The workshop opened with welcoming remarks from Karen S. Rheuban of the University of Virginia Health System, the chair of the IOM Planning Committee for a Workshop on the Role of Telehealth in an Evolving Health Care Environment. Dr. Rheuban then introduced the project sponsor, HRSA’s Office of Rural Health Policy (ORHP). Dr. Mary Wakefield, HRSA Administrator, gave additional welcoming remarks to set the context for the workshop.
Karen S. Rheuban, M.D.
University of Virginia Health System
For nearly 50 years, telehealth programs have served as innovative tools for the delivery of care, linking patients and providers separated by geographic and socioeconomic barriers, all the while mitigating specialty workforce shortages. Through an explosion of advanced technologies and with significant federal investments in telehealth programs and broadband infrastructure, millions of Americans, and likewise patients around the world, now benefit from care provided through telehealth. Telehealth programs are entirely aligned with the triple aims of the Centers for Medicare & Medicaid Services (CMS): better care, better health, and lower costs. With the passage and recent affirmation of the Patient Protection and Af-
fordable Care Act (ACA),1 the United States is at a strategic inflection point to further integrate telehealth into mainstream health care.
Mary Wakefield, Ph.D., R.N.
Health Resources and Services Administration
Telehealth is a key component in ensuring access to health care services in isolated geographic areas across the United States. More effective deployment of telehealth technologies will enhance our ability to better meet the health care needs of those in rural and frontier parts of the country. However, telehealth is important not just for rural communities, but for any underserved community. This workshop will focus on how we can drive telehealth in an even more robust fashion to improve patient outcomes, and how we can harness telehealth technologies to expand the reach of scarce health resources. That is, how can we capitalize on the promise and the opportunity of telehealth, with an obvious recognition of some of the challenges we have yet to overcome? There is no better time than right now to think about the role that telehealth can play in what is clearly a rapidly evolving health care environment.
When it comes to isolated populations, rural parts of the nation have real challenges. The rural population, nearly 20 percent of the U.S. population, is spread across about 80 percent of the nation’s countryside. Rural communities tend to be older, have people with lower incomes, and have higher rates of certain chronic diseases. Rural areas have particular challenges with attracting and retaining health care providers, and some of the smallest hospitals today operate on the thinnest of margins. All of this creates additional barriers for rural populations to obtain health care services in real time. Telehealth applications can be part of the solution.
The Patient Protection and Affordable Care Act
The importance of telehealth and its potential will continue to grow, especially as more and more people in rural and isolated areas across the United States are able to seek a full complement of health care services as a result of some of ACA provisions. As the ACA is more fully implemented, especially as the state-based insurance exchanges come online in 2014, there will be a dramatic increase in the numbers of Americans with health care coverage. The ACA expands insurance coverage in places where it is
1 Patient Protection and Affordable Care Act, P.L. 148, 111th Cong., 2nd sess. (March 23, 2010).
not frequently found, and some financial barriers to preventive care will be removed (e.g., elimination of copays), putting even more demand on the system. The ACA also focuses on improving health care quality through team-based, patient-centered care; telehealth has a role in linking team members. In addition, the ACA focuses on addressing health disparities and improving public health, both of which are very important to rural areas.
As a result of the ACA, about 16 million Americans living in rural areas no longer face lifetime limits in terms of dollar amounts on their health benefits. Additionally, about half of all of the workers who live in remote communities are employed by small firms that now qualify for tax credits, which can help them provide coverage for their employees. The nation will also be at a critical juncture in terms of the implementation of electronic health records as part of the push toward meaningful use. By 2014, the expansion of community health center infrastructure and investments in the growth of primary care providers will be finishing up.
Telehealth has already started to play an even more important role, especially as we move away from the traditional fee for service system and toward new models of care, including accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and other strategies that focus on outcomes. At the same time, the costs of telehealth technologies are dropping and becoming even easier to use. These technologies are becoming more widely prevalent in the marketplace, more accessible, and consequently, can be adopted more easily than perhaps 5 or 10 years ago. The pace of technological innovation is accelerating, but the cost of innovation is falling.
Advances in technology have important implications for the workforce: both for the cost of health care services and for the availability of health care providers in remote areas. They also have implications for the types of training that health care providers will need in order to acquire proficiency in deploying and using technology. In addition, health information technology–derived information is critical to quality improvement strategies. The data generated by all these technologies may enable the development of quality measures that can contribute to timely and understandable feedback for safety net providers and other members of clinical teams. In this rapidly changing environment, strategies for leveraging these technologies to improve health outcomes will be extremely important, especially to reduce health disparities.
The Role of the Federal Government
The Federal Government and Rural America
The current administration has made rural America a high priority. HHS Secretary Sebelius is a knowledgeable advocate for the unique challenges and opportunities for rural communities and rural health care infrastructure. President Obama created the White House Rural Council, the first council of its type, with an eye toward the economic health of rural communities. This council has been active in advancing many issues, including health care. Additionally, HRSA has worked with CMS and others to engage small rural hospitals for its Partnership for Patients, and rural communities are mentioned in many of the newly funded initiatives in the Center for Medicare & Medicaid Innovation (CMMI).
The Federal Government and Telehealth
HHS has become increasingly engaged with, and invested in, telehealth. Recently, HRSA signed a Memorandum of Understanding with the Indian Health Service (IHS) to develop a joint quality strategy. The IHS has been an innovator in telehealth, given the geographic challenges they face in delivering health care services to the most rural and remote populations. HRSA has also been working closely with CMS to include measures in the proposed rule for stage two of meaningful use that reflect the underserved and vulnerable populations served by HRSA’s grantees. These include measures on oral health, behavioral health, rural populations, and maternal and prenatal care. The ORHP has an initiative titled the “Flex Rural Veterans Health Access Program,” which is using telehealth to increase access to mental health care services for veterans who are returning from Iraq and Afghanistan to their rural homes. Currently three grantees are being funded through that initiative—Alaska, Montana, and Virginia—all of whom provide mental health services, including crisis intervention, detection of post-traumatic stress disorder, care for traumatic brain injury, and care for other injuries that veterans have suffered. Through the Office for the Advancement of Telehealth, HRSA has also established a series of grant programs to support the development and expansion of telehealth, including a focus on the licensure portability. This includes supporting state professional licensing boards to develop and implement policies designed to reduce the statutory and regulatory barriers to telehealth. In addition, the National Library of Medicine funds a number of projects that are examining how to leverage telehealth to improve health care outcomes.
Others in the federal government are also looking at the opportunities that telehealth offers. The U.S. Department of Defense (DoD) invests
heavily in telehealth. The U.S. Department of Agriculture (USDA) and the Department of Commerce have focused heavily on expanding broadband capacity, which is integral to telehealth utilization. Telehealth is also an area of focus for the White House Rural Health Council (not just through HHS work, but also through the engagement of the U.S. Department of Veterans Affairs [VA] and the Federal Communications Commission [FCC]) to identify ways they can work together on telehealth issues designed to improve access to care for veterans who reside in rural and remote parts of the country.
Looking to the Future
Where do we need to go next? We are well past the point where we need to prove how telehealth applications work. The focus now needs to be on how we can do a better job of harnessing the technology to improve care and to do that as effectively and efficiently as possible, to ensure that telehealth is embedded in the fabric of health care for rural populations. However, this focus raises many questions, such as
- What is or what can be the role of telehealth in a health care system that is predicated on value and improving patient outcomes?
- How should we use this technology in efforts that are designed to improve care coordination?
- What is the role of telehealth in team-based, interprofessional care?
- How can telehealth decrease care fragmentation?
- What can telehealth do to help clinicians work more effectively together and use data in real time for the care of patients and communities?
While there are many challenges going forward, there are also many opportunities. We need renewed thinking on what we need to do to overcome barriers and capitalize on opportunities. We need to think not just about the clinical applications of telehealth, but also telehealth’s utility for continuing education, new training opportunities, and distance-based health professions training oversight. Clearly, telehealth can play a role in supporting the health care workforce just as it can help us to be more efficient, particularly in underserved areas. We need to think about what could happen in the long term if we start to put the right pieces in place. A lot of that building is not just from the federal government, but it is what the federal government can be doing in tandem with state governments, private-sector partners, and others. All of the opportunities in telehealth can make a real difference in the health care system in terms of access, quality, and efficiency.