1. Telehealth:
A tool for the 21st century
Karen S. Rheuban MD
Professor of Pediatrics
Medical Director, Telemedicine
University of Virginia
ATA President
VTN Board Chair
Board Member, CTEL
3. Definitions
“Telemedicine” is the use of medical information
exchanged from one site to another via electronic
communications to support
• Medical diagnosis
Ongoing patient care
Remote patient monitoring
“Telehealth” encompasses a broader definition of
remote healthcare that does not always involve
clinical services
Health-related distance learning
5. Services
Videoconferencing for patient care
Store and forward applications
Distance learning
health professionals
patients
students
6. UVA Specialty/Subspecialty Participants
Cardiology Obesity
Dermatology Oncology/Tumor boards
Diabetes Pain management
Emergency Medicine Pediatric cardiology
Endocrine Pediatric nephrology
ENT Pediatric oncology
Gastroenterology
Plastic surgery
Genetics
Geriatrics Psychiatry
Gynecology Pulmonary medicine
Hematology Radiology
Infectious Disease Rheumatology
Nephrology Surgery
Neurology TCV
Neurosurgery Toxicology/Poison control
Ophthalmology Urology
Orthopedics
Wound care
7. Partnerships
Academic-community hospital linkages
Academic-academic hospital linkages
Rural clinics (FQHCs, Veteran’s clinics)
Virginia Department of Health
Virginia Department of Corrections
School health
Nursing home
Home telehealth – remote monitoring
Habitat for humanity
8. Benefits of telehealth
Patients:
• Timely access to locally unavailable services
• Spared burden and cost of transportation
• Improvement in quality of care
Health professionals (workforce shortages)
• Access to consultative services
• Access to CME
• Primary care retains oversight of patient care
Rural communities
• Enhanced healthcare/economic empowerment
9. Federal investment in telehealth
Department of Health and Human Services Department of Veterans Affairs
• National Institutes of Health Department of Commerce
• Health Resources Services Administration Department of Agriculture
• Agency for Health Research Quality Department of Labor
• Centers for Medicare and Medicaid Services Department of State
• Centers for Disease Control and Prevention
• Substance Abuse and Mental Health Services INDEPENDENT AGENCIES AND COMMISSIONS
Administration • NASA
• Food and Drug Administration •National Science Foundation
• Indian Health Service •Federal Communications Commission
•Social Security Administration
Department of Homeland Security •Office of Personnel Management
Department of Housing and Urban Development •Consumer Products Safety Commission
CDC •Appalachian Regional Commission
Department of Defense •US Agency for International Development
• Army Telemedicine Activities
• Navy Telemedicine Activities
• Air Force Telemedicine Activities
• DARPA
• Armed Forces Institute of Pathology
• Uniformed Services University of the Health
Services
10. State commitments to telehealth
Medicaid
State Rural Health Plan
State Stroke Systems of Care Task Force
Diabetes Council
Center for Innovative Technologies
Virginia Telehealth Network
Office of Minority Health and Policy of VDH
Joint Commission on Health Care
• Workforce analysis
Tobacco Indemnification Commission
Medical schools and large hospital systems
Virginia General Assembly
11.
12.
13. Patients served: UVA program
>18,000 patient encounters
> 30,000 teleradiology services/year
Services in >30 different specialties
• Emergency
• Urgent
• Single consults/follow up visits
• Block scheduled clinics
• Screenings with store forward technologies
• New mobile digital mammography van
• Retinopathy
14. More than technology and numbers:
Saving lives: Infant with Interrupted aortic arch
17. Educational programs
Broadcast continuing health
professional education
UME, GME
Patient education*
School Health Projects
18. Clinical Telemedicine – examples
High risk obstetrics
Antenatal Neonatal Guidelines, Education and
Learning System (ANGELS)
• 26% reduction in neonatal mortality in Arkansas
UVA High Risk Obstetrics Telehealth Program
• Virginia PIF grant – from Secretaries Chopra and Tavenner
• Shortage of maternal-fetal medicine specialists
• High risk population
partner with FQHC in Harrisonburg and community obstetricians
• 1st year – no NICU admissions
19. Tele-ophthalmology
Tele-ophthalmology technologies: live or store forward
Screening for diabetic retinopathy (primary cause of blindness in working
adults)
Retinopathy of prematurity
ATA: Tele-ophthalmology standards
20. Pediatric cardiology
Incidence of CHD is 8/1000 live births
Traditional models of care:
Schedule appointment
Emergency transfer
Wait for field clinic
Obtain echo and mail, courier
Tele-echocardiography has become standard of care
Live interactive support of remotely located technologists
Store forward images sent in digital format
21. Acute stroke intervention
Challenge of lack of access to stroke
neurologist in rural areas
High cost, high morbidity condition
Time is of the essence (3 hour window for
thrombolytic agents
Increase use of TPA in rural hospitals
• <0.5% utliliization in Virginia
• >25%
Medicare FLEX Health IT grant
• Bath County Community Hospital
22. HIV/AIDS
Outcomes: UVA Telehealth HIV Program1
213 correctional patients treated with 1812 visits over 5 year
period
Of patients naïve to therapy:
– 77% attained undetectable viral load (<50 copies/ml)
– 50-60% in HIV clinic
– 40% receiving community based care by non-HIV specialists
1Rheuban,KS, Wispelwey B et al HIV/AIDS, HRSA Telemedicine Technical
Assistance Documents 2004
24. Tele-pathology
Second opinions
Collaborative tumor boards
Remote access to clinical trials
25. Tele-mental health
Shortage of mental health providers in rural
areas
Consultations, medication management
• Improve access, shorter wait times
• High rates of patient satisfaction in all age groups
• Controlled studies show efficacy = face to face psychiatry
• Huge cost savings in geriatric care facilities
26. e-ICU
Two Models
• VISICU model with continuous monitoring
– Hospital mortality decreased from 12.9-9.4%, ICU
length of stay shorter 4.35-3.63 days
• Consultation model (UC Davis model) using VTC
27. Pediatric emergency medicine
Geographic disparities in pediatric emergency services
(ratio:1.6/100,000 children)
92% of children seen in non CH emergency rooms
2-3% of seriously injured children receive initial treatment at a
pediatric trauma center
Rural EDs have limited access to pediatric specialists, and may
not be trained in PALS, NALs, nor equipped
UC Davis PICU connects with rural ERs in northern California
Parsapour,K, Presentation Pediatric Telehealth Colloquium, 9/07
28. Tele-otolaryngology
AFCHAN telehealth project and use of video-
otoscopy1
• 31% decrease in the use of antibiotics when video-
otoscopy services added to community health clinic
services1
Medicare permits payment for store forward in Alaska*
29. Chronic Disease Management
Remote monitoring and Home telehealth
10% of Medicare beneficiaries account for
66% of Medicare costs
VA Care Coordination and Home Telehealth
19% reduction in readmission for the same
diagnosis,
25% reduction in hospital days
31. Challenges:2010
Funding of telehealth (Stark, Anti-kickback Laws)
Reimbursement
Confidentiality
Credentialing and Privileging
Licensure
Malpractice
Telecommunications venue/costs
Integration with EMRS/HIE
Interagency alignment related to policies
ARRA, Health reform
Outcomes
32. Reimbursement varies by state
Reimbursement
- Virginia Medicaid (urban and rural) - ~ 30 Medicaid states
- Medicare (rural, non-MSA, store forward Alaska and Hawaii)
- ~ $2 million/year
- Private payers:
- Virginia becomes the 12th state to mandate
- Anthem grant for Virginia
- Contracts
- Peds cardiology
- Psychiatry
- Dept of Corrections
34. Credentialing and Privileging
2004 JCAHO standards
Credentialing and privileging by proxy
Remote hospital medical staff agree to telehealth
relationship
Link to quality data
Legal agreements between institutions
2010 Medicare Conditions of Participation, medical
staff standards
July 15, 2010 Credentialing and privileging at all sites
THANK YOU CMS for considering alternative solutions
35. Malpractice
Serve primarily Virginians
Malpractice cap in Virginia
UVA faculty are self insured
Informed consent
New local standard of care?
Limited precedents in case law
37. Telecommunications
POTS – Fiber
Universal service fund
Rural healthcare pilot program
NATIONAL BROADBAND PLAN !!!!
Addresses interagency lack of coordination
Addresses barriers to adoption
Universal service reform
If we build it, will they come?
38. Confidentiality
HIPAA
Encrypted data
Network design and architecture
39. ARRA, Health Reform opportunities
Health Reform:
CMS Innovation center
Independence at home – care coordination program
Multi-billion dollar funding ARRA
NIH
DoC/NTIA
USDA
HRSA
ONC
40. The future of telehealth
Outcomes
Standards
Demonstration projects (ARRA, Health reform)
Broadband plan
Integration into mainstream medicine
Innovation
Collaboration amongst providers, policymakers
Champions at all levels