Memorial telemedicine 2015

Telemedicine-2015
Memorial Healthcare
By Garry A. Moore
5-22-2015
1

Table of Contents
 Overview of Analysis
 What is Telemedicine
 Types of Telemedicine Specialty Consultation Services
 Methods of Delivery
 What are the Challenges if Telemedicine
 Reimbursement
 Hospital Assessment
 Case Studies
 Costs
 Vendors
 Misc.
 Telemedicine Organizations
2

Overview of Analysis
This project has been put together so that Memorial Healthcare can be made more aware of the facts behind
Telemedicine, what it is, the components of Telemedicine and more.
The information was derived from various research projects throughout the US, as well as numerous discussions with
existing Telemedicine users and technology vendors that support these services . These discussions consisted of
interviews as well as written information to support the information provided.
As you will read through the information , you will find that there are various formats of use in Telemedicine and how it
is used. The typical 3 formats are:
1. Individual Hospital use - having hospital have technology provided to conduct remote consults with Specialists from
other hospitals that may be within the State or could be utilized with other specialists in other states or medical facilities
such as Yale, Massachusetts General or others.
2. University reach out Programs – These would be University Medical Centers that would extend their already
developed Telemedicine programs to rural or other hospitals for a fee. Some resistance with going with these
programs have been identified as a way of retaining patients from the rural areas they serve and as a media hype of
showing how the University programs are helping patients in each rural area they serve.
3. Large Hospitals that have rural location hospitals under its ownership that provides a Hub and Spoke Model which
will be described in this report.
3

What is Telemedicine?
Formally defined, telemedicine is the use of medical information exchanged from one site to another via electronic
communications to improve a patient’s clinical health status. Telemedicine includes a growing variety of applications
and services using two-way video, email, smart phones, wireless tools and other forms of telecommunications
technology.
Starting out over forty years ago with demonstrations of hospitals extending care to patients in remote areas, the use of
telemedicine has spread rapidly and is now becoming integrated into the ongoing operations of hospitals, specialty
departments, home health agencies, private physician offices as well as consumer’s homes and workplaces.
Telemedicine is not a separate medical specialty. Products and services related to telemedicine are often part of a
larger investment by health care institutions in either information technology or the delivery of clinical care. Even in the
reimbursement fee structure, there is usually no distinction made between services provided on site and those provided
through telemedicine and often no separate coding required for billing of remote services. ATA has historically
considered telemedicine and telehealth to be interchangeable terms, encompassing a wide definition of remote
healthcare. Patient consultations via video conferencing, transmission of still images, e-health including patient portals,
remote monitoring of vital signs, continuing medical education, consumer-focused wireless applications and nursing call
centers, among other applications, are all considered part of telemedicine and telehealth.
While the term telehealth is sometimes used to refer to a broader definition of remote healthcare that does not always
involve clinical services, ATA uses the terms in the same way one would refer to medicine or health in the common
vernacular. Telemedicine is closely allied with the term health information technology (HIT). However, HIT more
commonly refers to electronic medical records and related information systems while telemedicine refers to the actual
delivery of remote clinical services using technology.
4

What Delivery Mechanisms Can Be Used?
Networked programs link tertiary care hospitals and clinics with outlying clinics and community health centers in rural or
suburban areas. The links may use dedicated high-speed lines or the Internet for telecommunication links between
sites. ATA estimates the number of existing telemedicine networks in the United States at roughly 200 providing
connectivity to over 3,000 sites.
Point-to-point connections using private high speed networks are used by hospitals and clinics that deliver services
directly or outsource specialty services to independent medical service providers. Such outsourced services include
radiology, stroke assessment, mental health and intensive care services.
Monitoring center links are used for cardiac, pulmonary or fetal monitoring, home care and related services that provide
care to patients in the home. Often normal land-line or wireless connections are used to communicate directly between
the patient and the center although some systems use the Internet.
Web-based e-health patient service sites provide direct consumer outreach and services over the Internet. Under
telemedicine, these include those sites that provide direct patient care.
5

What Services Can Be Provided By Telemedicine?
Sometimes telemedicine is best understood in terms of the services provided and the mechanisms used to provide
those services. Here are some examples:
Primary care and specialist referral services may involve a primary care or allied health professional providing a
consultation with a patient or a specialist assisting the primary care physician in rendering a diagnosis. This may involve
the use of live interactive video or the use of store and forward transmission of diagnostic images, vital signs and/or
video clips along with patient data for later review.
Remote patient monitoring, including home telehealth, uses devices to remotely collect and send data to a home health
agency or a remote diagnostic testing facility (RDTF) for interpretation. Such applications might include a specific vital
sign, such as blood glucose or heart ECG or a variety of indicators for homebound patients. Such services can be used
to supplement the use of visiting nurses.
Consumer medical and health information includes the use of the Internet and wireless devices for consumers to obtain
specialized health information and on-line discussion groups to provide peer-to-peer support.
Medical education provides continuing medical education credits for health professionals and special medical education
seminars for targeted groups in remote locations.
6

What Delivery Mechanisms Can Be Used?
Networked programs link tertiary care hospitals and clinics with outlying clinics and community health centers in rural or
suburban areas. The links may use dedicated high-speed lines or the Internet for telecommunication links between
sites. ATA estimates the number of existing telemedicine networks in the United States at roughly 200 providing
connectivity to over 3,000 sites.
Point-to-point connections using private high speed networks are used by hospitals and clinics that deliver services
directly or outsource specialty services to independent medical service providers. Such outsourced services include
radiology, stroke assessment, mental health and intensive care services.
Monitoring center links are used for cardiac, pulmonary or fetal monitoring, home care and related services that provide
care to patients in the home. Often normal land-line or wireless connections are used to communicate directly between
the patient and the center although some systems use the Internet.
Web-based e-health patient service sites provide direct consumer outreach and services over the Internet. Under
telemedicine, these include those sites that provide direct patient care.
7

What Are the Benefits of Telemedicine?
Telemedicine has been growing rapidly because it offers four fundamental benefits:
Improved Access – For over 40 years, telemedicine has been used to bring healthcare services to patients in distant
locations. Not only does telemedicine improve access to patients but it also allows physicians and health facilities to
expand their reach, beyond their own offices. Given the provider shortages throughout the world--in both rural and
urban areas--telemedicine has a unique capacity to increase service to millions of new patients.
Cost Efficiencies – Reducing or containing the cost of healthcare is one of the most important reasons for funding and
adopting telehealth technologies. Telemedicine has been shown to reduce the cost of healthcare and increase
efficiency through better management of chronic diseases, shared health professional staffing, reduced travel times,
and fewer or shorter hospital stays.
Improved Quality – Studies have consistently shown that the quality of healthcare services delivered via telemedicine
are as good those given in traditional in-person consultations. In some specialties, particularly in mental health and ICU
care, telemedicine delivers a superior product, with greater outcomes and patient satisfaction.
Patient Demand – Consumers want telemedicine. The greatest impact of telemedicine is on the patient, their family and
their community. Using telemedicine technologies reduces travel time and related stresses for the patient. Over the past
15 years study after study has documented patient satisfaction and support for telemedical services. Such services
offer patients the access to providers that might not be available otherwise, as well as medical services without the
need to travel long distances.
8

Types of Telemedicine Specialty
Consultation Services
A telemedicine specialty consultation service is one that provides care to patients or advice to other medical providers
in a particular medical subspecialty or healthcare specialization where the recipient of that service is located at a
different geographic location from that of the provider. Typically, such services originate from health care systems,
hospitals or large medical group practices that employ a diverse collection of expert and highly experienced medical
and healthcare specialists. The specialists communicate with patients and/or providers at physically separate locations
using a variety of communications and information technologies and tools to exchange medical information. These
technologies may range from complex live, interactive videoconferencing with associated examination devices to simple
image capture and transmission for storage and review. The specialist examines the patient, may or may not order
additional diagnostic tests, may or may not provide direct treatment, but generally creates a consultation report for the
referring physician. The specialist is typically reimbursed the same amount as if he or she had seen the patient in his or
her own office.
What is a live, interactive video consultation?
A live, interactive videoconference consultation is one in which the specialist and the patient are present at the same
time, but not in the same location. The specialist is often located either in a special telemedicine facility or in his or her
office. The patient is at a different location, such as a clinic, nursing home or hospital, and may be accompanied by a
telemedicine presenter, who is a staff member at that location. Communication is facilitated typically by using secure
digital videoconferencing where the specialist’s image is captured by a video camera, digitized and transmitted over
secure, broadband speed telecommunications lines to where the patient is located and where it appears on a video
screen to be viewed by the patient. At the same time, the patient’s image is captured by a similar process and
transmitted to a video screen for viewing by the specialist. The conversation between the patient and the specialist is
captured and transmitted in the same way. The transmission speeds are sufficiently fast that the specialist and the
patient can conduct conversations as if they were in the same room and hence the use of the descriptor “live,
interactive” for these types of consultations.
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What is a store-and-forward consultation?
A store-and-forward consultation is one in which information is captured from the patient at one time and location and
evaluated by a specialist at another time and location. It derives its name from the fact that information is captured and
“stored” in a digital file at one location and then transmitted or “forwarded” to another location for evaluation.
Dermatology provides a good example of this type of consultation. In a dermatology store-and-forward consultation, a
provider at a remote site typically takes digital pictures of the patient’s skin lesion with a digital camera and then
uploads those images to a secure server along with other clinical information about the patient. At a later time, the
dermatologist signs into that server, views the images and reviews the clinical information and writes a set of
recommendations that are stored on the server. The referring physician or the original provider at his or her
convenience can then sign into the server, review the recommendations and inform the patient of the results and any
recommended treatments. Teleradiology is the most widely recognized and used type of store-and-forward
consultation. As the longest-standing application of this type and to date the only one that is fully reimbursable, it has
evolved into its own area of application and does not fall within the scope of this module.
What is a hybrid consultation?
Hybrid consultations are those that use components of both live, interactive and store-and-forward consultations.
Typically, these are used in specialties such as dermatology or cardiology where higher quality images than those
provided by standard video are important diagnostic tools and direct patient interaction is necessary. In pediatric
cardiology, the specialist would use videoconferencing to observe the patient and to talk with the parents while viewing
an echocardiogram that had been obtained by the technician just prior to the videoconference. A hybrid consultation
has the advantage of making better use of all technologies that are available to diagnose and care for the patient and is
not limited to a single communications channel.
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What are the different kinds of specialty consultation services that are being offered today?
The following is a list of specialties and services that are often offered through telemedicine.
Specialty/Subspecialty
Allergy/Immunology
Anesthesia
Cardiology
Critical Care
Dentistry
Dermatology
Otolaryngology (ENT)
Emergency Medicine
Endocrinology
Family/General Practice
Gastroenterology
Infectious Diseases
Internal Medicine
Maternal/Fetal Medicine
Mental/Behavioral Health
Neurology
Oncology/Hematology
Ophthalmology/Optometry
Orthopedics
Pathology
Pediatrics 11

Cont’
Psychiatry
Pulmonology
Rehabilitative Medicine
Rheumatology
Surgery
Urology
12

Services
Case Management
Correctional telehealth
Deaf/hearing services
Diabetic retinopathy screening
Dietician services
Disease management
Doctor-to-doctor consultation
Enterostomal therapy
Forensic/court services
Genetic counseling
Long-term Care
Medication therapy management (MTM)
Neonatal/Pediatric intensive care unit (NICU/PICU)
Pain management
Palliative care
Pre/post-natal care
Speech therapy
Spine therapy
Telestroke
Wound care
13

Services Cont’
Adult, Individual and Group, Marital, Family and Sex Therapy
Behavioral psychology and health (including mood, eating disorders)
Chemical dependency aftercare (Addiction therapy follow-up)
Chemical dependency therapy (Addiction therapy)
Consultation to Schools
Couples’ counseling
Developmental (lifespan) counseling
Psychiatric medication therapy management
Psychological Assessment
Psychological testing and interpretation
Psychopharmacology
Stress and health management
14

Methods of Delivery
Point-to-point connections using private networks are used by hospitals and clinics that transport services directly or out
sourced specialty services to self-governing medical service providers at ambulatory care areas. Radiology, mental
health and even intensive care services are being provided under contract using telemedicine to deliver the services.
Web-based e-health patient service sites offer direct consumer outreach and services over the Internet. These include
those areas that offer direct patient care, under telemedicine.
Networked programs connect tertiary care hospitals and clinics with remote clinics and community health centers in
rural or suburban areas. The connections may use high-speed lines or the Internet for telecommunication links between
sites. It is determined that there are about 200 telemedicine networks in the United States involving close to 3,500
medical and healthcare institutions throughout the country, according to the studies conducted by many agencies within
the federal government.
Connections to monitoring center from home are used for pacemaker, cardiac, pulmonary or fetal monitoring, home
care and related services that provide care to patients in the home. Typically, general phone lines are used to
communicate directly between the patient and the center although some systems use the Internet. It is estimated that
over 200,000 patients use such services, only in the United States.
Primary or specialty care to the home connections involves connecting primary care providers, specialists and home
health nurses with patients over single line phone-video systems for interactive clinical consultations.
15

What are the challenges of
Telemedicine?
Legal issues about physician licensing, liability, and patient confidentiality exist. As physicians are licensed by states,
this presents a legal problem when physician consults cross state lines. It is necessary in order to fully benefit from
telemedicine that states engage in interstate provision of service.
Liability is an obstacle in providing telemedicine.
Cost is an important obstacle to access. It has been predicted that the startup cost for a rural facility can be $100,000.
Besides start up costs, deliberation must be given to the charge by the consultation team. This may range from $75-
250 per hour, depending on the type and number of consultants involved.
Reimbursement is another barrier in supplying telemedicine services.
16

Reimbursement
For purposes of Medicaid, telemedicine seeks to improve a patient's health by permitting two-way, real time interactive
communication between the patient, and the physician or practitioner at the distant site. This electronic communication
means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.
Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care
(e.g., face-to-face consultations or examinations between provider and patient) that states can choose to cover under
Medicaid. This definition is modeled on Medicare's definition of telehealth services (42 CFR 410.78). Note that the
federal Medicaid statute does not recognize telemedicine as a distinct service.
Telemedicine Terms
Distant or Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time
the service is provided via telecommunications system.
Originating or Spoke site: Location of the Medicaid patient at the time the service being furnished via a
telecommunications system occurs. Telepresenters may be needed to facilitate the delivery of this service.
Asynchronous or "Store and Forward": Transfer of data from one site to another through the use of a camera or similar
device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation.
Asynchronous or "store and forward" applications would not be considered telemedicine but may be utilized to deliver
services.
Medical Codes: States may select from a variety of HCPCS codes (T1014 and Q3014), CPT codes and modifiers (GT,
U1-UD) in order to identify, track and reimburse for telemedicine services.
Telehealth (or Telemonitoring) is the use of telecommunications and information technology to provide access to health
assessment, diagnosis, intervention, consultation, supervision and information across distance.
Telehealth includes such technologies as telephones, facsimile machines, electronic mail systems, and remote patient
monitoring devices, which are used to collect and transmit patient data for monitoring and interpretation. While they do
not meet the Medicaid definition of telemedicine they are often considered under the broad umbrella of telehealth
services. Even though such technologies are not considered "telemedicine," they may nevertheless be covered and
reimbursed as part of a Medicaid coverable service, such as laboratory service, x-ray service or physician services
(under section 1905(a) of the Social Security Act).
17

Reimbursement
Cont’
Provider and Facility Guidelines
Medicaid guidelines require all providers to practice within the scope of their State Practice Act. Some states have
enacted legislation that requires providers using telemedicine technology across state lines to have a valid state license
in the state where the patient is located. Any such requirements or restrictions placed by the state are binding under
current Medicaid rules.
Reimbursement for Telemedicine
Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal
requirements of efficiency, economy and quality of care. States are encouraged to use the flexibility inherent in federal
law to create innovative payment methodologies for services that incorporate telemedicine technology. For example,
states may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the
originating site. States can also reimburse any additional costs such as technical support, transmission charges, and
equipment. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an
administrative cost by the state. If they are separately billed and reimbursed, the costs must be linked to a covered
Medicaid service.
State Flexibility in Covering/Reimbursing for Telemedicine Services and the Application of General Medicaid
Requirements to Coverage of Telemedicine Services
Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care
(e.g., face-to-face consultations or examinations between provider and patient). As such, states have the
option/flexibility to determine whether (or not) to cover telemedicine; what types of telemedicine to cover; where in the
state it can be covered; how it is provided/covered; what types of telemedicine practitioners/providers may be
covered/reimbursed, as long as such practitioners/providers are "recognized" and qualified according to Medicaid
statute/regulation; and how much to reimburse for telemedicine services, as long as such payments do not exceed
Federal Upper Limits.
18

Reimbursement
Cont’
If the state decides to cover telemedicine, but does not cover certain practitioners/providers of telemedicine or its
telemedicine coverage is limited to certain parts of the state, then the state is responsible for assuring access and
covering face-to-face visits/examinations by these "recognized" practitioners/providers in those parts of the state where
telemedicine is not available.
Therefore, the general Medicaid requirements of comparability, state wideness and freedom of choice do not apply with
regard to telemedicine services.
CMS Approach to Reviewing Telemedicine SPAs
States are not required to submit a (separate) SPA for coverage or reimbursement of telemedicine services, if they
decide to reimburse for telemedicine services the same way/amount that they pay for face-to-face
services/visits/consultations.
States must submit a (separate) reimbursement (attachment 4.19-B) SPA if they want to provide reimbursement for
telemedicine services or components of telemedicine differently than is currently being reimbursed for face-to-face
services.
States may submit a coverage SPA to better describe the telemedicine services they choose to cover, such as which
providers/practitioners are; where it is provided; how it is provided, etc. In this case, and in order to avoid unnecessary
SPA submissions, it is recommended that a brief description of the framework of telemedicine be placed in an
introductory section of the State Plan and then a reference made to telemedicine coverage in the applicable benefit
sections of the State Plan. For example, in the physician section it might say that dermatology services can be
delivered via telemedicine provided all state requirements related to telemedicine as described in the state plan are
otherwise met.
19

Reimbursement
States with Coverage for
Telehealth Services 20

Reimbursement
Snyder signs bills to promote access to telemedicine
Thursday, June 28, 2012
LANSING, Mich. - Gov. Rick Snyder recently signed legislation harnessing technology for the
best delivery of medical information and services.
House Bills 5408 and 5421, sponsored by state Reps. Gail Haines and Matt Lori, require health
insurance providers to recognize claims for health services delivered by telemedicine methods.
Telemedicine uses telecommunications technology such as computer, Internet and telephone to
connect physicians and patients, providing the best available care regardless of physical location.
This allows for easier home maintenance of chronic conditions and promotes access for
underserved populations.
"Telemedicine offers an incredible opportunity to easily provide health care to Michigan's
elderly, disabled and rural communities," Snyder said. "I applaud the Legislature's initiative to
use technology to save lives."
The bills passed with unanimous support in both chambers and earned the support of Blue Cross
Blue Shield of Michigan, the Michigan Association of Health Plans, Priority Health and
numerous other organizations.
The bills now are Public Acts 214 and 215 of 2012.
22

Reimbursement
Michigan 2013
Michigan State Law/Regulations
Definition of telemedicine/telehealth: "Telemedicine means the use of an electronic media to link
patients with health care professionals in different locations. To be considered telemedicine, the health
care professional must be able to examine the patient via a real-time, interactive audio or video, or both,
telecommunications system, and the patient must be able to interact with the off-site health care
professional at the time the services are provided. Source: MI Compiled Law Svcs. Sec. 500.3476 (2012).
Medicaid Program: "Telemedicine (also known as telehealth) is the use of as electronic media to link
beneficiaries with health professionals in different locations. The examination of the beneficiary is
performed via a real time interactive audio and video telecommunications system. This means that the
beneficiary must be able to see and interact with the off-site practitioner at the time services are
provided via telemedicine." Source: MI Dept. of Community Health, Medicaid Provider Manual, p. 397
(Oct. 1, 2012).
Live Video Reimbursement
Michigan law states that "contracts shall not require face-to-face contact between a health care
professional and a patient for services appropriately provided through telemedicine," which includes live
video. Source: MI Compiled Law Services Sec. 500, 3476 (2012).
Michigan Medicaid reimburses for the following services via live video:
Consults
Office visits
Individual psychotherapy
Pharmacologic management 23

Reimbursement
Cont’
End stage renal disease (ESRD) related services. However, there must be at least one in-person visit per
month, by a physician, nurse practitioner, or physician's assistant, to examine the vascular site for ESRD
services.
Where face-to-face visits are required, telemedicine service may be used in addition to the required
face-to-face visit, but cannot be used as a substitute. Source: Dept. of Community Health, Medicaid
Provider Manual, p. 1414 (Oct. 1, 2012).
The following health professionals may provide telemedicine services:
Physician
Osteopath
Podiatrist
Nurse practitioner
Nurse midwife
Physician's assistant, (billed under the supervising physician)
Psychologist
Social worker
Source: Dept. of Community Health, Medicaid Provider Manual, p. 1415 (Oct. 1, 2012).
Store and Forward Reimbursement
No reimbursement based upon definition of "telemedicine" which describes telemedicine as occurring in
"real time." Source: MI Compiled Law Svcs. Sec. 500. 3476 (2012).
Michigan Medicaid does not reimburse for store and forward based upon the definition of telemedicine
which describes telemedicine as occurring in "real time." Source: Dept. of Community Health, Medicaid
24

Reimbursement
Cont’
Provider Manual, p. 397 (Oct. 1, 2012).
Location
The distant site and originating site must be at least 50 miles apart, except for Federal telemedicine
demonstration projects funded or approved by the Secretary of Human Services as of Dec. 31, 2000.
Source: MI Dept. of Community Health, P. 1415.
Eligible originating sites:
County mental health clinics or publicly funded mental health facilities
Federally Qualified Health Centers
Hospitals (inpatient, outpatient, or Critical Access Hospitals)
Physician or other providers' offices, including medical clinics
Renal dialysis facilities
Rural Health Clinics
Skilled nursing facilities
Tribal Health Centers
Source: MI Dept. of Community Health, P. 1415.
In-state providers are to be used whenever possible for distant site services. Source: MI Dept. of
Community Health, p. 1415.
25

Reimbursement
Cont’
Private Payers
Contracts shall not require face-to-face contact between a health care professional and a patient for
services appropriately provided through telemedicine, as determined by the insurer or health
maintenance organization. Telemedicine services shall be provided by a health care professional who is
licensed, registered, or otherwise authorized to engage in his or her health care profession in the state
where the patient is located. Telemedicine services are subject to all terms and conditions of the
contract. Source: MI Compiled Law Services Sec. 500.3476 (2012).
Miscellaneous
1. List of codes in Appendix A (copy all codes)
2. Telemedicine Reimbursement in Appendix B
3. Medicaid Coverage in Appendix C
26

Reimbursement
MISC. information
*Blue Cross/Blue Shield of Michigan (BCBSM) announced, in the August 2003 RECORD publication, that telehealth is
now a payable service for the state of Michigan. Please refer to the RECORD publication for the billing guidelines or
contact me and I will fax a copy to you. BCBSM will be paying practitioners and facility fees for telehealth services.
*Upper Peninsula Health Plan (UPHP) a Medicaid Managed Care provider now covers clinical telemedicine. This
announcement and billing guidelines are available in the August 2004 PROVIDER NOTES, Volume 7, Issue 3. UPHP is
reimbursing practitioners and originating site fees for telemedicine services as of July 1, 2004.
*United Healthcare announced they would be reimbursing for telemedicine services following Medicare’s guidelines for
patients in the Upper Peninsula.
*Preferred Provider of Michigan (PPOM) also announced they will be following Medicare’s guidelines for telemedicine
reimbursement for patients in the Upper Peninsula.
27

Hospital Assessment
Telemedicine and telehealth have the potential to increase access to care, improve quality of care and decrease costs.
For instance, the American Telemedicine Association proposed legislation that would expand telemedicine and save an
estimated $186 million over the next 10 years. In addition, the U.S. Department of Agriculture has devoted significant
resources to the development of telemedicine, including recent grants totaling more than $30 million for telemedicine
projects throughout the country. Here, several experienced hospital professionals share 10 best practices to build a
successful hospital telemedicine program.
1. Conduct a market assessment. "The first step is to do an honest assessment of your capabilities and the needs [of]
communities," says Tim Smith, MD, vice president of research for the Center for Innovative Care at St. Louis-based
Mercy. Mercy started its telemedicine process with a community needs analysis. The executive leadership engaged the
community at different events to find what healthcare services the community needed, according to Dr. Smith.
In addition to direct communication, hospitals can analyze data to assess the needs of the community. "Patient
outcomes data can also be very helpful in determining what services to develop and which communities have a high
need for a particular service," says Doug Lawrence, telemedicine program manager at Indianapolis-based Indiana
University Health. "As an example, if a particular county in a state has poor patient outcomes for stroke and no local
stroke-trained physician, developing a telestroke service to provide virtual stroke care to that county is an obvious
solution."
2. Conduct a self-assessment. Hospitals need to evaluate their capabilities for providing the service lacking in the
community as identified in the market assessment. "You need to be able to speak to your strengths within the service
[and] match that with the needs of the community," says Aaron Bair, MD, medical director for the Center for Health and
Technology at Sacramento-based UC Davis Health System. "It doesn't make sense to start down the path where the
market is already saturated or you do not have specialists available. If want to do pediatric neurology, you better have a
certain number of pediatric neurologists interested in providing telemedicine." 28

Hospital Assessment
Hospitals should decide how to focus their telemedicine programs "based on an analysis of their own market, the
anticipated return on investment, whether there are strong clinical champions and the goals for the organization," says
Karen Rheuban, MD, medical director of the Office of Telemedicine and director of the Center for Telehealth at
Charlottesville-based University of Virginia Health System. She says hospitals should also consider new regulations
that may affect service delivery, such as penalties for readmissions.
Furthermore, decisions on telemedicine should be made by a multidisciplinary group of stakeholders. "It is helpful to
perform a readiness assessment to determine starting points at each facility," Mr. Lawrence says. "Risk management,
legal, IT, telecommunications carriers (in some instances) and clinical leadership should all be involved."
3. Align goals with the organization's mission. "Align the goals of your telehealth program with the mission of your
organization," says Shelley Palumbo, chief administrative officer of the Center for Health and Technology at UC Davis
Health System. This alignment will help hospital leaders develop a telemedicine program that is strategically valuable
for the organization by working towards the hospital's overall goals.
"Consider and define the purpose for developing services," Mr. Lawrence says. "Is the purpose to better manage a
disease state or health population within the hospital or health system, improve public health at the statewide level,
[serve] as a patient satisfier reducing travel time and costs?" Defining the purpose can guide hospitals toward strategies
to meet their goals.
29

Hospital Assessment
Cont’
4. Develop a timeline for implementation. Hospitals should organize implementation of a telemedicine system by
creating a timeline for key stages of the project. Many factors affect the timeline, including the size of the hospital and
the goals of the telemedicine program. "Ample time should be allowed for a market/needs assessment, ordering and
installation of equipment, testing and troubleshooting of the equipment, training of clinical and administrative staff,
conducting practice sessions with the partnering site(s) and account[ing] for any other issues that might arise during the
implementation process," says Ms. Palumbo, whose center at UC Davis provides telehealth training and education. Mr.
Lawrence suggests hospitals also consider time needed for credentialing, which he says say can take up to 120 days.
Less tangible factors such as support of the program by hospital leadership and buy-in from physicians should also be
accounted for. "Any time you do something innovative, your timeline is going to be dictated by the level of support you
have from the highest level of leadership," says Dr. Smith. "It's amazing how quickly and efficiently you can get things
done when you have the support of your organization's executive leadership and when they make this a priority. You
can cut months, even years off of development."
Physician leadership is also key to a streamlined implementation process. "A realistic timeline for development and
deployment must be linked to provider engagement, development of institutional champions, a careful analysis of the
ROI and the infrastructure needed for the program," Dr. Rheuban says.
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5. Gain administrative support. Executive leadership is important not only for a tighter timeline for telemedicine, but
also for accessing needed resources, gaining buy-in from physicians and encouraging patients to use the technology.
"One of the advantages Mercy brings is strong executive leadership who made this a priority," Dr. Smith says. Mercy's
creation of the Center for Innovative Care, which is dedicated to driving innovative projects, also helps programs like
telemedicine succeed.
6. Identify clinician champions. "On-site champions and/or leaders should be put in place to drive development and
ongoing support of the service," Mr. Lawrence says. "Physician leadership is a vital component as the physician(s)
have to understand and desire the benefits of providing telehealth services and drive the development of the service
within the hospital." Dr. Rheuban says hospitals can encourage physician champions by sharing success stories and
visiting other successful telemedicine programs to highlight the potential benefits of the program.
One benefit is that seeing patients via telemedicine can enable physicians to delegate their time more efficiently. Dr.
Bair says telemedicine allows physicians to spend more time with patients who really need care and effectively manage
patients who need less care. For example, physicians can view a patient on video and decide whether that patient
needs intervention, potentially saving the patient from traveling to a facility only to be told to continue the current
treatment, Dr. Bair says.
7. Train providers. "Training is a key component of a successful program," Ms. Palumbo says. "Telehealth technology
isn't that difficult to integrate, but it doesn't eliminate the need for training. Each of our practitioners goes through a
hands-on program to learn how to use the equipment prior to seeing patients via telehealth. This enables practitioners
to become comfortable with the video and audio components and discuss any remaining questions or concerns," she
says.
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8. Start simple. Hospitals should begin using telemedicine for simple services before ramping up to complex services
such as multi-provider calls and interventions transmitted through the technology, Dr. Bair says. For instance, hospitals
can start by using telemedicine for gathering patient history and providing consultations. As programs increase in
complexity they can provide services in behavioral health, neurology and endocrinology, Dr. Bair says. "[Telemedicine]
is somewhat tiered — starting simple with things that are easy to approach without a lot of additional technology, then
higher levels of coordinated, multi-personnel [services] with augmented exam techniques."
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9. Analyze outcomes. Hospitals should track outcomes from telemedicine over time to identify any gaps in care or
opportunities to expand the service. "It is imperative that health systems that implement this technology and these kinds
of programs study what they're doing and report out on that," Dr. Smith says. Studying outcomes and sharing them with
others will help hospitals develop additional best practices, he says.
10. Integrate telemedicine with other systems. Dr. Smith suggests integrating telemedicine with other technologies
such as electronic medical records to ensure efficiency and to better understand the data. "We are fully integrating all
processes to study [data] more systematically and inform improvement process and optimization," he says. While
integration is difficult, benefits such as being able to quickly access population health information and having a single
database for patient records makes the process worthwhile. "Ultimately you get the best outcomes and best
functionality if you can tie [telemedicine and EMR] together," Dr. Smith says. "It takes a lot of work; you have to have
the stomach for it. It's much easier to do disconnected work, but in the long run I think most health systems will
ultimately want everything fully integrated."
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Case Studies
REACH MUSC Program -Telestroke Program
MUSC’s stroke team provides urgent consultations at select hospitals in South Carolina through a Web-based outreach
initiative called REACH MUSC.
"REACH" stands for Remote Evaluation of Acute ischemic Stroke.
This potentially life-saving network connects partnering hospitals with immediate, round-the-clock access to MUSC's
stroke care experts, who can remotely provide urgent consultations after virtually examining patients and brain imaging
studies.
Many rural, community medical centers have stroke patients arrive in their emergency department, but don't have
a neurologist on staff or do not have enough neurologists provide an around-the-clock stroke team capable of rapid
stroke evaluation and treatment.
REACH MUSC was created to provide urgent evaluation and treatment at outlying hospitals and if needed
transfer patients to MUSC for additional diagnosis and treatment.
The REACH MUSC program is a part of the SmartState SC Centers of Economic Excellence Program. The Stroke
Center of Economic Excellence program is focused on reducing the incidence of stroke and augmenting provision of
acute stroke care in South Carolina.
With the activation of the REACH Network, more than 76% of the South Carolina population is now with-in a 60 minute
drive expert stroke care compared with only 38% prior. The MUSC REACH program had provided expert consultative
care to close to 4,000* (2008 - July, 2013) stroke patients in South Carolina.
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Telehealth takes the lead in rural, urban post-discharge care
Treatment for many serious conditions doesn’t end once a patient is discharged from the hospital, but that doesn’t
mean it’s always easy for those patients to keep in touch, visit for follow-ups, and stay on track with their post-acute
care plans. Rural patients often face the challenge of distance, but urbanized areas are just as difficult to navigate if
patients don’t have access to a car and aren’t able to take the bus with an oxygen tank or tender surgical incision. To
reduce preventable readmissions after patients have been treated for heart failure, heart attacks, or pneumonia, Vree
Health has started two major projects, one in Montana and one in heavily populated Connecticut,
employing telehealth as a means to ensure that patients are adhering to their recommended courses of treatment.
“Helping patients transition from hospital to home is a major healthcare challenge that requires providing individual
attention for each patient after they leave the hospital,” said Kathleen Martin, vice president for patient safety and care
improvement at Griffin Hospital in Connecticut, which will use Vree’s TransitionAdvantage program to stay in touch with
patients daily over the phone.
With CMS preparing to penalize hospitals for preventable readmissions within 30 days of discharge, keeping patients
healthy at home will become a financial issue as well as a quality of care problem. Griffin Hospital, with 160 beds that
serve more than 107,000 residents in and around Derby, Connecticut, will benefit from TransitionAdvantage’s 24/7 call
center staffed by “transition liaisons” to coordinate a patient’s move back to their own home. The platform interfaces
with the hospital’s EHR to create an electronic patient profile to help guide them towards healthy choices that will keep
them feeling well.
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The digital tools, including the always-available telephone hotline, will be just as useful for rural patients in Montana,
where the Frontier Medicine Better Health Partnership includes all of the state’s hospitals. The Partnership and Vree
Health are funded by a $10.5 million CMS Innovation Grant to help get TransitionAdvantage in communities where the
nearest hospital might be hundreds of miles away. Vree hopes that all 48 of Montana’s facilities, which serve 100,000
Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries, will have access to the call center
and other tools by the end of its 3-year roll-out.
“While transitional care is a challenge throughout the health system nationwide, rural communities like these in
Montana have unique needs,” said Denyse Traeder, FMBHP’s director, in a press release. “We are excited to partner
with the experts at Vree Health to develop new approaches to improve the transition from hospital to home in these
areas.”
Telehealth is becoming increasingly popular with providers nationwide to supplement the care of a variety of patient
populations, from suburban parents looking for a quick way to identify a child’s rash to stroke patients in need of
immediate attention and treatment. With the remote monitoring and telemedicine market set to hit nearly $300
million by 2019, TransitionAdvantage is just one of hundreds of initiatives taking off around the county, helping to bring
patients and caregivers together through technology.
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Mayo Clinic Researchers Show Telestroke is Cost-Saving
PHOENIX — Jan. 16, 2014 — Researchers have found that using telemedicine to deliver stroke care, also known
as telestroke, appears to be cost-effective for society. The research was recently published in the American Journal of
Managed Care.
In telestroke care, the use of a telestroke robot allows a patient with stroke to be examined in real time by a neurology
specialist elsewhere who consults via computer with an emergency room physician at another site which may not have
neurology specialists (typical rural hospitals). Mayo Clinic provides telestroke care by acting as a single source of
specialized care – a hub – to connect a network of multiple hospitals – spokes.
"This study shows that a hub-and-spoke telestroke network is not only cost-effective from the societal perspective, but
it's cost-saving,” says neurologist Bart Demaerschalk, M.D., director of the Mayo Clinic Telestroke Program, and the
lead investigator of the telestroke cost effectiveness study. “We can assess medical services, like telemedicine, in
terms of the net costs to society for each year of life gained."
The study estimates that compared with no network, a modeled telestroke system consisting of a single hub and seven
spoke hospitals may result in the appropriate use of more clot-busting drugs, more catheter based interventional
procedures and other stroke therapies, with more stroke patients discharged home independently. Despite upfront and
maintenance expenses, the entire network of hospitals realizes a greater total cost savings.
When comparing a rurally located patient receiving routine stroke care at a community hospital, a patient treated in the
context of a telestroke network incurred $1,436 lower costs and gained 0.02 quality-adjusted life-years over a lifetime.
37

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The improvement in outcomes is associated with reduced resource use (inpatient rehabilitation, nursing homes,
caregiver time). Although treating patients in a telestroke network is associated with higher upfront costs due to the
setup of the telestroke network and more costly treatments during the initial hospitalizations, it can potentially lead to
cost savings over a lifetime.
The results serve to inform government organizations, insurers, healthcare institutions, practitioners, patients, and the
general public that an upfront investment in telemedicine and stroke network personnel can be justified in our health
system,” Dr. Demaerschalk says.
The study was conducted by researchers at Mayo Clinic, Georgia Health Sciences University, Analysis Group.
Mayo Clinic was the first medical center in Arizona to do pioneering clinical research to study telemedicine as a means
of serving patients with stroke in nonurban settings, and today serves as the hub in a network of 13 spoke centers.
Since the telestroke program began more than 4,000 emergency consultations for stroke between Mayo stroke
neurologists and physicians at the spoke centers in Arizona have taken place. Mayo Clinic Telestroke is represented
nationally, with hubs in Arizona, Florida, and Minnesota and serves more than 20 healthcare institutions in seven
states.
Disclosures: Authors Drs. Jeffery Switzer and Demaerschalk have served as consultants for Genentech, Inc. Authors L.
Fan and Drs. J. Xie and E. Wu are employees of the Analysis Group, which received funding from Genentech, Inc.
Author K.F. Villa is an employee of Genentech, Inc.
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Case Studies
FCC to offer rural hospitals $400M for telemedicine
The Federal Communications Commission will provide $400 million in funding to rural hospitals and care facilities to
support telemedicine infrastructure.
Starting at the end of the summer in 2013, nonprofit hospitals will be able to apply for funding to build or expand their
broadband networks, allowing rural clinics to connect to urban medical centers to allow remote consultation with
specialists and the sharing of electronic health records. Eligible care facilities will receive a 65 percent discount on
broadband services, equipment, and connection to research and education networks. They can also get a 65 percent
discount on constructing new facilities if they can show it’s the most cost effective way to get connected.
The funding will come through the FCC’s new Healthcare Connect Fund, the new permanent program implementation
of the FCC’s Rural Healthcare pilot program, which began in 2006. It has more than 50 active pilots in rural hospitals
across the country.
“The new Healthcare Connect Fund program builds on the success of the FCC’s Rural Healthcare pilot program and
will expand the Commission’s health care broadband initiative from pilot to permanent program,” FCC Chairman Julius
Genachowski said in a statement. “For years, the FCC’s primary healthcare program made it difficult for hospitals
serving rural patients to get high bandwidth connections needed for modern telemedicine by limiting the services
eligible for funding, and by making it hard for consortia to effectively bargain for the lowest cost service.”
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The FCC said in a statement that the following groups are eligible for the funding: public or not-for-profit hospitals, rural
health clinics, community health centers, health centers serving migrants, community mental health centers, local
health departments or agencies, and post-secondary educational institutions, teaching hospitals, or medical schools.
Starting in 2014, the FCC will also launch a Skilled Nursing Facilities Pilot Program, devoting up to $50 million of the
funds to test how to effectively bring broadband to nursing facilities.
Such a show of support from the FCC bodes well for the passage of the Telehealth Promotion Act introduced to the
House at the end of the last Congress. That bill, which is currently awaiting re-introduction, would help fund telehealth
for individuals by making it easier to get reimbursed by Medicare and Medicaid.
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Case Studies
Return on Investment (ROI) on Telemedicine Programs a Needle in a Haystack?
Often the closest that we can come to real money is cost-effectiveness. A new report by the Mayo Clinic suggests that
telestroke programs, like the ones it operates, are “cost-effective” for rural hospitals that don’t have the specialty. The
research is in the latest issue of Circulation: Cardiovascular Quality and Outcomes. Other studies have already shown
that they are cost-effective in terms of preserving patients’ quality of life even though the costs and benefits from the
small hospitals in the stroke networks have never been fleshed out.
Some skeptics in medicine have perpetuated a myth that a telestroke network becomes a financial burden for a
hospital. However, the Mayo study revealed a telestroke program was likely to save the hospital money while
improving patient outcomes and discharging them sooner. Even if telestroke coverage costs a hospital a couple
thousand dollars more to save a patient’s quality of life, Dr. Bart Demaerschalk at Mayo says, “It’s a bargain really.”
A story about the study, titled Telestroke is Cost-Effective for Hospitals, Mayo Clinic Researchers Show, is available on
the Mayo Clinic Web site.
Here’s where the ROI comes in. Data supplied by the Mayo Clinic and the Georgia Health Sciences University indicate
that a small hospital with a telestroke program can treat 45 more patients every year with clot-busting drugs and 20
more with endovascular stroke therapies. According to the study, this represents more than $100,000 in cost savings
each year. If reimbursement opportunities increase, the hospitals might save even more money. Dermaerschalk says,
“The upfront costs associated with setting up the telestroke technology and managing the network organization are
quickly offset by the financial gains that result from a higher proportion of patients receiving clot busting drugs and the
reduced stroke-related disability and subsequent reduced need for rehabilitation, nursing home care and assistance at
home.”
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When it comes to a telestroke program, the small hospitals on the patient end benefit economically. The study
suggests that the spoke hospitals that enjoy this increase in revenues should share them and help finance the
telestroke network system.
Telestroke programs are the easiest to justify among telemedicine programs because with them outcomes can be so
dramatically better. Since the American Academy of Neurologists says that 45% of Americans live 60 minutes away
from the nearest specialist, providing greater access to that higher level of healthcare is essential in preserving a
patient’s independence. Most stroke victims who don’t get clot-busting drugs are incapacitated; many live on for
decades in nursing homes unable to care for themselves. Like the old Fram oil filter commercials: you can pay me
now, or you can pay me (a lot more) later.
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Case Studies
Analysis finds telestroke model saves costs, improves outcome
Using telemedicine to deliver stroke care, also known as telestroke, appears to be cost-effective and improve patient
outcomes, according to a recent cost-utility analysis.
In telestroke care, the use of a robot allows a patient with stroke to be examined in real time by a neurology specialist
who consults via computer with an emergency room physician, typically at a rural hospital that doesn’t have a neurology
specialist. Through its telestroke system, the Mayo Clinic acts as a hub connecting a network of multiple hospitals, or
spokes.
“This study shows that a hub-and-spoke telestroke network is not only cost-effective from the societal perspective, but
it’s cost-saving,” Bart Demaerschalk, MD, neurologist, director of the Mayo Clinic Telestroke Program and the study’s
lead investigator, said in a news release. “We can assess medical services, like telemedicine, in terms of the net costs
to society for each year of life gained.”
For the study, researchers with the Mayo Clinic in Phoenix, Georgia Health Sciences University in Augusta and the
Boston-based Analysis Group Inc. used a model with one stroke center (the hub) and seven community hospitals, with
a hypothetical cohort of 1,112 acute ischemic stroke patients. The patients’ average age was 68 based on previous
studies of patients with first-time strokes. Their findings were published Dec. 20 on the website of the American Journal
of Managed Care.
The study found the modeled telestroke system may result in the appropriate use of more clot-busting drugs, more
catheter-based interventional procedures and other stroke therapies, with more stroke patients discharged home
independently when compared with no network. Despite upfront and maintenance costs, their model showed the entire
network of hospitals saw a greater total cost savings. 43

Case Studies
Cont’
When the researchers compared a rural patient receiving routine stroke care at a community hospital, a patient treated
in the context of a telestroke network incurred $1,436 less in costs and gained 0.02 quality-adjusted life-years over a
lifetime.
The improvement in outcomes is associated with reduced use of resources such as inpatient rehabilitation, nursing
homes and caregiver time.
44

Case Studies
Expanding Access with Video-Based and Online Consultations
For over 10 years, the Center for Connected Health and Partners Online Specialty Consultations (POSC) has provided
thousands of patients and their providers virtual access to specialty care at Partners-affiliated hospitals. Secure online
and video-based consultations provide unprecedented access to specialists at Brigham and Women's and
Massachusetts General Hospitals, Dana Farber/Brigham and Women's Cancer Center, and Massachusetts Eye and
Ear Infirmary.
A recent review of POSC consultations found that in only 5% of the cases, the specialist opinion was in complete
agreement with the patients' current recommended treatment plans. In more than half of the cases, the consulting
specialist recommended a complete change in treatment plan, suggesting profound implications for clinical care.
"This program works really well and, as a consulting physician, we have all of the information available to quickly make
an informed recommendation," said Arnold S. Freedman, MD, Associate Professor of Medicine, Harvard Medical
School, and Clinical Director of the Lymphoma Program at Dana-Farber Cancer Institute.
When diagnosed with non-hodgkins lymphoma, a businesswoman and expatriot living in Asia turned to POSC for help
to determine the most effective treatment plan. Dr. Freedman was the consulting physician on her case.
"My local physician is head of hematology at a major hospital in Asia. He had previously met Dr. Freedman and was
delighted to have the opportunity to collaborate with him," she said. Within just two days, the patient and her local
physician received a comprehensive report and treatment recommendations. "The completeness of the report, and the
experience of Dr. Freedman and the Cancer Center, gave us great confidence that we were making the right
decisions," she added.
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Case Studies
Patient Profile: Teleneurology Provides Swift, Lifesaving Treatment
As a long time nursing director with Christus St. Michael Health System and a member of its stroke team, Sandra
Bowden realized the debilitating impact stroke was having on her community of Texarkana, TX.
Not unlike the national figures, stroke was the fourth leading cause of death for adults and the number one cause of
disability in her community hospital serving four states in a 25 mile radius. Sandra was committed to making a
difference and took a leadership position on the hospital’s stroke planning team, spearheading their campaign to
become a certified stroke center.
When she began to experience stroke symptoms at work, however, her interest in stroke became extremely personal.
Sandra's Experience
Shortly after an early morning meeting with the Christus stroke team, Sandra began to feel a tingling sensation around
her ear and toward her face. By the time it spread down her left arm, a colleague noticed the left side of her face was
drooping and she quickly escorted Sandra to the emergency room.
Once there, the Christus St. Michael Health System emergency department initiated stroke protocol and after the
emergency room physician had checked her condition, she was immediately sent for a CT scan.
Top-Notch Treatment
By the time Sandra returned to the emergency room from her CT scan, Specialists On Call had been notified and their
neurologist was already speaking with her attending physician.
“It was just a short time before the television monitor was brought in and the neurologist introduced himself. By the time
he was doing the neurological exam, however, I felt like he was right there in the room,” Sandra explains.
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Sandra was treated by Specialists On Call’s neurologist, Dr. Todd Samuels. A board certified neurologist who has been
in private practice for
more than 22 years, Dr. Samuels has worked with Specialists On Call for over three years. He chose to work with
Specialists on Call because of its proven clinical effectiveness.
“I’ve been on both sides of the situation,” Dr. Samuels says. “I’ve been a community neurologist and I know for
emergency situations I can provide much more timely care as a teleneurologist than I can as a bedside neurologist.”
Quick, Lifesaving Care
Via telemedicine, Dr. Samuels conducted a complete neurologic assessment of Sandra with the help of the attending
nurse.
“During my consultation with Dr. Samuels, I was the center of his attention,” Sandra says. “He did his examination. He
asked me questions. He addressed me by my name and did the same with my husband. We were his entire focus and
he answered all my questions and made us feel comfortable during a very difficult time.”
Dr. Samuels explained to Sandra that he believed she was suffering a stroke and was eligible for the clot busting drug,
tPA. He then went through the benefits and risks associated with that particular therapy and gave Sandra and her
husband time to make a decision. Once they had decided to pursue treatment, Dr. Samuels oversaw the administration
of tPA and was able to check in on her periodically.
“I don’t know what I thought he was going to do...I assumed he would order the drug and that was that, but he stayed
and checked in on me,” Sandra recalls. “In a short time, I started to have resolution of symptoms and you could see Dr.
Samuels was very pleased with the outcome.”
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A Successful Outcome
Shortly thereafter, Sandra was transferred to the ICU where her condition continued to improve. The left side of her
face continued to droop for the next couple of days and she experienced a minor issue with her gait and balance, but
physical therapy resolved those conditions and today she lives a normal life with no deficits.
“By the time I got down to the ED and everything had been done, Specialists On Call was involved, Dr. Samuels was
there, and all the proper things had been done with his guidance—the care I received was the highest quality,” Sandra
recalls.
“I could not have asked for any better care. Dr. Samuels guided the treatment and the assessment, and the decision
making included me and my husband. I couldn’t have asked for higher quality care,” says Sandra.
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Case Studies
Using Telemedicine in Rural Georgia to Provide Children with Access to Child Abuse Physicians
Every year, thousands of children in Georgia who are sexually or physically abused need specialized medical
evaluation. Yet this service is typically available only in urban centers. Much of Georgia, like much of the country as a
whole, is rural, so many children are either unable to obtain needed care or they must travel great distances to reach a
specialty clinic. To address this need, the Children’s Healthcare of Atlanta Center for Safe and Healthy Children
(CSHC) started using telemedicine in January 2009.
The CSHC has two outpatient clinics in metro Atlanta to provide forensic interviews and medical evaluations to children
and adolescents who are suspected victims of abuse or neglect. The CSHC collaborated with the Georgia Partnership
for Telehealth and several child advocacy centers throughout the state to create the ability to provide children in rural
communities access to child abuse physicians.
Child advocacy centers provide prevention, intervention and treatment services to victims of abuse and are ideal
partners for bringing telemedicine evaluations to local children. In the case of suspected abuse, the police contact a
local child advocacy center associated with the telemedicine network. They immediately call the Children’s
Telemedicine Program to schedule a consultation. At the appointed time, the child and parent come to the local child
advocacy center where they are greeted by a social worker and a medical provider, usually a nurse. They enter an
exam room equipped for teleconferencing. The nurse explains the procedure and introduces the specialist to the family.
From a desk in Atlanta, the specialist greets and engages the family in conversation to help them relax. The interaction
takes place through high-resolution screens that allow the patient, family and doctors to communicate in real time.
Together, the nurse and specialist obtain information about the abuse event and the child’s general health. The nurse
performs a head-to-toe physical exam on the child with the specialist guiding the process utilizing telemedicine
equipment.
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According to Jordan Greenbaum, M.D., Medical Director of Children’s CSHC, telemedicine has several tangible
benefits. “An evaluation utilizing telemedicine reduces parental anxiety and stress by providing prompt access to expert
care and support. It also saves time and resources for authorities, who can lose a workday driving to and from Atlanta.
And for rural medical providers, telemedicine relieves some of the burden of accurately identifying abuse and
interpreting physical findings.”
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Case Studies
Telemedicine Brings Much-Needed Specialty Care to Rural Hospitals
If you cannot recruit specialists to your rural hospital, the next best thing may be bringing them on board remotely.
Hopkins County Memorial Hospital in Sulphur Springs is working with a group of physicians and a medical technology
firm 80 miles west in North Texas to leverage real-time specialist consultations to increase quality of care.
US Medical IT, based in an incubator on the University of Texas at Dallas campus, supplies a cart with two monitors,
one of which is the electronic medical record while the other is focused on either the patient or monitoring equipment.
The screen’s resolution allows the physician to examine the patient almost as if he or she is onsite. Physicians from
Access Physician: Global Telemedicine Solutions (AP Global) use FDA-approved telemedicine equipment such as
stethoscope, ophthalmoscope, and peak flow monitor to examine patients.
After a pilot test, the technology has been a fixture at the hospital since November. AP Global offers cardiology,
pulmonary and emergency-medical consultations. It plans to expand the service to include neurology.
AP Global has contracts pending at three long-term acute care facilities, a surgical center, and three other acute-care
hospitals.
Chris Gallagher, MD, AP Global president and cofounder, and Eduardo Vadia, a pulmonologist and assistant professor
of internal medicine at UT Southwestern, say the services most in demand at rural hospitals are the three they currently
offer, as well as neurology and psychiatric care. AP Global and US Medical IT plan to offer all those services.
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Stephen Cracknell, US Medical IT chief executive officer, said the technology challenges were affordability and
reliability. The hospital rents the cart for about $1,000 a month, which costs about $30,000 to build. Cracknell said the
cart could be operated by a wireless connection, a 4G card, or can simply be plugged into a wall. He said the hospital
servers recently went down and the telemedicine connection was undisturbed.
The physicians working with the Sulphur Springs hospital are doing so part-time. However, AP Global officials believe
the company’s growth will allow it to hire full-time physicians in multiple facilities in the near future.
Robb Sexton, registered nurse in the hospital’s intensive care unit, said telemedicine has been a boon to the facility. He
said the hospital previously relied on weekly visits from a pulmonologist, and frequently had to transfer more
complicated cases to hospitals in Dallas or Tyler. He said telemedicine has allowed the hospital to keep those cases
and allow convenient patient access for families.
Sexton said patients seem to like telemedicine, although many are too sedated to know the difference. He said he
recently had a family raving about the service because the patient previously was transferred out of town for care.
Sexton said AP Global’s intensivists have especially improved care in the emergency department (ED). He said local
physicians on-call had up to four hours to respond to the hospital. He said the cart usually is set up and the
telemedicine intensivist is present by the time the patient is wheeled into the ED.
Only about 10 percent of physicians practice in rural America despite the fact that it contains nearly one-quarter of the
U.S. population. Rural Americans also have greater health and socioeconomic challenges. They tend to be poorer,
have more chronic conditions, rely more on food stamps, are less likely to have employer-sponsored insurance, and
less likely to have prescription drug coverage, compared with urban dwellers. In Texas, some rural counties have
uninsured rates as high as 50 percent.
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Texas rural hospitals provide access to routine and emergency health care for 15 percent of the state’s population, but
cover 85 percent of the state’s geography, according to theTexas Organization of Rural and Community Hospitals.
There are areas in Texas that are more than 100 miles away from the nearest hospital. Texas rural hospitals are also
shedding jobs because of government insurance reimbursement cuts.
As of 2010, there were 32 Texas counties without a family practice physician, 27 with one family practice physician, and
12 counties with physicians, physician assistants, or nurse practitioners. There were also 40 counties with one or no
pharmacists. About three-fourths of the 2,050 rural counties in the U.S. include a primary care health professional
shortage area. Nearly one in 10 rural counties has no primary care physician.
The shortage is even more acute for specialists. Rural areas have about 40 specialists per 100,000 residents,
compared with 134 per 100,000 in urban areas. The more highly specialized the physician, the less likely he or she will
settle in a rural area.
Death and serious injury accidents account for 60 percent of total rural accidents versus only 48 percent in urban areas.
One reason for the disparity is that in rural areas, prolonged delays can occur between a crash, the call for emergency
medical services (EMS), and the arrival of EMS personnel. Many of these delays are related to increased travel
distances and personnel distribution across the response area. National average response times from motor vehicle
accident to EMS arrival in rural areas was 18 minutes, or eight minutes greater than in urban areas.
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One answer to provider shortages has been telemedicine, which has spread rapidly within the last decade. The number
of patients cared for through the technology has risen to about 10 million people in rural as well as urban settings,
according to the American Telemedicine Association.
Market analyst IHS expects U.S. telemedicine spending will grow eight-fold by 2018 to about $2 billion.
A new lobbying group, the Alliance for Connected Care, was announced in February to advocate for federal and state
policy changes to encourage the industry’s growth. The group is led by former U.S. Senate Majority Leaders Tom
Daschle, Democrat from South Dakota, and Trent Lott, Republican from Mississippi. The group’s members include
health care and technology giants Verizon, WellPoint, CVS Caremark, Walgreens, and Dallas-based Teladoc.
Counties with 75,000 or fewer residents are considered rural. Hopkins County has about 35,000 residents. About half of
U.S. rural hospitals use telemedicine to close gaps in specialist care. Thirty-five state Medicaid programs reimburse for
telemedicine, including Texas. Texas is also one of a handful of states that mandates private insurers reimburse for
telemedicine. Texas Insurance Code generally requires healthcare coverage providers to treat telemedicine consults as
if they had occurred in a face-to-face environment.
54

Case Studies
Bon Secours Hampton Roads: Teleneurology Brings Better Outcomes, More Profitability
Like all health systems, Bon Secours Hampton Roads (BSHR) continually seeks ways to improve its competitive
advantage. However, developing a growth and differentiation strategy is challenged by the fact that its southeastern
Virginia and northeastern North Carolina catchment area is right in the backyard of a large, $3.5 billion, fully-integrated,
non-profit health system.
BSHR’s flagship hospital, Bon Secours Maryview Medical Center, is a 346-bed acute care hospital located in
Portsmouth, VA. It’s the largest hospital within the Bon Secours Hampton Roads health system, which also includes
Bon Secours DePaul Medical Center, Bon Secours Health Center at Harbour View, Bon Secours Mary Immaculate
Hospital and Bon Secours Health Center at Virginia Beach. With a patient population that suffers a high incidence of
cerebrovascular disease, Maryview Medical Center was the best choice for initial rollout of a new neurosciences service
line that the health system decided to launch. The first step: making Maryview a Joint Commission-certified primary
stroke center.
Finding the Best Coverage Option
To obtain primary stroke certification, Maryview needed to provide 24/7/365 emergency neurology coverage. Although
fortunate to have one local neurologist taking call, providing round-the-clock on-call coverage was becoming an
overwhelming burden for one neurologist to sustain. Like many hospital administrators around the country, Smith found
few local neurologists willing to take call. And those that did required that the hospital pay them $800 a day, or
approximately $300,000 annually. This extra line item made the service line pro forma less compelling, especially in the
start-up phase.
55

Case Studies
Cont’
Looking at the traditional alternatives of recruiting neurologists or hiring locum tenens, Smith quickly dismissed the latter
since it was not optimal. The recruitment process was not immediately fruitful either and Maryview required a minimum
of one or two additional neurologists to provide 24/7 emergency neurology coverage to achieve primary stroke center
certification. Conversely, while $300,000 for stroke stipends seemed exorbitant, locum tenens would actually have been
more expensive and only a temporary solution, not the foundation of a new stroke center.
Selecting Teleneurology
Fortunately, another hospital in the Bon Secours network previously overcame these challenges as it sought stroke
center certification. After extensive due diligence, Richmond Community Hospital (RCH) had selected the Specialists
On Call teleneurology solution to solve its coverage challenges.
RCH reported that even in the first year, Specialists On Call decreased costs and improved care quality. Satisfaction
among RCH physicians, staff, and patients was high. With a ringing endorsement from RCH, Maryview also
implemented Specialists On Call’s emergency teleneurology consultation service.
Raising Care Quality, Creating a Bottom Line Impact
Before partnering with Specialists On Call, ambulance services handling stroke patients routinely bypassed Maryview.
Since implementation, the hospital’s stroke volume has steadily increased. Within the first 12 months of go-live,
Maryview experienced numerous benefits, including the following:
56

Case Studies
39 percent growth in admissions
$486,000 increase in contribution profit—not factoring any cost savings from the elimination of $300,000 annual
stipends
0.5 day decrease in the average length of stroke patient stay
$200-plus decline in cost per case
More than triple the number of cases in which tPA was administered
Setting the Stage for Future Growth
When using the teleneurology service, the hospital’s emergency department physicians are now guaranteed a 15-
minute response by Specialists On Call’s top-quality neurologists. Patients and staff alike appreciate their quick
response, evidence-based treatment recommendations and quality service.
Maryview’s hospitalists no longer need to cover the ED for neurology patients, and they can contact Specialists On Call
with any followup questions. Local neurologists, too, are relieved of the disruption of emergency calls, which gave
Maryview the ability to more easily recruit and employ three additional neurologists to support the growth in
the neuroscience program.
Within the first year of partnership, Specialists On Call helped the stroke program at Maryview grow volume and profit
by 35 to 40 percent, along with an across-the-board improvement in quality outcomes.
“Specialists On Call delivered on everything I expected. And the physicians feel that way too, which is even better yet,”
explains Smith. “We were a little concerned about patient perception, but it turns out they love it! It’s new and modern
healthcare.”
As a result of the benefits Specialists On Call has brought to Maryview, Smith is now implementing the service in other
BSHR facilities
57

Costs
Return on investment
As a clinician or healthcare facility representative, return on investment is likely a key concern when you consider
adding telemedicine to your healthcare delivery options. Turning a profit on such an investment in two years is
considered an appropriate ROI. One GlobalMed customer, a rural hospital, tracked their ROI in a 6-month study and
found they saved $540,000 in patient transfer expenses after establishing their telecardiology program. The success of
that program led to the creation of teleneurology and telepulmonology programs as well. ROI benefits can be realized
by other healthcare providers and patients alike. The benefits are financial but also qualitative that can affect bottom
line. For primary care physicians, telemedicine provides the ability to extend their practices beyond the immediate
community or to connect easily with patients in a number of surrounding, smaller communities. Studies have shown that
the percentage of appointments kept is higher when patients need to travel less. And they tend to show up for their
telemedicine appointments on time because there is less travel involved. Specialists who incorporate telemedicine into
their practices for care and consults can save time and travel expenses they would otherwise incur without such
technologies. Telemedicine can also make your expertise more widely available, providing an additional added value.
Telemedicine’s major benefit to patients is convenience. They appreciate the savings that result from a reduction in
travel and the costs associated with it. Depending on the distance traveled, a doctor’s appointment may consume part
of, or the whole day. When factoring in a day away from the job or the cost of daycare for children while the adult
patient makes a regular in-person visit, telemedicine shows substantial savings of both time and money. And
considering patients for whom travel is difficult if not impossible, the face-to-face interaction that telemedicine provides
is invaluable.
58

Costs
Estimated Costs and Savings of an Operational Telemedicine Configuration
Appendix E
The Cost Reduction
Appendix F
Cost is an important obstacle to access. It has been predicted that the startup cost for a rural facility can be $100,000.
Besides start up costs, deliberation must be given to the charge by the consultation team. This may range from $75-
250 per hour, depending on the type and number of consultants involved.
http://www.telemedconsultant.com/ecotel.pdf (very important to read)
59

Vendors
1. GlobalMed http://www.globalmed.com/
2. In touch Health http://www.intouchhealth.com/
3. United Telehealth http://www.unitedtelehealth.net/
When you are ready I have discussed the above companies to come and end and present their Products.
Directory of Vendors
http://atatelemedicinedirectory.com/
http://www.vreehealth.com/
Will Discuss.
60

Misc.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
http://www.michigan.gov/documents/MSA_06-22_155090_7.pdf
http://ippsr.msu.edu/publications/ARTelemedicine.pdf
http://www.michbar.org/health/pdfs/telemedicine.pdf
http://www.telemedconsultant.com/ecotel.pdf (very important to read)
Research outcomes – Appendix D
61

Telemedicine Organizations
Link to Organizations
American Telemedicine Association (ATA)
The ATA, established in 1993, is a leading resource and advocate for promoting access to medical care via
telemedicine.
Center for Telehealth and E-Health Law (CTeL)
The CTeL, created in 1995, serves as a resource and advocate for understanding and overcoming legal barriers to
telehealth and e-health.
LearnTelehealth.org
LearnTelehealth.org is the website for the South Central Telehealth Resource Center. It is a portal to give users
interested in telehealth a virtual place to exchange ideas and information through the use of learning activities and
materials.
The Office for the Advancement of Telehealth
The Office for the Advancement of Telehealth is part of the Health Resources and Services Administration (HRSA), an
agency of the United States Department of Health and Human Services. The HRSA promotes the use of telehealth to
reach underserved people by facilitating partnerships among governmental agencies, evaluating current practices, and
promoting knowledge exchange.
Telehealth Resource Centers (TRCs)
The national TRC comprises 5 regional TRCs that assist healthcare organizations in the establishment of telehealth
systems. Regional networks include the California Telemedicine and eHealth Center, the Great Plains Telehealth
Resource and Assistance Center, the Midwest Alliance for Telehealth and Technology Resources, the Northeast
Telehealth Resource Center, and the Northwest Regional Telehealth Resource Center. Though each regional TRC
functions separately, a goal of the national TRC is to share experiences and best legal and regulatory practices across
regions.
62

Telemedicine Organizations
Telemedicine.com
Telemedicine.com is a consulting resource featuring a community discussion forum, a worldwide directory, grant
information, and job, event, and conference updates.
Universal Service Administrative Company (USAC)
The USAC provides discounted telecommunication services for eligible rural healthcare providers through the Rural
Health Care Program of the Universal Service Fund. The program reimburses telecommunications and Internet service
providers for services rendered to rural healthcare providers, and the discount is passed along to the program
participants.
63

Memorial telemedicine 2015

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