There goes telehealth, taking it on the chin again

I happen to have an inside look at this because we are assisting with some EMR implementations and meaningful use, plus my wife is working directly with doctors to implement technology at a major medical institution.

I think there is an incorrect assumption that doctors don’t want to push telehealth because it means they are missing out on a patient visit and resulting reimbursement. Doctor’s time is at a premium and most of them have a maxed out schedule, so that patient would just be taking up a slot in an already full day anyways.

While I applaud the advances in telehealth and other technologies, we won’t see widespread adoption until it is covered by insurance or until doctor’s are done swallowing the EMR pill that they are still in the process of implementing and maximizing (a process that continues through 2015 I believe). After that, institutions will look for the incremental gains that telehealth could provide, mostly on lowering readmission rates. Until then, I understand why they are focusing on the basics – even though, as a technologist, I’d love to see them implement the full array of technologies that are out there to provide better care.

The telehealth that we are seeing implemented is either by patients paying for it themselves or institutions that were ahead of the curve in EMR implementation (the VA’s EMR system is widely recognized as the gold standard). Patients that are implementing telehealth are paying for it out of their own pocket. It’s probably because it makes more economic sense for them to utilize telehealth instead of paying out of pocket for a home care nurse to do the same thing at a higher rate. The VA is obviously seeing benefits as well.

It seems we’ll just have to either wait a few years for complete EMR implementation or wait for another act of congress.

Fourteen years ago I met a young man who had demonstrated through the use of a Super Nintendo game that when people engage with health information on a regular bases, they change their behaviors and have less problems managing their chronic conditions. Sounds like common sense to me – when you monitor a person’s vital signs and symptoms, educate and motivate them to engage with self management behaviors, and remind them when to take their medications, of course they will do better. I have always wondered why we felt we needed randomized clinical trials to “prove” what just makes sense to those of us who have been working with chronically ill patients for 30+ years. As you mention, the VA has been implementing a successful telehealth program for many years now. Here’s the difference between what they have done and the randomized clinical trials of the world. The VA didn’t just purchase technologies and deploy them in a controlled environment; they developed a new model of care for their high-risk, high-cost veterans. In this care coordination model, they identified potential veterans for the program and then carefully assessed their needs to determine first what their care needs were and if they needed any technology and if so, what technology would be most appropriate for that particular veteran. You see, their model was focused on coordinating care for the veteran to ensure they were getting the right care at the right time in the right place. They did a wide scale implementation that has delivered positive results overall for their Veterans and their bottom line (absent of any randomized clinical trials).

I believe the randomized clinical trials at Mayo and other locations were conducted with the highest regard for scientific merit and in an extremely well organized and methodical way – as clinical trials should be conducted. I also commend the researchers for their keen observations of why they did not see results – they now understand that it is the idea of delivering care differently that makes the difference, and not the technology alone. You must identify the right types of patients for these new care models; you must utilize the data to drive your interventions; you must match the needs of the patients to the appropriate technology; and you must train your clinicians to deliver care differently than they are used to if you want to see the positive impact from a telehealth model of care. While the clinical trials were well conducted, the reality of this new care delivery model is that you must treat each patient based on their needs and following a strict protocol for all patients may in fact introduce all kinds of other variables that muddy the water and make it tough to see a positive impact. So, we get back to common sense – if you are monitoring a patient on a daily basis, using that data to intervene in a timely manner when there is an indication of a change in their status, reminding them to take their medications and teaching them how to engage in self management behaviors, then of course, the patients will do better! Does anyone disagree with me? If so, I would love to hear from you. Julie Cheitlin Cherry, RN, MSN Clinical Nurse Specialist in Gerontology Director of Clinical Development Intel-GE Care Innovations

You said it all! I've recently entered the health field, in a patient advocacy position and the prevalence of paper-and-person, technology free health systems is mind boggling and still capable of shocking me every single day. We are in the very midst of health care reform debate here in the United States, yet it is all talk and very little action. Dare I be the skeptic, but it's almost as if these large for-profit hospitals/entities do not really want to pursue serious discourse on decreasing rehospitalization efforts because - hold on I'm about to spin some common sense here - it will ultimately hurt their bottom line! I must always remember - this is about dollars, not sense!

I think there are a lot of things in play here. Our whole medical system is in a need of a change in order to accommodate the use of these types of technology. I have no doubt that if there were healthcare workers trained in monitoring vitals or whatever data is collected with some of telehealth style systems, that a lot of health crises could be avoided. However, there needs to be a new breed of healthcare workers spending time on this and helping patients understand when something is going wrong. To do this, there definitely needs to be a shift in the way reimbursement from insurance companies works for such services.

Spot on, Laurie! It was very naughty of the study authors not to attempt to suggest why the monitoring was associated with more deaths. There are all sorts of possible explanations, including that too much medical attention increases your chances of complications...which is an encouragement to avoid going into hospital if you possibly can. How? Try telehealth monitoring!

Steve Hards
Editor, Telecare Aware