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March 1, 2010

No Better Time for Telehealth
By Selena Chavis
For The Record
Vol. 22 No. 4 P. 20

Numerous studies tout the benefits associated with remote monitoring, leading many healthcare experts to believe the industry could be ripe for more widespread adoption.

Timing is everything, and according to many healthcare industry professionals, some of the barriers to implementing and sustaining solid telehealth and remote monitoring initiatives are beginning to crumble.

With a solid research foundation in place, technological advances and greater provider acceptance have heightened the advancement of telehealth and will continue to do so, according to Jonathan Linkous, CEO of the American Telemedicine Association (ATA). “The pieces are in place and the time is right,” he says. “The research has been done, the efficacy has been proven, and the cost savings are evident.”

While there has long been data available to suggest the advantages of remote monitoring through telehealth technology, two recent scientific studies add credence to these claims: one completed within the home health sector by the University of Missouri School of Medicine and another focusing on patients with diabetes utilizing the wireless diabetes management system at Pennsylvania-based SymCare.

According to Cheryl Pegus, MD, chief medical officer for SymCare and author of the diabetes study, research indicates that remote monitoring initiatives are not only creating better efficiencies in healthcare management, but they are also laying the foundation for better provider-patient relationships, which results in better outcomes as patients develop more ownership of their healthcare.

“People who utilize remote monitoring find they are more engaged,” she points out. “And much more important, they think their nurses and physicians are great.”

The process effectively establishes a better trust relationship between patients and providers, adds David Fleming, MD, chairman of the internal medicine department at the University of Missouri School of Medicine and director of the school’s Center for Ethics. “What remote care technology does is provide a connection. … One can almost term this a security blanket,” he says. “There is comfort in knowing their healthcare provider is there and can be accessed quickly.”

Rural Health Advantages
Linkous says the foundation behind telehealth initiatives can be found in rural healthcare, where patients have often had limited access to the expertise that can be found in metropolitan areas. As technology has evolved, many industry professionals saw obvious and inherent advantages associated with narrowing the distance between rural patients and specialty providers through telehealth.

“Telemedicine today is not at all like it was five years ago,” he notes, adding that technology advances have paved the way for better acceptance across the board. “Just like at home, we now have DSL with greater speed at a fraction of the cost. Healthcare is not different.”

To confirm the advantages associated with telehealth practices in rural areas, the Application of Remote Monitoring to Improve Health Outcomes to a Rural Area study was completed at the University of Missouri School of Medicine. According to Fleming and Lanis Hicks, PhD, the study’s authors, the primary objectives focused on evaluating the impact of remote monitoring within a home health setting as it specifically related to client and provider satisfaction, clinical outcomes, and cost.

“We wanted to be able to do monitoring on a more continuous daily basis,” Hicks says, describing the project design as a pragmatic evaluation of the technology in a real-world setting at an operation scale rather than a controlled clinical trial. “That way, there are not the fluctuations in situations where you might see patients only once or twice a week in a home healthcare setting.”

A home health agency was chosen in a Midwestern state that serves a seven-county rural area with a population of approximately 160,000. Five of the seven counties served have a population density of fewer than 30 people per square mile, and the closest metropolitan statistical area is approximately 100 miles away.

Hicks notes that the patients monitored were selected by the identified home health agency, while a random sample of other agency clients was selected for comparative purposes. Fleming says each group was composed of 47 patients with varying diagnoses typical to the home health space, such as diabetes and heart disease.

One of the strongest pieces of data produced by the study was the cost savings and efficiencies created by the need for fewer hospitalizations, according to Hicks. Not only were there fewer hospitalizations, but those who were hospitalized had shorter length of stays.

The study, which ran from January through June 2005, revealed that hospital expenses associated with patients using remote monitoring were $212,828, while those associated with patients not using remote monitoring were $336,656.

Among the other notable findings was the discovery that telehealth patients spent less time with their clinicians than those whose care did not involve the technology. While the total number of visits by home health aides was higher for those patients using remote monitoring, the cost to deliver those services was lower.

The total personnel costs for home telehealth clients were $17,100, or $2,074 less than the $19,174 expended on the clients who did not have telehealth services. “That was a positive outcome although it was different than what we anticipated when we started,” notes Hicks, adding that logic would dictate an increased number of visits would lend to increased costs, but because hospitalizations decreased, that didn’t occur.

Quantitative and qualitative data from the study suggest that when remote monitoring technology was utilized, both clients and providers were very satisfied with services. Specifically, Hicks says they felt it was easy to communicate and the technology was convenient and user friendly.

“Some of the comments made were that they felt more comfortable with their care, and the nurse had more information and could help them make better decisions,” she notes.

In the report, one patient commented, “It saved my life because the water in my oxygen machine was filled to full and I wasn’t getting enough air. With this machine going straight to the hospital, the nurse called me to ask what was going on and I told her I didn’t know, so we started looking for the problem and found it. If I had not had this machine, I might have died that day from lack of air, so I am grateful for this machine because it saved my life.”

Improved Disease Management
Linkous says the telehealth space is also home to another attractive option: mHealth or mobile telemedicine applications. With approximately 3.5 billion cell phones in use across the globe, mobile electronic health tools and telemedicine technologies are expected to rapidly transform the face and context of healthcare service delivery.

The SymCare initiative, known as the Diabetes Remote Monitoring Evaluation (DREME) Study, utilized mobile and wireless applications to monitor blood glucose levels in a random sample group of diabetes patients. With industry statistics suggesting that more than 50% of type 2 diabetes patients lack the information and engagement to adequately control their condition, SymCare introduced the inTouch diabetes management system to improve the care and cost of treating this population.

According to estimates from the American Diabetes Association, the cost of diabetes to the U.S. economy increased 32% between 2002 and 2007, topping out at $174 billion. Also, the Centers for Disease Control and Prevention estimates that 60% of people with diabetes do not follow their physicians’ advice on how to manage their disease—an issue that goes to the heart of the patient-provider relationship and the ability of a patient to be fully engaged in care, according to Pegus.

She says the legal and regulatory support SymCare received from its parent company (Johnson & Johnson) allowed the initiative to quickly move into the diabetes arena, where other initiatives may have struggled. “We wanted to bring credible information to this scientific space,” she explains. “It’s the first randomized clinical trial being done that is peer reviewed with remote monitoring.”

In the DREME study, 172 subjects diagnosed with diabetes ranging in age from 18 to 64 were chosen for a six-month study that began in April 2008. The remote monitoring process consisted of a cell phone, a glucometer marketed by SymCare, and a Bluetooth cradle.

According to Pegus, the study centered around patient satisfaction with disease management services and changes in glycemic control. Outcomes revealed significant improvements in both areas.

Of the 172 subjects, 87 participated as standard disease management patients (DM-Standard) and 85 participated as disease management patients with remote monitoring (DM-Plus). Compared with DM-Standard, the DM-Plus group reported greater satisfaction with their disease management experience in terms of believing program staff were helpful, articulate, better educated, and accessible. The results also showed the DM-Plus group improved self-care and had more stable glycemic control.

Pointing to the complexities of managing diabetes, Pegus notes that baseline data taken prior to the study suggested that patients who appeared to be engaged in treatment—in that they tested blood glucose more frequently—often had more problems with hyperglycemia or hypoglycemia.

“The decisions you make are very important with diabetes. How are you empowered to begin conversations with your doctor?” Pegus asks, noting that with remote monitoring, a clinician is able to offer an informed analysis of a patient’s condition. “What we saw is that people doing finger sticks frequently … they were doing it because they thought something was wrong. They just didn’t know what to do about it.”

She says the DREME study received similar results as its University of Missouri counterpart in that it found telehealth could improve the patient-provider relationship and allow patients to take more ownership of their care.

Reimbursement Concerns
While technology and physician acceptance have poised the telehealth movement for more widespread adoption, industry experts suggest significant barriers remain.

When considering the benefits of using remote monitoring with home healthcare, Hicks says many agencies will likely opt not to move forward due to start-up costs. And until there are grants or incentives available, it is unlikely the industry will realize the technology’s potential.

“They [home health agencies] don’t receive a tangible benefit even though the healthcare industry saves money by decreased hospitalizations,” she says. “They have to absorb the cost of the equipment.”

Unfortunately for telehealth boosters, national health reform initiatives tend to ignore the technology’s prowess, says Linkous. “Health reform is a big barrier and continues to be,” he explains, pointing out that while the current legislation includes provisions for extending coverage to individuals, there needs to be more focus on how the technology can improve care and reduce costs.

“To the point that Medicare needs to reimburse telemedicine—that’s the real barrier,” Linkous says. “It’s better covered in the private sector and even better covered by Medicaid than Medicare.”

Technical advances have improved the telehealth landscape, but Linkous says there is room for improvement. “In some rural areas, there is still some issue with getting broadband,” he acknowledges. “And in some cases, it’s very expensive.”

Fleming believes psychological barriers still exist, especially in areas where clinicians may not be overly tech-savvy. “Anytime you introduce technology where you are going to be away from the patient, there tends to be resistance,” he explains. “There often tends to be a psychological barrier for both clinicians and patients. That said, there is a general attitude developing that this is a technology that is here to stay.”

— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to healthcare and travel.