Telehealth: “The Doctor is In… Another City”

A decade of advances in telehealth have improved patient outcomes in underserved California counties, but continued promise of reducing the state’s wide health disparities depends on overcoming several financial, policy, and technical hurdles.

Once strictly termed telemedicine, today’s expansive definition of telehealth includes a variety of distance services: video conferencing with a specialist, home monitoring of acute or chronic disease, or collecting remote health data like x-rays or dermatology photographs for review by a specialist.

Telehealth’s popularity has spread by necessity, said Christine Martin, executive director of the California Telemedicine and eHealth Center (CTEC). Escalating healthcare costs, an aging population, rapid increases in chronic disease, and dwindling access to healthcare in underserved urban and rural areas have necessitated a speedier adoption of telehealth.

CTEC is considered the information hub for California’s network of telehealth organizations, and has been designated the western region’s official resource center by the federal Health Resources and Services Administration.

The state’s existing health disparities are vast. In rural Yuba county, there were 2,602 residents for every primary care physician according to 2008 statistics, far in excess of the suggested 60-to-1 ratio. A 2007 survey of South Los Angeles by the California Endowment showed that patients had to wait six months or more to see specialists in cardiology, dermatology and orthopedics. Today, the central San Joaquin Valley has an acute shortage of endocrinologists, dermatologists, neurologists, pediatric psychiatrists, and other specialty care physicians.

Access to health care professionals is only one reason for health disparities and might not be the biggest. The conditions in which people live probably affect their health and longevity more than their ability to see a doctor when needed. But a leading authority on healthcare disparities says telehealth is California’s greatest hope for providing equal access to treatment statewide.

“My interest in this area is not because of the technology,” says Thomas Nesbitt, director of the Center for Health and Technology for the UC Davis Health System. “My passion is to reduce geographic health disparities, and technology is the tool to do that.”

Long considered a pioneer in telehealth, UC Davis has led the state’s dialogue on health disparities since the early 1990’s when Nesbitt spearheaded creation of its telehealth programs.

The UC Davis Medical Center is scheduled to open its California Telehealth Resource Center next summer. The four-story, $36 million building will offer medical consultations, emergency critical care services, distance education, and health training.

The center will also foster its Rural-PRIME program for 50 medical students who will train at rural clinics and hospitals, connecting with UCD’s medical school through virtual classrooms with the ultimate goal that the students will remain in these typically underserved communities after graduation.

“It’s really hard to get a specialty doc to locate into a rural area,” said Steve Barrow, policy director for the California State Rural Health Association, a locus for rural healthcare concerns. “There are far fewer healthcare workers than you would find in an urban setting.”

In rural areas, added Barrow, telehealth can prevent economically-strapped patients from missing work, help reduce the effects of nursing shortages, improve home monitoring of chronic disease, and provide access to distant ICUs and specialists – all acute problems in remote geographic settings.

Emergency and specialty care are two of the most immediate uses for telehealth, and are already proving beneficial.

The Sutter Health network uses video technology and early warning software to remotely monitor more than 30,000 critically ill northern California patients each year with its eICU (emergency ICU). Two central hubs in San Francisco and Sacramento monitor over 400 ICU beds within its network of hospitals, improving reaction time for emergencies and reducing incidence of sepsis. a bacteriological infection. Sutter says from 2007 to 2010 sepsis-related deaths decreased 28%.

Sutter estimates that its remote monitoring saved 1,300 lives during the period, and length of stay dropped by 15%.

The Center for Connected Health Policy (CCHP), a health policy think tank, is co-sponsoring the Specialty Care Safety Net Initiative (SCSNI), which pairs 38 of the state’s safety net health clinics (that treat impoverished Californians) with five University of California medical schools signed on to provide high-end specialty care.

“Say you’ve got a diagnosis for diabetes and need to see an endocrinologist,” says Sandra Shewry, president and CEO for CCHP. The SCSNI program is “is designed to see if we can use telehealth to put together unprecedented specialists with our underserved communities.”

The five participating medical schools include University of California Schools of Medicine in Los Angeles, Irvine, San Diego, San Francisco, and Davis.

Now in its second year, the SCSNI program has served 1,200 patients – half on Medi-Cal, half uninsured. Shewry estimates that “several thousand” more will be served this year.

The challenge for the program in its second year is to streamline efficiency and find a business model that makes it cost-effective.

“In a year or two when this project ends,” says Shewry, “it will make sense for the UC’s… as part of their mission of serving California (to make the program) a break-even proposition for Medi-Cal patients.” Currently, the SCSNI is funded through March, 2012.

The California Telehealth Network (CTN) is providing broader bandwidth connection to remote healthcare facilities with its Rural Health Care Pilot Program (RHCPP). Operated by the Federal Communications Commission, the RHCPP program has 850 California healthcare sites now qualified to receive broadband service, eventually targeting 2,000 rural hospitals and clinics.

CTN provides the subsidized broadband service to encourage greater adoption of telehealth in areas often lacking high-speed connections.

The CTN system is part of a national FCC plan to provide broadband access throughout the county, with a focus on health and education. The program is federally subsidized through July, 2016 with $9.1 million from the Department of Commerce.

However, besides the time needed to install the high-speed connections, CTN faces challenges training staff and other technical hurdles.

When CTN was launched a year ago, ZDNet Healthcare blogged that California TeleHealth Network has fail written all over it claiming RHCPP is focused on state-owned facilities rather than private hospitals and insurers, meanwhile ignoring national technology standards.

Eric Brown, CTN’s president and CEO, said that private healthcare facilities can still access CTN’s broadband services, but would not receive subsidized service. Brown said CTN is currently negotiating with Catholic Healthcare West, Kaiser Permanente and others to integrate existing health records within the CTN network.

“We felt we had to walk until we could run,” admitted Brown. In May, CTN hired consulting firm Booz Allen Hamilton to provide business development plans and address technical standardization issues. CTN hopes to find a business model for the program after its Department of Commerce subsidy ends.

While telehealth can in many cases save money, programs like SCSNI and the CTN broadband initiative have largely been funded by foundations and grants, and need to find profitable business models, especially when delivering specialty care.

“I don’t know that providing medical specialty care in rural areas is going to break even with telemed,” said Martin, “but it’s the right thing to do.”

She quickly added that telehealth should be viewed holistically, “as a system” that offers substantial savings, especially when monitoring and controlling chronic disease.

Martin says one obstacle is that health insurers are sometimes unwilling to pay for treatment unless provided in a licensed healthcare facility – which often excludes home care. She says telehealth won’t be used “if the payment rates that are available through different health plans are viewed as insufficient by the care providers.”

One health insurer moving forward aggressively with telemedicine is Anthem Blue Cross. Its Telemedicine Program has 58 “presentation sites” where insured patients can access a remote specialist in 24 of the state’s 58 counties. The most commonly-accessed specialists include psychiatry, dermatology, endocrinology, neurology and pediatrics.

Martin says CTEC wants all healthcare providers to offer dedicated telehealth services, provide consumers access to telehealth whenever appropriate, and ensure that telehealth is covered and reimbursable by all health insurance plans.

Pending legislation intends to address many of these issues, making telehealth automatically covered like any office visit or specialty treatment, regardless of where the patient is treated.

The bill, AB 415, would eliminate both the need for an additional signed consent form before receiving telehealth services, as well as the requirement for an in-person visit to a health provider before receiving treatment. In addition, it would remove a “sunset date” on telehealth to make such services available permanently.

Fifteen years ago, cautious California lawmakers passed the Telemedicine Development Act of 1996 (TDA). Although considered a progressive health standard used as a template by other states, TDA nevertheless required additional consent from the patient and restricted telehealth services to the most highly-trained providers – physicians and surgeons – among other restrictions.

Yet even today, some lawmakers are hesitant to accept the speeding changes in healthcare delivery.

William Monning, Democratic chair of the state’s Assembly Health Committee, said care should be taken when moving forward with these new technologies.

“Telehealth has the potential to improve access to health care providers and services where there is little or no access today,” said Monning, who warned that patients also need to retain “the full and undivided attention of their doctors in the exam room.”

Barrow said while telehealth addresses a wide variety of healthcare needs, “in-home monitoring for isolated, aging people is going to be really critical.” Commercial firms hoping to capitalize on the aging Baby Boomer generation have already introduced telehealth products to a willing market.

The private firm Care Innovations, a joint effort of Intel and General Electric headquartered in Roseville, California, currently provides a number of monitoring products and computerized wellness systems for homes and assisted-living facilities.

Despite existing policy, financial and technical challenges, the cost-savings of telehealth in a stressed healthcare system are providing hope for many without easy access to services.

“I think initially it’s going to make the most difference in hospitals and clinics, and will be slower getting into the home because or reimbursement issues,” said Nesbitt. He added that over the long-term telehealth will have more applications in the home “because chronic disease is such a big part of the healthcare problem in this country.”

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