Running head: EFFECTS OF TELEHEALTH ON U.S.

HEALTH CARE

Effects of Telehealth on U.S. Health Care Ashley Bennett, Christeen Davis, Bridget Mullins, and Eric Weberding Miami University

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Effects of Telehealth on U.S. Health Care The rapid evolution of technology is impacting all facets of our lives from entertainment to health care. The impact of technology in health care is especially evident in the increasing use of telehealth technologies. The Office for the Advancement of Telehealth (OAT), part of the Office of Rural Health Policy, located within Health Resources and Services Administration (HRSA) at the U.S. Department of Health and Human Services (USDHHS, 2010) defines telehealth as the use of telecommunications and information technologies to provide health care services at a distance, to include diagnosis, treatment, public health, electronic medical records, consumer health information, and health professions education (para. 1). Currently, the two types of telehealth applications are real-time communication and store-and-forward. Real-time communication allows patients and health care providers to connect with health care providers via video conference, telephone or a home health monitoring device, while store-and-forward refers to transmission of data, images, sound or video from one site to another for evaluation (U.S. Department of Health and Human Services [USDHHS], 2010). Increased use of telehealth technologies has the potential to positively impact health care outcomes by increasing accessibility to health care for all regardless of their geographic location and making systems more efficient and cost-effective. Although telehealth technologies provide many opportunities, they also provide some unique challenges. In spite of the extensive evidence supporting the benefits of telehealth, there are opponents who maintain providing patient care via telehealth is neither legal nor safe. Stanberry (2001) contended that current professional guidelines and state licensure systems do not support the effective implementation of telehealth services. He maintained the current stateby-state licensing systems requires health providers to obtain multiple state licenses and adhere

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to diverse and sometimes conflicting state medical practice rules in order to treat patients in multiple states. Opponents also cited difficulty in enforcing practice standards and disciplining doctors in other states. The existing system only allows state medical boards to investigate and sanction doctors within their borders (Stanberry, 2001). In response to licensure concerns, the American Telemedicine Association (ATA, 2012) has proposed a massive overhaul of the current medical licensure system. The ATA is working to remove state licensure barriers to telehealth practice by seeking the support of Congress, state medical boards, and federal regulators to create a federal "licensure portability" law that would allow physicians to practice via telehealth in any state. They believe this law would eliminate the duplicative structures of multiple state boards and promote quality health care and patient safety across state boundaries (American Telemedicine Association [ATA], 2012). However, instead of waiting for a massive overhaul of the current medical licensure system, some states have initiated their own licensure revisions. The states of New Mexico and Alaska have elected to address the challenge of health care providers not being in the same state as their patients by creating a special telehealth licensure provision. This licensure provision allows out-of-state physicians to provide services with consent from the patient (Helseth, 2011). Another challenge related to the delivery of telehealth services is funding. Opponents of telehealth services cited the limited reimbursement policies for telehealth services as a deterrent to initiating and providing innovative telehealth care. According to Jones (2004), with the exception of teleradiology and selected telehealth services offered through limited grant programs, the majority of insurers, including Medicare, only reimbursed physicians for medical care that was delivered face-to-face. He contended that until reimbursement policies are expanded, the potential for improved access to quality health care through telehealth will not be

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utilized. However, limited reimbursement policies can be addressed through proposed policy changes as discussed later in this paper. In the United States, individuals with diverse health care needs who live in a variety of geographic locations have benefited from increased access to quality health care through telehealth technologies. One organization that has assumed a leading role in utilizing telehealth is the Veterans Health Administration (VHA). The VHA has demonstrated that telehealth technologies have the potential to improve access to quality health care and health outcomes. In 2003, the VHA expanded its use of telehealth with the creation of the Office of Care Coordination. This new office incorporated the Telemedicine Strategic Health Care Group and the Office of Social Work Service (Darkins, 2003). The primary responsibilities of the Office of Care Coordination were to manage the increased use of telehealth technologies in the national rollout of VHA Care Coordination programs, to direct the clinical input into e-health information to patients, and to create MyHealth-eVet so that each patient would have easy access to his/her health records. To support these comprehensive telehealth initiatives, the VHA increased their requests for proposals by $5 million to $12 million in FY2004 (Darkins, 2003). In 2010, the name, Office of Care Coordination Services was officially changed to the Office of Telehealth Services with renewed focus on the goal of ensuring Veterans receive the right care in the right place at the right time (U.S. Department of Veterans Affairs Health [VA], 2010 January, p.1). By 2011, the VHA was ranked as the worlds largest telehealth programs. The VHAs closed system model consisting of patients, providers, and payers, was adequately funded and assumed a leading role in the areas of telehealth research, development, standards, integration, needs assessment, and cost-benefit studies (VA, 2011b). In 2011, the VHA allocated $163

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million of its annual budget to telehealth to improve health care by increasing access, eliminating travel, reducing costs, and producing better patient outcomes (VA, 2010 February). Therefore, to accomplish its goal of increased access to high quality health care, the VHA offers a variety of telehealth services to veterans. VHA community-based outpatient clinics utilize Clinical Video Telehealth (CVT) to bring the expertise of specialists to clinics located closer to the veterans homes. Home telehealth services are offered to meet the health care needs of the growing population of aging veterans managing chronic diseases. The implementation of new telehealth technologies increases access to mental health services and intensive rehabilitation services for wounded veterans with complex medical needs (VA, 2011b). The VHA has evolved from a hospital based system of large regional medical centers to a more patient-centered care system including over 700 community-based outpatient clinics providing specialty care via CVT. CVT is used to make diagnoses, manage care, perform checkups, and provide care. The utilization of this telehealth technology has brought specialized care in areas such as cardiology, neurology, and psychiatry, closer to veterans homes and eliminated potentially long and draining trips to access medical care at one of the regional VHA Medical Centers. In 2010, over 6,000 veterans accessed CVT services in just one of the 21 VHA service regions in the United States (VA, 2011a). Another application of telehealth is the VHAs program, Care Coordination/Home Telehealth (CCHT). CCHT provides home-based services that help aging veterans to manage chronic conditions, to maintain independence, and to avoid unnecessary admission to long-term institutional care facilities. Between July 2003 and December 2007, CCHT patients increased from 2,000 to 31, 570 (Darkins et al., 2008). CCHT patients were predominately male and 65 years or older. Through the systematic use of health informatics, home telehealth, and disease

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management technologies, CCHT helped aging veterans live independently at home. According to Darkins, et al. (2008) a data analysis of 17,025 CCHT patients indicated a 25 percent reduction in numbers of bed days of care, 19 percent reduction in hospital admissions, and a satisfaction score rating of 86 percent after enrollment in the CCHT program. Additional costs savings were also noted when comparing the CCHT cost of $1,600 per patient per year to the cost of hospitalization or long-term nursing home care. In another study of the effectiveness of VHAs home telehealth services, Wakefield et al. (2008) compared the effectiveness of telehealth care to traditional care in recently discharged outpatients with heart failure. In this randomized controlled clinical trial, the treatment subjects received electronic blood pressure monitors and scales; they were instructed to measure daily vital signs, weights, and ankle circumference. This information was communicated via telephone or videophone to a registered nurse. Registered nurses managed intervention delivered by either telephone or videophone for 90 days following discharge from the hospital. The control subjects received traditional outpatient care. Data analysis indicated that although there were no differences in Urgent Care visits or mortality, telehealth interventions were effective in reducing time to first readmission during the active intervention time and up to 12 months later. Wakefield et al. (2008) attributed this to the potential of telehealth-facilitated care to support earlier detection of critical clinical symptoms, leading to early intervention and resulting in a reduced need for hospitalization. The VHA is responsible not only for the physical health of veterans but for the mental health of American veterans as well. Meeting the mental health needs of veterans presents a growing challenge. The VHA estimates 18.5 to 42.5 percent of recently returned service members and veterans have been found to have a mental disorder (Watkins & Pincus, 2011).

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In an attempt to provide access to quality mental health services, the VHA has initiated the use of telehealth to deliver evidence-based psychotherapy. Although the number of studies on the effectiveness of delivering psychotherapy via telehealth services is limited, one study by Gros, Yoder, Tuerk, Lozano, & Acierno, ( 2011), suggested cognitive behavioral therapy delivered via telehealth was effective in reducing the symptoms of Post Traumatic Stress Disorder, anxiety, depression, and stress. Additionally, their study indicated that telehealth mental health services may have distinct advantages over in-person treatments in terms of easy access, eliminating transportation costs, decreasing travel time, reducing absenteeism from employment, and eliminating stigma that may deter some veterans from accessing mental health services (Gros, Yoder, Tuerk, Lozano, & Acierno, 2011). The increasing severity and complexity of combat injuries has mandated long-term rehabilitation to support the medical needs of Operations Iraqi Freedom and Enduring Freedom veterans (Cruise, Darkins, Armstrong, Peters, & Finn, 2008). In order to meet the unique needs of these veterans in a timely manner and provide multiple locations for access to specialized rehabilitation care, the VHA developed a sophisticated and highly-specialized Polytrauma Telehealth Network (PTN). The PTN connects the Polytrauma Rehabilitation Center (PRC) hub sites located at four Department of Veterans Affairs Medical Centers (VAMCs) in Richmond, Virginia; Tampa, Florida; Minneapolis, Minnesota; and Palo Alto, California. These four hub sites have specialized clinical expertise in polytrauma and are linked via PTN to polytrauma network sites (PTNs) in regional VAMCs. This network provides tiered interdisciplinary rehabilitation services for veterans at multiple VHA facilities across the U.S. and eliminates extensive travel for severely wounded veterans and their families (Cruise et al., 2008).

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During the past decade, the VHA has extensively reconfigured patient health care delivery to reduce barriers to quality health care. As a result of this transformation, the VHA has emerged as a leader in the delivery and research of telehealth services. The VHA serves as a model for private and other public health care systems as they seek innovative ways to effectively implement telehealth technology. Veterans are not the only group of Americans to benefit from telehealth technology. Citizens in underserved areas in rural America receive a variety of health care services via telehealth. The HRSA works to promote and improve health care in these underserved areas by fostering partnerships among federal and state agencies and the private sector. The HRSA also administers telehealth grant programs while providing technical assistance. Telehealth technology and programs are evaluated through the HRSA as agencies work collaboratively to improve access to quality health services in underserved areas (USDHHS, 2010). The HRSA houses the Office for the Advancement of Telehealth (OAT) which promotes the use of telehealth technologies for health care delivery, education, and health information services (USDHHS, 2010). This office is part of the Office of Rural Health Policy, which also supports the HRSAs mission to assure quality health care for underserved, vulnerable, and special needs population. In 2005, the OAT administered 159 telehealth/telemedicine projects, of those, 92 were awarded funds totaling more than $34.9 million (USDHHS, 2010). According to the OAT grantee directory, projects administered by OAT received funds in the following four ways: 1. The Telehealth Network Grant Program (TNGP): The TNGP funded projects that demonstrate the use of telehealth networks to improve healthcare services for medically underserved

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populations in urban, rural, and frontier communities. The networks can be used to expand access to high quality of health care services; improve and expand the training of health care providers; and/or expand and improve the quality of health information available to providers, patients, and their families. The primary objective of the TNGP is to assist communities in building capacity to develop sustainable telehealth programs and networks. 2. Congressionally Mandated Projects (CMP): OAT also administered funds specially earmarked by Congress to support a wide variety of telehealth initiatives to improve access to health care. 3. Special Projects: These projects were funded through OAT grantees to support program evaluation and distribution of telehealth technologies among grantees. 4. Rural Telemedicine Grant Program (RTGP): The OAT awarded competitive grants through 2002. The goal of the RTGP was to improve quality health services for rural residents and reduce the isolation of rural practitioners through the implementation of telehealth technologies (USDHHS, 2010). As telehealth expands, rural community hospitals are gaining virtual access to the expertise of board certified emergency physicians, neurologists, intensivists, pharmacists, cardiologists, dermatologists, psychologists, as well as wound and infectious disease specialists. In the 1990s, a privately owned medical company, Avera, moved into the virtual world using closed circuit televisions to provide eConsult, live doctor-patient consultations. Today, Avera connects rural patients and providers with specialty providers using telehealth services such as eEmergency, eICU, eStroke, eConsult, eNursery, ePharmacy, and eUrgent Care (Helseth, 2011). Averas eEmergency is their most highly requested eCARE service. This service is a hospital-based telehealth emergency support service that connects rural hospitals with board certified emergency physicians and emergency-trained nurses 24 hours a day. These specialists

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provide treatment advice, initiate diagnostic testing, and facilitate patient transfer if indicated. According to Deanna Larson, Vice-President of Quality Initiatives and eCARE Services, eEmergency has reduced patient length of stay, patient transfers to tertiary facilities, and overall costs. Larson also noted a high level of satisfaction among clinicians at the remote sites (Helseth, 2011). In 2003, Sutter Health, a northern California-based health care organization, became the first health care organization on the West Coast to connect a rural hospital to eICU. According to Sutter Health, death related sepsis decreased by 28 percent and patients lengths of stay have also decreased by 15 percent from 2007 to 2010 (Helseth, 2011). Teresa Rincon, Sutter Health eICU nurse director, attributed these improved outcomes to community medical staffs, eICU nurses, and intensivists working closely together to quickly detect and treat infections and other of life-threatening symptoms that occur in these critically ill patients (Helseth, 2011). According to the National Conference of State Legislatures (NCSL, 2012), a national bipartisan organization, patients in rural America face unique challenges to access health care due to the limited numbers of physicians practicing in their communities. The NCSL (2012) noted that although 20 percent of the U.S. population lives in rural settings, only 10 percent of physicians practice there. This has resulted in disparities between rural and urban physician supplies. To address this problem, the Affordable Care Act (ACA) provides workforce incentives to encourage medical providers to practice in rural areas. However, recruiting and retaining physicians in rural settings continues to be a challenge. In an attempt to improve access to health care in rural areas, telehealth networks are being increasingly used to connect patients and providers in various settings (NCSL, 2012).

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In the private sector in patients homes, telehealth technologies are also removing distance barriers and assisting patients to manage chronic illnesses from their homes. Home health monitoring devices allow chronically ill patients to transmit vital signs and health status data remotely to care providers who monitor their health status and provide timely medical interventions. Providing such accessible interaction and disease management has helped reduce hospital readmission rates as well as decrease medical emergencies (Helseth, 2011). Similar benefits of telehealth were also noted in rural California. According to Steve Barrow, Policy Director for the California State Rural Health Association, telehealth services have decreased the number of days economically strapped patients are absent from work due to traveling long distances to health care facilities, reduced the effects of medical provider shortages, and improved management of chronic diseases (NCLS, 2012). Additionally, a 2010 report by the Federal Communications Commission estimated that remote patient monitoring for heart disease, diabetes, pulmonary disease, and skin disease could save an estimated $197 billion nationwide over 25 year (as cited in USDHHS, 2010). Accordingly, many states have begun to include telehealth technology in public health efforts to increase access to underserved populations. Currently 39 states provide some form of Medicaid reimbursement for telehealth services, and 12 of these states require private insurance plans to cover telehealth services. In 2005, New Mexico created the Telehealth Commission to offer coverage for telehealth services to Medicaid recipients and to fund telehealth services at school- based health centers. Alaskan state officials have also been working to establish a large telehealth network that connects rural and remote Alaskans to medical care providers. Rural communities face unique challenges when attempting to access health care providers and suffer greater health disparities than urban communities (Helseth, 2011). To meet the unique health

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care needs of rural communities, state policies need to mandate reimbursement by Medicare and Medicaid for telehealth costs to eliminate health care disparities in rural areas. Another application of telehealth technology is the use of Electronic Medical Records (EMRs). According to OpenClinical, a nonprofit international organization providing resources on advanced technological health care, progress in medical informatics over the last 30 years have supported the evolution of EMRs. When compared to paper-based health care records, the advantages of EMRs are immense. EMRs not only support improved access to quality health care but also support efficient and cost-effective health care (OpenClinical, 2012). Technologic advances support the ongoing inclusion of all patient data, including clinical documentation, diagnostic tests, and imaging studies directly into the electronic record. To protect the patients privacy, access to the EMR is password protected and data are encrypted. EMRs support convenient access to multiple providers, hospitals, and offices within a particular record system. Simultaneous access by multiple providers supports timely decisions and the continuity of care. Commonly used EMR systems include Epic, Meditouch, Vitera, and Allscripts (OpenClinical, 2012). Embedded features of EMRs support efficient practice and improved outcomes for patients. The decision support component gives clinicians easy access to guidelines and literature related to their patients care; it also generates clinical reminders to facilitate treatment and preventive care. The physician order entry feature reduces common transcription errors and automatically searches for drug interactions. The patient support component gives patients access to portions of their medical records through systems such as My Chart. Furthermore, EMRs patient support provides education and home monitoring to assist patients as they manage their health care. In terms of telehealth services ability to improve administrative

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processes in the hospitals and clinics, EMRs streamline scheduling and prompt servicing of patients (OpenClinical, 2012). The advantages of EMRs are extensive; however, to attain maximum benefits from EMRs, state and federal policies and incentives are needed to support national participation and system interconnectivity. The benefits of telehealth to diverse populations in the U.S. are well documented. However, to ensure all patients have maximum access to telehealth technologies, extensive policy change is needed. To accomplish this, we propose that the Obama Administration directs the Centers for Medicare and Medicaid Services (CMS) to uniformly provide the same coverage for health care services delivered either in person or through telehealth services. The exclusion of health care services from coverage because they are delivered via telehealth technologies would be forbidden unless contraindicated. This policy change would support MedicareMedicaid payment and service models for hospital intensive care unit services from telehealth intensivists and other specialists, telehealth outpatient services, including telerehabilitation for stroke or traumatic brain injuries, and telemental health counseling; the use of telehealth to provide chronic care coordination for conditions such as Parkinsons, autism, muscular sclerosis, epilepsy and Alzheimers; and telehealth models for serving at-risk pregnancies, premature infants, and newborn screenings (ATA, 2011). Additionally, the CMS should work diligently to improve telehealth coverage by expanding the use of video conferencing to deliver services to Medicare-Medicaid beneficiaries in metropolitan areas with a focus on telestroke diagnosis and emergency cardiac care. The CMS should implement plans to improve the delivery of Medicare-Medicaid services using store-and-forward technology, particularly for specialist consultations using medical images to target key medical conditions, such as diabetic retinopathy screening and wound management

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(ATA, 2011). These proposed policy changes will provide funding to reduce disparities in access to care, improve medical specialists availability, reduce health care costs, improve quality of care, and provide patients with greater choices for health care options. In conclusion, the numerous benefits of telehealth easily outweigh the manageable challenges of licensure and reimbursement. Telehealth technologies are valuable tools that have the proven capacity to improve access to quality health and make health care delivery systems more efficient and cost-effective. Telehealth can improve communication of essential patient data and deliver crucial medical services where they are needed most by removing barriers of time, distance, and provider scarcities. Individuals in remote, rural areas and medically underserved urban communities benefit from telehealth innovations. However, only a fraction of telehealths potential has been realized to date. With adequate state and federal funding, telehealth technologies have the power to improve the performance of the U.S. health care system and eliminate health disparities across America.

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References American Telemedicine Association. (2011). Telemedicine priorities for the Center for Medicare and Medicaid Innovation. Retrieved from http://www.americantelemed.org/files/public/policy/SixFixes_TelemedicinePrioritiesFor CMSInnovation.pdf American Telehealth Association. (2012). Removing medical licensure barriers: increasing consumer choice, improving safety and cutting costs for patients across America. Retrieved from http://media.americantelemed.org/licensurewebsite/ Cruise, C., Darkins, A., Armstrong, M., Peters, J., & Finn, M. (2008). Enhancing access of combat-wounded veterans to specialist rehabilitation services: VA polytrauma network. Archives of Physical Medicine and Rehabilitation, 89(1), 182-187. Darkins, A. (2003). Creation of new VHA office of care coordination benefits VHA telemedicine. Veterans Health Administration Telemedicine Newsletter (Policy Newsletter), III (II) Retrieved from http://www.telehealth.va.gov/newsletter/2003/091103-newsletter summer_03.pdf Darkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., & Lancaster, A. (2008). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veterans with chronic conditions. Telemedicine and e-Health, 14(10), 1118-1126. doi:10.1089/tmj.2008.0021

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Gros, D., Yoder, M., Tyerk, P., Lozano, B., & Acierno, R. (2011). Exposure therapy for PTSD delivered to veterans via telehealth: Predictors of treatment completion and outcome and comparison to treatment delivered in person. Behavior Therapy, 42(2), 276-283. Helseth, C. (2011). e-Emergency services bring specialists to rural patients with the push of a button. Rural Assistance Center. Retrieved from http://www.raconline.org/newsletter/summer11/feature.php#story1 Jones, J. W. (2004). Payment and other legal obstacles slow telemedicine growth. Managed Health Executive, 53-54. Retrieved from http://managedhealthcareexecutive.modernmedicine.com/mhe/data/articlestandard/mhe/1 22004/89059/article.pdf National Conference of State Legislatures. (2011). Telehealth and rural health care delivery. Retrieved from http://www.ncsl.org/issues-research/health/telehealth-and-rural-healthcare-delivery.aspx OpenClinical. (2012). Electronic medical records. Retrieved from http://www.openclinical.org/emr.html Stanberry, B. (2001). Legal, ethical and risk issues in telemedicine. Computer Methods and Programs in Biomedicine, 64(3), 225-233. Retrieved from www.sciencedirect.com/science/article/pii/S0169260700001425 U.S. Department of Health and Human Services, Health Resources and Services AdministrationRural Health. (2010). Telehealth. Retrieved from http://www.hrsa.gov/ruralhealth/about/telehealth/index.html

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U. S. Department of Veterans Affairs. VHA Office of Telehealth Services. (2010, January). The office formerly known as care coordination services. VHA Telehealth Quarterly, 9(3). Retrieved from http://www.telehealth.va.gov/newsletter/2010/011510-Newsletter_Vol9Iss3.pdf U. S. Department of Veterans Affairs, House Committee on Veterans Affairs. (2010, February). Statement of the Honorable Eric K. Shinsekise, Secretary, U.S. Department of Veterans. Retrieved from http://www.va.gov/OCA/testimony/hvac/100204EKS.asp U. S. Department of Veterans Affairs. (2011a). VISN 4 Strategic Plan FY2011-2013. Retrieved from http://www.virec.research.va.gov/DataSourcesName/Medical-SASDatasets/MedSAS-Outpt-RUG/MedSAS-RUG-Outpt09er.pdf U. S. Department of Veterans Affairs. VHA Office of Telehealth Services. (2011b). What is telehealth? Retrieved from http://www.telehealth.va.gov/index.asp Wakefield, B., Ward, M., Holman, J., Ray, A., Scherubel, M., Burns, T.,Rosenthal, G. (2008). Evaluation of home telehealth following hospitalization for heart failure: A randomized trial. Telemedicine and e-Health, 14(8), 753-761. doi:10.1089/tmj.2007.0131.

Watkins, K. E. & Pincus, H. A. (2011). Veterans Health Administration mental health program evaluation. Sponsored by the Veterans Health Administration. http://www.mentalhealth.va.gov/docs/capstone revised TR956 compiled.pdf

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