014; Marketing and Planning Leadership Council interviews and analysis. Real Time Video -Risk Based approach Source: Marketing and Planning Leadership Council interviews and analysis. Remote Diagnoses, treatments follow reliable standard protocols based on evidence-based medicine Suggested therapies are nearly always effective Physical exam not required, visual exam adds nominal value LOW RISK Emerging Areas for Virtual Care Management, Maintenance Chronic disease checkups, follow-ups Care plan updates Specialist consults Diagnosis, Treatment Remote diagnostics Self-guided interventions HIGH RISK FOLLOW UP In-Person Diagnoses, treatments more complex, may vary within disease category Therapies may need careful selection and monitoring Physical exam or diagnostic test required to correctly identify issue and select treatment Intervention required (i.e., immunization) Courtesy Advisory Board How likely are you to keep referrals/transfers within our health system if this TELE-CONSULT was available? MidMichigan Provider Survey of over 400 providers 7

8 How Would TeleMedicine affect MidMichigan Provider Survey of over 400 providers Telemedicine and Post Acute and long Term Care Medicine In the news: Modern Doctors House Calls: Skype Chat and Fast Diagnosis By ABBY GOODNOUGH JULY 11,

9 In the news: Telemedicine can help and we should streamline licensing and explore how to make that reimbursable under Medicare. Democratic presidential candidate and former U.S. Secretary of State Hillary Clinton speaks to guests gathered for a campaign event on the campus of Des Moines Area Community College on August 26, 2015 in Ankeny, Iowa. Telemedicine Use in SNFs A recent systematic review identified 22 studies. Most studies employed interactive services (17) Focused on economic, feasibility, satisfaction, reliability, and service implementation. Edirippulige S, et al. J Telemed Telecare Use Teledermatology Teledermatology consults may replace some onsite consultations by offering quality care in a cost effective manner. 9

10 Use Dementia Case-based video-consultation program can be successful in improving the care of elders with dementia and/or delirium related behavioral issues by linking specialists with long-term care providers University of Nebraska Medical Center Department of Psychiatry Services for Geriatric Patients in Nursing Homes Use Long-term care/telemedicine Correctional telemedicine as a model Similar scenarios Desire to not transport patients off site Limited on-site primary care No on-site specialty care Must maintain certain level of staff on-site at all times Have stringent rules and regulations to follow 10

11 Grabowski and O Malley, Health Aff February 2014 vol. 33 no Benefits in Post Acute and Long Term Medicine Enhance and increase on-site primary care Enhance and increase on-site specialty care Reduce ambulance transportation for off-site care Reduce unnecessary ER visits Reduce risk of injury associated with transports Reduce loss of revenue to nursing homes Allow better community ambulance coverage with less nursing home transports Benefits Provider Perspective Communication/Collaboration with other teams Addressing issues, answering questions raised by patient/family Patient/Family education Better evaluation of urgent cases Follow up on different patients with stable chronic conditions Saves time, travel to different facilities 11

12 Number of patients 10/4/2015 Benefits Patient Perspective Access: in a timely manner Health Provider Collaboration Enhanced Communications with provider and family Increase patient satisfaction with care Payment Will Medicare Part B pay for initial and subsequent nursing facility visits furnished by telehealth? In 2011, CMS approved the addition of subsequent visits ( ) to the list of Medicare telehealth services with the limitation of: One telehealth subsequent nursing facility care service every 30 days. The initial visit and Federally-mandated periodic visits should be conducted inperson. It may not be furnished through telehealth. Medicare beneficiaries are in an originating site (SNFs are an authorized originating site) located in a rural health professional shortage area or in a county outside of a Metropolitan Statistical Area. As a condition of payment, an interactive audio and video telecommunications system must be used that permits real-time communication between a physician or practitioner at the distant site and the beneficiary at the originating site. Payment Patients seen at two SNFs in 2014 CPT Codes Telemedicine visits per month GT GT GT Apr May Jul Aug Sep Oct Nov Dec 12

13 Tools Real-Time Videoconferencing between a Physician and critically-ill resident 37 Tools Rollabout with Electronic Equipment Telemedicine Carts Video Conferencing Exam Cameras ENT Digital Otoscopes Electronic Stethoscopes Dermascopes Ophthalmoscopes 12 lead EKG Adoption Driver of Adoption Barrier to Adoption Consumer Needs & Preferences Technological Advancements Regulations: Privacy, security, and confidentiality. Licensing and Credentialing issues / Liability Provider Concerns: Reimbursement Infrastructure: IT Cost 13

14 Summary Telemedicine is coming to Post Acute and Long Term Care Facilities Simply making it available does not guarantee its use by nursing home staff. Engagement is the key to the use of telemedicine. Additional steps needed to encourage buy-in among nursing home administrators, front-line staff members, and physicians. Health care providers and governments should work together for the best results We should get ready and plan to take an action. Mere Vehicles - Mere Tools Telemedicine is just a vehicle that permits the delivery of health care services but it has no greater impact on healthcare than the truck that delivers our groceries has on our nutrition. It is the content of the vehicle that permits effective health care, not the vehicle. Thank you! Questions 14