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There goes telehealth, taking it on the chin again

It's another health tech day and Mayo Clinic concludes a study. So who knew? Telehealth monitoring is not effective at keeping patients out of the hospital! So reports a new study from those who (repeatedly) study these things. Does that bode ill for telehealth marketers, who fervently hope that pending re-hospitalization penalties would energize a long-lived but relatively small market. Use of telemonitoring equipment, the study concluded, should continue to be limited to studies. And oh, by the way, doctors need to 'learn how to do something with all of that data!' Yeah, no kidding. Apparently, knowing nothing about the patient's condition except for 'routine' primary care visits with doctors ($$) and specialists ($$$), we learn that with only 205 elderly patients from Minnesota, half (103? 102?) were chosen to be monitored by the now-defunct Intel Health Guide, reborn last year in a GE-Intel spinoff as the Care Innovations Guide

Being monitored is a risk to one's health. Here's how the Mayo Clinic study apparently worked: It was comprised of "five to ten minutes of measurements taken daily and [participants] also talked with nurses over the phone and could video-conference with them if they needed help." Among those monitored, there were more deaths, in comparison to those who continued with their regular face-to-face see-the-doctor routine. Would you conclude that there is a correlation, unexplained, between telehealth monitoring and risk of death? Or perhaps you said to yourself, maybe we have seen this one before. Might one wonder about the resemblance of this study to the 2010 Yale study (also deemed an indicator of the 'failure' of telehealth) in which patients were required to telephone in their results?  Oh, right, there's that 'tele' in telehealth. We certainly wouldn't connect it to the VA study of 2008 that demonstrated improved outcomes for patients whose 'non-institutional' care was coordinated and supported by telehealth technologies used by the (thousands) of participants and which the VA, no surprise, continues to deploy.

Duh, could there be a slight difference in reimbursement? Meanwhile, the wireless health market will reach $38 billion by 2016 (!!!) with 45% of the share coming from the US in 2011. Oh, but they must still be talking about fitness, fertility tracking and white noise generation. These do not require a prescription from your doctor, who is facing a 'cash crunch' and apparently in the Medicare realm may be motivated to encourage repeat visits, which may not be 'convenient' for the patient. Exactly. So what can encourage the doctor to refer or deploy a telehealth device?  Many believe that fear of patient readmission to the hospital is a near-term enabler. These readmission incidents are being counted in reports now being generated to prepare for looming October 2012 penalties. But was there a specific recommendation of telehealth as an admission-avoidance tactic? Read this summary: "Essentially, the Act authorizes subsidizing some of the cost hospitals will incur in their efforts to reduce readmission rates.The program is to include patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by appropriate healthcare professionals." So the hospital and doctors can rely on people to keep Mr. Smith and Mrs. Jones from readmission within the 30-day period, using home visits, phone calls, and whatever else. So does anything fundamentally change? Not until the reimbursements are rearranged in favor of telehealth, as is underway in Australia, for one. Why would a doctor, outside of a doomsday study funded at Mayo Clinic, Yale or wherever, be really serious about making telehealth work?

Excessive use of telemonitoring studies could do more harm than good. There are plenty of technologies out today that could help in the care of frail and at-risk seniors, whether in a hospital, in a skilled nursing facility, or in assisted living. You can search for them on this site and many others. They include bed sensors that suggest to a nurse that a patient be turned to avoid bedsores, wireless devices that enable a wandering patient (even en route to the bathroom) or resident to be tracked, remote and home monitoring technologies, self-care devices, including telehealth-enabled blood pressure cuffs, weight scales and fall detectors, that patients and residents could be trained to use before a repeat emergency room visit is required. Insurance companies -- giants like Humana, for example -- along with hospitals, Medicare, and everybody else are also in the yet-another-research-study mindset before committing themselves to inclusion of telehealth technology in their strategies. With everyone waiting for the Godot of studies to end all studies, medications are routinely mismanaged, patients fall out of bed, changes in vital signs are missed, and risk reduction and preventive treatments continue to depend on the labor of an ever-scarcer population of skilled people who deliver most of that care face-to-face. Can it be that so many other aspects of our lives are dramatically altered when a technology is introduced (books, travel, communication, car safety) and yet we continue to stumble along in a paper-and-person and nearly technology-free health system?



I happen to have an inside look at this because we are assisting with some EMR implementations and meaningful use, plus my wife is working directly with doctors to implement technology at a major medical institution.

I think there is an incorrect assumption that doctors don’t want to push telehealth because it means they are missing out on a patient visit and resulting reimbursement. Doctor’s time is at a premium and most of them have a maxed out schedule, so that patient would just be taking up a slot in an already full day anyways.

While I applaud the advances in telehealth and other technologies, we won’t see widespread adoption until it is covered by insurance or until doctor’s are done swallowing the EMR pill that they are still in the process of implementing and maximizing (a process that continues through 2015 I believe). After that, institutions will look for the incremental gains that telehealth could provide, mostly on lowering readmission rates. Until then, I understand why they are focusing on the basics – even though, as a technologist, I’d love to see them implement the full array of technologies that are out there to provide better care.

The telehealth that we are seeing implemented is either by patients paying for it themselves or institutions that were ahead of the curve in EMR implementation (the VA’s EMR system is widely recognized as the gold standard). Patients that are implementing telehealth are paying for it out of their own pocket. It’s probably because it makes more economic sense for them to utilize telehealth instead of paying out of pocket for a home care nurse to do the same thing at a higher rate. The VA is obviously seeing benefits as well.

It seems we’ll just have to either wait a few years for complete EMR implementation or wait for another act of congress.

Fourteen years ago I met a young man who had demonstrated through the use of a Super Nintendo game that when people engage with health information on a regular bases, they change their behaviors and have less problems managing their chronic conditions. Sounds like common sense to me – when you monitor a person’s vital signs and symptoms, educate and motivate them to engage with self management behaviors, and remind them when to take their medications, of course they will do better. I have always wondered why we felt we needed randomized clinical trials to “prove” what just makes sense to those of us who have been working with chronically ill patients for 30+ years. As you mention, the VA has been implementing a successful telehealth program for many years now. Here’s the difference between what they have done and the randomized clinical trials of the world. The VA didn’t just purchase technologies and deploy them in a controlled environment; they developed a new model of care for their high-risk, high-cost veterans. In this care coordination model, they identified potential veterans for the program and then carefully assessed their needs to determine first what their care needs were and if they needed any technology and if so, what technology would be most appropriate for that particular veteran. You see, their model was focused on coordinating care for the veteran to ensure they were getting the right care at the right time in the right place. They did a wide scale implementation that has delivered positive results overall for their Veterans and their bottom line (absent of any randomized clinical trials).

I believe the randomized clinical trials at Mayo and other locations were conducted with the highest regard for scientific merit and in an extremely well organized and methodical way – as clinical trials should be conducted. I also commend the researchers for their keen observations of why they did not see results – they now understand that it is the idea of delivering care differently that makes the difference, and not the technology alone. You must identify the right types of patients for these new care models; you must utilize the data to drive your interventions; you must match the needs of the patients to the appropriate technology; and you must train your clinicians to deliver care differently than they are used to if you want to see the positive impact from a telehealth model of care. While the clinical trials were well conducted, the reality of this new care delivery model is that you must treat each patient based on their needs and following a strict protocol for all patients may in fact introduce all kinds of other variables that muddy the water and make it tough to see a positive impact. So, we get back to common sense – if you are monitoring a patient on a daily basis, using that data to intervene in a timely manner when there is an indication of a change in their status, reminding them to take their medications and teaching them how to engage in self management behaviors, then of course, the patients will do better! Does anyone disagree with me? If so, I would love to hear from you. Julie Cheitlin Cherry, RN, MSN Clinical Nurse Specialist in Gerontology Director of Clinical Development Intel-GE Care Innovations

No surprise that Julie makes a clear, logical, common sense reply. My reply to the study would be far too obvious (and use far too many curse words) to be useful - so I'll simply throw my support behind Julie's comments. Very few, if any, people have the industry experience and knowledge (both of the highs and the lows) to really understand the total picture as her. I will make one addition - this should be the *last* 10-100 person pilot in the space. We have more than enough data that the basic idea works (Especially for CHF). Let's start really focusing on the other things Julie mentioned - the more important items like clinical workflow, data analysis, design - more than just technology for technology sake. The industry needs to move on, move forward - these are discussions that were widely understood in 1999 - even the VA national contract that Julie speaks of was 2004.

You said it all! I've recently entered the health field, in a patient advocacy position and the prevalence of paper-and-person, technology free health systems is mind boggling and still capable of shocking me every single day. We are in the very midst of health care reform debate here in the United States, yet it is all talk and very little action. Dare I be the skeptic, but it's almost as if these large for-profit hospitals/entities do not really want to pursue serious discourse on decreasing rehospitalization efforts because - hold on I'm about to spin some common sense here - it will ultimately hurt their bottom line! I must always remember - this is about dollars, not sense!

I think there are a lot of things in play here. Our whole medical system is in a need of a change in order to accommodate the use of these types of technology. I have no doubt that if there were healthcare workers trained in monitoring vitals or whatever data is collected with some of telehealth style systems, that a lot of health crises could be avoided. However, there needs to be a new breed of healthcare workers spending time on this and helping patients understand when something is going wrong. To do this, there definitely needs to be a shift in the way reimbursement from insurance companies works for such services.

Spot on, Laurie! It was very naughty of the study authors not to attempt to suggest why the monitoring was associated with more deaths. There are all sorts of possible explanations, including that too much medical attention increases your chances of complications...which is an encouragement to avoid going into hospital if you possibly can. How? Try telehealth monitoring!

Steve Hards
Editor, Telecare Aware

Laurie, I will concur with Steve and point out not only the low N and a certain lack of geographic diversity, but also the age of the survey group--mean of 80.3 years. This was an old, high risk (as stated) group that may have other preferences (e.g. active carers). In short, not your average group of older adults using health monitoring. What also is not there in the abstract (and may be in the published study) is 1) did the users find the Health Guide and the peripherals easy to use or confusing? 2) was there a consistency pattern (i.e. they used it at first and fell off?) and 3) the care management methodology. Were these patients being actively 'managed' with access to a care manager, home health assistance and education, or was that left to the 'box'? Finally I will agree with Carl--EMRs and another set of initials, the ACA, evaporated whatever money there was and left connected health dry....this was obvious to any observer working in the field starting in 2008.

Donna Cusano Editor, North America Telecare Aware