Hci 315 tel heath and telemedicine

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At the Intersection of Health, Health Care and Policy
Cite this article as:
Joseph Kvedar, Molly Joel Coye and Wendy Everett
Connected Health: A Review Of Technologies And Strategies To Improve Patient
Care With Telemedicine And Telehealth
Health Affairs, 33, no.2 (2014):194-199
doi: 10.1377/hlthaff.2013.0992
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Overview
By Joseph Kvedar, Molly Joel Coye, and Wendy Everett
10.1377/hlthaff.2013.0992
HEALTH AFFAIRS 33,
NO. 2 (2014): 194–199
©2014 Project HOPE—
The People-to-People Health
Foundation, Inc.
doi:
Joseph Kvedar is director of
the Center for Connected
Health at Partners HealthCare
System, in Boston,
Massachusetts.
Molly Joel Coye is chief
innovation officer at
University of California, Los
Angeles (UCLA) Health, UCLA
Medical Center, in Los
Angeles.
Wendy Everett (weverett@
nehi.net) is president of NEHI
(Network for Excellence in
Health Innovation), in
Cambridge, Massachusetts.
Connected Health: A Review Of
Technologies And Strategies To
Improve Patient Care With
Telemedicine And Telehealth
ABSTRACT With the advent of national health reform, millions more
Americans are gaining access to a health care system that is struggling to
provide high-quality care at reduced costs. The increasing adoption of
electronic technologies is widely recognized as a key strategy for making
health care more cost-effective. This article examines the concept of
connected health as an overarching structure for telemedicine and
telehealth, and it provides examples of its value to professionals as well
as patients. Policy makers, academe, patient advocacy groups, and
private-sector organizations need to create partnerships to rapidly test,
evaluate, deploy, and pay for new care models that use telemedicine.
C
hief among the policy goals achieved
by the passage of the Affordable Care
Act (ACA) was the mandate to expand access to health care to millions of additional Americans.While
admirable, this mandate will increase the strain
on an already overburdened and extremely costly
delivery system. In particular, given the shortage
of primary care providers,1 affordable, high-quality health care for increasing numbers of elderly,
chronically ill people may not be available without adopting new ways of delivering care. The
growth in chronic illness will continue to spiral
upward, with a 40 percent increase in heart disease and a 50 percent increase in cancer and
diabetes projected for 2023.2 Baby boomers
are just beginning to enter their high-maintenance health care years of sixty-five-plus,3–6 while
workforce statistics show that physicians and
nurses are both in short supply.7,8 The Centers
for Medicare and Medicaid Services (CMS) predicts that health care costs could reach almost
20 percent of gross domestic product (GDP) by
2022 without interventions.9 Policy makers,
payers, providers, and patients are actively exploring ways to control the cost of health care
through value-based purchasing plans, innovative care delivery systems, and novel means of
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empowering patients to manage their own illnesses.
One promising solution lies in rapidly expanding the uses of technology in health care. Telemedicine (the use of technologies to remotely
diagnose, monitor, and treat patients) and telehealth (the application of technologies to help
patients manage their own illnesses through improved self-care and access to education and support systems) are being applied and combined to
create new ways to deliver care. When properly
implemented, the broad adoption of connected
health has the potential to extend care across
populations of both acute and chronically ill patients and help achieve the important policy
goals of improving access to high-quality and
efficient health care.
Telemedicine And Telehealth
The term telemedicine literally means “healing at
a distance” through the Latin “medicus” and
Greek “tele.”10 Although there is no single commonly accepted definition of telemedicine, the
use of technology to deliver health care services
and information at a distance in order to improve
access, quality, and cost is a common theme
found throughout professional descriptions of
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these services. According to the American Telemedicine Association, “telemedicine is the use of
medical information exchange from one site to
another via electronic communications to improve a patient’s clinical health status.”11 This
includes “the use of telecommunications and information technology to provide access to health
assessment, diagnosis, interventions, consultation, supervision and information across
distance.”12
Over the past four decades, telemedicine has
become an increasingly cost-effective alternative
to face-to-face care and has evolved into an integrated technology used in hospitals, physicians’
offices, patients’ homes, and many other settings. Telemedicine can take many different
forms. For example, live interactive video and
the transfer of electronic information can enable
providers to consult with patients, provide diagnoses, and recommend treatment plans. Some
telemedicine devices can be used in patients’
homes to collect and send data to health care
professionals for analyses and follow-up.11
In contrast, telehealth services allow consumers to access health education and support for
self-management through the Internet, via their
home computers or wireless devices. Patients
can obtain personalized education materials
and coaching and may participate in online discussions and support groups as additional
means of managing their health. The proliferation of mobile devices such as mobile phones and
tablets has markedly increased consumers’ access to such telehealth services and has given
rise to the term mHealth for services accessed
through mobile wireless technologies. Given
policy makers’ proclivity to debate definitions,
it may be more helpful to use the umbrella term
“connected health” to encompass this entire
family of technologies and services.
Extending Provider Capacity
One of the ways in which health care providers
have responded to the call for value-based health
care is through patient-centered medical
homes,13 whose defining characteristic is the
use of multidisciplinary teams to create more
patient-centric experiences. This team-based approach to patient care is intuitively appealing,
and there are some data to suggest improved
outcomes.14 However, a major flaw in the model
is the projected shortage of physicians and
nurses to bring such a vision to scale.7,15
Another approach is the development of accountable care organizations (ACOs), through
which providers may be financially rewarded
for controlling costs and improving outcomes
but assume some measure of financial risk if they
fail to do so. ACOs thus will have incentives to use
specialist physician care for patients in the most
efficient manner. For example, providing remote
dermatology or radiology consultations to primary care providers instead of referring patients
to additional (and expensive) specialty visits
may become a safe and recommended practice.
There is a growing body of literature demonstrating that connected health technologies can
make health care more effective and efficient by
electronically connecting clinicians to clinicians, patients to clinicians, and even patients
to other patients. This approach facilitates remote diagnosis and treatment, continuous monitoring and adjustment of therapies, support for
patient self-care, and the leveraging of providers
across large populations of patients. Because
these technologies improve the sharing of data
and tasks among teams, they also allow team
members to practice at their highest levels of
skill and training. Physicians and nurses can
then work more efficiently by allocating their
time to the patients who most need attention.
The promise of these technologies will be further
extended as devices become smaller; are powered by longer-lasting sources of energy; and
are connected more effectively to other devices
and to repositories of data, such as electronic
health records. Stated another way, connected
health can extend access to care to a large population of people while improving quality and reducing costs. This approach is consistent with
the current necessity to “restructure health care,
in part, through the use of technology enabled
models of care which include lower cost health
professionals.”16
Technologies In Use Today
There are many examples of applications that
illustrate connected health’s potential for improving access, quality, and efficiency in health
care. The following examples highlight a variety
of technologies that are in use today.
Telehealth For Congestive Heart Failure
For patients with congestive heart failure (CHF),
a number of studies have addressed the impact of
home telemonitoring on health outcomes, with a
decrease in both hospital readmissions and mortality having been reported.17–20 In a program at
Partners HealthCare,21 for example, more than
3,000 CHF patients received care using in-home
monitoring of weight, blood pressure, heart rate,
and pulse oximetry. These data were uploaded
daily, and decision support software identified
those patients who needed attention. With this
approach, hospital readmissions dropped by
44 percent as compared to usual care, with three
to four nurses caring for a daily panel of 250
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H e a lt h A f fai r s
195
Overview
patients. The program generated cost savings of
more than $10 million over a six-year period.21
Considering that those same nurses, in a certified home care agency, would be caring for only
four to six patients daily, the benefit of telemonitoring to extend the reach of providers to larger populations of patients becomes evident.
Home Health Program For Veterans On a
larger scale, over a four-year period the Veterans
Health Administration (VHA) introduced a national home telehealth program called Care Coordination/Home Telehealth that integrated
home telemonitoring and health informatics
with disease management technologies. Data
gathered from 17,025 participating patients having one or more of six chronic illnesses (ranging
from diabetes to depression) demonstrated high
patient satisfaction levels with the program, plus
a 25 percent reduction in numbers of bed days of
care and a 19 percent reduction in the number of
hospital admissions as compared to usual care.22
The impact of the VHA’s telehealth strategy
has grown substantially. In 2012 the agency’s
national home telehealth program, designed to
provide care for veterans via remote monitoring
and videoconferencing, reached 119,535 veterans and generated annual savings of $1,999
per patient.23 The program also facilitated the
independent living of 36 percent of these patients, who would have otherwise qualified for
long-term residential care. Additionally, hospital admissions decreased by 38 percent compared to the previous year, inpatient bed days
of care decreased by 58 percent, and patient satisfaction scores remained at a strong 85 percent.23 The VHA example illustrates that as the
prevalence of chronic disease grows in the United States, telemedicine can be an extremely
promising solution for managing and reducing
these illnesses.
Access To Specialty Physicians Equally
compelling is the idea that telehealth can be used
as a tool to extend access to specialized knowledge across geographic boundaries. Two places
where this vision is being realized are in the
fields of diagnostic radiology and laboratory
medicine. Innovations in digital imaging, the
establishment of international global standards
for the interoperability of health information
technologies (Health Level Seven International,
or HL7), and the Internet now allow specialty
physicians to provide services in both a timeand place-independent manner. For example,
radiologic images are now routinely read by specialists at great distances from where they are
taken, and reports are sent back to the primary
care providers in a timely manner. Retinal images can be read remotely by ophthalmologists
consulting with referring physicians on diabetic
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retinopathy. Given the success of these applications, the range of innovative uses of telemedicine for remote consultation will expand rapidly
over the coming years. Many specialty physicians who are only comfortable with diagnosing
conditions based on directly observing the patient have been slow to adopt telehealth technologies. Exceptions to this include dermatologists,
who have become comfortable with two-dimensional imaging for performing diagnoses. Dermatologists have adopted teledermatology more
rapidly than other specialty physicians have
adopted diagnostic technologies.
Using dermatology as an example, specialist
access can be enabled via two types of telehealth
strategies. One strategy relies on the use of interactive videoconferencing, which has now become ubiquitous, is low in cost, and provides
benefits to patients, especially when they live
far from their physician or provider. Numerous
studies have shown the quality of care resulting
from interactive videoconferencing to be very
high—streamlining care, reducing waste, and
leading to faster problem resolution.24
The second strategy to provide remote specialty care is called “store and forward.” For example, in this approach, a referring physician uploads images of skin lesions to a secure storage
site along with the relevant patient history; a
consulting dermatologist then accesses this information and responds. This strategy takes
advantage of digital imaging, asynchronous
communication, and robust communication networks. With the expansion of high-resolution
cameras on smartphones and high-bandwidth
mobile networks, all this can now also be accomplished using mHealth devices.25
As the “store and forward” approach is more
widely adopted, it has the potential to create real
gains in efficiency. Dermatologists at Kaiser Permanente in San Diego, California, treat approximately 800 such cases per month using this
method, handling 50 percent more cases than
they could through face-to-face visits (Jeffrey
Benabio, Kaiser Permanente, personal communication, August 12, 2013). The most recent innovation in teledermatology is a novel online
service in which patients take mobile phone pictures of their lesions and send them to their
dermatologist, who, in turn, sends them a diagnosis; therapeutic recommendation; and, if appropriate, a prescription for treatment.26 Although these services are increasing in
number, they need to be evaluated for their potential to provide convenient and efficient care
for specialty services.
Remote Intensive Care Intensive care units
(ICUs) are a key component of hospital care,
treating the most fragile and complex patients
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Physician and nurse
champions will need
to take the lead in
ensuring that
providers embrace
emerging models of
care management.
in the health care system. While many hospital
inpatient units are being downsized with the
shift to outpatient care, ICUs are expanding to
the point that they now provide care for six million patients per year, at an annual cost of
$107 billion. This number has remained constant
over time, with the United States spending approximately 1 percent of GDP on ICU care annually. Meanwhile, as the population ages, the
number and severity of critical care patients is
growing just as the supply of critical care physicians is decreasing.
Several studies conducted by NEHI (Network
for Excellence in Health Innovation) and the
University of Massachusetts Memorial Medical
Center have shown that ICU care provided remotely by physicians trained as intensivists
can decrease mortality by more than 20 percent,
decrease ICU lengths-of-stay by up to 30 percent,
and reduce the costs of care.27,28 Additionally, the
supply of intensivists is not adequate to meet the
needs of the ICUs across the country, leaving
critical care at many small community and rural
hospitals to be provided primarily by community
physicians and ICU nurses.
Tele-ICU technologies can leverage intensivist
coverage over more ICU beds and increase productivity by providing direct consultation and
management of ICU patients at a distant site
through remote two-way audio, visual, and physiologic monitoring. Central tele-ICU units are
typically staffed with one or more intensivists,
critical care nurses, and other specialists, who
observe patients in distant hospital units; provide proactive care by anticipating crises before
they happen through sophisticated computerized physiologic, laboratory, and medication
monitoring; and provide direct consultation to
on-site nurses and physicians.
Approximately 13 percent of ICU beds in the
United States are currently supported by tele-
ICU technologies.27 Given the positive system
and financial improvements resulting from this
remote monitoring, the expansion of effective
implementation of tele-ICU care will substantially benefit patients and providers across the
country.
Helping Patients Adhere To Medication
Regimes Patient medication adherence is another example of a pervasive problem that can benefit from telehealth support.29,30 Although millions of Americans suffer from chronic
illnesses that could be effectively managed with
prescription drugs, on average, patients take
their medications as prescribed only about half
the time.30 Yet compelling data show that patients who adhere to treatment regimens for
chronic illnesses have fewer clinical problems
and are less costly to care for over time compared
with nonadherent patients.29,31
There are a number of technologies that help
patients better adhere to their medication regimens, although these technologies have different mechanisms of action. For example, smartphone applications remind patients to take their
pills and can help order refills. Internetconnected pill caps alert patients (through music, ringtones, and flashing lights) to take their
medications and often have the ability to send
e-mail to remote caregivers, create adherence
reports, and refill prescriptions. As another example, pharmaceutical packages designed to improve patient adherence have dated calendars
printed on medication cards (or “blisters”) that
help patients take their drugs as prescribed.32
In the future, technology-enabled medication
reminders may be built into automatic pill dispensers, watches, and alarm clocks and potentially encapsulated in sensor-enhanced pills that
can track when the patient swallows the medication.
The Center for Connected Health, a division of
Partners Healthcare, conducted a randomized
clinical trial using a wireless electronic pill bottle
to remind patients with high blood pressure to
take their medication. Initial findings demonstrated a 68 percent higher rate of medication
adherence in patients using the Internetconnected medication packaging and feedback
services compared to controls.33
Although these technologies are relatively
new, initial evaluations suggest that connected
health technologies can prove useful in the context of well-managed medication care, increasing patient self-management, improving outcomes, and lowering costs.
Reducing Referral Wait Times eReferral is a
service model for referrals and consultations
through which primary care providers can exchange privacy-protected, templated e-mail mesFebr uary 201 4
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◀
3
Criteria
For telemedicine to
succeed, 3 criteria must
be met: (1) assurance of
quality, (2) alignment of
financial incentives, and
(3) more cost and quality
research.
sages with specialists. The program was developed at San Francisco General Hospital in 2005,
when wait times for specialty appointments
ranged from seven to eleven months. The program now covers more than forty specialties and
services. Similar programs have since been established at the Los Angeles County Department
of Health Services, the Mayo Clinic, and at UCSF
and UCLA. In each implementation, use of this
telemedicine technology has produced shorter
wait times, reduced the number of in-person
specialty visits by 20 percent or more, improved
preparation of patients for specialty visits when
required, and strengthened primary care provider-specialist collaboration and satisfaction. Because the rate of outpatient specialist referrals
has almost doubled in the United States over the
past decade, this application may become an important means of leveraging specialist capacity.
tients, following similar legislation regarding
Medicaid reimbursement for remote monitoring
in eighteen states.34
Finally, more health policy research that evaluates the quality and cost impacts of connected
health is essential. To demonstrate its value, providers will need to devote more dedicated leadership, expertise, and time to the implementation of connected health innovations. This
includes changing the provider culture and
workflow systems in order to allow the full incorporation of telemedicine into traditional
care. Because clinicians have historically resisted
changes in how care is delivered, physician and
nurse champions will need to take the lead in
ensuring that providers embrace these emerging
models of care management.
Conclusion
Designing Telemedicine Approaches
To Succeed
Each of the above examples shows how telemedicine tools can allow providers to extend care to a
wider population of patients, improve the quality of care, reduce costs, and increase patient and
provider satisfaction. For telemedicine to reach
its full potential, three criteria must be met. First,
enough evidence must be compiled to assure that
the new model does not sacrifice quality or cause
harm to patients. To date, good progress has
been made, and, as many of the articles in this
issue of Health Affairs demonstrate, there are
enough studies of the net benefits of telehealth
to patients, providers, and payers for the connected health model to meet this criterion.
Second, early progress is being made in aligning providers’ financial incentives so that they
produce desired outcomes. For example, health
reforms such as the expansion of ACOs are realigning financial incentives to encourage the
use of telehealth to leverage the skills of providers across a broader population of patients.
In addition, CMS recently published for comment a proposal that would allow physicians
to be paid for non-face-to-face encounters in
the management of chronically ill Medicare pa-
Current care processes are insufficient to address the coming mismatch in supply and demand of health care providers—a trend that will
be exacerbated by reform measures that are beginning to increase access to care for millions of
Americans. The addition of telemedicine technologies and asynchronous provider-to-patient
communication can create a connected health
model of care that will ensure an ability to improve access and the quality of care while decreasing costs and more efficiently using the
skills of highly trained professionals—as well
as enabling patients to participate more directly
in their own care.
For policy makers to capitalize on this exceptional opportunity, a partnership needs to be
created among government agencies, academe,
patient advocacy groups, and private-sector organizations to rapidly test, evaluate, deploy, and
pay for new care models that use telemedicine.
Without the knowledge that can be gained from
such a coalition and applied widely across health
care, policy makers will miss a golden opportunity to create truly innovative, efficient delivery
systems within the structure of national health
reform. As professionals committed to improving the lives and care of patients, they should not
allow this opportunity to slip away. ▪
Joseph Kvedar is a consultant and equity
holder in Healthrageous and an advisory
board member at Qualcomm Life.
NOTES
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