Using connectivity to expand telehealth to rural and remote areas

On April 21, 2015, the U.S. Senate Subcommittee on Communications, Technology, Innovation, and the Internet, heard from witnesses on the progress made by the private sector and government entities to expand the benefits of telehealth nationwide, particularly in rural areas. The hearing also explored the connectivity challenges facing many health-care providers and patients attempting to take advantage of innovative telehealth applications.

Background

Globally, the number of patients using telehealth services is predicted to grow from 350,000 in 2013 to 7 million by 2018. Last Congress, the Senate passed a resolution (S. Res. 588) recognizing that access to hospitals and health-care providers for patients in rural areas is “essential to the survival and success of communities in the United States.” The resolution further stated that Congress must address the unique health-care needs of rural areas, in order to ensure that those communities continue to thrive.

Witnesses

The subcommittee heard testimony from four witness: (1) Dr. Kristi Henderson, Chief Telehealth and Innovation Officer, University of Mississippi Medical Center; (2) Jonathan D. Linkous, Chief Executive Officer, American Telemedicine Association; (3) Dr. M. Chris Gibbons, Distinguished Scholar in Residence, Connect2Health Task Force, Federal Communications Commission; and (4) Todd Rytting, Chief Technology Officer, Panasonic Corporation of North America.

Henderson

Henderson’s testimony focused on the use of telehealth in Mississippi, which leads the nation in prevalence of multiple chronic diseases and has the lowest number of doctors per capita of any state in the nation. According to Henderson, the greatest challenge is winning federal level reimbursement parity that will make telehealth attractive in the marketplace and securing the reliable, high quality connectivity.

She urged the subcommittee to focus on three issues: (1) the need for continued support of the Universal Service Fund, which, through its Rural Health Care Support Mechanism, allows rural health care providers to pay rates for telecommunications services similar to those of their urban counterparts, making telehealth services affordable; (2) broader application of the Federal Communication Commission’s (FCC) E-rate program, which connects the nation’s schools and libraries to broadband; and (3) the need for a more inclusive Health Care Connect Fund, which would allow large hospitals to receive a more robust reward for serving as a consortium lead for a network of smaller rural hospitals and clinics.

Linkous

Linkous gave examples of telehealth growth. He testified that, in 2015, over 125,000 patients who suffer stroke symptoms will be diagnosed by a neurologist in an emergency room using a tele-stroke network; tele-ICU will be used for 11 percent of the nation’s intensive care beds to help oversee almost 500,000 critically ill patients; and about one million patients with an implantable pacemaker or suffering from an arrhythmia will be remotely monitored.

Despite this growth, Linkous testified that certain reforms are necessary to achieve the full benefits of telehealth. These reforms include: (1) providing the infrastructure to physically enable telehealth services; (2) making sure that benefit coverage will financially enable telehealth networks; and (3) the need for Congress to direct or facilitate the development of new telehealth networks.

Gibbons

Gibbons described activities of the FCC’s Connect2Health Task Force. According to Gibbons, the Task Force is a senior-level, multi-disciplinary effort to move the needle on broadband and advanced health care technologies by thinking across various FCC silos, with the Task Force serving as an umbrella for the FCC’s health-related activities.

Gibbon’s assured the subcommittee that: (1) telehealth and other broadband-enabled health solutions are playing (and likely will continue to play) a significant role in helping to achieve the national objective of a healthier America; (2) the FCC is actively engaged in efforts to ensure that telehealth and other broadband-enabled health technologies are accessible in rural and remote areas, on tribal lands, and in other underserved sectors of the country; and (3) tangible progress on rural telehealth is within reach if broadband is done right and done now in rural areas, outreach and education is provided, better tools to measure progress are provided, solutions are tailored to the locality, and collaboration with public-private stakeholders occurs.

Rytting

Rytting testified that Panasonic is committed to the effort to transform America’s healthcare system through the power of information technology supported by robust broadband connectivity. Panasonic believes, according to Rytting, “that a fully-connected and interoperable health information and communications technology (ICT) ecosystem will provide the foundation to improve the coordination and quality of care, better health outcomes, and reduced overall costs.”

Because a key component of this ICT ecosystem is the utilization of telehealth and remote patient monitoring services, “Panasonic…urge[s] that national policy…reflect the dynamic and transformative nature of advanced ICT solutions, and not inhibit the innovation that holds the promise to continually improve the care delivery system even as it can contain costs.”

Rytting suggested that: (1) Congress and federal agencies should ensure that their approaches utilize a technology-neutral approach, so as not to “lock in” a limited set of solutions that, while deemed adequate for today, may impede innovations; (2) well-intentioned overregulation can act as a disincentive to investment and innovation in the healthcare space, potentially short-changing or harming patients; (3) there is an ongoing need for cross-agency coordinated inquiries into opportunities for wireless broadband allocations that can be utilized by healthcare applications; (4) in the Universal Service Fund context, the FCC’s policies should constantly be re-examined for ways to foster innovation; and (5) the solutions needed for a fully connected healthcare system must be able to utilize both licensed as well as unlicensed spectrum, and be permitted to operate with appropriate sharing arrangements.

Report highlights 2014 quality improvement achievements, 5-year goals

CMS’ 2014 Quality Improvement Organization (QIO) Program report describes its new program structure, highlights its recent statistical achievements, offers examples of its successes, and outlines its five-year goals for the QIO program.

Program structure

According to the report, the new structure of the QIO program follows a functional model with two types of QIOs: (1) Quality Innovation Network-QIOs (QIN-QIOs); and (2) Beneficiary and Family Centered Care-QIOs (BFCC-QIOs). This dual function structure separates the regulatory complaint review process from quality improvement work. For example, 14 regional QIN-QIOs work with providers, community partners, and beneficiaries on initiatives to improve patient safety, reduce harm, engage patients and families, improve clinical care, and reduce health care disparities. Two BFCC-QIOs manage all beneficiary complaints and appeals across the nation.

Achievements

According to CMS, recent achievements from the program include:

  • nearly $1 billion in cost savings from combined QIO programs;
  • recruitment of 1,826 professionals potentially impacting 4.1 million beneficiaries;
  • 53 percent reduction in central line-associated blood infections;
  • 20 percent improvement in controlling blood sugar levels among participants screened;
  • 5,021 nursing homes participating in a national collaborative;
  • 6,250 beneficiaries in 981 nursing homes now restraint-free;
  • 3,374 bed sores prevented or healed in 787 nursing homes; and
  • 44,640 potential adverse drug events prevented.

Examples of success

CMS offered examples of its successes in the areas of better health, better care, lower cost, hospital engagement, using data from the Centers for Disease Control and Prevention (CDC) for prevention, and the Million Hearts® initiative.

  • Better health. CMS highlighted the following better health efforts: (1) using faith-based organizations to promote heart health; (2) maximizing electronic health record system benefits for physicians and patients; (3) the Everyone with Diabetes Counts program going national; and (4) partnering with local colleges to train bilingual diabetes educators.
  • Better care. Highlights of better care initiatives included: (1) collaboration with hospitals to reduce health care-associated infections (HAIs); (2) creating a replicable model for sustainable quality improvement; (3) enabling peer-to-peer learning and sharing for nursing home staff; (4) using new processes to prevent adverse drug events; and (5) tools for improving discharge communications and fewer drug errors.
  • Lower costs. Initiatives to lower costs included: (1) implementation of agreed-upon quality measures; (2) the use of value-based payment and quality reporting models; and (3) helping providers in multiple care settings to navigate quality reporting requirements.
  • Hospital engagement. CMS highlighted the cooperation of the Washington State Hospital Association and Qualis Health Quality Innovation Network, the QIN-QIO for Idaho and Washington, which are jointly tackling common health concerns, including reducing hospital readmissions and HAIs.
  • CMS highlighted a 2014 CDC pilot program with seven QIOs to reduce catheter-associated urinary tract infections.
  • Million Hearts campaign. CMS reported that QIN-QIOs are adding a community level connection to the Million Hearts initiative to prevent one million heart attacks and strokes by 2017.

Five-year goals

The QIN-QIO five-year goals focus on the patient and a commitment to achieving better care, better health, and lower costs. They include:

  • improving cardiac health and care disparities;
  • increasing diabetes awareness and education;
  • improving prevention through meaningful use of health information technology;
  • reducing HAIs;
  • improving nursing home resident care and safety;
  • reducing antipsychotic drug use in long-term care facilities; and
  • using a community approach to fully support coordination of care and the reduction of preventable hospital admissions and readmissions.

Senate takes ‘spring break'; CMS delays ‘doc cuts’ and ‘two-midnight rule’

CMS has indicated that it will give Congress until April 15 to prevent Medicare payments cuts to physicians, and will extend the delay on enforcement of the “two midnight” payment rule until the end of April.

Doc cut

The Medicare payment cuts to physicians are triggered by Medicare’s “sustainable growth rate” formula (SGR), which established yearly targets for physicians’ service under Medicare, and are intended to control the growth in aggregate Medicare expenditures for physicians’ services. Congress has been trying to repeal the SGR formula since 1997.

On March 26, the House approved a $214 billion bill, H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, which would repeal the SGR formula. The vote was 392-37, with 180 Democrats and 212 Republicans voting yes. The Senate left on its spring break before taking action on the bill. When the Senate reconvenes on April 13, it will have only two days to act before the physician payment cuts kick in.

The 21-percent SGR cut was actually scheduled to take effect on March 31, but CMS indicated it would hold off processing claims at the lower rate until April 15, and will reprocess claims paid at a lower rate to reflect the new payment rates, if the Senate passes the bill.

The American Medical Association and the American Hospital Association both expressed extreme disappointment after the Senate failed to pass the SGR repeal bill before it recessed (see Extremely disappointed’ in SGR repeal voting delay, AMA implores Senate to act; AHA concurs, March 30, 2015.

Two-midnight payment rule

CMS also announced that it will delay enforcement of the “two midnight” payment rule for short hospital stays until April 30. This delay will allow the Senate time to pass H.R. 2, which not only repeals the SGR formula, but includes a six-month delay in enforcement of the two-midnight payment rule.

The two-midnight payment rule, which is opposed by inpatient hospitals, assumes that an inpatient admission is appropriate and Medicare Part A payment is warranted if a patient’s stay spans two midnights.

The two-midnight rule was designed to address an increase in observation stays inspired by hospital fears that Medicare’s recovery audit contractors would challenge their admissions. The policy has been repeatedly delayed by legislative and regulatory action. Hospitals claim that the policy undermines their professional judgment to admit a patient for less than two midnights (see Whether two midnights or more, observation is costly for patients, Health Law Daily, September 9, 2014).

CMS plans to continue its Inpatient Probe and Educate process until April 30, 2015, and will thereby continue to prohibit recovery auditor inpatient hospital patient status reviews through that date.

2015 Health IT certification criteria would enhance interoperability

The HHS Office of the National Coordinator for Health Information Technology (ONC) has issued an advance release of a Proposed rule introducing a 2015 Edition of Health Information Technology (IT) Certification Criteria (2015 Edition), proposing a new 2015 Edition Base Electronic Health Record (EHR) definition, and modifying the ONC’s Health IT Certification Program to make it accessible to more types of health IT and health IT supporting various care and practice settings.

The 2015 Edition Proposed rule would also establish the capabilities, standards, and implementation specifications that Certified Electronic Health Record Technology (CEHRT) would need to achieve meaningful use by eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) under the Medicare and Medicaid EHR Incentive Programs (EHR Incentive Programs).

Background

The Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 (the Recovery Act) (P. L. 111–5), was enacted on February 17, 2009. The

HITECH Act amended the Public Health Service Act (PHSA) (42 U.S.C. 201 et. seq.) and created “Title XXX – Health Information Technology and Quality” to improve health care quality, safety, and efficiency through the promotion of Health IT and electronic health information exchange. Section 3001(c)(5) of the PHSA (42 U.S.C. sec. 300jj-11) provides the National Coordinator with the authority to establish a certification program or programs for the voluntary certification of health IT.

On July 28, 2010, HHS issued a Final rule adopting the initial set of standards, implementation specifications, and certification criteria and realigning them with the final objectives and measures established for the Medicare and Medicaid EHR Incentive Programs Stage 1 (75 FR 44590), referred to as the “2011 Edition Final rule.”

On September 4, 2012, a Final rule was issued to adopt the 2014 Edition set of standards, implementation specifications, and certification criteria and realign them with the final objectives and measures established for the EHR Incentive Programs Stage 2 as well as Stage 1 revisions (77 FR 54163), referred to as the “2014 Edition Final rule.”

Then, on September 11, 2014, another Final rule was published which revised the 2014 Edition EHR certification criteria to provide flexibility, clarity, and enhance health information exchange (79 FR 54430), referred to as the “2014 Edition Release 2 Final rule.”

2015 Edition certification criteria

HHS’ 2015 Edition Proposed rule builds on this prior rulemaking to facilitate greater interoperability and enable health information exchange through new and enhanced certification criteria, standards, and implementation specifications. HHS believes that these changes will spur innovation, open new market opportunities, and provide more choices to providers when it comes to electronic health information exchange. To achieve these goals, the 2015 Edition Proposed rule would:

  • improve interoperability for specific purposes by adopting new and updated vocabulary and content standards for the structured recording and exchange of health information, including a Common Clinical Data Set composed primarily of data expressed using adopted standards; and rigorously testing an identified content exchange standard (Consolidated Clinical Document Architecture (C-CDA));
  • facilitate the accessibility and exchange of data by including enhanced data portability, transitions of care, and application programming interface (API) capabilities in the 2015 Edition Base EHR definition;
  • establish a framework that makes the ONC Health IT Certification Program open and accessible to more types of health IT, health IT that supports a variety of care and practice settings, various HHS programs, and public and private interests;
  • support the Medicare and Medicaid EHR Incentive Programs through the adoption of a set of certification criteria that align with proposals for Stage 3;
  • address health disparities by providing certification standards for the collection of social, psychological, and behavioral data; for the exchange of sensitive health information; and for the accessibility of health IT;
  • ensure all health IT presented for certification possess the relevant privacy and security capabilities;
  • improve patient safety by applying enhanced user-center design principles to health IT, enhancing patient matching, requiring relevant patient information to be exchanged, improving the surveillance of certified health IT, and making more information about certified products publicly available and accessible;
  • increase the reliability and transparency of certified health IT through surveillance and disclosure requirements; and
  • provide health IT developers with more flexibility and opportunities for certification that support both interoperability and innovation.

The 2015 Edition Proposed rule will publish in the Federal Register on March 30, 2015. Comments on the Proposed rule may be submitted through May 29, 2015.