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As health care organizations puzzle over how to fit together a strategy for access to care — clinicians where they are most needed, patients benefiting from the right care at the right time — telemedicine is taking shape as that key piece of the picture.

Using modern communication tools to enable virtual face-to-face encounters and send vital clinical data, hospitals nationwide are transcending the limits of geography to put a more complete set of health services in place. Plummeting costs and nifty technological advances have improved providers' access to telemedicine itself, enabling deployment in ways that quicken the care process, bring medical expertise to areas unable to attract or support specialty practices, and make home care more vigilant and efficient.

These innovations allow the virtual transport of more than a dozen types of specialists from four different states to bedsides of a small hospital in northeastern Oregon. Conversely, a regional hospital in northern Wisconsin is able to push its broad range of specialty coverage out to five critical access hospitals and other clinical sites hours away. And a nurse at a critical access hospital in a Plains state is able to summon an emergency doctor to a computer screen within seconds while waiting for one of the town's only physicians to arrive.

In use since the early 1990s, video and monitoring technology designed to put clinicians in touch with patients and other medical professionals used to be cumbersome and barely practical, says Fran Turisco, a health care consultant with Aspen Advisors. "People have this view of large rooms filled with huge, bulky equipment," she says. "Ten to 12 years ago, those [technology barriers] were huge issues, and now I'm kind of watching them melt away."

Telemedicine's maturation comes at a time when the health care industry is in business-model transition, planning for payment formulas based on preventing or easing medical problems and not just taking fees for addressing ills that crop up. Trustees are faced with making investments aimed at that new model and, meanwhile, they have to mind the fee-for-service store.

Telemedicine is one of those rare investments that can operate in both worlds, experts say. It can manage the evolving shifts in payment by gradually emphasizing new goals for the same technical networks and the processes built around them. "It's a great tool that will evolve as the care delivery process changes," says Laura Jacobs, executive vice president of the health care consulting practice of the Camden Group.

For board members, "the question is not if we should be utilizing telemedicine, but how we can utilize this tool given our current position along this path between fee for service and accountable care," Jacobs says. "That's the key message: Where do we put our resources, and how is our organization going to deploy it?"

Bridging the Miles

Grande Ronde Hospital, a critical access facility in LaGrande, Ore., started out five years ago as one spoke in a grant-funded initiative to link small hospitals remotely to a hub of specialists at Saint Alphonsus Regional Medical Center in Boise, Idaho. "The hub-and-spoke model allowed us to take advantage of the specialties that the hub site was offering," says Douglas Romer, Grande Ronde's executive director of patient care services. But after becoming familiar with the technology and with board support, "we went way beyond the hub site and started our own network."

That network has grown to 18 different programs, supplying access to everything from oncology and dermatology in Walla Walla, Wash., to cardiologists in Boise, neurologists in Portland, Ore., and intensivists in St. Louis. The specialists appear as the "face" of highly mobile robots that can enter any room where a local physician and patient are waiting, and provide not only face-to-face contact but special cameras and data transmitters to inspect the patient and swap images, lab results and trending information from electronic health records.

Located 90 miles from Walla Walla, 170 miles from Boise and 260 miles from Portland, Grand Ronde's efforts to bridge the miles through telemedicine have made both urgent and routine interventions minutes away instead of hours or days, preventing expensive travel, says board chair Lynn Harris. "It enables us to keep care locally, and that's very important to us."

For health care systems serving a wide area, telemedicine's ability to allow specialists to work more of the time from a flagship hospital instead of subjecting them to frequent travel to the system's outer reaches is another take on keeping care local.

Aspirus Network, with a regional hospital in Wausau, Wis., two critical access hospitals in neighboring counties and three in the western Upper Peninsula of Michigan, enables its specialists to do follow-up visits on a high-definition television screen with a local physician to help with the evaluations, says Jerry Mourey, Aspirus vice president for information technology. If that network were not in place, specialists would have to make the visits personally in many cases, while being out of productive service during what's known as "windshield time," Mourey says.

That's one of many clinical and practical uses of a network powering a range of access-minded services, which also include telemonitoring of patient vital signs in their homes, says Jean Burgener, vice president of post-acute care.

Besides spreading medical professionals' expertise, telemedicine helps hospitals meet essential needs. Avera Health, a 27-hospital system based in Sioux Falls, S.D., is in the third year of operating an "e-emergency" hub from its flagship Avera McKennan Hospital & University Health Center to 50 emergency departments in North Dakota, Minnesota, Iowa, Nebraska and Wyoming, says Deanna Larson, vice president of quality initiatives.

All but five emergency care links are at critical access hospitals, and nearly half are non-Avera sites under contract. Surging demand will boost the number of sites to 60 within a few months. The next-biggest telemedicine program, at 40 facilities, is e-pharmacy, which provides 24-hour oversight of new ordered medications to hospitals that do not have a pharmacist on staff.

The Reimbursement Picture

Services provided through telemedicine are more likely to be reimbursed by government and commercial payers as its technology improves and its comparability to face-to-face visits becomes more accepted. But payment still hinges largely on where a provider or patient is located and the type of service rendered, says Jonathan Linkous, chief executive officer of the American Telemedicine Association.

For example, traditional Medicare fee for service pays only for patients outside metropolitan areas, to certain facilities, and for certain diagnosis codes, he says. Offsetting that somewhat is the move to managing care under contract or through the Medicare Advantage HMO-type program, in which telemedicine becomes a care management plus rather than a payment hit.

"The fact that telemedicine has not been fully reimbursed by Medicare is certainly a factor [in payment considerations], but that has not in any way delayed a lot of hospitals from deploying it," Linkous says. "We've grown substantially in the utilization of telemedicine in the past few years despite the fact that fee-for-service payments are not fully implemented yet for telemedicine. So I think it's a great sign that we've done this much without some of the barriers being overcome."

In areas designated as having health professional shortages, Medicare will pay for telemedicine in the care of a patient, Burgener says. "The federal government has certainly recognized that specialty care will ultimately reduce long-term costs accrued under the Medicare system, so the best payer we have in telemedicine is Medicare." The Wausau area is the only Aspirus location not designated as having a medical shortage, she says.

Aspirus is gathering evidence of health care cost avoidance during the past several years to persuade payers to include telemedicine as a benefit as new contracts come up, says Maria Gulan, vice president of Aspirus clinics, operations and service development. For example, use of home monitoring tools cut the readmission rate for patients with congestive heart failure to 6 percent compared with 30 percent for a control group opting not to be monitored.

There's reason to believe health systems can make their case. At Avera Health, specialists linked to other clinics using a camera "get the same reimbursement as if they were face-to-face in their clinic," says Larson.

Grande Ronde's use of telemedicine played a part in persuading Oregon's legislature to pass a law two years ago requiring reimbursement, Romer says. "What it said to commercial carriers is if you insure somebody and will pay for this service in person, and it's appropriate to be done telemedically, then you're obliged to pay for it," he says. Oregon is among 12 states to mandate such payment.

Applications for All Occasions

Decisions about telemedicine should not be based solely on the prospects for fee-based reimbursement — there are plenty of other reasons for considering it, says Linkous. Examples include using telemedicine:

  • as a market-share builder. Telemedicine can help an urban hospital reach out to clinics in a metropolitan area, providing services that can be reimbursed at least partially, but more importantly, establish relationships with patients whose conditions might eventually require more intense intervention, Linkous says. Patients are likely to stay with the doctor they've been "seeing." He says member organizations in the telemedicine trade association using this approach have seen their admissions rise substantially compared with those of competitors.
  • as a management aid. Aspirus has a visiting nurse agency that serves 16 counties in Wisconsin and six counties in Michigan, and it uses telemonitoring to keep track of patient conditions and health status. It isn't covered by the traditional Medicare home health benefit, but it has guided the agency in assigning nurses and avoiding unnecessary visits, says Burgener.
  • as a primary care extender. Besides bringing specialty care to underserved areas, telemedicine "also can help on the primary care front," Jacobs says. That not only goes for physician coverage, but also for communicating patient needs to nurses or other clinicians, she says. In addition, generalists can be in short supply in locations such as nursing homes. Avera Health began a new program in December to support thinly spread primary care doctors who can't make it to every nursing home medical situation, says Larson. A remote physician is available to look in on residents, intervene early and perhaps head off an emergency trip.

Those and other uses of telemedicine then are positioned to serve the different approaches to efficiency and care delivery envisioned for accountable care. For example, a multihospital system using telemedicine as a market-share tool also can use it for more efficient use of specialists, Linkous says.

He gives the example of a group providing neonatal service on call at any number of facilities at a fraction of the cost of a hospital's instituting an entire department. "You can just see … what it's going to do in terms of the cost factor," he says. "That's what we hear from our members all the time. Most of the leading hospital systems are moving into it aggressively."

Getting expertise to where it's needed also saves money in the accountable care era by helping clinicians catch problems when they're less expensive to treat, says Gulan. "By reducing delays in care, you're helping to treat patients earlier and with more preventive services to keep them out of inpatient stays, out of the emergency department, and, therefore, lower health care costs."

On to New Care Models

Reform initiatives "will propel the use of telemedicine way beyond where it is today," Jacobs says. "Whereas the reimbursement models today really have been focused on the face-to-face visit, the traditional use of telemedicine to provide better access is great. But when you layer on these new payment models that say, 'Well, now we need to think about the whole coordination of care and the total cost of care,' really putting telemedicine to use to keep people healthy and not so dependent on the face-to-face visit will allow us to make use of this technology even more."

Aspen Advisors' Turisco recommends that trustees "start with a program that addresses immediate problems, and look at the barriers." Home monitoring of discharged hospital patients may be warranted in light of the Medicare rule taking effect in October that will deny payment for readmission of certain patients within 30 days. It will require a process to support the technology, including training the patient, deploying the monitor, responding to alerts and contacting physicians.

"But once you have that in place and you get it working, it'll work for any other patient that you're trying to monitor once they leave the hospital," Turisco says. "As Medicare grows in terms of the number of diagnoses it is following, and as commercial payers follow suit, applying the same sort of financial disincentives to having patients come back, you have the program in place."

John Morrissey is a freelance writer in Mount Prospect, Ill. For more on telemedicine, please see "Care and Colleagues, Across the Miles."

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