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CONTENTS Executive Summary TELEMEDICINE 1 Virtual Care Is Becoming Real Advancing From Pilot to Practice In Depth 2 The Reality of Virtual Care

10 Diversification and Virtual Care Services

11 Telehealth Gets More Coverage From CMS

12 Telemedicine Providers Welcome AMA Guidelines

13 Weighing Telehealth’s Pros and Cons

15 Sports Medicine Turns to Telemedicine

17 Telemedicine’s Expanding Options

Case Study 20 Banner TeleHealth: Reducing Length of Stay and Mortality with TeleICU

Featured Webcast 21 The Telemedicine Playbook: Mercy & Nemours Models

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VIRTUAL CARE IS BECOMING REAL HealthLeaders Media editorial staff

Telemedicine is ready for its close-up. faced a disaster like an earthquake or By having an infrastructure in place, As laws have become more liberal and a hurricane. Telehealth technologies’ we can now expand what we offer to patients have grown more comfortable inviting prices and increased availability external partners more rapidly and at with remote delivery of care, payers are driving their presence in every lower costs.” have updated their policies to reflect corner of healthcare. newly available technologies, and more In this Insider Report, HealthLeaders providers have gotten into the game to “Over the past decade, Mercy has Media takes a look at where this game- offer telehealth options. invested more than $200 million in changing technology is headed, what developing infrastructure, teams, and changes users can expect, and how It’s not hard to understand why. solutions for telemedicine,” Randall healthcare providers have overcome Telemedicine allows patients in remote Moore, MD, president of Mercy Virtual, challenges. In six original articles, a areas access to specialists they otherwise part of the Mercy health system in St. case study, and an expert webcast, might not have, lets patients be seen Louis, told HealthLeaders Media Senior practitioners share their experiences in “after hours” by clinicians in a different Technology Editor Scott Mace. “We developing a successful program. Find time zone, and facilitates prompt were an early adopter, willing to take out what matters now as telemedicine access to care in areas that have recently risks because we saw the potential. … moves from idea to implementation. n

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THE REALITY OF VIRTUAL CARE Scott Mace, HealthLeaders Media

Telemedicine is removing REMOVING BOUNDARIES geographical boundaries and Lynn Britton is president and CEO of bringing patients and providers the Mercy health system, based in St. together. Louis. He says that healthcare need not be constrained by local or regional Virtual care is not a new idea. boundaries, and that a virtual dimension Videoconferencing dates back several can enable a comprehensive approach. decades. Remote monitoring in ICUs began more than a decade ago. Telestroke and remote behavioral health programs have been on the radar in many settings for years.

But two major factors have given virtual care a big boost in the past year. Healthcare’s notorious inefficiency is pushing health systems to balance workloads and workflows, erasing businesses that are offering software, always had a regional dimension to it. distance and time as limiting factors on hardware, and even clinical and medical If you couldn’t get something done in the provision of care—using virtual care staff to facilitate technical innovations. your hometown, you went to the next to do much of the balancing. Second, Large hospitals are using virtual care biggest place to get it. But our belief is telemonitoring technology is providing to help small ones. Doctors, nurses, that to be comprehensive, we have to improved ease of use and simplicity, and pharmacists—some affiliated with have the virtual dimension of it; that while more attractive price points and large providers, some freelancing—are removes the geographic boundaries that performance capabilities are driving providing care where and when it’s constrain us, and it has a huge impact virtual care innovation into all of needed, 24 hours a day, 365 days a year. on our ability to enhance quality and healthcare’s costly nooks and crannies. the service experience for patients.” The team behind the camera Forty-six states and the District of “Healthcare delivery is simultaneously Britton says telemedicine has been Columbia offer some form of Medicaid local and virtual,” says Lynn Britton, a 10-year journey at Mercy. Today, payment for telemedicine services, president and CEO of Mercy, a St. Mercy monitors 450 ICU beds in 28 according to the American Medical Louis–based system with operating ICUs and two step-down units in 15 Association—though Medicaid payment revenue of about $4.5 billion, 4,231 hospitals across five states, with 40 for more advanced uses, such as remote licensed acute beds, and operations in board-certified critical care intensivists. patient monitoring, is available in only seven states. “For as long as I’ve been The system has telestroke capability in 14 states. 26 of its 35 hospitals, and it is soon to in healthcare, people have talked about come in the remaining facilities. On-call The drive to virtual care is also creating how it’s all local, and frankly that’s neurologists view CT scans and evaluate partnerships between providers and never been completely accurate. It’s

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patients through a secure encrypted evidence it points to as virtual care’s network and two-way video screens on return on investment. mobile carts. Sixteen of the intensivists “To be comprehensive, we have Assessing the benefit are certified in neurocritical care and are to have the virtual dimension of part of Mercy SafeWatch, the teleICU To cut the cost of sepsis, Mercy it; that removes the geographic program. extended telemedicine to a skilled nursing facility that had been receiving boundaries that constrain us.”

All these efforts are supported by low-level monitoring, such that the LYNN BRITTON, PRESIDENT AND CEO more than 80 critical care nurses. In standard for collecting vital signs was OF MERCY, ST. LOUIS May, Mercy will open a freestanding to do so once a day—too infrequently 120,000-square-foot telemedicine center to spot downward trends. By using that will house 300 clinicians who telemedicine hospitalists and nurses, outcomes in areas such as teleICU, provide 24/7 care, but with the patients and trend-spotting algorithms telesepsis, and telestroke, but we are all located elsewhere. developed in conjunction with Philips, moving into a second phase of testing the global technology company, Mercy and measuring to further validate.” Like many other organizations cutting has been able to increase early sepsis a virtual-care path, the rural nature The benefit is not just internal. “By identification in a population of of Mercy’s Missouri catchment area having an infrastructure in place, hundreds by 31%, reducing cost per was a telemedicine crucible. But as the we can now expand what we offer to case by $2,800 and decreasing length benefits of eliminating distance and external partners more rapidly and of hospitalization stays by two days, time accumulated, Britton and his team at lower costs,” Moore says. “We can says Wendy Deibert, RN, MSN, vice realized they could also make profound even address specific patient groups president of telehealth services for improvements in overall quality and needs. Because each market is Mercy. systemwide by leveraging virtual care. unique—as well as patient groups and But that was just the start. “As we programs—we have to take into account “We need to succeed at telemedicine kicked that off, our hospitalists said multiple factors in order to account at a big enough scale so that we have they were struggling getting their for clinical, operational, and financial the facts to convince the payers that admissions done at night, so we value.” they’re better off to pay for it, and to thought: What if we took cross-coverage convince the broader community of “So the return is there,” Britton says, and moved it up to the centralized medical professionals that it really “and it varies depending on which monitoring center? And now we are works,” Britton says. “That’s one of service you’re talking about and what answering all the calls from across the the reasons for the virtual center that your economic model is as far as hospital,” she says. we’re building, to create significant reimbursement. If you’re in some sort of ACO structure, then using some of enough scale to make the point that it’s “Over the past decade, Mercy has the population healthcare management irrefutable. invested more than $200 million in capabilities where you monitor chronic developing infrastructure, teams, “What’s taken off in the past four or disease patients in the home, intervene and solutions for telemedicine,” says five years is the way our physicians have early, and keep them out of the office Randall Moore, MD, president of embraced” telemedicine, Britton says. and the hospital—then that’s a benefit Mercy Virtual. “Our investment in “They now see these technologies as that pays for itself pretty quickly.” telemedicine is very similar to how we a clinical tool, and they’re imagining invested in an integrated electronic how to practice medicine using Moore explains that measuring the health record. We were an early them, and are driving, in a sense, the return varies based on the specific adopter, willing to take risks because experimentation and the innovation application. “From purely financial we saw the potential. We believe good going on.” returns, we are not yet net positive. patient outcomes will follow our But if you are talking about improved As this occurs, Mercy assembles the virtual investment. We have seen good patient outcomes, increased access, 3 IN DEPTH HLMINS DER TOC

and lower costs of care, then yes, we are HEALTHCARE I.T. AND TELEMEDICINE net positive,” he says. “Mercy supports transformation within and beyond Relatively few healthcare leaders place telemedicine in the top three areas of our system. We have met or exceeded healthcare IT that are of strategic importance in supporting their organization’s many of our objectives. Our goal is financial targets over the next three years. to continue to identify programs that can and will drive value in our Clinical IT 26% current system, while accelerating our capabilities within population and Electronic health record 21% personalized medicine.” Data analytics 21% Tackling hazards and complexity Data integration 10% Virtual-care techniques pioneered Financial IT 8% in ICUs are spreading to general and pediatric hospital bed settings. ICD-10 6% Nemours—which owns and operates Telemedicine 6% Nemours/Alfred I. duPont Hospital Actuarial skills for risk assessment 3% for Children in Wilmington, Delaware, and Nemours Children’s Hospital in SOURCE: HealthLeaders Media Industry Survey 2015: Succeeding in the Risk Era: How to Accelerate Progress Orlando, Florida, along with major Toward a Value-Based Future, January 2015 pediatric specialty clinics in Delaware, Florida, Pennsylvania, and New Jersey, employs more than 600 physicians and linear relationship between medical hazards topped the ECRI Institute’s reported net patient service revenue of errors and the number of tasks assigned Top 10 Health Technology Hazards $732 million in 2013. to a bedside provider. The more you do, list—the fourth consecutive year. “We wanted to provide an extra set the more likely there’s going to be an To address this concern, Nemours of eyes for nursing, facilitate rapid error.” created a Clinical Logistics Center, responses of care as need be, not waiting From Nemours’ own internal review described in the October 2014 issue minutes but down to seconds, [and to] of its claims, the organization found of the Journal of Hospital Administration. establish more of a central monitoring that the recognition and monitoring The CLC is a hub where all of … to troubleshoot issues, while creating oversight of things like code blue care issues were associated with 55% of its Nemours’ monitoring technology is coordination and just-in-time aspects malpractice incidents and 80% of the integrated and tracked 24 hours a day, of things,” says Stephen T. Lawless, malpractice payouts. 7 days a week, by trained paramedics. MD, MBA, vice president of quality and Traditional communications tools— Real-time surveillance safety for Nemours. phone calls, yelling down hallways— “Instead of just looking within “Hospital ward beds are what ICU beds cannot adequately address the false our box of how we do alarms, we were 10 or 15 years ago,” Lawless says. alarm that traditionally reaches a decided to take cues from other “More complexity [and] higher ward clinician once every 92 seconds on industries,” Lawless says. “We looked acuity is now becoming more the norm. average, Lawless says. Indeed, in 2013, for continuous improvement of That actually leads to more alarms for The Joint Commission approved a new redundancies. We looked at the the monitoring being done, and alarms National Patient Safety Goal on clinical airline industry, air traffic control, subject you to alarm fatigue. Medical alarm safety for hospitals and critical NASA, aircraft carriers, nuclear research is really showing almost a access hospitals. Also, this year, alarm power plants, trying to look at why

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they are acting a lot of times at a Six Sigma level. All these systems had CENTRAL MONITORING systemic redundancies to ensure failsafe Stephen T. Lawless, MD, MBA, is vice responses, rather than just individual president of quality and safety for alarms.” Nemours, a children’s health system The CLC doesn’t exist just to monitor based in Wilmington, Delaware, that has alarms, however. “We needed to create operations in four states. He says more of a real-time surveillance,” care is increasingly complex and that Lawless says. Nemours’ Clinical Logistics Center serves So the CLC also assists busy clinicians as a hub where monitoring technology is with order entry. “Even those who integrated and tracked 24/7 by trained have electronic medical records know paramedics. that entering orders into an electronic medical record could take 45 minutes to an hour, hour and a half,” Lawless says. “There are ways of designing and having other people listen in and work with you in terms of facilitating those orders and getting them verified. These “It’s near 24 months since the CLC Center. This cost includes staffing and are the specifications, along with using startup, and we’ve had no unexpected infrastructure updates.” the National Patient Safety Goals, for mortality events on the general wards,” how we designed our logistic approach.” Lawless says. “We have expanded Lawless compares this cost to that of a to a second hospital that we’ll be more traditional unit-based monitoring “Limitations of the CLC are a result of monitoring within our system.” approach. “Using a traditional model, its young age,” Nemours researchers we estimated costs of $200,000 per wrote in the JHA article. “Acceptance Costs and benefits unit or $800,000 for just one hospital, by the bedside staff is slowly growing. By establishing a centralized including wiring, monitors, and other Many staff members do not have monitoring approach, Nemours has infrastructure needs,” he says. “In a experience with this innovative alarm cut costs by two-thirds over more state where beds are clustered, staffing management approach.” traditional models, while increasing would also be more extensive.” standards for patient safety and quality One positive development is that nurses Lawless notes that while CLC doesn’t care, Lawless estimates. are more willing to ask for help than generate revenue, the value it brings before the CLC was implemented, and “We were very fortunate to include the to Nemours Children’s Health Lawless cites data to demonstrate that infrastructure for the Logistics Center’s System is from the patient harm it willingness: “We consider this 38%– centralized monitoring system as we helps prevent. “Using the centralized 50% increase from baseline of other built Nemours Children’s Hospital monitoring system, we have not seen children’s hospitals a good thing.” The and expanded to Nemours/Alfred any unexpected mortalities in either value of asking for help through the I. duPont Hospital for Children,” hospital. We’ve also seen more timely CLC system is that it replaces a previous Lawless says. “The start-up cost for this responses to patient calls and alarms, pager-based system where average infrastructure, like wiring, cameras, and greater nurse satisfaction and patient response time was 5.5 minutes; now, monitors, was $250,000. Continuing experiences. Through decision- that has drastically been reduced to a operating costs total around $500,000 supports, we’ve reduced errors by sub-30-second response time from CLC annually to monitor patients from delivering medications on time and personnel. both hospitals through the Logistics alerting providers of critical lab results.

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These outcome metrics define success pass by that patient.” for Nemours in our move to become a “We need to succeed at value-based health system.” Banner has now fully implemented telemedicine-powered surveillance telemedicine at a big enough Transforming care monitoring outside the ICU at all beds scale so that we have the facts Leaders at Banner Health described in two of its hospitals, according to to convince the payers that their efforts in “Transformational Julie Reisetter, RN, chief nursing officer they’re better off to pay for it.” Telemedicine,” a HealthLeaders of the Banner Telehealth division. Media LIVE event in December 2014. LYNN BRITTON, PRESIDENT AND CEO, While Banner continues to study MERCY, ST. LOUIS During the discussion, listeners had the data in its tele-acute facilities, the opportunity to learn how the early results indicated a reduction in Phoenix-based 25-hospital system transfers to the ICU from the ward by has been using telehealth and trend- rendered. nearly 50% and a decline in the fall rate spotting algorithms since 2006 to gain from 3.1 to 2.2 per 1,000 patient days. On October 31, 2014, CMS released efficiencies needed to transform itself Reisetter points to anecdotal stories a new final rule on payments to from a hospital-based company into a from nursing staff “where they’re physicians, which included a provision population–health focused company. monitoring this population of patients effective this year to cover remote multi- Banner’s teleICU initiative in 2013 in this facility, and all of a sudden symptom chronic care management yielded 33,000 fewer ICU days than they’ll have an alert for a high heart using a new CPT code with a monthly would have been predicted, 47,000 rate,” she says. unadjusted, nonfacility fee of $42.60 fewer hospital days, $89 million in cost per month per qualified patient. In all, “They’ll put on their headset. They’ll avoidance, and more than 1,900 lives CMS added seven new telemedicine quickly camera into the room, and next saved, according to Michael Simons, billing codes, including psychotherapy, thing they know, they’re saying, ‘Stay MD, medical director for Banner prolonged office visits, and annual in bed; we’re going to get someone. Estrella Medical Center Intensivists. wellness visits. Hold on,’ and we have the ability to “Physicians in general, intensivists simultaneously get the team. So it’s “Eight million newly covered people probably in particular, are not great fascinating to be able to tie some of actually want to go get care, and that at surveillance,” Simons said in the those physiologic triggers to something puts more stress on the primary care program. “They are good at reacting that we think can potentially help system,” says Jason Gorevic, CEO of to incidents, emergencies, identifying reduce falls.” Teladoc, a Dallas-based independent the patient and then acting to stabilize provider of virtual care services to more The financial urgency and set a care plan for that patient. But than 8 million members. “Teladoc is what they are not particularly adept at The rapid growth in newly insured due a sort of pressure-release valve for the is walking by patients continually to see to the Patient Protection and Affordable primary care system.” how are they doing: Is there some subtle Care Act is exacerbating already existing clinician shortages. Providers say virtual With customers primarily drawn from evidence of decompensation that has employers’ health plans, Teladoc is not risen to the level that it piques my care addresses these shortages by load balancing available clinician resources taking stress off brick-and-mortar curiosity? And that is what the teleICU systems, Gorevic says. “One-fourth of software and the collaboration with across the Internet in a wide spectrum of care settings. our users who seek care from Teladoc the teleICU nurses brings to bear. It would have otherwise ended up in the brings those population management In response, the federal government via emergency room,” he says. “Another tools and computer algorithms to help the Centers for Medicare & Medicaid probably 35%–40% would have ended identify those patients that you should Services, commercial payers, and up in an urgent care center. look at, and bring those to the attention state agencies are accelerating steps of physicians who traditionally might to reimburse for virtual care services “As hospital systems begin to take more

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HEALTH I.T. INVESTMENT AND TELEMEDICINE

Among the relatively few healthcare leaders who do place telemedicine in the top three areas of healthcare IT that are of strategic importance in supporting their organization’s financial targets over the next three years, those who rank it No. 1 are prepared to invest heavily.

Major new Minor new No new investment needed investment needed investment needed Don’t know Base

Telemedicine 56% 41% 3% 0% 34 Data analytics 55% 39% 1% 5% 119 Clinical IT 53% 40% 3% 3% 149 Actuarial skills for risk assessment 53% 27% 7% 13% 15 Data integration 51% 34% 3% 12% 59 Electronic health record 45% 38% 9% 8% 119 Financial IT 43% 41% 4% 12% 49 ICD-10 42% 33% 8% 17% 36

SOURCE: HealthLeaders Media Industry Survey 2015: Succeeding in the Risk Era: How to Accelerate Progress Toward a Value-Based Future, January 2015

and more risk, and act like payers, more outpatient centers, inpatient care, care offering through the launch of and more they’re looking to solutions homecare, and employer medicine, AnywhereCare, online services that like telehealth to help manage the says Lawrence R. Wechsler, MD, vice provide a personalized response from overall risk of the population, help president of telemedicine services of a UPMC provider, usually within 30 manage the cost of care, and help UPMC. minutes of submitting symptoms. manage the leakage outside of their If needed, prescriptions can be sent system,” he says. “It’s the redistribution of specialty directly to the member’s pharmacy, and care,” says Wechsler. “Pennsylvania is a e-visits cost $38 or less, depending on A December 2014 actuarial study fairly rural state. You don’t have to go the patient’s insurance provider. by Red Quill Consulting found that far outside of Pittsburgh before things telehealth can save $100 or more are pretty rural. While there’s primary According to Sokolovich, episodes compared to the estimated cost for care in many of these areas, even 50 or of care are an estimated $86.60 less in-person care. The study used de- 100 miles away from Pittsburgh, you expensive when UPMC members utilize identified data provided by Teladoc, can’t get specialty care, so patients have AnywhereCare instead of presenting in Anthem, American Well, Doctor on to drive two, three hours to get to either primary care, the ED, or urgent care. Demand, and Optum. The study also Pittsburgh or Philadelphia.” Telepharmacy opportunities found that 83% of telehealth visits resolved the issue for which care was At present, UPMC provides these Another example of how virtual care being sought, requiring no additional telemedicine services at clinics in can bend healthcare’s cost curve is follow-up care. Franklin, Bedford, and Hermitage. the advent of telepharmacy services. Across the three locations, UPMC has In the small town of Ogdensburg, Redistributing specialty care seen 1,200 patients virtually, according New York, which is situated on the At UPMC, the Pittsburgh-based health to Natasa Sokolovich, executive director U.S. side of the St. Lawrence River, system that operates more than 20 of UPMC’s telemedicine program. Claxton-Hepburn Medical Center, hospitals with more than 5,100 licensed a 100-staffed-bed hospital, uses a In 2013, UPMC extended its virtual beds, virtual care now encompasses service known as PipelineRx. This 7 IN DEPTH HLMINS DER TOC

CARE ACCESS AND TELEHEALTH More than half of healthcare leaders expect to begin or increase investment in telehealth to improve access to care as part of their population health strategy.

Improve access to midlevels such as NPs, PAs 74%

Patient engagement program(s) 66%

Public outreach programs to foster wellness 60%

Employ physicians to improve access 57%

Telehealth 51% Participate in an ACO 42%

Participate in a physician-hospital organization 25%

No access-to-care investments expected 1% Don’t know 1%

SOURCE: HealthLeaders Media Intelligence Report, Population Health: Are You as Ready as You Think You Are?, October 2014 permits remote licensed pharmacists The service, which connects into the “There are peaks and valleys within to verify doses, check drug allergies hospital’s electronic medical record and all their organizations and in the and food interactions, and determine order entry systems via the Internet, prescription flow.” cost appropriateness of delivering also overcomes a problem that arose medication via IV versus oral with the introduction of EMRs. “When PipelineRx can provide its own therapy—20 potential interventions in nurses were doing paper medication pharmacists to staff the telepharmacy, all. It also provides pharmacist approval administration, they could pencil in Roberts says, or can provide its for orders without having to be on the drug that they needed, and we technology via software as a service, site, says director of pharmacy Greg had a system where they could get the so hospitals can optimize their own Guimond. medication out of a night cabinet and internal infrastructures. administer the drug,” Guimond says. Kiosk care “For me, it adds an entire evening and “Whereas since it’s all computerized night shift,” Guimond says. “I have a Virtual care is changing not just the now, if a pharmacist doesn’t verify it, location of healthcare providers but pharmacist available for the facility just the nurse doesn’t even know they have a phone call away without having to also the way in which care is delivered. to give it. So we really need to have the Mark Ciota, MD, CEO for Mayo hire my own staff. It helps stretch my ability to verify those orders 24/7.” employment dollars further. I can hire Clinic Health System sites in Austin a telepharmacy company for probably The advent of telepharmacy is a natural and Albert Lea, Minnesota, deployed half the price per hour that it would follow-on to earlier services such as a HealthSpot virtual-care kiosk in cost me to hire a pharmacist with salary teleradiology, says Brian Roberts, October 2014 at the 40-staffed-bed and benefits.” CEO and founder of PipelineRx, a Austin hospital, initially piloted San Francisco–based medication with employees and dependents. The PipelineRx can afford to provide such management services company that 8-foot-by-5-foot walk-in kiosk features service for half the price because its focuses on clinical telepharmacy to privacy for patients and an array of pharmacists support multiple facilities acute care hospitals. “Pharmacies are instruments that remote clinicians can at the same time, Guimond says. overstaffed by 50%,” Roberts says. use to evaluate kiosk visitors, including

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a stethoscope, thermometer, pulse Like some other virtual-care entrants, of MDLIVE, a Sunrise, Florida–based oximeter, magnascope, otoscope, and HealthSpot works with systems such as virtual-care provider for more than blood pressure cuff; the kiosk also Mayo or Kaiser Permanente San Diego 500 enterprise customers, according to features a UV-based cleaning system for (which has deployed the HealthSpot Parker. between visits. kiosk at a government employment “We have doctors that are operating as center) to put their own clinicians “It’s a whole different process for 1099 [independent contractors] so that behind the camera. a patient to end up in there for a they can schedule whenever they have treatment,” Ciota says. “That is HealthSpot, based in Dublin, Ohio, availability to provide the virtual care,” different than the typical method where also recently announced that Rite Aid Parker says. you have to get an appointment and Corporation will be piloting the kiosks MDLIVE also is signing exclusive you have to try to show up on time for in Ohio pharmacies. geographic partnerships with large that appointment. It’s usually a little bit healthcare providers such as Sutter late. You have to then wait in a waiting “When CVS opens a MinuteClinic Health, Sentara, Trinity in Michigan, room. For a 15-minute visit with the with the original model, they spend and Yale School of Medicine, Parker provider, that can take a half a day. approximately $250,000,” says HealthSpot founder and CEO Steve adds. “With the HealthSpot, you get your Cashman. “It costs $15,000 to install “If you just have virtual low acuity, appointment—online or on the phone— a HealthSpot. When CVS hires two you will be able to take cases that you skip all those other steps and you nurse practitioners to work in there, would have inadvertently maybe gone show up and you key yourself into they spend approximately $300,000 in to the emergency department, but it it and you go into it. You have your payroll to hire two NPs. All they need becomes commoditized and you have visit with your provider. You can get with me is a medical attendant at 12 still a fragmentation,” Parker says. “But your prescription there or have it sent bucks an hour to greet people and clean having a continuity of care between a somewhere else. And then you’re done. the unit afterwards.” virtual network, connected deeply to That’s it. So the visits are much more a physical network, sharing the same efficient from a patient viewpoint.” Cashman notes that HealthSpot- operated kiosks can keep up with the medical record, having the integration Mayo opened a HealthSpot—called the latest developments in point-of-care of the ability to schedule that consumer Mayo Clinic Health Connection—in medical device technology as it becomes is what we’re building on a national early March at Ellis Middle School as available. basis.” part of a new initiative with Austin Beyond the remote locations, kiosks, Public Schools, in the service area for Not to be outdone, Rite Aid rival and retail locations looms the prospect Mayo’s Austin hospital and clinic. A Walgreens recently announced it would of more and more virtual care being second Mayo Clinic Health Connection deploy virtual-care provider MDLIVE in delivered directly to the home, or also was established at a Mayo facility pharmacies, starting in California and anywhere consumers are. next to Austin High School. Michigan. Basic MDLIVE telehealth visits cost $49 (or less, based on health “You can do it in your home, and soon, Ciota says Mayo is even thinking insurance coverage) and include an frankly, I think consumers will be able about deploying a Mayo Clinic Health on-demand encrypted video copy of the to do it no matter where they are, with Connection in the waiting areas of some visit for customers. all these biometric monitoring devices of its own emergency departments. and wearable related technologies,” says “That allows that patient to get timely “Someone is going to become the Uber Mercy’s Britton. n care. It also then unloads the ER system of healthcare, and we’re positioning for patients who really do need the ourselves to be that,” says Randy more acute services,” he says. Parker, founder, president, and CEO

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DIVERSIFICATION AND VIRTUAL CARE SERVICES Scott Mace, HealthLeaders Media

In numerous cases, virtual care virtual care services to other healthcare organizations. “What [telehealth] allows our is a new growth strategy for clinicians to do is reach out and “We’re in dialogue with a number of healthcare systems. different healthcare systems across get the specialists that they need.” the country to provide them different Because third parties such as Teladoc TARA LARKIN, OPERATIONS DIRECTOR FOR kinds of virtual care services, and even TELEHEALTH SERVICES, INTERMOUNTAIN and PipelineRx can provide care to international conversations are going HEALTHCARE, SALT LAKE CITY health plans and systems, health on with a couple of countries that are systems can choose to pursue growth years ago, and annual growth has considering Mercy to provide a national by providing virtual healthcare to averaged 35% per year, says Silverman. other healthcare systems through level of service for their country,” partnerships. Britton says. “So it’s very much a SSM St. Mary’s, a 175-staffed-bed growth strategy for us.” hospital based in Jefferson City, Intermountain Healthcare has deployed Missouri, and part of the SSM Health At UPMC, Lawrence R. Wechsler, MD, virtual care infrastructure in all 260 ICU Catholic healthcare system, became vice president of telemedicine services rooms and 140 emergency departments a customer of Advanced ICU Care in of the physician services division, systemwide, says Tara Larkin, 2006. “One of our challenges was to says, “We are doing international operations director for telehealth convince all of the physicians that telemedicine in several different places.” services for Intermountain Healthcare, practice in our ICU that we were a Salt Lake City–based system that Virtual care suppliers can also offering them additional expertise,” includes 22 hospitals and more than complement and advance the efforts of says Alice Chatley, chief nursing officer 185 clinics. healthcare providers. Take, for example, at SSM St. Mary’s. “We don’t have neurologists or St. Louis–based Advanced ICU Care. When the pushback reached its height, intensivists or infectious disease docs The 10-year-old company operates two some physicians claimed the patients available in all of these locations, and state-of-the-art telemedicine facilities, as their own and reserved the right to so what it allows our clinicians to do is with two operations scheduled to open order any consultations. In response, reach out and get the specialists that this summer, that work directly with “we sold it as, this is our ICU,” Chatley they need,” Larkin says. But like Mercy, bedside clinical teams. says. “We want your patient in our Intermountain is also planning to offer “Clinicians, particularly intensive care itself as a virtual care provider for other ICU to get the best care, and so this clinicians, are in short supply. As part healthcare systems. is a service that we, the hospital, are of our strategy, we have opened in providing for you and your patient. And “It is a revenue diversification several markets to recruit clinicians in we kept saying that, singing that song strategy,” says Lynn Britton, president these areas,” says Advanced ICU Care over and over, and now it’s just a given.” and CEO of St. Louis–based Mercy. chairman and CEO Lou Silverman. “We “Organizations that are early adopters have a very robust set of experiences As for outcomes, mortality declined, are sort of riding that wave of growth in in implementing services for a wide not because ICU clinicians at SSM St. an emerging new sector of healthcare,” range of installations at a wide range Mary’s were treating patients wrong, he says. Both Intermountain and of hospitals in more than 20 states.” but because they weren’t documenting Mercy were first-time exhibitors at Originally started to provide bedside all the necessary information, a the 2014 American Telemedicine staffing of intensivists, the company problem corrected by Advanced ICU’s Association trade show, offering their expanded into teleICU services seven participation, she says. n 10 IN DEPTH HLMINS DER TOC

TELEHEALTH GETS MORE COVERAGE FROM CMS John Commins, HealthLeaders Media

Among the new rules it in conjunction with monitoring of those chronic conditions is a big step “More than 2,000 hospitals are provisions that will forward and a very substantial change have a penalty this year in pay for remote chronic for Medicare.” their Medicare rates because care management. “The Capistrant says the new rules also of readmissions. There is an represent an acknowledgement by CMS increasing demand for this kind combination of the chronic care that reimbursing for chronic care could of service, and it fits together.” management code and being prove to be cost-effective. GARY CAPISTRANT, SENIOR DIRECTOR OF PUBLIC able to use it in conjunction “It’s an important policy move. POLICY, AMERICAN TELEMEDICINE ASSOCIATION with monitoring of those Whether it is sufficient, time will tell, but it is certainly a step in the right chronic conditions is a big step direction and an important initiative,” “First, they’ll have to see what is forward,” says the American he says. “There has been a lot of involved in being a chronic care focus on primary care, even with the manager and to what extent you want Telemedicine Association. Medicare population. That may be the to add that to your practice. It may 80% of the people, but it is only 20% involve some internal staff changes,” New rules from the Centers for of the problem. There’s an increasing Medicare & Medicaid Services he says. “There are services required emphasis on looking at the 80% of the significantly broaden coverage for that a lot of physicians just don’t do problem that is 20% of the people, and chronic care telehealth services. right now, in part because they are not that is chronic and specialty care. They paid for it. This is probably the kind understand that the government is The rulemaking changes are inside the of thing that physicians may not be spending a huge amount for chronic 1,185-page document issued in October too interested in doing for one or two care conditions and that there is a value 2014, detailing Medicare payments to patients, but if they can get 100 or 200 managing those to reduce the overall physicians and other providers. patients, then they’ve got the economies expenditures.” The American Telemedicine of scale going to make it work right.” Association, which had sought the As a practical matter, Capistrant says, Hospitals might also take a greater expanded coverage for five years, notes the new evaluation management code interest in chronic care management if that among the rules are provisions for chronic care management will be only to avoid readmissions penalties. that will pay for remote chronic care much more commonly used because “More than 2,000 hospitals have a management using the new current “it’s a better fit between management penalty this year in their Medicare rates procedural terminology (CPT) code and monitoring.” 99490, with a monthly unadjusted, because of readmissions,” Capistrant As for the reimbursements, Capistrant non-facility fee of $42.60. says. “There is an increasing demand for says “only time will tell whether those this kind of service, and it fits together.” “For us, it was more important to amounts are sufficient to get physicians begin to specifically address chronic to focus on chronic care management The new rules also include seven new care,” says Gary Capistrant, senior and monitoring. I think it will be covered procedure codes for telehealth, director of public policy at the ATA. attractive to physician community, including annual wellness visits, “The combination of the chronic care geriatricians, and others who deal with psychotherapy services, and prolonged management code and being able to use these chronic conditions. services at physicians’ offices. n 11 IN DEPTH HLMINS DER TOC

TELEMEDICINE PROVIDERS WELCOME AMA GUIDELINES Jacqueline Fellows, HealthLeaders Media

In its recommendations, the step in the right direction. We need better evidence, and clinical practice “The fact that the AMA has AMA cements what providers guidelines for telemedicine.” recognized telemedicine is have been hearing for years: The ATA also commends the AMA’s great. It’s an excellent step Telemedicine needs more policy recommendations. ATA CEO in the right direction. We Jonathan Linkous says the AMA and need better evidence and regulation and reimbursement. ATA have had “positive dialogue” over the years, but calls this step major clinical practice guidelines for In what is seen as its biggest step progress. telemedicine.” forward in acknowledging the value BEN GREEN, MD, MEDICAL DIRECTOR, of telemedicine, the American Medical “We have a good working relationship CARENA, SEATTLE Association issued, in early June 2014, with them for the first time in 20 years,” a list of eight policy recommendations he says. for providers who provide telemedicine hoping for improvements.” The one sticking point the ATA has services to follow. with the AMA’s recommendations There are two proposals circulating that The AMA’s suggestions include is requiring physicians to have a would ease the state-by-state licensing establishing a “valid patient-physician license to practice in each state where requirement. The one that Linkous their patients live. The suggested relationship” before telemedicine holds out hope for is reciprocity, requirement is a barrier, says Linkous, services are provided; requiring where one state recognizes the license because people become attached to physicians to be licensed in the state of provider in another state. That’s their doctors. where the patient who is receiving the easiest approach, but likely to telemedicine services resides; and “Take snowbirds, for example,” says encounter stiff resistance from state transparency in services and cost, as well Linkous, referring to the seasonal medical boards. as encouraging more reimbursement, travelers who leave behind the snow for Another proposal is from the research, and support for telemedicine sand in winter. “We’re saying patients Federation of State Medical Boards, pilot projects. should have the ability to choose their physicians.” which creates a simplified pathway to The overall message received by the get an out-of-state license to practice. telemedicine provider community was a Green, an ATA member, calls the Under the FSMB proposal, willing reflection of what other organizations, requirement limiting, but not a states would step forward and enter including the American Telemedicine barrier. Green is one of more than into a compact. Association, have been saying for years a dozen providers at Carena who about telemedicine: It needs regulation deliver telemedicine care in six states: Providers would have to fill out one and reimbursement. Washington, California, Illinois, set of forms for an out-of-state license. Missouri, Kentucky, and Nebraska. They’d still have to pay the individual “The policy, as a whole, is a good one,” state medical board fees, but the says Ben Green, MD, a medical director “The policy is a good one,” Green says paperwork would be reduced. at Carena, a primary and urgent care regarding the AMA’s stance on state telemedicine provider based in Seattle. licensure. “We’ve been able to get our Karen Rheuban, MD, director for the “The fact that the AMA has recognized providers licensed in those states, but it University of Virginia Health System’s telemedicine is great. It’s an excellent takes time. It’s not a new issue. We’re all Center for Telehealth, and past ATA 12 IN DEPTH HLMINS DER TOC

president, says the AMA’s strict policy Medicine to determine the success Wellpoint, Aetna, and Medicare and stance is understandable and sound of this new process. There are Medicaid. because it protects patients. She says: many patients who can benefit from consulting with providers The adoption of telemedicine as a The AMA and the Federation of in another state, and as compared viable access point to providing care has State Medical Boards have taken to true licensure portability, this moved more quickly than legislators this position so to ensure the new process still risks being time and state medical boards, but the ability of the boards to respond consuming and costly to providers, AMA’s policy recommendations are a to complaints and enforce actions albeit very much an improvement. shot in the arm to telemedicine, despite against providers. The Federation the state licensing requirement, says is in the process of developing an Telemedicine policies on regulation Linkous. expedited licensure process that and reimbursement vary from state still will require any physician who to state. In some states, obtaining a “Even though there are some issues provides services in another state to license is relatively easy compared to where we disagree, we both agree on obtain a license in that state, albeit others. For that reason, Green says appropriate regulation, reimbursement, more quickly. Once implemented, Carena works with states “friendly” to and some of the other rules,” he we look forward to working with telemedicine. Some insurers do pay for says. “In all honesty, we have a better the Federation and our Board of some telemedicine services, including relationship with AMA now.” n

WEIGHING TELEHEALTH’S PROS AND CONS Lena J. Weiner, HealthLeaders Media

Remote teams can cut hospital a small town of just over 1,800 people on the southwestern Kansas frontier. Telemedicine “is much more costs and help fill staffing “The nearest Walmart is 55 miles away,” efficient. If they’re prescribing an gaps, but HIT and regulatory says Bryan Coffey, the hospital’s CEO. While it’s typically difficult to recruit antibiotic, [physicians] can finish requirements can be daunting, staff to work in such remote care the video consult in 15 minutes, especially for small, remote settings, Coffey has found a technology- then move on to the next.” based strategy for both keeping the BRUCE CAROTHERS, VICE PPRESIDENT OF hospitals. hospital fully staffed and cutting costs. TELEHEALTH SOLUTIONS, AMN HEALTHCARE

A human-size robot roams the halls of “We’re the perfect model for telehealth Hamilton County Hospital. Through and remote teams,” says Coffey. cameras and a tablet mounted at eye his patients would be better served level, doctors working as far away as “I have a passion for two things: rural by access to more specialists than Hamilton County could realistically California, New York, or Massachusetts healthcare and telemedicine,” he attract or support, Coffey found that view and treat patients in this rural continues. Delivery of care in Coffey’s telemedicine is the right answer to his Kansas hospital remotely. part of Kansas is not always easy. “This is a region where people have hospital’s staffing challenges. Hamilton County Hospital is a 25-bed to drive eight hours one way to see a The robot, identical to robots used critical access care hospital in Syracuse, pediatric specialist.” Recognizing that for healthcare by the Department of

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Defense, costs $2,300 a month to rent. child or eldercare responsibilities, in a very remote area like Hamilton “But, if we keep even one patient [at this or lack of access to transportation a County. “This is improving every year,” hospital], it pays for several months of chance to work. says Carothers. “Currently, 20 states the robot,” Coffey says. mandate that commercial payers pay for Radiologists available at any hour telehealth services. But this has … been a Not only can rural hospitals take “There’s a whole sector of teleradiology downside.” advantage of talent from outside the called ‘nighthawking,’ ” explains immediate area, hospitals in areas Carothers. “They find U.S.-licensed Coffey concedes there are certain jobs where labor is expensive can take physicians who live oversees who around the hospital that still require advantage of less expensive labor pools can look at images on weekends and in-house staffing. “Housekeeping and in other areas, says Bruce Carothers, at night.” It’s one way to ensure all maintenance … Phlebotomists, bedside vice president of telehealth solutions radiology results are in by Monday RNs that need to touch the patient or at AMN Healthcare, a healthcare morning. change bedding, and wound care all recruiting firm. “You can definitely cut have to be done on-site,” he says. Some organizations, especially in costs by employing specialists part time remote areas, also employ a team of And that brings to mind an additional and remotely,” he says. remote telepharmacists who can review obstacle: bridging the gap between both Besides dealing with regional labor prescriptions after hours. Because doctor and patient. While the goal is issues, there are many other benefits to the pharmacists are employed by an seamless delivery of care, sometimes implementing a telehealth program. outside service and shared by multiple the distance becomes noticeable. “It’s hospitals, they are a less expensive critical to establish a relationship prior Convenience option, and provide just the right to telemedicine,” says Carothers. Cost-saving is just one benefit of amount of coverage for weekends and telehealth. He cautions that it’s important to evenings. properly collaborate with and manage “It’s much more efficient,” says But there are some challenges to be a remote team as well. “There’s always Carothers. Telemedicine allows doctors mindful of when considering remote a little bit of a gap when doing things to quickly log out of an appointment staffing. remotely relative to a face-to-face with one patient and into another conversation. It isn’t always easy.” appointment in seconds. “If they’re Remote possibilities He suggests putting in extra effort to prescribing an antibiotic, they can finish As attractive as telehealth can be, the fill the void with phone calls, instant the video consult in 15 minutes, then barriers to adoption are many. For messages, and video call services such as move on to the next,” adds Carothers. starters, a hospital must have robust Skype and FaceTime. “Many physicians toward the end of and reliable high-speed broadband their careers choose this as a way to connectivity to support clinical Coffey insists, however, that Hamilton start winding down.” functions. County’s patients hardly notice the distance once they spend a few minutes Aside from clinicians, other roles Another vital requirement: Physicians with a remote doctor evaluating them that lend themselves to remote teams must be properly licensed to practice via the robot. “You would be shocked include customer service, radiology, in remote locations. Since licensure is how many people extend a hand and triage, billing, coding, and “anything regulated by the states, this can be very say ‘thank you, doc,’ only to remember that doesn’t involve having to touch or complicated. there’s no hand to shake on the robot.” n manipulate the patient,” says Carothers. As for reimbursement, traditionally, The flexibility afforded by telehealth Medicare and insurance companies technologies allows workers who have only covered telemedicine cannot commute due to health issues, appointments when the patient was

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SPORTS MEDICINE TURNS TO TELEMEDICINE Scott Mace, HealthLeaders Media

Advances in telehealth Earlier sensors, attached to these, could provide inaccurate readings. “I’ve always been interested technology are revolutionizing When CheckLight measures a in applying technologies that how healthcare providers dangerous acceleration, the technology make sense to medicine and respond to the hard knocks and switches on a yellow or red light, trying to improve my practice, depending on the severity of the trying to improve access head injuries athletes sustain acceleration. Coaches and trainers on for patients, improve the the sidelines of the playing field can experience patients have and on the football field, soccer clearly see the light displayed below the pitch, and ice rink. bottom edge of the helmet. the value of the interactions.”

It may be baseball season, but I’ve got Coaches and trainers then can bring VERNON WILLIAMS, MD, MEDICAL DIRECTOR, KERLAN- JOBE CENTER FOR SPORTS NEUROLOGY, football on my mind. the player to the sidelines and run a LOS ANGELES symptom checklist, which more and Not the game itself, but the injuries more coaches and trainers have been Sensors are fine, but seeking qualified that can result from it, and specifically, trained to administer. how new technology can help detect medical assessment quickly is the other concussions, those hard knocks that According to officials at MC10, the technological tool being deployed to can do so much damage and yet be so sensors measure both linear and treat concussions. I spoke with Vernon difficult to detect. rotational acceleration to the head, Williams, MD, medical director of which together calculate the total the Kerlan-Jobe Center for Sports Sensor technology and telehealth energy being delivered to the head. Neurology in Los Angeles. Williams also technology are revolutionizing how works with a group called the Sports the healthcare system responds to the Players with stronger necks will Concussion Institute. In other words, football field’s hard knocks, and the experience less acceleration than he’s a concussion expert. same technology could apply to other players with weaker necks, says Isaiah sports such as hockey, soccer, and Kacyvenski, director of MC10’s sports “I’ve always been interested in applying anywhere else where sharp blows to the segment. technologies that make sense to medicine and trying to improve my noggin are part of the game. With medical device maker Medtronic practice, trying to improve access as one of its investors, MC10 is also At the International CES show in Las for patients, improve the experience pushing forward with even more Vegas, I got to see technology up close patients have and the value of the invisible wearable sensors. At CES it from a firm called MC10 that forms interactions,” Williams says. the basis for Reebok’s CheckLight, showed Biostamp, a seamless sensing which collected a CES Innovations 2014 sticker due out this year that can A common scenario goes like this: An Design and Engineering Award. stretch, flex, and move with the body. athlete will sustain a blow to the head The company says Biostamp will be able during a Tuesday practice or a Friday The soft garment fits over the head, but to measure a variety of physiological game, but the parent who needs to underneath a player’s helmet. Sensors functions: data from the brain, muscles, take him to the doctor cannot take off within the garment measure direct heart, body temperature, even hydration work for several days, or geography accelerations experienced by the head, levels. (No pulse oxymetry—at least not is a barrier, often for the initial rather than to the helmet or chin strap. yet.) appointment, but especially for follow-

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up appointments. Teams working with doctors also now place alongside tablets, because cameras have a far more consistent approach on these towers can pan, zoom and tilt. So, either the player’s symptoms go to their players being returned to But tablets are still usable as well. unchecked and don’t get care in a play, with consistent evaluation and timely fashion, or due to lack of care or management, Williams says. It also “With the iPad, then they have to either follow-up, patients are told by trainers helps neurologists schedule these position the iPad or someone else has to to sit out for weeks or even skip the rest follow-ups more efficiently as well. be holding it and reposition it so that of the season. they can be seen, but it’s still achievable, Of course, once a platform like this and we still do it, and it works very “That’s when I came up with this is in place, it has benefits that go far well,” Williams says. concept of using telemedicine and beyond concussion treatment. “We can videoconferencing, and as it turns out, clearly see benefits where an athlete may After two full football seasons of it was great,” Williams says. have a good trainer on the other end use with high schools and colleges, where they’re actually competing and Williams’ clinic has conducted By sitting the athlete in front of a video hundreds of telemedicine assessments session, the neurologist on the other participating and practicing,” Williams says. of athletes. With 49 out of 50 end can ask the athlete to answer some states requiring clearance from a questions or perform some simple “That trainer may have a question licensed healthcare professional exercises that help the neurologist about range of motion or an ankle prior to returning to play, the access confirm the concussion diagnosis and injury or what have you, and they can telemedicine affords is making a big its severity. fire up that videoconference and speak difference in treatment. directly with an expert, and say, ‘Hey And because injuries from concussions Add the sensor data to the mix, and you sometimes evolve rapidly, the ability here’s what’s going on, here’s what his exam looks like, what do you think? have the kind of analytics that can lift to schedule follow-up assessments a whole population of at-risk athletes via video chat is a whole lot more Should he come in? Does he need an x-ray? Does he need an MRI? Should we and provide a much larger evidence base convenient than scheduling a to look at concussion and other sports succession of doctor’s office visits. advance his therapy or his activity level another step?’ So it is, I think, a great injury trends over time. Now, more and more trainers are tool for improving communication Finally, it also provides yet more placing telemedicine “towers” (kiosks and improving consistent and efficient scenarios where a patient’s initial optimized for a video session) in evaluation and management.” encounter with medical help takes their training rooms, so that injured A big enabler of all this has been the place via technology. Some said it athletes, with a trainer and even parents wasn’t possible or advisable. But sports by their side, can be evaluated by the plummeting cost of those telemedicine towers, which in the past three years medicine is yet another example of this neurologist. n have gone from a cost of $15,000 to new reality. “The communication is far more something equivalent to a tablet with consistent,” Williams says. “We don’t its ever-sharper display, built-in camera, have to rely on just sending pieces of and HIPAA-compliant software to paper saying yes he’s cleared or no he’s ensure privacy, Williams says. not cleared.” Telemedicine towers still have their

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TELEMEDICINE’S EXPANDING OPTIONS Scott Mace, HealthLeaders Media

Spurred by new laws and consultation between its members and a physician with an average wait time of “We believe this is the next policies that permit online less than two minutes, Marek says. The generation of retail care service never costs more than $45, and that we saw at Target and teleconsultations, both payers patients are reimbursed by the health MinuteClinic years ago, where and providers are exploring plan like a claim. Some employers are even considering moving to a $0 copay we’re truly trying to serve ways to enable patients’ access to encourage employees to use online the consumer beyond normal to care in ways that also meet care. doctor hours.” growing industry demands. Although BCBS of Minnesota has MATT MAREK, VICE PRESIDENT OF PRODUCT offered this service since 2010, use of AND MARKETING, BLUECROSS AND Encouraged by interest from insurance the service is now growing 200% per BLUESHIELD OF MINNESOTA , ST. PAUL companies and employers, physicians year, and BCBS expects that growth to are ramping up their ability to make accelerate this year. BCBS of Minnesota Online consultation cannot and an increasing number of patient is also expanding the coverage it does not replace many in-office visits, encounters online or over the phone. offers to employers in its service area. Marek notes. American Well physicians After initially serving only employees perform necessary triage to advise those “We need to meet consumers where in Minnesota, BCBS of Minnesota’s who should seek in-person medical they are, knowing that often consumers Online Care Anywhere service now help. aren’t able to get to the doctor during permits employees of those companies the workday or on the weekends, and to utilize the service in 46 states and “The intent has never been to take they end up going to the emergency the District of Columbia, Marek says. services away from the doctors or room or the urgent care room for This makes Online Care Anywhere compete with them,” Marek says. “This inappropriate use of care, and so we the fastest-growing service in BCBS of is not a disruptive strategy. Rather, this have a service that truly gets to the Minnesota’s set of service offerings. is a strategy to better serve consumers, consumer 24 hours, seven days a week, and also it has the potential to allow 365 days of the year, and it’s a real Sparking the move are liberalized doctors to be more effective and doctor every single time,” says Matt laws and policies throughout the efficient with their services, especially if Marek, vice president of product and United States that now permit online you can imagine the emergency room marketing at 2.6-million-member teleconsultations. “There are many doc who may have some downtime BlueCross BlueShield of Minnesota , states today that now allow online care could also log on and serve members based in St. Paul. or telemedicine to exist, where three, and patients, and so that is being four years ago we never thought we explored as well.” “We believe this is the next generation would get as far as we have,” Marek says. of retail care that we saw at Target and At Mount Sinai Health System in MinuteClinic years ago, where we’re These days, those encounters include New York City, a relatively new but truly trying to serve the consumer video over wireless carriers’ networks. fast-growing service called Teladoc beyond normal doctor hours,” Marek “We’re able to have a high-definition became part of the organization’s rapid says. videoconference consult with the doctor response to Hurricane Sandy in 2012. without having the very highest-speed Using technology from American Well, network available without having to be “We launched it right after Sandy had BCBS offers high-definition video connected into a landline,” Marek says. hit, and it was a direct-to-consumer

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service,” says Adam Henick, senior vice option to pay $48 a visit without an president of network development for annual registration fee, which Henick “Every person that goes on Mount Sinai Health System and Mount says is significantly less than the cost Teladoc, one of the initial Sinai Beth Israel, a 1,083-bed hospital of a doctor office visit in New York. questions is, ‘Where would with $1.1 billion in annual revenues, “We’re not getting a particularly robust which became part of Mount Sinai response to it,” he says, so now Beth you have gone for service had Health System last year. Israel is modeling the service with you not chosen this option?’ its own employees, who pay $15 per so we’re collecting that data Under the program, New Yorkers who Teladoc consultation. were willing to attest to their residency and seeing what the cost could access a physician via telephone “Every person that goes on Teladoc, one would have been had they not or video chat for $38. of the initial questions is, ‘Where would accessed this service, and then you have gone for service had you not “Teladoc’s model historically has been balanced it against our cost of chosen this option?’ so we’re collecting picking up the cost of the visit to either contract with an insurer to that data and seeing what the cost provide the service to their beneficiaries, would have been had they not accessed above $15.” or to contract with an employer to this service, and then balanced it provide the service to their employees,” against our cost of picking up the cost ADAM HENICK, SENIOR VICE PRESIDENT he says. “They had not done a direct-to- OF NETWORK DEVELOPMENT, MOUNT of the visit above $15,” Henick says. SINAI HEALTH SYSTEM AND MOUNT consumer offering, and we wanted to SINAI BETH ISRAEL, NEW YORK CITY try that, and so we launched it.” This time, Beth Israel’s internal usage reflects a return of 7 to 8 times the Despite “great media coverage,” investment required, and as soon as in the morning, because they’re working however, customer turnout for the it has collected a sufficient sample, on some computer algorithm and service was disappointing. “After about Henick believes it can return to its don’t want to leave their office or their three months, we started doing focus payers with this data and its direct-to- apartment, and they’re going to want groups to figure out what we were doing consumer product will be able to get to access it that way, and we need to be wrong, and it turned out that the model insurance company participation and able to deliver it that way,” Henick says. was you paid an annual registration enable the service to take off. fee of $30, and that enabled you to get Some physicians also view services such visits at $38 a visit,” Henick says. Henick sees it all as an extension of as Teladoc as their new career path. Beth Israel’s earlier forays into urgent Timothy Howard, MD, was a family Those prospective customers who care centers. And the way Beth Israel practitioner in Huntsville, Alabama, had no healthcare insurance were very Medical Group has arranged its Teladoc for 20 years. In 2009, to earn additional unlikely to prepay anything, and those partnership, all calls go first to its own income, he began working for Teladoc who were insured wondered why Beth tier of doctors who have joined the as one of its physicians reachable by Israel was not participating in their own Teladoc network. If call volume rises telemedicine technology, primarily via insurance. “So what intuitively seemed such that response times lengthen, telephone. like a logical idea to us met resistance other patients would be routed to non– because of barriers, even though they Beth Israel doctors, who are licensed in This January, after providing several were low-level barriers,” he says, adding New York and credentialed by Teladoc, months’ notice, the 52-year-old left that even for those with insurance, Henick says. private practice to work for Teladoc between copays and deductibles, full time. “I want to practice actual traditional visits still would have cost “The Teladoc offering is just basically medicine and take care of people and more than accessing the service. “But I continuing down that path of saying, not a bunch of administrative things,” think it’s more a psychological barrier.” there are going to be some young, hip he says. “You’re talking directly to the consumers that are going to want to be patient. You don’t have a third party or Last September, Beth Israel added an able to video chat with their doctor at 2 someone else telling you ‘Restrictions 18 IN DEPTH HLMINS DER TOC

here, restrictions there, do this, this is health systems to outsource their preapproved,’ this kind of thing. It’s primary care capability. “Don’t ever outsource your core really pretty straightforward.” “Don’t ever outsource your core business. Our core business At the top of the list of conditions business,” says Shez Partovi, MD, vice is delivering care. I’m not Howard treats via telemedicine: sinus president of informatics and CMIO in sure if health systems should problems, urinary tract infections, Dignity Health’s Arizona service area. outsource their core business.” allergies, flu, cough, and ear infections. “Our core business is delivering care. Video is “exclusively requested by the I’m not sure if health systems should SHEZ PARTOVI, MD, VICE PRESIDENT OF INFORMATICS AND CMIO, DIGNITY patient, when they desire to either let outsource their core business.” HEALTH, PHOENIX you see them or their child,” he says. Still, Partovi is just as optimistic about Due to Teladoc’s low overhead, “it’s the growth of direct-to-consumer very possible to earn a living with it,” telehealth services. Like many other the interaction, Partovi says. “We have a Howard says. Out of an average of health systems, Dignity already does lot of focus on understanding the user 180–240 patients per week, four or five a thousands of internal physician-to- experience,” he says. week have problems severe enough that physician telehealth consults annually. he refers them to seek in-person help. As accountable care and patient- Still, Dignity plans to have as many centered medical home efforts expand, as 250 physicians trained in the next “The key is that we’re episodic,” Howard the demand for direct-to-consumer phase of the rollout, and Partovi is also says. “We are not seen as the primary telehealth at Dignity is the next big chairman of the telehealth committee care physician. The urgent may take the telehealth wave, he says. for all of Dignity. Partovi says there are place of the important. But that’s one markets where Dignity will compete of the nuances, and I tell patients all the So far, Dignity Arizona has started with the Teladocs and American time, ‘I said, the best way to be cared for with a small pilot, training three Wells of the world for the business of as a patient by a physician is a hands-on physicians to respond to its own direct- employers seeking direct-to-consumer exam.’ ” to-consumer telehealth service last fall telehealth options. and launching the service in the fourth Services such as Teladoc also set quarter of 2013. So far, only about Ultimately, such competition may also and monitor their own quality 20 consults are happening monthly, hinge on health systems providing a standards, such as whether doctors are Partovi says. broader set of offerings to employers overprescribing antibiotics, Howard than just telehealth, Partovi says. says. Part of Dignity’s approach is to deeply understand how video encounters “Last year we actually responded to One chief medical information officer change the doctor/patient experience, two RFPs where it was broader,” he whose health system is moving into this including on-site testing where doctor says. “It was about providing a medical type of telemedicine is leery of allowing and patient are both on site, but in community for the employer, and we services such as Teladoc to permit separate rooms, and Dignity studies feel that’s a key part of our strategy.” n

19 CASE STUDY HLMINS DER TOC

REDUCING LENGTH OF STAY AND MORTALITY WITH TELEICU Jim Molpus

Deborah Dahl, vice president of patient care innovation at Dahl and Robert Groves, MD, vice president of health Banner Health, headquartered in Phoenix, says “we learned management for Banner Health, emphasize the teleICU team is early on that the telehealth tool, starting in the ICU, allowed us not replacing bedside nurses or physicians. The teleICU service a platform to meet [the] Triple Aim.” provides four critical backup needs, Groves says:

Telemedicine has been a tool in the ICU for many years, 1. Immediate response by a specialist to a request for help often for a consultation when a difficult case presents. But from the patient or bedside team. “That immediate that was too episodic to make a major difference in key availability of an intensivist virtually in the room is a measures, including length of stay. Even if Banner wanted to big piece of it,” Groves says. “They can start working on rapidly increase the number of bedside intensivists for 24- the problem immediately while we wait for the bedside hour coverage, there simply were not enough, Dahl says. “I team to arrive or in lieu of the bedside team in certain believe there were about 8,000 intensivists across the country. circumstances.” In order to pull that off across the U.S., we needed 33,000. 2. Monitor for adverse trends before they become adverse Telemedicine was a way to take intensivists’ amazing cognitive outcomes. skills and spread them from Fairbanks to Phoenix and to focus 3. A safety net to ensure compliance with best practices and their work on what that patient needs that is not hands on,” to prevent unnecessary testing. “So when I say that 30% Dahl says.” is waste, well, it’s because we run tests we don’t need to in Launched in 2006, Banner’s teleICU operations center is in some cases and because we don’t run tests we do need to Mesa, Arizona, and added other physician sites in Tel Aviv, in other cases. So the third role of a telemedicine strategy Israel; Santa Monica, California; and Denver, this last site in a is to make sure that we’re aligned with evidence-based new partnership with National Jewish. The teleICU physicians practice.” and nurses monitor ICU patients in 430 ICU beds in 22 Banner 4. Continuously measure “so that we can continue to hospitals across five states. improve it.”

Each of Banner’s ICU rooms is equipped with eICU technology It took some time, but the workflow of the teleICU and bedside from Philips, which includes a two-way audio-video system teams have become complementary, says Dahl. The nature and a bedside monitor that sends real-time vital signs to of intensive care is a balance between constant monitoring the teleICU team. The system interfaces with the electronic and urgent intervention. With the teleICU team support, the medical record so the teleICU and bedside teams can view lab bedside team can deal with the immediate issues and still have results or medication orders. time to develop a comprehensive plan of care, she says. n

SOURCE: HealthLeaders Media LIVE From Banner Health: Transformational Telemedicine, December 2014

20 FEATURED WEBCAST HLMINS DER TOC

THE TELEMEDICINE PLAYBOOK: WEBCAST Mercy & Nemours Models Presented by: Wendy Deibert, RN, BSN, and Stephen Lawless, MD, MBA

Arising out of the eICU movement, At the conclusion of this program, participants will: healthcare systems are now tackling • Understand the untapped value of remote patient monitoring as a way problems with telemedicine solutions. to improve care The thinking is to provide a virtual care • Learn key performance indicators of using remote monitoring effectively system whereby sophisticated analytics (i.e., reduced alarms, improved staff morale, reduced medication errors, integrated with remote monitoring improved response time, increased interventions) systems and video allow remote personnel • Determine care areas uniquely positioned for telemedicine in the to track patient stability. This technology continuation of care comes with challenges, but the economics • Discover strategies for changing behavior of frontline healthcare of care, combined with the Internet’s personnel toward alarm response technology power and sophistication, are driving it forward anyway. AGENDA Leaders from Mercy Health System • New tools in use to reduce unnecessary alarms in hospitals and Nemours reveal how they are using internal telemedicine and remote • Effective ways to use technology to extend the efficiency of unit-based monitoring to reduce medical errors, personnel improve response times, and alleviate • The variety of ways in which telemedicine is in use throughout the alarm fatigue in frontline healthcare healthcare system (i.e., not just video appointments) personnel. • Challenges of remote monitoring

MEET THE SPEAKERS

Wendy Deibert, RN, BSN Stephen Lawless, MD, MBA Vice President, Mercy Virtual VP of Quality and Safety, Nemours In her 29 years of nursing, Wendy Deibert has served as a bedside clinician, manager, Stephen T. Lawless earned his BS in biology from Fordham University and his senior consultant, and operations director. Currently, she oversees and supervises medical degree from UMDNJ Robert Wood Johnson Medical School. He completed a the daily operations, nursing staff, and support personnel for Mercy SafeWatch and pediatric residency at St. Christopher’s Hospital for Children and a pediatric critical Mercy Telehealth Services. Since 2006, she has converted 450+ critical care and care fellowship at Children’s Hospital of Pittsburgh. Dr. Lawless subsequently earned step-down beds to electronic ICU technology at 15 hospitals across five states. Mercy an MBA from the Wharton School of Business at the University of Pennsylvania. has launched 70+ telehealth projects across the healthcare continuum and beyond Since 2006, he has served in the role of the vice president of quality and safety for the Mercy Health System. Nemours. In this role, Dr. Lawless is charged with the oversight and coordination Deibert is the recipient of the 2011 Cindy Gregory Excellence in Leadership Award of quality and safety within all of Nemours. In addition, he seeks to use Nemours’ presented by Philips Healthcare and is a member of AACN, American Association combined technologies and knowledge to make systems simpler and error-free, of Critical-Care Nurses TeleICU Task Force, American Telemedicine Association, whether those systems are used for business or healing. Telehealth Alliance in Oklahoma, Tele Acute, and Critical Care.

This webcast is included with your purchase of HealthLeaders Media Insider: Telemedicine: Advancing from Pilot to Practice. You will receive a link to download the webcast upon purchase. If you have any trouble accessing, please contact customer service at 800-753-0131.

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