Tap­ping tele­health for com­plex cases

Modern Healthcare - - NEWS - By Shelby Liv­ingston

Shortly after Thanks­giv­ing last year, Ron Cob­b­ley woke up with a stiff neck. Ibupro­fen did noth­ing to help the South Jor­dan, Utah, res­i­dent. Soon the pain be­came so in­tense that Cob­b­ley headed for the emer­gency room at In­ter­moun­tain Health­care’s River­ton Hospi­tal.

Sev­eral MRIs and CT scans later, Cob­b­ley’s doc­tors no­ticed a staph in­fec­tion nes­tled where his col­lar­bone meets his ster­num. The doc­tors or­dered surgery. While re­cov­er­ing, Cob­b­ley, 74, turned on his hospi­tal room’s high­def­i­ni­tion tele­vi­sion, out­fit­ted with a zoom cam­era, speak­ers and mi­cro­phones, to meet with Dr. Todd Vento, In­ter­moun­tain’s med­i­cal di­rec­tor of in­fec­tious dis­eases tele­health ser­vices.

Vento con­ducted the post-op­er­a­tive eval­u­a­tion from his of­fice at the sys­tem’s In­ter­moun­tain Med­i­cal Cen­ter in Mur­ray, Utah, its flag­ship cam­pus. He ex­am­ined Cob­b­ley’s in­ci­sions and spoke with the lo­cal care team to dis­cuss med­i­ca­tions.

“It was kind of space age,” Cob­b­ley re­called.

In­ter­moun­tain, whose tele­health sys­tem is among the most ad­vanced in the coun­try, is us­ing the tech­nol­ogy to ex­tend its spe­cial­ists’ skills into the smaller com­mu­nity hos­pi­tals and ru­ral lo­ca­tions in its net­work. These med­i­cal out­posts rarely have the clin­i­cal ex­per­tise nec­es­sary to han­dle the more-com­plex cases

“Tele­health al­lows you to kind of com­press time and space and use that core group of ex­per­tise across a broad net­work of hos­pi­tals.”

Dr. Alan Shatzel, neu­rol­o­gist and med­i­cal di­rec­tor of the Dig­nity Health Telemedicine Net­work

that come through their front doors.

The sys­tem has in­stalled video­con­fer­enc­ing set­ups in 1,000 rooms across its 22 hos­pi­tals. In­ter­moun­tain’s 35 tele­health pro­grams in­clude spe­cial­ists pro­vid­ing con­sul­ta­tions on stroke, new­born crit­i­cal care, be­hav­ioral health, wound care and can­cer care. In­ter­moun­tain is also us­ing remote mon­i­tor­ing for chronic dis­ease pa­tients with con­di­tions such as hy­per­ten­sion and heart fail­ure.

In­stead of hir­ing 22 in­fec­tious dis­ease doc­tors to staff each lo­ca­tion, tele­health “en­ables the lo­cal team to man­age those high-acu­ity pa­tients,” said Brian Wayling, In­ter­moun­tain’s as­sis­tant vice pres­i­dent of tele­health ser­vices. That saves In­ter­moun­tain money and al­lows the pa­tient to stay in the lo­cal com­mu­nity.

For more than a decade, some hos­pi­tals and health sys­tems have turned to tele­health to reach pa­tients in ar­eas squeezed by physi­cian short­ages. More re­cently, providers an­swered pa­tients’ calls for con­ve­nience by of­fer­ing on-de­mand video vis­its for rou­tine health prob­lems. Now the lead­ing health sys­tems are har­ness­ing tele­health to treat pa­tients with more com­plex con­di­tions in ways that lower costs by pre­vent­ing com­pli­ca­tions, re­duc­ing lengths of stay and, when used in home or posta­cute set­tings, re­duc­ing read­mis­sions.

That’s be­com­ing es­sen­tial as the U.S. health­care sys­tem moves to­ward pay­ing physi­cians for value in­stead of the quan­tity of care. Providers tak­ing part in ac­count­able care or­ga­ni­za­tions and bun­dled pay­ments now must look for ways to de­liver care more ef­fi­ciently. Tele­health has emerged as an im­por­tant tool in that ef­fort.

“The beauty of tele­health is you can bet­ter man­age peo­ple and pop­u­la­tions,” said Frances Dare, man­ag­ing di­rec­tor in con­sult­ing firm Ac­cen­ture’s health strat­egy prac­tice.

Much like In­ter­moun­tain, San Fran­cisco-based Dig­nity Health launched its telemedicine net­work to broaden the reach of its highly trained spe­cial­ists’ skills to smaller com­mu­nity hos­pi­tals. Not all of these com­mu­nity hos­pi­tals are in ru­ral ar­eas. There just sim­ply aren’t enough spe­cial­ists to meet pa­tient de­mand, ex­plained Dr. Alan Shatzel, a neu­rol­o­gist and med­i­cal di­rec­tor of the Dig­nity Health Telemedicine Net­work.

But tele­health “al­lows you to kind of com­press time and space and use that core group of ex­per­tise across a broad net­work of hos­pi­tals,” he said.

Dig­nity started out with emer­gency stroke eval­u­a­tions in 2008 and has since ex­panded its use of tele­health for crit­i­cal care, men­tal health, dis­ease man­age­ment and other ser­vices across 45 hos­pi­tals and clin­ics. The net­work had 20,500 telemedicine en­coun­ters with pa­tients in 2016.

Pa­tients in New York, Penn­syl­va­nia and be­yond have to fight their way into Man­hat­tan to see physi­cians at the New York-Pres­by­te­rian health sys­tem. So last year, the sys­tem, which is af­fil­i­ated with Columbia Univer­sity Med-

ical Cen­ter and Weill Cornell Med­i­cal Col­lege, launched its telemedicine pro­gram to reach more peo­ple.

It’s all about de­liv­er­ing care more ef­fi­ciently, said Daniel Barchi, the sys­tem’s chief in­for­ma­tion of­fi­cer. “If we can cre­ate an en­vi­ron­ment where a vir­tual visit al­lows that doc­tor to see many pa­tients in a re­ally ef­fi­cient model, that’s the ul­ti­mate goal,” he said.

The sys­tem so far is see­ing the big­gest im­pact from its telepsy­chi­a­try con­sults. A pa­tient who comes into one of New York-Pres­by­te­rian’s 11 hos­pi­tals with a bro­ken arm but also needs a psy­chi­atric eval­u­a­tion could sit in the emer­gency room for up to 24 hours if there’s no psy­chi­a­trist avail­able, Barchi said. But vir­tual vis­its can slash that wait time to just two hours.

New York-Pres­by­te­rian also con­ducts vir­tual fol­low-up vis­its for pa­tients with a num­ber of con­di­tions. Most fol­low-up care doesn’t re­quire a hands-on eval­u­a­tion. So it doesn’t make sense to have pa­tients travel to the hospi­tal for a 10-minute con­ver­sa­tion, Barchi said.

The sys­tem also launched vir­tual ER vis­its for pa­tients with non-life-threat­en­ing con­di­tions through its NYP On­De­mand plat­form. In­stead of wait­ing to see an ER doc­tor face-to-face, pa­tients can en­ter a pri­vate room and have a video visit with an ER physi­cian who’s sit­ting just 200 yards away in an of­fice. It takes just half an hour, Barchi said. That same ER physi­cian is also con­duct­ing ur­gent­care vis­its with pa­tients sit­ting at home on the couch.

To de­liver on-de­mand care to pa­tients at home, New York-Pres­by­te­rian part­nered with Amer­i­can Well, one of the many di­rect-to-con­sumer tele­health com­pa­nies now turn­ing its sights on serv­ing the needs of hos­pi­tals and health sys­tems. But while lead­ing health sys­tems say on-de­mand care is a nice perk to of­fer busy pa­tients, it does lit­tle to drive ef­fi­ciency and bring down health costs.

The di­rect-to-con­sumer plat­forms—in­clud­ing Amer­i­can Well, MDLive, Te­ladoc and Doc­tor on De­mand— largely han­dle low-acu­ity con­di­tions, such as skin rashes, headaches, coughs and colds. Some are start­ing to of­fer be­hav­ioral health ser­vices. But those aren’t the high-dol­lar chronic dis­eases that drive hospi­tal spend­ing.

Crit­ics con­tend ex­pand­ing low-acu­ity tele­health ser­vices could drive up costs. A March Health Af­fairs study by RAND Corp. found that although di­rect-to-con­sumer tele­health vis­its are cheaper than in-per­son care—they av­er­age about $40 to $50 a pop—the con­ve­nience fac­tor en­cour­ages peo­ple to use more health­care than they nor­mally would.

“The di­rect-to-con­sumer star­tups can do one thing and do it well,” said Nathaniel Lack­t­man, chair­man of law firm Fo­ley & Lard­ner’s telemedicine in­dus­try team. They have done a good job of ex­pand­ing ac­cess to low-acu­ity care. But health sys­tems are well-po­si­tioned to use tech­nol­ogy

Thirty-one states and the District of Columbia re­quire pri­vate in­sur­ers to pay for tele­health vis­its. But the laws dif­fer from state to state in what they cover.

to care for “the sick­est of the sick” who ac­count for the great­est share of health­care spend­ing, he said. That’s where there’s an op­por­tu­nity to drive real change in out­comes and true cost sav­ings.

The health sys­tem “that can crack that nut, so to speak, will be a game-changer,” Lack­t­man said.

Mercy Health is chang­ing the game with its $54 mil­lion Mercy Vir­tual Care Cen­ter. While the Ch­ester­field, Mo.-based sys­tem of­fers on-de­mand video vis­its, “we don’t think it is go­ing to change the health sys­tem and the care ex­pe­ri­ence for peo­ple nearly enough,” said Dr. Randy Moore, pres­i­dent of the Vir­tual Care Cen­ter.

In­stead, Mercy fo­cuses on mon­i­tor­ing and in­ter­ven­ing on be­half of the sick­est pa­tients both at home and in the hospi­tal. There are no beds or pa­tients at the Vir­tual Care Cen­ter—just nurses, doc­tors and lots of IT staff sit­ting be­hind an ar­ray of mon­i­tors. Part of the cen­ter is de­voted to Mercy SafeWatch, which is con­nected to more than 500 ICU beds across the Mercy sys­tem and sev­eral out­side health sys­tems. Clin­i­cians use tele­health tech­nol­ogy and data to mon­i­tor pa­tients, or­der bed­side care and fol­low-up.

The re­sults have been as­tound­ing, Mercy of­fi­cials say. The length of stay de­creased be­tween 30% and 40%, and 1,000 peo­ple who were ex­pected to die went home last year, Moore said.

In an­other pro­gram, teams of trained clin­i­cians at the Vir­tual Care Cen­ter mon­i­tor 4,000 beds for signs of sep­sis, a lead­ing cause of hospi­tal deaths. Mercy also con­nects with pa­tients re­cov­er­ing at home and is able to re­spond to their re­quests at any time. That’s led to a 60% re­duc­tion in acute-care ser­vices and dra­mat­i­cally im­proved qual­ity of life, Moore said.

Tele­health isn’t about see­ing a pa­tient re­motely, he said. “It’s about see­ing a pa­tient much ear­lier as they start to de­te­ri­o­rate, which opens up sim­pler, much more ef­fec­tive in­ter­ven­tions that are usu­ally less costly, and the per­son doesn’t get the bur­den of ill­ness.”

The cen­ter also op­er­ates a range of other tele­health pro­grams, from stroke care to spe­cialty physi­cian con­sults.

Low or no re­im­burse­ment for vir­tual care has long worked against tele­health adop­tion, but health sys­tems that are cap­i­tated or in­volved in risk-based con­tracts aren’t so wor­ried about re­im­burse­ment. “We are al­ready paid a fixed fee, so if we can bring our costs down (through our tele­health pro­grams), and our length of stay while we im­prove out­comes, we can keep that mar­gin to do other things within our mis­sion,” Moore said.

Many ser­vices are still paid for on a fee-for-ser­vice ba­sis, how­ever. Smaller providers in­ter­ested in ex­tend­ing their reach through tele­health may have no way to en­ter a riskbased con­tract. For them, get­ting paid is im­por­tant.

Pay­ment for tele­health ser­vices re­mains in­con­sis­tent and de­pends heav­ily on the payer, the state and the type of care. That de­ters some providers from tak­ing the plunge, said Kofi Jones, prin­ci­pal and owner of con­sult­ing firm KJ Health Mat­ters in Bos­ton and for­mer vice pres­i­dent of gov­ern­ment af­fairs for Amer­i­can Well.

Thirty-one states and the District of Columbia re­quire pri­vate in­sur­ers to pay for tele­health vis­its. But the laws dif­fer from state to state in what they cover.

Med­i­caid pro­grams in ev­ery state have some type of cov­er­age for tele­health. But Medi­care re­stricts pay­ment to very nar­row cir­cum­stances. For in­stance, pa­tients must be out­side of a metropoli­tan area and at a spe­cific clin­i­cal site when re­ceiv­ing tele­health ser­vices.

“We’re in­vest­ing more in these pro­grams than we’re get­ting re­im­burse­ment for,” said Barchi of New York-Pres­by­te­rian. “It’s more about cre­at­ing the in­fra­struc­ture so we can do this well.”

For now New York-Pres­by­te­rian is will­ing to take a loss for tele­health ser­vices if vir­tual care makes more sense than re­quir­ing a pa­tient to come for an in-per­son visit. It’s gambling that the ser­vice will even­tu­ally gen­er­ate pos­i­tive re­turns as the sys­tem moves into more risk-based con­tract­ing.

“We want to use this to move into much more ag­gres­sive value-based con­tracts where we will be re­warded for keep­ing peo­ple healthy at a lower cost,” Mercy’s Moore said.

In­ter­moun­tain Health­care in­ten­sivist Dr. Terry Clem­mer (seen on the screen) uses tele­health tech­nol­ogy to con­sult with on-site nurse Michelle Rosqvist about care for an ICU pa­tient at LDS Hospi­tal in Salt Lake City.

In­ter­moun­tain has in­stalled video­con­fer­enc­ing set­ups in 1,000 rooms across its 22 hos­pi­tals.

Mercy SafeWatch is the largest sin­gle-hub elec­tronic in­ten­sive-care unit in the na­tion. Doc­tors and nurses mon­i­tor pa­tients’ vi­tal signs and pro­vide a sec­ond set of eyes to bed­side care­givers in 30 ICUs across five states.

Dr. Gavin Hel­ton, med­i­cal di­rec­tor of the Mercy Vir­tual Care Cen­ter’s am­bu­la­tory medicine pro­gram, con­sults with a nurse.

Mercy’s four-story, 125,000-square-foot Vir­tual Care Cen­ter not only houses the na­tion’s largest sin­gle­hub elec­tronic ICU, but also pro­vides a cen­ter for telemedicine in­no­va­tion and a test­ing ground for new health­care prod­ucts and ser­vices.

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