Taking Telemedicine to Heart Care

The patient was short of breath, pale and his echocardiography results spelled trouble. He clearly failed the eyeball test, even if the eyeball making that assessment was 95 miles away and looking at a computer monitor. One angiogram, two stents and a short time later, he received care that might have been delayed by as much a month had he not enrolled in a pilot telecardiology program.

“We have had many examples of patients who otherwise would have waited two to four weeks to see someone in person who were seen the next day or week,” says Marc C. Newell, MD, a cardiologist and director of the telecardiology program at the Minneapolis Heart Institute. The program, launched under the Allina Health system in 2014, complements a cardiac outreach program that encompasses more than 40 communities, some 100 miles or more from Minneapolis. About 100 patients, including the one Newell referred for PCI, received telecardiology services within the first six months of the program.

Providing better, less costly, patient-focused care drives many telemedicine initiatives. Timing is in their favor. The confluence of technical advancements, patient buy-in and the shift in reimbursement models has helped these programs take off. They might not be profitable for hospitals and health systems—yet—but they offer potential efficiencies, cost savings and patient benefits that become increasingly relevant under healthcare reform.

“We are still in a fee-for-service world but we know we are shifting to a value-based world,” observes Christine Bent, MHA, senior vice president of clinical service lines at Allina. “We are trying to look for some bridging strategies. This appeared to be one where we potentially could have a win-win.”

The telecardiology program builds off long-standing relationships between Minneapolis Heart and the many small and rural practices and hospitals in Minnesota and Wisconsin that its general cardiologists assist with periodic on-site visits. It is the institute’s second attempt. The first, piloted about 15 years ago, met with an early demise.

“The feeling was that the relationships were strong enough now and the technology was good enough,” Newell says. Their partners in the towns and smaller cities needed to be reassured that cardiology services would be maintained with telemedicine. The program hired a nurse practitioner to drive to sites that didn’t have one present to conduct ultrasound exams and be with the patients during virtual visits. The telecardiology team also made sure the visual and audio components of the program were high quality with high fidelity. When they rolled out the program in June, a member of their IT staff stayed with them to ensure the patients and outreach partners had a positive experience.

“Part of it, too, was patient perception,” Newell says, noting that in today’s digital world even grandparents Skype, so seeing and talking with someone through computer screens and speakers is familiar for the older population commonly in need of cardiac care. “Patients were ready.”

Telemedicine also saves patients time and the expense of traveling to Minneapolis. For some patients, that required a full day’s commitment, possible lost wages for them or family members and a long drive to or fro. “A lot of the places we go to are two hours or more from Minneapolis,” Newell says. “They are towns of several hundred to a few thousand people. They know and love their hometown clinic and they don’t like leaving it.”

Costs & efficiencies

Compared with Minneapolis Heart’s fledgling cardiology program, the heart failure telemonitoring initiative at Geisinger Health System in Danville, Penn., is long in the tooth—Bluetooth, to be exact. Geisinger implemented a Bluetooth-enabled system in 2008 as a way to serve its members in rural regions, replacing outreach efforts that dated back to 1998. Telemonitoring not only helps the system reduce heart failure readmissions, it also improves efficiencies and saves money.

“This program helped us sunset a very manual program,” explains Doreen Salek, RN, director of Population Management Partners at Geisinger. Previously, case managers had to telephone heart failure patients, ask for weights, calculate the algorithm and enter it into records. The process limited the number of patients they could accommodate and overburdened the staff. Geisinger replaced that labor-intensive process with tools that included Bluetooth scales with interactive voice response.

“The nurses have case loads of 125 to 150 patients,” Salek says, many of whom are complex. Calling to check in with each daily is not feasible. “Not only do they have these patients in their population, but every day new patients are identified who could benefit from the services and new referrals are going out. It helps them balance the outreach they need to do within a very robust caseload and a very busy day.”

Geisinger members with heart failure who are considered appropriate candidates for the telemonitoring program have a Bluetooth scale delivered to their home. The scales’ voice recognition system includes a list of questions designed to identify signs such as weight gain, swelling or shortness of breath that might trigger an exacerbation of their heart failure. The data feed into an EHR that can alert nurses who can check in with the patient and consult the patient’s primary care physician or cardiologist about treatment options.

Joann Sciandra, RN, BSN, associate vice president of population management at Geisinger, emphasizes that the focus should be not on the technology but rather what it enables, a view seconded by Newell and Bent. “What is nice about this tool is that it is not cookbook,” Sciandra says. “We built weight alerts around each patient. We worked with their primary care physician and we learned from the patient’s patterns when we should be concerned.”

That allows them to target cases and intervene before the problem worsens and requires hospital admission. The program has paid off, both in outcomes and costs. An analysis looking at claims and cost data on Geisinger’s heart failure patients before and after implementation found the odds of all-cause, 30-day and 90-day admission were 23 percent, 44 percent and 38 percent lower, respectively, with telemonitoring.

“When you look at the outcomes, you see the patients have not had to be hospitalized,” says Salek. She and Sciandra contributed to the study, which was published in Population Health Management in 2014. “They are managing their disease and they are not having to go the emergency department. These are things we don’t want people to have to do. We want people to stay at home and be as healthy as they can be in that environment.”

Based on expected vs. observed costs, the cost of care declined as well, with savings per member per month of $212 by 2012. For every dollar spent to launch the program, Geisinger saved $3.30. These promising results have given the system confidence to apply the approach more broadly; for instance, using a Bluetooth-enabled blood pressure cuff to monitor patients with kidney disease.

“It gives your case managers (the ability) to touch even more of a population with complex needs,” Sciandra says. “It helps with your staff management, also.”

More patients, more presence

Allina sees opportunities for efficiencies and cost savings through telecardiology as well. The outreach program requires cardiologists to travel to partner facilities, a time-consuming task that might swallow two to four hours of potential productivity. With telemonitoring, cardiologists can spend more time on cases and see more cases. Taking lessons learned from other telemonitoring programs, cardiologists assigned to remote consults read echocardiograms in their free time.

“Cardiologists, who are some of our most precious and expensive resources, have less windshield time,” Bent says. “We pay for their windshield time. So instead of being in their car, they can be reading echoes and between reading echoes, they can also do their telecardiology consults. That is fantastic.”

Being sensitive to the concerns of their partners, Minneapolis Heart initially made telecardiology a supplement to its outreach program. The cardiologists selected four sites with high demand for their services and started the rollout there. They later identified two sites whose low volume doesn’t support as many on-site visits but will sustain telecardiology consults. 

New Ulm, a two-hour drive from the Twin Cities with wait times that exceeded five weeks, became the inaugural site and now schedules weekly telecardiology visits. “They are averaging about five patients per week with telehealth,” Newell says. “We are seeing almost as many patients now per month with telehealth as we do with our face-to-face visits when we go twice a month.”

In a 2014 survey of 57 healthcare executives by Foley & Lardner, 84 percent of respondents considered developing telemedicine services as very important or important to their organizations. Half listed improving the quality of patient care as the top reason for implementing a telemedicine program, and 25 percent chose reaching new patients as their first or second highest motivator for starting a program.

With telemedicine, Allina potentially can expand its reach to touch a five-state expanse, Bent predicts, and take advantage of the deep expertise at Minneapolis Heart. The next step includes involving heart failure, electrophysiology and other subspecialists to “break down the barrier,” as Newell puts it, by allowing patients to learn more about treatments that might benefit them without committing to a long drive to Minneapolis.  

Nathaniel M. Lacktman, JD, a partner at Foley & Lardner in Tampa, Fla., who leads its telemedicine practice, says telemedicine offers specialists and subspecialists a great opportunity to expand their geographic footprint by giving more patients access to their expertise. It also helps administrators maximize their resources by allowing physicians to work within their interests. This is especially useful for “superstars,” physicians who are well known for certain skills and accomplishments—say, as pioneers in transcatheter aortic valve replacement.

“If they are a Ferrari, they like to be driven,” Lacktman observes. “If you give them that opportunity to have that level of work then it makes them satisfied; you can generate revenue; and it keeps them productive. They don’t need to do anything other than familiarize themselves with these telemedicine-based tools and then make it available to patients.”

Getting payers onboard

Some telemedicine programs make a reasonable business case for themselves based on the cost savings and efficiencies they provide. They also can play a key role in quality improvement and patient satisfaction. At Geisinger, many heart failure patients who have improved enough to graduate from the telemonitoring program say they would rather keep their Bluetooth scale. “They feel like they are getting a connectivity,” Sciandra shares. “When they get on the scale they feel like someone is checking on them every day, even though there might not be a daily phone call.”

Minneapolis Heart, which asks telecardiology participants to take voluntary surveys as part of its research, has had a 100 percent acceptance rate with lots of positive feedback, even from those who were skeptical at first. But telecardiology reimbursement depends on the payer, and while most pay, Bent says, reimbursement under healthcare reform has been dwindling.

“From a business perspective, is it going to be a huge money-maker up front? Probably not, if you are looking in terms of just purely billing of the visit,” Newell acknowledges. “But if you take a deeper dive in the business side of it, there are some clear wins for the group.”

In the Foley & Lardner survey, 48 percent of respondents ranked lack of reimbursement as their No. 1 challenge when implementing a telemedicine program, and another 17 percent placed it as their second most pressing challenge. “Reimbursement remains the primary obstacle to widespread implementation and adoption of telemedicine in this country,” Lacktman says.

Medicare still primarily uses a fee-for-service model with telemedicine and imposes geographic restrictions with a somewhat narrow scope of service. He describes Medicaid’s coverage in states that offer it as “a patchwork quilt without any particular rhyme or reason for what is or is not offered.” Few private insurers cover telemedicine unless mandated under state laws.

As of late 2014, at least 19 states required commercial insurers to cover telemedicine services as they cover in-person consults, according to the National Conference of State Legislators. “That is going to be the motivating catalyst to adoption, namely states need to pass legislation requiring commercial insurers to cover telemedicine services,” Lacktman says.

Having a critical mass of states with these requirements will let more patients use these services, which will give providers revenue to invest in the hardware and software to support robust telemedicine programs. “It will reach a tipping point when you have even more of a body of data and metrics of quality that the provider groups and hospitals and other institutional providers can see,” he predicts, which can be mined to prove telemedicine’s worth. “Payers then will be able to have a very robust case study and market case for telemedicine, if not as the standard of care, as an essential component to healthcare delivery.”

Making virtual care click with users

A cardiac rehabilitation program delivered to patients in small urban or rural communities in British Columbia beat standard care for reducing the risk of cardiovascular disease. But the initiative required some finesse to ensure success.

Scott A. Lear, PhD, of Simon Fraser University in Burnaby, Canada, and colleagues randomized 78 participants who had been admitted for either acute coronary syndrome or revascularization to either usual or virtual care (Circ Cardiovasc Qual Outcomes online Sept. 30, 2014). Patients randomized to virtual care received a heart rate monitor and a home blood pressure monitor. They also had access to an Internet program that included online forms, scheduled one-on-one conversations with a care team, weekly education sessions based on interactive slides, data capture for exercise stress and blood test results and a monthly expert group chat session. Usual care patients received guidelines on safe exercising, eating and nutrition and a list of Internet-based resources. 

Compared with the usual care group, the virtual care group’s total cholesterol, low-density lipoprotein cholesterol and dietary saturated fat were lower; their dietary protein was higher; and their maximal time on a treadmill was higher by 45.7 seconds at 16 months. The virtual care group recorded eight emergency room or major events vs. 22 in the usual care group.

The success of that program didn’t come overnight. A pilot and other work dating back to 2008 helped Lear’s team approach the program from the user’s perspective. “We’ve learned that even if people have internet, it doesn’t mean they are comfortable using all the aspects of a desktop computer,” he says. “Somebody may have home internet access and just use it for playing online games and outside of that box they are not comfortable with computer interaction. What we want to move toward is using technology as enabler and using the technology that fits best with the patient.”

The program is poised to be implemented in the Fraser system and Lear hopes to expand it across Canada in a study to assess if it shows equivalent benefits nationwide. “These are small numbers,” he says, “but if they actually translated similarly to patients in a larger study, that would be a phenomenal reduction.”