Telehealth Services Save Time and Money
Written by Peter A. Buxbaum
MMT 2011 Volume: 15 Issue: 4 (June)
The U.S. Department of Veterans Affairs operates one of the largest home telehealth services in the world, and it has grown prodigiously in the last few years. In 2003, the program served 2,000 beneficiaries. That number has since ballooned to over 40,000.
To some extent, organizational necessity spawned the adoption of home telehealth technologies. The Veterans’ Benefits Improvement Act of 1996 dramatically expanded the Veterans Health Administration’s population of beneficiaries from the relatively small number of warfighters wounded on duty to all Americans who have worn the uniform. At the same time the VHA transitioned away from its status as a hospital-based organization, paring down its number of beds from 53,000 in 1997 to 18,300 10 years later.
“As a result, there was a tremendous movement of care from hospitals to community and outpatient settings,” said Dr. Adam Darkins, the chief consultant in the VHA Office for Telehealth Services. “This reflected the need to manage people with chronic diseases in order to reduce hospital admissions.”
The hypothesis which drove the implementation of home telehealth technologies is that they could function as an early warning system to avert hospital admissions and outpatient appointments. “There is no evidence to suggest that the best way to treat patients with chronic disease is to see them in a clinic,” said Darkins. “The patient often deteriorates two weeks before or after the clinic appointment. The point was to see if we could treat the patient at just the right time.”
In fact, one of the leading trends in telehealth today is to get technology as close as possible to the patient, according to Nancy Green, the managing principal responsible for telehealth and mobile health at Verizon Communications Inc. “Instead of clinicians having to travel to the patient’s home, telehealth technologies enable them to do their job as best as they can,” she said.
Telehealth helps connect patients to doctors without an office visit. “The doctor and patient can be on opposite sides of the country yet confer on diagnosis and treatment as though they were in the same room with each other,” said Randall Porter, assistant vice president, AT&T ForHealth. “Overall, customers benefit from telehealth solutions as they expand the reach of scarce specialty care, reduce time and cost associated with travel for medical care.”
VA’s home telehealth program also saves the VA money, another important organizational goal. A recent study of 17,000 patients showed a 30 percent reduction in hospital admissions and a 20 percent decrease in hospital stays, according to Darkins. Studies have also shown that the average annual cost per patient of VA’s home telehealth program adds up to $1,600, a figure which represents a substantial savings over the $13,000 it would take to provide direct home care or the $77,000 a nursing home would cost.
Darkins manages two enterprise telehealth programs for VA in addition to home telehealth. The VA operates an imaging program focused on the diagnosis and treatment of diabetic eye disease. The implementation of this program, which allows testing to take place in the offices of primary care physicians and read remotely, went to 219 sites across the VA system. The number of patients screened through the program grew from 6,000 in 2006 to over 160,000 in 2010.
The third program, involving real-time video conferencing, links 127 hospitals and 550 community based outpatient clinics, and is focused primarily on veterans mental health issues. “We did 170,000 patient consultations in 2010 using video directly into clinics,” said Darkins.
The use of video is the current hot topic among telehealth applications, according to Lee Hicks, CEO of C Port Solutions. “The ability of a physician to actually see a patient,” together with other tools at the doctor’s disposal, he said, “makes for a very fast but very informed decision and produces positive outcomes for the patient.”
“Today, home based telehealth video systems can include integrated medical devices and the ability to ask the veteran about symptoms and general health,” noted Dr. Randall Moore, CEO at American Telecare Inc. “Such integrated information can increase the efficiency, effectiveness and impact of expert clinical teams to accelerate the shift in the care model from prescheduled visits, to seeing those veterans with the highest need. This shift continues to improve the ability to see veterans where and when needed, which, as the burden of illness grows, can enable a clinician to use a video visit within hours to change a care plan, averting a hospitalization which otherwise would occur a day or two later.”
Last April the VHA refreshed its home telehealth contract, awarding contracts to six providers: Authentidate, American Telecare, Cardiocom, HealthHero Network, ViTelCare and Viterion Telehealthcare. One of the purposes of the new contract awards was to update the technologies being used in VA telehealth, according to Darkins.
One of the key technologies to be incorporated in the new crop of devices and systems being acquired under the VHA contract is cellular connectivity. Viterion Telehealthcare, a contact awardee and division of Bayer HealthCare, recently introduced a product which allows its home telehealth monitor to connect via cellular networks.
“This way veterans with no access to a land line can still receive the benefits of telehealth,” said Rick Kates, the company’s global chief.
Viterion will be providing the VHA with its remote monitoring hub device, known as the V100 and V100 BGM, together with associated peripherals and back-end services, according to Kates. The hub connects to devices such as scales, blood pressure monitors and glucose monitors, allowing vital signs and other important data to be sent to health care professionals.
“The monitor also allows providers to send DMPs, or disease management protocols, to patients,” said Kates. “These are a series of questions that allow the health care professional to understand at a more behavioral level how the patient is doing.”
The back-end services Viterion will be providing include integration into the VA’s medical records and scheduling systems. They also include tracking and trending patient information based on the DMPs to complete the assessment of the patient.
Also included in Viterion’s VHA contract award is a new product that performs remote wound management. With this product, a patient can upload a photograph taken on a cell phone to a server which the caregiver can access. “With this tool, the provider can calibrate the wound,” said Kates, “track its progress or regression, and remotely manage wound care. We believe this will have broad application especially for patients with diabetic complications.”
Cardiocom received a VHA award to provide telehealth messaging and measurement devices as well as interactive voice response solutions for telehealth. “The messaging product provides disease management protocols that veteran patients respond to on a daily basis,” said Dan Cosatino, the company’s CEO. “These are presented in the telehealth device that is placed in the patient’s home. The patient responds to a series of questions and the responses educates the patient about his conduction and care. VA health care providers monitor the information and make adjustments to the care plan if necessary to improve care and help keep the patient out of the hospital.”
The device the company provides is a telehealth hub device called the Cardiocom Commander. The device communicates with the patient in writing and orally and is able to monitor blood pressure, weight, oxygen intake and other vital signs and transmits those to the VHA telehealth organization on a daily basis. “If a heart failure patient is gaining weight, a care coordinator will contact the veteran and review medications and dietary intake and make a determination if an adjustment in medications is warranted,” said Cosatino.
Cardiocom’s interactive voice response solution allows the patient to use a standard telephone or cell phone to call into a system and receive the same functionality as that of the monitoring hub. “This solution often suits younger and more mobile patients better,” said Cosatino.
DoD also has an extensive telehealth program, one serviced by companies like Carenet, which supports between 30 and 40 military medical treatment facilities (MTFs) in the United States. “We really pick up where the clinic leaves off,” said John Erwin, the company’s president. “They are open 40 hours a week. We fill the gap to supply beneficiaries with information 24/7.”
Military medical beneficiaries may call with a medical problem during off hours. Carenet nurses assess the situation and take appropriate action, which may include calling 911, making an appointment with the clinic for the next day, or directing the patient immediately to an alternative facility. The information collected by Carenet is then fed directly into the beneficiary’s electronic medical record.
“What we provide is a very elaborate and customizable telephony system,” said Erwin. “We can customize all of the greetings to a particular MTF. We also employ a sophisticated database to understand the services offered at any particular MTF. For example, in the case of aviators, there is a flight doctor on-call at all times to be consulted.”
The 15-minute telephone consultation the nurses provide generates a detailed assessment of the patient’s situation, according to Erwin. “It is important to us that beneficiaries have an experience that is just helpful,” he said. “We want to make life simpler for these hard-working people who we know are under a great deal of stress.”
C Port Solutions recently introduced a product called Medi Port, which aspires to converge all forms of communication and collaboration with patient data, medical applications and existing health care technologies. An in-hospital product, Medi Port is a mobile computing platform enabled with a high-definition video conferencing capability, which can be rolled anywhere it is needed. The device allows remote medical specialists to view patients and provide expert counsel, especially important for rural clinics and field hospitals with limited medical staff.
“What we designed is a full computing platform that provides multi-touch access to health care system medical records or anything else the user wants to integrate onto it,” said Hicks. “These functions appear as icons which are accessible by touch much like a tablet computer. Video conferencing is just one part of it.” Also integrated into the system are digital cameras and stethoscopes, white boarding, and the ability to annotate X-ray, CT scan and MRI images on the spot.
AT&T offers AT&T Virtual Care, which is a custom telehealth solution that enables real-time and interactive second opinions, consultations and follow up. “The solution includes video conferencing equipment from Cisco, Polycom and AMD Global Telemedicine medical peripherals with various management options,” said Porter. “AT&T also has a new telehealth solution in pilot phase called AT&T Telepresence Clinic, which is comprised of components including Cisco HealthPresence, connectivity to the AT&T Business Exchange, and AMD Global Telemedicine medical peripherals.”
Darkins attributes several factors to VA’s telehealth success. One is the elevation of telehealth programs to the enterprise level. Local programs depend on a “particular clinical champion or enthusiast,” said Darkins, “and often its longevity was limited to the presence of that particular provider.”
Another element is VA’s emphasis on standardization and integration. “The development of this field is not dependent on finding some blue-sky new technology,” Darkins said, “but on robust systems that already exist but need to be scaled up as they go from pilots” to serving thousands of patients.
“Telehealth is not a panacea and will not replace all of health care,” he added. “But it is becoming recognized as one way health care can be delivered in the future.”
“The opportunity or home based video telehealth to build upon the strong base created by Dr. Darkins and the VA team,” said Moore. With current ATI video systems able to connect over normal telephone lines, cable or phone broadband, or satellite, the VA’s Patient Aligned Care Teams (PACT) can extend the medical home all the way into the veteran’s home.
Verizon is currently piloting a home telehealth solution that would provide connectivity by way of the company’s FiOS cable television service. Instead of having a separate telehealth hub installed in a patients home, video connectivity and health monitoring would be provided through hookups to the patient’s existing set box.
“FiOS can be used as a high speed backbone to the same information source as before,” said Green, “but it’s now more trusted and faster. Also the patient doesn’t need a separate box. We have found that the less stuff being brought into patients’ homes the better. They are much more comfortable utilizing what they already have.”
For Erwin, the future of telehealth involves enhancing the health care experience for the patient. “In the traditional model, it is hard to get an appointment with a doctor and the patient may only see the doctor for a short time,” he said. “The next generation of telehealth will involve a multimedia approach to connect to patients, provide them with information, and schedule tests and visits.”
On the technology level, there is a move away from proprietary devices and towards systems that are hardware agnostic. “We want everyone to be able to use our software,” said Hicks. “The future will see telehealth being directed closest to point of care. That means allowing video and medical information to flow to device that people carry such as smartphones and tablets.”
Kates agreed that extending telehealth to today’s consumer electronics and to cloud computing represents an opportunity for industry. “If you think about where technology is going and where telehealth is today, you understand that there are still tremendous opportunities for telehealth,” he said. “We can do a much better job for patients and providers extending functionality to take advantage of what technology has to offer. We should be trying to make the user experience better for patients and to provide more and better tools for health care professionals. I think there is a real opportunity for us to step up our game collectively.”