Telehealth Contribution to Health Care Access in Maine

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Telehealth Contribution to Health Care Access in
Maine

• Ron Emerson, RN
• Director, Maine Telemedicine Services
• Michael Edwards, PhD
• Director, Research Evaluation
• HealthWays/Regional Medical Center at Lubec

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What is Telemedicine?

• Broadly defined, telemedicine is the transfer of
  electronic medical data (i.e. high resolution
  images, sounds, live video, and patient records)
  from one location to another.

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Why Telemedicine?
Increase Access

• By moving information, rather than patients,
  telemedicine promises to enhance health care
  while dismantling the barrier of where and when
  medical services are provided

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Advantages of Telemedicine

• Increased access and timeliness to specialty
  services
• The stress and cost of patient travel to receive
  care is reduced, and waiting times are often
  shorter
• The primary care provider can give more input
  into patient care, facilitating enhanced quality
  and continuity of care

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• Maine Telemedicine Services

• State Infrastructure Building
  
• Reimbursement
• Regulations-Credentialing, Licensing
• Equipment Service Contracting
  
  

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Maine Telemedicine Services

• Education/Training
  
• Service Development
• Grant, Evaluation and Research Services
• Advocacy for Favorable Policies

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Maine Health Access Issues Large rural areas
e.g. 6 counties, 300K pop., 21K sq. mi., 17/sq.
mi. Many HPSA/MUAs Often 2-4 hrs. driving
time from tertiary care hospitals Specialty
care doctors scarce 50 elevation over state
poverty unemployment rates
Most Rural Counties
Maine Hospitals
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• Telemedicine Access
• All 5 tertiary hospitals
• 37 of 39 hospitals
• 4 mental hosp., 33 agency sites
• 29 rural clinic/health center sites
• 6 prison facilities
• 18 DHHS
• 7 private practices
• 19 other health social services
• 7 legal aid
• 14 comm. action sites

Maine Hospitals
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Telehealth Services Delivered in Maine
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Content/Result of Consults
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Home Telehealth Project

• Began in 1999 as collaboration between home
  health agencies in two most eastern and northern
  counties
• Goal to use telehealth to increase health care
  access, timeliness of service, reduce delivery
  costs for elders with chronic disease
• In period of 1999-2004, over 5,000 telehomecare
  visits were been logged for nearly 150 clients by
  the two agencies

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Home Telehealth Program Elements

• Equipment was ATI Aviva units with BP and
  stethoscope or 8x8 videophone units
• ATI Central Stations located in VNA offices or,
  in laptop versions, in on-call nurse homes

• Placement with client based on diagnosis, need,
  permission of the client, and clients ability to
  use the equipment
• Most common diagnoses were CHF, COPD, cancer

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Benefits of Home Telehealth

• Timelier and/or more frequent client assessments
  and monitoring
• Client sense of security in accessing a nurse
  when needed, not just to speak to them
• Fewer clinic, ER, and hospital visits, as
  documented in a few good studies
• Savings on agency transportation costs
  expected--depends on effective substitution of
  some in-person care with telehomecare

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Home Telecare Effort and Savings on In-Person
Visits for CHF Clients

• Home telecare clients with CHF got 0.41 fewer
  in-person visits per week than non-telehealth CHF
  clients
• Time to achieve savings of one nurse visit 2.4
  weeks
• This is equivalent to the average 6 telehealth
  visits per month saving nearly 2 in-person visits
  per month per client, i.e. roughly 3 telehealth
  equal 1 in-person visit

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Recent Initiatives
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Sunbeam Mobile Telemedicine Clinic
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Sunbeam Telehealth Room

• Telemedicine Equipment with otoscope, hand-held
  camera and stethoscope.
• Able to do blood draws (has centrifuge), strep
  tests, pregnancy tests, pulse oximetry. Fully
  equipped for dressing changes etc.

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Sunbeam Island Health Program Sites
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What is VRI?

• Sign language interpreting
• Two or more parties at same location
  communicating through a distant interpreter
• 384 kilobits per second

• 30 frames per second
• ISDN-based system
• Open architecture
• Uses licensed, certified medical interpreters

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Video Relay Interpretation for the Deaf
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Maine Telepsychiatry Initiative
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Maine Telepsychiatry Initiative
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Current Initiatives
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Maine Nursing Home Telehealth Network
Location of nursing homes providers
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Maine Nursing Home Telehealth Network
Specialty Care Services Requested

• Dermatology
• Geriatric psychiatry
• Wound care
• Pain management
• Mental health counseling
• Rheumatology
• Post-op orthopedics

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Maine Nursing Home Telehealth Network
Specialty Care Services Developed

• Wound Care
• Pain Management/addiction medicine
• Mental Health
• Developed--not used
• Asthma/allergy
• Occupational medicine
• Available--not used
• Sign Language Interpreting
• Endocrinology

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Maine Nursing Home Telehealth Network

• Specialty Care Telehealth Activity
• 104 consults over 3 yrs.
• 38 Wound Care, 57 Mental Health, 2 Pain
  Management, 7 Primary Care
• Overall provider satisfactionvery87
• Could adequately assess patient88
• Helped with diagnosis, treatment-63, 67
• Improved quality of care75
• Helped avoid patient transfer71

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Patient Satisfaction with Clinical ConsultsN27,
12/-4-2/06
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Maine Nursing Home Telehealth Network
Estimated Savings on Transport Costs Wound care
consults judged to have averted needed transports
to doctor for direct care
(Average roundtrip distance between patient and
provider for all 84 tele-consults208 mi.)
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Maine Nursing Home Telehealth Network
Education-- Monthly Sessions targeted to CNAs
RNs22 topics

• Antibiotic resistant infections
• Wound care
• Pressure ulcers
• Colstomy management
• Pain management
• Swallowing disorders
• Nutrition and diabetes
• Respiratory infections

• Polypharmacy issues
• Geriatric psychiatry
• Dementia and pain
• Combative patients
• Dementia assessment
• Food safety
• Injury prevention
• Emergency preparedness

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Origins of Maine Telepharmacy Project

• 15 rural pharmacy closings over a 2 year period
• Causes
• change in reimbursements by Medicaid
• pharmacist shortages and related salary rise
• competitive advantage of large chain stores and
  mail order
• Closing of Lubecs necessitated a 1 hr. round
  trip drive to closest other pharmacy
• Health care impact hardest on the elderly, the
  poor, and children
• Maine Health Access Foundation funded proposal

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Components of Telepharmacy System
Pharmacist or tech travels to load ADDS with
selected formulary
Nurse scans label and transmits for verification
by pharmacist
Videophone is made available for patient
consultation with pharmacist (required for Pts
new to pharmacy)
Pharmacist receives Rx order, uses software to
order drug dispensing at distant clinic
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Telepharmacy Implementation Steps

• State Pharmacy Board approval and registration
  with Nat. Council of Rx Drug Programs and DEA
  attained as needed legally and for reimbursement
  
• Telepharmacy Solutions Unit selected with needed
  capacity
• Vendor Installs ADDS (Automatic Drug Dispensing
  System) cabinet and custom PC
• Vendor trains staff on software
• Providers and pharmacist select appropriate
  formulary for unit
• Protocols and procedures developed and tested by
  teampharmacist, PCP, nurses, techs, billing
  clerk

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Telepharmacy Program Operations

• HealthWays adopts formulary for acute Rx needs,
  i.e. antibiotics, anti-nausea, diuretics
• Some providers resistant to using system due to
  time taken away from direct care
• Support staff assigned to facilitate faxing of Rx
  and attending to pharmacist responses
• Usage rate of 20 Rx/month, with good fraction of
  poor, elderly, or young children served
• Pt. access to cheaper drugs in nearby Canadian
  pharmacy limits usage volume
• 8 other Maine FQHCs request help from HealthWays
  in setting up telepharmacyRUS grant used to fund
  expansion

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Redplanned telepharmacy sites
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Northeast Telehealth Resource Center Goals

• Foster development of needed telehealth programs
  through technical assistance and clinical program
  support
• Enhance the capacity of rural providers through
  CME/CEU opportunities and clinical peer review by
  videoconferencing
• Conduct evaluations and special projects to align
  telehealth technologies with health care needs
• Support favorable regulatory and reimbursement
  environment for telehealth through policy and
  planning efforts

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FQHCs and Health Professional Shortage Areas
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Northeast Telehealth Resource Center Goals

• Foster development of needed telehealth programs
  through technical assistance and clinical program
  support
• Enhance the capacity of rural providers through
  CME/CEU opportunities and clinical peer review by
  videoconferencing
• Conduct evaluations and special projects to align
  telehealth technologies with health care needs
• Support favorable regulatory and reimbursement
  environment for telehealth through policy and
  planning efforts

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Telemedicine Capacity in Health Care Facilities
in Northeast States
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Experience of Network with Telehealth
Applications
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Barriers to Success of Telemedicine

• Both primary care and consulting specialist
  providers are resistant to adopting new
  technologies or changing routine of practice
• The high cost of telecommunications, including
  line charges for ISDN or dedicated T1 lines
• Additional personnel resources and training are
  required at both spoke and hub sites

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Barriers to Success of Telemedicine

• Solutions to liabilities and credentialing/privil
  eging issues must be worked out
• Reimbursement development in some states is slow
  Maine has been forthright in reimbursement