By Lisa Fratt
The jury is still out on telemedicine. Proponents and many patients appreciate its ability to deliver virtual patient care and to extend the reach of experts beyond the brick-and-mortar setting of a hospital. But the real question about telemedicine is: Does it make it difference? Does is it improve care and if so, in what circumstances?
TeleCAPE, a small pilot project at Boston Children’s Hospital, inches the dial toward "yes" for some patients – in particular, home-ventilated patients.
Home-ventilated patients require an inordinate amount of health care resources for even minor conditions. Costs for a simple urinary tract or viral respiratory infection that might be managed without hospitalization can reach up to $83,000 because the child’s complex medical needs require ICU admission.
From CAPE to TeleCAPE
The TeleCAPE program, funded by an Innovestment Grant from the hospital’s Innovation Acceleration Program and implemented with the assistance of the Telehealth Program, boosts the capabilities of Boston Children’s CAPE (Critical Care, Anesthesia, Perioperative Extension & Home Ventilation) program with remote teleconference visits.
Established in 2007, CAPE serves more than 250 home-ventilated patients. CAPE staff, including two part-time intensivists, a nurse practitioner, a respiratory therapist, a social worker and an administrator, provides home visits and telephone-based triage services to these patients. Patients range in age from infants to young adults. The majority carry primary diagnoses leading to progressive respiratory insufficiency, such as muscular dystrophy, spinal muscular atrophy or cerebral palsy.
It’s a successful program. Keeping kids out of the ICU and facilitating discharge to home care or a lower-intensity rehabilitation setting eliminated nearly $1 million in charges in 2009 and 2010. A less quantifiable, but equally important, outcome is the trusting relationships between CAPE providers, patients and their families.
Room for further improvement?
The doctors on the CAPE team – David Casavant, MD, and Robert Graham, MD, from the Division of Critical Care Medicine – sought to answer several questions during the TeleCAPE pilot from January 2012 to September 2013. They wondered if it would be possible to teleconference with patients in their homes, with high enough audio and visual quality to be useful, and whether this could help in making clinical decisions.
Casavant, Graham and their team selected 14 patients, ranging from 6 months to 35 years old, to participate in the pilot. "We wanted patients who represented our population, who used our services more often, who might be helped by the telemedicine visits," says Casavant. Participants had to have a computer, Web camera and Internet access.
The telemedicine virtual visits use encrypted, HIPAA-compliant software (Vidyo) to enable voice and visual connections between clinicians and their patients at home. Providers conducted 27 telemedicine visits: 15 for routine health care maintenance, 10 follow-ups for clinical problems and two visits for acutely sick patients.
In surveys, the families gave the technology high marks for ease of use, minimal cost and audio and visual quality. When families were asked to compare phone with video as an effective means of observation, video emerged superior. "It’s not too surprising. Most people thought we could appreciate clinical nuances like work of breathing better with telemedicine," says Casavant.
The addition of video also improved families’ confidence in clinical management.
Yet major questions remained. Does the program make a difference in clinical care and, if so, in which patients and in what circumstances?
The case of a 6-month-old New Hampshire infant with chronic lung disease illustrates how video visits can improve the care process. The parents phoned the CAPE service and described the child’s breathing as progressively worsening. In the past, this would have prompted transport to the hospital and admission to the ICU.
Casavant and Graham conducted a telemedicine visit and realized the infant’s condition was not as compromised as described. They recommended that the parents perform maneuvers to clear lung secretions and improve oxygenation, and followed up with a second telemedicine visit a few hours later. During the followup, the parents agreed that the intervention had succeeded and a visit, transport and subsequent ICU admission were avoided. Based upon estimates from national health care utilization data, this resulted in an approximate savings of $90,000 for ICU admission.
"When we reviewed the visits of the pilot study, we found that the telemedicine encounters for routine health care issues usually revealed a calm, relaxed patient and did not change our plan for care," Casavant says. "On the other hand, in patients who had active clinical issues, the telemedicine image was crucial in our decision-making. In these sicker patients, the image added information about the patient’s clinical state such as fatigue, the effort required to breathe, how aggressive a skin infection was and whether the patient was showing signs of withdrawal. This information influenced our clinical decision-making."
The TeleCAPE program pairs technical innovation with payment and policy innovation. Although several federal and state bills, including the federal Telehealth Promotion Act, are aimed at reimbursing clinicians for telehealth visits, Casavant and team are thinking beyond reimbursement for each encounter.
"Our approach is about efficiency more than reimbursement," explains Casavant. "As the payment model transitions toward a global payment or a single reimbursement for the care of a patient, reimbursement for a single visit becomes less important. Providers will be compensated based on how efficiently they care for a patient."
Taking a closer look at the financial impact of telemedicine in this patient population will be the next challenge as the TeleCAPE program continues.