Transcript Telehealth and Health IT for Hospice and Homecare

Benefits and Liability of Health
IT for Homecare and Hospice
Deborah Randall, Esq.
Law Office of Deborah Randall
[email protected]
Overview
• Telephonic, wireless and mHealth developments for
home health and hospice
• HIT studies on chronic disease management, aging
services and diagnostics
• Working home HIT into medical homes and RHIOs
• Efforts in the EU, Ireland, UK in home telehealth
• Quality of care, patient access, control and ethics
• Reimbursement, licensure and risk management
Concerning Medicare and
Telehealth
• "A recent xxxxxx came to visit and was
impressed by [telehealth] technology but
even though [he] may want it, no one in
the health department was incentivised to
take it on because their seats are more
carefully retained if they do more of the
same -- they see disruptive technology as
too risky," Cellar said.
Legislation under Review
• S. 2741, the Rural Telemedicine Enhancing Community
Health (TECH) Act of 2009
• Telehealth pilot projects to analyze clinical outcomes and
cost effectiveness associated with telehealth services in
a variety of geographic areas;
• “Originating sites" = urban areas; telestroke coverage
• Expanded access = store-and-forward and video
conferencing technologies.
• Centers for Medicare and Medicaid Services (CMS)
required to allow credentialing and privileging on multiprovider-site basis, reducing costs/duplication.
Health Reform Legislation
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HHS Center for Innovation
Demonstration for bundled care
Medical Home
Mental Health Parity for Private Insurers
Reduction in Home Health
Reimbursement; quality outcomes factor
• Direction for new Hospice payment review
National Pilot on Patient Bundling
• Pilot for integrated care during an episode of
care around a hospitalization and post-acute
care services
• Looking at factors, to include
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a mix of acute and chronic conditions
evidence for need of quality of care improvement
significant variation in readmissions
significant variation in post-acute care spending
• Common assessment instrument [again]
• Combo of hosp/MD/SNF/HHA may apply
Independence at Home Demo.
• Physician/NP or group[s] of same, and
support team with experience providing
home-based primary care
• In-home visits, access for care 24/7
• 200+High-cost chronically ill beneficiaries
• ‘uses electronic health information
systems, remote monitoring and mobile
diagnostic technology’
• Per capita spending targets& -5% bonus
Fate of the ‘Innovation Center’
• Given the unknowns in any health care
reform progress after Mass. election, what
room is there for additional HHS
infrastructure
• Re-organization of HRSA has
disconnected portions of the grant-making
apparatus, appearing to emphasize rural
settings and ‘traditional’ telehealth
Unsafe at Home - Drugs
• A new national survey of people ages 65 and older who use
medications reports that 51% take at least five different
prescription drugs regularly. Of these:
•
One in four take between 10 and 19 pills each day
35% are not sure they can name all the medications they use
………
17% worry about drug interactions
Source: "New Survey Shows Seniors Struggle Under the Weight of
Multiple Medication Use," Medco Health Solutions press release,
December 29, 2009,
http://medco.mediaroom.com/index.php?s=43&item=417
Unsafe at Home - Falls
• GE QuietCare, a remote passive activity
and behavioural monitoring system for the
elderly, alerts caregivers to subtle changes
= potential health issues, emergency, fall
or emerging health problem.
• Initially in assisted living facilities but now
aimed at clinical decision support at home.
• Alzheimer’s Ass’n funded research.
UK National Health Service
• 2009 /10 National Health Operating
Framework: Primary Care Trusts have as
a “first priority” a new prevention package
for older people that will ‘initially improve
falls and fracture services, foot care,
intermediate care, telecare and audiology
services, with the aim of enabling older
people to live longer, healthier and more
independent lives’
UK PROJECTS
• NHS Efforts with Whole System
Demonstrator; lessons learned about
assumptions of social supports
• Pilot in No.East Essex w Intel and
Turnstall and County installing 400 units
for individuals with COPD and other
chronic illnesses
6000 Persons –WSD telehealth
• Recent NHS publication on
‘Improving the life of health and well-being
of people with long-term conditions’
http://www.dh.gov.uk/dr_consum_dh/group
s/dh_digitalassets/@dh/@en/@ps/docume
nts/digitalasset/dh_111187.pdf
EU/UK Furthest Ahead?
• Clinical trials in Newham,Kent and Cornwall,
United Kingdom, involve 400 patients in each
county suffering from illnesses such as diabetes,
high blood pressure, and heart disease.
• monitored at home via diagnostic equipment
linked by broadband internet connections to
local hospitals and clinics. Savings = “millions of
pounds,” per Britain’s Department of Health
(DoH), because > 14.5 million have chronic
conditions that require monitoring.
UK PROJECTS
• 25 units in private homes; 15 in community
settings such as long term care residences
• Measuring: Physical: blood glucose, ECG,
blood pressure, pulse rate, weight, oxygen
saturation levels, and temperature.
Behavioral/symptom: questionnaires on
symptoms; programmable questions on
coughs, inflammation, medication
adherence and healthy eating.
UK – Scotland COPD Project
• " …patients love the HomePod as it offers
them an unprecedented sense of freedom
and also peace of mind that they are
taking charge of their own health.
• Crucially, it also removes the temptation
for self-diagnosis, either through books
and magazines or on the Internet, which is
all too common but which can also be very
dangerous. " www.ehealthnews.eu
“Telecare” and Dementia
Objective 10: Considering the potential for housing
support, housing-related services and telecare to
support people with dementia and their carers.
The needs of people with dementia and their carers
should be included in the development of housing
options, assistive technology and telecare. As
evidence emerges, commissioners should consider
the provision of options to prolong independent living
and delay reliance on more intensive services.
LIVING WELL WITH DEMENTIA, A NATIONAL DEMENTIA
STRATEGY, UK DEPT OF HEALTH, 2/3/09
Unsafe at Home – Chronic
Symptoms- EU
• New Product [VITALSEN] is a disposable electrode
patch and a reusable clip-on transmitter for management
of chronically ill patients at home and monitoring
inpatients and out-patients attending
• Data measured include heart rate, ECG, temperature
and levels of activity in the chest area, transmitted by
Bluetooth to software in a PC or laptop in the patient’s
home, or in the hospital ward.
HAS CE DESIGNATION IN EUROPE AND IS SEEKING
FDA APPROVAL
Unstable at Home – Chronic Illness
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Blackpool, England [52% predictable long-term health condition for over 65
year olds]
Remote monitoring =>
75% reduction in hospital admissions for COPD & Heart Disease, 12mo
85% reduction in GP visits
43% reduction in home visits.
Patient response =
80% of respondents strongly agreed ---better understanding of their medical
conditions,contributing to management.
70% strongly believed their quality of life had improved. Pilot protocols had
alerts as well as trended data.
FUTURE – Telehealth in obesity management; workplace BP monitoring
Unsafe at Home – Congestive
Heart Failure [CHF]
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Congestive Heart Failure (CHF) Program.
Meridian Health System and MedApps' products [wi-fi;web-based]
pilot generates biometric data for monitoring nurses and attending
physicians. The program will:
1) Monitor signs and symptoms immediately after discharge from
hospital environments and provide comprehensive, individualized
education and follow up support;
2) Promote patient self-management, independence and adherence to
prescribed treatments; and
3) Help identify early signs / symptoms of worsening conditions in a
post acute environment.
4) Reduce re-admission rates and ER utilization of patients with CHF.
• DUKE UNIV. study shows use of remote monitoring and nurse calls
greatly improves outcomes for cardiac patients
New Study in British Columbia
• Telemonitoring of CHF shown to improve outcomes but expensive
equipment.
• Web site study of 20 participants who entered weight and symptoms
onto the Web site for 6 months. Seventeen completed the study.
• Nurse monitored the Web site for changes in participant health
status and telephoned the participants as necessary.
• Self-care, quality of life, 6-minute walk test, and N-terminal
prohormone brain natriuretic peptide (NT-proBNP).
• A significant change in the Self-Care of Heart Failure Index (p =
0.039).
• A Web site to facilitate telemonitoring favorably accepted.
Ill at Home – Mental Health
• American Telemedicine Association [ATA]
issued Standards for telemedicine in
behavioral health field in 2009.
• MSWs, advanced practice psychiatric
nurses, psychologist could provide
counseling to at-home patients.
• Distanced counseling has demonstrated
benefits in clinical outcomes studies.
• Third party insurers might reimburse.
Unstable at Home – Frantic
Caregivers
• Distanced educational benefits from
telemedicine, plus possibilities of grant
funding
• Family and lay caregivers with chronically
ill or terminally ill patients to be guided
through intervention steps prior to calling
EMS or transporting to emergency room
settings.
Unstable at Home – Living Alone
• Falls prevention = clinical trials on medical
devices worn by patients, imbedded in
flooring, sensor and movement driven
• Information about clients conveyed from
‘Smart Homes’. TRIL laboratory with
couples living in experimental housing
sensored for multiple dimensions.
• Making private homes ‘assisted’ living
Ill at Home – Pain Management
and Palliation
• Palliative care physicians are now able to
be Board-certified; specialization and
research interests are increasing
• Patients can be counseled, educated,
advised, offered therapy via social work
services, brought into the hospice care
plan management with videoconferencing
• Studies underway on increased quality of
life and decreased unnecessary ER visits
Unstable at Home – Diagnosis and
Rehabilitation
• UCLA is initiating the Clinical Movement
Assessment System [CMAS] – potential in-home
use to assess progress after neurotraumas and
as a rehabilitative tool to expand the reach of
telemedicine.
• Could possibly be used to differentiate and help
diagnose diseases states, such as Parkinson's
• Clinical assessment device and associated
software captures current and ongoing muscle
and neuromotor functions, yielding quantifiable,
real-time data
At Home-Avoiding Doctors’ Offices
• Maine institutes ‘e-visits’ to reach out of
state patients, students; schedule
appointments, check on test results.
• Anthem Blue Cross and Eastern Maine
Healthcare Systems, and primary doctors
• Between office visits communications
• Specific protocols
• No co-pay for participants
At Home - Rehabilitation
• Grants for seniors’ remote patient monitoring
programs
The Center for Technology and Aging (CTA)- Oakland,
CA
• Up to six one-year grants, totaling $500,000, to
organizations with remote health improvement programs
for elderly adults.
• Must use already-proven technologies that are ready to
be used more broadly.
• Prior experience with remote patient monitoring
technologies and must be able to demonstrate a positive
and measurable impact in the near term. LOI March 12;
start date July 1.
1 http://www.techandaging.org/grants_home.html
At Home – Teenage Patients
• Remotely monitored in-home virtual reality video games improved
hand function and forearm bone health in teens with hemiplegic
cerebral palsy, helping them perform activities of daily living such as
eating, dressing, cooking, and other tasks for which two hands are
needed, according to a study by researchers at Indiana University
School of Medicine (IUSM) and Rutgers University TeleRehabilitation Institute. The findings suggest that such games could
also benefit other persons with movement-hindering afflictions from
strokes, arthritis, multiple sclerosis and orthopedic injuries,
according to study lead author Dr. Meredith R. Golomb, associate
professor of neurology at IUSM. Each participant was asked to
exercise their affected hand 30 minutes per day, five days per week,
using a specially fitted sensor glove linked to a remotely monitored
video game console in their home. The study appears in the January
issue of Archives of Physical Medicine and Rehabilitation.
http://newsinfo.iu.edu/news/page/normal/13065.html
At Home – Teenage Patients
• Type-1 Diabetes
Text messaging for blood sugar levels,
interactions with physicians, general
compliance and maintenance
• Compliance enhanced by rewards of text
minutes- UK studies over five years
Why Isn’t Telehealth Moving
Faster?
• ARRA monies largely emphasize EHRs,
not service delivery..BUT there are ways…
• Hospitals and physicians over HHAs, LTC
and hospices
• HHS attitudes persist in reluctance to
acknowledge evidence of positive
outcomes in community care setting
• The Privacy Paralysis issue
Inertia – Regulatory ‘Mazes’
• ‘Maze-like regulatory regimes that differ
from federal agency to federal agency and
from state to state, as well as hard-tonavigate reimbursement policies on the
part of government and private insurers
are the challenge of the extraordinary
promise of this industry’ ,Hyung Kim, VP
Research, Ascension Health [in 20 states].
Inertia – Public Trust
• Transparency- who has the data and
where is it going
• Control – by the patient as to what
happens to the data and with whom
• Security – of the content of data, in
balance with the concept that even
motionless, paper-based data can be
subject to security breach
Ethical Considerations
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Non-malfeasance = “do no harm”. Are we in danger of doing more
harm than good? Example: Is there a risk that a piece of equipment
may lead to more confusion or distress.
• Beneficence = striving consciously to be “of benefit” to a person.
Enabling access to support or help if they fall or helping them take
their medication.
• Autonomy = respecting the person’s rights to things like self
determination, privacy, freedom, and choice. If a device such as a
sensor mat helps monitor falls risk, would it be used just to tell the
person not to walk or get up, or would the person be offered a
companion to walk with safely?
• Justice = treating everyone fairly. Equal access to technology, or
taking into account diversity and individual differences.
Stephen Wey, University College of York St. John / WSDAN
National Quality Forum Measures Home Care =>Telehealth Options?
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timely initiation of care;
patient and caregiver education;
preventive services;
pain intervention and assessment;
improvement and assessment of clinical
symptoms;
• improvement in functional status;
• assessment of need for emergency care or
hospitalization;
• patient experience of care.
Where are we on Liability?
• JAMA : “HIT Vendor Contracts Shift
Liability to Health Care Providers”, Ross
Koppel & David Kreda, 3/25/09
• “Hold harmless” clauses in computer
software contracts
• “Learned intermediary” defense
• Providers’ experience: software contracts
averse to risk sharing or “partnering”
Where are we on Liability?
• Physician practice across state lines
• Increased number of states with “special”
telemedicine licenses/requirements
• Prosecution and sentencing of physician
who, without speaking with the person,
renewed prescription for generic Prozac to
college student who committed suicide
• CMS/JCAHO on hospital credentialing
Limited Research on Liability
Telemedicine & E-Prescribing:Evolving Ethical,
Licensing & Reimbursement Rules & Realities,
ABA 2008
E-Health Hazards, Sharona Hoffman and Andy
Podgorski, Case Western Reserve Research Paper
Liability Coverage for Regional Health Information
Organizations - Lessons from the AHRQ-Funded
State and Regional Demonstration Projects in
Health Information Technology and Other
Community Efforts, AHRQ No. 09-0071-EF
Standards in Homecare HIT
• American Telemedicine Ass’n [ATA] has a
set of Homecare and Remote Monitoring
Standards available on their website.
www.americantelemed.org
• Workgroup on Hospice and Palliative Care
of the ATA, which I chair, looking at goals
and directions but not yet ‘standards’ given
very early adoption.
Agency on Aging Grant Chronic
Disease Self-Management
• Submission window closed Feb. 12th
• One grant per state; ceiling one million
• Criteria –Tested through randomized controlled trials
• i. effective at improving and/or maintaining the health
status of older people
• ii. suitable for community-based human services
organizations and involve non-clinical workers and/or
volunteers
• iii. research results published in a peer-reviewed
scientific journal
• iv. translated into practice; ready for national distribution
QUESTIONS?
THANK YOU
Deborah Randall
[email protected]
202-257-7073