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The Role of Telehealth in the Triple Aim

August 11, 2014 | Mario Gutierrez, MPH | As originally published in iHealthBeat

In the February issue of Health Affairs dedicated to Connected Health, several of the best thinkers in the field -- Joe Kvedar, Molly Coye and Wendy Everett -- called for a partnership to be created among government agencies, academia, patient advocacy groups and private-sector organizations to capitalize on the exceptional opportunity offered by a "connected health model of care." This model would help improve access and quality of care while decreasing costs, more efficiently using the skills of highly trained health professionals and allowing greater patient participation. The knowledge to be gained from this partnership could lead to true innovations and efficiencies to advance the goals of national health reform.

In response to this call to action, the Center for Connected Health Policy (CCHP), which I direct, embarked upon a six-month intensive effort to critically assess the current and potential future role of telehealth in strengthening health care delivery within the dimensions of the Triple Aim objectives of national health reform: improved quality, improved health outcomes and reduced costs. This "Telehealth and the Triple Aim" project has given us a deeper understanding of the barriers inhibiting the full adoption of telehealth and has resulted in a series of action recommendations for how health care providers, public and private payers, and consumers working together in partnership can best advance the use of telehealth in support of better and more efficient health care delivery for the underserved.

Working under the guidance of a select group of advisers composed of national leaders in health care policy, research, clinical care and financing, our team of staff and consultants initiated a process to critically assess the state of telehealth adoption across the country and determine to how telehealth could affect the Triple Aim. This research was supplemented by interviews with a cross section of experts from around the country. 

The project culminated with a one day national forum of 40 thought-leaders from provider, payer, research, consumer, policy and technology organizations to review the project's findings, hear presentations from successful innovators from the field, engage in dialogue to identify adoption barriers and help shape recommendations for advancing the integration of telehealth within the context of the Triple Aim.


Highlights of What We Learned

One of the most important findings that emerged from this study was that changing the public- and private-sector policy environment alone is insufficient for achieving widespread adoption of telehealth care. By examining the "paths to maturity" of two well-established specialties, teledermatology and telemental health, it became clear that having a solid base of credible evidence and improving financing and reimbursement are important key drivers of telehealth adoption. These coupled with the "on the ground" drivers of consumer demand, provider leadership and commitment, and rapid advances in technology comprise the six critical drivers that together must be understood and mobilized to achieve the optimal integration of telehealth practices into the health care delivery at scale.

Health Systems Transformation

The movement away from the fee-for-service reimbursement model toward value-based coverage with universal payments, coupled with the anticipated increase in the number of insured have created a renewed focus on how to position telehealth as an attractive alternative to traditional care modalities for achieving the Triple Aim objectives. Telehealth can lead to more efficient and effective use of the primary care provider's time and can provide for greater flexibility in the use of mid-level providers across the health care spectrum. The case presented by Kaiser Permanente was particularly enlightening, with the expectation that by 2016 more than half of its routine visits nationally will be conducted virtually through communications by email, phone or video.

It is vital that telehealth be considered part of the larger spectrum of connected care with the electronic health record and the use of communications technology for consumer education, self-management and health information exchange among the members of the care team. The single biggest obstacle to fully connected care continues to be the interoperability among systems that prevent the free flow of information, with concerns about data security also creating some limitations. A partnership between providers, payers and the major proprietary EHR systems is needed to find a workable solution to this serious problem.

Telehealth is technology-enabled health care -- not simply the overlay of new technologies on a broken, inefficient system of care delivery and communication. To ultimately be successful, a thoughtful re-design of existing systems should be undertaken requiring the creation of a shared vision among executive and clinical practice leadership. This point was best illustrated at the Forum by the University of Pittsburg Medical Center, where for the past seven years UPMC has been integrating telehealth practices throughout its delivery system. A key to its success was treating this transformation as a long-term research and development investment to best position them for the future and not merely be limited to the demonstration of the short-term "return on investment" test.


Our gap analysis of the telehealth research evidence revealed several important findings. Most research studies have been relatively short-term (median duration was six months) and too small to substantially evaluate telehealth effectiveness. A 2012 systematic review of performance metrics used to evaluate telehealth studies found that clinical outcomes -- either diagnostic accuracy or clinical effectiveness -- and patient satisfaction (for remote patient monitoring only) were frequently reported, but other evaluation metrics that play important roles in decision making are rarely included. Longer-term studies (lasting years, not months) are needed to examine clinical outcomes and effectiveness to evaluate telehealth impacts.

The majority of all telehealth pilot projects reviewed were focused on managing chronic disease. Further, there have been few telehealth studies looking at cost-effectiveness, and they generally have used different criteria and have included different metrics and variables, making it impossible to calculate a pooled estimate. New economic models are needed to monetize savings related to telehealth such as the reduced use of transportation, real estate and energy, along with saved hours of missed work by patients and the caregivers who accompany patients on traditional office visits. Given the importance of cost savings to policymakers, greater attention and funding should be given to this area of evidence development.

Federal resources should be directed to rapidly test, evaluate and deploy new models of care that incorporate telehealth. Both public and private stakeholders can collaborate to spread the knowledge gained from telehealth implementations and create innovative and efficient delivery systems within the structure of national health reform. In addition, through increased collaboration investigators should strategize to approach funding agencies with a formalized, unified voice.

Public Policy

Federal Medicare and state Medicaid telehealth laws and regulations are outdated, confusing and represent multiple barriers to adoption. There are now a multitude of bills in Congress to remedy various aspects of definition, reimbursement and scope of practice. Greater leadership from the Administration is needed to promote comprehensive and timely reform, as well as establishing a workable system for interstate professional licensing and regulation. Similarly, continued leadership is needed from telehealth advocacy and industry groups to provide guidance to the states for legislation to streamline reimbursement, expand the definitions of telehealth to incorporate asynchronous and remote monitoring, and provide needed incentives for telehealth use.

Greater advocacy is needed to incorporate telehealth into national broadband policy and EHR meaningful use adoption. Government-sponsored incentive programs for health IT adoption, such as the Health Information Technology for Economic and Clinical Health Act of 2009, have successfully spurred EHR adoption. Telehealth leaders should work with the Office of the National Coordinator for Health IT to ensure telehealth integration is considered part of the ongoing meaningful use program and provide for full access to high speed broadband and the internet.

Consumer Demand

There was growing concern that health IT costs and other implementation complexities may result in "haves" and "have-nots" that disadvantage vulnerable populations who rely upon safety-net providers and public programs for their care. As the benefits and convenience of telehealth care becomes more widely known, telehealth leaders should find ways to harness the power of consumers and consumer advocacy organizations to incent health care transformation and expanded access to telehealth care. Federal subsidies for connectivity need to be continued to ensure the expansion of telehealth to the underserved both rural and urban.


Next Steps

CCHP is now taking the appropriate, actionable recommendations resulting from the Telehealth and the Triple Aim project and putting them into practice through ongoing collaboration with program advisers and key stakeholders in the six key areas of research, practice, technology, consumer support, policy and financing.

This includes organizing a California-focused "Connected Health and the Triple Aim" working conference to continue project momentum and build the needed cross-sector partnerships to achieve the promise and potential of these technologies to transform health care in support of the Triple Aim. The full report from this project will be available in September.


Gutierrez is director of PHI's Center for Connected Health Policy