This document discusses telehealth models in 21st century healthcare. It provides an overview of telehealth definitions and benefits, including improving access to care for aging and chronic disease populations. The University of Virginia Center for Telehealth is presented as a case study, serving over 41,000 patients across Virginia through telestroke, telepsychiatry, tele-ophthalmology and remote patient monitoring programs. The document concludes with discussing needed policy changes to improve Medicare and Medicaid reimbursement and licensing requirements to further support telehealth expansion.

1. Telehealth models in
21st Century healthcare
The Teledactyl (Tele, far; Dactyl, finger — from the Greek) is a future
instrument by which it will be possible for us to “feel at a distance.”
Gernsback, Science and Invention Magazine, 1925
Karen S. Rheuban, MD
University of Virginia Center for Telehealth

2. Definition: Telehealth
The delivery of healthcare and health related education
over a distance using telecommunications technologies.
Live interactive videoconferencing
Store and forward technologies
Remote patient monitoring
Virtual care, e-care, m-Health
Not a specialty in and of itself!

3. The need, the opportunity and why telehealth?
• We are an aging population
By 2030, more than 71.5 million Americans will be older than 65
• We suffer from high rates of chronic illness
Nearly 50% of American adults have at least one chronic illness
• Chronic disease is expensive
More than 75% of healthcare costs are spent on chronic disease
25% of spending is on inpatient costs
• There are serious workforce shortages and geographic mal-distributions
of providers
• There remain serious barriers to access to care nationwide

4. • Patients
Benefits of telehealth
Timely access to locally unavailable services
Improves chronic disease management
Reduces the burden and cost of transportation for care
• Health professionals (workforce shortages)
Access to consultative services
Supports collaborative care delivery models
• Hospital systems
Decreases readmissions
Improves triage, keeps patients local when appropriate
• Communities
Increased broadband deployment, hospital viability

5. UVA Center for Telehealth
• Integrated program across the service lines and schools
within the University that facilitate our missions of:
Clinical Care
Teaching across the continuum
Research and innovation
Public service/Public policy
• Centralized coordinated program within Health System
• HRSA funded Mid Atlantic Telehealth Resource Center (MATRC)
• Academic partner with Specialists on Call

6. UVA Telemedicine Partner Network (132 sites)
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Scale Legend
Mile(s)
0 20 40
* Includes emergency preparedness only sites.
Community Hospitals
Health Systems
Rural Clinics (FQHCs, Free Clinics)
Virginia Department of Health
Virginia Department of Corrections
Community Service Boards
School Health
Nursing Facilities (2014 USDA grant)
Dialysis Facilities (2014 USDA grant)
PACE programs
Home Telehealth

7. Patients served
• >41,000 patient encounters in Virginia
Additional international outreach
Additional remote patient monitoring
• Partner with teleradiology
• Spared Virginians > 14.5 million miles of travel
• Services in >45 different sub-specialties
Emergency
Single consults/follow up visits
Block scheduled clinics
Screenings with store forward technologies
Care coordination/remote patient monitoring program

8. Metrics tracked: clinical, technical and operational
Continuous process improvement to allow us to support expansion

9. Technologies: secure, interoperable, FDA approved

10. Tele-stroke
 Need: High morbidity, high mortality, high cost condition – when
every second counts
 Low utilization of TPA nationwide
 Telemedicine improves access to stroke and other neurology services

11. Tele-mental health
• Shortage of mental health providers
• Consultations, medication management, emergency
telepsychiatry
Improve access, shorter wait times
Fewer no shows
Controlled studies show efficacy comparable to face to face
psychiatry
• NUMBER ONE request for services at UVA (> 18,000
encounters)

12. High risk obstetrics
• Governor’s productivity investment fund and HRSA grant
• 363 patients saved 162,126 miles of driving from 5 sites
Parameters Before HROB Program After HROB Implementation
Gestational Age at First Visit 13.6 weeks 13.8 weeks
Missed 1 or more
57.1% 21.3%
appointments
NICU admission rate 12.0% 10.8%
NICU days 22.11 13.42

13. Tele-ophthalmology
• Conditions requiring screening and/or annual
examinations (diabetic retinopathy)
• Practice guidelines
• UVA program > 1800 diabetic patients screened
18% patients diagnosed with diabetic retinopathy

14. Remote Patient Monitoring/Home telehealth
UVA-BroadAxe Care Coordination Center (“C3”)
• Launched in 2013 to address readmissions challenges
• Enrolled 688 patients discharged with CHF, AMI,
Pneumonia, COPD, now added TJR
• Care coordination model with remote patient
monitoring for 60 days
• Results: 688 patients, 41.5 % reduction in all cause
hospital readmissions

15. 2012 IOM Workshop
Actions to further the use of
telehealth to improve health care
outcomes while controlling costs

16. Improve Federal Payment Mechanisms
Medicare reimbursement of telehealth services
remains low
• 2012: CMS reported <$12 million dollars in
reimbursements nationwide to distant site providers
• Rural requirement for originating site including for ACOs
• Non-MSA definition of rural limits sustainability models
and more importantly, access to care for our seniors
• Rural definition is poorly aligned with specialty workforce
shortages

17. Federal actions regarding telehealth
• Waiver requested for ACOs under Medicare
• Rep. Thompson (D-CA) introduced H.R.5380 , Medicare
Telehealth Parity Act of 2014
• Sen. Thad Cochran (R-MS) introduced S.2662 the Telehealth
Enhancement Act of 2014
• Senate Aging Committee held a telemedicine roundtable in
September
• House Energy and Commerce Committee has indicated that
the committee's 21st Century Cures legislation
• Veterans' Access to Care through Choice, Accountability and
Transparency Act of 2014.

18. Improve State Policies and Payment Mechanisms
• Medicaid coverage of telehealth
Expansion opportunity
>45 state Medicaid programs currently cover telehealth
No two states are exactly alike
Most state programs pay for transportation
• Private pay mandates (21 states plus DC)
• Varying state regulations – BOM, Health Departments
• Correctional telehealth opportunities
• State health information exchanges
• NOBEL women – national champions for telehealth

19. States with Parity Legislation for Telehealth (ATA)

20. Other important actions in 2014
• AMA policy document on telehealth
• FSMB “SMART Working Group” recommendations
• FSMB Interstate Licensure Compact

21. The future of telehealth
• Safe, secure, sustainable care delivery models
• Collaboration with the AMA, the specialty societies,
FSMB, consumers and industry
• Improve access to care and care coordination
• Encourage greater federal inter-agency alignment
• Encourage state actions
• Integrate with health information exchanges
• True integration into mainstream healthcare