5/1/2013. Telehealth definition and promises to patients and practitioners. The VA telehealth program

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1 Incorporating Telehealth and Communications Technology into Sleep Medicine Practice May 4, 2013 Samuel T. Kuna, MD Center for Sleep and Circadian Neurobiology University of Pennsylvania and Pulmonary, Critical Care & Sleep Section Philadelphia VAMC Telehealth definition and promises to patients and practitioners Telehealth the delivery of healthcare services at a distance, using any communication modality that allows the physical separation of provider and patient while communicating about health issues. Increase access to healthcare information Increase access to care Decrease cost of care (reduce hospitalizations, ER visits) Improve healthcare for medically underserved populations Increase access to specialty services Enhance health literacy Expand the healthcare workforce through virtual education and training The VA telehealth program About one-half of all veterans live more than 25 miles from a VA hospital. Over one-third of all veterans live 25 miles or more from a VA clinic. Some form of telehealth care was delivered to 380,000 veterans in FY11 and to 480,000 veterans in FY12. It is projected that the number will rise to 820,000 or about 15% of the veteran population in FY13. 1

2 VA telehealth modalities Clinical Video (Real Time) Telehealth Exchanging health services or education live via videoconference Home Telehealth Transmission of medical data for diagnosis or disease management Store and Forward Telehealth Acquires and stores clinical information (e.g. data, image, sound, video, etc.) that is then forwarded to (or retrieved by) another site for clinical evaluation VA clinical video telehealth encounters FY Clinical video telehealth encounters Fiscal Year VA telehealth resources Established 3 telehealth training centers that develop and provide standardized training and resource materials nationwide Conducts biannual VISN reviews for integration of telehealth standards with JCAHO requirements for hospitial- and home-based care Uses its national databases to generate reports and analyses for metrics of performance of telehealth programs at the levels of the local VA medical center, the VISN and nationwide Fomrs mational contracts and contract support for telehealth technologies 2

3 Telehealth personnel at each VAMC Facility Telehealth Coordinator (FTC) supports creation and operation of telehealth programs at the local VAMC and integrate activities with the regional VISN office Telehealth Clinical Technicians (TCTs) trained to use the telehealth technology and equipment, schedule patient appointments, and provide customer service. The TCTs are the main point of contact with patients Practitioners, as well as all staff engaged in telehealth need to take telehealth-specific training in the VA s online educational system Veterans Integrated Service Network (VISN 04) VISN 4 Eastern Regional Sleep Center referral sources Wilmington VAMC Willow Grove CBOC PVAMC Sleep Center Coatesville VAMC Fort Dix CBOC Gloucester CBOC Camden CBOC 3

4 Current clinical pathway for OSA management at the Philadelphia VAMC Initial Evaluation In-lab PSG Home sleep study - DVD Non- OSA Non- OSA Diagnostic PSG AutoCPAP Split PSG CPAP AutoCPAP Clinic FU Long-term FU Telehealth pathway for management of OSA at the Philadelphia VAMC Initial Evaluation Video Teleconference In-lab PSG Home sleep study - DVD Diagnostic PSG AutoCPAP Split PSG CPAP AutoCPAP Wireless modem data transmission Clinic FU Telehealth pathway for management of veterans with chronic insomnia Referral of veteran with chronic insomnia In-person (1:1) Clinic evaluation ViTel (Group) Clinic evaluation In-person (1:1) Cognitive Behavioral Therapy for Insomnia (CBT-I) Program ViTel (Group) Cognitive Behavioral Therapy for Insomnia (CBT-I) Program 4

5 Video teleconferencing of CBT-I to veterans with PTSD and chronic insomnia Veterans with PTSD and chronic insomnia Group CBT-I by video teleconferencing Group CBT-I by in-person delivery Group in-person non-active intervention 2 weeks 2 weeks 2 weeks q 3 months q 3 months q 3 months Remote Monitoring of PAP Adherence Home Internet DME provider Sleep lab Patient Data Center Patient compliance data is uploaded to a secure, HIPAA-compliant website using the device s integrated wired modem Once uploaded, patient adherence data can be viewed, assessed and monitored by the healthcare team 5

6 Modem transmission of PAP data Impact of modem-based monitoring on PAP adherence in patients with OSA Patients with OSA (AHI > 15) prescribed autopap were randomized to standard care or telephone contact in the first month based on modem-transmitted PAP data Outcomes: PAP adherence after 3 mo, subjective sleep quality, and side effects Fox et al. Sleep 35: , 2012 Impact of modem-based monitoring on PAP adherence in patients with OSA Fox et al. Sleep 35: ,

7 A cautionary message from telecardiology Two large multicenter RCTs of telemonitoring for patients with heart failure (Tele-HF, n=1653; and TIM-HF, n=710) showed no effect on rehospitalization and death. In TIM-HF, 14% of those assigned to the intervention group would not use the system at all, and nearly half of those who did lost interest over time. Chaudhry et al. Telemonitoring in patients with heart failure. N Engl J Med. 2010;363: Koehler et al. Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. Circulation. 2011;123: Essential components of a home monitoring program Reassessment and follow-up Measure physiological information Transmission of data Timely intervention by contacting the patient Processing of data by qualified personnel Toward a Tobacco Free Future Effective July 1, 2013, the University of Pennsylvania Health System will cease hiring tobacco users in our efforts to improve the overall health of our workforce while reducing health care benefit costs. The new policy will not impact the employment of current UPHS employees who are tobacco users. Employees will be required to complete an attestation regarding their use of tobacco products. Employees who are not actively enrolled in a smoking cessation program or using nicotine replacement therapy can expect to pay a higher premium for their health care benefit. 7

8 Behaviors that were once seen as exclusively private often have profound societal effects. As a result, many stakeholders are trying to change unhealthy behaviors through mechanisms as varied as legislative requirements for calorie labeling in some restaurants, bans on the sale of large servings of sugar-sweetened beverages, and Affordable Care Act provisions allowing employers to provide rewards or penalties worth up to 50% of employees' health insurance premiums on the basis of health assessments, including smoking status. Tele-technologies will enable automated hovering. Tele-technologies with an engagement strategy informed by behavioral economics will be used to hover over patients. Asch et al. NEJM 367; 1-3: 2012 Using telehealth technologies to change healthcare behavior Empowerment Providing patients with their health information to promote self-management and greater understanding and participation in their healthcare VA Admission and Discharge summaries VA Allergies and Immunizations VA Appointments (future and past) VA Demographics, Vital Signs, Problem List VA EKG, Laboratory Results, Pathology Reports VA Progress Notes VA Radiology Reports VA Wellness Reminders VA Prescription Refill Department of Defense (DoD) Military Service Information 8

9 Websites for patients on PAP therapy Mobile app and web-based systems providing patients with personalized feedback allowing them to take an active role in their sleep apnea therapy. These portals will allow patients to: View equipment guides and educational videos about sleep apnea Monitor the progress of custom goals set by the patient Receive feedback on Troubleshoot common problems Changing Healthcare Behavior Transportation industries are mandating sleep testing of their drivers and annual recertification of drivers with OSA Mandates Current mandates are driven by concerns about cost and justified by concerns for public safety Changing Healthcare Behavior Empowerment Mandates 9

10 Changing Healthcare Behavior Incentives/ Disincentives Mandates CMS beneficiaries required to use PAP for at least 4 hr/day over 70% of days in a one month period in the first 90 days of Teletechnologies will enable automated hovering Empowerment Empowerment Incentives/ Disincentives Mandates Telehealth technologies Emerging and future tele-technologies Mobile phones are bridging the digital divide Implantable and surface sensors relaying physiological information via bluetooth technology Medical sensors (BP cuffs, peak flow meters, glucometers, etc.) that are embedded with 3G mobile chips enabling each sensor to have its own point of connectivity with the cellular network (or that send the data to a wireless home health hub) Biodegradable tablets that monitor medication adherence via wireless transmission Technologies identifying the individual wearing the monitor 10

11 Current challenges to telehealth Identify the patient populations that benefit from telehealth management Determine the organizations (hospitals, employers, or insurers) that should deploy the technologies Develop effective strategies to promote patient engagement and motivation Provide reimbursement for telehealth Develop tools that enable a provider to scan large data sets at a population level and at a moment s notice, drill into an individual s information to enable just-in-time decision making Protect patient privacy and security 11