By Dan Halpren-Ruder, MD, PhD
Rescue announces they are transporting a stroke patient and upon arrival, the patient has a dense left-sided hemiplegia and is unable to speak. The patient appears to be a superb candidate for chemical thrombectomy and we have a three-hour envelope from onset to treat with relative safety. I struggle to communicate with the patient as best as I can, in frustration, I look up and see three nurses gathered around the gurney intently working with their smartphones. My initial reaction is to admonish the staff for not helping when I quickly realize that they are working hard to find the patient’s family so we can define the timeline, risks, and receive consent to provide treatment to the patient. They are successful at social networking and the patient’s brother arrives shortly thereafter. He constructs the timeline, reviews risks, obtains consent and the patient is thrombolysed. An hour later, the patient is talking and shows no weakness.
The above event stands as a career-changing event for me. Until then, I had worked for 30+ years in the Emergency Department (ED) only rarely getting help from the outside world. This was the first time the internet intervened providing virtual healthcare. We have seen the evolution of practice aids and recordkeeping that substantially change the way healthcare is delivered. Now healthcare providers are challenged with virtual delivery of healthcare in the rapidly expanding area of telehealth.
What is telehealth?
Telehealth, as defined by the Health Resources Services Administration (HRSA, 2014), is the use of electronic information and telecommunications technologies to support long distance clinical health care, patient and professional health-related education, public health and health administration. These technologies include video conferencing, the internet, store and forward imaging, streaming media, and terrestrial and wireless communications.
HRSA differentiates telehealth from telemedicine. Telehealth refers to a broader scope of remote healthcare services such as non-clinical services, provider training, administrative meetings, and continuing medical education. Telemedicine is the provision of remote clinical services. These definitions are presented only to assist in an attempted differentiation and are often used interchangeably. For the purposes of this article, we will use the term telehealth.
Aspects of telehealth
Telehealth can be divided into four broad categories: interactive video conferencing, store and forward, patient monitoring, and mobile telehealth (mHealth).
Interactive video conferencing allows patients and healthcare providers to see and hear each other in real-time, whether they are across the street or on the other side of the world. Many sending stations are now equipped with stethoscopes, otoscopes, ultrasound, ophthalmoscopes, and other peripherals which can increase the richness of data and make decision-making more certain. This category of telehealth also includes professional to professional consultation (e.g., the pathologist that needs help with a puzzling frozen section). This can happen in real time and significantly affect the course of a clinical interaction. The video conferencing arm of telehealth has two subdivisions: scheduled virtual visits and the on-demand virtual visit. A scheduled virtual visit is just that, a scheduled visit between provider and a patient known to the provider. In an on-demand virtual visit it is rare for the provider to know the patient. On-demand telehealth is currently associated with a high level of entrepreneurial fervor.
An unexpected video conferencing service is the advent of the Tele-ICU. Small hospitals, largely unable to maintain a full retinue of intensivists, can take their ICU online to an intensivist staffed virtual ICU. The ICU monitors in both the hospital ICU and in the virtual ICU have the same readings. Intensivists can direct nursing and physicians through problems or arrange for transfer to an ICU with 24/7 staff intensivists.
Another video conferencing service is teleneurology which facilitates access to the neurology or neurosurgery expertise. This platform allows neurologists at a distant specialty hospital to interview patients and staff and help make decisions as to whether thrombolytic or neurosurgical expertise might improve outcomes. In this instance, for patients requiring neurosurgical expertise not available at the consulting hospital, the patient can be transferred for rapid stroke reversal in the OR.
The only real difference between interactive video conferencing and store and forward is that the latter is asynchronous. The provider and the patient are not interactive in real-time, but rather send a series of verbal and or video messages to each other. Clinicians may request consults that are nonurgent. This professional to professional consultative service has been particularly helpful in radiology, dentistry, dermatology, ophthalmology (diabetic retinopathy) and pathology.
Patient monitoring technology (generally asynchronous) can now go home with the patient. For many years now, nurses have been following patients at discharge from hospitals. The most common activity is monitoring for exacerbation of congestive heart failure after discharge. This activity can shorten hospital stay and head off exacerbations before they become critical. Currently, these activities are somewhat sporadic, although some have moved into continuous monitoring, such as the current day Holter cardiac monitor. Noninvasive, comfortably worn sensors can transmit to Internet capable phones and the data is sent to processing centers where either computers or personnel monitor for concerning changes.
Finally, there is mHealth (mobile telehealth) which is simply all of the above originating from mobile technology. It may be synchronous or asynchronous, but includes the essential video conferencing component. It just keeps on getting easier!
The best way to think about telehealth is to compare it to a familiar healthcare tool: the stethoscope. The heart sound was the most prominent sound emanating from the body heard by early physicians but simply holding the ear to the patient’s chest was problematic. So, the first stethoscope was a simple bamboo tube. But the tube revealed sounds that were difficult to hear and a diaphragm was added. And so on. So too for telehealth: the telephone was good but missed the unheard, visual elements of an interview. A picture is worth a thousand words and, by personal experience, a video raises that to the sixth power. Thus, telehealth is a new tool—not new medicine. It empowers both provider and patient to explore new dimensions of healthcare delivery. It has now been shown that Telehealth is effective in: (1) remote patient monitoring, (2) surveillance of chronic illness and (3) elements of behavioral health (Agency for Healthcare Research & Quality, 2016).
Telehealth is a fit in the drive to value-based healthcare
Telehealth addresses all the elements of the triple aim (Berwick et al., 2008) as it has the opportunity to (1) improve the individual’s experience of care, (2) improve the health of populations (by improving access), and (3) reducing the per capita costs of care. Berwick’s “triple aim” is an efficient restatement of the “Six Aims for the HealthCare System” put forth by the Institute of Medicine’s 2001 landmark publication: Crossing the Quality Chasm. (Institute of Medicine, 2001). Reviewing the IOM list in the context of Telehealth is instructive:
- Safe: Avoiding harm to patients from the care that is intended to help them.
- A video conference or a non-invasive monitor has a large index of safety. Otherwise the safety of Telehealth is that of the completeness of the interview and data evaluation generic to healthcare.
- Effective: Providing services based on scientific knowledge to all who could benefit from the services.
- Telehealth invites the right-sizing of services. In the world of procedural-based healthcare, many services are provided at a rate easily reduced by the efficiency of telehealth.
- Patient-centered: Providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.
- Arranging a significant portion of patient clinical time to be spent in a location of their comfort and without significant travel time/expenses could be an ideal vehicle to provide respectful and responsive care.
- Timely: Reducing wait times, and possibly avoiding harmful delays, for both those who receive and those who give care. Telehealth offers instant access.
- Efficient: Avoiding waste, such as waste of medical equipment, supplies, ideas, and energy.
- With telehealth, getting the provider and patient together could not be easier.
- Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status. Resistance in putting the provider and patient together is frequently geographic and/or socioeconomic issue. Telehealth can mitigate these obstacles.
The takeaway from this analysis is that telehealth answers all of the elements of the IOM metric and, by extension the Berwick Triple Aim. Telehealth is a tool that provides opportunities to move the medical encounter to a greater value.
Medicare is specific as to who can do what with every aspect of telehealth. Every year, Medicare revises the Physician Fee Schedule (PFS) and publishes a final rule in early November to take effect on January 1 of the following year. The final rule for 1JAN2018 was added to the Federal Register in November 2017. The final rule has a number of titles: CMS 1676-F is the easiest; you can find it here. It is easy to present the Medicare rules (because they are agonizingly precise). What follows is an extraction from current and past final rules. Medicaid largely follows Medicare but shows the expected state variability. Private insurers are significantly more liberal. In the case of Medicaid and private insurers, you will need to get state specific and insurer guidance. Using CMS rules is always the safest but major opportunities exist under Medicaid and private insurer regulations.
“Several conditions must be met for Medicare to make payments for telehealth services under the PFS. The service must be on the list of Medicare telehealth services and meet all the following additional requirements:
- The service must be furnished via an interactive telecommunications system.
- The service must be furnished by a physician or other authorized practitioner.
- The service must be furnished to an eligible telehealth individual.
- The individual receiving the service must be in a telehealth originating site.
When all of these conditions are met, Medicare pays a facility fee to the originating site and makes a separate payment to the distant site practitioner furnishing the service.” (CMS, 2017)
Originating sites (where the patient is) for Medicare telemedicine services include:
- The office of a physician or practitioner;
- A hospital (inpatient or outpatient);
- A critical access hospital (CAH);
- A rural health clinic (RHC);
- A federally qualified health center (FQHC);
- A hospital-based or critical access hospital-based renal dialysis
center (including satellites) (effective January 1, 2009);
- A skilled nursing facility (SNF) (effective January 1, 2009); and
- A community mental health center (CMHC) (effective January 1, 2009). (CMS, 2017)
Distant site practitioners under Medicare include:
- Nurse practitioners
- Physician assistants
- Registered dieticians or nutrition professionals
- Clinical nurse specialists
- Certified registered nurse anesthetists
- Clinical psychologists and clinical social workers (These providers cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation services under Medicare). (CMS, 2017)
Practitioners allowed to provide telemedicine services are subject to state law, although regulations may vary from state to state. The provider can be located anywhere in the United States, but MUST be licensed in the state where the patient is physically located. Concerns revolving around credentialing should be a major concern. If the encounter is provided as an extension of the provider’s relationship to a healthcare organization, that provider must be credentialed to participate in telehealth encounters. If this is a consult, the remote site provider will often be given courtesy privileges in order to participate in the patient’s care at the initiating site. All of this should be spelled out in each institution’s telehealth policy/procedure manual. Stakeholders in each telehealth application should sign off on these policies/ procedures. Marshaleen King, MD, provided a good example of a telehealth policy/provider manual in MagMutual Newsletter in 2017. In addition, law firm Foley and Lardner has published a superb telehealth compliance checklist.
Reimbursement for telehealth services
Telehealth is a service paid for by CMS as a group of allowed codes, no different than any other service. As with other healthcare services, proper documentation is required as that code’s documentation is described by CPT under the office or hospital setting. Not all codes have explicit documentation requirements and those codes should be documented as is policy at the involved institution. The established codes as well as codes added starting 1JAN2018 are listed in the Telehealth Services Bulletin.
Medicaid should follow CMS very closely but, as previously, states can occasionally identify their own preferences. Private insurers may have their own list and so will need to be consulted.
Consider how MACRA (Medicare Access and CHIP Reauthorization Act of 2015) is going to impact the telehealth world. Do you remember the Sustainable Growth Rate formula? This formula was to keep Medicare expenses in check but failed miserably, so it was replaced in 2015 with the Quality Payment Program (QPP). The final rule for MACRA/QPP came out in October 2016 and the plan had its first year in 2017. The goal of MACRA is to safely move healthcare from procedure to value based reimbursement. There are two paths to the QPP: MIPS (Merit-based Incentive Payment System) and the Advanced Alternative Payment Models (A-APMs). Clinicians selecting the MIPS framework will have a somewhat easier path but will not appreciate the full measure of quality reimbursement available to those selecting the Advanced APM measures. Advanced APM folks are going to be large provider/hospital systems that will work with CMS to structure quality and cost goals: meet or exceed and profit, miss and be punished by reduced compensation. MIPS has embedded quality processes in the presence of improvement activities (IA)—there are nine categories of IAs encapsulating 97 suggestions—and quality measures (there are 271 of them). In 2017, 60% of the MIPS score was for accomplishment of a number quality measures, 15% was for the IAs and 25% was for updating EMRs so that the accomplished quality measures and IAs would be appropriately mined. Cost, the fourth element, will be introduced in 2018. Both MIPS and A-APM groups are encouraged to shape their QPP activities in ways that create value. (CMS, 2018) Practices electing either MIPS or A-APM will find success in the value telehealth brings and not worry about its discrete reimbursement. “The statute (MACRA) allows for the incorporation of telehealth in coordinating patient care and includes telehealth use in MIPS scoring. The MIPS score determines payment adjustments to clinicians based on performance” (National Quality Forum, 2017).
On the A-APM side, some models allow practices to waive the originating site rules to allow various sites, including the patient’s residence. “For Medicare beneficiaries, this opens up new ways of engaging with their care team that would not require travel or increase burden,” according to the NQF’s framework report.
Quality in Telehealth
At one level, telehealth quality can be expressed as a series of technical metrics. These metrics are easily obtained from the records and digital footprint of the specific services provided. As the practices are quite different, metrics will vary as to the flavor of telehealth being monitored.
- On-Demand Metrics
- Number of physicians practicing
- Number of visits completed
- Visit duration
- Visit duration for in-person visit vs video visit
- Wait time
- Cost to patient for in-person (travel, tolls, parking, etc.) vs. video visit
- Resolved or referred?
- Referred to PCP, UC, ED, other? If ED: number of patients admitted to observation or hospital
- Was medication prescribed
- List of 10 medications prescribed
- Top chief complaints
- Top diagnoses
- Patient experience of care (NPS – net promoter score
- Scheduled Visit Metrics
- Number of departments/specialties
- Number of practicing physicians
- Number of visits completed
- Visit duration
- Visit duration for in-person visit vs video visit
- Wait time
- Cost to patient for in-person (travel, tolls, parking, etc.) vs video visit
- Was medication prescribed
- List of top 10 medications prescribed
- Top chief complaints
- Top diagnoses
- Patient experience of care (Net promoter score…likely to recommend and have you recommended)
- Specialty Episodic Consults Metrics (e.g., Neurostroke Network)
- Number of providers
- Number of community hospitals in the network
- Number of consults
- Number of TPA recommended
- Number of patients remaining at community hospital
- Number of follow-up scheduled visits with patients
- Critical Care Continuous Monitoring Metrics (provider to provider)
- O/P Mortality – observed to predicted
- O/P Length of stay
- Ventilator duration
- Number of consults requested (call from unit to the tele-ICU center)
- Number of intervention made
- Number of VAPs
- Number of CLBSIs
- Number of UTIs
- Number of ICU readmissions
At another level, quality metrics exist in the answers to specific, probing questions asked of the system under analysis. In 1996, the Institute of Medicine brought together both clinical and technical experts in the budding telehealth spectrum of services and published what was essentially a telehealth manual. Most of what resulted from this effort is still relevant. Nowhere is this more true than in the sections dealing with QA and QI. Box 7 details examples of questions of questions that are increasingly being asked of Telehealth.
In a discussion of the impact of diagnostic technologies, Fineberg and colleagues (1977) distinguished several process and outcome dimensions that might appropriately be assessed by evaluators. These dimensions include (The National Academies Press, 1996)
- technical capacity—whether a technology is safe, accurate, and reliable (e.g., how do transmitted digital images compare to films?)
- diagnostic accuracy—whether a technology contributes to a correct diagnosis (e.g., was an initial dermatology diagnosis by a primary care clinician corrected after review by a dermatologist?)
- diagnostic impact—whether a technology provides diagnostic information that is useful in making a diagnosis (e.g., after the telemedicine consult, is a face-to-face consultation still necessary?)
- therapeutic impact—whether a technology influences patient management or therapy (e.g., do paramedics perform better when they have access to emergency cardiac telemetry?)
- patient outcome—whether a technology improves patients’ health and well-being (e.g., are postsurgical patients telemonitored in a nursing home more or less likely to develop wound infections than patients remaining in the hospital?)
The first four dimensions involve processes of care. The last involves outcomes.
This 1996 groundbreaking report suggested areas of telehealth that should be considered in assessing quality management but suggested only a few indicators. In the interval, there has been an effort to evaluate quality in the telehealth sphere but validated indicators have not been established. Last year the National Quality Forum convened a working group, co-chaired by Ward and Hollander, to tease apart the elements of telehealth that would lead to a set of quality indicators. The result of this effort was published in final form in July 2017 (National Quality Forum, 2017). This is required reading for anyone looking forward and seeing their institution weaving telehealth into many if not most of their patient-facing encounters, peer-to-peer consultations, and in acquiring remote clinical and managerial expertise. Because the Framework also suggests many indicators (measures), it also challenges the quality management community to structure quality assessing processes such that a core group of validated indicators develops.
Dan Halpren-Ruder, MD, PhD, practiced emergency medicine until 2004 and then moved to urgent care where he is still clinically active. In academic 2016-’17, he was a Fellow in Virtual Healthcare at Jefferson University in Philadelphia, working with Dr. Judd Hollander and his team. He remains an instructor in emergency medicine at Jefferson. He is currently working with a local urgent care group experimenting with telehealth and census leveling. His interest in quality management stems from a nine-year tenure on the board and three years as president of the RI QIO (now Healthcentric Advisors). In that vein, he is working to establish outcomes measures for telehealth. Please direct questions to: email@example.com.
Agency for Healthcare Research & Quality, https://www.ahrq.gov/news/newsletters/e-newsletter/525.html#link1, accessed 10/2/2018.
CMS, CMS-1676-F, 2017, https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html, accessed 10/2/2018.
Health Resources & Services Administration, https://www.hrsa.gov/rural-health/telehealth/index.html, accessed 10/2/2018.
Institute of Medicine, 2001. Crossing the Quality Chasm: A New Health System for the 21st Century.
The National Academies Press, Telemedicine: A Guide to Assessing Telecommunications for Health Care, 1996. http://www.nap.edu/catalog/5296.html. Accessed 10/2/2018.
National Quality Forum, Creating a Framework to Support Measure Development for Telehealth, 2017, https://www.qualityforum.org/publications/2017/08/creating_a_framework_to_support_measure_development_for_telehealth.aspx.