The transformative virtualization of care delivery
Advances in telehealth technology coupled with EHR infrastructure investment and value-based care incentive programs have created new opportunities for deploying virtual care services. On-demand, low acuity telehealth services are just one of many high-value, telehealth-based, virtual care options for healthcare organizations.
Broadening the telemedicine and telehealth paradigms
Telemedicine has traditionally been used in a provider-to-provider context with limited reimbursement options in the fee-for-service environment. Telehealth expands telemedicine to include direct engagement of the consumer in a virtual care environment. In an era of high-deductible health plans, telehealth also provides a low-cost alternative to urgent care and emergency department visits for clearly defined low-acuity conditions. Low-acuity telehealth services provided by a third party are a low risk, virtual care entry point for healthcare organizations with a plan to offer consumerized healthcare products and services.
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Expanded use of EHRs coupled with integrated telehealth services elevates telehealth from an external third-party service that addresses a limited range of low-acuity patient encounters to full service virtual care that is a seamless part of workflow for primary and specialty care, as well as the revenue cycle. Health systems can also position fully integrated telehealth services as a patient engagement, market and loyalty differentiator. Requiring patient portal enrollment and registration for use of health system telehealth services, including on-demand and scheduled visits, will drive patient portal utilization.
Real-time claims and clinical data analytics coupled with virtual care services enables health systems and plans to close gaps in care and ensure continuity of care at an affordable cost. Timely gap closure can help healthcare organizations avoid negative CMS audits resulting in lowered star ratings, especially for health plans with sizeable Medicare Advantage insured lives.
We predict virtualists will emerge alongside the hospitalist and intensivist
Oakland, Calif.-based Kaiser Permanente has reported 13 million virtual visits in 2015 and forecasts 16 million virtual visits by 2018, including visits conducted using voice, video, secure email and secure text. By 2018, Kaiser forecasts that provider virtual visits with patients will exceed provider 'bricks and mortar' encounters. What are the key elements of a successful, integrated telehealth solution to deliver virtual care?
Telehealth services must be incorporated in every provider toolset at every level of care, including the need to:
- Fully integrate EHR workflow including scheduling, best practices, documentation and patient portal registration/utilization
- Integrate analytics to identify optimal telehealth treatment scenarios and options
- Identify value-based care metrics that are addressable with telehealth services
- Focus on the scalable telehealth services that deliver value and achieve target outcomes
- Enable timely care communication among and between acute and ambulatory providers as well as intermediate care providers including skilled nursing facilities, long-term acute care, rehab and in-home providers
Just as the provider designations and certifications for hospitalists and intensivists were created to meet a renewed focus on improving quality and patient outcomes in the fee-for-service reimbursement environment, we predict the designation and eventual certification of providers as Virtualists will emerge to support cost effective virtual care delivery, improve patient outcomes and meet value-based care performance targets.
Next-generation medicine via telehealth 2.0
The next generation for telehealth — Telehealth 2.0 — will be integrated with EHR and analytics infrastructure, act as a core driver of value-based care and facilitate higher levels of patient engagement around target outcomes. Telehealth 2.0 will drive cost savings, enable balanced utilization of provider time and skills for in-person patient encounters, as well as virtual encounters, and drive quality results that meet or exceed value-based care program targets. Telehealth 2.0 will be focused in seven areas of virtual care:
1. Informed on-demand and scheduled patient history for virtual care: EHR and analytics infrastructure will give providers on-demand patient history, including information for patients with chronic conditions who may see multiple providers, have labs ordered by multiple providers and/or have prescriptions ordered by multiple providers and filled by different pharmacies.
2. Timely, coordinated transitions in care: Integrated virtual care will give providers more options for confirming referrals, orders and appointments for specialist visits — including mandated behavioral care — after primary care encounters. It will simplify communication for verifying receipt of notifications at time of discharge, confirming 48-hour follow up visits to check recovery, verify medication adherence progress and provide reminders to drive compliance with scheduled follow-up primary care or specialist visits within 15 days after discharge.
3. Identify and close gaps in care: EHR and analytics infrastructure coupled with telehealth services gives providers more tools for identifying gaps in care. With these tools, providers can close gaps in a timely manner through virtual care encounters that can surface the need for medication adjustments, periodic labs associated with chronic conditions or overdue specialist visits.
4. Plan and coordinate personalized chronic care: Telehealth makes personalized chronic care planning manageable and affordable. Integrating remote device patient telemetry for patients with chronic conditions into EHR and analytics infrastructure enables real-time monitoring with alerts personalized to each patient's diagnosis and treatment plan. However, the system is designed to avoid "alert fatigue" among clinicians.
5. Coordinate and monitor discharges to skilled nursing facilities, long-term acute care, rehab and in-home care: For patients who are discharged to SNFs, LTACs, rehab facilities or with in-home care orders, telehealth enables timely two-way video communication between the discharging acute care providers and the attending providers at the intermediate facilities or with those providing in-home care. Virtual video visits at intermediate facilities or with in-home providers combined with vital signs and other patient data enables timely medication adjustments, changes in wound care and other treatment that can drive down avoidable readmission rates.
6. Telehealth as a reliable source of disease burden documentation and risk adjustment: Documenting disease burden and related risk adjustment are key components of value-based care programs that involve risk sharing. Telehealth services can be configured to capture the data required by various value-based care incentive programs, specifically the data required for the Hierarchical Condition Categories, to document the case for risk adjustment. Documenting disease burden is relevant for healthcare organizations participating in QHP/ACA, Medicaid and Medicare Advantage Plans.
Risk adjustment involves accurately capturing all aspects of a patient's conditions so the difficulty of managing and treating a specific population segment can be appropriately measured and valued under value-based care performance programs. Virtual care through telehealth lowers the barriers for providers to establish multiple patient contact points enabling providers to readily pick up and capture disease burden data. Using telehealth-enabled virtual visits to document patient disease burden and establish risk adjustment parameters enables health plans to optimize Medicare and Medicaid payments to health systems.
7. Internet of telehealth things and in-home presence services: Capturing actionable, relevant data from the growing array of consumer and medical grade devices and services — the 'Internet of Telehealth Things' — and coordinating with in-home presence offerings are two challenges where integrated telehealth services can give healthcare organizations more options for monitoring and delivering affordable care in the patient home.
Data from mobile devices, applications and wearables can provide useful diagnosis and treatment insight when combined with an accurate medical history and presented in providers' EHR-based workflow. Home-based activity sensors can be used to establish normal and abnormal patient activity patterns and issue relevant alerts to family members and/or home health providers.
Voice activated 'smart' assistants like Amazon's Echo and similar applications/devices from Apple and Google are configurable today to provide patients with generic answers to common health questions. Voice activated smart assistants in the future will be secure and configurable to specific patient conditions and care plans creating a new opportunity to extend personalized care to the patient home.
In addition to the various wearables, organizations like Pager.com, Matrix Medical and Heal.com offer on-demand and scheduled in-home licensed provider exam and treatment services that can be an affordable, timely and convenient alternative where a virtual visit with an in-network provider is not optimal for the patient's mobility limitations, location, condition or preferences. Organizations like Iggbo can dispatch licensed personnel to obtain specimens for labs at patient homes or places of work.
Virtual value-based care outlook
The key tactical elements of a successful virtual value-based care service for healthcare organizations will be:
- ü Health systems and health plans move beyond telehealth as a limited, third-party low-acuity service to offering virtual care services for primary and specialty care with full revenue cycle integration
- ü Healthcare systems leverage existing EHR and analytics infrastructure investments to support targeted telehealth solutions and services matched to incentive program performance targets
- ü Health systems and plans tie utilization of integrated telehealth solutions to specific quality and incentive program metrics
- ü Healthcare systems and plans focus telehealth solutions and virtual care services on transitions-in-care, closing gaps-in-care and delivering affordable chronic care planning and management
- ü Healthcare systems and plans use virtual care encounters to deliver the detailed disease burden and risk adjustment documentation required by CMS
Virtual care delivery should be a transformative strategic initiative for all healthcare organizations.
Successfully empowering virtual care delivery for healthcare consumers, patients and providers requires deep knowledge of telehealth technology and the healthcare industry. Integrating virtual care with next-generation incentive programs and electronic health system workflows will be a key requirement for telehealth success.
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