Linking Telehealth Strategies to Evidence Based Practice (T5B1)

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  • In April 2004, President George W. Bush revealed his vision for the future of healthcare in the United States. The President's plan involves a health care system that puts the needs of the patient first, is more efficient, and is cost-effective. The President's plan is based on the following tenets: Quality initiatives will measure performance and drive quality-based competition in the industry Clinical research will be accelerated and post-marketing surveillance will be expanded. Together, these tenets will revolutionize healthcare, making it more consumer-centric, and will improve both the quality and the efficiency of healthcare in the United States.
  • Linking Telehealth Strategies to Evidence Based Practice (T5B1)

    1. 1. Nina M. Antoniotti, RN, MBA, Ph.D. Marshfield Clinic TeleHealth Marshfield, Wisconsin <ul><li>Tying TeleHealth to Quality: </li></ul><ul><li>Where is Your Chasm? </li></ul><ul><li>American Telemedicine Association Annual Meeting </li></ul><ul><li>Nashville, Tennessee </li></ul><ul><li>May 2007 </li></ul>
    2. 2. TeleHealth/Telemedicine <ul><li>Telemedicine </li></ul><ul><li>The use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. </li></ul><ul><li>“ telehealth,” which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. </li></ul><ul><li>Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers. (Retrieved 04-23-07 www.americantelemed.org) </li></ul>
    3. 3. Quality
    4. 4. <ul><li>Quality can refer to: </li></ul><ul><li>Technical interpretation - A specific characteristic of an object ( the qualities of ice - i.e. its properties) </li></ul><ul><li>Philosophical interpretation - The essence of an object ( the quality of ice - i.e. &quot;iceness&quot;) </li></ul><ul><li>Practical interpretation - The achievement or excellence of an object ( good quality ice - i.e. not of inferior grade) </li></ul><ul><li>Metaphysical interpretation - The meaning of excellence itself </li></ul><ul><li>Scientific interpretation – In physics, the range of frequencies over which something will characteristically respond. ( www.wikepedia.com , accessed 5-07) </li></ul>
    5. 5. Quality <ul><li>Not limited by sector, form of payment, organizational type, or clinical discipline </li></ul><ul><li>Two fundamental components: </li></ul><ul><ul><li>Technical, scientific appropriateness, competency, and accuracy of care (Five R’s). </li></ul></ul><ul><ul><li>Delivered in a safe and technically competent manner that is acceptable to the patient. </li></ul></ul>
    6. 6. Definition of Health Care Quality <ul><li>The degree to which </li></ul><ul><li>Health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Lohr, 1990) </li></ul>
    7. 7. <ul><li>Evaluation of Quality </li></ul><ul><ul><li>Structure </li></ul></ul><ul><ul><ul><li>Provides the setting, credentialing standards and infrastructure to support good care </li></ul></ul></ul><ul><ul><li>Process </li></ul></ul><ul><ul><ul><li>Appropriate evidence-based care as a key component in achieving good outcomes for patients </li></ul></ul></ul><ul><ul><li>Outcome </li></ul></ul><ul><ul><ul><li>Considers the appropriateness, efficiency, and variation of care creating value-added and meaningful care </li></ul></ul></ul>                                                    
    8. 8. Determinants of Quality Characteristics of Quality IOM Six Chasms (2001) Haddad et al. (1998) Gooding (1999) Foundations of Quality (2000) President’s Advisory Commission (1998) Safe Conduct of health staff Availability of specialized care Technically safe and appropriate Reducing the underlying causes of illness, injury, and disability Effective Technical care including outcomes Personal relationship with health care provider Acceptable for the patient Expand research on new treatments and evidence on effectiveness Patient-Centered Convenience of facility Technology   Ensuring the appropriate use of health care services Timely Organization of care Familiarity   Reducing health care errors Efficient Drugs     Addressing oversupply and undersupply of health care resources Equitable       Increasing patient’s participation in their care
    9. 9. Chasm <ul><li>The Gap between average care… </li></ul><ul><li>… and the best care </li></ul>
    10. 10. IOM Six Chasms <ul><li>Safe – avoiding injuries to patients from the care that is intended to help them. </li></ul><ul><li>Effective – providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse). </li></ul>
    11. 11. Six Chasms <ul><li>Patient Centered – providing care that is respectful of and responsible to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. </li></ul><ul><li>Timely – reducing waits and sometimes harmful delays for both those who receive and those who give care. </li></ul>                                                                                  
    12. 12. Six Chasms <ul><li>Efficient – avoiding waste, in particular, waste of equipment, supplies, ideas, and energy </li></ul><ul><li>Equitable – providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socio-economic status (IOM, 2001, p. 39-40) </li></ul>
    13. 13. <ul><li>“… a health care system that achieved major gains in these six dimensions would be far better at meeting patient needs. Patients would experience care that was safer, more reliable, more responsive, more integrated, and more available. Patients could count on receiving the full array of preventive, acute, and chronic services from which they are likely to benefit. Such a system would also be better for clinicians and others who would experience the satisfaction of providing care that was more reliable, more responsive to patients, and more coordinated than is the case today.” (IOM, 2001, p.6) </li></ul>
    14. 14. Where Does TeleHealth Fit? <ul><li>Interactive video consultations </li></ul><ul><ul><li>Safe, patient-centered, timely, efficient, effective, equitable </li></ul></ul><ul><li>Store-and-forward </li></ul><ul><ul><li>Safe, timely, efficient, effective </li></ul></ul><ul><li>Remote monitoring </li></ul><ul><ul><li>Safe, patient-centered, timely, efficient, effective </li></ul></ul>
    15. 15. IOM’s Six Chasms of Quality <ul><li>Patient Centered </li></ul><ul><ul><li>Reduces the burden of access to health care </li></ul></ul><ul><ul><li>Provides necessary services in underserved, disparate areas </li></ul></ul><ul><li>Safe </li></ul><ul><ul><li>Diagnostic accuracy, technical superiority </li></ul></ul><ul><ul><li>Better patient compliance </li></ul></ul><ul><li>Timely </li></ul><ul><ul><li>Reduces time from referral to appointment </li></ul></ul><ul><ul><li>Introduces specialist earlier in the process of care </li></ul></ul><ul><ul><li>Early symptom management for chronic conditions </li></ul></ul>
    16. 16. IOM’s Six Chasms of Quality <ul><li>Efficient </li></ul><ul><ul><li>Time neutral or less time for providers </li></ul></ul><ul><ul><li>Patient is better prepared </li></ul></ul><ul><ul><li>No duplication of services </li></ul></ul><ul><ul><li>Higher productivity for providers – especially for health professions shortages </li></ul></ul><ul><ul><li>Increased collaboration/communication between providers </li></ul></ul><ul><ul><li>Lower no-show rate </li></ul></ul>
    17. 17. IOM’s Six Chasms of Quality <ul><li>Effective </li></ul><ul><ul><li>Quality, cost, outcomes studies </li></ul></ul><ul><ul><li>Stabilization of rural practices </li></ul></ul><ul><ul><li>Reduction in the number of ED visits, unnecessary physician office visits, unnecessary care </li></ul></ul><ul><ul><li>Reduction in the total number of visits </li></ul></ul><ul><li>Equitable </li></ul><ul><ul><li>Reimbursement </li></ul></ul><ul><ul><li>Transmission costs </li></ul></ul>
    18. 18. Quality Management <ul><li>Training </li></ul><ul><li>Operational Systems </li></ul><ul><ul><li>Scheduling and Appointing </li></ul></ul><ul><ul><li>Billing and Coding </li></ul></ul><ul><li>Patient Satisfaction </li></ul><ul><li>Provider Satisfaction </li></ul><ul><li>Monthly Management Reporting </li></ul><ul><li>Evidenced-based Practice </li></ul><ul><li>Clinical Outcomes </li></ul>
    19. 19. What TeleHealth Can Mean to Strategic Management <ul><li>Outpatient Specialty Clinics </li></ul><ul><li>In-patient assessment and support </li></ul><ul><li>Decision Analysis model for transfers </li></ul><ul><li>Disease Management, Remote Monitoring </li></ul><ul><li>Email consultations </li></ul><ul><li>Practitioner Support </li></ul><ul><li>Practice Support </li></ul><ul><li>CME, CEU, ancillary staff education </li></ul><ul><li>Collaboration between organizations </li></ul>
    20. 20. Pay-for- Performance <ul><li>The use of incentives to encourage evidence-based practices that promote better outcomes and ultimately may result in a transformation of the healthcare system. </li></ul>
    21. 21. Objectives of Pay-for-Performance <ul><li>Align payment and quality </li></ul><ul><li>Facilitate adoption of HIT </li></ul><ul><li>Reduce clinical practice variability </li></ul><ul><li>Creation of infrastructure </li></ul>
    22. 22. Objectives <ul><li>Decreased hospitalizations </li></ul><ul><li>Decreased re-hospitalizations </li></ul><ul><li>Decreased days of stay per episode </li></ul><ul><li>Improvement in health status towards specific indicators </li></ul><ul><li>Decreased use of medications, treatments driven by health status indicators </li></ul><ul><li>Increase in patient/family satisfaction </li></ul><ul><li>Quality and patient safety </li></ul>
    23. 23. <ul><li>Combination of: </li></ul><ul><li>Practice guidelines </li></ul><ul><li>Disease management </li></ul><ul><li>Decision support systems </li></ul><ul><li>Historically paid for: </li></ul><ul><li>Units of service </li></ul><ul><li>$ per person </li></ul>
    24. 24. Pay for Performance <ul><li>Setting performance expectations </li></ul><ul><li>Measuring performance </li></ul><ul><li>Rewarding results through financial and incentive systems </li></ul><ul><li>Measured expectations </li></ul>
    25. 25. <ul><li>Facets of Pay-for-Performance </li></ul><ul><ul><li>Structure </li></ul></ul><ul><ul><ul><li>Provides the setting, credentialing standards and infrastructure to support good care </li></ul></ul></ul><ul><ul><li>Process </li></ul></ul><ul><ul><ul><li>Appropriate evidence-based care as a key component in achieving good outcomes for patients </li></ul></ul></ul><ul><ul><li>Outcome </li></ul></ul><ul><ul><ul><li>Considers the appropriateness, efficiency, and variation of care creating value-added and meaningful care </li></ul></ul></ul>
    26. 26. Is this an Idea of the Week? <ul><li>Rising cost of health care </li></ul><ul><li>No accountability for outcomes </li></ul><ul><li>No payment for higher quality of care </li></ul><ul><li>When patients are kept healthy, doctors and organizations lose money </li></ul><ul><li>66% of persons are served by federal health care programs </li></ul><ul><li>National Academy of Sciences IOM – study proposing federal gov’t link payments to performance </li></ul>
    27. 27. Where Does TeleHealth Fit? <ul><li>Improved access </li></ul><ul><li>More timely access </li></ul><ul><li>More timely introduction of specialist into the process of care </li></ul><ul><li>Early symptom management </li></ul><ul><li>Involves the patient in the process of care </li></ul><ul><li>Decreased hospitalizations, days of care, repeat hospitalizations, use of medications </li></ul>
    28. 28. <ul><li>In a pay-for-performance strategy, TeleHealth is not the solution, but a tool that augments the delivery of care and transfer of information in a pay-for-performance strategy. The technology adoption currently present in TeleHealth may facilitate the adoption of other technologies that support pay-for-performance. </li></ul>
    29. 29. Tying the Knots <ul><li>Tying TeleHealth/Telemedicine – Quality – Pay for Performance – </li></ul><ul><li>together in a strategic management philosophy. </li></ul>
    30. 30. TeleHealth and Rural Health <ul><li>Improves Access </li></ul><ul><li>Provides Accurate and Available Information </li></ul><ul><li>Assists in the deployment of Electronic Medical Records </li></ul><ul><li>Provides Necessary Specialty Services </li></ul><ul><li>Provides Chronic Disease Management (Care Management) </li></ul><ul><li>Provides Health Services for the Elderly, Disabled, Home Bound </li></ul>
    31. 31. What TeleHealth Can Mean to Rural Providers <ul><li>Outpatient Specialty Clinics </li></ul><ul><li>In-patient assessment and support </li></ul><ul><li>Decision Analysis model for transfers </li></ul><ul><li>Disease Management, Remote Monitoring </li></ul><ul><li>Email consultations </li></ul><ul><li>Practitioner Support </li></ul><ul><li>Practice Support </li></ul><ul><li>CME, CEU, ancillary staff education </li></ul><ul><li>Collaboration between organizations </li></ul>
    32. 32. TeleHealth and their networks are uniquely positioned for the assessment, evaluation, implementation, and deployment of electronic medical records.
    33. 33. <ul><li>Soon, physicians may be looking for something that helps them prepare for a new reimbursement environment, one that requires that they measure and report on quality and safety indicators for their practice. </li></ul>
    34. 34. <ul><li>CCHIT Certified EHRs are tested against criteria that include the ability to monitor quality indicators . And as CCHIT’s certification criteria roadmap matures, product testing criteria will likely become more rigorous to keep pace with the growing requirement for quality monitoring. </li></ul>
    35. 35. <ul><li>With the introduction of future interoperability criteria, certification will help physicians and other providers choose products that have the ability to report across care settings and coordinate care between the patient and the physician. </li></ul>
    36. 36. Centers for Medicare & Medicaid Services (CMS) Physician Group Practice (PGP) Demonstration The first ‘value-based purchasing’ demonstration applied to providers.
    37. 37. PGP Objectives <ul><li>Align reimbursement with quality. </li></ul><ul><li>Promotes using utilization and clinical data for improving quality. </li></ul><ul><li>Encourage coordination of Part A and B services. </li></ul><ul><li>Promote efficiency in administrative structures and care processes. </li></ul><ul><li>Reward for improving health outcomes. </li></ul>
    38. 38. To CMS,  Quality = <ul><li>The higher of 75% compliance, or the Medicare mean, or … </li></ul><ul><li> 10 % reduction in gap between administrative baseline and 100% compliance, or… </li></ul><ul><li>70 th percentile of Medicare HEDIS </li></ul>
    39. 39. What were the stated goals? <ul><li>Encourage coordination of Part A and Part B services </li></ul><ul><li>Promote efficiency by investment in administrative structures and care processes </li></ul><ul><li>Reward physicians for improving health outcomes </li></ul><ul><li>In other words . . . . . </li></ul>
    40. 40. CMS wants to avoid this!
    41. 41. Bottom Lines <ul><li>Improving quality without improving efficiency results in $$ </li></ul><ul><li>Improving efficiency without improving quality results in $$ </li></ul><ul><li>Our challenge is to improve quality and efficiency, simultaneously </li></ul>and fast .
    42. 42. Starting Points <ul><li>Primary Prevention: Avoid disease </li></ul><ul><li>Secondary Prevention: Early detection </li></ul><ul><li>Tertiary Prevention: Chronic disease </li></ul><ul><ul><ul><li>Diabetes </li></ul></ul></ul><ul><ul><ul><li>Anticoagulation </li></ul></ul></ul><ul><ul><ul><li>CHF </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>CAD </li></ul></ul></ul><ul><ul><ul><li>Dementia </li></ul></ul></ul><ul><ul><ul><li>Depression </li></ul></ul></ul><ul><ul><ul><li>COPD </li></ul></ul></ul><ul><ul><ul><li>Frail & Elderly </li></ul></ul></ul>HIGH COST CONDITIONS
    43. 43. Fundamental Truth <ul><li>“ Every system is designed perfectly for the results it achieves” </li></ul>- Paul Bataldan, IHI
    44. 44. Quality’s Impact on TeleHealth <ul><li>Formalizes an informal initiative </li></ul><ul><li>Creates expectations for service </li></ul><ul><li>Allows wider distribution of evidence-based practice </li></ul><ul><li>Assists in attainment of benchmarks, goals </li></ul><ul><li>Moves TH out of the grant-funded arena </li></ul>
    45. 45. Quality’s Impact on TeleHealth <ul><li>Creates expectations </li></ul><ul><li>Demands attention to detail, performance, satisfaction </li></ul><ul><li>Pulls in strategic initiatives </li></ul><ul><li>Requires benchmarks </li></ul><ul><li>Proof of clinical outcomes, cost savings, increased value to the customer </li></ul>
    46. 46. Strategic Management for TeleHealth and Quality <ul><li>Ensure that Strategic Management is the foundation for TH/TM initiatives </li></ul><ul><li>Identify TH/TM initiatives within the strategic plan </li></ul><ul><li>Culture change to ‘a way of doing business’ </li></ul><ul><li>Become a TH/TM organization </li></ul>
    47. 47. <ul><li>Leaving out one small detail can make all the difference in the world. </li></ul><ul><li>Make TeleHealth a part of your quality initiatives and quality a part of TeleHealth ! </li></ul>

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