The Next Frontier: Telemedicine, Telehealth, and Telecare

Pat Stricker, RN, MEd
Senior Vice President
TCS Healthcare Technologies

The Association of American Medical Colleges predicts that by 2020 the U.S. will be facing a shortage of 90,000 physicians, including 45,000 patient care physicians. This shortage is a result of the large number "baby boomer physicians" who will be retiring this decade. In 2010, 26 percent of active physicians were over 60 years of age.

At the same time, the baby boomer generation and longer life spans have created an unprecedented growth in the number and proportion of older adults. The State of Aging & Health in America in 2013 report by the Centers for Disease Control and Prevention predicts the population of Americans aged 65 years or older will increase to about 71 million by 2030, and those 80 or older will increase to 19.5 million. In 2030, when the last baby boomer turns 65, older adults are expected to account for 19.6 percent of the U.S. population. These numbers will be double what they were in 2005.

More than 25 percent of Americans and two of every three older Americans have multiple chronic conditions. Treating this population accounts for 66 percent of the U.S. healthcare budget. Since providing care to a person over the age of 65 is three to five times higher than the cost for someone younger than 65.7, healthcare spending by 2030 is expected to increase by 25 percent. And these costs do no account for inflation or the higher costs of new technologies.

So, how do we handle the increasing number of elderly patients needing care with a dwindling number of physicians?

The number of medical schools, programs, and enrollments has increased over the past 10 years. However, the total number of new physicians will not be enough to provide an adequate number of practicing physicians needed by 2030. Physician assistant and nurse practitioner roles have increased to help fill the needs, but there will still not be enough physicians. We need to focus on finding other ways to deliver healthcare more efficiently. Just as we changed from inefficient house calls years ago, we now need to move from face-to-face office visits to a more efficient care delivery models. Telemedicine, telehealth, and telecare are booming new areas that are going to be able to help us make that change. With the advent of better technology, these programs allow us to deliver more care to more people with less face-to-face interactions, yet provide equal or better outcomes, quality, and satisfaction. Using these programs, will help us provide healthcare to those who need it, with fewer physicians.

Telemedicine, telehealth, and telecare are often used interchangeably, so it is important to define them:

• Telemedicine uses telecommunication technologies to exchange information from one site to another to support the delivery of remote medical diagnostic and treatment-related services, usually by physicians. It includes conducting diagnostic tests, closely monitoring a patient's progress after treatment or therapy, and facilitating access to specialists that are not located in the same place as the patient. Technologies include a variety of applications and services, including real-time two-way video, email, smart phones, monitoring of tracking devices, and the use of wireless tools. Examples of Telemedicine include virtual critical care staffing programs in ICU areas, specialty video consultations, 2^nd opinion audio/video consults, remote urgent care and office visits, and remote reading of X-rays.
• Telehealth is similar to telemedicine, however telehealth uses a broad variety of technologies and tactics to deliver virtual medical, health, and education services, including preventative, promotive and curative care delivery. The technologies include videoconferencing, the internet, store-and-forward imaging, streaming media, and wireless communications. Telehealth also provides remote services by nurses, pharmacists, therapists, or social workers, who help with patient health education, social support, medication adherence, and troubleshooting health issues for patients and their caregivers. Examples include telephonic 24/7 triage programs, transition of care or post-discharge programs, and disease or population health management programs.
• Telecare generally refers to programs that work toward allowing consumers to stay safe and independent in their own homes. It may include consumer-oriented health and fitness apps, sensors and tools that connect consumers with family members or caregivers, exercise tracking tools, digital medication reminder systems, or early warning and detection technologies that are used to supplement other more costly interventions, home visits, or office visits.

NOTE: This article will use the term telehealth, which describes most of our programs. However, some of the statistics will refer to telemedicine, if that was the term used in the resource document.

Due to advances in technology, lower technology costs, and an increased demand for technology providers and patients, all three of these programs are gaining huge momentum in the healthcare industry. The following statistics were collected from surveys and other data sources:

1. The global telemedicine market was $14.2 billion in 2012, but it is predicted to increase annually by 18.5 percent until 2018, a cumulative annual growth rate of more than 56 percent ($22 billion).
2. A technology report stated that telemedicine is expected to explode by 2018, with an expected 7 million users, up from 350,000 users in 2013.
3. In 2015, there were more than 200 pieces of legislation addressing telemedicine; 29 states and the District of Columbia mandate health plans to cover telemedicine services.
4. According to the American Hospitals Association, 70 percent of the "most wired" U.S. hospitals already provide telehealth.
   

5. In 2015, an employer-sponsored survey found that 35 percent of employers with on-site health facilities offered telemedicine services as an employee benefit, but 70 percent said they plan to offer the services by 2017.
6. A survey in 2014 found that 90 percent of healthcare executives said their organizations have implemented or are developing a telemedicine program.
7. A survey in 2015 found that 64 percent of patients would attend a video telehealth appointment, and 57 percent of the physicians said they would offer video appointments.

Information technology has been busy laying the groundwork for telehealth. Internet speed, cost, and capabilities have improved immensely over the past few years. Smart phones and iPads have become very popular and have allowed educational material to be automatically sent to patients based on needs identified in their patient profile and alert the provider and care team to follow-up with the patient to discuss the information. Mobile monitoring and auscultation devices allow physicians to listen remotely to heart, lungs, and bowel sounds, as if they were in the room with a patient. Communication applications allow all care team members to communicate with each other and carry out their care team tasks seamlessly. Video-conferenced exams and consultations provide better access and allow family members to be involved, leading to better patient adherence to the plan of care.

The adoption of telehealth has experienced multiple challenges, including reimbursements, affordability, and experience gaps. However there are many current healthcare industry trends that are helping the adoption of telehealth:

1. A paradigm shift from episodic care to wellness and preventive care.
2. Telehealth is being driven by value-based models to provide better data capture opportunities for patient care, resulting in proactive wellness and better quality of life for patients.
3. Distance is no longer a barrier, and new devices and platforms are being created that can tie the patient, doctor, and entire healthcare team together.
   
4. Technological advances have made medical devices smaller, easier to use, more consumer focused, and less costly.
   
5. Infrastructure and delivery models, like the cloud, have provided new capabilities and better usage of network and system resources.
   
6. Patients and providers are embracing technology. Mobile apps are a "necessity"; Consumers expect the same level of experience that they are used to in their banks or retail stores.
   
7. Tablets, smart phones, reduced technology costs and interoperability have made telehealth programs more affordable and accessible.
   
8. Telehealth is being integrated with EMRs, which enables continuity of care.
   
9. Parity laws are helping to integrate behavioral health and addiction programs with primary care.
   
10. A broader array of integrated healthcare services is being offered, using multi-disciplinary teams to address an individual’s total healthcare needs.
    
11. Telehealth reduces wasted time (traveling to doctors’ visits, waiting for exams or data, sitting in doctor's offices) and provides better time-efficiency for patients and providers.
    
12. Chronic conditions and improper post-discharge follow-up, resulting in medical complications, are causing providers and payers to encourage patients to use health and wellness tools.
    
13. Helping patients follow a post-discharge care plan avoids costly re-admissions.
    

Another major reason for an increase in telehealth programs over the past few years was the release of the 2015 Medicare Physician Fee Schedule (MPFS) Final Rule , which established payment levels and policy changes for Medicare Part B services. This rule allowed payment for " non-face-to-face chronic care management services, including the ongoing development and revisions of care plans, communication with other treating providers, and medication management."

Under this program, physicians, advanced practice nurses, physician assistants, clinical nurse specialists, and certified nurse midwives can be paid a monthly fee for chronic care management (CCM) and telemedicine visits via a telecommunications system provided to Medicare beneficiaries. Previously,  CMS primarily paid physicians and other healthcare practitioners for care management services as part of face-to-face visits. The new 2015 Medicare Fee Schedule added new payment codes for care coordination, telehealth, annual wellness visit, and prolonged evaluation and management services for Medicaid beneficiaries with 2 or more chronic conditions.

This expanded telehealth coverage increased access to specialty services for rural patients and their caregivers by allowing them to stay in their own community rather than travel long distances to a provider’s office. It also decreased the number of cancelled appointments due to weather/travel conditions; reduced the time for investigation, diagnosis, and treatment due to quicker consultations; and increased health education opportunities for patients and their families.

For organizations desiring to start a rural health program, the Telehealth Services for Rural Health training document from CMS’s Medical Learning Network provides detailed information on the 2017 Medicare Fee-for-Service Program. It includes definitions, billing payment information, resources, helpful links and websites, and a list of the approved telehealth services and their corresponding HCPCS/CPT codes. The Telehealth Resource Center also offers assistance to healthcare organizations, networks, and providers in implementing cost-effective telehealth programs to serve rural and medically underserved areas and populations. The Rural Health IT Adoption Toolbox is an introduction to health IT adoption in rural settings, including Federal Government initiatives to support rural health providers.

Telehealth programs have proven to be especially helpful in caring for patients who have a difficult time getting to an office visit and providing access to care for the nearly 20 percent of Americans residing in rural areas who have limited access to providers. Telehealth benefits include more proactive education; better management of chronic diseases; increased patient satisfaction levels due to improved access to care; the ability to see specialists; the feeling of getting personalized care; and the ability to communicate with a provider in a personal way. Since patients get more engaged in the process, they also tend to have better patient self-management.

Given the shortage of providers, telehealth has the unique ability to significantly increase the number of patients a provider can manage each day by reducing "wasted" travel time going from room to room or facility to facility. Physicians can handle more virtual office visits per day than actual face-to-face visits. Nurses and other care team members (counselors, pharmacists, therapists, etc), working closely with telehealth patients, help save the physician’s time to devote to patients who have more pressing needs.

There are numerous telehealth programs being implemented today. Some examples of the most popular programs include: urgent care, mental health and wellness, women’s programs, chronic care management, population health, stroke care, dermatology, home health, remote monitoring, pediatric care, post-discharge/transition of care, hospital re-admissions, triage, and provider-to-provider care.

The next question is — Do these telehealth programs result in good clinical outcomes, quality care, cost savings, and patient satisfaction?

Over 2,000 evaluative studies related to telemedicine have been published in two journals devoted to telemedicine. This American Telemedicine Association paper lists 75 studies that have evaluated the effectiveness, quality of care and patient satisfaction of telemedicine. The studies are consistent in finding that telemedicine is cost effective for patients, providers and payers when compared with traditional approaches for providing care. They also show that care was significantly improved for chronic care patients who were monitored and patients cared for remotely by specialists. And patient satisfaction is consistently very high related to access to care, the use of telecommunication technologies, and the remote care given by specialists.

Other telehealth statistics and trends show the following:

• A research study evaluating Telemedicine’s Impact on Healthcare Cost and Quality provides results of cost effectiveness, quality of care, and patient satisfaction.
• A Veterans Affairs telehealth program designed to keep chronically ill patients in their rural homes, instead of moving to assisted living facilities, demonstrated a 35 percent reduction in hospital admissions and a 59 percent decrease in bed days. Satisfaction rates were 84 percent, and the annual savings per person was $1,999. This program is increasing in size by about 22 percent annually.
• A United Kingdom (UK) Dept. of Health Study found that remotely monitoring blood sugar and cardiopulmonary disease reduced the risk of patient mortality by up to 45 percent.
  
• Another pilot study in the UK found that telehealth delivered the following reductions: emergency department (ED) visits (15 percent), emergency admissions (20 percent), elective admissions (14 percent), bed days (14 percent), and total costs per patient (8 percent). However another study showed that ED visits and hospitalization rates did not show any significant cost savings. Sixty-four percent in the tele-monitoring group were hospitalized or had ED visits versus 57 percent in the control group.
  

Telemedicine, telehealth, and telecare are already the next "new" innovation in healthcare. They offer organizations the opportunity to be creative and develop programs that fit their needs. A telemedicine vendor said they are already working with over 200 unique types of telehealth programs with over 130 million people having access to the programs.

These quotes seem to summarize the overall value and impact of telemedicine (term used to include telemedicine, telehealth, and telecare), as well as the value it has for the consumer.

Impact

"We view telemedicine as an important tool in increasing consumer access to high quality, affordable healthcare, improving patient satisfaction and reducing cost. Given recent advances in technology, telemedicine gives customers a new way to be more engaged in their care, and save time and money. Additionally, telemedicine contributes to the value-based care goals of patient engagement, expanded hours for primary care, population health management and care coordination."

Representatives from eleven private insurers , including Aetna,
Humana and Anthem, in a public letter to
Congressional Budget Office Director Keith Hall

Consumer Demand

"Clearly consumers are not only becoming aware of telemedicine but starting to demand access to it. It is becoming a part of the standard of care that should be made available throughout the country."

Jonathan D. Linkous
CEO of the American Telemedicine Association

Pat Stricker, RN, MEd, is senior vice president of Clinical Services at TCS Healthcare Technologies. She can be reached at pstricker@tcshealthcare.com.