VA sets the telehealth table

Each day, thousands of retired veterans don an electronic cuff at home that records their pulse and blood pressure and sends the information to care coordinators at the Veterans Health Administration. The patients also punch buttons in an electronic desktop box to indicate whether they feel shortness of breath or have swollen ankles. The care coordinators flag all problems that need immediate attention.

For Dr. Adam Darkins, the top telehealth executive at VHA, the greatest benefit of the Care Coordination/Home Telehealth program is that it allows older patients with chronic conditions to live at home independently for a longer time. And the patients indicate that they like it, too.

"We are getting patient satisfaction scores of 86 percent, which are very high levels,” said Darkins, VHA's chief consultant of care coordination. “The patients have to do less travel, and they can get problems resolved quickly.… They feel the care coordination system is their lifeline."

The Veterans Affairs Department has taken a lead role in adopting telehealth strategies, and it is expanding those programs as word has spread of its good results, such as reductions in hospital admissions and shorter hospital stays for the telehealth populations, which result in lower costs. “We have seen a sustained growth in telehealth, and it is exciting to be recognized for that,” Darkins said.

Related story: FCC, FDA, HHS also working on telehealth

Now VA’s quiet leadership in telehealth is about to gain a much broader audience. Policy-makers are eying the technology as a possible means of reducing costs and improving access to care as part of cross-cutting health care reforms. The White House and Health and Human Services Department are preparing to take a much closer look at telehealth solutions to see how they might be applied on a more widespread basis.

Telehealth, also known as telemedicine or e-care, refers to the use of devices and communications networks to deliver health care or health information to or receive medical information from patients. It is often used to allow patients at remote locations to consult with a physician or other medical specialist via videoconference or telephone. The term can also refer to electronic delivery of health data, images or metrics to assist in treating a patient. If mobile devices are used, it is sometimes called mobile health or mHealth.

Although telehealth technology has existed for decades, it has recently become more popular as video images and other tools have improved in quality and availability and as care and training protocols are tested and adopted at places such as VA. A research study by Frost and Sullivan measured the global telehealth market at $6 billion in 2008 and estimated that it will grow to $8 billion by 2012.

Several factors are driving the adoption of telehealth solutions.

• The anticipated entry of 32 million previously uninsured U.S. citizens into health insurance plans because of recent reform legislation, along with the general aging of the population, is contributing to shortages of primary care physicians nationwide and exacerbating shortages of specialists in rural areas. At current rates of graduation and retirement, there could be a gap of 150,000 physicians in five years, according to the Association of American Medical Colleges.
• The economic stimulus package of February 2009 set aside $7 billion for broadband networking, a portion of which will be devoted to rural telemedicine. The Federal Communications Commission’s National Broadband Plan, released in March, also points to telehealth as an area of emphasis. FCC’s plan calls on Medicare to increase reimbursements for telehealth and on the Food and Drug Administration to develop a regulatory regime for telehealth.
• The health care reform package includes provisions for exploring new models of care to reduce costs. It funds a Center for Medicare and Medicaid Innovation that has authority to test new modes of service delivery and payment, including telehealth. The reforms also set aside funds for HHS to conduct telehealth pilot projects.
• The telehealth industry, working with health providers, has developed new products and solutions in recent years, and standards of care, interoperability and training are being created. New devices and modes of care are still evolving.

The federal government serves as a provider of telehealth services at VA, the Defense Department, the Indian Health Service and the Justice Department. It also acts as a payer for such services through Medicare and various pilot programs, although reimbursements for telehealth are limited. HHS and state agencies also regulate aspects of telehealth, such as licensing physicians and establishing standards of care.

A New Cure?

In the next phase of growth, telehealth might become a building block of health care reforms in the drive to reduce costs and improve care. It is too early to say how large-scale that effort might be, but there are some positive indications in favor of telehealth expansion.

“There is definitely interest in cost savings from telehealth that will be part of the reforms,” said John Linkous, executive director of the American Telemedicine Association. “It is very encouraging. There has been a significant change in attitude.”

At the same time, for telehealth to become more widely used, it would need to overcome several hurdles. For example, protocols, technical standards and training for telehealth have developed only in limited applications — such as for patients with specific chronic diseases in VA’s home telehealth program. Commercial models for telehealth are not yet mature because of difficulties and uncertainties related to reimbursement, licensing, legal liabilities and regulation.

VA’s telehealth programs offer important lessons. For one, it is the largest telehealth program in the world, with 43,000 senior veterans receiving home telehealth care for chronic diseases. Another 49,000 patients in rural areas go to VA clinics to consult with physicians and specialists via telehealth videoconferencing services.

Those programs are about to expand. VA officials hope the telehealth budget will grow to $163 million in fiscal 2011, more than twice the $72 million spent in fiscal 2009. New VA telehealth programs in development include care coordination for substance abuse, weight loss and palliative care, Darkins said.

Each VA telehealth program has different protocols. The home telehealth program serves veterans with chronic conditions, such as diabetes or heart disease, enabling them to stay in their homes rather than at a medical facility. Each day, the patients send their vital signs to VA via devices that measure blood pressure, pulse, temperature and weight. The patients also provide information on their symptoms, such as shortness of breath or swelling. The information goes to a care coordinator at VA who reviews it daily to determine if immediate help is necessary. One coordinator can manage as many as 150 patients a day.

“Usually, about seven to 10 people a day need immediate help,” Darkins said. “They can be contacted by telephone, and their medications adjusted, or if necessary, they can be asked to come in. The idea is to intervene earlier before it becomes a crisis.”

A study of VA’s home telehealth program in 2008 revealed that it had reduced hospital admissions by 19 percent and decreased the average number of days spent in the hospital by 25 percent. Rural veterans experienced a 50 percent reduction in hospital admissions.

VA also operates a general telehealth program at clinics in rural areas that offers videoconferencing with clinicians. More than half of the 49,000 patients using the program are receiving mental health services for conditions such as depression and post-traumatic stress disorder. Studies have shown a 25 percent reduction in hospital admissions and a 24 percent reduction in bed days of care for those receiving the telehealth-based services, Darkins said.

Finally, VA captures and stores digital images that are used for diagnosis and screening, primarily for diabetic eye diseases and skin conditions. About 98,000 veterans have had remote retinal screenings.

A Health Care Game-Changer

One lesson VA has learned is that telehealth must be carefully integrated with traditional care. Much work must go into developing protocols and standards for the technologies, training and work routines so that the care meets high standards, Darkins said. VA has trained about 2,800 people for its telehealth programs, with most training lasting three weeks.

“The technology, along with changes in work processes, has the potential to change how care is delivered but only if used properly,” Darkins said.

Telehealth programs must maintain connectivity, continuity of operations, privacy and security. “The technology must be engineered and must be robust. It cannot fail,” Darkins said.

“We have had to work closely to make sure that there is standardization, interoperability and connectivity, so that if a veteran in the telehealth program moves from Washington state to Arizona, he or she will get the same standard of care,” he added.

Although VA offers valuable lessons for telehealth use, it is not clear how broadly its rules can be applied. For one, VA has a budget for telehealth and does not rely on reimbursements. Most providers are expecting insurers, including Medicare, to reimburse for the care, but to date, the payments have been limited. In fiscal 2009, Medicare reimbursed only $2.4 million for 33,000 telehealth services.

“Third-party payers are very reluctant to pay for telemedicine,” said Ed Meagher, senior principal of health programs at SRA International and former deputy assistant secretary for information and technology at VA.

Also, VA physicians can practice across state lines, but states are responsible for licensing nonfederal practitioners. Difficulties in obtaining multistate physician certifications and liability protections are two factors that are hindering widespread telehealth adoption.

“We have ongoing concerns about state-based regulations,” Linkous said, adding that the association supports national licensing rather than state licensing for telemedicine physicians. “Some of the state licensing rules can be used to prevent new health care providers from coming into the market. There are concerns about competition.”

Another factor slowing adoption is that federal policy-makers have not yet taken a comprehensive look at the technology. Uncertainty about the federal regulatory approach to telehealth should be addressed in the near term, said Dr. Farzad Mostashari, senior adviser to HHS' Office of the National Coordinator for Health IT, when he addressed a Senate committee in April.

“While there is evidence that certain telehealth applications can improve care and reduce certain unnecessary costs, more information is needed about which strategies are most effective and under what circumstances,” Mostashari said.

The government’s regulatory approach to telehealth has been piecemeal and lacks cohesiveness, Linkous said. Most recently, FDA has begun examining the possibility of regulating patient safety related to telehealth. “Folks are recognizing the need, and recognizing the problem is the first step. We’re optimistic,” he added.

Meanwhile, the technology, interoperability and applications of telehealth are still developing and evolving, raising the possibility that 10 years from now, telehealth will look different from today’s configurations. Cisco Systems recently introduced a HealthPrescence platform that offers patients virtual visits with physicians. For example, the system can offer a patient the opportunity to view the same image of his or her eardrum that the doctor is seeing.

“Our view is that telehealth has to go a step beyond just offering a relationship [with a physician] at a distance,” said Dr. Kaveh Safavi, vice president and global lead at Cisco’s health care practice. He said he believes HealthPresence and other solutions can gain acceptance by offering an enriched and personalized experience for patients. He added that the technology can bring competition into new markets — for example, by allowing a cancer center to make its specialists available for virtual consultation all over the world.

It’s too soon to say whether patients will seek such experiences and help spur adoption of telehealth. Although VA has earned high scores in patient acceptance of telehealth, the future path is unclear.

“Telemedicine is a disruptive technology,” Meagher said. “It is a game-changer. Because it changes business and work processes, its uses have to be very thought out.”

Darkins said he also sees the wisdom of moving deliberately as VA expands telehealth to new modes of care, such as treatment for substance abuse. Protocols for overseeing a patient’s care, monitoring symptoms effectively from a distance and recognizing the signs that indicate a need for immediate intervention are still being developed, he said.

“Telehealth should not be used just for the sake of technology,” Darkins said. "It has to be based on fulfilling a need."