Connecting healthcare providers to patients at home for remote monitoring and direct care via televisits yields substantial
reductions in emergency department and inpatient utilization and costs. Optimal results are achieved when telehealth care
teams implement redesigned care processes and coordinate with primary care physicians to watch over, improve and maintain
the health of patients, especially those with complex chronic conditions.
Current research continues to validate the effectiveness of telehealth even in programs without extensive process re-engineering.
For instance, a study of 17,025 Veterans Health Administration (VHA) patients in the VHA national telehealth program reported
a 19% reduction in hospital admissions and a 25% reduction in total inpatient days of care.
How can managed care attain the benefits of telehealth?
First, recognize that telehealth technologies range from the simple telephone with or without interactive voice response to
increasing levels of remote patient monitoring to full patient-provider connectivity with video. Leading telehealth technology
systems have a set of essential attributes:
- Compact, easy-to-use patient stations proactively prompt patients at home to respond to health status questions by touch screen
and to use integrated medical devices to take their vitals;
- Integrated medical peripherals (such as weight scales, blood pressure and blood glucose monitors, digital stethoscopes, and
pulse oximeters) enable clinical assessments;
- Narrated instructions with answer verification complement multi-media instructions and guide patients through their telehealth
tasks;
- Patient education and self-care instruction are integrated within the flow of patients' tasks;
- Health status questions, physiological parameters for monitoring, instructions and patient education are all customizable
so they can be personalized for individual patients;
- Video modules deliver high-quality images to support televisits, providing the ability to further assess patients and intervene
with timely care;
- Via HL7 messaging using Secure Socket Layer technology (over plain old telephone lines or broadband connections), patient
responses and data are transmitted to a central server where they are date- and time-stamped for trending;
- Presentation of patient responses to clinically relevant questions for each physiological measurement gives providers a context
for interpreting changes in the data from medical peripherals;
- A dashboard display on provider stations color-codes summaries of each patient's current health risk status. Clinicians can
set specific thresholds for each patient to red flag significant changes in a patient's condition; and
- Based on patient symptom and health status thresholds, automated prompts suggest specified self-care action steps and clinical
follow-up.
Thus, advanced telehealth technologies are clinical applications not just telecommunications systems. And as the burden and
complexity of disease increase, so too does the value in the level of connectivity and degree of telehealth-supported interaction
between patients and providers.
Second, the right technology is important and necessary but not sufficient. It has to be used to implement new systems of
connected care that establish and maintain ongoing monitoring of patients at home, timely detection of potential acute events,
and prompt intervention by care teams with the requisite knowledge and skill to attain positive clinical, health status and
financial outcomes.
Care teams must be created to use telehealth to supplement primary care with redesigned models of care management. Regional
tertiary health systems and integrated delivery systems can identify physicians who have demonstrated proficiency in caring
for patients with the most complex, difficult conditions. Care teams can include a physician plus four to six providers (nurses,
nurse practitioners, physician assistants) who have relevant clinical experience, such as working in ICUs, CCUs or in homecare
with technology-dependent patients.
Third, it is essential to target telehealth to the segments of health plan populations that have the highest need for telehealth-supported
connected care — patients contending with multifaceted medical problems that make their conditions exceedingly complicated
and difficult to manage and whose health status can fluctuate and deteriorate rapidly. Telehealth should be used to initiate
and sustain ongoing care with highest-complexity, highest-cost members for whom it can help attain the most immediate and
biggest gains in clinical, health status and financial outcomes.
Fourth, how telehealth is reimbursed will go a long way toward determining if managed care gains its benefits. The history
of managed care is replete with examples of new technologies that offered the promise of cost reduction — promise infrequently
fulfilled. Extending fee-for-service reimbursement for new technologies as a general benefit has proven time and again to
increase demand, utilization and costs. Instead of paying fee-for-service for telehealth services, managed care must pay for
performance. We should not pay for telehealth processes but reward health systems for the results care teams attain with telehealth
for patients with the most complex conditions.
In conclusion, a winning strategy to achieve the value of telehealth includes:
- Re-engineering care practices for implementation by dedicated care teams with exceptional expertise in complex care management;
- Patient and provider segmentation strategies that match complex medical needs with appropriate medical expertise;
- Advanced telehealth systems transcending the barriers of time and distance to keep care teams and high-risk patients connected
for continual monitoring, proactive problem identification and early intervention; and
- Reimbursement that aligns stakeholders' incentives toward improved clinical and health status outcomes at lower costs.
Randy Moore, M.D., M.B.A. is chairman and chief executive officer of American TeleCare, Inc.
