REMOTE MONITORING AND HOME-BASED
TELEHEALTH – Realities and Challenges
Deborah A. Randall, JD & Consultant
www.deborahrandallconsulting.com
Kathy Duckett, RN,BSN, Director
Clinical Services Partners Homecare
Moving Towards Electronically
Enabled Care Delivery@Home






HIT = Health Information Technology
HIE = Health Information Exchange
EHR = Electronic Health Record
EMR = Electronic Medical Record
PHR = Personal Health Record
ONC = Office of the National
Coordinator for HIT [DHHS]
Survey 2010: eHealth Initiative
61% of respondents agree or strongly
agree that significant progress has
been made in the successful adoption
and use of HIT since 2007.
BUT 54.9% disagree or strongly disagree
the value of HIE is clearly understood &
66.6% disagree or strongly disagree
outreach on value of EHR/HIE is effective



55.5% of respondents disagree or
strongly disagree that differences
between federal and state privacy laws
are not a barrier to consumer’s rights
to healthcare privacy.
56% agree or strongly agree that HIT
and HIE have had a positive effects on
care delivery.
Evolving Definitions







Telemedicine vs. telehealth
Doctor to doctor d2d
Doctor to patient d2p
Distance learning
Remote monitoring
eCare eHealth
“Smart” homes
Developments & Trends




New Medicare Reimbursement
Possibilities: SNFs; kidney, nutritional,
diabetes self-management; mental
health services
Devices as diagnosis-enhancers
Infrastructure for Telemedicine and
Telehealth
Legislation
LEGISLATION 2009-2010
HITECH ACT 2009- Stimulus Bill
HIT Policy Committee of ONC
Infrastructure got first funding
Aging Services Technology Study
PPACA – Health Reform Act 2010
Independence@Home; Medicaid Medical
Home; Chronic Care; Innovation Cntr
TELEHEALTH IMPACT
A. $2 billion in direct funding for health IT efforts, channeled
through the Office of the National Coordinator [ONC]
– $300 million reserved for supporting regional health
information exchange efforts and the state-based “extension
centers"
– $20 million reserved for NIST for work on health care
information enterprise integration
- BEACON GRANTS
B. Incentives Medicare and Medicaid to providers and hospitals
adopt and use health IT systems =AND THESE PHYSICIANS
CAN BE WORKING WITH HHAs and HOSPICES
HIGHTECH, cont.
– $85 million for the Indian Health Service to use on health IT
– $1.5 billion for community health centers, a sum that
can be used toward health IT acquisition
– $500 million for the Social Security Administration for
processing disability and retirement workloads, of which
up to $40 million may be used for health IT research
and adoption
– $1.1 billion to AHRQ, HHS, and the NIH for comparative
effectiveness research
BEACON: $16+Million Buffalo



Western NY Info.Exchange, Buffalo
clinical decision support –registries
;point-of-care alerts/reminders
innovative telemedicine =improve
primary/specialty care for diabetics,
↓preventable ER visits, hospitalizations
re-admissions for diabetes, CHF,
pneumonia; ↑immunization of diabetics
Patient Protection and
Accountable Care Act of 2010



“PPACA” --This is where the
expansion will continue to be.
PPACA drives the process towards
management of chronic disease.
Health information technology is finally
showing, with reliable data, that
telehealth can integrate with traditional
care and use staffing innovations.
PPACA Promises? Promises!






Post-hospitalization bundling pilot
Independence at Home demonstration
Innovation Center at DHHS; chief
policy person in place;telehealth focus
ACOs
Medical Home-Medicaid and Pilots
Face2face HHA provision w telehealth
Blue Cross/Blue Shield WNY

Blue Cross/Blue Shield Western New
York in May 2010 initiated online
physician-patient communication as a
compensated service; encouraging
telehealth communications and
webcam visits; measuring quality of
care and patient compliance factors
Technology-enabled Care:
Where are we now?






Satellite health facilities
In situ care w medical devices
Remote monitoring and sensors
Awareness and acceptance
European efforts in ambient care
The VA system –the Vanguard
Where is Telehealth in Use






Care coordination and Chronic
Disease
Patient self-management
Ambulatory care and safety
Palliative care
Rehabilitative services
Behavioral & mental health services
VA Chronic Care Coordination
via Telehealth Study
#
% DECREASE UTILIZATION
Diabetes
8,954
20.4
Hypertension 7,447
30.3
CHF
4,089
25.9
[congestive heart failure]
COPD
1,963
20.7
[chronic pulmonary obstruction]
CONDITION
VA Chronic Care Coordination
via Telehealth Study






Posttraumatic stress disorder 45.1%
Depression 56.4%
Other mental health condition 40.9%
Single condition 10,885 patients;24.8%
Multiple “ “
6,140 patients;26.0%
Interventions “just in time”; “air traffic
control”
VA Chronic Care Coordination
via Telehealth Study
The cost ($1,600.24 pp/yr compares favorably)
 direct cost of VHA’s home-based primary
care services of $13,121.25 per annum and
 market nursing home care rates that
average $77,745.26 per patient per annum”.
Conclusion: a flexible and cost-effective
adjunct to VHA’s existing services. Darkins
et al., Telemedicine & EHealth, 12/2008.
Telehealth and chronic illness

St. Vincent Health System's Visiting Nurse
Association [Arkansas] has used telehealth
computers to monitor patients in their homes
for several years, and in its 11 county region
had only about 4.5% of heart attack patients
re-hospitalized compared with a national
rate of 37%. [National Assn for Home Care
report]
Telehealth and Aging in Place


University of Missouri :sensors, computers and
communication systems, along with supportive
health care services monitor the health of older
adults who are living at home.
Motion sensor networks installed in seniors’ homes
can detect changes in behavior and physical
activity, including walking and sleeping patterns.
Early identification of these changes can prompt
health care interventions that can delay or prevent
serious health events.
HMSA: Ambulatory MD/Home




Hawai’i Medical Service Ass’n Jan 09
Online Care connects, 24/7, patients
and physicians via the Internet or
telephone;1st in the nation.
$10/45 for 10 minutes interaction
Physicians can be “anywhere”; service
is across all islands
Telehealth: Dementia Patients


Residential facilities designed to allow
movement of individuals through
facility and grounds; Families can track
on computer/internet based systems
Sensoring systems; Intel research;
TRILL; diagnostic sensoring for fall
prevention yielding data on Alzheimer
specific movement differentials
Telehealth:Dementia Patients

AlarmTouch GPS is a personal safety phone
with GPS location in Europe. The telecare
device includes a ‘Geofencing’ feature,
enabling accurate location of users in need.
When the wearer wanders outside a
specified zone – such as home or school
area - the system can send a short message
(SMS) alert to a monitoring centre or to a
relative or caregiver.
Home Telehealth - NY State



93 providers approved to bill

Daily rates as of 1/1/2010

Tier I – 62 $8.88/day/patient

Tier II – 31 $10.20/day/patient

Tier III – to be tied to regional connectivity

Medicaid Managed Care covered service
Electronic Medical Records

Approximately 50% - 60% utilization – generally
medium & large sized agencies
Multiple other “pieces”

Referral software, physician portals, med
management hardware etc.
Home Care Association of New York State
24
0-2 years
Length of Experience - Home Telehealth
16
2-3 years
Number of Providers
14
12
3-4 years
10
8
4-5 years
6
4
More than 5
2
0
Home Care Association of New York State
1
Multiple
programs25with
different lengths
CURRENT TECHNOLOGY UTILIZATION
#
Providers
Home Care Association of New York State
26
Disease Management
Home Care Association of New York State
27
Ambient Assisted Living
Programme - EU
23 EU member states with support of European
Community [EC]
-Enhance quality of life of older people
-Strengthen industrial base by use of Information and
Communication Technologies [ICT]
-Aging well at home, community and work
-Coherent framework for research into solutions which
are compatible with varying social preferences
www.aal-europe.eu
American Telemedicine Assn



Home telehealth and remote
monitoring practice group
Working group exploring opportunity
for, and prevalence of telehospice; I
chair this group.
www.americantelemed.org
Partners Home Care
Stats and Facts
175 Towns and Cities
2,500 Average Daily Census
24,000 Admissions Annually
360,000 Visits/Year
46% of Admissions are from non-Partners
Healthcare System Sources
4 Hospitals: Massachusetts General
Hospital, Brigham and Women’s Hospital,
North Shore Medical Center, Newton
Wellesley Hospital are the core hospitals for
PHS
Technology
383
305
Clinicians on POC
Telemonitoring devices – remote
monitoring
3800 Personal Emergency Response
units
Clinicians and Staff
700
244
25
131
7
61
32
11
4
185
Full, Part-time, Per-visit
Registered Nurses
Licensed Practical Nurses
Therapists: physical,
occupational, speech
Social Workers
Home Health Aides
Liaisons
Intake Nurses
Nutritionists
Other managers, clinical, admin
9 Essential Steps for Sustainability
1.
2.
3.
4.
5.
6.
7.
8.
9.
Set Program Goals
Gain Insight of Stakeholders
Get Buy-in
Patient Selection – choose wisely
Care Coordination – 5 “Ws” 1 “H”
Establish Clinical Standards
Equipment Management – DME matters
IS Infrastructure - IS is your friend
Quality Improvement – implement soon, evaluate
often
Success Follows
1. Set Program Goals


What is the problem you want to solve?
Set goals based on measureable outcomes

Why telemedicine?

Improved care

decrease number of emergency room visits

decrease number of hospital re-admissions

Increase patient involvement in care

Decrease home visits

Improved outcome and access/decreased costs
You’ve decided to choose to start a telemedicine program
What’s Next?
Recognize the Nature of a Paradigm Shift






Telemonitoring changes traditional notions of care
delivery
Incredible opportunity to improve care and
increase access
It builds careers and new skill-sets and improves
peoples lives …..BUT……
People resist change
Doing it “right” requires set up and perseverance
The 1st time takes longer than one would think
2. Gain Insight of Stakeholders
Senior
Leadership
Nurses &
Allied Health
Physicians
Operations
Patient
Quality &
Compliance
Finance
Information
Systems
3. Get Buy – In

4 Main Groups

Senior Organizational Leadership


Patient



CEO  Field Staff
Getting equipment in
 MD/nurse confidence
Clinicians/Allied Health Professionals
 Champions
 Touch and Play sessions
 Manager accountability/feedback loop
 Prizes
Physicians



Education
“Just in time” reports
Promised decreased calls from patients d/t triage by TM
staff
4. Patient Selection – Choose Wisely

Determine Patient Population


Based on program goals
Partners Telemonitoring criteria:






Moderate to high risk for re-hospitalization
Will benefit from telemonitoring
Can be managed with decreased nursing visit
frequency
Patient or caregiver is able/willing to assume
responsibility for monitoring
Working phone line in patient’s home
Home is safe environment for equipment
5. Care Coordination – 5Ws, 1H
Determine process flow




SN evaluations for program
admission
 By Whom?
Referrals
 Who refers?
 Where do referrals go?
 Who processes them?
Telemonitoring of patients
 Centralized – requires dedicated
TM staff
 Decentralized – integrated into
primary clinician work flow
Reporting – Why?
 Who
 What
 When
 Where
 How
6. Establish Clinical Standards






Best practice, evidence based standards
Must be able to individualize standards
Use clinical experts that clinicians will accept to
set standards
Educate clinicians regarding standards
Give clinicians autonomy to modify standards as
they deem necessary
Give clinicians algorithms/guidelines for further
autonomy in practice
7. Equipment Management – DME Matters






Rent vs. purchase
Identify who will manage
Establish responsibility and accountability for

electronic inventory control

system set- up and provisioning

installation/testing/break-fix

equipment recovery, sanitizing, storage and
redeployment
Training, retraining, written protocols
Begin with decentralized process (greater buy-in at local
level), migrate to centralized process (efficiency &
consistency) over time, selecting best of breed processes
Cultivate leadership
9. Quality Improvement



Implement Soon – Evaluate Often
Establish QI program at beginning of process
Establish planned review periods




Initially weekly
Include stakeholders as appropriate
Include all 8 essential elements as part of formal
QI program
Establish database for statistics at start of
program


If you think you might need it, get it
Build mechanisms for gathering data if not
inherent in EMR program

Excel, Access databases
Telemonitoring at PHC

PHC Telemonitoring Program - 2006



Connected Cardiac Care Program - 2007




Private Pay
Hospice


4 month home telemonitoring program
Patient Criteria
Strong educational component –
 1 Nurse visit to establish clinical status and knowledge deficits,
then no further nursing
 Bi-weekly telephonic educational phone calls
 Encourage direct patient/PCP relationship
Patient Choice Program


Patient Selection Criteria
Available for Medicare pts currently receiving PHC
Telehospice Pilot
CMS Pilot program
Positive Patient Outcomes





> 2100 patients cared for 2006- present
Average LOS 70 days
Average LOS with no rehospitalizations –
53 days
Average LOS with > 1 hospitalzation – 103
days
Average rehospitalization
 PHC program – 25%
 CCCP – 30% decrease year over year
1.3% - 1st 30 days
 3% -program completion

MD Acceptance - CCCP
Clinician Response



Decrease average SNV to 10
visits/episode with improved
outcomes for rehospitalization
Consistent referrals to
programs
Clinician comments:
 “I love it. I feel like I have a
better handle on my fragile
heart failure patients using
telemonitoring – they look at
them every day and let me
know if there is a problem I
need to be aware of.”
 “I think it’s great – it’s made
a huge difference for my
patients.”
Adm issions by Region FY10
45
40
35
30
South
25
Central
20
North
15
10
5
0
Q1
Q2
Q3
Q4
Com bined Program Census FY10
300
250
200
150
100
50
0
Oct ober
December
February
April
June
August
What are the New Directions?





Tele-rehabilitation; Falls prevention
Tele-mental and behavioral health
Continuous monitoring: diabetes;
cardiac
Impaired; Alzheimer’s & dementias
“Wellness”
Telehealth and Rehabilitation






Distanced assessments
Robots in SNFs
Telestroke => telerehab
Wii units in senior living facilities
Remote monitoring for falls anticipation
Traumatic brain injury;wounded warrior
Behavioral & Mental telehealth




On-going research
Post traumatic stress disorder
Tele-psychiatry
Distanced mental health services
under new Medicare reimbursement
provisions for community mental
health centers
Telehealth and Palliative Care


Telehealth and pain management
TeleHospice care
•bringing patient and family into the
interdisciplinary group [IDG]
•counseling to patients and family
when social workers are scarce
resources
Palliative Care






Pain and symptom management
Outreach and crisis management
Triage without transporting to facility
Psychological pain and suffering
Diagnostic opportunities; family
interactions
Ethical principles= autonomy enhanced
Prevalence of Telehospice






Informal survey
CIMIT Grant to review
Methodology
Findings
Follow-on research
Canadian telehealth research in
palliative area
Research on Telehospice



Initial research papers
Work in Missouri and Washington State
Directions –
IDG involvement patients and families
 Education and emotional support to
caregivers
 Reactions of patients to use of health
information technology
 Preferences of video versus audio only

Opportunities and Challenges




Medical Director and other physicians
Demonstrating cost savings, &/or
quality of care/life improvements- to
justify expense of equipment and staff
Training and staffing. Maintenance of
depth of field/bench so turnover is not a
problem. Need for a "champion".
Leading nurses to embrace technology
Telehealth: Government
Impediments






Reimbursement under Medicare
Medicaid
Grants
Outcomes, cost savings and Disease
Management concerns
Licensure and interstate barriers
Standards lacking:Interoperability
among devices/software/infrastructure
Legal Barriers and Concerns








Licensure
Liability
Consent
Reimbursement
Management of the Case
Privacy and confidentiality
Security of Communication
Fraud and Abuse
Licensure



Many states –New York is one--bar
physicians from practicing via
telehealth without a full or partial new
license=quality; control as issues
Some states now licensing the entity
which arranges for and participates in
telehealth services
Nurses—not surprisingly—more sane
Liability--Consent--Managment




Medical device or simply a conduit of
information
Manufacturer; Software vendors will
seek total immunity from exposure
Patients need to hear from physicians
and health entity about conditions,
errors and backup response
Insurers reluctant or ignorant
Telehealth: Privacy Laws and
Impediments to Data Exchange



State privacy laws
HIPAA
Congressional opposition on the HITECH
and other HIT bills –
Strong language extending privacy
protections including business assoc’s
Is ARRA destined to slow eHealth progress
Fraud and Abuse

Coordination of telehealth services vs.
Impermissible incentive to referral
source, including patient herself
and
If it is a new “service“ is it subject to
Stark law concerning physician
financial interests
Discussion – Are you involved




Audience experience in telehealth
Reluctance….and reasons
Board reactions…have they been
educated
Can our society afford not to bring
telehealth into our long term care
situations?
Contact Information








Deborah A. Randall
law@deborahrandallconsulting.com
www.deborahrandallconsulting.com
202-257-7073
Kathy Duckett, RN, BSN, Director
Clinical Programs Partners Home Care
kduckett@partners.org
781-290-4058