Raising the Standard: Using Telehealth to Provide Quality

by Dominick Gadaleta, MD, FACS, FASMBS; Martin Doerfler, MD; and Anthony T. Petrick, MD, FACS, FASMBS

Dr. Gadaleta is Chair of the Department of Surgery at Southside Hospital and Director of Metabolic and Bariatric Surgery at North Shore University Hospital, Northwell Health in Manhasset, New York; and Associate Professor of Surgery at Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Dr. Doerfler is Professor of Medicine and Science Education at Zucker School of Medicine at Hofstra/Northwell Health; Associate Chief Medical Officer; and Senior Vice President of Clinical Strategy at Northwell Health. Dr. Petrick is the Quality Director at Geisinger Surgical Institute and Director of Bariatric and Foregut Surgery for Geisinger Health System in Danville, Pennsylvania.

Funding: No funding was provided for this article.

Disclosures: The authors reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2019;16(8):8–9.

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Any patient, at any time, at any place, with any clinician. Some would argue that this approach is the best way to deliver healthcare. The broad field of telemedicine is a good option for providing patient care in real time without the constraints of geography or scarcity of resources. Telehealth is the practice of medicine when the care provider and patient are widely separated using two-way voice and visual communication (as by satellite or computer, tablet, or cell phone). This allows the care provider to visually examine the patient, as well as obtain a complete medical history. With the continuous rise in technological advances and usage, the possibilities seem endless. Areas of medicine such as intensive care, stroke management, psychiatry, rehabilitation, patient-centered medical home (PCMH), and the monitoring of chronic conditions, are just a few disciplines in which telehealth is being utilized.

TeleHealth at NorthWell Health

TeleICU. Northwell Health (NWH) hospitals, based in Long Island, New York, is an integrated healthcare system with 23 hospitals, five acute and subacute skilled nursing facilities, and 11 adult ICUs. NWH hospitals were the first in the New York metropolitan area to offer 24-hour remote monitoring of patients by critical-care physicians and nurses in intensive care units (ICUs). The ICUs use the telehealth to provide around-the-clock, proactive attending coverage by board-certified NWH intensivists, with registered nurses (RNs), physician assistants (PAs), or nurse practitioners (NPs) adding an additional layer of surveillance.

By using telehealth for critical-care patients, NWH continues to increase access to healthcare and improve outcomes, which is crucial to addressing more than 635,000 emergency department (ED) visits each year.

Telestroke. The telestroke program is available at 13 NWH locations, providing specialty care by stroke neurologists to ED patients who have signs and symptoms of a stroke. A fellowship-trained stroke neurologist is available to assess patients via video and audio. Since launching the telestroke program, NWH has observed a marked decrease in the time to administer tissue plasminogen activator (tPA), an intravenous (IV) therapy that dissolves blood clots and improves blood flow to the brain, as well as in the frequency of its use. An increase in recognition and referral of complex stroke warranting acute intervention have also been observed.

Telepsychiatry. The telepsychiatry program, which covers nearly every ED in the system, includes a board-certified psychiatrist and support team comprising logistics managers, licensed mental health providers, psychologists, and NPs. These healthcare professional teams are now seeing 350 to 400 cases per month, thus helping to reduce patient wait times for acute psychiatric consultation from an average of 12.5 hours to less than one hour, markedly accelerating time to treatment, whether discharged to home or admitted.

e-Skilled Nursing. Two of the NWH skilled nursing facilities use telehealth during off hours when physicians are not physically on site. In the first five months of implementing the e-Skilled Nursing program, hospital readmissions were reduced by more than 50 percent.

opportunities for bariatric surgery programs

A primary benefit of telehealth is the ability to connect patients and providers beyond their local geography, thus allowing busy surgeons and staff to see patients at multiple sites without the need for them to travel.

This has also been a game changer for bariatric surgical patients who live in remote areas because they can have surgery in the hospital of their choice and get eyes-on aftercare without the hours of roundtrip travel. Planning has also begun between the telehealth team and the bariatrics service to begin implementing pre- and postoperative nutrition and behavioral health assessments.

Direct-to-consumer TeleHealth

NWH launched its Direct-to-Consumer (DTC) platform in a number of practices around the system, including gastroenterology, dermatology, and radiation oncology. The platform initially focused on the global payment period because there are unsettled reimbursement issues for billable visits. It is also being launched for managed care or bundled payment areas, such as our postcardiac surgery program called “Follow my Heart” and for our house calls program for home-bound elderly patients. This program also includes the use of our community paramedicine program, where paramedics visit patients in need not to transport to the ED, but instead to treat with the telehealth backup of the attending physician.

The DTC software operates in a bring-your-own-device (BYOD) world. Patients and providers can use iOS or Android devices, whether it’s a phone, tablet, or computer. The scheduling software is integrated, so visits can be scheduled or on demand.  Working with the revenue department, a direct flow of physician documentation via the NWH ambulatory electronic health records (EHR) system (TouchWorks®, Allscripts®, Chicago, Illinois) corresponds to appropriate billing codes similar to face-to-face visits. Patients can be at their home, office, or another provider’s office to have specialist and generalist see the same patient simultaneously. Additionally, inline medical translation services are available for individuals who are not primary English speakers.

This structure is not yet more widespread because of issues with reimbursement provided for these services (i.e., you have to go to the office because your doctor only gets paid for the service provided when you show up in the office).

Impediments to Telehealth Adoption

Currently, the major impediment to telehealth becoming widespread is that the United States Centers for Medicare and Medicaid Services (CMS) only reimburses a few services outside of “designated rural underserved areas.” Some states have commercial and Medicaid payment parity for equivalent face-to-face services. Others have “coverage parity” where insurers need to cover but can set rates well below payment for equivalent office-based services. Some states have no parity legislation at all. It is impossible to launch new services to patients when the largest and dominant payor for those services does not cover them and when other payers in the market are all over the map with their policies. Paying equally for the same conditions and services, whether delivered in person or via telehealth, would vastly expand the market for telemedicine and the types of services that could be offered to patients in the comforts of their home or office.

There is some logic to having designated coverage areas by CMS while the value and best-use cases are determined. CMS does reimburse for telemedicine services in some areas that have been deemed to be underserved. But being an “underserved” area alone isn’t adequate to qualify. It must also be a specifically designated rural area. NWH serves many underserved communities in the greater New York City metropolitan area, but none of them qualify. In 2019, CMS allowed Medicare Advantage plans to begin covering telehealth as part of their benefits plans in 2020, but the announcement of the plans submission dates make it more likely that we won’t see any significant changes until 2021 or after.

The rationale behind Medicare not paying for telemedicine is that as it starts to provide fee-for-service “services” over the telehealth platform, the requests for telehealth consultations will increase significantly and, therefore, might break the bank. That kind of reasoning is terribly shortsighted. It assumes that everything is additive, with patients still using as many office- or hospital-based services with no preventive care benefit. If early telemedicine interventions make it possible to avoid expensive hospitalizations later on, it’s certainly worth it. As with any investment, there is some up-front cost, but investing money now can potentially prevent small problems from becoming big, expensive ones later.

Conclusion

As successful examples of telehealth systems at Northwell show, telemedicine is especially important for people with multiple complex conditions, and for seniors, who are far more likely to have multiple conditions and require frequent medical attention. Parents with young children might also find particular benefits in this program when trying to juggle demanding jobs and ill children who need clinical attention.

Telemedicine might also have the advantage of allowing the physician or other member of the care team to see the all-important home environment of the patient, not available in an office visit. A virtual visit might lead to a more thorough in-person examination with someone experiencing an obvious medical problem or whose condition has worsened when performed by the same provider who has been seeing them longitudinally over time. This can reduce the patient’s overall travel and lead to better, timelier, and directed care. 

Tags: quality improvement, telehealth

Category: Past Articles, Raising the Standard