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August 2014

The Bottom Line on Telehealth
By Juliann Schaeffer
For The Record
Vol. 26 No. 8 P. 22

The technology has earned wide praise for enhancing care, but questions remain about its financial impact.

There’s a broad range of telehealth products and services available to today’s health care organizations. And whether those services come in the form of provider-oriented solutions such as telestroke, tele-ICU, or telecardiology or the newer consumer access solutions, more hospitals are signing on to offer some form of telehealth.

While research data clearly point to the potential for real patient outcome and satisfaction improvements, the price tag of a telehealth program is a matter of debate. Because there’s no one-size-fits-all solution, it’s up to each hospital system to analyze certain economic factors before determining the best path forward. How it will measure the program’s success, whether it be financial or otherwise, also must be considered.

Benefits Abound
“We have seen a number of hospitals and clinics integrate telehealth technologies for a variety of use cases such as teledermatology, teleradiology, telestroke, etc,” says Tapan Mehta, head of global health care marketing for Cisco Systems. “For instance, the Stanford Dermatology Clinic expanded its outreach, treatment, referral, and consultative capabilities by introducing a weekly teledermatology clinic.”

“An increasing number of hospitals, including some renowned or large systems such as the Mercy System, Cleveland Clinic, Johns Hopkins, and UPMC [University of Pittsburgh Medical Center], are embracing telehealth,” says René Y. Quashie, a senior counsel in the Health Care and Life Sciences practice of Epstein Becker Green’s Washington, DC, office, who notes that hospitals turn to telehealth to solve various issues. “Many hospitals see telehealth as a way to control readmissions, expand reach, and increase branding. I see nothing but more systems embracing telehealth in the next half-decade.”

David Collins, MHA, CPHQ, CPHIMS, FHIMSS, senior director of HIMSS’ mHealth community, says telehealth’s versatility is a game changer. “Telehealth provides both the convenience and the ability to bridge the gap in access to care, to keep chronic conditions in check before they escalate, assist in avoiding unnecessary trips to the emergency department [ED], and assist with unnecessary inpatient admissions or readmissions,” he says. “That is, telehealth enables a relationship between patients and their providers and serves to promote a focus on wellness and prevention. This technology has the potential to meet the needs of health care’s transforming landscape from volume to value and help drive the cost/quality equation that will help accountable care organizations [ACOs] succeed.”

According to Mehta, adding telehealth to a hospital’s service line is all about creating efficiencies. “Telehealth technology has progressed to a point where a remote patient visit is as effective in determining a course of treatment as an in-person visit,” he says. “Simply put, telehealth allows patients, physicians, hospitals, and clinics to maximize their time. Patients avoid long waiting room times and reduce the amount of travel, while clinics can improve the efficiency of patient screenings.”

As outcomes data on telehealth programs start trickling in, it’s becoming apparent the technology has much to offer. “There are many programs with hard outcomes data regarding success. We collect that,” says Kathy Hsu Wibberly, PhD, director of the Mid-Atlantic Telehealth Resource Center at the University of Virginia Center for Telehealth. “Our high-risk obstetrics program has decreased premature births by 25%. Our stroke program has increased tPA [tissue plasminogen activator] administration in small rural hospitals from 0.05% to 6%, and there’s more.”

Potential Obstacles
Despite generally favorable outcomes data, teleheath faces significant legal and regulatory barriers before it can become more widely adopted, says Quashie, noting licensure, scope of practice, prescribing, privacy and security, and reimbursement concerns.

“From a lawyer’s perspective, it is important that hospitals and their physicians and other health care professionals ensure they are complying with applicable state laws and regulations governing issues such as licensure, prescribing, privacy and security, and fraud and abuse,” he adds. “Too often, stakeholders implement programs prior to ensuring compliance, and state regulators are increasingly becoming concerned with telehealth and how it may impact patient safety.”

According to Mehta, the reimbursement situation is looking brighter. “More and more organizations are willing to offer telehealth services because they are seeing increasing reimbursements on both the private and public side,” he says. “To date, reimbursement had been one of the biggest hurdles in the industry, but that is starting to change.”

Even if reimbursements are becoming more commonplace, are the initial fixed costs to start a telehealth program too imposing for any but the largest organizations? From billing and reimbursement issues to up-front costs, what are the various financial ramifications of telehealth programs? And does offering telehealth services give health systems a leg up on the competition?

Collins points to a February Health Affairs article by Adler-Milstein et al suggesting that the use of telehealth increases in more competitive markets. “While the article does not comment about why the usage of telehealth is higher in more competitive markets, it may be that organizations see providing telehealth services to patients as a way to maintain or increase market share,” he says.

While no vendor or scientific research can guarantee a telehealth program will increase a hospital’s market share, Collins says it’s more important to gain a competitive advantage through patient engagement. “The ability to provide convenience and satisfaction to the patient and to have them return to the facility for future care [is key],” he says.

Jason Gorevic, CEO of Teladoc, a telehealth services company, says that by providing new ways to access care, health systems can attract consumers by setting themselves apart from their competitors, which can lead to referrals and additional follow-up care.

“Telehealth allows a hospital or clinic to extend its reach while lowering the cost of accepting new patients,” Mehta says. “It also makes for a more convenient patient experience. When you can reach more people while still providing a high quality of service, hospitals can see the financial benefits.”

Economic Factors
Mehta says before rolling out telehealth technology, health systems must consider several factors, including service type, the availability of in-house expertise, infrastructure, buy-in from key stakeholders, return on investment modeling, “and most importantly, establishing measurable success criteria.”

Gorevic recommends hospitals begin any telehealth consideration by determining the project’s objectives. Whether the goal is to acquire new patients, reduce costs, improve care access and coordination, or make better use of employed physicians, prioritization will lend insight into the project’s financial implications. “Telehealth can have a particularly strong economic impact when a hospital system is taking risk, whether in an ACO or other shared-risk environment, as reduced unnecessary ED utilization and admissions can flow straight to the hospital’s bottom line,” he says.

HIMSS’ mHealth community works closely with hospitals and health systems, providing guidance on how to determine what types of telehealth technologies are the best fits. Collins says the price of the technology itself, both up-front and maintenance costs, and the organization’s eligible rate of reimbursement are the top two economic factors to consider. These will vary based on state, patient population, and payer mix, Collins says, noting that the white paper “Mobile Health IT in the States: A Policy Perspective Using the mHIMSS Roadmap” addresses reimbursement issues.

Profit by Specialty?
How do the various telehealth specialties stack up against one another? Will a hospital reap greater earnings by offering tele-ICU as opposed to a pediatric telehealth program?

According to Wibberly, those questions have no easy answers. “It depends on the service line,” she says. “Some service lines are more profitable than others because they are low cost to operate and have strong reimbursement mechanisms. Others are not, but it’s the right thing to do to bring access to care and quality of care to those unable otherwise to get that care.

“Most large telehealth programs strike a balance to ensure sustainability,” she adds, noting that remote patient monitoring, when done well, can save hospitals from paying readmission penalties. “However, it takes an up-front investment since there is little reimbursement, but the return in investment is huge.”

“Certainly every specialty focus for telehealth has a different economic potential for a hospital system,” Gorevic says. “Most important is optimizing for the total dollar amount at stake and the ability to make an impact on those monies via a telehealth solution.”

In general, Wibberly says any health care organization boasting a billing/coding team familiar with telemedicine codes will benefit financially from telehealth. However, how a hospital defines profitability also must be taken into account. “Small rural hospitals that implement a quality telehealth program may not reap big bucks,” she says. “However, by having telehealth, they may be able to keep more of their patients in their hospital and in the community. Many small rural hospitals are operating on very small margins so losing even a couple of patients a year who are transferred to a larger hospital can be the difference between staying open and shutting down.”

Wibberly says telehealth technology also can be a selling point to help recruit and retain providers. “Without providers, these hospitals again struggle with staying viable,” she says.

Determining Success
But just as the types of telehealth vary, so do the metrics that determine what constitutes a successful program. “For example, one organization might specialize in offering teledermatology, while others might specialize in teleradiology,” Mehta says. “Additionally, health care organizations set their own set of metrics to measure the effectiveness of telehealth services being offered by them, hence the importance of establishing measurable success metrics, and profitability could certainly be one of them.”

What measurables determine a telehealth program’s success? According to Mehta, the most important factors aren’t financial. The quality of the technology and service come first, he says, pointing out that negative patient feedback regarding virtual appointments dooms a telehealth program to failure. “Telemedicine is about making the process convenient, so as soon as the technology becomes a hindrance, the program will suffer,” he says. “From a service perspective, to run a telemedicine program successfully, you need staff that understands the technology and can use it effectively. If staff aren’t able to utilize telemedicine to its full abilities, patients do not get a complete care experience.”

To get the most out of the technology, Collins says it’s vital to gain C-level support and physician buy-in. “And any health IT must be seen as a process improvement that is not exclusively owned by IT,” he adds.

“Buy-in from physicians and other health care professionals is critical,” Quashie says. “Without it, a program may be doomed to fail.”

Wibberly recommends health care organizations devise a plan for program evaluation prior to implementation. “It is much harder to catch the bus after it has left the station,” she says.

By establishing defined metrics from the get-go, baseline data can be captured to measure the program’s impact. “Success is measured in a number of ways depending on the service line and the audience,” she says. “Clinical outcomes, of course, are central to defining success. Are patients having improved outcomes and receiving better quality care? Satisfaction measures are also important, as these are important for both clinician and patient engagement.”

Financial outcomes matter a great deal, but Wibberly says other outcomes should be given equal weight. “Equally important measures are things like the ability to retain patients and clinicians in the community setting if you are a smaller rural community,” she says. “If you are a larger urban center, you might want to look at things like miles saved for patients who would normally have to travel hours to come for an appointment.

Improving efficiency also can be a feather in telehealth’s cap. “Can physicians see more patients because they are spending less time on the road going to clinics and meetings? Are there less missed appointments and no shows because patients do not have to deal with transportation issues? These are just a handful of things that need to be considered,” Wibberly says.

Other benefits are more difficult to quantify. “Outside of the pure dollars out of the cost of technology vs. dollars in for billing revenues, it is very difficult to measure success, as there are so many factors to consider,” says Kevin B. Lasser, CEO of telehealth company JEMS Technology. For example, gaining concrete proof that telehealth attracts consumers generally isn’t worth the effort. “Some of our clients are advertising quicker, faster diagnosis with the usage of best-in-class technology,” Lasser says. “But do they gain an edge? None of our clients can quantify it.”

Still, Wibberly believes it doesn’t take an accountant to realize telehealth is worthwhile. “Any time a hospital or health care provider can provide better convenience for patients and offer better quality of care for patients, they will gain a competitive edge,” she says. “As with all things, it depends on the quality and scope of the telehealth services being offered. Telehealth is simply a mechanism for providing health care services.”

Mehta agrees: “Telehealth offerings certainly extend the reach of any health care organization and could be viewed as a potential differentiation against other competitors. At the end of the day, though, it is up to the organization to drive measurable differences and changes in the market they are serving, which will ultimately dictate any changes to top-line growth.”

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania.


Top Hospitals Failing To Meet Patients’ Digital Demands

Many of America’s top-ranked hospitals lag in extending their health care expertise beyond the walls of the hospital and into the online world where patients increasingly are seeking information, according to an analysis recently released by Evolve Digital Labs.

The report, “The Digital Health of Today’s Best Hospitals,” evaluated the online presence and patient use of digital assets offered by the nation’s top hospitals, as identified by U.S. News & World Report’s Best Hospitals 2013-14 publication.

The analysis reveals that top hospitals lag behind most other digital sources, such as third parties and industry, when it comes to helping a patient manage his or her health. Overall, many website features to serve patients were found to be inadequate for some of the leading institutions, including the following:

• Almost one-half of hospitals studied lacked a mobile-patient website.

• Sixty-seven percent failed to offer online rehabilitation and aftercare information.

• Only one in five had online preregistration to reduce patient wait time.

• Nearly one in three failed to facilitate online bill pay.

• At least 18% had on-site errors that hindered the patient experience.

• Nearly one in two hospitals did not support postprescription refill requests online.

Barriers that prevent hospitals from maximizing their use of digital technology for patient care include concerns regarding regulation of digital content, lack of clinical oversight of published content leading to inadequate sources of information for patients, lack of investment in digital technology and lack of understanding of the value or return on investment that it can play in enhancing patient outcomes, inefficient internal systems and processes, and an emphasis on legacy business methods that are not adapting or changing fast enough to deliver to patients the digital innovation available today.

While many hospitals have room to improve their online health information, the study also uncovered commonalities among those hospitals receiving high marks for digital prowess, such as the Mayo Clinic and the Cleveland Clinic. In addition to a clear commitment to patients’ digital health built into the institution’s values, many of them do the following:

• Serve patient needs beyond the hospital walls. They have a clear understanding of patient needs, types, and disease segments and associated online behavior. These hospitals create digital assets that make stronger digital connections with patients and provide them with virtual hospital expertise and influence along their digital health path to complement and supplement care.

• Drive digital governance across the entire organization/internal communications. Hospitals with the right digital tools invest in a framework for digital collaboration, which includes coordination among clinicians, IT, and marketing. These institutions strategically invest in online care just as they are investing in research and testing equipment.

• Provide a platform to deliver expertise. Those rated digitally proficient provide patient-friendly online tools and resources that realistically meet patient, caregiver, and physician needs. In addition, they publish content that addresses both clinical and lifestyle concerns. While most clinicians and hospital experts publish traditional content for medical journals and other professional sources, more patients could benefit if clinicians also would generate digital content that can be updated regularly to match changing patient experiences.

— Source: Evolve Digital Labs