“Are We There Yet?” Pediatric Cardiologists Work Through Telemedicine’s Glitches

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Pediatric cardiologist Sanket Shah, MD, MHS, was able to spare Winston Wahlgren and his parents a 200-mile commute from home to hospital by tracking the baby’s progress with a tablet-based home-monitoring program. Source: Children’s Mercy Kansas City.

Pediatric cardiologists say they can use telemedicine to improve patient care and ease the burden on patients’ families. But with the costs of these programs stretching into the hundreds of thousands, and a patchwork of reimbursement and regulations to contend with, what does it take to find success with pediatric telecardiology?   

When infant Winston Wahlgren was discharged from Children’s Mercy Kansas City after his first of three surgeries to treat single ventricle heart disease, he and his parents trekked the 200 miles home with a tablet computer. As part of the hospital’s now three-year-old program to electronically home-monitor babies with Winston’s condition who are between their first two surgeries, his parents used the tablet to send his oxygen levels and weight to the hospital. They also took daily 30-second videos of their son.

One day, Winston’s oxygen numbers were fine, but the video showed the good-natured infant wasn’t smiling and was breathing faster than usual, says Sanket Shah, MD, MHS, a pediatric cardiologist at Children’s Mercy. After an urgent transfer to the hospital, Winston had an emergency balloon angioplasty to correct the narrowing of his aorta.

Today, Winston is among more than 50 graduates of the tablet program. The program’s technology and software are being used at five other pediatric hospitals, and might be expanded to Children’s Mercy patients with heart failure and cardiomyopathy. And, with the tablet program, interstage mortality for single ventricle heart disease patients at Children’s Mercy is at 1 percent, Shah says. (Nationally, interstage mortality ranges from 2 percent to 20 percent, according to several studies.) “We believe in [the program],” Shah says, “and we’ve seen it improve patient care.”

In February, the American Heart Association published a scientific statement outlining the state of telemedicine in pediatric cardiology. “A large body of literature and real-world experience has developed, demonstrating that telemedicine increases pediatric cardiologists’ capacity to provide high-quality care to a greater number of patients by increasing the methods and efficiencies in which expert evaluation can be provided without geographic restriction,” the authors wrote (Circulation 2017;135:e648-78).

Shah, who was among the authors, says the time was right for a statement taking the pulse of the pediatric telecardiology world. “We have now mature technology and methodology to do pediatric cardiology telemedicine,” he says. “But in Missouri and Kansas and other parts of the country, there are legislative, legal and reimbursement limitations.”

Cost conundrum

Approximately 40 percent of patients treated at Rocky Mountain Hospital for Children in Denver come from outside the metro area, some from hundreds of miles across state lines, says Reginald Washington, MD, a pediatric cardiologist and the hospital’s chief medical officer. Over the last four years, rural hospitals in the area have purchased robots that connect to ultrasound machines to transmit images in real time back to the Denver hospital.

Respondents who had already had their child seen remotely were asked why they chose an online visit. Multiple responses were allowed. Source: Telemedicine in America 2017: Parents Use of Virtual Visits.
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But while the program yields faster test results and reduces travel for patients and families, it can be cost prohibitive for clinics. A robot can cost $20,000 to $30,000, with pediatric software and transducers adding another $5,000 or $10,000 to the bill, Washington says. And when Denver-based physicians travel to rural locations to train sonographers, while also seeing patients, their fees add up as well.

The tablet program at Children’s Mercy is even more expensive, according to a 2016 paper by its doctors (Circ Cardiovasc Qual Outcomes 2016;9[3]:303-11). The tablets represented a one-time cost of about $120,000, while cellular service came to $96,000 each year. By the third year of the program, the per-patient cost was down to $340 from $540, though these numbers don’t include development, program administration and data analytics. (The development and implementation of the tablet platform was grant funded.)

It’s tough to say if hospitals are recouping these costs. While Children’s Mercy hasn’t performed a business cost analysis, Shah says the program has helped avoid “a lot of unplanned ER visits and ICU admissions.” Washington says Rocky Mountain providers let the business office worry about the financials. “[The hospital is] not making a ton of money on this,” he says. “We look at it as a community service.”

Reimbursement & regulations

The hiccup is that telemedicine isn’t always reimbursed like a typical doctor visit. As of February, 31 states had telemedicine parity laws for private insurance, an improvement from previous years, according to the American Telemedicine Association (ATA). And while all 50 state Medicaid programs offer some type of telemedicine coverage, significant reimbursement barriers remain.

Ohio, where Nationwide Children’s Hospital is based, has no telemedicine parity law. That means commercial insurers can place barriers on reimbursement, such as stipulating that telemedicine visits are only covered if the patient is in another physician’s office, rather than at home or school, says Kerry Rosen, MD, a cardiologist there. Sometimes insurers refuse to cover telemedicine services at all. “That variability makes it a challenge,” Rosen says.

When it comes to telemedicine policy, each of the 50 states is different, with some state medical boards adopting different practice standards for telemedicine and licensure portability remaining a contentious issue, according to the ATA. For instance, all physicians in the Rocky Mountain system who use telemedicine must be licensed in Colorado, Wyoming, Kansas and Nebraska, Washington says. (Some states offer reciprocal licenses for telemedicine providers, but the practice is far from universal.) Not only that, but the physicians also need hospital privileges in more than a dozen facilities across those four states—a cost that ranges from $300 to $500 per physician per hospital per year.

Care & peace of mind

Pediatric telecardiology isn’t right for every scenario. Rosen says it might not benefit an older child with a minor issue that can be easily checked in a single office visit. Shah adds that it isn’t ideal for a first-time visit with a child who has a medical history. He would like the audio technology to be cheaper as well as improved to make it easier to hear heart sound nuances. “Those kinds of things are not as crystal clear as if you were using your own stethoscope,” he says.

But for individual patients and families, the positive impact of telemedicine can be significant. Nationwide Children’s Hospital uses video conferencing technology to hold joint discussions with providers from outside medical centers about the care of complex patients. These group video chats bring together multiple specialists to brainstorm on the best patient care plan. “It’s almost like a second, third and fourth opinion,” Rosen says.

Pre-procedure consultations, follow-up appointments and postoperative evaluations are good candidates for telemedicine. When one of Shah’s patients moved to Arkansas, the boy’s family would drive to a Children’s Mercy satellite in Missouri for telemedicine visits with Shah. A tele-facilitator, usually a nurse or medical assistant, would be in the room with the patient to position the stethoscope or use a handheld camera to check the surgery site. “I don’t have to travel to Joplin [in Arkansas] to see him,” Shah says, “but it also cuts [the family’s] commute in half.”

Now that most states require newborns to be screened for oxygen saturation, telemedicine can keep babies with low numbers from having to travel for a follow-up ultrasound. By using telemedicine, the infants can stay in their home hospital for the 20-minute study, which turns out normal about 95 percent of the time, according to Washington. “You can’t overestimate the convenience factor and the efficiency factor for the rural patients and their families,” he says.