REMOTE MONITORING AND HOME-BASED TELEHEALTH – Realities and Challenges

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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

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Moving Towards Electronically Enabled Care
Delivery_at_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

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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

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• 55.5 of respondents disagree or strongly
  disagree that differences between federal and
  state privacy laws are not a barrier to
  consumers rights to healthcare privacy.
• 56 agree or strongly agree that HIT and HIE have
  had a positive effects on care delivery.

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Evolving Definitions

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

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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

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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_at_Home Medicaid Medical Home Chronic
  Care Innovation Cntr

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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 care
• information 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

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HIGHTECH, cont.

• 85 million for the Indian Health Service to
  use on health IT
• 1.5 billion for community health centers, a
  sum that
• can be used toward health IT acquisition
• 500 million for the Social Security
  Administration for
• processing disability and retirement workloads,
  of which
• up to 40 million may be used for health IT
  research
• and adoption
• 1.1 billion to AHRQ, HHS, and the NIH for
  comparative
• effectiveness research

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BEACON 16Million 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

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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.

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PPACA Promises? Promises!

• Post-hospitalization bundling pilot
• Independence at Home demonstration
• Innovation Center at DHHS chief policy person
  in placetelehealth focus
• ACOs
• Medical Home-Medicaid and Pilots
• Face2face HHA provision w telehealth

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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

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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

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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

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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

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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 patients24.8
• Multiple 6,140 patients26.0
• Interventions just in time air traffic
  control

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VA Chronic Care Coordination via Telehealth Study

• The cost (1,600.24 pp/yr compares favorably)
• direct cost of VHAs 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 VHAs existing services. Darkins et al.,
  Telemedicine EHealth, 12/2008.

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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

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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.

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HMSA Ambulatory MD/Home

• Hawaii Medical Service Assn Jan 09
• Online Care connects, 24/7, patients and
  physicians via the Internet or telephone1st in
  the nation.
• 10/45 for 10 minutes interaction
• Physicians can be anywhere service is across
  all islands

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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

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TelehealthDementia 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.

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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.

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CURRENT TECHNOLOGY UTILIZATION
Providers
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Disease Management
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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
  preferences
• www.aal-europe.eu

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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

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Partners Home Care

• Stats and Facts
• 175 Towns and Cities
• 2,500 Average Daily Census
• 24,000 Admissions Annually
• 360,000 Visits/Year
• 46 of Admissions are from non-Partners Healthcare
  System Sources
• 4 Hospitals Massachusetts General Hospital,
  Brigham and Womens Hospital, North Shore Medical
  Center, Newton Wellesley Hospital are the core
  hospitals for PHS

Clinicians and Staff 700 Full, Part-time,
Per-visit 244 Registered Nurses 25
Licensed Practical Nurses 131 Therapists
physical, occupational, speech 7
Social Workers 61 Home Health Aides 32
Liaisons 11 Intake Nurses 4
Nutritionists 185 Other managers, clinical,
admin
Technology 383 Clinicians on POC 305
Telemonitoring devices remote monitoring 3800
Personal Emergency Response units
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9 Essential Steps for Sustainability

• Set Program Goals
• Gain Insight of Stakeholders
• Get Buy-in
• Patient Selection choose wisely
• Care Coordination 5 Ws 1 H
• Establish Clinical Standards
• Equipment Management DME matters
• IS Infrastructure - IS is your friend
• Quality Improvement implement soon, evaluate
  often
• Success Follows

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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
• Youve decided to choose to start a telemedicine
  program
• Whats Next?

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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

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2. Gain Insight of Stakeholders
Nurses Allied Health
Senior Leadership
Physicians
Patient
Operations
Quality Compliance
Finance
Information Systems
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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

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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 patients home
• Home is safe environment for equipment

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5. Care Coordination 5Ws, 1H

• Determine 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

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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

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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

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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

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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

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Positive Patient Outcomes

• gt 2100 patients cared for 2006- present
• Average LOS 70 days
• Average LOS with no rehospitalizations 53 days
• Average LOS with gt 1 hospitalzation 103 days
• Average rehospitalization
• PHC program 25
• CCCP 30 decrease year over year
• 1.3 - 1st 30 days
• 3 -program completion

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MD Acceptance - CCCP
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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 its great its made a huge difference
  for my patients.

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What are the New Directions?

• Tele-rehabilitation Falls prevention
• Tele-mental and behavioral health
• Continuous monitoring diabetes cardiac
• Impaired Alzheimers dementias
• Wellness

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Telehealth and Rehabilitation

• Distanced assessments
• Robots in SNFs
• Telestroke gt telerehab
• Wii units in senior living facilities
• Remote monitoring for falls anticipation
• Traumatic brain injurywounded warrior

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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

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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

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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

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Prevalence of Telehospice

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

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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

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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

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Telehealth Government Impediments

• Reimbursement under Medicare
• Medicaid
• Grants
• Outcomes, cost savings and Disease Management
  concerns
• Licensure and interstate barriers
• Standards lackingInteroperability among
  devices/software/infrastructure

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Legal Barriers and Concerns

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

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Licensure

• Many states New York is one--bar physicians from
  practicing via telehealth without a full or
  partial new licensequality control as issues
• Some states now licensing the entity which
  arranges for and participates in telehealth
  services
• Nursesnot surprisinglymore sane

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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

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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 assocs
• Is ARRA destined to slow eHealth progress

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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

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Discussion Are you involved

• Audience experience in telehealth
• Reluctance.and reasons
• Board reactionshave they been educated
• Can our society afford not to bring telehealth
  into our long term care situations?

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Contact Information

• Deborah A. Randall
• law_at_deborahrandallconsulting.com
• www.deborahrandallconsulting.com
• 202-257-7073
• Kathy Duckett, RN, BSN, Director
• Clinical Programs Partners Home Care
• kduckett_at_partners.org
• 781-290-4058