Overview

By Douglas McCarthy and Karen Fox

A state university created a telehealth network to improve the health of nearby underserved and isolated populations through education, research, and service.

Issue: Economically disadvantaged individuals living in isolated areas often have difficulty traveling long distances to access care in urban centers and, as a result, suffer disproportionately from poor management of chronic conditions. Such underserved populations are ideal candidates for telehealth applications, which provide remote access to specialty care and educational services that are not available locally. Challenges for evaluating the effectiveness of telehealth include defining standard metrics for measuring its financial and clinical value and meeting decision-makers' need for timely, tangible information to guide policy.

Objective: The University of Tennessee Health Science Center (UTHSC), in Memphis, created a Telehealth Network and Outreach Center to:

1. improve disadvantaged and isolated populations' access to specialty medical care;
2. develop and implement programs to improve access to health education for rural clinicians and families in disadvantaged and isolated areas;
3. promote innovative, community-based collaborations through technology that facilitates inter-community learning; and
4. conduct practical research on improving the delivery of health care to disadvantaged and isolated populations.

Organization: The UTHSC Outreach Center houses the UTHSC Telehealth Network, one of the largest of its kind in the United States. Outreach Center staff coordinate scheduling, care, medical records, billing, and protocols to ensure the privacy of telehealth patients.

The UTHSC Telehealth Network links more than 100 sites, including the university's five colleges on four campuses (Memphis, Knoxville, Chattanooga, and Martin), rural hospitals and clinics, pharmacies, health departments, youth development centers, community health centers, schools, cancer outreach clinics, rural diabetes sites, agricultural extension sites, and a mobile dental van.

Date of Implementation: Implementation of the UTHSC Telehealth Network began in 2001.

Target Populations: The Telehealth Network serves disadvantaged and isolated populations in Tennessee, Mississippi, and eastern Arkansas.

Key Measures: UTHSC Telehealth Network projects have measures of success that include:

• Access and efficiency: no-show rate and patients seen per hour
• Patient experiences and outcomes: waiting time, satisfaction, and clinical outcomes (e.g., blood sugar control for diabetes)
• Safety: medication management and polypharmacy
• Cost: outpatient and pharmaceutical cost, travel time, and expense

Interventions: The UTHSC Outreach Center has initiated 16 ongoing telehealth projects, two of which are described below. (The Sidebar describes two additional projects focused on improving chronic disease management.)

The West Tennessee Hospital Telehealth Project established telehealth infrastructure at five rural hospitals outside Memphis, with startup funding from the federal Office for the Advancement of Telehealth. UTHSC and the Le Bonheur Children's Medical Center in Memphis provide specialty care services and educational programming using videoconferencing technology.

Rural or isolated physicians contact the Telehealth Network by phone to request specialty referrals and a coordinator arranges appointments. Many specialists have "blocked out" times for telehealth consultations, and all telehealth patients are tracked in secure registries.

A local nurse presents the patient to a specialty physician and is available to answer questions before, during, and after the videoconference examination. The nurse operates a special exam camera to view the patient's skin, throat, and eyes; an otoscope for ear examinations; a stethoscope; and a document camera to view X rays and photographs. By using such technologies, consulting specialists are able to see the same things that the nurse or other professional sees and "walk" them through procedures that they otherwise might not perform.

Following the exam, the Memphis-based specialist faxes relevant portions of the patient's medical record to the referring physician. In this way, the local physician can provide follow-up care and further referrals if needed. (The UTHSC Telehealth Network is currently implementing electronic medical record technology to transfer this information.)

Local physicians can use the videoconferencing technology to participate in weekly "grand rounds" at UTHSC. Each month, about 300 community members attend group and one-on-one videoconferences on topics such as chronic disease management, smoking cessation, and breastfeeding.

UTHSC and the University of Tennessee Cancer Institute recently initiated the Technology Exchange for Cancer Health Network (Tech-Net) with funding from the Agency for Healthcare Research and Quality. This three-year project links seven remote cancer outreach clinics with cancer specialists at UTHSC. It combines the Telehealth Network with an integrated electronic health record and decision-support system, online management of cancer protocols, electronic orders, and a medication management system to improve comprehensive adult cancer care.

In this and other projects, patients generally rate their telehealth visits positively (See Results). Anne Taylor, a patient who uses telehealth for follow-up oncology care, says, "I love it because I am very rurally located. I drive 40 miles one way to the doctor and have to take a day off of work." With telehealth consultations, she no longer has to spend extra money on gas to get to her appointments or lose a day's pay to access the specialty health care she needs.

UTHSC is reimbursed for telehealth services by 35 third-party payers, including Tenncare and Mississippi Medicaid, Blue Cross Blue Shield, and commercial insurers. Reimbursement rates are the same as, or in some cases higher than, in-person visits. UTHSC is also seeking to obtain reimbursement for non-physician services such as nutrition counseling and diabetic group meetings.

Results: More than 4,500 patients have been seen through the UTHSC Telehealth Network since 2003. Overall, the results indicate:

• The time between patient referral and treatment is 39 percent shorter for telehealth patients compared with in-person visits.
• Overall waiting room times are almost 50 percent shorter for telehealth patients compared with traditional patients.
• The no-show rate for telehealth visits ranges from 0.7 to 4.8 percent, as compared with 42 to 46 percent for patients referred to UTHSC from outside Memphis.
• Patient throughput is higher for telehealth visits, averaging 3.76 patients per hour versus 2.25 patients per hour for traditional specialty visits.
• Patients rate telehealth visits highly: 96 percent said they were as good quality as regular office visit and 53 percent rated them as higher quality; 100 percent agreed that the specialist's attention was as good as a regular visit and 60 percent rated it better.
• Care for chronic diseases has resulted in improved control of blood sugar, blood pressure, blood lipids, and asthma symptoms (See Sidebar).

Lessons Learned: Due to their demonstrated impact on access, quality, and cost, most of UTHSC's telehealth projects have continued beyond their initial grants through contracts or renegotiated reimbursement schedules. Collaborations with local community organizations minimize the risk of failure by leveraging existing resources and ensuring that telehealth services are meeting actual, significant, and ongoing community needs.

Following demonstration projects, larger service areas must be considered to realize the effective use of telehealth. Changes in the "culture" of referral patterns and use of technologies might require retraining local medical communities about new ways of getting patients the care they need. Focused projects, such as TechNET, that address a specific clinical area also generate considerable utilization and provide a valuable service to the community.

Telehealth services need to be located where individuals are most likely to use them. In some cases, that might be a clinical site while in others it might be a community center. The West Tennessee project's use of local hospitals helped establish the perception that telehealth services are available to the entire community.

Providing feedback to local practitioners on their patients' telehealth consultations is important to ensure continuity of care and enable them to resume care in the local community. Though patients referred to urban centers often continue to seek care there, it might not be the most cost-effective setting.

Beyond making services more accessible, telehealth provides opportunities to improve traditional care. Real-time monitoring through home-based telehealth applications, for example, enables more proactive patient management and can be important for vulnerable patients (See Sidebar).

Likewise, telehealth can provide subjective benefits that translate into improved care. Many practitioners avoid rural areas because of their perceived isolation from colleagues. Actively participating in grand rounds through videoconferencing can help rural practitioners maintain collegiality with urban specialists. Telehealth mentoring also gives professionals the knowledge and confidence to handle a crisis within their own community, avoiding expensive patient transports and possibly saving patients' lives.

Implications: Telehealth has the potential to improve health care access, quality, and efficiency. Although its cost-effectiveness needs further study, the evidence to date suggests that cost savings are shared by the patient (through reductions in waiting time, time away from work, and travel time), third-party payers (through reduced reimbursement for travel and more timely and appropriate treatment that averts costly complications) and providers (through efficiencies in the care process).

Scott Young, M.D., director for health information technology (IT) at the Agency for Healthcare Research and Quality, says telehealth is "one of the areas of real tangible benefit in health IT." The blending of telehealth, electronic health records, and clinical decision support is a promising development in use of health IT, he says.

"In the beginning, the potential of using telehealth as a means of providing more timely access to health care was not fully appreciated," adds William Rosenberg, M.D., a University of Tennessee Medical Group dermatologist who sees about 20 patients per month via telehealth. "However, it won't be long before everyone realizes that patients can receive the same, and sometimes better, quality health care through this technology."

For Further Information: Contact Karen Fox at kfox@utmem.edu.

Karen Fox, Ph.D., is vice chancellor for community affairs at the University of Tennessee Health Sciences Center, Memphis. She directs the university's Outreach Center, which is responsible for the University of Tennessee Telehealth Network and related research projects to evaluate the use and effectiveness of telehealth.

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SIDEBAR: UTHSC Telehealth Network Projects Aim to Improve Chronic Disease Management The Mid-Appalachia Telehealth Project is a partnership between UTHSC and several underserved mountain communities in East Tennessee focused on improving chronic disease management in accordance with Healthy People 2010 objectives. The federal Office for the Advancement of Telehealth provided startup funding for the project. Diabetes patients in need of close monitoring are given home-based telehealth equipment to record and forward daily glucose readings and other vital statistics to nurses in local health departments and community health centers. Nurses conduct weekly telephone assessments with patients and proactively call them when monitoring data indicate that something is amiss. The nurses also contact patients to offer preventive education, support adherence to treatment, adjust medications, and schedule appointments as needed. Videoconferencing capabilities (using ordinary phone lines) enable nurses to make visual contact and observations. Through a telehealth partnership with local schools and clinics, children with asthma are regularly monitored using peak flow meters available in the schools. Test results are electronically forwarded to local clinic nurses. The system flags readings that are out of normal range so that nurses can make changes in management as needed. Children receive a video game to learn about asthma self-management and attend weekly one-on-one educational sessions with a clinic nurse to review peak flow meter use and asthma management. Specialty pulmonary consultations are available when needed through the Telehealth Network. The project has conducted nearly 2,000 in-home televisits with 117 adult diabetes patients since 2004. Among 42 diabetes patients who completed six months in the program, 71 percent had an improvement in blood sugar control (hemoglobin A1c level) and one-third achieved a decrease of 1 percent or greater. Among 53 participating school children with asthma, two-thirds showed an improvement in peak flow meter readings after being in the program for an average of six months. The Delta Health Partnership is a collaboration between UTHSC and the University of Mississippi Medical Center, Jackson, that provides comprehensive diabetes care for an underserved population of predominantly African American patients in rural areas of the Mississippi Delta region. More than one-third of these patients lack health insurance coverage. The federal Office for the Advancement of Telehealth provided startup funding. The project uses videoconferencing to link local nurse practitioners, physician assistants, and pharmacists with a multidisciplinary diabetes team for patient consultations, patient and provider education, case management, and quality assurance. These specialty services would otherwise be available only through four- to six-hour round trips by patients or providers. The Delta Health Partnership has enrolled 61 patients for at least six months and provided more than 1,000 televisits during one year of operation. Preliminary outcomes include improved blood sugar control (average hemoglobin A1c level fell from 9.0 at entry to 7.5 after 12 months), improved blood pressure control, and improved blood lipids. Telehealth communications have reduced travel expenses and freed up about 20 percent of faculty specialists' travel time.

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This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.