10/4/2015

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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

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“It is an amazing invention, but who would

ever want to use one”

Rutherford Hayes 1882 - On the using

telephone for the first time

History...

History...

Boston Logan Airport to

Massachusetts General

Hospital 1967

10/4/2015

3

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

Courtesy – Advisory Board

Use

Ca

se

sM

od

alit

ies

Telehealth Use Cases, Relevant Modalities, and Investment Required

Videoconference Asynchronous

Store-and-

Forward

Remote

Device

Telephone

Professional

Consultation

Diagnosis &

Treatment

Education &

Engagement

Ongoing

Monitoring

& Care

Coordination

Patient

PortalMobile App

• Need software,

secure internet

access for

patients

• Home and

hospital-based

technology

• Need additional

bandwidth,

storage space

• Can replace

non-urgent

phone calls and

visits

• More expensive

hardware

investment

• Used for high-

risk patients in

non-hospital site

• Little tech

investment,

requires proper

staffing

• Used for pre-

visit triage

• High security

needs require

significant

investment

• Must integrate

EHR

• Minimal

hardware

investment for

providers

• Complex

security and

data storage

issues

Models and Medium

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Extending Access to Providers for High-Risk, Rural, and

Wellness Visits

Industry Overview

Source: Hirst, E. J., “Walgreens App Makes Virtual Doctor Visits a Reality,” Chicago Tribune, December 2014, http://www.chicagotribune.com/business/ct-walgreen-virtual-doctor-app-1209-biz-20141208-story.html

Industry Snapshot: Video Platforms

Use Cases

Chronic

disease

management

Behavioral

health video

consults

Rural

access to

care

24/7 coverage

“I think [virtual visits]

will become a normal

part of health care in

three to five years.”

Dr. Harry Leider

Walgreens CMO

Low-Cost Alternative to Traditional Primary Care

Cost of Walgreens virtual visit, most

of which goes to physician

$49Interactions per week via

Walgreens’ Pharmacy Chat virtual

visit platform

9,000Estimated new patients added per

day for MDLive following

partnership with Walgreens

2M

Major Vendors

• MDLive

• Teladoc

• American Well

• Zipnosis

• CampusMD

• Stat Doctors

• Sentara

Consumer Price Sensitivity Drives Decision-making

Purchasers Patients to Shop Based on Price

Source: Consumer Oriented Competition, Marketing and Planning Leadership Council 2014; Riffkin, R. “Cost Still a Barrier Between Americans and Medical Care,” Gallup, December 2014, http://www.gallup.com/poll/179774/cost-barrier-americans-medical-care.aspx.

Consumer Needs & Preferences: Cost

1) Consumer Directed Health Plan.

33%

Patients who put off medical treatment because of cost in 2014

9%

Increase in privately insured patients putting off care due to cost from 2013 to

2014

Price Sensitivity in Action

Consumers’ Utility Ratings of Clinic Attributes1

4.26

4.09

2.59

2.73

3.87

3.80

2.87

2.94The 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

Non-HDHP HDHP

By Health Plan Type

Consumers Increasingly Prefer “On-Demand” Care

Survey Finds Email Visits Preferred to Clinic Near Errands or Work

Source: 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council interviews and analysis.

Consumer Needs & Preferences: Convenience

1) Based on proportions of respondents interested in teleheatlh.

Increasing Consumer Preference

Emailing provider

with symptoms

Preference for Location of Services

Clinic location

near work

Clinic located

near errands

Clinic located

near the home

Young, Wealthy, Busy—Strongest Potential Telehealth Targets1

Of 18-29 years olds

54%Of those making >$71K per year

49%Of those working >35 hours per week

53%

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Industry Snapshot: Mobile Apps

Big Market in Early Stages of Development

Source: McCann, E. “mHealth Market Scales to New Heights,” Healthcare IT News, March 4, 2014, http://www.healthcareitnews.com/news/mhealth-market-growth-trajectory

Common Applications

EHR Access in

and out of care

site

Biometric data

collection and

transmission

Fitness/activity

tracking

Remote

communication

with providers

“Similar to the internet

revolution, mHealth is

revolutionizing the way of

patients receiving their care.”

Mary Annecharico

CIO at Henry Ford Health Systems

Mobile Health Market Rapidly Expanding

Estimated global mHealth

market size by 2020

$49.1BAmericans using mhealth

technologies in 2013

95MUS population covered by

mobile network

100%

Major Vendors

• Qualcomm

• Apple

• IBM

• GE

• Individuals and small start-

ups to large hospital

systems and payers

Mobile Apps, Cont.

Apple, Others Entering the Health Care Market

Source: Global eHealth Executive Council interviews and analysis.

• Integration: With hubs, providers will not

have to do as much work to make sure third-

party 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

Impact on Providers

• 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

Partnerships

• Apple HealthKit

• Microsoft HealthVault

• Google Fit

• Samsung S Health

Major Players

Keeping Providers and Patients Connected Regardless of Location

Source: Baum, S. “Report: 19 Million Will use Remote Patient Monitoring by 2018,” MedCity News, June 2014. http://medcitynews.com/2014/06/biggest-market-remote-patient-monitoring/

Industry Snapshot: Remote Monitoring Devices

Clinical Benefits

Reduced

readmissions

Reduced ED

visits

Improved chronic

disease-related

mortality

Improved care

coordination

“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.”

Jack Young

Head of Qualcomm Life Fund

Remote Monitoring has Wide Reach

Estimated patients connected

to remote monitoring devices

by 2018

19MTotal remote patient

monitoring market in 2013

$5.85BMarket share of connected

medical device manufacturers

76.7%

Major Vendors

• Noninvasive Medical

Technologies

• Corventis

• Pharos Innovations

• Honeywell HomMed

• McKesson

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Enables Growth in Telehealth

Technological Advances

Sources: “mHealth in an mWorld: How mobile technology is transforming health care,” Deloitte, available at http://www.deloitte.com/; Health Care IT Advisor research and analysis

Technology Getting Faster, More Widespread

4,160 4,848 5,791

10,381

20,804

32,702

36,100

2005 2006 2007 2008 2009 2010 2011

Medicare-Billed Telehealth Encounters

• 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

• 100% US population covered by mobile network

• Health information fastest-growing content accessed by US mobile users, up 134% between 2010-2011

Advancements in

TechnologyIncreased Population

Mobile Communication Saves Clinicians Time17

Preventing Wasted Time from ‘Phone-Tag’ with Specialists, Care Team

Benefit #3: Cost Management

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.

55%PINGMD messages

replace office visits1

30 minMedian response time

from physician to patient on PINGMD2

50%Physicians saving

15-60+ minutes/daywith application

More Streamlined Care Coordination Across Networks

• 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

Case Consult

Screen Shot

10 minMedian response

time between care partners

on PINGMD2

Source: PINGMD, available at: www.PINGMD.com, accessed October 1, 2013; Health Care Advisory Board interviews and analysis.

Proposed Rule Adds Procedures to List of Covered Telehealth Services

Source: Center for Medicare and Medicaid Services CY2015 Physician Fee Schedule Proposed Rule, 42 CFR 410.

CMS CY2015 Reimbursement Updates

Services Affected by Rule

Wellness Visits

Behavioral Health Visits

Geographic Service Area

Expansion of Service Impact on Providers

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

Psychoanalysis, family psychotherapy

(both with and without the patient

present), and prolonged service

Payments allowed for patients in rural

census tracts even if those tracks are

within metropolitan statistical areas

Because the Medicare definition of

telehealth involves two-way audio and

video coverage, providers can have and

be paid for meaningful, ongoing patient

relationships

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

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

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Case in Brief: Medical

Associates Clinic

Telehealth Pilot Shows Early Adopters Now Recruiting Early Majority

Benefit #1: New Patient Recruitment

Source: 2014 Primary Care Consumer Choice Survey; Teledoc, available at http://www.teladoc.com/healthplans/how-it-works-for-your-members/, accessed July 2014; “The Virtual Primary Healthcare Revolution,” Becker’s Hospital Review, available at http://www.beckershospitalreview.com/strategic-planning/the-virtual-primary-healthcare-revolution-what-health-systems-need-to-know.html, accessed July 2014; “Just how far in usage and savings can telemedicine take US healthcare?” mHealthNews, available at http://www.mhealthnews.com/news/just-how-far-usage-and-savings-can-telemedicine-take-us-healthcare, accessed August 2014; Marketing and Planning Leadership Council interviews and analysis.

Following Trial, Strong Preference for Virtual Care

71%Of midsized to large U.S.

employers anticipate

offering employees

telehealth services within

three years

92%Of a virtual visit

provider’s patients said

they would use the

service again

91%Of Zipnosis users would

recommend the service

to at least three friends

• 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

Real Time Video -Risk Based approach

Source: Marketing and Planning Leadership Council interviews and

analysis.

Courtesy – Advisory Board

Emerging Areas for Virtual Care

Remote In-Person

• 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

• 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)

Management, Maintenance

• Chronic disease checkups,

follow-ups

• Care plan updates

• Specialist consults

Diagnosis, Treatment

• Remote diagnostics

• Self-guided interventions

LOW RISK HIGH RISK – FOLLOW UP

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

10/4/2015

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MidMichigan Provider Survey of over 400 providers

How Would TeleMedicine affect

Telemedicine and Post Acute

and long Term Care Medicine

In the news:

Modern Doctors’

House Calls: Skype

Chat and Fast

Diagnosis

By ABBY GOODNOUGHJULY 11, 2015

10/4/2015

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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 2013.

Teledermatology

Teledermatology consults may replace some onsite consultations

by offering quality care in a cost effective manner.

1997 2007

Use

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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. 2014

Use

University of Nebraska Medical Center

Department of Psychiatry

Services for Geriatric Patients in Nursing Homes

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

Use

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Grabowski and O’Malley, Health Aff February 2014 vol. 33 no. 2 244-250

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

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

Benefits

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Patient Perspective

Access: in a timely manner

Health Provider Collaboration

Enhanced Communications with provider and

family

Increase patient satisfaction with care

Benefits

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 (99307–99310) 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 in-

person. 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

0

2

4

6

8

10

12

14

16

18

Apr May Jul Aug Sep Oct Nov Dec

0

5

10

15

20

25

30

35

40

99308 GT 99309 GT 99310 GT

CPT Codes Telemedicine visits per month

Num

ber

of

patients

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37

Real-Time Videoconferencing between

a Physician and critically-ill resident

Tools

Rollabout with Electronic

Equipment• Telemedicine Carts

• Video Conferencing

• Exam Cameras

• ENT Digital Otoscopes

• Electronic Stethoscopes

• Dermascopes

• Ophthalmoscopes

• 12 lead EKG

Tools

Adoption

• Consumer Needs & Preferences

• Technological Advancements

Regulations: Privacy, security, and

confidentiality. Licensing and

Credentialing issues / Liability

Provider Concerns: Reimbursement

Infrastructure: IT

Cost

Driver of

Adoption

Barrier to

Adoption

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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