THE ROLE OF

TELEHEALTH

IN AN EVOLVING
HEALTH CARE ENVIRONMENT

Workshop Summary

Tracy A. Lustig, Rapporteur

Board on Health Care Services

INSTITUTE OF MEDICINE

                      OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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THE ROLE OF TELEHEALTH IN AN EVOLVING HEALTH CARE ENVIRONMENT Workshop Summary Tracy A. Lustig, Rapporteur Board on Health Care Services

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The workshop that is the subject of this workshop summary was ap- proved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This activity was supported by Contract/Grant No. HHSH250200976014I between the National Academy of Sciences and the Department of Health and Human Ser- vices. The views presented in this publication do not necessarily reflect the views of the organizations or agencies that provided support for the activity. International Standard Book Number-13: 978-0-309-26201-9 International Standard Book Number-10: 0-309-26201-1 Additional copies of this workshop summary are available for sale from the Na- tional Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent ad- opted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. The role of telehealth in an evolving health care environment: Workshop summary. Washington, DC: The National Academies Press.

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"Knowing is not enough; we must apply. Willing is not enough; we must do." --Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding en- gineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PLANNING COMMITTEE FOR A WORKSHOP ON THE ROLE OF TELEHEALTH IN AN EVOLVING HEALTH CARE ENVIRONMENT1 KAREN S. RHEUBAN (Chair), Professor of Pediatrics; Senior Associate Dean for CME and External Affairs; and Director, University of Virginia Center for Telehealth, University of Virginia Health System NINA M. ANTONIOTTI, Director of TeleHealth, Marshfield Clinic KAMAL JETHWANI, Corporate Manager--Research & Innovation, Partners Healthcare Center for Connected Health; and Instructor in Dermatology, Harvard Medical School SPERO M. MANSON, Distinguished Professor and Director, Centers for American Indian and Alaska Native Health, University of Colorado Denver THOMAS S. NESBITT, Associate Vice Chancellor, University of California, Davis, Health System SHERILYN Z. PRUITT, Director, Office for the Advancement of Telehealth, Office of Rural Health Policy, Health Resources and Services Administration Project Staff TRACY A. LUSTIG, Senior Program Officer SAMANTHA ROBOTHAM, Senior Program Assistant ROGER C. HERDMAN, Director, Board on Health Care Services 1Institute of Medicine planning committees are solely responsible for organizing the work- shop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteur and the institution. v

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Reviewers This workshop summary has been reviewed in draft form by individu- als chosen for their diverse perspectives and technical expertise, in accor- dance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this workshop summary: MARY DeVANY, Great Plains Telehealth Resource and Assistance Center STEPHANIE LAWS, Wabash Valley Rural Telehealth Network DAVID LINDEMAN, Center for Aging and Technology ROB SPRANG, Kentucky TeleCare Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the workshop summary before its release The review of this workshop summary was overseen by HUGH H. TILSON, University of North Carolina Gillings School of Global Public Health. Appointed by the Institute of Medicine, vii

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viiiREVIEWERS he was responsible for making certain that an independent examination of this workshop summary was carried out in accordance with institu- tional procedures and that all review comments were carefully considered. Responsibility for the final content of this workshop summary rests entirely with the rapporteur and the institution.

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Contents 1INTRODUCTION 1 Workshop Statement of Task, 2 Definitions, 3 Organization of the Workshop Summary, 3 2 OPENING REMARKS 5 Welcome from IOM Planning Committee, 5 Welcome from Project Sponsor, 6 3 THE EVOLUTION OF TELEHEALTH: WHERE HAVE WE BEEN AND WHERE ARE WE GOING? 11 Home- and Community-Based Care, 11 Office-Based Telemedicine, 12 Ancillary Telemedicine Services, 13 Hospital-Based Telemedicine, 14 Concluding Remarks, 15 4 CHALLENGES IN TELEHEALTH 17 Overview of Common Challenges, 17 Licensure, 20 Broadband Connectivity, 21 The Definition of Rural, 23 Reaction and Discussion, 26 ix

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xCONTENTS 5 TELEHEALTH AND PAYMENT 31 Medicare, 31 Traditional Payment Models and Regulation, 34 Private Payment, 36 Center for Medicare & Medicaid Innovation, 37 Reaction and Discussion, 38 6 THE HEALTH CARE CONTINUUM 43 Promoting Health, Preventing Disease, and Prompting Population Progress, 43 Telehealth in an Acute Care Setting, 46 Chronic Disease Management, 50 Reaction and Discussion, 52 7 REMARKS AND DISCUSSION: DAY 1 55 Planning Committee Remarks, 55 Reaction and Discussion, 58 8 CURRENT EVIDENCE BASE 61 Current Research Base, 61 Using Data to Change Policies and Create New Standards of Care: Telestroke, 66 Reaction and Discussion, 70 9 TECHNOLOGICAL DEVELOPMENTS 75 Patients' Provision of Data, 75 Remote Patient Monitoring, 77 Social Networking, 80 Wireless Health, 82 Reaction and Discussion, 85 10 STATE-BASED PERSPECTIVES 89 The Virginia Perspective, 89 The Maryland Perspective, 90 The Delaware Perspective, 92 State-Based Advocacy: NOBEL Women, 94 Reaction and Discussion, 96 11 EXPERIENCES OF THE VA AND IHS 99 U.S. Department of Veterans Affairs, 99

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CONTENTS xi Indian Health Service, 104 Critical Relationships in Telehealth with American Indians and Alaskan Natives, 108 Reaction and Discussion, 111 12 STAKEHOLDER PERSPECTIVES 115 National Rural Health Association, 115 American Telemedicine Association, 117 American Public Health Association, 119 Reaction and Discussion, 122 13 CONCLUDING REMARKS AND DISCUSSION 125 Planning Committee Remarks, 125 Reaction and Discussion, 129 REFERENCES131 APPENDIXES A Definitions133 B Acronyms135 C Workshop Agenda 139

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