Stakeholder Perspectives

A panel of stakeholders who represent individuals who are involved in or receive health care services through telehealth technologies discussed their individual and organizational perspectives on telehealth. They also considered actions HHS could take to further the use of telehealth to improve health care outcomes while controlling costs.


Alan Morgan, M.P.A.
National Rural Health Association

We are at the perfect storm of health care: If we are to move forward in implementation of the ACA, if we are to address current workforce shortages in rural America, if we are to address quality and disparities, we have no other option than the use of telehealth as a clinical tool. The barrier to the implementation of telehealth is no longer the technology, as it was 20 years ago. Instead, the barriers remain in the rules, regulations, and guidelines that we have imposed. The National Rural Health Association (NRHA) focuses on four key policy areas to advance telehealth: reimbursement, credentialing, broadband and infrastructure, and research.


First, the NRHA recommends lifting the geographic patient requirements of receiving health care via telemedicine. As we proceed, we should

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12 Stakeholder Perspectives A panel of stakeholders who represent individuals who are involved in or receive health care services through telehealth technologies discussed their individual and organizational perspectives on telehealth. They also considered actions HHS could take to further the use of telehealth to im- prove health care outcomes while controlling costs. NATIONAL RURAL HEALTH ASSOCIATION Alan Morgan, M.P.A. National Rural Health Association We are at the perfect storm of health care: If we are to move forward in implementation of the ACA, if we are to address current workforce shortages in rural America, if we are to address quality and disparities, we have no other option than the use of telehealth as a clinical tool. The bar- rier to the implementation of telehealth is no longer the technology, as it was 20 years ago. Instead, the barriers remain in the rules, regulations, and guidelines that we have imposed. The National Rural Health Association (NRHA) focuses on four key policy areas to advance telehealth: reimburse- ment, credentialing, broadband and infrastructure, and research. Reimbursement First, the NRHA recommends lifting the geographic patient require- ments of receiving health care via telemedicine. As we proceed, we should 115

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116 THE ROLE OF TELEHEALTH not lose sight of the rural designations in ensuring that rural areas are served. However, rural providers are reimbursed less than their urban coun- terparts. If the financial equation for the urban base originating site does not work, telemedicine will remain as a fringe service. Second, the NRHA recommends the elimination of separate billing procedures for telehealth services. Telemedicine is a tool for the clinician; the use of separate, specific codes does not make any sense. The third recommendation is to reimburse care provided by physical therapists, respiratory therapists, speech thera- pists, and social workers. These services are in high demand in rural areas, but are often not available to rural communities. Finally, the NRHA recom- mends reimbursement for S&F applications. Credentialing We need to look at the cost of credentialing and privileging, as it is very burdensome to rural providers. A telehealth provider can administer health care services to patients anywhere in the country. The NRHA recommends that CMS adopt a policy to allow telehealth providers to receive deemed status (meaning that the providers meet Medicare and Medicaid certifica- tion requirements) and to allow for health care facilities receiving telehealth services to perform credentialing by proxy. Broadband and Infrastructure Investment in broadband will require the combined will of and col- laboration between government regulators and private industry. Research Much research on telehealth is already available. However, the NRHA calls for additional quality measures in telehealth treatments to improve the services in rural America. To be clear, the health care delivered in rural America is not of lower quality. This is reflected neither in the 2005 IOM report Quality Through Collaboration (IOM, 2005) nor in CMS Hospital Compare data that compare small critical access hospitals to their urban counterparts. Those sources indicate that rural health care is comparable (and sometimes even better) than the health care that is delivered in urban communities. However, it makes sense to look at some specialties to see if the quality of care has improved with the use of telehealth. The NRHA also calls for research to aid the telehealth resource centers and regional extension centers to improve the services they provide. The NRHA does not mean to imply these centers are not doing their jobs, but without the outcomes research of how their assistance is helping, they can-

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STAKEHOLDER PERSPECTIVES 117 not move forward in providing technical expertise to rural providers and communities. Finally, the NRHA calls for a study on the effect of telehealth on re- cruiting and training clinicians. Telehealth not only addresses the direct clinical application, but also can help address workforce challenges. AMERICAN TELEMEDICINE ASSOCIATION Stewart Ferguson, Ph.D. Alaska Native Tribal Health Consortium; American Telemedicine Association Providers who use telehealth usually start locally and then build to regional, national, and international efforts. Telehealth has largely been successful in Alaska--it is depended upon to decrease costs (especially travel costs) in the delivery of health care services, and Alaskan leaders are looking for incentives to increase the use of telehealth. Alaskan hospitals embrace telehealth as part of their strategies and business plans. Tribal part- ners mandate the use of telehealth, and have demanded increased use for access to specialty care. Just like others, Alaska has a vision that telehealth will be fully integrated into the health care system to improve the quality, access, equity, and affordability of health care throughout the world. After this type of success, the challenge will be trying to scale the system to meet the demand. The ATA provides resources to local telehealth providers such as its journal, webinars and webcasts, social media outlets, and opportunities for member participation. The annual meeting of the ATA is the largest of its kind anywhere in the world devoted specifically to telehealth. It convenes providers, device manufacturers, educators, and academics to discuss the best evidence and the best financial models. Aside from meetings, the in- fluence of the ATA has a lot to do with the participation of its members. Within the ATA, there are several special interest groups that are made up of subject matter experts who hold their own webinars and meetings. There are also various chapters, discussion groups, an Industry Council, and an Institutional Council (representing those who provide health care). These member groups are important in the development of practice guidelines, advocacy, training, and peer review. A major challenge in the adoption of new telehealth programs is not knowing the best practices for doing so; the ATA is a major resource for this information. With the involvement of academia, industry, provid- ers, and clinicians, the ATA has developed several evidence-based practice guidelines, with many more in progress (see Box 12-1). Guidelines and standards are especially important because telehealth is a solution of scale.

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118 THE ROLE OF TELEHEALTH BOX 12-1 American Telemedicine Association Practice Guidelines Completed In Progress Teledermatology Quick Remote Prescribing Guides for Live-Interactive and Desktop and Internet Telemental Health Store and Forward Remote Health Monitoring Data TelepresentingManagement Diagnosis of Diabetic TeleUrgent/Primary Care Retinopathy Tele-ICU Telerehabilitation Telepathology Telemental Health: Video-Based Telestroke Evidence-Based Telemental Teleradiology Health Core Standards for Telemedicine Networks Teledermatology Home Telehealth Telepathology SOURCE: Presentation by Stewart Ferguson, American Telemedicine Association. The investment and the change in the health care delivery system are just too difficult to do for too few patients. However, when you get to scale, the problems and challenges change. When you look ahead to an exponential adoption curve, the challenges are challenges of scale (e.g., going from 40 to 400 to 4,000 annual consultations). Much of this will require standardized training and methodologies and centralized support. In this vein, the ATA accredits telemedicine training programs. ATA Strategic Plan for Fiscal Year 2013 In the coming year, the ATA will continue to work on changes in public policy. They will develop and distribute an evidence base and care studies for telehealth and drive the adoption of best practices through standards and guidelines. They will work with the training programs on developing a comprehensive educational system. Finally, they will continue to work with consumers to ensure they are aware that telehealth technologies exist to meet their needs. The ATA is more than "American" and it is more than "Telemedicine." More than 10 percent of ATA members are international, which is good

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STAKEHOLDER PERSPECTIVES 119 because telehealth and health care go beyond the bounds of this country alone. The overall goal of the ATA is to bring people together and move the telehealth agenda forward. AMERICAN PUBLIC HEALTH ASSOCIATION Georges Benjamin, M.D., FACP, FACEP(E), FNAPA, Hon FRSPH American Public Health Association Public health looks at the world primarily from a population-based perspective, and not individual patients. Just like in our evolving health care system, there are also many new drivers of change for the population health system. These include the enhanced capacity to link and analyze large da- tasets, the speed at which technology is changing, and the requirement to better integrate primary care and public health (e.g., prevention and early intervention). The younger generation will be a major driver of much of this new change because they are much more comfortable with the use of emerging technology. Healthy People 2020 Healthy People 20201 includes, as one of its goals, the use of health communication strategies and health information technology to improve population health outcomes, to improve health care quality, and to achieve health equity. It also includes several related objectives that support shared decision making between patients and providers. The telehealth movement helps this shared decision-making and fundamentally changing the relation- ship between patients and providers toward an interaction that supports an informed, bilateral conversation to improve health. Other Healthy People 2020 objectives that support telehealth include goals to deliver reliable and actionable health information, goals to connect with culturally diverse and hard-to-reach populations, and a goal to provide sound principles in the design of programs and interventions that result in healthier behaviors. Telehealth and Population Health Telehealth brings enormous value to managing population health in- terventions. Public health has 3 core functions and provides 10 essential 1Healthy People is a set of national health objectives consisting of overarching goals for improving the overall health of all Americans and more specific objectives in a variety of focus areas. Every 10 years, HHS evaluates the progress that has been made on Healthy People goals and objectives, sets new goals and objectives, and sets new benchmarks for progress.

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120 THE ROLE OF TELEHEALTH services. The core functions are assessment of community health needs, policy development to address those needs, and assurance that all necessary health services are available. The 10 essential services focus on a range of public health services that are believed to be necessary to improve popula- tion health. They include the following: Monitor health status. Diagnose and investigate health hazards. Inform, educate, and empower people about their health. Mobilize community partnerships to solve problems. Develop policies and plans to support health. Enforce laws and regulations that protect health and safety. Link people to providers of care. Ensure a competent health workforce. Evaluate the effectiveness and quality of health services. Telehealth is going to be very helpful for tracking diseases and disease trends (e.g., immunization, cancer registries). With new disease outbreaks, telehealth provides new mechanisms to perform disease surveillance so that data can be collected not just from the health care system, but also pharmacies and grocery stores. These data can be combined with other data (e.g., school absences) to pick up on new disease processes based on clinical syndromes and community trends. Telehealth also provides a vari- ety of ways to communicate effectively with stakeholders, including social media. Mobilizing community partnerships can include partnerships with the private sector, civic groups, nongovernmental organizations, faith com- munities, and others to move entire communities toward health. When talking about linking people to systems and coordinating care, we can continue to talk about the 25 percent of the people who incur 75 percent of the costs of care, but the more interesting discussion may occur when we overlay the most costly patients with those who have problems impacted by the social determinants of health. For example, the communi- ties that are challenged in being connected to health care may also be the same communities that have food deserts, high levels of lead in the environ- ment, high crime rates, or lack of repair to roads and other infrastructure. These patients used to be called "noncompliant," but when we consider why they are noncompliant, we find that many things are fundamentally outside their functional control due to their socioeconomic status. From a community perspective, if we can fix those factors, we can begin to improve health. This partnership between the public health community and the health care community could work together using all these data to develop strong community programs or interventions that would make health im- provements easier.

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STAKEHOLDER PERSPECTIVES 121 A lot is happening with workforce development, including webinars, video conferencing, and interactive journals and blogs, all of which are trying to help improve skills. Additionally, much research is being done on health systems and public health systems. Social Media Tools The American Public Health Association (APHA) has invested a lot in social media tools due to their effectiveness in engaging communities. For example, the APHA's Flu Near You campaign challenges individuals to report how they feel on a weekly basis. This is an attempt to see if they are able to detect whether the flu has entered a community based on self- reported symptoms. If successful, this would allow authorities to send out targeted information on flu prevention (e.g., distancing, hand washing, vaccination) to populations at risk. Many other social media tools will be effective as we go forward to further engage people on a population basis. The Challenge of Paying for Population Health Information Technology Paying for population health information technology is always a chal- lenge. Obsolescence remains a problem, however. For example, before 9/11, the public health system was still operating off rotary phones. Now, public health systems are operating off the technologies that were put into place after 9/11, but in many cases resources have not been available to upgrade those technologies and so they have not been replaced. Additionally, ques- tions persist about adequately measuring the return on investment for many IT preventive activities, which makes the argument for continued invest- ments challenging. This will continue to be a problem until the hard work is done to show the fiscal as well as the health value for those technologies Ideas to Advance the FieldBenjamin stated that first, we clearly need to make strategic investments in population-based health information technol- ogy and data systems. Second, we need to require appropriate linkages of the public health and health care data systems. Finally, we need to demand accountability for population-based outcomes from everybody. Many states have remained at the bottom of the public health rankings for a long time, yet this does not seem to have as much impact or related activism as rank- ings for crime or education. Telehealth can not only help to document health outcomes, but help to target solutions so that we can make a real difference.

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122 THE ROLE OF TELEHEALTH REACTION AND DISCUSSION Moderator: Nina M. Antoniotti, Ph.D., M.B.A., R.N. Marshfield Clinic An open discussion followed the panelists' presentations. Antoniotti noted that based on these presentations, we still need to document return on investment in health care in general, we need to link and look at large datasets, and we need to enhance the use of public policy. Audience mem- bers were then able to give comments and ask questions of the panelists. The following sections summarize the discussion session. Interoperability and Support One participant noted that while he agreed that the focus should not be on the technology itself, he wondered why there is not more focus on interoperability standards. The participant noted that his university has been marketed to by companies that have interesting systems that are proprietary and so will not work with other systems. Ferguson agreed that interoperability has been a struggle from the beginning. He said that while the ATA does not address interoperability directly, it is often addressed through standards and guidelines or on the Industry Council. He added that other groups are focused on this directly, such as standards for device interactions. He also noted that some solutions are emerging, such as the development of middle-ware that can communicate with any electronic health record, and the use of direct messaging. Collaboration One participant questioned whether there was an opportunity to build a shared support network for providers. Ferguson noted there are some na- tional support centers, but they have not developed to the level they could, and Ferguson thinks they will continue to develop. Antoniotti asked each panelist to speak to how they are working together to advance telehealth, and how others might work with them. Morgan noted that the NRHA and the APHA have worked together on nu- merous issues, but not telehealth, so this is a prime opportunity. He stated that by the nature of the health care delivery process in rural America, the NRHA and the ATA speak on a regular basis. Morgan further added that they need to bring other organizations into the discussions as they move forward. Benjamin concurred, adding that health educators are key partners, especially with the amount of misinformation on the Internet. He added that as an example, the APHA spent a lot of time responding quickly

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STAKEHOLDER PERSPECTIVES 123 to misinformation about vaccines. Ferguson added that ATA also works with many organizations, including other professional organizations as well as disease-specific organizations. Oral Health One participant urged the audience to be inclusive of all types of health care services. He stated that the disparities in oral health are far beyond those in general health, and that telehealth has tremendous opportunity for those who are unable to access the traditional oral health care system. He further noted that California law was changed to replace the word telemedicine with telehealth to be more inclusive, and the July 2012 is- sue of the California Dental Association journal (a free download) was devoted to describing the technologies and methodologies for teledentistry. Antoniotti added that the Marshfield Clinic has used teledentistry since 2005. Ferguson responded that teledentistry has been occurring in Alaska for many years. He described the dental health aide therapist program in which people come in from villages, receive some training, and then return to their homes to provide some dental care. Dental health aide therapists are trained in telehealth, such as for taking images that are reviewed by distant supervisors. Licensure One participant noted that licensure has been mentioned multiple times as a challenge in telehealth. She added that as the cochair of a subcommit- tee of the ATA, they invited physical therapy, occupational therapy, and speech and hearing licensure boards to join their discussions about license portability, and noted that the boards wondered why they had not previ- ously been asked to participate. The participant urged everyone to invite all parties that are involved in licensure in these discussions. She also noted that it is not always the licensure boards that are the obstacles in licensure challenges, but that the professional societies may be creating some of these roadblocks. Ferguson referenced some changes, including that federal enti- ties now do not require consultants to hold a license in the state in which the patient is being served, and that the ATA board has voted to take this on as a major policy issue. Benjamin stated that licensure issues will be driven and resolved by bigger business interests like ACOs and integrated health care systems that cross state lines.

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124 THE ROLE OF TELEHEALTH Chronic Disease One participant acknowledged that organizations need to be responsive to their membership, but asked why they have not demonstrated more lead- ership in managing chronic disease. Morgan responded that meeting agen- das are based on topic submissions, and opined that this begs a much larger question--namely, why are providers not placing importance on chronic disease? Benjamin stated that the APHA does address chronic disease both locally and internationally, but is focusing on primary prevention, the built environment (e.g., food systems, transportation), and social determinants of health as approaches to addressing chronic diseases. He noted that the APHA is certainly involved in all the clinical preventive health services, and they advocated for the $15 billion prevention fund of the ACA that targets physical inactivity, nutrition, and tobacco. Benjamin added that these areas are tied to the leading causes of death and disability (e.g., car- diovascular disease, cancer, some injuries, chronic obstructive pulmonary disease). Benjamin stated that we need to get people into healthier lifestyles from earlier on in their lives to change communities and prevent much of the chronic disease we are seeing. He further added that there has been an enormous assault on the public health prevention fund as well as money for the Centers for Disease Control and Prevention, and the APHA has been focused on preserving the core funding for infrastructure and public health. Ferguson noted that home telehealth and remote patient monitoring has been the largest growing sector of the telehealth industry, and the ATA does have a significant industry representation in its membership and is doing everything it can within its scope to be involved in these issues.