Standard process flow

Based on the mock consultations, the team developed a standard work process flow diagram (Figure 26.1).

The diagram illustrates the roles of staff at KGH and at the SHWC. Project developers revised the flow diagram several times to add details and reflect ongoing process efficiency enhancements. Process and role refinements were made in various areas, including confirming referral orders and preauthorization, scheduling visits, registering patients, and assembling patient’s medical information and histories. All patients were asked to have a family member, friend or caregiver participate in both the assessment visit and follow-up visit. A Medical Office Assistant (MOA) was assigned to room patients and their caregivers; the MOA was not required to be in the examination room at all times during the visit, but could be called in as needed. The team later developed promotional materials and user forms to support the process.

The billing processes were clarified, with KGH billing the facility fee and the SHWC billing the professional fee. Electronic billing systems and paper forms were modified to note the required telemedicine qualifier.

Results

As of this writing, the Geriatric Telemedicine Consultation Service has served 17 patients, ranging from 70 to 95 years of age. The reasons for referral mirrored outpatient assessments in Oregon, including changes in physical functions, changes in mental functioning, and exacerbation of problem behaviors. Geriatrician assessments were also similar (such as diagnoses, medication interventions, behavioral interventions, caregiver recommendations, and social service referrals).

The geriatrician experience

The geriatrician reported that, using telemedicine, he was able to complete all of the assessments he would normally complete in an office visit (including mobility and mental status examinations). The camera could be moved into the hallway to observe gait, and the resolution was sufficient to allow him to observe the clock-drawing test. As with conventional outpatient assessments, the assessment process primarily entailed review of medical records, observing patients and interviewing patients, family members and caregivers. The geriatrician believed that the telemedicine interview process was as effective as an in-office interview; he believed having a side-by-side view of the patient with the electronic medical record is critical for optimizing visit efficiency and thoroughness.

Patients and caregivers experience

Patients or their accompanying caregivers were asked to complete a brief survey following the visit. They were very positive about their telemedicine experience and were more than willing to do it again, if necessary. Patients became comfortable with the telemedicine process after a few minutes of interaction with the distant telemedicine coordinator in Oregon and prior to the geriatrician entering the interview. One patient commented that the process did not seem unusual because, “I talk back to my television all the time.” Several patients commented that they were pleased to have access to geriatric specialty care without being required to leave their community.

Referral sources

Feedback from the caregiver teams at both the KGH SNF and the ALF was very positive. The geriatric assessments facilitated discharge planning at the SNF and helped staff manage behavior at the ALF. Direct interaction between the geriatrician and these local care teams was found to be most valuable.

Financial results

Professional fee and facility fee reimbursement has mirrored payments received for office visit assessments. However, these are now split between the originating and distant sites. The originating site does not benefit from the professional fee and the distant site does not benefit from the facility fee. The distant site does incur costs beyond that of the geriatrician (for example, the coordinator’s time, which is not covered directly by a facility fee). Telemedicine assessments continue to be more time consuming for the geriatrician than office visit assessments. More time is spent gathering and reviewing medical records. There are opportunities to further refine the process, saving time and cost. The originating site facility fee does not entirely cover the cost. The likely cost benefits for the originating site’s skilled care unit have not yet been quantified. Geriatric assessments have contributed to more effective care plans, reduced medications and, in some cases, progress towards discharge.

Lessons learned

• Partnerships with referring communities should begin with confirmation that caregivers and the local medical community strongly believe in the need for geriatric specialty care. Local health care leadership needs to explicitly support the service. Most importantly, a local physician should serve as the “champion” of the service; in this case, the KGH medical director was invaluable in facilitating implementation.
  
• If the referring organization does not have other existing telemedicine services, they should be given clear, written technology requirements, including the American Telemedicine Association’s program standards.
  
• Geriatric provider organizations should develop internal partnerships to advance telemedicine services across clinical service lines. The infrastructure for geriatric telemedicine cannot be developed and sustained independently of other programs (see replication discussion below).
  
• A telemedicine visit should not be considered “special.” In most respects, a telemedicine visit is the same as any other office visit. By de-mystifying the telemedicine service, program developers will increase patient and clinician comfort, as well as clinical effectiveness.
  
• Work process flow, including specific roles and responsibilities, should be explicitly agreed upon and clearly mapped.
  
• The devil is in the details. Every aspect of the standard visit (for example, registration, medical records, and billing) should be reviewed and adjusted if necessary to accommodate care provision via telemedicine.
  
• Consider the telemedicine experience from the patient’s point of view. The nuances inherent in telemedicine interactions should be acknowledged and addressed. For example, patients and caregivers require a brief orientation to the process before the consultation begins, and should be informed about who is in the room at the provider (distance) location. Clinicians should practice providing telemedicine care to ensure that they are comfortable working with the technology and that they know how their actions will be viewed by patients. For example, clinicians should make regular eye contact with the camera and reduce the viewing angle between the camera and monitor; otherwise, the provider appears to be looking down at the patient’s lap.
  
• The technology infrastructure should be reliable, fast, and clear, while the end-user technology should be simple to operate. Ideally, telemedicine should be supported with high-speed fiber-optic connectivity. It is vital to avoid network disruptions, slow response times, and poor audio-visual quality. Although maintaining network quality can be complicated and available IT expertise is essential, using the technology (such as accessing the network and operating the camera) should be straightforward and intuitive.
  
• Clinicians can conduct comprehensive geriatric assessments using telemedicine. Geriatric assessments largely do not require clinicians to touch patients. Although peripheral telemedicine devices can allow providers to do physical examinations (such as listening to chest and lung sounds), these devices are costly and generally are not necessary.
  
• Elderly patients acclimate to telemedicine relatively quickly. Moreover, providers and staff also quickly become accustomed to telemedicine interactions. The experience is not that different from other types of telecommunications we use in our daily lives.
  
• The ultimate value of geriatric consultations is based on the degree to which the clinician’s findings and recommendations can be shared with the care team and integrated into the care plan. To the extent possible, telemedicine geriatric consultations should be incorporated into the local care planning process and the geriatricians should be considered part of the local care team. For example, the Geriatric Telemedicine Consultation Service strived to include a representative of the care team in each visit, especially during the second visit when recommendations are shared. The physical setting of the local telemedicine visit (originating site) should allow for participation of family members and the patient’s local care team.
  
• Although telemedicine can improve access to geriatric services and extend the reach of geriatric providers, it does not necessarily enhance the capacity of geriatric providers. There continues to be a serious national shortage of geriatricians and telemedicine services can only be developed where there is capacity. Most health care systems will be challenged to stretch a limited number of geriatric providers across the continuum of care.

Policy implications

Geriatric telemedicine will be encouraged or limited to the degree that CMS polices allow for reimbursement. Medicare currently only pays for telemedicine services provided to patients who reside in either a HPSA or a federally designated MSA. HPSA designation is based on the ratio of primary care providers to residents in a given area. However, this is frequently not the most relevant access issue, as telemedicine is often most applicable to medical specialties with little or no presence in a community. Furthermore, the CMS policy requiring HPSA or MSA designation for telemedicine reimbursement erroneously implies that access to medical services is primarily a rural issue. There are significant needs and opportunities to employ telemedicine in urban areas as well (for example, hospitals and SNFs could benefit from geriatricians regularly rounding on patients via telemedicine). CMS policy implies that telemedicine is inherently inferior to traditional face-to-face visits. Although there are some limitations to the services that can be provided during a telemedicine visit, there is no evidence that the care is substandard. On the contrary, patients and providers report that telemedicine visits are beneficial and appreciated, especially given the vastly greater convenience for patients who would otherwise be required to travel to receive specialty care.

It is encouraging that CMS is broadening coverage for telemedicine, albeit incrementally. In 2008, CMS expanded the list of services that could be provided via telemedicine and allowed reimbursement for telemedicine services provided in nursing facilities. There could be significant patient benefit in telemedicine home visits, especially when accompanied by telemedicine home monitoring.

In March of 2011, CMS is expected to issue new regulations allowing originating site organizations to accept the credentialing, privileging, and peer review processes of providers at the distant site. This would address one of the most significant barriers to broadening access to telemedicine services.

Recent increases in funding for health care technology adoption is very encouraging. The 2009 economic stimulus package passed by Congress provides substantial funding for the further development of health information networks that will provide the backbone for telemedicine services. It also includes funding for telemedicine demonstration projects. These resources will facilitate the adoption of telemedicine and improve access to specialty care for patients with a broad array of care needs.

References

American Telemedicine Association. Telemedicine Defined. American Telemedicine Association, Washington, DC. Available at: http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3333

American Telemedicine Association. (2008) Telemedicine Standards and Guidelines. American Telemedicine Association, Washington, DC. Available at: http://www.americantelemed.org/i4a/pages/index.cfm?pageID=3311.

Brignell, M., Wooton, R., & Gray, L. (2007) The application of telemedicine to geriatric medicine. Age and Aging, 36, 369–374.

Jones, B.N., Johnston, D., Reboussin, B., et al. (2001) Reliability of telepsychiatry assessments: subjective versus observational ratings. Journal of Geriatric Psychiatry and Neurology, 14, 66–71.

Stock, R., Reece, D., & Cesario, L. (2004) Developing a comprehensive interdisciplinary senior healthcare practice. Journal of the American Geriatrics Society, 52, 2128–2133.

Stock, R., Mahoney, E.R., Reece, D., et al. (2008) Developing a senior healthcare practice using the chronic care model: effect on physical function and health-related quality of life. Journal of the American Geriatrics Society, 56, 1342–1348.

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