Despite recent evidence that telehealth and remote patient monitoring can play an important role in improving patient outcomes, according to a recent audit from the Government Accountability Office (GAO), Medicare’s payment and coverage restrictions are largely responsible for holding back progress and access to telehealth services.
That doesn’t mean telehealth isn’t gaining traction in the healthcare industry, however. In fact, some industry experts are calling 2017 the year of telehealth, fueled by faster internet connections, the ubiquity of smartphones and other personal devices, and new commercial software platforms that more easily connect patients with providers.
In addition to technology advances, patients also are becoming more aware of–and interested in using–telehealth. A study by NTT Data Services found that 74 percent of patients said they would use a telemedicine service if available. And another study found that 20 percent of patients, or as many as 50 million, would actually switch to a different primary care provider if that meant access to video visits.
On the provider side, as many as 78 percent of physicians polled by the American Academy of Family Physicians believed the use of telemedicine improved both access to and quality of healthcare. But only 15 percent of doctors had actually used telemedicine technology, which means that while the evidence and demand for the benefits of telehealth are mounting, both providers and payers need a push toward greater adoption.
That push may come in the form of reduced costs and innovative uses of telehealth, especially as they relate to emergency medicine.
A Decade of Telemedicine Use in the ED
Some aspects of telehealth have been utilized in the emergency room for at least a decade. According to the American College of Emergency Physicians (ACEP), teleradiology is one of those services. “Teleradiology is a branch of telehealth in which radiologists provide remote reporting on radiologic images,” explains Neal Sikka, M.D., FACEP; Sara Paradise, M.S.I.V.; and Michael Shu, M.S.I.I., George Washington School of Medicine in their “Telehealth in Emergency Medicine: A Primer.” “The field has been widely used for more than a decade, providing a good example of the rapid change in infrastructure and the results of transitioning from an on-site to remote form of communication.”
More recently, “telestroke” consultations, teletrauma (where “experienced trauma surgeons can bypass obsolete practices such as ‘spine clearance,’ suggest against CT scans and X-rays in certain cases, and provide current guidelines for reversal of therapeutic anticoagulation,”), and even acute wound assessment are ways telemedicine is changing emergency department practices and protocols.
Innovative Telemedicine Applications in the ED Today
Several hospitals and healthcare systems currently are using or piloting telehealth programs in their emergency departments to triage patients, reduce wait times, extend care into rural or remote areas, or provide routine care to patients non-emergent conditions. Here are a few examples of the ways telehealth is being used in emergency departments around the country.
- Milwaukee, Wis.-based Aurora Health Care is using a telemedicine triage solution powered by EmOpti, a company founded by Edward Barthell, M.D., an emergency physician. An off-site Aurora physicians sees emergency department patients at any of Aurora’s three locations via video, with a on-site healthcare professional in the room with the patient. The onsite nurse gets the patient’s history and takes vital signs, and then the remote physician speaks directly to the patient and orders labs, radiology, or other tests so that when the on-site staff physician arrives to the room, all the necessary information to diagnose and treat the patient has been collected. “This solution helps us get orders started immediately, obtain results quicker and treat people faster— ultimately, it helps us provide an enhanced patient experience to all who visit the ED. That is critically important for an ED that is as busy as the one at Aurora Sinai,” says Paul Coogan, M.D., president of Aurora Emergency Services and an emergency department physician at Aurora Sinai.
- Duke University Hospital’s emergency department recently piloted the use of an interactive telehealth tool called TeleHealth Cart to begin treatment of non-critical patients soon after they arrive. Like EmOpti, the TeleHealth Cart connects patients with off-site physicians who can begin ordering labs and other tests before a patient is even taken back to a treatment room. “So, then when [patients] do ultimately get into a room, a lot more information is already back,” said Duke emergency physician Dr. Neel Kapadia. “It saves them an hour and allows us to turn over the room faster and get that next patient into a room.”
- Health PEI, Prince Edward Island’s island-wide health system, is looking into a virtual visit platform for the emergency room in their Kings County Memorial Hospital, a 30-bed community hospital in Montague, that was forced to reduce its emergency room hours to 8 a.m. to 10 p.m. last year. “The technology is available, is well-proven, we’re not re-inventing the wheel,” local businessman Ray Brown told CBC News, estimating the project would cost $20,000 to $28,000. “We’re simply taking the best of technology that is available elsewhere in the world. If you become sick on the space station, you’re seen immediately by a doctor via telemedicine … I’d like to see the same services here in Montague.”
- New York-Presbyterian Hospital recently launched NYP OnDemand, a multi-use platform that, among other telehealth services, accommodates virtual ER visits for patients with non-life-threatening conditions through their Express Care option. According to a recent Modern Healthcare article, “Tapping Telehealth for Complex Cases,” patients utilizing NYP OnDemand go to a private room and have a video visit with an ER physician who’s sitting in another office just 200 yards away. Visits average about 30 minutes. A Wall Street Journal article about the same program, “Can Tech Speed Up Emergency Room Care?, explains that all patients who come to the emergency department receive a “standard, in-person emergency room triage—where a nurse practitioner or physician assistant screens them.” As well, a nurse practitioner or physician assistant is on hand to perform procedures or assist with ordering labs or xrays. “Meanwhile, doctors can now treat patients from more than one hospital from their desk, and pivot to their administrative tasks more quickly in between visits.” According to Rahul Sharma, the emergency physician-in-chief at Weill Cornell, because patients have a full triage and medical screening exam, Express Care visits are billed just like any other emergency department visit and have been covered by most insurance companies.
Controlling Costs through Telemedicine
Unlike the Express Care program, not all telehealth services are separately reimbursable. According to Modern Health’s Shelby Livingston, payment for telehealth varies widely by state, payer, and the type of care provided. Medicaid programs in every state offer payment for some telehealth services, and 31 states plus the District of Columbia require reimbursement for some level of telehealth services. Medicare, on the other hand, restricts telehealth payments to cases in specific geographical and clinical sites.
New York-Presbyterian’s Express Care program also differs from other telehealth services in that the video conference is paired with in-person care and is thus billed at the same rate as standard services. According to the RAND Corp.’s March Health Affairs study, direct-to-consumer telehealth visits on average are usually cheaper than standard care and run about $40 to $50 per visit. The problem, according to some critics, is that their low-cost incentivizes patients to consume more healthcare services than they might otherwise.
Generally, cost savings is cited as a benefit of telehealth services, however. Not only are telehealth visits often cheaper than in-person visits, but telehealth can increase access to healthcare services in general, allowing patients greater access to primary care services, earlier prevention and detection of acute conditions, and more effective management of chronic conditions. These in turn reduce overcrowding in and inappropriate use of emergency departments. As well, using telehealth triage to reduce wait times and speed up treatment can create greater efficiencies and reduces costs in emergency departments.
Calling Medicare to Greater Coverage
According to Gary Capistrant, chief policy officer at the American Telemedicine Association, the GAO’s audit report should be the impetus Congress needs to lift restrictions on Medicare coverage of telehealth services.
“Congress wanted more information before moving forward on removing restrictions on Medicare telehealth coverage. They got a good overview on federal use of telehealth and a fuller picture on what a laggard Medicare is,” Capistrant told Health Data Management.
Indeed, telehealth services already are included in the Merit-based Incentive Payment System’s performance criteria, and a bill introduced in the Senate in March, the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017, allows payment for telehealth services for patients with chronic conditions.
If 2017 is going to be the year of telemedicine, Capistrant says now is the time for Congress to act: “We hope that Congress will stop asking for studies and soon include expanded Medicare coverage of telehealth, especially for the Medicare Advantage and other plans bearing the full financial risk for the cost of care.”
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