An initiative launched by the American Academy of Pediatrics in 2015 is set to unveil a set of standards aimed at measuring the effectiveness of pediatric telehealth programs across the country.
– A program launched in 2015 to study pediatric telehealth services has unveiled a set of standards aimed at improving hospital programs across the country.
The Supporting Pediatric Research on Outcomes and Utilization of Telehealth (SPROUT) program, developed by the American Academy of Pediatrics (AAP), is set to publish a paper in Pediatrics that lays out the guidelines for analyzing the effectiveness of pediatric telehealth programs.
The article was made available for prepublication release due to urgency of evaluating connected health programs in the midst of the coronavirus pandemic, which has seen telehealth use skyrocket. The Children’s Hospital of Philadelphia (CHOP) for example, saw daily telehealth visits jump from as many as 10 to more than 1,500, while the Ann & Robert Lurie Children’s Hospital in Chicago trained more than 800 providers in just a few weeks to handle the surge.
“Now is a critical opportunity to systematically evaluate telehealth care delivery, identify patient cohorts who can benefit, and explore ways to incorporate telehealth into patient care workflows,” the article, authored by John Chuo, MD, MS, IA, and Scott Lorch, MD, MSCE, of CHOP and the University of Pennsylvania’s Perelman School of Medicine and Michelle Macy, MD, MS, of Northwestern University, states. “This knowledge will evolve our healthcare system to improve how care is delivered now and during crises.”
“While a few measurement standards exist to guide the assessment of telehealth’s impact on care delivered, current literature lacks a unified approach to evaluate telehealth in pediatric healthcare delivery,” Chuo and his colleagues note.
The article lays out a guide to telehealth evaluation called the STEM (SPROUT Telehealth Evaluation and Measurement) profile, which pulls together concepts developed by the National Quality Forum (NQF), World Health Organization (WHO) and Agency for Health Research and Quality (AHRQ). From that work, the STEM profile outlines four measurement domains: health outcomes; health delivery – quality and cost; experience; and program implementation and key performance indicators.
“Findings from rigorous telehealth program evaluation in these areas can inform data driven reimbursement and policy changes that encourages appropriate telehealth use, especially amidst the explosion of telehealth services associated with the COVID pandemic,” the paper concludes.
The STEM profile comes out of a 2019 initiative by SPROUT to create a national database for pediatric telehealth research and best practices. Spearheaded by the Medical University of South Carolina (MUSC), one of two federally recognized telehealth centers of excellence and funded by a $3.6 million federal grant, the initiative aims to support “the development of telehealth research efforts, metric development, identification of best practices and the development of collaborative policy and advocacy materials” specific to pediatric programs.
“This is a huge step forward in the development of safe and impactful telehealth programs across the country,” S. David McSwain, MD, a physician with MUSC Children’s Health, associate professor of pediatric critical care and chief medical information officer who helped develop the program, said at the time. “Academic research into the real impact of telehealth services is a critical component of developing and growing programs with the greatest potential to improve our health care system. Many physicians and other health care providers are hesitant about incorporating telehealth into their practices because it’s difficult to separate the theoretical benefits from the real value.”
“Research into the real impact of telehealth services is a critical part of developing and growing programs with the greatest potential to improve our health care system,” he added. “Many doctors and other health care providers are hesitant about incorporating telehealth into their practices because it’s difficult to separate the theoretical benefits from the real value.”
Faced with the need to improve patient satisfaction and reduce unnecessary delays in care, hospitals and medical practices are using telehealth and mHealth tools to create a virtual waiting room.
– With the COVID-19 crisis putting the kibosh on crowds, hospitals are turning to telehealth and mHealth to take the wait out of healthcare.
The crowded, clamorous, stuffy, sniffly waiting room has long been the scourge of healthcare, a sign of both inconvenienced patients and overworked providers. It’s here that patients are asked to announce their presence, fill out forms and check their insurance, while staff sort through the data to match them to the right provider at the right time slot.
Prodded by the pandemic, health systems are now using mHealth apps, online portals and telehealth platforms to handle those administrative tasks, so that a patient arriving at the hospital or doctor’s office is seen and treated as quickly as possible.
“When you think of healthcare from the perspective of a claim, there’s a lot of hands touching the data,” says Jay Roszhart, MHA, FACHE, president of the Memorial Health System Ambulatory Group, rolling off a list of services that includes scheduling, registration, check-in, insurance verification, coding, billing and appointment reminders – all potentially handled by a different person or department. “That’s just an incredible number of hands in the pot.”
To improve that process, the Illinois-based health system recently launched a virtual waiting room, complete with AI-powered chatbots that help both patient and provider collect and sort all that data before the patient sets foot in a doctor’s office.
“When you’re dealing with (a pandemic), one of the things you realize very quickly is that you have these waiting rooms where people congregate … and fill out forms,” Roszhart says. “That really is not the ideal experience and it certainly isn’t a safe experience.”
Roszhart says a connected health platform that encompasses several tools – including chatbots, apps and portals – “takes away the mundane and repeatable tasks” that dominate the waiting room and delay care, not to mention taking time away from doctors and nurses who’d rather be dealing with patients than dealing with paperwork.
“And you’re making the experience much more pleasant for the patient,” he adds.
Memorial Health is partnering with California-based LifeLink on the telehealth platform, which uses chatbots to guide the conversation between patient and doctor’s office. LifeLink is one of dozens of companies in the space, offering virtual services to health systems, hospitals, clinics, practices and doctor’s offices looking to digitize all the tasks that take place before the actual doctor-patient encounter.
The opportunities are numerous. A medical practice or clinic that can push these services online enables patients to check in virtually and arrive at the exact time that they’re scheduled to meet with a doctor, with all the clinical and insurance information automatically added to the medical record. A hospital or urgent care clinic, meanwhile, can use the platform to speed up care coordination, making sure the right doctors are in place to treat patients coming through the ER.
These services have come under the spotlight during the COVID-19 crisis, when many hospitals have restricted access to their ERs and smaller clinics and practices have closed their waiting rooms. Faced with the need to diagnose and treat patients with the minimum of in-person interaction, they’re using telehealth and mHealth tools to triage patients outside the hospital, even in the home.
On the back end, these platforms need to be interoperable, so that the right information is connected to the right patient at the point of care. On the front end, the technology needs to be easy to use, intuitive and friendly, so that the patient feels welcome.
“You have to design this to give patients a pleasant experience,” says Roszhart.
He says Memorial Health chose a chatbot with the idea of making the process more human, “with the development of a conversation that doesn’t sound like you’re talking to a robot.” The platform must also integrate with other services at key points in the conversation to enter data and kick back to a live person when help is needed.
While the health system is still working to get the platform up and running, Roszhart says success will be measured by patient engagement – how many complete the process, where do people drop out and ask for help, how they feel about the process – and cost savings. And while that latter metric might refer to the fewer number of staff needed to handle these administrative duties, he sees this as an opportunity to train them in other departments.
Would a virtual waiting room, then, eliminate the need for the physical waiting room?
That may be the goal, Roszhart says, but it’s a long ways off.
“Healthcare’s insistence on maintaining the status quo … has really hurt our ability to modernize our practice,” he points out. In addition, there will always be a percentage of the population that prefers, out of habit or familiarity, to avoid technology and sit in a waiting room.
For the time being, Memorial Health has a waiting room concept that caters to every whim. Those who prefer to do everything online will be able to do so, while others can request to have their documents e-mailed or mailed to them, or even brought out to their car in the parking lot.
Eventually, Roszhart envisions a waiting room much more inviting than the typical room with old furniture and magazines and the occasional fish tank and water cooler. He sees a space offering health and wellness resources and personalized care experiences.
“I see the physical space of a primary care office being entirely different,” he says.
– The coronavirus pandemic is helping to shine the spotlight on the use of telehealth and mHealth to improve care coordination in places ranging from a patient’s home to an accident scene.
With COVID-19 patients, providers are using a teletriage platform to diagnose patients at home and develop care management plans that can evolve into remote patient monitoring programs. These same tools have been used by first responders, meanwhile, to improve care coordination in the field, reducing ER transports and improving care outcomes for people who spend a lot of time going to and from the hospital.
“First responders have a great opportunity to use telehealth in ways that we really haven’t seen before,” says Carl Marci, chief medical officer for Ready, a two-year-old provider of mobile healthcare services that has seen business skyrocket during the coronavirus. “We’re redefining the house call for a whole generation who doesn’t even know what a house call is.”
Originally created to help communities, businesses and other organizations dispatch care providers to the home or other locations for non-emergency medical issues, the company launched a “COVID-19 fast lane” service to screen patients suspected of having the virus at home. They’re now partnering with municipal authorities in locations like New York, Las Vegas, Baltimore, Washington DC, Reno and New Orleans (where they work with Ochsner Health).
“This model of care is ideal” for a pandemic, says Marci.
Beyond COVID-19, Marci touts the success of programs with hospitals and community health centers to bring care to the homes of people with multiple chronic conditions – sometimes called “frequent flyers” for the amount of time they spend in hospitals. These mobile integrated health programs, he says, can reduce ED transports by as much as 50 percent by focusing on health and wellness and addressing the social determinants that create health issues.
“You’re building relationships with people” who often don’t see those types of interactions in the emergency room, he points out. “You’re helping people to understand how to take better care of themselves and how to decide when to go to the ER and when there’s a better way” of accessing care.
That’s especially important during the COVID-19 crisis, he says, when people are avoiding the ER out of fear of the virus and aren’t getting the care they need – or they’re going to the ER and unnecessarily putting their lives at risk. In New Orleans, for example, a survey found that some 70 percent of the people served by Ready would have otherwise headed to the hospital.
“This is a new way of delivering care for a lot of people,” says Marci, who’s now fostering a direct-to-consumer service line and envisions future programs that address mental health, pediatric and maternity concerns.
Mobile integrated health programs, which focus on bringing healthcare and other services to the home to improve health and wellness and reduce unnecessary 911 calls and doctor’s office visits, have been around for a few years. COVID-19 has given them more of a spotlight, as health systems look to reduce traffic in the hospital while still providing chronic care management.
In Pueblo, CO, Parkview Medical Center launched a partnership with the Pueblo Fire Department to create Directing Others to Services, of DOTS. The hospital-funded community paramedicine program, which identifies and provides home-based care for frequent flyers, has halved 911 calls – all but eliminating unnecessary transports – and saving the health system thousands of dollars.
“What we’re finding is that people aren’t connected to resources in their community,” says Kelly Firestone, Parkview’s community Risk reduction coordinator. “We find the barriers that exist in their lives and we break through those barriers.”
Firestone, who visits the homes of recently discharged patients identified as ideal candidates for DOTS, sees many different barriers to care, from transportation issues to an unhealthy or challenging home life.
“These problems aren’t being fixed in the emergency room,” she says.
Kelea Nardini, Parkview’s assistant vice president of quality and post-acute care, says the program helps these patients find the resources they need to maintain a healthier lifestyle at home. That often includes access to primary care providers, pharmacies and social workers, and soon will include telehealth access to substance abuse counselors, mental health counselors and other care providers.
“We’re a community-based care transition program, with the emphasis on community,” she says. “We take care of our community.”
They point out that DOTS, which was launched in 2015, was originally intended to last just three months, but they found that each patient’s needs are very different and have to be addressed as such – one person might need just one or two visits, while another might need frequent check-ups for six or nine months.
“We know these people, and who does what they say they’re going to do?” Firestone says.
Pueblo Fire Chief Barb Huber says the program slowed down a bit when COVID-19 surfaced just because no one knew how to manage it in the midst of a pandemic. They quickly realized, however, that the program would be even more important to seniors and those with ongoing care needs who couldn’t venture outdoors or were scared of doing so.
“The message is critical right now that people still do need to take care of themselves,” she says. “They still need to see their doctor. And we have a program here that is a critical part to the community because it serves that need.”
Giving Mobile Integrated Health a National Platform
While the pandemic has allowed more communities to experiment with mobile integrated health programs, it has also highlighted the challenges those programs face – particularly around federal recognition and funding.
The Centers for Medicare & Medicaid Services recognized that need when it introduced the Emergency Triage, Treat and Transport (E3) payment model in late 2019. CMS had planned to enroll some 200 healthcare providers, including health systems and EMS providers, in the program, to study how connected health tools could be used to reduce unnecessary 911 transports and improve care coordination for Medicare beneficiaries.
CMS put a hold on that program when COVID-19 took over, but some say it was flawed from the start, and needs to be redesigned.
“Is this really a value-based care model?” asks Jonathan Feit, co-founder and CEO of Beyond Lucid Technologies, a develop of mHealth technology for EMS providers. “They focused on the how but left out the why, which is the most important part.”
Feit, whose company has been partnering with communities across the country to improve EMS response and care coordination during the pandemic, says federal support has focused on the idea of better managing transportation for patients.
“That’s a travel-based model,” he says. “They want to know where I took you instead of why I took you there or how did I do.”
Feit says CMS has to understand the root causes for shifting transports away from the ER, and that delves into examining what factors lead up to a 911 call and what healthcare resources can be used to avoid those calls and better serve patients after they’ve made the call.
“They have to recognize that EMS is not just a first responder but an extension of the health system,” he says.
With COVID-19 closing or restricting many hospitals and clinics, many health systems and EMS providers have practically been forced to look at other ways to help patients in need of care. If the ER is filled with coronavirus patients or closed, there has to be an alternate route to care. That’s where mobile integrated health comes into play.
“COVID-19 is a catalyst,” Feit says. “The virus has forced people to challenge their assumptions in ways that they’ve never done before.”
That, he says, may lead to further refinements in the mobile integrated health model, and maybe even scrapping the E3 program in favor of a better model, based on lessons learned from COVID-19.
Feit sees syndrome surveillance and chronic care management as community paramedicine 2.0. On the horizon, he says, will be a model – community paramedicine 3.0 – that addresses and even bigger need in healthcare: mental health and substance abuse.
Two North schools will receive high-speed Internet access with the help of federal coronavirus relief money.
Aiken Electric Cooperative will receive $151,955 to construct and extend fiber cable from its network to the North Middle/High School and North Elementary School as part of the Coronavirus Aid, Relief and Economic Security Act Coronavirus Relief Fund.
Construction will begin Oct. 1, with installation complete by the end of December, according to the cooperative’s application submitted to the S.C. Office of Regulatory Staff.
The ORS is responsible for administering the CARES Act money as part of the state’s Broadband Infrastructure Program.
McCall-Thomas Engineering will provide the design and construction services for the project.
The broadband project will bring 1 gigabyte speed to the schools and will aim to offset some of the technological challenges that have come to light due to the coronavirus in the areas of education.
“Most, if not all, school systems in S.C. are allowing parents to select either ‘in school’ or ‘distance learning’ for their children,” the cooperative wrote in its application for the funding. “Having the ability for the teacher to provide ‘distance learning’ while at the same time providing ‘in school’ learning allows students a similar learning experience.”
The S.C. General Assembly and Gov. Henry McMaster approved spending about $50 million of CARES Act funds for the broadband program.
Of that total, $20 million was budgeted for the ongoing Online Learning Initiative, and $29.7 million was allocated to support broadband infrastructure expansion.
The state’s broadband program was created to provide high-speed broadband internet access to communities or households hindered in their ability to respond to the challenges of COVID-19 due to a lack of broadband.
The Aiken Electric project is among 81 submitted by 13 broadband service providers across the state and tentatively approved by ORS. The projects cover 29 counties and total $26 million.
The broadband infrastructure program could bring service to approximately 27,994 homes and 771 businesses, supplementing industry investment with federal CARES Act funding. Based on the applications received, the average federal CARES Act funding is approximately $884 per home and business.
Tele consultation may not be a silver bullet for all COVID-19 related problems but it will help hospitals and doctors to continue with patient consultations anytime – anywhere, improving the hospital’s image and at the same time maintaining a steady revenue stream
The concept of tele consultation has been around for a while, but its use was extremely limited or almost no-existent in regular doctor and patient interactions. But the COVID-19 pandemic changed everything and now it has become the platform for choice.
Today physical distancing measures are of the utmost importance, even while regular consultations, especially for life style diseases, senior citizens, and specifically for those having heart diseases, high / low BP, diabetes, and other ailments, cannot be missed.
Consultations in hospitals substantially increases the possibility of infections for doctors as well as patients. For hospitals, it adds various overheads in terms of mandating the use of PPEs for everyone attending patients, additional sanitisation of hospital buildings/consulting rooms, patients’ pre-health check ups, and much more. These factors add significant costs, reduce productivity and burdens hospitals to the point of break down.
Tele consultation may not be a silver bullet for all these problems but it will help hospitals and doctors to continue with patient consultations anytime – anywhere, improving the hospital’s image and at the same time maintaining a steady revenue stream.
SoftLink TeleHealth is a revolutionary platform that can work in tandem with HIMS, PACS, or as an independent TeleHealth solution. It enables consultation between patient and primary care physician or a specialist without a physical meeting. As a fully integrated platform, the consulting doctor will have access to patient records with charts, vitals, images, and results of diagnostic tests before the consultation, putting doctors in an informed position to offer the best advice. SoftLink TeleHealth Platform is a cloud-based solution that can be used “Anytime Anywhere” with a baseline internet connectivity such as a 3G cellular network.
Tele consultation will not replace the need to visit hospitals completely in foreseeable future as some basic investigations and physical check is not possible but it is a great blessing when physical meetings are not an option for patients and doctors. There is a possibility that in future wearables will be able to collect certain clinical parameters and add further value to the telehealth proposition but affordability for masses may become a concern.
All in all, industry experts observe that tele health has made serious inroads in patient care and it is definitely here to stay.
By Lindsay Street, Statehouse correspondent | South Carolina’s legislators will begin a flurry of activity starting Aug. 24 with a meeting of the state budget’s revenue forecasters.
They are expected to answer the ultimate budget questions of how exactly the pandemic impacted the state’s biggest revenue year in history, how much of the projected surplus is still available, and what exactly could the next 22 months look like in this fiscal year.
Those questions are expected to have answers during a 1 p.m. Aug. 24 meeting of the S.C. Board of Economic Advisors, the state budget’s revenue forecasters.
The meeting will take place physically at South Carolina Educational Television’s Bank of America room at 1041 George Rogers Blvd. The public has been invited to join the meeting virtually here or via call-in at 571-317-3112, access code 849-535-589. For questions about the meeting, call 843-734-2265.
House Equitable Justice committee to meet Aug. 25-26. A newly-formed House committee formed in light of racial justice and policing calls around the nation will convene three times next week: 10 a.m. Aug. 25 on sentencing reform, 1:30 p.m. Aug. 25 on law enforcement training and accountability, and 10 a.m. Aug. 26 on criminal laws. All meetings take place in room 110 of the Blatt building on Statehouse grounds in Columbia.
House Ways and Means panel meets on CARES Act funding.The House CARES Act Ad Hoc Committee will discuss updates to federal pandemic aid spending so far in the state and further expected expenses beginning next week. Meetings, to be held virtually, are at 2 p.m. on Aug. 26, Sept. 2 and Sept. 9. See the agenda here.
Senate reconvenes Sept. 2 on voting. South Carolina’s Senate will meet Sept. 2 to address early voting, according to an Aug. 17 statement from Senate President Harvey Peeler, R-Gaffney. He said while it is unclear “what the situation will be like in November,” the state should prepare now for “safe and secure voting.” Peeler’s announcement did not detail what measures the Senate will consider. Earlier this year, the legislature allowed the expansion of absentee voting in the state ahead of the June primaries amid the coronavirus pandemic, but did not expand that for any other elections. In recent weeks, more have pushed for the state to again expand absentee rules. Those who have joined the call to expand absentee voting have included Peeler, House Speaker Jay Lucas, R-Hartsville, and leaders of the S.C. Association of Registration and Election Officials.
Related: Lucas, Peeler trying to stop federal intervention into voting questions. Read more.
Senate Finance to meet in early September. A schedule has yet to be released to the public yet, but the Senate Finance Committee staff has confirmed the committee will begin meeting virtually via Zoom around the first of September and over six meetings to discuss the 2020-2021 budget. Check back here for meeting announcements.
In other news:
Keep an eye on the tropics over the weekend. Tropical Depression 13 appears unlucky, depending on all the things hurricanes depend on. A static cone image released the morning of Aug. 21 by the National Hurricane Center shows the storm strengthening to tropical storm-status by Saturday and potentially reaching hurricane-status by Tuesday along the west coast of the Florida peninsula. There is another storm vying for name-status, Tropical Depression 14 (which is expected to remain in the Gulf of Mexico), so it is unclear which storm will get the name Laura or Marco should they both continue to increase in intensity as expected.
Post Office frustrations aired in S.C. U.S. Rep. Jim Clyburn held a press conference Tuesday decrying changes to the U.S. Postal Service, which were seen as disproportionately impacting rural Americans and potentially causing mailed-in ballots for the Nov. 3 election to go uncounted. That same day, Postmaster General Louis DeJoy announced retail hours won’t change, no mail processing facilities will close, overtime for workers will be approved, and mail processing equipment and collection boxes will remain in place. But it was unclear whether moves ahead of that decision will remain in place — and some, like chicken producers in Maine, are reporting delays impacting businesses. DeJoy was to testify today at the Senate Committee on Homeland Security and Governmental Affairs.
ORS approves $26.1M in broadband spending. As part of the broadband infrastructure component of the CARES Act, the S.C. Office of Regulatory Staff (ORS) has approved the funding of 81 applications submitted by 13 Broadband Service Providers. The move will spend $26.1 million of the $50 million appropriated for expanding internet access in the state. According to ORS, the infrastructure expansion will make high-speed broadband available to 27,994 homes, 771 businesses, and other entities like schools and health care facilities in unserved areas. Projects must be completed no later than Dec. 18.
S.C. Supreme Court to hear case over private school grant program. The S.C. Supreme Court agreed this week to hear arguments in the lawsuit over McMaster’s decision to spend $32 million in federal coronavirus aid on grants to help students afford private school tuition. Read more.
Brittain wins GOP nomination for Horry Co. House seat. Case Brittain of Myrtle Beach earned more than 70 percent of the vote in a special primary election for House District 107 Tuesday against his GOP foe to replace Republican Rep. Alan Clemmons, who unexpectedly resigned earlier this summer. Brittain faces Democratic candidate Tony Cahill and Libertarian candidate William Dettmering III in the Nov. 3 election.
S.C. top attorney seeks S.C. high court opinion on law. S.C. Attorney General Alan Wilson asked the state’s Supreme Court last week to determine whether the state’s monument protection law, the Heritage Act, is constitutional. He asked the court to weigh in on a lawsuit filed by the widow of state Sen. Clementa Pinckney, who is suing to overturn the law passed in 2000 that protects monuments, like those honoring Civil War-era generals or the Confederate battle flag, on public grounds from removal. Read more.
A portion of the Coronavirus Relief Fund will pay for the expansion to increase capacity for distance learning, telework, or telehealth, according to SC Office of Regulatory Staff.
“The faster your internet connection, the more data you can transmit over that connection in a given period of time,” the ORS website explains. “With the recent pandemic, the internet has become even more important as an access point for education, telehealth, and other crucial activities of daily living.”
Many of the 550 areas identified as “unserved and impacted by COVID-19” are located in rural parts of the state.
“With those people being restricted to their homes over the last five months, not being able to be properly educated or receive healthcare or even be able to work, again all of America has seen a necessity to be able to provide internet services to those people,” Director of Safety, Transportation and Telecommunications Tom Allen said. “This is something that’s been talked about for decades now.”
The coronavirus pandemic has served as the gateway for funding. In total, 182,294 households were identified in SC to be without high-speed, affordable internet access. That includes about 10,000 households in the Tri-county area. However, officials say not every household will be included in this first round of expansions.
“We are making progress. We are taking steps to get people connected in South Carolina, and this is just what I think is going to be the first of many steps,” Allen said. “Once the shovels go in the ground and the service is delivered, I believe the leaders of the state are going to be even more motivated to be able to expand service throughout South Carolina.”
So far, fourteen vendors have submitted applications to the Office of Regulatory Staff to provide broadband support.
The list includes Home Telecom, Spectrum, and TruVista Communications, Inc. among others.
“The areas identified are THE areas South Carolina needs developed going forward. This piece of CARES Act funding was never going to be enough to complete the job or even get it halfway there. Much more funding is needed for that to become a reality, and it’s likely that more funding will come, either through additional appropriations from the legislature of existing CARES Act allocations, new federal funding through bills currently being considered or a combination of both,” ORS Media Relations Manager Ron Aiken said. “The good thing, this initial funding does put shovels in the ground immediately to begin the work that state and national leaders have agreed is the most significant infrastructure need our state, and country, faces.”
The projects are set to be completed by mid-December.
“I’ve learned that Telemedicine has unlimited potential to change our lives. It allows us to have doctor/patient interactions that are more convenient for the patient and more informative for the doctor. What is required to make all this happen? Broadband. There are places in South Carolina where you might as well be on the moon when it comes to getting cell phone service and high speed internet.”, Sen. Graham said.
The boardroom at Prisma Health’s Columbia office was brimming with state health advocates and politicians eager to find a solution to what has become a digital divide between urban and rural areas and along socioeconomic lines, making it difficult for some citizens to obtain quality healthcare. This divide has been an ongoing healthcare issue but has recently come to the forefront amid the COVID-19 pandemic.
“A wake-up call has descended upon the nation after the Coronavirus in a couple of areas, one of which is Telemedicine. A lot of people can’t get out of their homes for different reasons. A lot of seniors, people with mental health issues. The bottom line is: we can actually, through technology, reestablish a doctor/patient relationship that is incredibly personal. They tell me that about 20-30% of patient interactions today could be done just as well through a telemedicine platform as an actual office visit. And as technology improves, so can the interaction,” said Sen. Graham.
This week, Senator Graham and Senators Mark Warner (D-Virginia) and Tim Scott (R-South Carolina) will introduce legislation to allocate $10 billion to help governors across America speed up the deployment of broadband in areas where there is the greatest need. Senator Graham anticipates that South Carolina would receive roughly $170 million out of the overall fund.
Nationwide, there are 21 million Americans who do not have access to the FCC standard for high speed Internet with 650,000 of those living in South Carolina. According to Senator Graham, this grant is an emergency measure aimed at increasing access this fall to Americans who either live in a coverage dead-zone or are unable to afford service.
“This, to me, is an absolute medical essential requirement. Can you imagine living your life today without electricity? If you don’t have broadband, in many ways, you’re just as much in the dark in the 21st century as you would be if you had no electricity in your house. So here’s my goal: to get some money in the next stimulus package – and I believe we’ll have a breakthrough – that will expedite the delivery of broadband access to rural and urban areas that are basically dark,” said Sen. Graham.
Mark Sweatman, MUSC Director of Government Relations and Secretary to the Board of Trustees; Kathy Schwarting, Palmetto Care Connections CEO; Senator Graham; Meera Narasimhan, MD, DFAPA, Associate Provost Health Sciences USC, Professor and Chair Department of NeuroSciences and Behavioral Science, USC School of Medicine; Ken Rogers, MD, Director of SC Department of Mental Health; and Mark Wess, MD Chief Medical Information Officer at Prisma Health were in attendance.
For more information, follow @sctelehealth on Facebook and Twitter.
In an industry plagued by burnout, hospitals and health systems are using telehealth to give providers virtual access to mental health counselors – and to make their jobs less stressful.
– Like any profession that deals in life and death, healthcare has a stress and burnout problem – to which telehealth could be the answer.
Writing in the American Journal of Medicine, Scott Yates, MD, MBA, MS, FACP, of the Plano, Texas-based Center for Executive Medicine, says burnout affects roughly half of all physicians in practice, manifesting itself in medical errors, lower quality of care and higher costs. Furthermore, it’s a systemic issue, rather than an individual one, and COVID-19 certainly isn’t helping.
At a time when the coronavirus pandemic is putting extra pressure on care providers to reduce in-person visits, hospitals and health systems are launching telehealth platforms to put doctors and nurses in front of mental health support at the time and place – and on the device – of their choice. And they’re looking to telehealth to reduce the burden on providers by automating many of the tasks that are causing stress in the first place.
“The appeal of telemedicine isn’t just that it makes things easier (though it certainly can),” Adrian Rawlinson, MD, a California-based sports medicine specialist, explained in a column on physician burnout for the online journal Medium. “Telemedicine is a unique and necessary new approach to healthcare that allows providers the freedom to administer the care that works best for both them and for their patients, and it gives patients greater flexibility in managing their health.”
Using Telehealth to Help Providers in Peril
Although the COVID-19 pandemic cast the spotlight on provider stress and burnout, the issue has been around long before the virus appeared. And networks like Providence Health have already taken steps to address it.
The Washington-based health system, with more than 50 hospitals in eight states, rolled out its Telebehavioral Health Concierge program in January 2020, offering virtual care visits with a counselor within two days. They’ve since renamed it the Behavioral Health Concierge program and expanded its reach to include caregivers and family members in Oregon, California and Montana.
“We wanted to build something dedicated to caregivers,” says Josh Cutler, a licensed clinical social worker who helped launched the service. “Before and especially during (COVID-19), we have been at the center of an epidemic of burnout and suicide in healthcare. We needed to give (providers) something that would address that on their terms.”
Providence caregiver meets with Cutler for a telebehavioral health visit.Source: Providence Health
Arpan Waghray, MD, a psychiatrist and chair of the health system’s behavioral medicine clinical practice group who joined Cutler in developing the program, says the platform not only connects with people in crisis, but can be used to provide health and wellness resources that help providers before they reach that crisis stage.
“You automatically equate mental health with mental illness, as opposed to mental health and wellness,” he says. “With this program, our goal was to move upstream and meet people where they are.”
That points to one of the strengths of an online program: Giving users the resources they need and the freedom to access what they need at their own pace. For those who don’t feel comfortable talking to someone else about their problems, a self-serve platform might be more effective.
“It’s very consumer-centric to do this, but it’s not very provider-centric,” Waghray says. “In some ways we have to adjust our thinking.”
Cutler notes that doctors and nurses are trained to give care, but often aren’t sure how or when to seek it themselves. They’re either uncertain of how to access help or embarrassed about needing it.
A telehealth platform makes it easier to find help, he says, and gives them the opportunity to connect discretely at the time and place of their choice.
“I can talk to people who are sitting at home or in their parked car,” he says. “It’s all about giving them the space to talk, and establishing that connection.”
Technology as the Cause and Solution?
While health systems and hospitals are using connected health platforms to connect stressed out staff with counselors, they’re also touting the value of telehealth in reducing stress. And that benefit has been around since well before COVID-19.
The American Telemedicine Association made physician well-being and stress reduction a cornerstone of its 2019 conference and exhibition in New Orleans. The effort was spearheaded by Peter Yellowlees, MD, a professor of psychiatry at the University of California at Davis and Chief Wellness Officer at UC Davis Health.
“We have not worked well with technology in the past,” Yellowlees said. “We’re actually causing poor care with the way we use technology,” he says. “We have to understand how to use it better.”
Causes of clinician burnoutSource: AHRQ
“The main issue is documentation,” he said, pointing out that American doctors spend three times as much time documenting as do their counterparts in Australia and Europe.
But while older technology platforms – including telemedicine – may have been cumbersome, newer versions are smaller and more portable. Whereas providers once had to go to the technology, such as a nurse’s station or a computer in the office, they can now bring the technology with them as they make their rounds.
“The beauty nowadays is we’re freed up to do more of what we want to do,” he said.
The same applies to seeing patients. Providers who once had to jump through several different hoops to set up a telehealth visit can now connect with a patient on a laptop or smartphone from the comfort of their own homes. They can set schedules that fit better into their daily lives, setting aside time for family and for seeing patients.
“It actually is a much more egalitarian relationship,” says Yellowlees, who uses a telemedicine platform to see patients at home “Patients feel like this is a much more normal interaction.”
A connected care platform can also foster collaboration and teamwork, a cornerstone of the industry’s move toward value-based care and the patient-centered medical home. Through telemedicine, doctors and nurses can collaborate with each other, and with specialists, reducing stress on one provider and enabling different providers to handle the tasks more suited to them.
“Healthcare is increasingly a team game,” says Yellowlees. “The future (of the industry) lies in virtual care, and virtual care teams.”
How Telehealth Improves the Work-Life Balance
Aside from improving patient care and reducing costs, a selling point for the adoption of telemedicine technology has always been that it can help improve clinician workflows by reducing administrative tasks and giving them access to clinical decision support. This, in turn, allows the clinician to practice at the top of his or her license and focus on the patient.
One such example can be found in teleneurology.
Keith J. McAvoy, MD, the medical director of teleneurology for New Hampshire’s Dartmouth-Hitchcock Medical Center in Manchester, says a telemedicine platform that links neurologists at a central site, like Dartmouth-Hitchcock, to smaller hospitals across the region can reduce stress on doctors and nurses in those rural hospitals who have to transfer critically injured patients to a larger facility because they don’t have the skills or resources to treat on-site.
“Healthcare is increasingly a team game. The future (of the industry) lies in virtual care, and virtual care teams.”
“There are many of our spoke hospitals that have no neurology coverage at all, so we provide that neurology coverage,” he said of a network that provides on-demand services to close to a dozen locations in New Hampshire, Vermont and Maine, to a tune of roughly 800 consults a year.
McAvoy, speaking at a recent virtual conference coordinated by the Northeast Telehealth Resource Center and the Mid-Atlantic Telehealth Resource Center, said a telehealth platform gives providers in those spoke hospitals the resources and support they need to treat more patients, and it helps to reduce self-doubt and feelings of isolation.
The platform also gives neurologists more of an opportunity to expand their horizons and treat more patients – not only by administering emergency care to those suffering a stroke, but in offering specialist consults and follow-up services to any number of rural and remote locations.
That’s an often-overlooked benefit for a specialty that ranks in the top 5 in burnouts.
They “address many conditions without a known cure,” he said, which is often stressful. “Telling a patient that they don’t have a neurologic condition,” he added, is often the best part of being a neurologist.
Dartmouth-Hitchcock Medical CenterSource: Dartmouth-Hitchock
Telehealth “has the potential for providing more dedicated and consistent care,” McAvoy says, which in turn improves outcomes for patients and perks up the providers.
“A happy neurologist means better care for the patients,” he added.
Another example can be found in eConsults.
With the COVID-19 crisis expanding the ranks of the unemployed and pushing more and more people off their insurance plans, community health clinics, federally qualified health centers and rural health clinics all expect to see a surge in business. This puts pressure on clinic staff who already have a lot on their plates.
Expanded telehealth coverage for FQHCs and RHCs is one of the cornerstones of a legislative plan to continue telehealth’s momentum beyond the coronavirus. This would allow these providers to, among other things, use telehealth channels to seek specialist consults and support.
That’s what the MAVEN Project does. Launched in 2014, this Massachusetts-based group provides mentoring and consults to health clinics in high-stress, low-resource environments. Their services are free of charge, and their support group is comprised of retired and semi-retired physicians who want to give back to their profession.
“What we have are a group of physicians who are truly best in class, and want to share their skills with others.”
“They offer a wealth of knowledge and expertise and decades and decades of clinical experience,” Lisa Bard Levine, MD, MBA, the organization’s CEO, told mHealthIntelligence in 2018. “What we have are a group of physicians who are truly best in class, and want to share their skills with others.”
One of the guiding principles of the MAVEN Project is to help harried providers who need some advice or support.
“We’re here to give these providers support that’s really needed,” Levine says. “A lot of these primary care providers are newly trained, or working for clinics that struggle to provide necessary support for their physicians. A lot of them are realizing that this is a gray area in healthcare.”
Making Telehealth the Rule, Rather Than the Exception
While health systems like Providence Health create virtual care programs to care for the caregivers, telehealth advocates say the advances in telehealth coverage brought on by the COVID-19 crisis will, in the long run, reduce provider stress.
The hope among many is that using telehealth and mHealth tools will become second nature for care providers, resulting in improved workloads, reduced stress and a better work-life balance. And while using those tools to help their patients, they’ll also make us of them to help themselves when and where necessary.
“When it’s going right, all the technology disappears, and we have this connection,” says Cutler, at Providence Health, whose work has helped dozens – if not hundreds – of care providers address their health struggles. “This has been some of the most meaningful clinical work that I have done.”
The Centers for Medicare & Medicaid Services (CMS) recently issued its proposed 2021 Physician Fee Schedule rule, enumerating the services CMS proposes to add (and remove) from the list of telehealth services covered under Medicare. This year’s list is unusually robust because CMS took into consideration all the telehealth services Medicare currently covers on a temporary basis due to the COVID-19 Public Health Emergency (PHE).
CMS grouped the telehealth services into three lists: 1) nine (9) codes that will become permanent; 2) seventy-four (74) codes that will be removed when the PHE expires; and 3) thirteen (13) codes to add to the list, but only on a temporary basis (CMS dubbed these Category 3 codes). Concurrent with the CMS proposed rule, the White House issued an Executive Order designed to enhance access to telehealth services under Medicare by charging CMS to create even more virtual care coverage opportunities.
This article discusses the new Medicare telehealth service code proposals specifically related to the Public Health Emergency. For a companion piece discussing CMS’ proposed 2021 changes for Medicare telehealth and virtual care generally, click here.
Telehealth services that will become permanent
CMS proposed adding nine codes to the list of telehealth services covered under Medicare, to remain covered even after the PHE ends. The codes are set forth in the table below.
Service Type
HCPCS/CPT Codes
Group Psychotherapy
90853
Domiciliary, Rest Home, or Custodial Care services, Established patients
99334-99335
Home Visits, Established Patient
99347- 99348
Cognitive Assessment and Care Planning Services
99483
Visit Complexity Inherent to Certain Office/Outpatient E/Ms
GPC1X
Prolonged Services
99XXX
Psychological and Neuropsychological Testing
96121
Keep in mind, these codes are already Medicare-covered telehealth services, albeit on a temporary basis under the PHE waiver rules. Subject to CMS’ final rule, these services are expected to be added, on a permanent basis, effective January 1, 2021.
Telehealth services that will be removed when the PHE expires
CMS proposed removing seventy-four (74) codes when the PHE expires. Although CMS temporarily allows the services addressed by these codes to be delivered via telehealth, CMS found no likelihood of clinical benefit after the PHE ends. Even with the development of additional clinical evidence, CMS believes these services are unlikely to satisfy Category 2 criteria to justify including on a permanent basis.;
Service Type
HCPCS/CPT Codes
Initial nursing facility visits, all levels (Low, Moderate, and High Complexity)
99304-99306
Psychological and Neuropsychological Testing
96136-96139
Therapy Services, Physical and Occupational Therapy, all levels
Domiciliary, Rest Home, or Custodial Care services, New
99324-99328
Home Visits, New Patient, all levels
99341- 99345
Initial and Subsequent Observation and Observation Discharge Day Management
99217-99220, 99224- 99226, 99234-99236
While there are many codes slated for removal, this is only a proposed list. Stakeholders can submit comments and clinical data in support of making one or more of these codes permanent. However, barring any such compelling information submitted by telehealth industry advocates, we do not expect these codes to continue as telehealth services after the PHE expires.
New telehealth services during the Public Health Emergency (Category 3 codes)
CMS created a new category of codes designed for adding new Medicare-covered telehealth services, but on a temporary basis. Codes added this way would remain covered through the end of the year in which the PHE expires. For example, if the PHE expires in March 2021, these codes will remain Medicare-covered telehealth services until December 31, 2021. The reason for this unique approach is because CMS believes these codes have promise to be added on a permanent basis, but require additional data, real-world use experience, and feedback from stakeholders before CMS can make a final determination. CMS will not remove these codes concurrent with the PHE expiration because it wants to give the public an extra opportunity to gather data and submit requests to CMS, asking CMS to add some of these codes to the Medicare telehealth services list on a permanent basis.
The Category 3 codes demonstrate CMS’ openness to innovation and experimentation as it continues to expand coverage of virtual care services in the Medicare program. In short, Category 3 services are those likely to provide clinical benefit when furnished via telehealth, but for which there is not yet sufficient clinical evidence to evaluate making them permanent under existing Category 1 or Category 2 criteria. For a Category 3 service to become permanent, stakeholders will need to submit to CMS: 1) a description of relevant clinical studies that demonstrate the service, when furnished via telehealth, improves the diagnosis or treatment of an illness or injury, or improves the functioning of a malformed body part (including dates and findings of those studies); and 2) a list and copies of published peer reviewed articles relevant to the service when furnished via telehealth.
CMS proposed adding the thirteen (13) codes set forth below to the Category 3 list:
Service Type
HCPCS/CPT Codes
Domiciliary, Rest Home, or Custodial Care services, Established patients
99336-99337
Home Visits, Established Patient
99349-99350
Emergency Department Visits, Levels 1-3
99281-99283
Nursing facilities discharge day management
99315-99316
Psychological and Neuropsychological Testing
96130- 96133
These codes are currently listed as Medicare-covered telehealth services for the duration of thePHE, but would be included on a more extended temporary basis, starting January 1, 2021. CMS is accepting public comment regarding whether any additional codes should be added to the Category 3 list.
How to submit comments to CMS
Providers, technology companies, entrepreneurs, and advocates interested in telemedicine and digital health should consider submitting comments to the proposed rule anonymously or otherwise via electronic submission at this link. Alternatively, commenters may submit comments by mail to:
Regular Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1734-P, P.O. Box 8016, Baltimore, MD 21244-8016.
Express Overnight Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1734-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850 (for express overnight mail).
If submitting via mail, please be sure to allow time for comments to be received before the closing date. CMS is soliciting comments on the proposed rule until 5:00 p.m. on October 5, 2020.
Conclusion
The proposed changes for 2021 demonstrate CMS’ commitment to expanding meaningful patient access to care via telemedicine and digital health technology, both during the PHE and beyond. CMS is developing a post-pandemic strategic plan for telehealth, and industry advocates, entrepreneurs, and healthcare providers can use this moment to share their recommendations, ideas, and suggestions during the public comment period. This feedback—both policy ideas and by submitting clinical studies and concrete data—will be vital to CMS’ continued ability to improve and innovate under the Medicare program.
Palmetto Care Connections (PCC) is the telehealth network for South Carolina that offers telehealth support services to rural and underserved health care providers.
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