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7 Remarks and Discussion: Day 1 In this session, the members of the planning committee summarized their individual perceptions of the themes discussed during the first day of the workshop. Subsequently, the planning committee members had an open discussion with workshop participants, including audience members. PLANNING COMMITTEE REMARKS Karen S. Rheuban, M.D. University of Virginia Health System When integrated into acute and chronic disease management, telehealth can improve access, improve quality, and in most cases lower costs. Tele- health reduces the burden and cost of travel for both patients and payers. For example, the University of Virginia telehealth program has documented the avoidance of 7.2 million miles in travel. Telehealth is a force multiplier. It can mitigate workforce shortages and even create a new workforce. With the necessary regulations, telehealth is perfect for integration into new payment delivery mechanisms, such as PCMHs, ACOs, and bundled payments. However, constraints remain due to outdated payment delivery mechanisms, federal and state statutes, and regulations that limit the expan- sion of services and interstate commerce in health care. To move forward, we need greater provider engagement, sharing of best practices, collaboration with the specialty societies, the advancement of innovative care coordination models, and the evaluation of telehealth 55
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56 THE ROLE OF TELEHEALTH programs and innovative payment models. Finally, a fresh look at point- of-care and site-of-service definitions is needed to mitigate current barriers. Nina M. Antoniotti, Ph.D., M.B.A., R.N. Marshfield Clinic Problems in telehealth are problems in health care. We should stop thinking about them as separate. Telehealth is a strategy to deliver health care services, but it is also subject to everything else that is going on in health care. Telehealth is not different than in-person care; rather, it is just that the two people are not physically in the same place. Adopting this philosophy eliminates many of the barriers in telehealth. In terms of payment, shared savings models are probably the way to go. Then again, instead of paying for consults under a fee-for-service model or shared savings model, maybe it would be better to have payment for the in- frastructure. The development of compelling evidence for value is necessary for acceptance by business leaders. In addition, we should not move ahead with assumptions about what patients want or value. Telehealth leaders also need to look more closely at existing models to learn more about who the providers of telehealth care actually are. Although telehealth presents many barriers, many innovative projects are going forward and making people healthier. Payers are adopting telehealth and the government is a participating partner. Kamal Jethwani, M.D., M.P.H. Partners Healthcare Center for Connected Health; Harvard Medical School Technology provides the opportunity to create a new model of delivery that keeps care simple, patient centered, and with a focus on overall health instead of illness. Technology will also help make care more collaborative. For example, health care providers will not just instruct patients to lose weight, but they will be able to give patients the tools and feedback needed to help them lose weight. Focus needs to move away from just demonstrat- ing cost savings and move toward creative demonstrations of the value of investment. Similarly, newer research models are needed to collect and analyze data in order to prove the positive outcomes that result from the use of telehealth.
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REMARKS AND DISCUSSION: DAY 1 57 Spero M. Manson, Ph.D. University of Colorado Denver It is particularly important to not isolate the discourse among those in this particular section of the industry from the broader narrative about health care. The issues regarding telehealth usage are matters of degree and emphasis not substantively different than what all others in the health care industry are facing. Telehealth leaders need to ensure that discussions take place within the broader landscape. In spite of challenges, RCTs are possible in telehealth. The challenges associated with the methods and procedures of telehealth are the same ones faced in other studies, but may require more creativity to design studies that elevate the level of the science of telehealth. Telehealth leaders should not shy away from seeking to meet the highest expectations around scientific merit. Telehealth intervention research provides an opportunity to pursue the science of dissemination to enhance the diffusion, adoption, and opera- tionalization of effective models. In that regard, further study is needed to analyze and describe the critical components of successful telehealth models and how they can be assembled in various settings or geographic areas in a way that remain true to the original models that gave rise to them. Thomas S. Nesbitt, M.D., M.P.H. University of California, Davis, Health System Ongoing discourse about telehealth is needed, especially with those who are not telemedicine enthusiasts. In some ways telehealth is held to a higher standard of evidence, but we need to move past that. Also, due to the current environment, evidence on value is essential. Technology is not an end in and of itself. Instead of talking just about telehealth, we need to be talking about evidence-based models of care that are better facilitated with the use of technology. Lastly, consideration is needed for the implications of student and resident training. Rural practitioners need to be prepared for the next century rather than trained for the past century. Sherilyn Z. Pruitt, M.P.H. Health Resources and Services Administration These are exciting times that include both change and chaos. Whenever there is a lot of change, there is a lot of opportunity. Innovative models have shown tremendous successes, and along with that will be some failures. For example, it would be interesting to find out why some providers have aban- doned the use of telehealth--what did they do and why did it not work? The discussions of the day have raised many questions:
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58 THE ROLE OF TELEHEALTH · Are the days of the rural independent provider over? Will all pro- viders become part of a larger system? Will the rush to increase market share leave out small rural providers or underserved urban populations? · How will the move toward clinicians reaching their patients di- rectly in their homes impact comprehensive care? Will this infor- mation get into their electronic medical records? Who will be their primary care provider? What about the continuity of care? · How will rapidly evolving technologies continue to change how health care is delivered and how can we keep up with these changes? · What is the best way for HRSA to share best practices? REACTION AND DISCUSSION Moderator: Karen S. Rheuban, M.D. University of Virginia Health System An open discussion followed the planning committee members' re- marks. Audience members were able to give comments and ask questions of the planning committee members and other workshop participants. The following sections summarize the discussion session. Rapidity of Change One participant commented that the opportunity costs of telehealth have been discussed in the multiple specialty journals in this country and around the world for nearly 20 years. He added that the government is not keeping up with the technology, and so policies are needed that can easily adapt to the rapid changes in technology. He also suggested that because other countries around the world are using these technologies, we should look to them for lessons. Consumerism One participant raised the issue of consumerism--stating that consum- ers are going to demand the availability and usage of telehealth technolo- gies. He suggested that lack of a telemedicine consult might be considered a breach in the standard of care if the technology is available, but not used. Rheuban agreed, stating that in some instances, case law has reflected the use of telemedicine as a standard of care in rural communities. Another participant agreed, stating that the younger generation already values tech- nology and will expect technology to be available for their health care.
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REMARKS AND DISCUSSION: DAY 1 59 Education and Training Arora commented that when medical students are exposed to the ECHO model, they question why everybody is not approaching care in this manner (e.g., where colleagues share information), but as they move through the education system, they become more "indoctrinated" to the fee-for-service system. Antoniotti noted the slow change from resistance by physicians, to schools and residency programs beginning to teach telehealth, to new graduates expecting availability of telehealth in their practices. She noted that policy has not moved as quickly as practice to embrace telehealth. Nesbitt added that technology is being used for telementoring. That is, as has been done in the past with a phone call, colleagues are asking each other advice without a formal consultation.
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