1 State of Telemedicine Hill briefing on new telemedicine evidenceDecember 9, 2016
2 Outline The need for telehealth Our work Policy barriers
3 Outline The need for telehealth Our work Policy barriers
4 At the turn of the century, the Institute of Medicine called for a paradigm shift in healthcareCrossing the Quality Chasm “The American health care delivery system is in need of fundamental change. Between the health care we have and the care we could have lives not just a gap, but a chasm.” “This higher level of quality cannot be achieved by further stressing current systems of care. The current care systems cannot do the job. Trying harder will not work. Changing systems of care will.” Source: Institute of Medicine (2001). Crossing the Quality Chasm. Washington, D.C.: National Academy Press
5 We are still working to cross this quality chasm todayProportion of Medicare beneficiaries with PD who do not see a neurologist Source: Neurology 2013; 80:
6 Number of publications citing “telehealth" since 1962In 1996, the Institute of Medicine identified telehealth’s potential to bridge this chasm Number of publications citing “telehealth" since 1962 “With the nation’s health care system undergoing profound changes and experiencing relentless financial pressures, telemedicine is being investigated for its utility in urban as well as rural settings…telemedicine has the potential to radically reshape health care in both positive and negative ways and to fundamentally alter the personal face-to-face relationship that has been the model for health care for generations.” (IOM 1996) Source: Institute of Medicine (1996). Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, D.C.: National Academy Press
7 Outline The need for telehealth Our work Policy barriers
8 Research increasingly demonstrates the benefits of telemedicineRandomized controlled trials of telemedicine providing care into a patient’s home Study (year) Condition N Sites Findings National randomized controlled trial of virtual house calls for individuals with Parkinson disease (Connect.Parkinson) (2016) Parkinson disease 195 18 Providing specialty care remotely into the homes of individuals with Parkinson disease was feasible and not more or less efficacious than usual care Interest and satisfaction with the care model was high Patients preferred virtual visits to usual in-person care Randomized controlled clinical trial of “virtual house calls” for Parkinson disease. (2013) 20 2 Virtual house calls were feasible As effective as in-person care A randomised trial of a remote home support programme for infants with major congenital heart disease. (2012) Congenital heart defects 83 Clinicians were more confident in treating patients in video visits vs. telephone Parents were satisfied with video visits Healthcare resource utilization was lower in video-conferencing group A new multidisciplinary home care telemedicine system to monitor stable chronic human immunodeficiency virus-infected patients: a randomized study (2011) HIV Satisfaction with Virtual Hospital was high Clinical outcomes were similar for both groups Home videoconferencing for patients with severe congenital heart disease following discharge (2008) Severe congenital heart disease 30 1 Videoconferencing decreased anxiety levels compared to telephone and allowed better clinical information Functional and Clinical Outcomes of Telemedicine in Patients With Spinal Cord Injury (2008) Spinal cord injuries 137 4 Telemedicine patients at one out of four sites had statistically significant better functional improvement Satisfaction with interactions with nursing and medical staff and information and treatment received were higher in the telemedicine group Telemedicine improved diabetic management (2000) Type II diabetes 28 Some clinical outcomes improved significantly more in the telemedicine group Quality of life was unchanged Sources: Connect.Parkinson, Trials. 2016;17(7)
9 Connect.Parkinson was a randomized controlled trial of telemedicine for individuals with Parkinson disease Study overview 200 people with Parkinson disease 100 randomized to receive usual care 100 randomized to receive usual care + 4 virtual visits over one year Aims To demonstrate the feasibility of virtual house calls To evaluate its effect on quality of life To assess the impact on quality of care To determine its value to patients and caregivers Source: Connect.Parkinson study
10 The study was national in scopeIn collaboration with: Source: Connect.Parkinson study
11 Over 11,000 individuals from 80 countries and 50 states visited the study websiteMap of visitors to Connect.Parkinson website Source: Connect.Parkinson study
12 Ultimately, 195 individuals were randomized across 18 sitesMap of Connect.Parkinson participants Source: Connect.Parkinson study
13 Participants were well educated and likely receiving good careConnect.Parkinson participant baseline data All randomized participants (n = 195) Virtual house calls (n=97) Usual care (n=98) Demographics Age as of screening , [mean (SD)] 66.4 (8.1) 65.9 (7.8) 66.9 (8.5) Women [n (%)] 91 (46.7) 49 (50.5) 42 (42.8) White [n (%)] 187 (95.9) 92 (94.9) 95 (96.9) Bachelor’s degree or higher education, [n (%)] 143 (73.3) 71 (73.2) 72 (73.5) Internet use and familiarity Participants that use the internet or at home [n (%)] 95 (97.9) 92 (93.9) Participants that have ever used their desktop or laptop computer to participate in a video call or video chat [n (%)] 105 (53.8) 43 (44.3) 62 (63.3) Clinical characteristics Parkinson disease duration – year (n = 185) 8.0 (5.6) 8.3 (6.15) 7.6 (4.9) Parkinson disease care Participants that have seen a Parkinson disease specialist in the last 12 months [n (%)] 64 (66.0) 79 (80.6) Participants that were satisfied or very satisfied with care they received at last visit [n (%)] 160 (82.5) 79 (81.4) 81 (83.5) Source: Connect.Parkinson study
14 Providing care via telemedicine is feasible but did not significantly impact quality of life or carePrimary and secondary outcome measures Feasibility Out of the 97 individuals randomized to receive virtual house calls, 95 completed at least one virtual house call (98%) Of the total 388 virtual house calls, 91% were completed as scheduled Quality of life Evaluated using the Parkinson Disease Questionnaire 39 (PDQ-39) Between the two groups there was no significant change in the PDQ-39 as the mean difference was 0.3 points (p = 0.78) Quality of care Evaluated using the Patient Assessment of Chronic Illness Care (PACIC) Between the two groups there was no significant change in the PDQ-39 as the mean difference was 0.0 points (p = 0.79) Value Each virtual house call saved patients an average of 169 minutes (p < ) Each virtual house call saved patients an average of 56 miles per visit (p < ) Source: Connect.Parkinson study
15 Virtual visits flip the care paradigmPatient time spent on in-person versus telemedicine visits Source: abstract Source: JAMA Neurology 2013;70:
16 Patients receiving virtual house calls indicated a greater improvement in their PD overallPatient Global Impression of Change p = Source: Connect.Parkinson study
17 Physicians were generally satisfied but had concerns about the quality of the connectionProvider satisfaction with virtual house calls (n = 361) Source: Connect.Parkinson study
18 Patients were very satisfied with virtual house callsPatient satisfaction with virtual house calls (n = 320) Source: Connect.Parkinson study
19 Patients found care, convenience, and comfort in virtual house callsSelected patient feedback Care “With the virtual visit, I am asked questions and given a more thorough, longer lasting visit. I like the doctor and have more faith in his philosophy. He listens and asks more questions. I feel like I am getting better care from my virtual visits.” “Excellent help accompanied by warmth, compassion and expertise.” “I love everything about it! It is difficult for me to get to town. It is not worth while for me to take half day to go to town to visit a doctor who would spend less than 5 minutes…I finally gave up…I really hope [this] becomes one of the standard methods of providing treatment for Parkinson patients…Not having to drive and sit for long periods of time in waiting room is a BIG bonus.” Convenience “The excellent expertise of my doctor and the relaxed atmosphere encourage an in depth conversation that is sometimes more difficult in a hospital/office setting. It encourages note taking that I don't consider doing elsewhere. I like this approach very much.” “I find it easier to be more comfortable expressing my PD via a remote device than I do during a face-to-face visit.” Comfort Source: Connect.Parkinson study
20 Physicians and patients felt connected to one anotherFeedback from a Connect.Parkinson physician “…evidence of the patient-physician bond that can be established using telemed is that we both had great difficulty saying 'goodbye'. He asked for another visit, and it was so hard to say there would be no more. I felt as if I were abandoning him.” – Doctor participating in the Connect.Parkinson study Source: Connect.Parkinson study
21 Patients preferred virtual house calls to in-person visits on a variety of aspectsParticipants relative preference of virtual house calls (n = 68) Better personal connection Source: Connect.Parkinson study
22 Connect.Parkinson met most, but not all of the Institute of Medicine’s six aims for improving healthcare Crossing the Quality Chasm Six aims Connect.Parkinson Safe Yes Effective Patient-centered Timely Efficient Equitable No
23 The digital divide is the biggest barrier to providing equitable care via telemedicineCharacteristics of Connect.Parkinson population vs. general US population Connect.Parkinson General population Age [n (%)] 66.4 36.8 Women [n (%)] 47% 51% Bachelor’s degree or higher education[n (%)] 73% 32% White [n (%)] 96% 77% Use the internet or at home [n (%)] 84% Sources: https://www.census.gov/hhes/socdemo/education/data/cps/2014/tables.html, Pew Internet & American Life Project question database, Connect.Parkinson study
24 We recently launched PDCNY to enable any New Yorker with Parkinson Disease to receive care from usWho: Any New Yorker with Parkinson disease What: Multidisciplinary care + optional use of smartphone to track disease When: May 2016 Where: New York state, especially the 9 counties surrounding Rochester Why: To provide comprehensive care to New York residents, especially the underserved How much: Free Supported by: Greater Rochester Health Foundation and the Safra Foundation For more information:
25 Outline The need for telehealth Our work Policy barriers
26 Policy barriers prevent broader implementation of telehealthReimbursement Limited and fragmented insurance coverage of telehealth, specifically for Medicare beneficiaries and the privately insured State licensure laws prevent providers from seeing patients outside the state they are licensed States differ in regard to which services physicians can provide remotely Legal Clinical Some states require that any care provided via telehealth must be preceded by in-person care
27 The government has addressed these barriers for the Veterans Health Administration (VHA) but not for Medicare Overview of VA and Medicare telehealth activities VHA Medicare Budget $60 billion $646 billion Beneficiaries 7 million 56 million Money spent on telehealth services $1.1 billion $0.02 billion Telehealth related claims 2,000,000 270,000 Covers telehealth services in-home Yes No Requires clinicians to be licensed in state Sources: https://www.va.gov/budget/docs/summary/Fy2017-BudgetInBrief.pdf, https://www.healthcarelawtoday.com/2016/03/03/medicare-payments-for-telehealth-increased-25-in-2015-what-you-need-to-know/, https://fas.org/sgp/crs/misc/R43579.pdf