Guide: Telemedicine benefits held back by lack of reimbursements
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As they move out of pilot initiatives and into implementations, telemedicine projects are taking a star role in pediatric care models across the country, a seemingly natural fit for extending the reach of scarce subspecialists beyond the four walls of their offices.
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Telemedicine care works the same -- mostly -- for pediatric patients as it does for adults -- save for a slightly different approach to "looking into a little kid's ears" as opposed to a grown-up's, said Dr. Neil Herendeen, associate professor in the University of Rochester's department of pediatrics.
Hospitals are thinking in terms of providing the needed services in the most effective and cost-effective way, and that's probably not having everyone come to the doctor's office.
Herendeen is the medical director at Health-E-Access, a Rochester, N.Y.-based telemedicine program that provides videoconference doctor "visits" with children, who link directly from their schools or daycare centers. Using such examination tools as digital stethoscopes and high-definition cameras, physicians and nurse practitioners at Golisano Children's Hospital connect with on-site telemedicine assistants to diagnose and treat routine childhood illnesses, as well as to communicate their findings and recommendations.
Parents cheer for technology implementation
The advantages of telemedicine reflect a new approach permeating healthcare organizations: delivering care when and where patients need it, Herendeen said.
"Hospitals are thinking in terms of providing the needed services in the most effective and cost-effective way, and that's probably not having everyone come to the doctor's office. A lot of this care can be done by letting patients stay where they are," said Herendeen, adding that hospital CEOs should consider the advantages of telemedicine services for patient-centered accountable care models as they gain ground in U.S. healthcare and require more efficient checkups and treatments.
Busy parents appreciate the services most, Herendeen said. He mentioned a mother of seven who was in his office every other week with one of the children, missing half a day's work for each visit. "You're facing families with a real hardship if you're forcing them to define how to be a good parent -- if that means staying at work to put food on the table, or leaving to take care of their kids," he said. "For fevers and other routine illnesses, you know as soon as you get the child home, he or she will be fine, but you still need to make sure. Doing that in the school saves everyone time and money."
Since 2001, Herendeen and his team have conducted more than 12,000 telemedicine pediatric patient visits. In that time, there has been a 63% reduction in preschool absences due to illness and a 23% reduction in evening-hours emergency room visits. "It's not anything that's taking more of my time," he said, explaining that the remote care actually saves overhead costs for the hospital and frees up bed space.
Florida ERs book e-psych consultations
Models similar to Health-E-Access have taken root across the country. In Florida, outlying emergency rooms use telemedicine to refer potential child abuse victims to off-site pediatric psychologists. In rural North Carolina, school nurses link with primary care physicians to facilitate everything from mental health counseling to sports physicals in a school-based telemedicine program.
Dr. Steve North founded MY Health-e-Schools in 2007. At the mostly grant-funded facility, two nurse practitioners conduct the bulk of patient care, working with school nurses to manage both sore throats and ear infections and similar conditions, and chronic illnesses, such as diabetes and hypertension. Last year MY Health-e-Schools partnered with 10 schools in rural North Carolina, serving 2,600 students and 200 faculty members. North hopes to add four more schools this spring.
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Because MY Health-e-Schools essentially swaps primary care physicians with computer screens, one might expect dissent from local practitioners. But North said in an area like western North Carolina, which has been federally designated as having a health professional shortage, clinicians welcome the alleviation of preventable emergency room visits.
North recounted the story of one primary care physician who was opposed to the program before North diagnosed one of the physician's patients, a 6-year-old child, as having a rare kidney disorder mimicking strep throat. The diagnosis saved the child and his family many days of travel and hospitalization. After that, the skeptical doctor became a vocal MY Health-e-Schools advocate.
"Maintaining close communication with the local primary care physicians is key for this to work," North said, advising that facilities considering implementing a school-based telemedicine program to begin by assessing the need for the service in the community. "You need to understand if there's enough volume for service. Then you have to work to build relationships with the schools so they're involved with the planning process every step of the way."
For developing rural telemedicine programs, the school nurses who work in the MY Health-e-Schools program have begun writing a curriculum to train next-generation school-based telemedicine assistants.
Telemedicine tech trains rural docs
Farther west, Dr. Bryan Burke, associate professor of general pediatrics and neonatology at the University of Arkansas, uses the same Web-based telemedicine videoconferencing technology as North -- but for physician education.
Burke and a colleague created Pediatric Position Learning and Collaboration Education (Peds PLACE), a virtual peer group designed to link academicians at the University of Arkansas with private, often rural, pediatric practitioners in Arkansas and surrounding states. The meetings are conducted in a collegial, conversational fashion, focus on a particular topic in pediatric care and are facilitated by a real-time, interactive videoconferencing application. "Whatever the topic is -- whether it's cystic fibrosis or facial trauma from a dog bite, a guy in one town is talking directly to a guy in another about how he approached the problem, and it could be [that] he has a better solution," Burke said. He said he hopes to connect with every pediatrician in Arkansas by the end of the year. "Just as much knowledge flows from Little Rock to rural facilities and vice versa. You learn from each other because the way you practice medicine can vary greatly depending on your location."
Both private practitioners and University of Arkansas faculty submit topic ideas and case studies for the Peds PLACE discussions, which take place once a week. A 2009 University of Arkansas study found that 93% of participants indicated the information from the presentations would translate into their professional practice and enhance patient care, and 98% said it increased their knowledge.
"I just love the concept," Burke said. "A doc in the smallest town in Arkansas, from the comfort of his own office, can sit down to eat lunch, receive free CMEs [continuing medical education credits], ask questions and make comments, and learn from the best experts in Arkansas -- and indeed the nation and the world, finish his salad, and go see the next patient."
Peds PLACE offers private physicians four state-required CMEs free of charge, connects them with local academicians to bolster trust among referring clinicians, and gives them a chance to stay relevant in an ever-adapting health IT landscape. What's more, the telemedicine technology required is basic: Doctors need a fast Internet connection to download the videoconferencing application. Peds PLACE uses the Jabber instant messaging service. "One thing that's difficult when you have a private practice is to stay as current as you would like. And it's almost impossible to avoid staying current at an academic institution," said Burke, who has practiced at both private and academic institutions in his 31-year career. "There's a whole cadre of people who need to stay up-to-date on the latest clinical mind-set to treat the thousands of children in their clinical database."
Peds PLACE also translates the sessions into accessible resources for physicians, compiling 10 presentations a year into guidelines -- brief, peer-reviewed summaries of the discussions -- offered as points of reference for doctors in need of a quick case study or best-practice procedure. "We as educators and academics have always done a good job at teaching and instructing residents, students and fellows," Burke said. "But once they leave the institution, we tend to, for lack of a better word, neglect them."
Extending pediatric ER expertise
On the West Coast, Dr. James Marcin heads a program providing immediate consultations to acutely ill and injured children at outlying emergency rooms. He is a professor of pediatric critical-care medicine and serves as director of the University of California Davis Children's Hospital's pediatric telemedicine program, which has been online since 2000.
Telehealth is a paradigm shift in the way we deliver care, but hospitals can start with the programs that are easiest to implement, and that are in strong demand.
chief innovation officer,
Boston Children's Hospital
UC Davis has used devices ranging from a basic webcam to a $20,000 high-speed, high-definition mobile video conferencing cart to conduct more than 5,500 emergency pediatric consultations, reaching a network of 23 sites in northern California. The telemedicine program offers otherwise unavailable expertise to rural healthcare. But in addition to that, the program has practical benefits, Marcin said: It saves time for parents who can't afford to make a trip to a specialist, and money for hospitals whose remote experts can prevent unnecessary transfers or advise less expensive modes of transfer, such as an ambulance instead of a helicopter.
The program's care model reflects pending IT mandates through the Affordable Care Act's efforts to reform payment around quality, instead of the traditional fee-for-service structure. But there is still work to be done -- namely, on the payer side to help share the savings with the doctors who make those savings happen, Marcin said. "Telemedicine is getting laid on a broken healthcare system," he said. "What happens is, even if I am able to see kids in an emergency setting via telemedicine and help end readmissions and unnecessary transfers -- save thousands of dollars -- those savings aren't necessarily realized by us or our hospitals, or anything like that. It's washed revenue."
This is in part why telemedicine isn't expanding as rapidly as it otherwise might, Marcin said; there's no incentive for physicians to cut those costs. But, he said, the remote services can become a marketing tool for pediatric programs in competitive regions, where increased capacity for care may appeal to more patients and communities.
Getting physicians on board
At Boston Children's Hospital, Chief Innovation Officer Naomi Fried said if physicians aren't actively invested in the telemedicine services, the programs are not going to work. "Finding clinical champions who will really embrace the technology and be interested in new forms of care is critical. Without it, you can't have successful implementation," she said.
In her three years at Children's, Fried has helped deploy six telemedicine pilots. One utilizes a post-care home-monitoring robot, sold by VGo Communications Inc. The robot was pioneered by one such champion clinician, Dr. Hiep Nguyen, director of robotic surgery research and training at the hospital. Another telemedicine pilot, driven by Dr. David Hunter, Children's Ophthalmologist-in-Chief, evaluates retinopathy of prematurity, a condition among premature infants that can lead to blindness.
Fried's team also established the FastTrack Innovation in Technology Award, an incentive program for software developers that has the double benefit of giving innovators a chance to pitch their ideas to the software development team at Children's while giving the hospital's telemedicine program access to state-of-the-art healthcare technologies.
"In our work, where we provide care to patients directly via new technologies, we need to make sure both the kids and parents are comfortable with them," Fried said. "I think telehealth is a paradigm shift in the way we deliver care, but hospitals can start with the programs that are easiest to implement and that are in strong demand from both their patients and clinicians."