Issue Brief

Telehealth's Applications for Preparedness and Response

A Component of the Resilient and Ready: Healthcare's Impact in Emergency Preparedness Report Table of Contents

1 Introduction 3 Overview 3 What is telehealth? 3 Modalities of Telehealth Acknowledgments 4 Governance and Regulation 4 Governance We would like to sincerely thank the many thought leaders and subject-matter experts who graciously 4 Regulation provided their time and insights during interviews conducted as part of the research for this effort. This includes representatives from the American Red Cross, the American Telemedicine Association, the 6 History of Organized Efforts to Incorporated Center for Connected Health Policy, the CDC’s Office of Public Health Preparedness and Response, HHS/ Telehealth into Preparedness and Response ASPR/Office of Policy and Planning, Division of Health System Preparedness, HHS/Office of the National Coordinator, the Mid-Atlantic Telehealth Resource Center, the National Association of County and City 8 Challenges and Barriers Health Officials (NACCHO), Northwell Health, Special Assistant to the NASA Chief Health and Medical Officer Chuck Doarn, Teladoc, University of Maryland Department of Emergency Medicine, and Yale New 10 Uses in Routine Care Haven Health System’s Center for Disaster Preparedness. 10 Emergency medicine and the Prehospital Arena Additionally, we extend deep thanks to many of the partners listed above and others for their valuable 11 Chronic Disease Management feedback during the review process. 11 Applications for Emergency Preparedness and Response 12 Telemental Health The research and publication of this report was made possible due to the generous support of Healthcare Ready’s members and supporters 13 Applications for Emergency Preparedness and Response 14 Uses in Emergency Preparedness and Response 14 Natural Disasters 14 mHealth and Remote Patient Monitoring for Preparedness 15 Synchronous and Asynchronous Telehealth for Disaster Response 15 Videoconferencing and Telemental Health for Disaster Recovery 16 Disease Outbreaks and Public Health Emergencies 18 Call Centers and Phone Triage 18 Remote Patient Monitoring 19 Synchronous and Asynchonrous Technologies for Decision-making 20 Medical Supply Dispensing and Resource Awareness 20 Challenges 22 Conclusion healthcare facility preparedness. Mobile apps for Introduction tracking health can allow providers to know sooner It is no secret that technology has – and continues – if a patient requires additional care, potentially to revolutionize the delivery of healthcare. Advances keeping them out of the emergency department, ith demands on healthcare continuing We chose to explore telehealth as the first topic and text messaging can allow providers and public to increase and funding for public health area of the report due to its incredible potential. in technology have enabled countless innovations health to share information about events that highly variable, Healthcare Ready is Technologies to support healthcare delivery in patient care and increasingly, public health. As W many studies suggest, and responses to real world impact health, for example. proud to research trends in healthcare that are and education are evolving at a rapid pace, and events support, telehealth technologies have the strengthening preparedness and response. We are telehealth is on track to be a truly disruptive Approximately 40-50% of all hospitals and 63% potential to dramatically strengthen healthcare and using this research to develop a report showcasing force in healthcare, ushering in dramatic changes of US healthcare institutions offer some form of public health emergency response. Telehealth is the these trends – Resilient and Ready: Healthcare’s in means of providing care and collecting and telehealth.2 Over three quarters of Americans application of information and Impact in Emergency Preparedness. This report will sharing health data. For many reasons, outlined in (77%) own a smartphone, with 95% of Americans technologies to support healthcare delivery, share the emerging technologies, forward-leaning greater detail in this issue brief, telehealth is also a owning a cell phone. In the US, the telehealth education, and more.1 It can take many forms, policy changes, innovations, and best practices we remarkable asset for healthcare and public health market was valued at $572 million in 2014 and is preparedness and response. such as a video conference between a provider 3 are seeing and hearing about from partners in the expected to reach $2.83 billion by 2022. Statistics and patient, or a wearable device that obtains and like these underscore the potential telehealth public and private sectors that are strengthening We hope this issue brief helps to highlight why transmits clinical information, or systems that allow holds for preparedness and response, and suggest resilience. and how telehealth is such an important trend providers to send images and patient information a compelling reason to build preparedness and in healthcare for emergency preparedness and Resilient and Ready will examine several different securely to specialists. response telehealth programs: telehealth is response. While telehealth continues to face areas in healthcare and public health. In an effort to becoming an increasingly large component of significant policy barriers, advances in technology In oversimplified terms, telehealth makes it encourage conversation around the challenges and routine healthcare, and growth in mobile devices are rendering it an increasingly indispensable possible, provided certain criteria are met, to is making patients available nearly any time. opportunities of each trend or innovation, we will be resource. This document aims to summarize deliver or support healthcare delivery almost releasing issue briefs and shorter issue snapshots these challenges while also showcasing instantly, anywhere. This capability makes it a trend Telehealth has been underutilized due to to convey critical information and considerations innovations and success stories. in healthcare that holds incredible potential for numerous policy, regulatory, legal, infrastructural, for the preparedness and response community. emergency response. In times of crisis, telehealth standard of care quality assurance, and even So we are pleased to share this first issue brief, This issue brief, Telehealth’s Applications for can act as a force multiplier, allowing virtual cultural hurdles, which are summarized later in but even more excited for the conversations that Preparedness and Resilience, represents the first of resources to support responders and enable this paper. Chief among these hurdles is limited follow. Healthcare and public health preparedness these. Healthcare and public health preparedness real-time information sharing. Equally important, reimbursement and coverage. Providers surveyed is an issue that affects us all. Resilient and Ready: is a dynamic space and we are eager to share what telehealth has the potential to bolster patient and by the US Government Accountability Office (GAO) we are learning from leaders in different spaces Healthcare’s Impact on Emergency Preparedness aims to prompt conversations and increase within the field. More importantly, we are eager to awareness of trends that can benefit us all and we hear your feedback and engage with our partners look forward to engaging with you on it. We are on these topics. It is our hope that these briefs, eager to hear partners’ thoughts on the different Telehealth: Strengthening Preparedness and Response and ultimately the report, not only share innovative topics and receive input, so we encourage readers practices but also foster relationships and add new Allows for earlier interventions and delivery of care to reach out with their ideas and reflections. perspectives and considerations to preparedness and response conversations. Potential to enhance situational awareness and support decision-making before and during incident response

Ability to provide medical expertise from a distance or where it otherwise would not be available

Cost-effective way of making care available, particularly in light of decreases in funding for Nicolette Louissaint, Ph.D. preparedness at the federal and state levels Interim Executive Director, Healthcare Ready Allows for equitable delivery of care

Ability to educate, inform, and empower patients and caregivers

1 Distinctions between telehealth and telemedicine Telehealth Overview are important because differences in the definition What is telehealth? can impact how telehealth is regulated and reimbursed within and across states. A uniform, commonly accepted definition of telehealth does not exist. Definitions vary across Modalities of telehealth Federal agencies and states. Differences, though While the definitions of telehealth may differ, the typically minor, are important because they technology used in practicing telehealth largely impact how telehealth is understood, applied, and does not. The four types of telehealth include:8 funded within agencies and states. Varying uses and regulations of telehealth can in turn impact Live Videoconferencing or ‘Synchronous’: its influence in emergency preparedness and Real-time interaction between a person response. (patient, caregiver or provider) and a healthcare provider using audiovisual technology. For the purposes of this paper, telehealth is understood as it is defined by the Health Store-and-Forward or ‘Asynchronous’: Resource Services Administration (HRSA), Transmission of health and medical or “the use of electronic information and information and data (such as images, pre- telecommunications technologies to support recorded videos, and other forms of data) and promote long-distance clinical health care, through a secure electronic communications cited inadequate payment and coverage options With telehealth increasingly being integrated patient and professional health-related education, system to a practitioner. Asynchronous 4 5 as the principal barrier to adoption. into routine healthcare, combined with the trend public health and health administration.” This communications can include secure text of decreased or flat funding for public health commonly used definition embraces the Center messaging between providers and patients. Telehealth also faces distinct challenges in being preparedness at the federal and state levels, it for Connected Health Policy’s definition of applied to emergency preparedness and response is vital that every effort is made to incorporate telehealth as a “collection of means and methods Remote Patient Monitoring (RPM): efforts. For example, connectivity is essential for telehealth into preparedness and response, for enhancing healthcare, public health, and health Collection of personal health and medical data telehealth technologies, however, communications 6 where appropriate. education.” from a patient in one location transmitted to a systems are often impacted during disasters. It provider in a different location. is also important to note that telehealth is not This paper aims to highlight the potential telehealth Telehealth differs from telemedicine in that appropriate in many aspects of disaster medical holds for preparedness as well as response to telemedicine has a narrower scope, referring Mobile Health (mHealth): Provision of care, particularly in instances where the standard two of the major threats to communities, natural to technologies used for clinical care purposes healthcare services, personal health data and of care is at risk of being compromised 7 disasters and disease outbreaks, by showcasing such as diagnosis and patient monitoring. public and practice through Importantly, telehealth includes telemedicine. mobile devices, particularly smartphone apps However, telehealth’s potential to be a valuable how it is already being used in these efforts. The asset in key areas of disaster responses and paper also summarizes the challenges telehealth public health emergencies is only growing. While faces in each of these areas in an effort to foster telehealth has been used in response efforts for continued conversation on identifying solutions and Examples of Telehealth decade, its full potential has not been realized. innovations around them. Synchronous or Video Conferencing: Direct-to-consumer consults via mobile app; telepsychiatric evaluations; provider to provider consults

Asynchronous or Store-and-Forward: X-rays, CT scans, EEG printouts transmitted for telehealth’s potential to be a valuable interpretation asset in key areas of disaster responses and Remote Patient Monitoring: Holter monitors, remote EKG recorders mHealth: Mobile phone apps for collecting health data, entered manually or public health emergencies is only growing. automatically; portable, wearable sensors that can collect health data

2 3 Licensing: Licenses to practice medicine and Governance and Regulation provide healthcare are controlled and issued Advances in telehealth technology, in conjunction by state medical boards. This is important with increased adoption of telehealth, healthcare as the point of care during telehealth reform efforts, and the federal system of encounters is the location of the patient, even government in the US have combined to create a if the provider is located in another state. complex, constantly evolving regulatory arena for This requires that telehealth providers be licensed where they are as well as where the telehealth. With over 200 telehealth related bills patient is. Obtaining multiple licenses is often introduced in 42 states in 2015, and over 150 burdensome for providers and can take a introduced in 30 states in 2016, the telehealth significant amount of time. policy landscape is constantly changing.9,10

Governance Providers have attempted to address the burden associated with obtaining multiple Federal level: At the federal level, the US licenses with compacts. In April of 2017 the Food and Drug Administration (FDA) is the Federation of State Medical Boards (FSMB) lead agency for ensuring the safety and launched an Interstate Medical Licensure 12 effectiveness of medical devices used for Compact (IMLC). The Compact creates an the event of a declared disaster have been This is significant for emergency preparedness telehealth, including medical mobile apps that expedited process for qualified physicians to created. Chief among these are the Emergency and response as it prevents providers, fall under the agency’s definition of a mobile obtain a license in states that are a member System for Advance Registration of Volunteer patients, and systems from implementing and medical device.11 Reimbursement policies for of the compact.13 Currently, eighteen states Health Professionals (ESAR-VHP), Emergency becoming familiar with telehealth processes Medicare are set by the Center for Medicare have adopted the Compact and eight states, Management Assistance Compact (EMAC), and systems that could benefit them in the and Medicaid Services (CMS). plus the District of Columbia, have introduced event of a crisis. legislation in support of a path to licensure and Uniform Emergency Volunteer Health State level: State legislatures, through portability.14 Practitioners Act (UEVHPA.) Credentialing and Privileging: CMS state medical boards, establish operating regulations allow hospitals and critical access Though progress is being made in reducing definitions of telehealth and/or telemedicine The Nurse Licensure Compact was created hospitals to credential by proxy. In this process, the burden associated with obtaining multiple and related standards of care and may in 2000 and allows nurses to obtain one patient sites (the ‘originating’ site) contracts with licenses, limited awareness and adoption develop legislation to govern their use. multistate license that allows for practices in a a hospital or critical access hospital (the ‘distant’ Definitions are important as they influence nurse’s home state and other compact states. of these regulations continues to render site) for the distant site to provide telehealth reimbursement and regulatory processes. Twenty five states have adopted the compact. licensing a significant barrier to telehealth services and credential those providers. Under The Center for Connected Health Policy Physical therapists, psychologists, and other adoption. Slow development of regulations is Joint Commission requirements, practitioners maintains an interactive map of all pending professions are also pursuing multi-state not keeping up with technology, which in turn providing care through live interactive systems and current laws and regulations at the state compacts that would allow for reciprocity of limits the potential telehealth has to be used are subject to credentialing and privileging of level. Reimbursement policies for Medicaid licensure.15 more widely, and in a more uniform fashion. the location of the patient. are set by each state. State-level control of licensure leads to Regulation a complex environment in the event of a disaster or public health emergency. While Much of telehealth practice is determined many states suspend licensing requirements by state legislatures and regulated by state during emergencies declared by the President medical boards. This can often create a barrier or the state governor, this is not universally to wider adoption, particularly in the context of true and does not alleviate challenges preparedness and response, where healthcare during smaller-scale events. Mechanisms operations often cross states. for licensure verification and reciprocity in

4 5 and recovery to events impacting public health telemedicine programs and technologies can History of Organized Efforts surged following Hurricane Katrina. The Pandemic be used to increase access in impacted areas, to Incorporate Telehealth into and All Hazards Preparedness Act of 2006 (PAHPA) address surge, and overall enhance incident Patient Unified Lookup System Preparedness and Response included a provision that called for HHS/ ASPR response and risk reduction.25 Additionally, the for Emergencies (PULSE): to examine the state of telehealth in emergency Office of the National Coordinator for Health Collaboration for Health Federal agencies have been active in telehealth responses, identify challenges and barriers, Information Technology (ONC), as the federal Information during a Disaster for decades. Early pioneers in the field included and develop recommendations.22 The report agency designated with coordinating nationwide NASA and the military. By nature of their mission, developed in response to this charge concluded efforts to implement and use advanced health First responders often do not have access NASA implemented programs in the 1960s aimed that while progress was being made, telehealth information technology and electronic information to patient medical records during a at monitoring health from a distance.16,17,18 Due technologies were still underutilized during sharing, leads a number of telehealth-related response, which can serve as a challenge both to the nature of the department’s work (e.g. public health emergencies and disaster medical initiatives and has developed a Federal Telehealth when providing care. ONC partnered with deployments) and a defined patient population, responses and a National Telehealth Strategy Compendium cataloging telehealth activities and HHS/ASPR, HHS’s Chief Technology Officer, 26 the Department of Defense continues to be active could help coordinate and align efforts.23 In 2009, resources across the Federal interagency. and the State of California to develop a and innovative in telehealth efforts, including the National Institutes of Health conference on the program EMS and responders could use the creation of Telemedicine and Advanced future of telehealth included a breakout session during declared emergencies that would Technology Research Center within the US Army.19 on telehealth tools for public health, emergency, allow them to query health information ,20 The Department of Veterans Affairs (VA) serves and disaster preparedness and response.24 While exchanges, health systems, and hospitals as another leader in telehealth. The VA operates this group identified research priorities and for current health records. This program, the largest integrated healthcare system in the US recommendations, including the formation of a the Patient Unified Lookup System for and has cited the ‘mission-critical’ role telehealth telehealth advisory board, it appears little follow Emergencies (PULSE), stands to protect plays in enabling the agency to provide access up action was taken. The American Telemedicine patients and strengthen healthcare by to care to all veterans, particularly the estimated Association (ATA) had an Emergency Preparedness enabling timely information exchange through a system available statewide. 30% that live in rural areas. 21 The department and Response Special Interest Group for a number has implemented telehealth in over 900 VA sites of years that produced white papers and fostered Source: ONC and Making Personal Health Data Available During an Emergency: HHS Ventures Fund Alumni Making Data of care and is available for over 50 specialty areas discussion on the topic among members, though Available When and Where it’s Needed of care. the group no longer exists.

Federal government interest and resultant policy More recently, the 2015-2018 National Health addressing the potential telehealth holds for Security Strategy and Implementation Plan improving and enhancing preparedness, response, included a provision to explore how existing

Spacebridge to Armenia

One of the earliest uses of telemedicine to support disaster response and recovery was by NASA in 1988. Following a catastrophic earthquake in Armenia, NASA and international partners used telecommunications technology to connect hospitals in the US to the disaster zone to support diagnoses and care through telemedicine.

As one of the foremost uses of telemedicine during an emergency, a significant body of literature exists on the effort and its influence on telemedicine and disasters today.

Source: Doarn, Charles R., and Ronald C. Merrell. “Spacebridge to Armenia: a look back at its impact on telemedicine in disaster response.” Telemedicine and e-Health 17.7 (2011): 546-552.

6 7 Challenges and Barriers effects. When providers are not reimbursed Medical Specialty Standards: As telehealth and practice typically requires significant for telehealth in the same way they are for continues to expand across medical financial investment, willingness to innovate, While advances in technology have contributed to traditional services, they are less likely to specialties, some specialty providers are and openness to new technologies and uses an increased demand for telehealth and expanded provide it. Accordingly, patients may not wary of adopting telehealth as equivalent to for healthcare. uses and applications of telehealth, major barriers be exposed to telehealth technologies that in-person care due to concerns about the remain. In addition to the regulatory challenges could improve their own care or be familiar limitations of telehealth data and resolution. At the state and federal levels, many highlighted above, telehealth also faces a number with technologies that could benefit them in practitioners and thought leaders in the field cite Interoperability: Ensuring health of other challenges and barriers. the event of a disaster. Similarly, healthcare a dearth of strategic leadership and vision as a facilities may be missing out on opportunities information technology (HIT) and telehealth primary barrier to wider adoption of telehealth. Reimbursement: Reimbursement is to implement telehealth technologies that platforms across agencies and healthcare widely considered the largest barrier for could improve their own preparedness systems can share information can be difficult Telehealth programs often require a measure telehealth. Medicare includes strict limitations posture and response capabilities. but is important in ensuring providers and of sustainable funding (e.g. for technology on reimbursing by location (i.e. for rural responders alike can access electronic maintenance, upgrades, etc.). This can create Malpractice Liability & Insurance: The facilities only), type of provider, and type health records and share information. These a challenge for public health departments in number of malpractice liability cases involving of service. Between 2014 and 2016, less capabilities are vital for patient continuity of particular that rely on grant funding that can telehealth to date is low, and uncertainty than one percent of Medicare beneficiaries care during a disaster response. vary from year to year. used telehealth services.27 Medicaid remains how these cases would play out in Health IT Infrastructure: Telehealth an emergency context. Additionally, not all Education: Telehealth thought leaders cite carriers provide malpractice coverage for requires certain IT infrastructure requirements the minimal availability of formalized telehealth telehealth and coverage may not carry over to be in place or implemented in order to be training in medical and public health schools to another state. practiced. An important component of this Between 2014 and as an indirect barrier to the underutilization infrastructure is back-up capabilities, such as of telehealth. In recognition of this fact, the Privacy: Developing and selecting the cloud storage. 2016, less than one technology best suited for telehealth services American Medical Association (AMA) adopted comes with several related challenges and Leadership Buy-in and Funding: a policy in 2016 aimed at encouraging the percent of Medicare barriers, including privacy concerns and Introducing telehealth to healthcare systems teaching of telemedicine in clinical practice.29 the ability to meet HIPAA requirements. beneficiaries used HIPAA does not have distinct requirements for service delivered via telehealth, which telehealth services. requires telehealth providers to meet the same requirements as if the services were delivered in person. When services are reimbursement, though more inclusive, varies provided with telehealth, providers must widely by state. Private payers similarly vary ensure that both the technology used widely, with differences in types of services meets the standard and providers take reimbursement and amount reimbursed any additional steps needed to ensure for telehealth vs. in-person. Varied policies compliance. 28 across Medicare, Medicaid, and private payers are also constantly evolving, compounding Varying Laws: Laws governing telehealth vary challenges in understanding reimbursement between states, from licensing, to privacy and for telehealth. security requirements, to standards of care. Taken together, these varying legal environments Within programs that do reimburse telehealth pose a significant challenge to wider adoption services, it is often reimbursed at a lower rate. of telehealth and could factor into disaster The absence of reimbursement, or limited responses for events across state lines. These and inconsistent reimbursement, is a major challenges can be even further compounded in factor in telehealth use and has cascading the event of an international emergency.

8 9 Applications of telehealth within the emergency Uses in Routine Care department are assisting emergency physicians BlueStar App Telehealth is being woven into day-to-day and emergency department staff particularly healthcare operations in new ways practically Telehealth is being used in rural areas where patients are less likely to BlueStar is the first prescription-only app every day. Some of the more common be treated at a trauma center and more likely for managing chronic disease. Developed 33 uses include telehealth for chronic disease to deliver more advanced to suffer fatal injuries. In rural healthcare by WellDoc for patients with Type 2 management, , tele-icus (e-ICU), facilities that do not have certified emergency diabetes and approved by the FDA in 2010 telepathology, , video consultations, care in the prehospital medicine physicians on staff, synchronous after a clinical trial demonstrated improved remote monitoring, , and asynchronous forms of telehealth provide patient outcomes, BlueStar analyzes data access to emergency medicine physicians, , and physical rehabilitation, to name arena, as well as prevent entered by the patient, developing tailored trauma surgeons, and other specialists for timely but a few. While this is not a comprehensive list coaching and guidance and allowing consultations for trauma cases. This access and patients to track and engage in their and uses continue to grow, several applications unnecessary trips to the decision-making support can greatly improve treatment. The app also sends data back to of telehealth are particularly relevant to the level and quality of care patients receive, no healthcare providers. strengthening communities and enhancing the emergency DEPARTMENT. matter their location. The availability of telehealth preparedness posture and response capabilities Source: https://www2.bluestardiabetes.com in emergency departments has also been of healthcare systems and public health. demonstrated to improve the recruitment and Emergency Medicine and the the emergency department and keep low-acuity retention of healthcare providers in rural areas.34 and reminders, and help effectively educate 37 Prehospital Arena patients out of hospitals. Studies have shown In addition to teletrauma consultations, telestroke patients, among other benefits. RPM platforms telehealth technologies can deliver safe, feasible, programs, teleradiology, and telepsychiatry and and methods include wearable devices that can Emergency medical services (EMS) and paramedics and reliable care in the prehospital arena.30 telemental health platforms are contributing to automatically collect and transmit data such as have employed various forms of telehealth for EMS providers and ambulances equipped with improving emergency medicine care. watches and Holter monitors, as well as apps that decades, calling emergency rooms when patients laptops or other devices connected to dedicated allow patients to review collected data, manually Chronic Disease Management are in route to deliver status updates and seek telehealth platforms are able to conduct video enter data, and possibly communicate with healthcare providers through secure messaging guidance. Recently, telehealth is being used to consults, complete electronic reporting, and issue Managing and treating chronic diseases systems. Virtual visits through video platforms on deliver more advanced care in the prehospital notifications to hospitals. continues to dominate healthcare spending in phone can also facilitate more routine, convenient arena, as well as prevent unnecessary trips to the US, accounting for 86% of spending, while the A particularly successful program is Project ETHAN check-ins. prevalence of these costly conditions continues (Emergency TeleHealth and Navigation) within the to increase.35 By 2030, the number of people with Houston Fire Department. The program connects Applications for Emergency Portable Telemedicine Kits three or more chronic diseases is predicted to first responders with a call center that is staffed Preparedness and Response climb to 83.4 million, nearly triple the number of In recognition of the fact that telehealth with emergency medicine physicians. When people with three or more chronic diseases in Many of the commonly cited benefits of devices in the field depend on connectivity, paramedics are responding to a call and need 2015 at 30.8 million.36 supporting chronic disease management with companies continue to develop equipment the assistance of a physician, the ETHAN platform telehealth applications apply to healthcare with increasingly advanced technology allows them to connect to a physician in the call n the face of growing prevalence and surging I preparedness and resilience. Telehealth reduces designed to allow devices to perform center. The physician then, through a video chat costs of managing chronic disease, in addition to the number of hospitalizations and emergency even in areas with low bandwidth. These on the responder’s ETHAN tablet, can assist in an aging, less mobile patient population, telehealth department visits, potentially saving hospitals and technologies play an important role in evaluating the patient, accessing medical records, has proven to be a valuable tool in chronic disease health systems unnecessary costs while improving providing care in remote areas as well as and determining if transportation is required.31 management. This value can be attributed largely patient quality of life. It also allows for elderly during critical transport of patients. Studies designed to compare the effectiveness to the benefits remote patient monitoring (RPM) patients and those with access and functional of the ETHAN model with traditional EMS creates in data collection and information sharing. These ‘backpacks’ and kits are equipped needs to remain at home and still receive care. delivery found the use of telehealth in EMS to be RPM technologies allow data to be collected and with redundancies and antennas designed effective and successful at reducing unnecessary shared more frequently between the patient Managing chronic diseases with telehealth to protect connectivity, long-lasting batteries emergency department visits (by 56%) and and providers and the healthcare team and technologies has distinct benefits for healthcare (some with solar panels), diagnostic tools, increasing EMS productivity by allowing units to also allows providers to monitor medications, preparedness and resilience as well. For example, and more. return to service quicker.32 improve medication adherence through alerts healthcare preparedness leaders cite the ability

10 11 the response to Hurricane Katrina, a single portal, Applications for Emergency Telepharmacy KatrinaHealth.org, was set up to allow authorized Preparedness and Response Statewide Telepsychiatry: NC- pharmacists and providers access to prescription STeP Telepharmacies are increasing access to medication records for tens of thousands of Telemental health is increasing the resilience pharmacy services, particularly in rural evacuees.38 Though no longer active, ICERx (In of healthcare by expanding access to care and In North Carolina, where thirty five areas. Generally, telepharmacy allows a Case of Emergency Prescription Database) grew reducing the impact patients in need of mental counties are classified as Mental Health licensed pharmacists to remotely monitor out of KatrinaHealth and was a public-private healthcare are having on emergency departments. Professional Shortage Areas and twenty and supervise a pharmacy technician in collaboration that allowed authorized pharmacists Telepsychiatry is increasingly being integrated eight do not have a psychiatrist, law into emergency departments, for example, where providing full-service pharmacy operations. and providers assisting patients impacted makers recognized the strain patients approximately one in eight visits to emergency Supervision is accomplished through by disasters to access medication records.39 seeking care in the emergency department departments involves mental health or substance store-and-forward technology, with Addressing prescription restoration during and was having on hospitals. In 2013 the images of pills, labels, and bottles all sent abuse.42 While telemental health services following an emergency is a persistent challenge, state passed a law directing the Office of to pharmacists for review and approval. provided outside the emergency department have and telehealth technologies have provided Rural Health to implement and oversee a Patients then have a video or audio been shown to reduce trips to the emergency significant strides in overcoming and preparing for statewide telepsychiatry program, North consultation with the remote pharmacist department and hospital admissions, telemental this challenge. Carolina Statewide Telepsychiatry Program when picking up their prescription. health services, specifically telepsychiatry, play (NC-STeP). The program has led to Telepharmacies could serve as import Telemental Health a valuable role within emergency department reduced lengths of stay in the emergency resources during a natural disaster when functions by helping to reduce wait times for department for patients waiting to be roads are closed and full-service, in-person Telehealth, in iterative forms, has been used for patients in crisis, and assisting providers in triaging transferred to inpatient treatment and staffed pharmacies may not be accessible decades to provide mental health assessments patients and communicating urgent needs to number of involuntary commitments 43 for patients with critical needs. and deliver care. The US Department of Defense providers on site with the patient. Telepsychiatry to local hospitals or state psychiatric and Department of Veterans Affairs (VA) are provided in the emergency department has also hospitals. been linked to reductions in subsequent inpatient recognized pioneers in the field, with the VA Source: North Carolina Center for Policy Research. stays, costs, and the likelihood of readmission.44 RPM platforms and other telehealth technologies operating an expansive telemental health program Evaluating the Use of Telepsychiatry for Rural Mental Health Similar to other telehealth offerings, telemental Services. March 31, 2014. http://www.nccppr.org/drupal/ have to allow patient care and access to providers that is used to treat nearly all mental health content/news/2014/03/31/4348/evaluating-the-use-of- health services in the emergency department are telepsychiatryfor-rural-mental-health-services to remain more stable during an event in which disorders, including anxiety and substance abuse valuable in improving access to care and making healthcare infrastructure or transportation disorders.40 Successful utilization of telehealth for is impacted. Since care and communication mental health services in these spaces helped lay would ideally already have a foundation of being the foundation for use in routine care. expertise available where it otherwise would not delivered virtually, those virtual communication be. For rural emergency departments and facilities lines would already be established and thoroughly Advances in technology, particularly video where the impact of mental health disorders is tested in the event of an emergency and could conferencing, complemented by the growth Telepsychiatry plays greater, and where mental health providers are continue to be relied upon. and accessibility of mobile devices capable of scarce, telemental health represents a safe and video, have helped make telemental health more a valuable role within effective way to provide care. Additionally, RPM data could potentially aid in prevalent. Dozens of studies have demonstrated identifying patients that require expedient care that in addition to increasing access to care, emergency department Facilities without mental health providers may during an emergency. Hospitals and healthcare telemental health is effective for diagnosis and enter into agreement with private telemental facilities and providers receiving transmitted data health providers to not only make mental health assessment within many patient populations (e.g. functions by helping to could alert responding agencies of patients whose services available, but to make them available children, adult, etc.) and for treating a spectrum data appears abnormal. 24 hours a day. In the event of a natural disaster of disorders in different settings, including the reduce wait times for or other crisis, the benefits of telemental health emergency department.41 While most literature Telehealth can also help reduce exacerbations services both in and out of the emergency focuses primarily on video conferencing, uses patients in crisis. of chronic conditions that can be brought on department would be vital in ensuring timely and efficacy of asynchronous methods are being during an emergency with its ability to help access to care for those who need it and reducing explored and mobile apps for mental health are a restore and renew prescriptions. Patients can refill the impact on hospitals. prescriptions through apps on their phone. During burgeoning field.

12 13 damage facilities patients rely on for care, impact Uses in Emergency Preparedness transportation routes patients and providers rely and Response on, and directly injure patients and exacerbate existing conditions. Telehealth is recognized as text programs and mHealth allow planners With its ability to provide care virtually following a valuable asset for the life cycle of disasters, a disaster, and capacity to facilitate real-time or from preparedness to recovery. From sending and healthcare providers to share information near real-time information sharing, telehealth messages to patients about anticipated impacts holds great potential for improving emergency to health or preparedness actions to take for before an event, provide real time updates, and preparedness and response to natural disasters expected events such as hurricanes, to making and public health emergencies. It is important to health and medical expertise available where enhance situational awareness. note, however, that connectivity is an incredibly it would not otherwise be following a disaster important consideration when applying telehealth and during recovery, telehealth is being used to disaster response planning specifically. Many to enhance resilience through the lifecycle of telehealth uses during a disaster rely on availability the IMS Institute for Healthcare Informatics posture of communities and patient groups. From disasters. of cellular service and/or broadband . found there were over 165,000 mobile health disaster-specific apps from the American Red While there are mechanisms for addressing this 47 mHealth and Remote Patient Monitoring apps available to users. While many of these Cross, to apps specially designed for public health challenge, such as incorporating secondary and may not be useful for preparedness, they do emergency responders and apps managed by for Preparedness tertiary communications methods into plans signal the possibility for patients to be more federal, state and local authorities, mHealth has and hardening systems to the greatest extent Protecting access to healthcare, ensuring patients involved and aware of their own health conditions, the potential to help educate patients and the possible, the potential to be without utilities upon and communities are informed and empowered which can in turn position them to be more public and instill preparedness in daily routines which telehealth relies upon remains a barrier for 48 to manage their health conditions, and ensuring prepared. Apple’s iPhones currently come with through the use of mobile devices. telehealth use in disaster response efforts.45 responders have the tools and resources required a HealthKit platform. This suite of health-related Synchronous and Asynchronous Natural Disasters to provide disaster medical assistance are among apps includes a health records app that allows the primary planning considerations in natural providers to make health records available in a Telehealth for Disaster Response Natural disasters – hurricanes, winter storms, disaster preparedness. Telehealth can be used variety of approved methods. As the number of Various forms of telehealth have been employed tornadoes and more – threaten healthcare in each of these instances, with mHealth holding health and emergency mobile apps continue to in response to natural and man-made disasters for and patients in many ways. These events can particular value. grow, this rapidly emerging field provides many decades and recent advances in technology position avenues for encouraging preparedness at the it to be more useful than ever before. Telehealth With its ability to push information, and studies individual level and improving the preparedness suggesting 90% of all text messages are read acts as force multiplier during a response by making Text Messages for Rx Refills within three minutes of delivery, text programs health expertise available where it otherwise and mHealth allow planners and healthcare would not be and minimizing safety and logistical NATO Telemedicine Partnership A study conducted by CVS Health and HHS/ providers to share information before an event, challenges necessary in transporting providers to ASPR found that pharmacy text messages to 49 provide real time updates, and enhance situational North Atlantic Treaty Organization impacted areas. This virtual surge capacity can be patients with chronic conditions encouraging awareness. 46 Health departments can use text (NATO) partners harnessed the power of brought to impacted areas by connecting to existing them to refill medication prescriptions messages to share information with the public telehealth for international emergency networks that support telehealth, through specially was effective in prompting the desired on expected impacts to health, resources for response efforts by developing a multi- developed telehealth systems, or increasingly though preparedness action. The study additionally assistance, and more. Smartphone apps and national telemedicine system that mobile devices. found that public-private partnerships were texting also make it easier for patients to refill allows emergency responders to access helpful in facilitating timely outreach by During the acute response phase, telehealth prescriptions. Many chain drug stores allow specialists virtually for diagnoses and pharmacies. (primarily synchronous methods) can be used to patients to manage prescriptions through apps. In recommendations. Launched in 2017, assist with field triage, patient monitoring during Source: Lurie N, Bunton A, Grande K, Margolis G, Howell addition to sending alerts when prescriptions are the program allows responders to B, Shrank WH. A Public-Private Partnership for Proactive transportation, and logistics coordination. During Pharmacy-Based Outreach and Acquisition of Needed ready and refill reminders via text message, apps deploy with portable telemedicine kits Medication in Advance of Severe Winter Weather. JAMA Intern the subacute phase, or the days and weeks Med. 2017;177(2):271-272 allow patients to refill prescriptions. that connect with specialists. following an event, telehealth could be used Source: NATO develops telemedicine system to save lives mHealth can also store and make health in emergencies to conduct consultations with specialists and information more accessible. A 2015 study by triage patients in a manner that mitigates against

14 15 American Red Cross and Teladoc Partnership needed. Researchers showed telehealth methods area, it will likely continue to remain a primary were effective in meeting disaster-related mental consideration as technology continues to In 2016, the American Red Cross and Teladoc, the nation’s first and largest telehealth provider, needs for communities impacted by Hurricane advance and agencies and healthcare systems partnered to deliver remote medical care to communities that are affected by disasters. Katrina. 53 Video conferencing allows for patients continue to implement telehealth technologies Teladoc virtual physician visit services will be made available via web, Teladoc’s mobile app in disaster-impacted areas with scarce mental at different rates. and phone to address the primary health care needs of individuals whose access to health health resources to access mental health care providers has been limited or is unavailable after large-scale disasters. The consultations providers. This capability is especially important Routine Use of Technology: Experts in both will make it possible for disaster victims to access needed health services during events in in light of the notion that the demand for mental preparedness and healthcare emphasize which distance and time are important factors. health services is soaring amidst a documented that the key to integrating telehealth into 54 Source: ‘Teladoc and American Red Cross partner to provide disaster victims with remote medical care through leading telehealth mental health care provider shortage in the US. preparedness initiatives and response platform’ (Press release) plans is using, or adapting, systems and Just as telemental health is increasingly being used processes providers are already using in as a means of routine care to treat mental health normal operations. This ensures providers are disorders unrelated to disasters or traumatic familiar with workflows and systems and are events, telemental health is also beginning to be not required to learn a new system during an used to provide behavioral and mental health emergency, or just for an emergency. overwhelming hospitals and emergency facilities. help the care team – responders and remote resources for public health crises, such as the Additionally, throughout a disaster response, providers – determine the appropriate medical opioid crisis. 55 Connectivity and Access: Many telehealth telehealth can enable just-in-time education to facility to which a patient needs to be transferred. technologies requires a power source (or is Telemental health can also help provide responders and patients alike on the specific This capability is particularly important when at best limited in length of use due to battery specialized mental health services that may be disaster and/or relevant healthcare knowledge transporting patients in rural areas, when delivery life), an internet connection, or a cellular required during a response, such as making for the situation, as well as allow providers from a of lifesaving care is time sensitive and facilities with signal in order to function as desired during pediatric mental health providers or mental health distance determine if special healthcare supplies the capabilities and resources required may be an emergency. While many efforts can be providers with expertise in disasters available to need to be sent to the impacted area. It also helps father away. Alternatively, as seen in applications taken to harden these technologies and build communities and healthcare facilities with scare foster equitable delivery of care by making more of telehealth technologies to routine 911 calls, it in redundancies, dependence on the very resources. care available virtually and standardizing care.50 can also help prevent unnecessary transport to utilities that are frequently lost or damaged hospitals and emergency facilities, reducing the during an event continues to pose a challenge Direct-to-consumer (DTC) telehealth technologies Challenges impact on hospitals and likely saving costs. to telehealth’s adoption into emergency could be used during the acute response While telehealth holds great promise for disaster management. phase to engage bystanders in supporting preparedness, response, and recovery, it is still timely response efforts by using synchronous Disease Outbreaks and Public Health confronted by several distinct challenges. It is technologies to connect bystanders with trained Video Conferencing and Telemental Emergency important to note that these challenges are not medical professions to deliver care such as Health for Disaster Recovery insurmountable, but are important considerations In the event of a disease outbreak or other public cardio-pulmonary resuscitation (CPR). 51 While the when developing plans and policy regarding health emergency, telehealth can be employed to authors cite the shortcomings of DTC systems in During the weeks and months following an event, telehealth and disaster response. accomplishing this due to a requirement to have healthcare infrastructure may be compromised or great effect to share information, provide decision- making support, minimize risk to the public and an existing account to initiate an encounter with limited, and some health resources or providers Challenges particularly relevant to achieving optimal providers, and possibly allow for preemptive a DTC provider, they suggest slight structural may not be accessible or restricted. Telehealth use of telehealth in disaster response include: changes could better position DTC to be a conducted through healthcare systems could care to take place. Synchronous communications response resource. help fill gaps in access to specialty care, while DTC Interoperability: Ensuring systems are technologies and remote patient monitoring have services could augment strained primary care interoperable is paramount in disaster both been demonstrated to improve patient Advances in technology are enabling telehealth providers.52 response, particularly when health information and provider safety, as well as patient outcomes, to maximize patient safety and provide decision- and medical records need to be accessed in combatting infectious diseases. mHealth making support during critical transport, Studies and real-world events demonstrate the and shared, as they are during a disaster. applications for sharing event information particularly from rural areas. In addition to value and promise telemental health holds for Though federal working groups, in partnership with patients and the public, as well as health connecting responders to specialists and other disaster recovery, particularly when mental health with private sector partners, have made and information between providers and patients, are needed providers, telehealth technologies can providers with disaster and trauma training are continue to make marked progress in this continuing to be explored and developed.

16 17 Call Centers & Phone Triage an outbreak to push event and health information to the public. Call centers staffed by healthcare professionals For highly infectious Project ECHO Public health messaging programs have proven have been shown to be effective in assessing and diseases, RPM represents Started in 2003 by a liver disease specialist, to be effective. The CDC’s Text4Baby program, a directing patients to appropriate care facilities Project ECHO (Extension for Community in the event of a pandemic or disease outbreak. the safest means of Healthcare Outcomes) is a well-known free text messaging service for pregnant women Call centers and hotlines staffed by health model for telemedicine that uses a ‘hub and new moms that provides critical health and professionals can be used to provide health and treatment for patient, and spoke’ model to connect specialists safety information such as reminders about event information that can reassure or prompt providers, and the at the ‘hub’ with primary care and other immunizations, nutrition, and more, has been callers to seek care, potentially protecting them providers at ‘spokes.’ This model could be found to benefit enrollees and improved health from unnecessary exposure and minimizing risk community by allowing for used during an outbreak to train providers. outcomes and could serve as a model for health of infection. Triage lines staffed by healthcare departments interested in developing their own Source: Arora, Sanjeev, et al. “Academic health center 60 providers can also be used to screen callers, management of chronic diseases through knowledge programs. Studies examining the effectiveness specialists to develop care networks: Project ECHO.” Academic medicine: journal of the determine if they require immediate care and help Association of American Medical Colleges 82.2 (2007). of text messages to notify healthcare facilities patients obtain antivirals. plans from a safe distance. of outbreaks in resource-limited areas have demonstrated text message systems to be Equally important, call centers and triage lines effective in timely notification and enhancing reduce the surge on hospitals by assessing the monitoring and treating the disease ranged from disease surveillance.61 ‘worried well’ and reassuring them that they do not wearable devices that continuously monitor vital Remote Patient Monitoring need to seek unnecessary care. This in turns helps signs to sophisticated Ebola treatment centers in Similar to receiving text messages regarding ensure that only those patients with the most acute hospitals that leveraged video conferencing and RPM technologies already play an important – and prescription refills before a disaster, public health need seek in-person care. Transmission of the other tele-ICU technologies.57 58 growing role – in managing chronic diseases. Many agencies are researching the feasibility of using text infectious disease is also reduced by keeping healthy messages to track and encourage adherence in the of these same technologies could be used during The US Centers for Disease Control and Protection people away from those with the infectious disease. event of a pandemic that requires multiple courses a disease outbreak to provide and manage care (CDC) also relied on telecommunications of antivirals. After receiving the first course, patients while also protecting providers and the public technologies to follow and monitor personnel would receive a text message reminder when it was from exposure. Providers could monitor data returning from deployments to West Africa. Returned time to take the subsequent course. transmitted from patient devices to determine deployers that had potentially been exposed were Flu on Call® if and when an intervention is needed. Similarly, quarantined for 21 days and self-monitored and Synchronous and Asynchronous RPM devices could be used to determine the reported updates as directed though text messages, In the event of a severe pandemic, the type of intervention required, whether it is a visit Technologies for Decision-making phone, and email. The CDC also developed guidance Centers for Disease Control and Prevention from a home healthcare worker or admission for local health departments for monitoring both Support & Expertise has developed a national network of phone to the hospital. More timely interventions have travelers and healthcare workers that had potentially lines, Flu on Call®, that can be used to been shown to reduce emergency department Various telehealth technologies can provide been exposed.59 provide information and triage callers. This visits and hospitalizations. RPM devices can also important decision-making support to healthcare network of call centers engages United Way help educate patients and family members or Healthcare preparedness experts suggest providers during the response to a disease 2-1-1 help lines, poison control centers, and caregivers about treatment plans and engage that RPM technologies could be used to even outbreak in several different ways. As previously nurse advice lines. patients more proactively in care, which could help greater benefit in the event of an outbreak by indicated, RPM can allow a provider to determine if assuage anxieties about access to care.56 an intervention or disease screening is required, or Callers will be assessed by healthcare facilitating preemptive care. Patients susceptible even consult with family members and caregivers. providers via phone and given information or vulnerable to infectious diseases could receive For highly infectious diseases, RPM represents the The more or less continuous provision of data as well as directed to appropriate care sites, RPM devices at the outset of an outbreak. Early safest means of treatment for patient, providers, and health information, compared to the episodic e.g. hospital, clinic, etc. This minimizes the monitoring could help prevent exposure and/or and the community by allowing for specialists to information afforded by traditional care, could play impact on hospitals while ensuring those facilitate an early intervention if needed. develop care plans from a safe distance. Perhaps a significant role in the event of a pandemic or who require care are directed to the most the most well-known example of RPM being mHealth for Information Sharing other outbreak. appropriate facility. employed to treat a highly infectious disease Source: ASTHO Flu on Call FAQ outbreak was the Ebola virus disease outbreak of mHealth is increasingly being explored as a tool Importantly, telehealth can also enable 2014. RPM technologies found to be effective in public health departments may use in the event of consultations and interaction with disease

18 19 specialists and other healthcare providers during dispensing (PODs) sites as a means of filling a be adaptable and able to scale up for an outbreak and facilitate equitable care. An potential gap in dispensing operations when emergencies and built with an all hazards outbreak of a familiar disease, such as pandemic medical screenings are required but the availability approach in mind. For example, RPM systems influenza, could see infectious disease specialists of healthcare professionals is limited due to the may be engaged and relied upon much more and critical care nurses providing support to rural event at stake.63 Thought leaders in public health heavily during an outbreak and systems must healthcare facilities through video conferencing preparedness also cite the possibility of using be able to accommodate this surge in data and other modalities. Similarly, an outbreak of an mobile devices to report inventory levels at PODs transfer. emerging infectious disease could see disease- to a centralized source managed by public health Privacy and Security: The 2009 report by ASPR specific specialists and researchers providing departments. This data could then in turn be used in response to PAHPA points out that privacy expertise to multiple healthcare facilities. to help direct the public to the best-resourced POD near them. laws regarding personally identifiable health Congress’s passage of the Expanding Capacity for information differ by state and could impact data Health Outcomes (ECHO) Act in December of 2016 Challenges sharing through telehealth in a multi-state event. has laid the foundation to make the Project ECHO As it applies to , health departments In addition to the challenges and barriers a national model for telehealth. With the model’s have also expressed uncertainty at the ability to summarized earlier, applying and integrating 64 successes and efficiencies well documented, the use mHealth for messaging. telehealth into public health emergency and legislation holds importance for the application disease outbreak response efforts faces a distinct Public health departments may face a unique set of telehealth to disease outbreaks. The legislation set of challenges. Primary challenges include: of challenges in implementing telehealth programs calls on HHS to examine and prepare a report for preparedness and response, including on the model’s effect on public health programs, Adapting Technology: Healthcare and public including those related to disease prevention, health experts point out that state and local Funding: Telehealth initiatives frequently disease outbreaks, and public health surveillance.62 agencies are likely to invest in systems that will require funding both for technology and be used in normal operations over systems program design, implementation, and Medical Supply Dispensing & Resource more oriented for response. Therefore, in evaluation. Public health programs are often Awareness order for telehealth to be incorporated into funded by grants from both public and preparedness and response it will likely have private organizations that are typically tied to Telehealth and technology are increasingly to be done by engaging systems already in a specific use. This can lead to difficulties in being used to ensure the public has timely place and possibly not designed with response sustainably funding telehealth programs. access to medical countermeasures and other efforts in mind. medicines they might need in an emergency. Competing Priorities: Public health The 2009 Pandemic and All Hazards Report to System Flexibility: Demands on telehealth departments are often occupied dealing with Congress cites the inclusion of remote telehealth systems are likely to surge during an outbreak “the disease or disaster of the day.” This can consultations at countermeasures points of or public health emergency. Systems must leave limited resources and staff available to identify and implement new programs such as telehealth initiatives.

Telehealth and technology are increasingly being used to ensure the public has timely access to medical countermeasures and other medicines they might need in an emergency.

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