1. Telehealth:
A tool for the 21st century
Karen S. Rheuban MD
Professor of Pediatrics
Medical Director, Telemedicine
University of Virginia
ATA President
VTN Board Chair
Board Member, CTEL

2. Disclosure

3. Definitions
“Telemedicine” is the use of medical information
exchanged from one site to another via electronic
communications to support
• Medical diagnosis
 Ongoing patient care
 Remote patient monitoring
“Telehealth” encompasses a broader definition of
remote healthcare that does not always involve
clinical services
 Health-related distance learning

4. Mission
Facilitate the Health System’s missions of
• Clinical Care
• Teaching
• Research
• Public Service

5. Services
 Videoconferencing for patient care
 Store and forward applications
 Distance learning
health professionals
patients
students

6. UVA Specialty/Subspecialty Participants
Cardiology Obesity
Dermatology Oncology/Tumor boards
Diabetes Pain management
Emergency Medicine Pediatric cardiology
Endocrine Pediatric nephrology
ENT Pediatric oncology
Gastroenterology
Plastic surgery
Genetics
Geriatrics Psychiatry
Gynecology Pulmonary medicine
Hematology Radiology
Infectious Disease Rheumatology
Nephrology Surgery
Neurology TCV
Neurosurgery Toxicology/Poison control
Ophthalmology Urology
Orthopedics
Wound care

7. Partnerships
 Academic-community hospital linkages
 Academic-academic hospital linkages
 Rural clinics (FQHCs, Veteran’s clinics)
 Virginia Department of Health
 Virginia Department of Corrections
 School health
 Nursing home
 Home telehealth – remote monitoring
 Habitat for humanity

8. Benefits of telehealth
 Patients:
• Timely access to locally unavailable services
• Spared burden and cost of transportation
• Improvement in quality of care
 Health professionals (workforce shortages)
• Access to consultative services
• Access to CME
• Primary care retains oversight of patient care
 Rural communities
• Enhanced healthcare/economic empowerment

9. Federal investment in telehealth
 Department of Health and Human Services Department of Veterans Affairs
• National Institutes of Health Department of Commerce
• Health Resources Services Administration Department of Agriculture
• Agency for Health Research Quality Department of Labor
• Centers for Medicare and Medicaid Services Department of State
• Centers for Disease Control and Prevention
• Substance Abuse and Mental Health Services INDEPENDENT AGENCIES AND COMMISSIONS
Administration • NASA
• Food and Drug Administration •National Science Foundation
• Indian Health Service •Federal Communications Commission
•Social Security Administration
 Department of Homeland Security •Office of Personnel Management
 Department of Housing and Urban Development •Consumer Products Safety Commission
 CDC •Appalachian Regional Commission
 Department of Defense •US Agency for International Development
• Army Telemedicine Activities
• Navy Telemedicine Activities
• Air Force Telemedicine Activities
• DARPA
• Armed Forces Institute of Pathology
• Uniformed Services University of the Health
Services

10. State commitments to telehealth
 Medicaid
 State Rural Health Plan
 State Stroke Systems of Care Task Force
 Diabetes Council
 Center for Innovative Technologies
 Virginia Telehealth Network
 Office of Minority Health and Policy of VDH
 Joint Commission on Health Care
• Workforce analysis
 Tobacco Indemnification Commission
 Medical schools and large hospital systems
 Virginia General Assembly

13. Patients served: UVA program
 >18,000 patient encounters
 > 30,000 teleradiology services/year
 Services in >30 different specialties
• Emergency
• Urgent
• Single consults/follow up visits
• Block scheduled clinics
• Screenings with store forward technologies
• New mobile digital mammography van
• Retinopathy

14. More than technology and numbers:
Saving lives: Infant with Interrupted aortic arch

15. More than technology and numbers:
Facilitating expert care

16. Enhancing access
Remote Area Medical – 60% insured

17. Educational programs
 Broadcast continuing health
professional education
 UME, GME
 Patient education*
 School Health Projects

18. Clinical Telemedicine – examples
High risk obstetrics
 Antenatal Neonatal Guidelines, Education and
Learning System (ANGELS)
• 26% reduction in neonatal mortality in Arkansas
 UVA High Risk Obstetrics Telehealth Program
• Virginia PIF grant – from Secretaries Chopra and Tavenner
• Shortage of maternal-fetal medicine specialists
• High risk population
partner with FQHC in Harrisonburg and community obstetricians
• 1st year – no NICU admissions

19. Tele-ophthalmology
 Tele-ophthalmology technologies: live or store forward
Screening for diabetic retinopathy (primary cause of blindness in working
adults)
Retinopathy of prematurity
 ATA: Tele-ophthalmology standards

20. Pediatric cardiology
 Incidence of CHD is 8/1000 live births
 Traditional models of care:
 Schedule appointment
 Emergency transfer
 Wait for field clinic
 Obtain echo and mail, courier
 Tele-echocardiography has become standard of care
 Live interactive support of remotely located technologists
 Store forward images sent in digital format

21. Acute stroke intervention
 Challenge of lack of access to stroke
neurologist in rural areas
 High cost, high morbidity condition
 Time is of the essence (3 hour window for
thrombolytic agents
 Increase use of TPA in rural hospitals
• <0.5% utliliization in Virginia
• >25%
 Medicare FLEX Health IT grant
• Bath County Community Hospital

22. HIV/AIDS
Outcomes: UVA Telehealth HIV Program1
 213 correctional patients treated with 1812 visits over 5 year
period
 Of patients naïve to therapy:
– 77% attained undetectable viral load (<50 copies/ml)
– 50-60% in HIV clinic
– 40% receiving community based care by non-HIV specialists
1Rheuban,KS, Wispelwey B et al HIV/AIDS, HRSA Telemedicine Technical
Assistance Documents 2004

23. Cancer outreach:
Mobile digital mammography

24. Tele-pathology
 Second opinions
 Collaborative tumor boards
 Remote access to clinical trials

25. Tele-mental health
 Shortage of mental health providers in rural
areas
 Consultations, medication management
• Improve access, shorter wait times
• High rates of patient satisfaction in all age groups
• Controlled studies show efficacy = face to face psychiatry
• Huge cost savings in geriatric care facilities

26. e-ICU
 Two Models
• VISICU model with continuous monitoring
– Hospital mortality decreased from 12.9-9.4%, ICU
length of stay shorter 4.35-3.63 days
• Consultation model (UC Davis model) using VTC

27. Pediatric emergency medicine
 Geographic disparities in pediatric emergency services
(ratio:1.6/100,000 children)
 92% of children seen in non CH emergency rooms
 2-3% of seriously injured children receive initial treatment at a
pediatric trauma center
 Rural EDs have limited access to pediatric specialists, and may
not be trained in PALS, NALs, nor equipped
 UC Davis PICU connects with rural ERs in northern California
Parsapour,K, Presentation Pediatric Telehealth Colloquium, 9/07

28. Tele-otolaryngology
 AFCHAN telehealth project and use of video-
otoscopy1
• 31% decrease in the use of antibiotics when video-
otoscopy services added to community health clinic
services1
Medicare permits payment for store forward in Alaska*

29. Chronic Disease Management
Remote monitoring and Home telehealth
 10% of Medicare beneficiaries account for
66% of Medicare costs
 VA Care Coordination and Home Telehealth
19% reduction in readmission for the same
diagnosis,
25% reduction in hospital days

30. Chronic Disease Management
Remote monitoring and Home telehealth
Targets
 CHF
 Diabetes
 Hypertension
 COPD/Asthma
 Obesity
 Alzheimers disease
Devices:
 Wired
 Wireless
Broadcast patient education

31. Challenges:2010
 Funding of telehealth (Stark, Anti-kickback Laws)
 Reimbursement
 Confidentiality
 Credentialing and Privileging
 Licensure
 Malpractice
 Telecommunications venue/costs
 Integration with EMRS/HIE
 Interagency alignment related to policies
 ARRA, Health reform
 Outcomes

32. Reimbursement varies by state
 Reimbursement
- Virginia Medicaid (urban and rural) - ~ 30 Medicaid states
- Medicare (rural, non-MSA, store forward Alaska and Hawaii)
- ~ $2 million/year
- Private payers:
- Virginia becomes the 12th state to mandate
- Anthem grant for Virginia
- Contracts
- Peds cardiology
- Psychiatry
- Dept of Corrections

33. Licensure
 No portability
 UVA telemedicine serves Virginians
 Consultation based model

34. Credentialing and Privileging
2004 JCAHO standards
 Credentialing and privileging by proxy
 Remote hospital medical staff agree to telehealth
relationship
 Link to quality data
 Legal agreements between institutions
2010 Medicare Conditions of Participation, medical
staff standards
 July 15, 2010 Credentialing and privileging at all sites
 THANK YOU CMS for considering alternative solutions

35. Malpractice
 Serve primarily Virginians
Malpractice cap in Virginia
UVA faculty are self insured
 Informed consent
 New local standard of care?
 Limited precedents in case law

36. Malpractice

37. Telecommunications
 POTS – Fiber
 Universal service fund
 Rural healthcare pilot program
 NATIONAL BROADBAND PLAN !!!!
 Addresses interagency lack of coordination
 Addresses barriers to adoption
 Universal service reform
 If we build it, will they come?

38. Confidentiality
 HIPAA
 Encrypted data
 Network design and architecture

39. ARRA, Health Reform opportunities
 Health Reform:
 CMS Innovation center
 Independence at home – care coordination program
 Multi-billion dollar funding ARRA
 NIH
 DoC/NTIA
 USDA
 HRSA
 ONC

40. The future of telehealth
 Outcomes
 Standards
 Demonstration projects (ARRA, Health reform)
 Broadband plan
 Integration into mainstream medicine
 Innovation
 Collaboration amongst providers, policymakers
 Champions at all levels

41. Champions
Congressman Rick Boucher

42. Champions
State Senator William Wampler

43. Champions
Senator Mark Warner

44. Champions
Governor Bob McDonnell

45. Champions
Aneesh Chopra, Chief Technology Officer

46. Champions
Marilyn Tavenner, Deputy Administrator, CMS