REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges

Deborah A. Randall, JD & Consultant

www.deborahrandallconsulting.com

Kathy Duckett, RN,BSN, Director

Clinical Services Partners Homecare

Moving Towards Electronically Enabled Care Delivery@Home

HIT = Health Information Technology HIE = Health Information Exchange EHR = Electronic Health Record EMR = Electronic Medical Record PHR = Personal Health Record ONC = Office of the National

Coordinator for HIT [DHHS]

Survey 2010: eHealth Initiative

61% of respondents agree or strongly agree that significant progress has been made in the successful adoption and use of HIT since 2007.

BUT 54.9% disagree or strongly disagree the value of HIE is clearly understood &

66.6% disagree or strongly disagree outreach on value of EHR/HIE is effective

55.5% of respondents disagree or strongly disagree that differences between federal and state privacy laws are not a barrier to consumer’s rights to healthcare privacy.

56% agree or strongly agree that HIT and HIE have had a positive effects on care delivery.

Evolving Definitions

Telemedicine vs. telehealth Doctor to doctor d2d Doctor to patient d2p Distance learning Remote monitoring eCare eHealth “Smart” homes

Developments & Trends

New Medicare Reimbursement Possibilities: SNFs; kidney, nutritional, diabetes self-management; mental health services

Devices as diagnosis-enhancers Infrastructure for Telemedicine and

Telehealth Legislation

LEGISLATION 2009-2010

HITECH ACT 2009- Stimulus Bill

HIT Policy Committee of ONC

Infrastructure got first funding

Aging Services Technology Study

PPACA – Health Reform Act 2010

Independence@Home; Medicaid Medical Home; Chronic Care; Innovation Cntr

TELEHEALTH IMPACT

A. $2 billion in direct funding for health IT efforts, channeled through the Office of the National Coordinator [ONC]– $300 million reserved for supporting regional health information exchange efforts and the state-based “extension centers"– $20 million reserved for NIST for work on health careinformation enterprise integration- BEACON GRANTS

B. Incentives Medicare and Medicaid to providers and hospitals adopt and use health IT systems =AND THESE PHYSICIANS CAN BE WORKING WITH HHAs and HOSPICES

HIGHTECH, cont.

– $85 million for the Indian Health Service to use on health IT

– $1.5 billion for community health centers, a sum thatcan be used toward health IT acquisition

– $500 million for the Social Security Administration forprocessing disability and retirement workloads, of whichup to $40 million may be used for health IT researchand adoption

– $1.1 billion to AHRQ, HHS, and the NIH for comparativeeffectiveness research

BEACON: $16+Million Buffalo

Western NY Info.Exchange, Buffalo clinical decision support –

registries ;point-of-care alerts/reminders innovative telemedicine =improve

primary/specialty care for diabetics, ↓preventable ER visits, hospitalizations re-admissions for diabetes, CHF, pneumonia; ↑immunization of diabetics

Patient Protection and Accountable Care Act of 2010

“PPACA” --This is where the expansion will continue to be.

PPACA drives the process towards management of chronic disease.

Health information technology is finally showing, with reliable data, that telehealth can integrate with traditional care and use staffing innovations.

PPACA Promises? Promises!

Post-hospitalization bundling pilot Independence at Home demonstration Innovation Center at DHHS; chief

policy person in place;telehealth focus ACOs Medical Home-Medicaid and Pilots Face2face HHA provision w telehealth

Blue Cross/Blue Shield WNY

Blue Cross/Blue Shield Western New York in May 2010 initiated online physician-patient communication as a compensated service; encouraging telehealth communications and webcam visits; measuring quality of care and patient compliance factors

Technology-enabled Care: Where are we now?

Satellite health facilities In situ care w medical devices Remote monitoring and sensors Awareness and acceptance European efforts in ambient care The VA system –the Vanguard

Where is Telehealth in Use

Care coordination and Chronic Disease

Patient self-management Ambulatory care and safety Palliative care Rehabilitative services Behavioral & mental health services

VA Chronic Care Coordination via Telehealth Study

CONDITION # % DECREASE UTILIZATION

Diabetes 8,954 20.4

Hypertension 7,447 30.3

CHF 4,089 25.9

[congestive heart failure]

COPD 1,963 20.7

[chronic pulmonary obstruction]

VA Chronic Care Coordination via Telehealth Study

Posttraumatic stress disorder 45.1% Depression 56.4% Other mental health condition 40.9% Single condition 10,885 patients;24.8% Multiple “ “ 6,140 patients;26.0% Interventions “just in time”; “air traffic

control”

VA Chronic Care Coordination via Telehealth Study

The cost ($1,600.24 pp/yr compares favorably)

direct cost of VHA’s home-based primary care services of $13,121.25 per annum and

market nursing home care rates that average $77,745.26 per patient per annum”.

Conclusion: a flexible and cost-effective adjunct to VHA’s existing services. Darkins et al., Telemedicine & EHealth, 12/2008.

Telehealth and chronic illness

St. Vincent Health System's Visiting Nurse Association [Arkansas] has used telehealth computers to monitor patients in their homes for several years, and in its 11 county region had only about 4.5% of heart attack patients re-hospitalized compared with a national rate of 37%. [National Assn for Home Care report]

Telehealth and Aging in Place

University of Missouri :sensors, computers and communication systems, along with supportive health care services monitor the health of older adults who are living at home.

Motion sensor networks installed in seniors’ homes can detect changes in behavior and physical activity, including walking and sleeping patterns. Early identification of these changes can prompt health care interventions that can delay or prevent serious health events.

HMSA: Ambulatory MD/Home

Hawai’i Medical Service Ass’n Jan 09 Online Care connects, 24/7, patients

and physicians via the Internet or telephone;1st in the nation.

$10/45 for 10 minutes interaction Physicians can be “anywhere”; service

is across all islands

Telehealth: Dementia Patients

Residential facilities designed to allow movement of individuals through facility and grounds; Families can track on computer/internet based systems

Sensoring systems; Intel research; TRILL; diagnostic sensoring for fall prevention yielding data on Alzheimer specific movement differentials

Telehealth:Dementia Patients

AlarmTouch GPS is a personal safety phone with GPS location in Europe. The telecare device includes a ‘Geofencing’ feature, enabling accurate location of users in need. When the wearer wanders outside a specified zone – such as home or school area - the system can send a short message (SMS) alert to a monitoring centre or to a relative or caregiver.

Home Care Association of New York State 24

Home Telehealth - NY State

93 providers approved to bill Daily rates as of 1/1/2010 Tier I – 62 $8.88/day/patient Tier II – 31 $10.20/day/patient Tier III – to be tied to regional connectivity Medicaid Managed Care covered service

Electronic Medical Records Approximately 50% - 60% utilization – generally

medium & large sized agencies Multiple other “pieces”

Referral software, physician portals, med management hardware etc.

Home Care Association of New York State 25

Length of Experience - Home Telehealth

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Multipleprograms withdifferent lengthsof operation

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CURRENT TECHNOLOGY UTILIZATION

#Providers

Home Care Association of New York State 27

Disease Management

Ambient Assisted Living Programme - EU

23 EU member states with support of European Community [EC]

-Enhance quality of life of older people-Strengthen industrial base by use of Information and

Communication Technologies [ICT]-Aging well at home, community and work-Coherent framework for research into solutions which

are compatible with varying social preferenceswww.aal-europe.eu

American Telemedicine Assn

Home telehealth and remote monitoring practice group

Working group exploring opportunity for, and prevalence of telehospice; I chair this group.

www.americantelemed.org

Stats and Facts175 Towns and Cities2,500 Average Daily Census24,000 Admissions Annually360,000 Visits/Year46% of Admissions are from non-

Partners Healthcare System Sources4 Hospitals: Massachusetts

General Hospital, Brigham and Women’s Hospital, North Shore Medical Center, Newton Wellesley Hospital are the core hospitals for PHS

Technology

383 Clinicians on POC305 Telemonitoring devices –

remote monitoring3800 Personal Emergency Response

units

Clinicians and Staff

700 Full, Part-time, Per-visit244 Registered Nurses 25 Licensed Practical Nurses131 Therapists: physical,

occupational, speech7 Social Workers

61 Home Health Aides 32 Liaisons 11 Intake Nurses 4 Nutritionists 185 Other managers, clinical, admin

Partners Home Care

9 Essential Steps for Sustainability1. Set Program Goals2. Gain Insight of Stakeholders3. Get Buy-in 4. Patient Selection – choose wisely5. Care Coordination – 5 “Ws” 1 “H”6. Establish Clinical Standards7. Equipment Management – DME matters8. IS Infrastructure - IS is your friend9. Quality Improvement – implement soon,

evaluate often

Success Follows

1. Set Program Goals What is the problem you want to solve? Set goals based on measureable outcomes

Why telemedicine? Improved care

decrease number of emergency room visits

decrease number of hospital re-admissions

Increase patient involvement in care

Decrease home visits

Improved outcome and access/decreased costs

You’ve decided to choose to start a telemedicine program

What’s Next?

Recognize the Nature of a Paradigm Shift

Telemonitoring changes traditional notions of care delivery

Incredible opportunity to improve care and increase access

It builds careers and new skill-sets and improves peoples lives …..BUT……

People resist change Doing it “right” requires set up and

perseverance The 1st time takes longer than one would

think

2. Gain Insight of Stakeholders

Patient

Nurses &Allied Health

Physicians

Quality &Compliance

InformationSystems

Finance

Senior Leadership

Operations

3. Get Buy – In 4 Main Groups

Senior Organizational Leadership CEO Field Staff

Patient Getting equipment in

MD/nurse confidence Clinicians/Allied Health Professionals

Champions Touch and Play sessions Manager accountability/feedback loop Prizes

Physicians Education “Just in time” reports Promised decreased calls from patients d/t triage

by TM staff

4. Patient Selection – Choose Wisely Determine Patient Population

Based on program goals

Partners Telemonitoring criteria: Moderate to high risk for re-hospitalization Will benefit from telemonitoring Can be managed with decreased nursing visit

frequency Patient or caregiver is able/willing to assume

responsibility for monitoring Working phone line in patient’s home Home is safe environment for equipment

5. Care Coordination – 5Ws, 1HDetermine process flow SN evaluations for program

admission By Whom?

Referrals Who refers? Where do referrals go? Who processes them?

Telemonitoring of patients Centralized – requires

dedicated TM staff Decentralized – integrated

into primary clinician work flow

Reporting – Why? Who What When Where How

6. Establish Clinical Standards Best practice, evidence based standards Must be able to individualize standards Use clinical experts that clinicians will

accept to set standards Educate clinicians regarding standards Give clinicians autonomy to modify

standards as they deem necessary Give clinicians algorithms/guidelines for

further autonomy in practice

7. Equipment Management – DME Matters Rent vs. purchase Identify who will manage Establish responsibility and accountability for

electronic inventory control system set- up and provisioning installation/testing/break-fix equipment recovery, sanitizing, storage and

redeployment Training, retraining, written protocols Begin with decentralized process (greater buy-in at

local level), migrate to centralized process (efficiency & consistency) over time, selecting best of breed processes

Cultivate leadership

9. Quality Improvement Implement Soon – Evaluate Often Establish QI program at beginning of process Establish planned review periods

Initially weekly Include stakeholders as appropriate Include all 8 essential elements as part of

formal QI program Establish database for statistics at start of

program If you think you might need it, get it Build mechanisms for gathering data if not

inherent in EMR program Excel, Access databases

Telemonitoring at PHC PHC Telemonitoring Program - 2006

Patient Selection Criteria Available for Medicare pts currently receiving PHC

Connected Cardiac Care Program - 2007 4 month home telemonitoring program Patient Criteria Strong educational component –

1 Nurse visit to establish clinical status and knowledge deficits, then no further nursing

Bi-weekly telephonic educational phone calls Encourage direct patient/PCP relationship

Patient Choice Program Private Pay

Hospice Telehospice Pilot

CMS Pilot program

Positive Patient Outcomes > 2100 patients cared for 2006-

present Average LOS 70 days Average LOS with no rehospitalizations

– 53 days Average LOS with > 1 hospitalzation –

103 days Average rehospitalization

PHC program – 25% CCCP – 30% decrease year over year

1.3% - 1st 30 days 3% -program completion

MD Acceptance - CCCP

Clinician Response Decrease average SNV to 10

visits/episode with improved outcomes for rehospitalization

Consistent referrals to programs

Clinician comments: “I love it. I feel like I have

a better handle on my fragile heart failure patients using telemonitoring – they look at them every day and let me know if there is a problem I need to be aware of.”

“I think it’s great – it’s made a huge difference for my patients.”

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Combined Program Census FY10

What are the New Directions?

Tele-rehabilitation; Falls prevention Tele-mental and behavioral health Continuous monitoring: diabetes;

cardiac Impaired; Alzheimer’s & dementias “Wellness”

Telehealth and Rehabilitation

Distanced assessments Robots in SNFs Telestroke => telerehab Wii units in senior living facilities Remote monitoring for falls anticipation Traumatic brain injury;wounded warrior

Behavioral & Mental telehealth

On-going research Post traumatic stress disorder Tele-psychiatry Distanced mental health services

under new Medicare reimbursement provisions for community mental health centers

Telehealth and Palliative Care

Telehealth and pain management TeleHospice care

•bringing patient and family into the interdisciplinary group [IDG]

•counseling to patients and family when social workers are scarce resources

Palliative Care

Pain and symptom management Outreach and crisis management Triage without transporting to facility Psychological pain and suffering Diagnostic opportunities; family

interactions Ethical principles= autonomy enhanced

Prevalence of Telehospice

Informal survey CIMIT Grant to review Methodology Findings Follow-on research Canadian telehealth research in

palliative area

Research on Telehospice

Initial research papers Work in Missouri and Washington State Directions –

IDG involvement patients and families Education and emotional support to

caregivers Reactions of patients to use of health

information technology Preferences of video versus audio only

Opportunities and Challenges

Medical Director and other physicians Demonstrating cost savings, &/or

quality of care/life improvements- to justify expense of equipment and staff

Training and staffing. Maintenance of depth of field/bench so turnover is not a problem. Need for a "champion".

Leading nurses to embrace technology

Telehealth: Government Impediments

Reimbursement under Medicare Medicaid Grants Outcomes, cost savings and Disease

Management concerns Licensure and interstate barriers Standards lacking:Interoperability

among devices/software/infrastructure

Legal Barriers and Concerns

Licensure Liability Consent Reimbursement Management of the Case Privacy and confidentiality Security of Communication Fraud and Abuse

Licensure

Many states –New York is one--bar physicians from practicing via telehealth without a full or partial new license=quality; control as issues

Some states now licensing the entity which arranges for and participates in telehealth services

Nurses—not surprisingly—more sane

Liability--Consent--Managment

Medical device or simply a conduit of information

Manufacturer; Software vendors will seek total immunity from exposure

Patients need to hear from physicians and health entity about conditions, errors and backup response

Insurers reluctant or ignorant

Telehealth: Privacy Laws and Impediments to Data Exchange

State privacy laws HIPAA Congressional opposition on the HITECH

and other HIT bills –Strong language extending privacy protections including business assoc’s

Is ARRA destined to slow eHealth progress

Fraud and Abuse

Coordination of telehealth services vs.Impermissible incentive to referral source, including patient herself

and If it is a new “service“ is it subject to

Stark law concerning physician financial interests

Discussion – Are you involved

Audience experience in telehealth Reluctance….and reasons Board reactions…have they been

educated Can our society afford not to bring

telehealth into our long term care situations?

Contact Information Deborah A. Randall law@deborahrandallconsulting.com www.deborahrandallconsulting.com 202-257-7073

Kathy Duckett, RN, BSN, Director Clinical Programs Partners Home Care kduckett@partners.org 781-290-4058