Telehealth and Telemedicine

January 23, 2016

James Coviello, MD
Andrew Moleski
Brook Watts, MD, MS
 Agenda
1. Introduction and Overview
2. Telemedicine at the VA
3. UH Telemedicine Development
4. Q&A

January 23, 2016 Confidential 2

 Telemedicine and Telehealth
Telemedicine: The use of technologies to remotely
diagnose, monitor, and treat patients

Telehealth: The application of technologies to help

patients manage their own illnesses through improved
self-care and access to education and support
systems

Source: Connected Health: A Review of Technologies and Strategies to Improve Patient Care with Telemedicine
and Telehealth; Health Affairs 2014

January 23, 2016 Confidential 3

 What is Telemedicine?
Use Cases May Be Achieved Across Multiple Modalities
Telehealth Use Cases, Relevant Modalities, and Investment Required
Ongoing
Professional Diagnosis & Education &
Use Cases

Monitoring
Consultation Treatment Engagement & Care
Coordination
Modalities

Videoconference Asynchronous Remote Device Telephone Patient Mobile App

Store-and-Forward Portal
• Need software, • Need additional • More expensive • Little tech • High security • Minimal hardware
secure internet bandwidth, hardware investment, needs require investment for
access for patients storage space investment requires proper significant providers
• • • staffing investment
Home and Can replace non- Used for high-risk • Complex security
hospital-based urgent phone calls patients in non- • Used for pre-visit • Must integrate and data storage
technology and visits hospital site triage EHR issues

Source: Marketing and Planning Leadership Council

interviews and analysis. (Advisory Board)

January 23, 2016 Confidential 4

 5

More Services Being Provided Virtually

Services Can be Offered at a Lower Cost

Remote Emerging Areas In-Person

• Diagnoses, treatments for Virtual Care • Diagnoses, treatments
follow reliable standard more complex, may vary
Management, Maintenance
protocols based on within disease category
evidence-based medicine • Chronic disease checkups,
follow-ups • Therapies may need careful
• Suggested therapies are selection and monitoring
nearly always effective • Care plan updates
• Physical exam or diagnostic
• Physical exam not • Specialist consults test required to correctly
required, visual exam adds Diagnosis, Treatment identify issue and select
nominal value • Remote diagnostics treatment
• Self-guided interventions • Intervention required
(i.e., immunization)

Source: Marketing and Planning Leadership Council interviews and

analysis. Advisory Board
Following Trial, Strong Preference for Virtual Care
Telehealth Pilot Shows Early Adopters Now Recruiting Early Majority

Of a virtual visit provider’s

92% patients said they would
use the service again Case in Brief: Medical Associates
Clinic

Of Zipnosis users would
91% recommend the service to
at least three friends
Of midsized to large U.S.
71% employers anticipate offering
employees telehealth
services within three years
• Four-physician practice in
Kentucky
• Piloted the Me-Visit mobile app
to offer online care for primary
care and chronic condition
follow up needs
• In 30-month pilot, 20% of
patients used the app, and 97%
of users preferred the service to
in-person care

January 23, 2016 Confidential 6

Technology Getting Faster, More Widespread
Enables Growth in Telehealth

Advancements in Increased Population Medicare-Billed Telehealth Encounters

Technology
• Remote monitoring • 100% US population 36,100
32,702
devices with cellular or covered by mobile
fixed-line modems network
enabling data • Health information fastest- 20,804
transmission without growing content accessed
computer or by US mobile users, up 10,381
smartphone 134% between 2010-2011
• Expanded memory and 4,848 5,791
4,160
processing capabilities
• Geospatial tracking
2005 2006 2007 2008 2009 2010 2011
• Movement tracking
• Touch-screen
technologies

Sources: “mHealth in an mWorld: How mobile technology is transforming health care,”

Deloitte, available at http://www.deloitte.com/; Health Care IT Advisor research and
analysis
Examining CMS Coverage Requirements
Specific Criteria Must be Satisfied to Qualify for Reimbursement

Core Eligibility Requirements for CMS Reimbursement

Geographic Location Type of Health Provider Type of Institution
1 2 3
of Receiving Site Delivering Service Delivering Service
• Must be provided to an • Physician • Office of a physician or
eligible beneficiary in an • Nurse practitioner practitioner
eligible site • Hospital
• Physician assistant
• Site must be located • Rural health clinic
outside of a • Nurse midwife
Metropolitan Statistical • Clinical nurse specialist • FQHC1
Area
• Clinical psychologist • Skilled nursing facility
• Eligible sites do not • Hospital-based dialysis center
• Clinical social worker
include a patient’s
• Registered dietitian or • Community mental health
home
nutrition professional center

• Sources: “Medicare Telehealth Payment Eligibility Analyzer,” U.S.

Department of Health and Human Resources,
http://datawarehouse.hrsa.gov/telehealthAdvisor/telehealthEligibility.aspx;
Cardiovascular Roundtable research and analysis.

January 23, 2016 Confidential 8

Telemedicine in Ohio
1. Private insurers are not mandated to cover
telemedicine visits
2. Limited coverage by Medicare
3. Medicaid reimbursement for live consults began
January 2015
4. OhioHealth and Ohio State have well-established
and expansive Telestroke networks
5. VA has the largest telemedicine program in the U.S.
6. Cleveland VA Medical Center has the 2nd largest
telemedicine program in the VA

January 23, 2016 Confidential 9

 Cleveland VAMC

Telehealth Use Cases, Relevant Modalities, and Investment Required

Ongoing
Professional Diagnosis & Education &
Use Cases

Monitoring
Consultation Treatment Engagement & Care
Coordination
Modalities

Videoconference Asynchronous Remote Device Telephone Patient Mobile App

Store-and-Forward Portal
• Need software, • • More expensive • Minimal hardware
Need additional • Little tech • High security
secure internet bandwidth, hardware investment for
investment, needs require
access for patients storage space investment providers
requires proper significant
• Home and • Can replace non- • Used for high-risk staffing investment • Complex security
patients in non- and data storage
hospital-based urgent phone calls • Used for pre-visit • Must integrate
technology and visits hospital site issues
triage EHR

Source: Marketing and Planning Leadership Council

interviews and analysis. (Advisory Board)

January 23, 2016 Confidential 10

 Cleveland VAMC FY15
• 3rd most complex VHA facility in the country
• Total Unique Patients : 109,962
• 34% are classified as Rural Patients
• Admissions: 10,416; ADC: 508
• Outpatient Encounters: 1,965,061
• Outpatient Visits: 1,480,712
Areas We Serve

The Louis Stokes Cleveland VAMC

provides care for 110,000 Veterans residing in 24 counties
12
 Cleveland VAMC
Home Telehealth – Unique Patients
1,800
1,700
1,600
1,535
1,500
1,400

1,200
Unique Patients

1,000 1,000
971

800

673
600 628

400

213 237
200

78 103
0 2
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 (Proj.)
Fiscal Year

January 23, 2016 Confidential 13

Cleveland VAMC
Home Telehealth
 Diagnoses
 Diabetes
 CAD
 CHF
 COPD
 Hypertension
 Spine Cord Injury
 Depression
 Schizophrenia
 PTSD
 Bipolar
 Dementia
 Low ADL
 MOVE!
 Smoking Cessation
 Substance Abuse
 Daily monitoring
 Easy to use and transport
 Interactive Voice Response
 Cleveland VAMC
Clinical Video Telehealth
12,000

10,000 10,000

8,000 8,090
Encounters

6,000 5,889

4,582
4,000

2,000 2,012

908 825 816 973

463
0 2 96
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 (Proj.)
Fiscal Year
January 23, 2016 Confidential 15
 Cleveland VAMC
Clinical Video Telehealth
 Tele-Nutrition
 Tele-Traumatic Brain Injury
 Tele-Audiology
 Tele-Speech Pathology
 Tele-Physical Therapy
 Tele-Occupational Therapy
 Tele-Blind Rehab
 Tele-Spinal Cord Injury
 Tele-Amputation
 Tele-Urology
 Tele-Diabetes  Tele-Pain Medicine
 Tele-Gastroenterology  Tele-Mental Health
 Tele-Pulmonary  Tele-Substance Abuse
 Tele-Nephrology  Tele-HUD/VASH
 Tele-Neurology  Tele-PTSD
 Tele-Primary Care  Tele-PRRC
 Tele-Genomic Medicine  Tele-Justice Outreach
 Tele-MOVE!  Tele-Physical Medicine
 Tele-Surgery  Tele-Cardiology
 Tele-Prosthetics  Tele-Orthotics
 Tele-Pharmacy  Tele-Healthy Cooking
 Tele-Retinal Imaging
Cleveland VAMC Tele-Dermatology
Tele-Wound Care
Store and Forward Tele-Spirometry
9,000

8,500
8,000 8,090
7,898

7,000

6,000

5,000
Encounters

4,000
3,797

3,000 2,900 2,994

2,849
2,592

2,000

1,000
775
446
0 27
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 (Proj.)
Fiscal Year
January 23, 2016 Confidential 17
 The Evidence (in one slide)
• VA-specific

• Circumstantial

• Usually part of a complex intervention

• Few randomized trials

. . .but patients like it

January 23, 2016 18

Confidential
 Telehealth vs Face-to-Face

• Cochrane review 2010

• Little evidence of clinical benefits (though no clear harms either)

• Cost effectiveness not clear

• Patients were satisfied

• . . . But only 7 trials met inclusion criteria (had to compare

telemedicine to face-to-face)

January 23, 2016 19

Confidential
19
Telemedicine at University Hospitals
Program Classification Leader
Online Scheduling Patient Access Maria Kamenos
Tele-Urgent Care Direct to Consumer Andrew Moleski
Tele-EPAT Video Consult Bob Ronis, MD
CEM Child Telepsych Video Consult John Hertzer, MD
Home Care Remote Direct to Consumer Keith Maitland
Rainbow Care Connection Population Health Mgmt Andrew Hertz, MD
(Nurse Triage) Patient Access
Video Concierge Patient Access Maria Kamenos
Telestroke Video Consult Tony Furlan, MD
Transplant Institute Patient Education Barb Loiselle
Teleradiology Store and Forward Pablo Ros, MD
Maternal Fetal Medicine Video Consult Michelle Walsh, MD
Neonatology Video Consult Michelle Walsh, MD
Remote Second Opinion Direct to Consumer Erin Slay
Pediatric Specialty Consults Video Consult Robin Strosaker, MD

Emmi Solutions Population Health Mgmt Nate Hunt

UH Patient Portal Direct to Consumer Kathy LeBrew
Martii Virtual Translation Patient Access Ron Dziedzicki

January 23, 2016 Confidential 20

Telehealth Opportunities for UH
Goal Currently Gain Improve Improve Lower Manage
Generates Market Access Quality Costs/ Defined
Revenue Share Improve Populations
Efficiency (ACO and
Direct
Employer)
1 Tele-Urgent Care Yes Yes Yes Yes Yes Yes

2 Online Yes Yes Yes Yes

Scheduling

3 Clinical Video Yes Yes Yes Yes Yes Yes

Telemedicine (Limited)

4 Expanded Home No Yes Yes Yes Yes Yes

Telemonitoring

5 Remote ICU Possible Yes Yes Yes

6 E-visits through Possible Yes Yes Yes Yes

Patient Portal
7 Store and Yes Yes Yes Yes Yes
Forward (Radiology
Programs Only)

January 23, 2016 Confidential 21

“If we scale the tele-health system to its full
potential, it will become the dominant way that
outpatient medicine is rendered.”

- Eric Topol, MD – Author of “The Patient Will See You Now”

“Before you become too entranced with gorgeous

gadgets and mesmerizing video displays, let me
remind you that information is not knowledge,
knowledge is not wisdom, and wisdom is not
foresight. Each grows out of the other, and we need
them all.”

- Arthur C. Clarke

January 23, 2016 Confidential 22

Q&A

January 23, 2016 Confidential 23