Telemedicine and Telehealth ealth care professionals have heard about the wonders of telemedicine and telehealth technologies for the past decade, but few—especially in the home infusion therapy provider community—have actually seen these advances put to use. To cynics, the promise of telemedicine has gone largely unfulfilled, similar to the unmet “Jetson-like” expectations of space cars and meals-in-a-pill described by Daniel Wilson in Where’s My Jetpack? A Guide to the Amazing Science Fiction Future that Never Arrived. Well, dust off your spacesuits, folks, because telemedicine isn’t as far away from our front doors—and your practices—as you may think. Sure, it’s taken longer than expected for the technology to reach the point of affordability and ease of use— remember, the first Texas Instruments “pocket” calculator cost nearly $400 in the 1970s. In addition, our country’s information infrastructure needed to grow to the point where most households could support the demands of digital communication, and the general population had to ride the learning curve before reaching a baseline comfort level with the electronic age and all its associated gadgets and gizmos. Now, with a decade of advances behind us—and the delivery of medical services more dependant on technology than ever—the stage is set for telemedicine and home telehealth to start reaching into our world. If you’re willing to think outside the box,

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To cynics, the promise of telemedicine has gone largely unfulfilled, similar to the unmet “Jetson-like” expectations of space cars and meals-in-a-pill. Well, dust off your spacesuits, folks, because telemedicine isn’t as far away from our front doors—and your practices—as you may think.

BY J EANNIE COUNCE

Monitoring Coming Soon to a Provider Near You

The Basics Today, telemedicine takes different forms but largely describes remote medical services that link directly to a patient or clinician. There are three basic types: institution-based networks, point-to-point services, and home telehealth monitoring. Institution-based networks are the forerunners of—and what most people think of when they talk about— telemedicine. These networks consist of large hospitals or institutions linked to outreach clinics that enable videoconferenced patient exams and follow-up as well as the movement of data. They were designed to break down access barriers for patients in rural communities and largely funded by state and federal funds, as well as the growing telecommunications infrastructure. These networks have been very successful and continue to grow. Today there are approximately 215 networks linking 3,000 sites, according to the American Telemedicine Association (ATA). Point-to-point services are a second form of telemedicine that facilitate communication between practitioners. In this model, data is exchanged, via store-and-forward technology, to allow for analysis and consultation. A current example is the outsourcing of radiology services to cope with the shortage of radiolo-

gists. To more effectively manage staffing—and curtail overtime costs— many hospitals are sending x-rays, MRIs, and other images via point-topoint services to external—often overseas—experts for interpretation. The third form of telemedicine, telehealth monitoring, is the most applicable to home infusion. Telehealth, according to the ATA, is continuum of approximately 60 clinical services that can range from a web portal where patients document health information to a monitor that collects and transmits vital signs via a computer chip implanted in a medical device, such as remote cardiac monitoring of a pacemaker. The ATA says that there are approximately one million patients in the country using some form of remote monitoring. Home telehealth monitoring can also include interactive devices in the home that patients use to communicate with clinicians in some way. This interaction can take a variety of forms—with many more in development. Currently, options can include digital devices that read vital signs, such as blood pressure, weight, and pulse oximetry, and send them to a central nursing station for analysis. Others ask patients a series of daily questions; some even connect via computer screen or TV to a live nurse. According to the ATA, there are about 100,000 patients in the U.S. using this technology now. About a quarter of those are part of the Veterans Affairs health care system, which plans to double its use of

telehealth monitoring over the next several years.

Got To Wear Shades Although economic challenges to widespread use still exist, the future of home telehealth monitoring is bright, according to Johnathan Linkous, ATA’s Executive Director. “As the cost of telehealth goes down, the probability of it taking off goes up,” he explains. “We’re not at that price point yet, but soon.” Linkous notes four major trends leading the way. Number one, the cost of the technology is coming down. Just like that $400 calculator that has evolved into a marketing giveaway, technology in the free market has a way of becoming affordable to the masses. Second, standardized platforms are becoming the norm. “Soon, devices like stethoscopes, blood pressure cuffs, scales, and the like will be able to plug and play with any software,” observes Linkous. If you’ve been in health care for more than a week, you’re undoubtedly familiar with these next two trends, but consider them in terms of telehealth. Linkous predicts that these factors will drive many aspects of telehealth monitoring into the mainstream retail sector, a shift he is already beginning to witness. Our population is aging and at the same time becoming more health conscious. As the boomers, a generation that has learned to play an active role in its health care, ages, they’ll want to keep tabs on their

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it won’t take long to see how telemedicine could be just another tool to help deliver quality care in a more cost-effective manner.

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progress and how they compare to their cohorts. In the event an illness befalls them, this same generation will want to be a guiding force in its medical care. “Independent companies offering health and fitness services are moving into the home health monitoring market,” explains Linkous. These are markets that were previously occupied by visiting nurse agencies, he says, but since a number of services do not require a registered nurse— they are more like personal trainers and coaches—they are being commoditized as consumer services. Likewise, as the sandwich generation is taking on more of their parents’ health and caregiving issues, they are creating a consumer market for home monitoring technology that intersects with existing telemedicine devices. Telemed companies are now being bought by large consumer electronic and alarm system companies, says Linkous. For example, Phillips recently purchased Lifeline, the makers of a personal emergency response unit, and Honeywell acquired home telemedine device maker HomeMed. “They see emergency response and other elder monitoring services as a compliment to their existing home security and monitoring services,” he explains. It’s still too early to know how it will all shake out, or “where to put your money,” continues Linkous, but the prospects are exciting.

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B eyond the WOW Factor The prospects are exciting, but perhaps a little more muted, for health care delivery. In the long-term telemedicine is beginning to be viewed as a means

of cutting the escalating costs of health care. Just last month, former National Coordinator of Health Information Technology, David Brailer, announced he was involved in the start-up of a $700 million private equity fund, Health Evolution Partners. Brailer reported that his firm was going to “invest in things that can reduce the crushing costs of health care.” Health Evolution Partners, he said, would invest in companies with new ideas in fields like remote monitoring of patients, the management of chronic diseases, and telemedicine, among others. But since the near-term health care world revolves around reimbursement—surprise, there isn’t much for these services yet—telehealth’s current penetration is less dazzling. However, as with most technologies, the early adapters are finding innovative ways to apply telehealth services and reaping financial rewards beyond direct reimbursement. Because telehealth monitoring can reduce hospitalizations and the use of emergent care as well as offer operational efficiencies, commercial payers are becoming more receptive to reimbursing for them. “Increasingly these services are being covered, in a broad sense,” Linkous says. “Payers are not covering every service—and of course it differs from payer to payer— but in general they are cost-savers and payers typically support that.” Medicare has been slower to receive the technologies, taking a middle-of the-road stance. The program doesn’t offer any explicit coverage for home telehealth, although it doesn’t forbid its use. The equipment is not covered under the durable medical equipment (DME) benefit

and reimbursement for the services as a component of nursing is complicated, according to Linkous. “When a physician writes a patient care plan, it can include telehealth, however the services are not covered,” he explains. Under the prospective payment system (PPS), a Medicare-certified home health agency (HHA) must make a certain number of required nursing visits per patient, which must be made in person. However, any additional visits, which aren’t reimbursed under PPS, can be made via telehealth. “The HHA is effectively paying for the service itself,” Linkous explains, “but many choose to cover the costs of the service for additional visits because it’s more cost-effective than a home visit.” For example, if an agency is reimbursed for six visits, but to care for the patient really requires 10, it can do the additional four via telemedicine and realize the savings. The most significant barrier to getting home telehealth into patients’ homes is still cost, according to Christy Johnston, Executive Vice President of the New York Association of Health Care Providers, Inc. “The cost of the devices isn’t reimbursed so they are typically acquired through grants or a provider’s business decision to invest in the technology.” There are benefits that offset the investment, she continues, but providers need to balance the two. Johnston says that many of her association’s members have experience with telemedicine, which they have largely adopted as a way of servicing rural patient populations in the face of a nationwide nursing shortage. “Agencies are able to stretch their nursing staffs further by saving

Because telehealth monitoring can reduce hospitalizations and the use of emergent care as well as offer operational efficiencies, commercial payers are becoming

windshield time and schedule in-person visits more appropriately,” she explains. For example, if a telemed visit shows a problem, the nurse can go out the next day rather than the next scheduled visit day. This kind of early intervention helps reduce hospitalizations. “Our members are seeing better disease management with fewer highs and lows in the patients’ condition,” adds Johnston. The increased patient contact has also improved patient compliance and patient and caregiver education. “Patients are more engaged in their own care,” she observes. “There is some accountability for their actions—there is even a socialization component to it—plus nurses are better able to address issues when they come up.” Initially there was some resistance from nurses, says Johnston of the technology “A few thought they were being replaced, but soon they realized that it’s a tool that helps them be more efficient.”

Making the Investment With the financial components still hazy, it’s tough for agencies to decide when and how to take the plunge; still

many are. Willcare in Buffalo, New York started a telemedicine program in November of 2006 partly because it “wanted to be in the forefront of technology in home care,” according Estelle Brickner, M.S.N., Director of Healthcare Operations. In addition, she says that Willcare “understood how making the investment could help with patient satisfaction, physician and referral source satisfaction, and reduce hospitalizations.” The program has reaped numerous benefits and demonstrated a return on investment within six months. Willcare uses Honeywell’s HomeMed system, which monitors vital signs and is preprogrammed with questions based on diagnosis and physician parameters. “Every morning. The device gives the patient an alert to do the vitals and answer a series of questions, and the information is sent to a central station monitored by a nurse,” Brickner explains. “The nurse follows up with any patients who failed to transmitted data, and reviews the data that’s been received to see if any patients are outside their parameters. If so, she’ll call and ask more questions (how are you feeling, what did you have to eat last night, are your ankles

swollen) and schedule a home visit if necessary.” To close the circle of care, physicians are notified about patients who went outside their parameters. For every patient, the physician is faxed vital signs in graph format so they can track progress. Soon a new service will allow them to see that data online, she adds. “When paired with point-of-care technologies that nurses take into home visits, telemedicine allows clinicians access to patient data 24/7 from anywhere, which is great for those on-call.” Brickner reports that the technology and increased efficiency have been especially helpful in dealing with the nursing shortage and rising gas prices. “We’ve also documented reduced nursing visits, reduced patient load per nurse, and decreased hospitalizations, which has an indirect effect on our final reimbursement because we earn higher OASIS scores.” “It’s also been beneficial from a marketing standpoint, because not everyone is doing it,” she continues. “The physicians like it because they get better information on their patients, the hospitals like because they feel better about discharging

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more receptive to reimbursing for them

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The physicians like it because they get better information on their patients, the hospitals like because they feel better about discharging patients into a care plan that includes telemedicine—so it’s increasing our referrals and sales patients into a care plan that includes telemedicine—so it’s increasing our referrals and sales.” There are a few drawbacks, according to Brickner. “You need the right nurses who can adapt to the technology, and ‘sell’ it to the patients who initially resist. It also requires more time with the patient on the front end getting set up.” There are ongoing costs associated with having a nurse in the central station, monthly service fees—and there’s no direct reimbursement, so “you have to be sure to have the right patient and business mix to balance that out,” Brickner advises.

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Crossing Over

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With more and more nursing agencies adopting this technology, when will the use of telemedicine overlap with the delivery of home infusion therapies? It already has. Telehealth monitoring is typically used with vulnerable patients with high-maintenance chronic conditions, such as congestive health failure (CHF), chronic obstructive pulmonary disorder (COPD), and diabetes. It’s also been used to treat heart patients on dobutamine and expectant mothers on tocolytic therapies—all areas of treatment that are not uncommon to the home infusion provider. “Our nursing agency doesn’t own a telehealth system, but we do coordinate care with agencies that provide that service,” observes Shari Mailander, COO/ Owner of Option Care of East & Central Iowa. “Some of our IV inotropic therapy patients have

benefited from the use of telehealth.” Mailander says that the improved data from monitoring has proven very useful in treating heart failure patients whose therapy is a bridge to transplant or end-of-life. “The assessment data from visits is given to home infusion pharmacists through the care conferences with nurses,” she explains. “We get data from different times of day—sometimes twice a day—which gives a clearer picture of what’s going on with that patient.” The result is that clinicians have more material with which to counsel patients, or refer them to other clinicians and ancillary care providers, such as a dietician. And they remain more stable, which helps them be at home with fewer hospitalizations. “I can also see a potential application for TPN patients who are being transitioned from a continuous infusion to a cycled infusion," adds Mailander. "The telehealth would allow us to monitor their blood sugars more closely and make sure they are handling the dextrose load. It would also be helpful in monitoring accurate weights. I haven’t seen that yet, but I can see how it would be helpful.” Sharon Johnson, M.S.N., R.N.C., C.A.N., Director of Home Health and Hospice for the Home Care Network of Jefferson Health System in Pennsylvania agrees that there are IV applications for telehealth monitoring—she has even discussed them with her colleague Brian Swift, R.Ph., Pharm.D., Director of Jefferson Home Infusion and NHIA member. She says they can definitely see areas of applicability to home infusion

care. “One is for COPD patients who are monitored,” she explains. “If their weight goes up and a physician issues an order, a caregiver could give an IV lasix injection immediately without a nurse coming to the home.” Johnson says that after seeing a demonstration of the equipment, Jefferson’s home infusion nurses saw features that can be useful to them as well. “They were most excited about the video conferencing feature as an educational tool,” says Johnson. “They could teach over the monitor, watch return demonstrations, and reinforce teaching on issues such as administration, medication reconstitution, and line care.” As the technology evolves and becomes more common, the number and type of uses that can be applied to it are almost limitless. Kathleen Marcais, R.N., B.S., Director of Staff Education for New York Community Health Center may have summed it up best. “I’ve been a nurse for a long time and seen all kinds of change, including the transition from glass to digital thermometers—this is the same issue,” asserts Marcais. “Changing equipment is a challenge, but telemonitoring is a necessary tool. I see it becoming more prevalent and one day being as essential to delivering care in the patient’s home as your computer or cell phone are to you today.” Jeannie Counce is the Editor-in-Chief of Infusion. She can be reached by phone at 406-522-7222 or e-mail at [email protected].