In early 2019, HITEQ completed a literature review of recent research and publications about telehealth. Within this compendium, HITEQ summarizes these articles and discusses possible implications or considerations for health centers.
Summary of Literature and Articles
Authors: Erin Shigekawa, Margaret Fix, Garen Corbett, Dylan H. Roby, and Janet Coffman
Brief Summary:
- In this rapid review, the authors searched for systematic reviews and meta-analyses of the use of telehealth services by patients of any age for any condition published in the period of January 2004 to May 2018. They identified 20 systematic reviews and meta-analyses that fit this criteria. These reviews and meta-analyses reported on care delivered through live video conferencing, asynchronous store and forward of data, telephone, email, text, and chat. They related to the clinical areas of: telemental health, telerehabilitation, teledermatology, teleconsultation, and other (e.g., oral anticoagulation management, nutrition management, and diabetic foot ulcer treatment). The purpose of the rapid review was to determine whether the current research shows that services delivered via telehealth are equivalent to in-person services and if the use of telehealth services affects the use of other services. They found that, overall, telehealth is comparable to in-person care, however further research is needed to determine the impacts of telehealth use on other services. In other words, the question of whether telehealth can effectively substitute in-person care remains unanswered.
Health Center Takeaway:
- In most research to date, telehealth appears to be as effective as in-person care in providing services, therefore making it a viable consideration for expanding access to care.
- There are mixed findings in the literature regarding the impact of telehealth use on patient services. Health centers who are looking to measure the efficacy of telehealth programs, especially from a financial investment and return perspective, should track data on patient services such as hospitalizations, repeat visits, and length of both in-person and virtual visits.
Authors: Courtney Lyles, PhD and Urmimala Sarkar, MD, MPH
Brief Summary:
- This article describes a large-scale telemedicine diabetic retinopathy (DR) screening program in the Los Angeles County Department of Health Services. The implementation of the screening program led to improvements in wait times and rates of screening for DR. The key implementation strategies used were: standardizing referral workflow, standardizing a system for optometrists to make triaging decisions about which patients should be seen, and organizing communication between clinics about screening results and scheduling.
Health Center Takeaway:
- Effectiveness in telemedicine screening programs goes beyond just the telemedicine camera technology. Outcome of screening programs are dependent on the use of technology in the context of new team-based clinical workflows.
Author: Lauren P. Daskivich, MD, MSHS; Carolina Vasquez, BA; Carlos Martinez Jr, BA; et al
Brief Summary:
- The Los Angeles County safety net examined whether a primary care-based teleretinal DR screening (TDRS) program reduces wait times for screening and improves timeliness of care. After initiation of the program, the median time to screening for DR decreased significantly (158 to 17 days) and the annual screening rates for DR increased by 16.3%.
Health Center Takeaway:
Often, the significant wait time for patients to see optometrists leads to lengthy time between referral and screening for DR and therefore decreases overall screening rates. Building relationships with specialists who utilize telemedicine, such as optometrists, can decrease these wait times for screenings and improve screening rate.
Authors: Haiden A. Huskamp, Alisa B. Busch, Jeffrey Souza, Lori Uscher-Pines, Sherri Rose, Andrew Wilcock, Bruce E. Landon, and Ateev Mehrotra
Brief Summary:
- This article identified the characteristics of telemedicine for SUD (tele-SUD) users and examined how tele-SUD is being used in conjunction with in-person SUD care. Researchers found that tele-SUD visits accounted for a very small share (1.4%) of telemedicine visits for any health condition reimbursed in the study period. Therefore, this finding indicates that there are regulatory and reimbursement barriers to the use of tele-SUD.
Health Center Takeaway:
- The most common model of tele-SUD is a physician with expertise in addiction treatment providing, via telemedicine, an initial assessment or prescription of SUD medication, while local clinicians provide counseling and follow-up in person. The provision of tele-SUD depends on having primary care physicians deliver SUD treatment, especially for prescribing medications. Project ECHO (Extension for Community Healthcare Outcomes) uses teleconferencing to provide training from addiction medicine specialists to primary care physicians in underserved areas. Programs like this can be used by health centers to help expand the provision of tele-SUD services and lessen workforce barriers.
Authors: Ching-Ching Claire Lin, Anne Dievler, Carolyn Robbins, Alek Sripipatana, Matt Quinn, and Suma Nair
Brief Summary:
- This study examined factors associated with and barriers to (e.g., location, patients, operation, and reimbursement policies) telehealth use by federally funded health centers. Almost half of the health centers were located in rural areas and almost all of the centers were in a state where Medicaid reimbursed some form of live video. In states where Medicaid reimbursed live video or store-and-forward services, health centers had a higher probability of using telehealth. The most cited reasons by both urban and rural health centers for not using telehealth were cost, reimbursement, and technical issues such as lacking equipment and having incompatible electronic health record (EHR) systems.
Health Center Takeaway:
Despite the potential benefits (e.g., potential to improve access to care in rural or urban areas with limited health care resources), telehealth has not been fully adopted by health centers. This is often due to perceived lack of need for telehealth or lack of information and training around the topic. An opportunity exists to leverage Health Center Controlled Networks (HCCNs) and other health center partners to increase health centers’ telehealth use through education, training, and health IT advancement.
Authors: Denise L. Anthony, Celeste Campos-Castillo, and Paulina S. Lim
Brief Summary:
- The responses of 2,325 insured patients to the 2017 Health Information National Trends Survey were analyzed to characterize patient portal nonusers and reasons for nonuse. Of the patient population examined, a majority (63%) reported that they did not use a portal during the prior year. Nonusers were more likely to be male, be on Medicaid, lack a regular provider, and have less than a college education, compared to users. The main reasons for non-use included the desire to speak directly to providers and privacy concerns.
Health Center Takeaway:
- To address barriers to patient portals, efforts must be focused on more than just increasing access to technology. Patients expressed that they perceived the drawbacks to using technological tools and telehealth were concerns for their privacy and the desire for their interactions with providers to be in-person. To help facilitate the use of patient portals, it is important for providers to understand these concerns and address them. The provider-patient relationship must still be taken into account, even when communication is not face-to-face.
Authors: Jeongyoung Park, Clese Erikson, Xinxin Han, and Preeti Iyer
Brief Summary:
- Researchers analyzed four years of data from a nationally representative consumer survey to examine telehealth use trends and the effects of state health policy on telehealth usage. They found that the fastest growth in use of telehealth is live video communication. Usage of live video communication was found to be significantly associated with population characteristics, with age, health status, insurance type, income, and rural location among the biggest predictors. Interestingly, there was no significant association between less restrictive state telehealth policies and increased use of live video communication (after controlling for population characteristics).
Health Center Takeaway:
- This study found that more patients reported that they are willing to use live video communication than are actually using it. Therefore, creating incentives for providers and health centers to invest the time and funds needed to use telehealth can increase patients’ access to care. A method for incentivizing providers is to offer financial incentives for telehealth adoption. For example, Kaiser Permanente Medical Group provided 9,000 physicians with a complimentary iPhone and data plan to support telehealth use. Their medical group counts Telehealth visits the same as in-person visits and these visits count towards providers’ new consult targets. As a result of this program, all of the providers have participated in some video visits.
Author: Telehealth and Medicine Today, interview with Robert Abel
Brief Summary:
- During this interview, Robert Abel, the Chief Nursing Officer and Director of Palliative Care for MaineHealth Care at Home, answered questions about the MaineHealth Telemedicine Program. The palliative care department telemedicine program uses virtual visits with its palliative care and heart failure patients. Nurses’ aides from the home health agency set up the equipment (e.g., scales, BP cuffs) in patients homes and provide education on how to use the tools. Physician treatment parameters are received for all patients in the program and protocols are triggered if patients’ vitals fall outside the parameters. When the protocol is triggered, typically a full set of vitals is taken daily and a nurse reviews the data remotely. Nursing staff use video calls on their cellphones to connect with patients. MaineHealth convenes a workgroup quarterly to assist in facilitating this telemedicine program. They are working on developing an atrial fibrillation program next.
Health Center Takeaway:
- When working in large service areas covering states, like Maine, it is important for telemedicine devices, both for staff and patients, to be adaptable such as using multiple cell phone service providers depending on the service area. Additionally, it is helpful to use a single medical database when implementing telehealth programs, especially when the health center has many sites or covers a large service area. Another consideration is how to effectively and efficiently train patients to use the new technology. Beyond initial patient education provided by health center staff, training tutorials can be provided through the telehealth tool. Staff time spent providing hands-on training techniques can be minimized by creating built-in training protocols. Additionally, built-in training can be helpful long-term resources that patients can save and view multiple times. Additional information on Maine’s program can be found here.
Author: Eric Wicklund
Brief Summary:
- The North Country Telehealth Partnership of New York state has 33 active telehealth and telemedicine projects. This partnership works together to help collaborate and sustain telehealth projects in rural areas. In underserved areas of New York, provider and funding shortages can be a great barrier to telehealth projects, so networks are an important resource for extending clinical capacity and improving services. A network that functions in a similar capacity is the Georgia Partnership for Telehealth.
Health Center Takeaway:
- Early provider buy-in is vital for telehealth projects to succeed. Engagement with programs can be targeted by finding telehealth programs that pique interest and have measurable success. For example, a telehealth program with local school districts could track the number of children kept in school and out of health centers or acute care so that reportable results could be seen. Additionally, telehealth programs should focus on emphasizing the ease to workflows and less crowded clinics or waiting rooms to providers as an incentive.
Author: Rachel Z. Arndt
Brief Summary:
- The University of Mississippi Medical Center Center for Telehealth utilizes SnapMD’s virtual platform for conducting visits. At UMMC, a portion of providers only do telehealth visits, though most do both virtual and in-person visits. A system is in place to send telehealth visit information to patients’ primary care providers and for providers to connect patients they meet with virtually with other practitioners in their area. At this point, certain requirements must be fulfilled for the center to receive payment from Medicare, Medicare coverage varies by state, and commercial reimbursement is even more variable.
Health Center Takeaway:
- For telehealth delivered in healthcare facilities, webcams are most commonly used. An important lesson learned is that analog supports are needed when using this method of communication. For example when communicating numbers and measurements, it can be easy to misinterpret numbers, such as medication doses, so it is best practice for providers to write numbers on a pad of paper and hold it up to the camera for verification.
Author: PHI's Center for Connected Health Policy
Brief Summary:
- The Public Health Institute's Center for Connected Health Policy (CCHP) conducted a study of five California community health centers to evaluate the costs and potential revenue sources for telehealth care. This financial analysis, completed with the assistance of an actuarial firm, showed that telehealth programs are not self-sustaining due to several factors: complex billing and reimbursement rules, provider shortages that lead to difficulty in securing services, data reporting issues, and inconsistent coding of telehealth-related claims and encounters.
Health Center Takeaway:
- The current state of unsustainable telehealth programs in community health centers can be addressed by improving the tracking of telehealth-related services and costs, improving data systems and interoperability, and maintaining consistent use of modifiers for coding telehealth-related claims and encounters.
Author: Eric Wicklund
Brief Summary:
- The Centers for Medicare & Medicaid Services’ 2019 Physicians Fee Schedule and Quality Payment Program, released in the fall of 2018, defined a new code for asynchronous (store-and-forward) telehealth services. HCPCS Code G2010 covers “Remote Evaluation of Pre-Recorded Patient Information” and will provide some reimbursement to providers for analyzing images submitted by an established patient and sending back a timely diagnosis.
Health Center Takeaway:
- While there are no frequency restrictions to using this code, there are several time frame limitations that are important for providers to note. For example, if the review of the patient-submitted image and/or video originates from a related evaluation and management (E/M) service provided within the previous 7 days by the same physician or other qualified healthcare professional, then the service is considered bundled into that previous E/M service and would not be separately billable. Additionally, if the review of the patient-submitted image and/or video leads to an E/M service or procedure with the same physician or qualified health care professional within the next 24 hours or soonest available appointment, then the is considered bundled into the pre- or post-visit time of the associated E/M service, and will similarly not be separately billable.
Author: Eric Wicklund
Brief Summary:
- The Centers for Medicare & Medicaid Services (CMS) issued the final 2019 Physician Fee Schedule and Quality Payment Program in November 2018. This finalized plans to reimburse healthcare providers for specific remote patient monitoring (RPM) and telehealth services. This program represents government support of telehealth and future expansion and reimbursement of innovative service delivery. CMS released a fact sheet that provides further information on the changes.
Health Center Takeaway:
- In this update, CMS outlined three new CPT codes for Chronic Care Remote Physiologic Monitoring (RPM). Health centers using RPM should review these CPT codes (CMS 99453, 99454, 99457). CPT 99457 allows RPM services to be performed by “clinical staff” such as RNs and MAs, not just physicians or other qualified healthcare professionals. This code will make it easier for health centers to integrate RPM into their clinical workflows, especially when past barriers to use have been provider buy-in and difficulty incorporating RPM into protocols. At this time, CMS has not provided guidance on what technologies will be covered under these CPT codes.
Author: Jennifer L. Wiler, MD, MBA, Nir J. Harish, MD, MBA & Richard D. Zane, MD, FAAEM
Brief Summary:
- The landscape of healthcare is quickly changing. The system currently in place of hospitals being the primary providers of care will not be a sustainable method for delivery quality and efficient care in the future. We will see remote monitoring, community paramedicine, telemedicine, mHealth, large-scale EHR platforms, and, eventually, prescriptive intelligence replace the traditional hospital-based delivery models. While hospitals will still continue to serve an important role in the healthcare system, the changing needs of consumers and developing technologies will move care-delivery into communities and patients’ homes.
Health Center Takeaway:
- As healthcare is becoming more decentralized, health systems have developed new care delivery methods such as mobile health clinics or community paramedicine. The Geisinger Health System in Pennsylvania recently completed a pilot program in which their “Mobile Health Team” provided care to patients with congestive heart failure (CHF) in their homes. This program limited ED visits and hospital admissions significantly. The University of Colorado Health has also seen promising early results in rapid remote diagnosis with their mobile stroke unit (MSU). The MSU is dispatched to patient homes in a specialized ambulance equipped with a small CT scanner, point-of-care testing capabilities, and virtual care access to a stroke specialist.
- Mobile health delivery models have shown the benefit in diversifying how care is provided. Health centers may pursue opportunities to leverage their existing expertise, combined with innovative delivery methods, to provide effective care directly to patients in the community.
YouTube Videos
Posted by The National Network of Telehealth Resource Centers, 9/17/2015
Brief Summary:
- This National Telehealth Webinar Series webinar reviewed the findings of a study commissioned by the Center for Connected Health Policy. During this study, one year of data was collected from five California health centers that represented a cross-section of the state’s health centers. The goal of the project was to assess the cost and reimbursement of telehealth, as payment policies vary by payer source, and to explore the barriers for adoption among health centers. They found that the volume of telehealth encounters varied by health center. For all of the health centers, program expenses exceeded revenue and thus multiple sources of fundings were used to cover the additional expense. Challenges health centers experienced were that volume-based reimbursement models could not be sustained, high provider contracting rates, complexity of billing and reimbursement, data management issues, EHR transitions, lack of interoperability, and inconsistent use of modifiers for coding. Potential solutions outlined were better tracking methods, develop learning collaboratives, pool telehealth volume to contract with distant providers.
Health Center Takeaway:
- Health centers providing lower volumes of telehealth services should consider a movement from volume to value. Alternative payment methodologies would establish per member per month (PMPM) capitated payment that is equivalent to the PPS rate for FQHCs/RHCs and Medicare ACOs provider more flexibility in reimbursement for telehealth.
Posted by Shasta Community Health Center, 1/9/2019
Brief Summary:
- Shasta Community Health Center in Redding, California is using telehealth to connect patients with speciality care. The video tells the story of Maurice, a pediatric patient with cerebral palsy, who prior to taking part in Shasta’s telehealth program, had to travel several hours to the closest medical specialist in Sacramento and frequently had to be transferred by air flight to a hospital when he experienced seizures. Through Shasta’s telehealth program he was able to regularly see a pediatric neurologist at UC Davis. This led to better control of his seizures and fewer missed appointments.
Health Center Takeaway:
- Shasta Community Health Center’s pediatrician has been working closely with the pediatric neurologist at UC Davis for several years. They have built a standardized workflow in which the pediatrician at Shasta completes the physical examination of the patient while the specialist obtains the patient’s history and views the physical exam. Despite working together from afar, they have been able to create a strong working relationship that contributes to the quality of care they provide patients.
Posted by El Dorado Community Health Center (EDCHC), 12/12/2018
Brief Summary:
- El Dorado Community Health Center (EDCHC) in California has worked with partners to implement a telehealth program that provides dental care, especially preventative care, to children in local schools. In El Dorado county there are few dental clinics that accept Medi-Cal insurance and it is difficult for parents to navigate busy work schedules to get children in for dental appointments. They use a dental van equipped with telehealth technology to travel to schools to provide dental care. The van is used to provide cleanings and take x-rays, which are sent back to the health center for a dentist to review and establish care plans.
Health Center Takeaway:
- Besides the dental care that the EDCHC dental van provides, one of the secondary goals of the program is educating children on good dental care behaviors, especially preventative care, so that positive associations around dental clinic visits can be enforced early on. This reinforcement of health behaviors aims to target overall wellness through the lifecycle and eliminate the strain placed on the healthcare system over time.
Posted by Northwest Regional Telehealth Resource Center, 7/28/2016
Brief Summary:
- During this webinar, Libbey Chuy from the Association for Utah Community Health (AUCH) reviewed the definition and function of primary care associations and community health centers, described Utah’s community health center network in terms of the number and location of the health centers and the population served, and the current telemedicine landscape in community health centers. She also reviewed AUCH’s active telemedicine programs in teleophthalmology and teledermatology (utilize AUCH’s Telemed Platform), telebahavioral/mental health, telepharmacy, Project ECHO (provider-to-provider eConsult), and teleradiology.
Health Center Takeaway:
- AUCH utilizes a video conference-based program for medical Spanish for healthcare professionals. This is an 8-week course that is available to providers outside of Utah. Programs such as this that provide important staff training are integral for building the adaptability of the health workforce in community health centers. Education programs for Spanish-speaking patients are extremely beneficial, however there is a lack of qualified trainers who are fluent in Spanish to teach these telehealth programs. These trainers are in high demand and there is a need for partnerships amongst health centers to collaborate on trainings and share resources.
Posted by TEDxUSD Talk by Linsey Meyers, 3/29/2017
Brief Summary:
- This TEDxUSD talk focused on the benefits of telemedicine in spanning gaps in healthcare in rural areas. Linsey Meyers described several examples of innovative telemedicine provided by Avera Health, a regional health system based in South Dakota. One program works with aging patients to facilitate end of life care planning, long term care patient prescription reviews, and consults for long term care patients who may require ED visits. Avera Health is also working with Indian Health Services on a telehealth project that connects neonatal care specialists with rural health centers. Finally, Avera has an eICU telemedicine program that provides remote patient monitoring of critical care patients
Health Center Takeaway:
- Rural healthcare also has the unique factor of multiple relationships between providers and patients due to small communities (e.g., ED physician treats neighbor or close friend). This can lead to additional stressors on an already taxed workforce. Telemedicine can help to ease the burden on rural providers by providing specialist referrals that help make providers feel informed and supported in their decision-making, helping to counteract the rate of provider burnout and extend careers.
Posted by Northwest Regional Telehealth Resource Center, 7/28/2016
Brief Summary:
- During this recorded webinar, Kim Schwartz from Roanoke Chowan Community Health Center (RCCH) in North Carolina presented on remote patient monitoring (RPM) and chronic care management. RCCH has partnered on a bi-coastal program with Central Oregon telehealth network to develop a RPM framework for patients with chronic illnesses. According to their framework patient take their vitals at home (e.g., weight, glucose levels, BP) and nurse monitors their vitals remotely and if a value(s) flag then the nurse follows up with phone call. The patient’s PCP is contacted if their vitals reach a threshold. The provider also reviews a trend report that is generated every two weeks and uses the patient portal to communicate the results of the report to their patient. They have tracked various factors including the patients’ number of PCP visits, hospital bed visits, ED visits, contact by monitoring nurse, patient satisfaction ratings, Patient Activation Measures Survey (PAM) results, compliance, clinical indicators, and costs. Data is collected for 6-months pre-RPM, 6-months during RPM, and 3-years post. They have found a decrease in number of hospital bed days, ED visits, and hospital charges during both 6-months of RPM and 3-years post.
Health Center Takeaway:
- During the testing of the RPM framework, RCCH produced a blog that detailed their ongoing work on the project so that they could share important lessons learned, barriers encountered, the surveys and measurement tools utilized, and preliminary results. They found that this blog was a valuable part of their process and that it was also a beneficial resource for other health centers developing similar protocols concurrently.
- RCCH’s collection of baseline data, six months of data during RPM implementation, and then three years post demonstrates the longitudinal effect of RPM with measurable results. This data-tracking shows both the improvement in patients’ clinical indicators and the long-term financial implications for health centers and patients. These extensive results go far to proving to patients, health centers, potential partners, and funding opportunities the value in investing in RPM.