Telemedicine Legislative Watch

House Resolution 2068: Medicare Telehealth Enhancement Act,
This bill will expand mediciare reimbursement to urban and suburban area. Currently telemedicine reimbursement is limited to rural areas, which essentially excludes 80% of the population.

Telemedicine has been shown to increase access to healthcare. This is especially important given the current physician shortage. Used effectively, telemedicine can improve efficiency and reduce costs. It also has the potential to improve quality, especially in reducing re-admissions, avoiding needless emergency room visits and inpatient admissions. This bill may actually help in making telemedicine more mainstream.

Nursing HomeTelemedicine Videos

We have put together several videos demonstrating the use of telemedicine in the care of nursing home patients:

Reducing 30 day Hospital Readmission rates

The Institute of Healthcare Improvement or IHI, has launched a grant funded initiative for reducing Rehospitalizations. It is supported by the Commonwealth fund. The goal is to reduce the 30-day rehospitalization rate by 30%. Another stated goal is to improve patient and family satisfaction with transitions of care and with the coordination of care.

IHI recommends these 4 elements at the time of hospital discharge:

1. Enhanced assessment of post-discharge needs;
2. Enhanced teaching/learning;
3. Enhanced communication at discharge; and
4. Timely post-acute follow up

IHI states that success is dependent on active partnerships with providers across the continuum of care: hospitals, skilled nursing facilities, home health, ambulatory settings and patient/caregiver.

The focus of this project will have implications in healthcare payment reform, so it will be important to follow the progress of this project. There's a strong emphasis on improving care transitions and to identify those important services that will enhance this process. Unfortunately, many of these services are currently not reimbursed. It will require an out-of-the-box thinking beyond the current fee-for-service payment model in order to finally develop solutions that really work.

WSJ writes about the perils of an EMR stimulus

From the opinion page of the WSJ from April 14, 2009: "A competitive marketplace would produce the most innovative medical-records system"

I wrote earlier about the dangers of having the government force physicians into buying the "right" EMR systems. That is, systems approved or certified by the government, possibly CCHIT certification. This may have the unintended consequences of stifling competition and innovation. Can you imaging if the government had mandated that all businesses use a "certified" word processing system or a "certified" search engine? If this was the case, we'd all be using a Wang word processing system and Google may never have been created.

The WSJ puts it very nicely in this opinion piece:

"The ideal system would be an open platform for many developers to write applications that are allowed to succeed and fail, much like Apple's iPhone software. They argue that the key is "allowing competition and 'natural selection' for high-value, low-cost products."

"The stimulus hands the Obama Administration the power to define and approve "certified" records, therefore the power to create a health-tech monopoly. With stimulus money being shoveled out as quickly as possible, doctors and hospitals may end up prematurely investing in the costly systems that happen to have the government seal of approval -- and in the process freezing out an innovative marketplace."

Medicare Reform: Denying payment for 30 day re-admissions

Connected Health: Expanding its Role to Prevent 30-day Hospital Readmissions

Friday, August 22, 2008 | Allison McDonough, MD

Dr McDonough makes the following Points:

• "Connected health can contribute significantly to preventing such readmissions by improving monitoring of patients after discharge."
• "May provide additional benefit by assisting with access to timely ambulatory care for high risk patients."
• "There is ample room for improvement in 30 day readmission rates."

• "In 2005, an average of 18% of patients were readmitted within 30 days of their hospital discharge, with a range of 14% at the 10th percentile to 21% at the 90th percentile (Commonwealth Fund National Scorecard on U.S. health system performance, 2008)."
  
• "Medicare estimates that 13% of these readmissions were “potentially avoidable,” based on the IPPS rule, with major areas of concern including poor communication with patients at discharge, especially around medications, and inadequate post hospital discharge monitoring."
• "Prevention of these avoidable readmissions could save Medicare about $12 billion per year. (Report on Medicare Compliance, Volume 17, Number 24, June 30, 2008)"

• "Post Hospital Discharge Monitoring: Remote daily measurement of vital signs and symptoms in the heart failure population has shown great promise already in reducing readmissions, through improved monitoring as well as patient education."
  
• "IT platforms which facilitate interactions with Primary Care Providers will enhance the effectiveness and efficiency of telemonitoring."
  
• "These interactions may also improve patients’ access to timely ambulatory care, avoiding Emergency Department visits and readmissions."

Great comments made by some readers:

"I would like to also suggest hospital/physician referral's to Skilled Nursing Facilities. Many people still have the idea that a "Nursing Home" is the end of the road of life, however this is no. Most SNF's can handle much higher levels of care post-acute and most offer wonderful rehab programs and all disciplines (PT, ST, OT). It would be nice to develop a "circle" of care. From Hospital to SNF and then home with home health. This would really help deter the emergency room visits and the costs asscoiated with such visits. Also, a way to educate about the Medicare 30 day window, post hospital stay, for patients and the hospital staff would be very beneficial. Most of the hospital case managers and ER staff are not aware of this benefit."
Posted by: Robin Davis



Comments by the Author: Allison McDonough, MD

• "There is clearly a vital role for the visiting nurse in caring for our sickest patients. SNF and Rehab facilities are also an essential part of the continuum of care. However, as you know, many very sick or complicated patients are still not homebound, and do not qualify for VNA services. I see connected health as one way to fill this gap."
• "...dangers patients face in periods of transition, e.g. hospital or SNF to home."
  
• "Research from Kaiser found that >90% of hospital discharge medication lists contained errors (such as duplicative medication classes, interactions, inappropriate dosing)."
  
• "Patients often feel, and sometimes are, abandoned."
  
• "Economic incentives to discharge early mean that patients are frequently sent home while they are still fairly ill."
  
• "we need to embrace the patient and guide them through the entire continuum of their care"

Nursing Home Care- A Literature review

Here are some interesting articles highlighting some problems related to lack of physician availability to care for nursing patients in the current health care system.

Although this is a blog with a primary focus on health IT, it is important to have a clear understanding of the problems faced by practitioners in order to create an IT solution.

I have listed some key information from my literature search

..."the quality of care in nursing homes remains inconsistent and in many respects suboptimal."
(11. Scanlon WJ. Nursing Homes: Prevalence of Serious Quality Problems Remains Unacceptably High, Despite Some Decline. Testimony before the Committee on Finance, U.S. Senate, GAO 03-1016T, 17 July 2003)


A case for Nursing Home Physician Specialists in the Annals of Internal Medicine, March 2009

Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes (36–38).

Nursing home practice is only 4% of work time among the 20% of physicians who practice in a nursing home, one third of whom are internists (12). Often rooted in reality, perceptions among nursing home physicians of excessive regulation, paperwork, professional liability, and lack of nursing support remain barriers to developing a widespread nursing home specialist culture (13). Perhaps more important, many physicians still find it difficult to overcome logistic challenges (for example, caring for a sufficient number of patients while traveling from one facility to another), even though reimbursement for nursing home visits has increased. Without salary derived from administrative duties associated with being a medical director, many practitioners find nursing home care untenable. Waning interest in primary care and geriatrics (14), coupled with few credible role models (15), further constrains physician involvement in nursing homes. In a survey of graduating residents, fewer than 15% felt "very prepared to provide nursing home care" (16). .

1997 Study on Nursing Home Medical Practice

RESULTS: Most (77%) physicians reported spending no measurable time caring for nursing home patients

CONCLUSIONS: With increasing numbers of older and frailer residents, nursing homes will continue to be integral components of the future healthcare system. However, physicians currently spend minimal time caring for nursing home patients, with physician characteristics best predicting involvement. Questions remain about the future of nursing home medical practice and how to best recruit, staff, and train future cadres of physicians to provide sufficient quality care for nursing home patients in an evolving health care system.

Physician involvement in nursing home patient care is important in decreasing needless hospital admissions and in improving outcomes:

"Physician care positively influences residents' hospitalization rates, functional status, and satisfaction (33–35). Marginal physician involvement impedes communication and integration of the physician into the nursing home culture, with detrimental patient outcomes"