Telehealth - Megan Coffman
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The document summarizes research from the Robert Graham Center on telehealth projects and surveys of family physicians and residency directors. It finds that while family physicians see benefits to telehealth, adoption has been limited due to barriers like reimbursement and technology issues. A survey of family physicians found 15% had used telehealth in the past year, with higher rates in rural areas. Barriers to more use included reimbursement, costs, and preference for in-person visits.
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Telehealth - Megan Coffman
- 1. Robert Graham Center: Summary of Telehealth Projects Megan Coffman, MS October 28, 2016
- 2. Robert Graham Center The Robert Graham Center aims to improve individual and population healthcare delivery through the generation or synthesis of evidence that brings a family medicine and primary care perspective to health policy deliberations from the local to international levels.
- 3. Robert Graham Center – Who We Are
- 6. What is Telehealth? • Telehealth: the exchange of medical information from one location to another via electronic communications
- 7. Why Telehealth? • Telehealth is shown to: – expand patients access to care, – increase continuity of care, – improve coordination of care – reduce healthcare costs, and – improve health outcomes • Some indication of low usage in primary care
- 8. Family Physicians and Telehealth Funded by Anthem,Inc.
- 9. Highlights from the Literature Review and Expert Panel • There is very little research on telehealth in primary care • The literature indicates that patients appreciate the convenience of access to telehealth services, and are satisfied with the care they receive remotely • Patients see saving time and travel as benefits of telehealth compared to in-person care
- 10. Survey Objectives • Measure penetration of telehealth into primary care setting – Hypothesis: low penetration • Characterize Family Physicians (FPs) who use telehealth – Hypothesis: higher use in rural setting, larger practices, and younger physicians • Investigate Attitudes/Beliefs of FPs regarding telehealth – Hypothesis: Users have more favorable attitudes/beliefs
- 11. Who did we ask? • Survey of 5,000 randomly selected FPs – AMA Physician Masterfile (2014) linked to AAFP member list – FPs in direct patient care – Oversample rural 2:1
- 12. The Survey
- 13. Telehealth Defined Telehealth services defined as: 1. Primary care services: a physician providing care for a patient via live interactive video and/or 2. Primary care and specialist referral services: a primary care provider consulting with a specialist via live interactive video and/or 3. Store and Forward: sharing electronic patient data between a primary care provider and specialist across locations
- 14. Survey Data • 1,557 survey responses were analyzed – 1,630 surveys were returned (31% response rate) – 53 surveys were returned but not used • Non-unique ID • Respondent indicated they did NOT engage in direct patient care or did not answer this question • Sample weights were used to ensure the estimates computed were representative of family physicians across the United States
- 15. Results: Demographics • 15% had used telehealth services in the last 12 months (85% had NOT) (N=225) • Telehealth users were more likely to – rural setting (26% versus 12%, p<0.01) – use an EHR (97% vs. 92%, p<0.01) – work with six+ FPs (40% vs. 29%, p<0.01)
- 16. Prevalence of Telehealth Use by Type of Service Used Source: Robert Graham Center Analysis of 2014 AAFP Telehealth Survey of Family Physicians, N=225
- 17. Results: Attitudes and Beliefs • Telehealth users and non-users agree: – Telehealth improves access to care for my patients. (89% users vs. 77% non-users, p<0.01) – Telehealth improves the continuity of care for my patients. (75% vs. 68%, p<0.01) – Patients prefer to see their doctor in person. (83% vs. 94%, p<0.01)
- 18. Results: Barriers to Using Telehealth
- 19. Benefits and Barriers to Telehealth Use
- 20. FP Survey Study Conclusion • FPs views of telehealth are generally positive • Barriers to larger adoption remain • Small but significant number of family physicians who are providing telehealth services for patients
- 21. CERA Survey of Family Medicine Directors 18% 11% 71% Telehealth Capacity of Residency Programs Surveyed Video and Evisits or Store Forward VideoOnly Evisits or Store Forward Only
- 22. Percent of Residency Programs Who Indicated Each Reason by Mode of Telehealth Service Delivery 48.6 11.4 22.9 28.6 20.0 17.1 48.1 21.7 55.7 49.1 16.0 36.8 0 10 20 30 40 50 60 Diagnosis & Treatment Second Opinion Follow-up Chronic Disease Management Emergency Care Administration Live Interactive Video Evisits / Store Forward
- 25. Consumer Survey
- 26. Thank You and More • To learn more about the Robert Graham Center’s work, visit our website: http://www.graham-center.org/rgc/home.html • If you have specific questions on the telehealth project, email me at: mcoffman@aafp.org
Notas del editor
- Good morning everyone. Thank you for waking up early this Saturday morning to be here. My name is Megan Coffman and I work at the Robert Graham Center. Today, I am here to talk about some of our recent work on telehealth, but before I dive into that piece of the presentation I want to tell you a little bit about the Robert Graham Center.
- We are division within the AAFP with editorial independence that allows us to pursue a variety of research projects. We are a multi-disciplinary research team. The team includes: clinician researchers Health Economist Sociologists Geographers Health Informaticists Public health This team includes HealthLandscape, an AAFP Enterprise that I’ll speak a bit more about shortly. In addition to the Robert Graham Center staff, we are lucky to have Visiting Scholars and Fellows who also contribute to our work.
- Under the umbrella of primary care research, we organize our work into these 8 categories. You may be wondering how we tackle this variety of topics, and it is through our scholars, fellows, and key partnerships that enable us to cover this wide breadth of research interests. Much of the Graham Center’s research has focused on secondary data analysis using large datasets like the Medicare claims data. Recently, the team has started collecting primary data by fielding surveys, conducting key informant interviews and focus groups.
- In addition to research, the team, mainly our colleagues at HealthLandscape develop and deploy mapping tools. You may be familiar with the MedSchool Mapper, UDS Mapper, or World Health Mapper. Most recently, the HealthLandscape team rolled out the Health Workforce Mapper for the AMA. This tool allows users to get a lay of the health workforce land at a variety of geographies.
- This is a sample of some of the Robert Graham Center’s recent publications: Beginning with Workforce projects to behavioral health integration to including social determinants into Electronic health records
- recent technological innovation in connecting clinicians to patients Big national group thinks this is a part of the future and wonders why pc is not adopting usage – funded to take a deeper dive into the issue However, penetration of telehealth into primary care setting is thought to be low and is poorly quantified in terms of the dimensions and barriers and is little understood. As there is little representative research.
- Context: Telehealth offers the potential to facilitate the nation’s triple aim by shifting delivery of care to less expensive settings while improving access and convenience, yet the technology has limited penetration into the primary care arena. We focus on Family Physicians’ (FPs) perceptions and priorities in utilizing telehealth to provide health care services. Objective: Identify FP provider and practice characteristics and attitudes of telehealth use stratified by users and non-users.
- We focus on Family Physicians’ (FPs) perceptions and priorities in utilizing telehealth to provide health care services.
- Survey of 5,000 randomly selected FPs AMA Physician Masterfile (2014) linked to AAFP member list Family Physicians in direct patient care Oversample rural 2:1 Paper and on-line survey with reminders and incentive Analysis: Descriptive statistics, numbers and %ages, bivariate analysis of statistically significant differences between groups
- Paper and on-line survey with reminders and incentive. The survey included a variety of question formats including Likert scale, open questions, pre-defined responses. We tested the survey with a variety of Family Physicians to make sure the survey was well designed and questions were easy to answer. paper survey was mailed out to 5,000 members and included a $2 bill incentive Each survey had a unique identifier so we were able to see who completed the survey and then send follow-ups to individuals who had yet to complete the survey.
- Literature review of peer-reviewed articles and grey sources, expert panel discussion, RTI survey methodology expert consultant, and field testing of the questions To assess the landscape we separate the sample into users and non-users The survey included a variety of question formats including Likert scale, open questions, pre-defined responses. “LI-KERT”
- Telehealth is the use of medical information exchanged from one location to another via electronic communications to improve a patient's health. We are using telemedicine and telehealth interchangeably. For the purpose of this project, we are defining telehealth services as: 1. Primary care services: this service involves a physician providing care for a patient (not necessarily a patient in their practice) through the use of live interactive video; and/or 2. Primary care and specialist referral services: this service usually begins with a primary care provider who consults with a specialist through the use of live interactive video; and/or 3. Sharing of diagnostic images, vital signs, video clips, or patient data between a primary care provider and specialist when the specialist and patient are not in the same location (sometimes referred to as store and forward).
- Twenty of the surveys were returned due to an incorrect mailing address. Overall 1,630 responses were received. The final analysis sample consisted of 1,557 respondents who had a valid survey identifier (38 did not) and were engaged in direct primary care (35 were either not in direct patient care or did not answer this question). Results: Of the 1,631 respondents, 15% indicated that they used teleheath services in the last 12 months. Users and non-users differed significantly in key ways; telehealth users were more likely to provide a wider scope of service, currently use an EHR, and were more likely to practice in an integrated health system. Self- identified telehealth users preferred offering visits through real time interactive video consultations with specialists and using telehealth for chronic disease management, mental health, and diagnosis and treatment over other types of consultations. Both groups reported reimbursement as a factor when considering whether to provide telehealth services. Users and non-users agreed that first time visits via telehealth were not preferably. Users and non-users both agreed that more research on the effectiveness of telehealth is needed.
- The majority of the sample were male (62%, Table 1), Allopathic (84%), providing general primary care (84%). The sample contained physicians from each age range with 28% having practices for ten or fewer years, 34% for 11 to 20 years, 24% for 21 to 30 years, and 14% for more than 30 years. Overall 37% of the sample indicated that their practice was privately owned, 42% were owned by a hospital or health system, and 21% were owned by an integrated health system or had another ownership structure. Telehealth users were statistically different from non-users in terms of their practice location, their EHR usage, the type of care they provide to their patients, the number of providers at their practice, and the ownership of their practice. Telehealth users were more likely to be located in an rural setting (26% versus 12%, p<0.001), to use an EHR (97% versus 92%, p=0.0056), to provide general primary care to their patients (76% versus 86%, p=0.0028), and to work in a practice with six or more family physicians (40% versus 29%, p=0.0047). Additionally, telehealth users were less likely to work in a practice that is not privately owned (22% versus 39%, p<0.001).
- Does not sum to 100 because some did not answer the question.
- Both groups reported reimbursement as a factor when considering whether to provide telehealth services. Conclusions: FPs views of telehealth are positive. Three key barriers to adoption emerged: cost of equipment, lack of training, and need for reimbursement. There was a high degree of agreement among all survey respondents that effectiveness and implementation research is needed.
- Both groups reported reimbursement as a factor when considering whether to provide telehealth services.
- Which of the following are barriers to using telehealth in your practice? Cost of equipment (35% users vs. 47% non-users) Lack of training about how to use telehealth in a family medicine practice (40% vs. 55%) Reimbursement by insurers (46% vs. 54%) Potential liability issues associated with the use of telehealth (26% vs. 41%)
- We attempt to overcome these barriers by … using our literature review of peer-reviewed articles and grey sources, our expert panel discussion, our RTI survey methodology expert consultant, and our field testing of the questions
- Issues that must be addressed include creation of guidelines for clinical practice, definitions of quality and outcomes, demand for interoperable systems among the variety of users, assurance of privacy and security for the public and providers plus standardized reimbursement procedures. Pilot and demonstration programs should be established on a national level to create the information and knowledge base necessary to assure that telehealth represents an improvement in access and quality, or that it is at least is as good as current standards of care. Administrative issues including billing codes, reimbursement, licensing and credentialing, and appropriate physician, practitioner and staff training are all aspects that need to be addressed, codified and implemented. Users and non-users differed significantly in key ways; telehealth users were more likely to provide a wider scope of service, currently use an EHR, and were more likely to practice in an integrated health system. Self- identified telehealth users preferred offering visits through real time interactive video consultations with specialists and using telehealth for chronic disease management, mental health, and diagnosis and treatment over other types of consultations. Both groups reported reimbursement as a factor when considering whether to provide telehealth services. Users and non-users agreed that first time visits via telehealth were not preferably. Users and non-users both agreed that more research on the effectiveness of telehealth is needed.
- ACGME accredited US family medicine residency program directors as identified by the Association of Family Medicine Residency Directors E-visits: an asynchronous electronic visit with a doctor, either through e-mail, patient portals or a structured online form. and/or
- Robert Wood Johnson Foundation Grant to survey telehealth user on their attitude and beliefs around telehealth.
- Survey will target consumers who have registered for Anthem’s Live Health Online and had a visit, individuals who have registered, but not had a visit and individuals who have access, but have not registered or had a visit.