While some companies give birth to new ideas, like Apple releasing the iPad, The BlueCross BlueShield of Tennessee Health Foundation has an idea that helps women give birth. In January 2009, the nonprofit organization funded a $1.8 million, three-year pilot project to determine whether telemedicine technology could provide effective perinatal consulting services to women who have high-risk pregnancies and live in rural areas of Eastern Tennessee.
Maternal fetal medicine specialists and healthcare professionals at Regional Obstetric Consultants of Chattanooga and Knoxville offer care to women with high-risk pregnancies. However, women living in the valleys and mountains of Eastern Tennessee frequently would miss appointments due to travel time. These missed appointments could result in increased health-related problems in both mother and child.
To improve patient outcomes and access to care, ROC collaborated with Community Health Network to form Solutions to Obstetrics in Rural Counties (STORC). The goal of the BlueCross BlueShield–funded project is to use videoconferencing technology by New York City–based Tandberg to connect rural patients with ROC specialists.
“It’s about bringing an individual with highly specialized knowledge and being able to access them in a very timely fashion,” says Joe D’Lorio, manager of healthcare services for Tandberg.
Have specialist, don’t travel
An obstetrician may refer a patient to STORC because she has a high-risk condition, such as multiple gestation, diabetes, or a suspected anomaly with the fetus. Even though The BlueCross BlueShield of Tennessee Health Foundation funds the project, it is open to any patient referred by any doctor regardless of the patient”s insurance situation.
“We’re so grateful to the BlueCross BlueShield of Tennessee Health Foundation for providing funds for programs like this,” says Debbie Lance, director of the STORC project. “There are organizations out there that are looking to be able to help.”
ROC uses a computer-based system to schedule appointments with the added variable of location. It blocks time for the remote locations, and nurse practitioners can make adjustments depending on patient volume and need. On the day of the appointment, a nurse practitioner and a sonographer from ROC meet with the patient at his or her local hospital or physician’s office.
“We can be in a hospital setting where they give us an exam area to set up the equipment, or we can be in a physician’s office,” says Lance. The equipment at the remote location consists of videoconferencing technology, a display monitor, and a laptop.
During a typical visit, the nurse practitioner takes the patient’s history and the sonographer performs the ultrasound. Then they transmit the ultrasound images to one of the hub sites, where the consulting physician views the images on an oversized screen in an exam room.
The consulting physician can look at the patient, the nurse practitioner, and the sonographer on a videoconferencing screen and review the ultrasound images with them. The specialist can guide the sonographer to take additional views of the fetus with the ultrasound.
Bringing specialty services to the patient’s location has made a huge difference in reducing the number of appointments missed. “Patients are compliant with actually keeping that appointment,” Lance says. Since the launch of the project, STORC has logged a mere five missed appointments by mothers who had already delivered their babies at their hometown hospitals.
Providing accessibility to specialist care so patients can deliver at their local hospital is one of the goals of the program. According to Lance, the project has had “tremendous success” in the area. “Normally, the outcome would be that they wouldn’t necessarily get the care they needed,” she says. “Most of these babies would probably have to be transported for delivery. The fact that they’re able to stay with their support system in their local hospital is amazing.’
Thinking beyond telemedicine
In addition to consults with specialists, the telemedicine tools also allow genetic counselors and diabetic educators to connect with patients. This eliminates the wait time between appointments with the counselor or educator, the specialist, and the referring obstetrician. It also eliminates the use of letters and phone calls to communicate a patient’s status.
“It’s the immediacy of bringing that genetic counselor in and having the doctor, the specialist, the patient, and the genetic counselor all talking about patient-centric issues wherever they may be,” says D’Lorio, who describes it as a “tremendous value proposition.”
Hometown obstetricians are also beginning to attend events and earn continuing medical education (CME) credits using the technology. “If you consider a physician in a little town, there may only be two obstetricians there,” says Lance. “This means they have to share calls for each other. It would be very difficult for them to get out to a conference in San Francisco to get the CMEs they need.”
STORC, recognizing the need for such education services, recently completed its first grand rounds across the network.
It brought a speaker to the ROC Chattanooga location and had both live and remote event participants. “We had about 11 different locations which were linked via the telemedicine connectivity,” says Lance. “They were watching real time. They were able to ask questions. They were able to get CME credit for it and it’s right there in their local area.”
Over the next year and a half, Lance says STORC will expand this program and hold events more frequently to help relationships between specialists and physicians.
Nurse practitioners have identified another possible application for the technology. They have suggested networking patients from several locations for an evening event where they could talk with one another about common concerns. Lance says it would allow patients who share diagnoses to realize they’re not alone.
According to Lance, some of the facilities may not have had any telemedicine services prior to the project. “It has opened a door for them to explore other ways they could apply this technology, and we’re helping them with that,” she says. For example, the Tullahoma site recently used its videoconferencing tools to connect an overseas military father with his wife’s hometown hospital so he could “attend’ the birth of his child.
“We see video communications really streamlining and changing the way a number of businesses do work,” says D’Lorio.
“We see that telemedicine is having an impact in changing the way that healthcare is delivered in just a very positive way.”
A virtual handshake
When patients learn that their specialist plan to use telemedicine services for an appointment, the typical reaction is: “What is it going to cost me?” For example, one patient’s spouse commented that the services made it possible for him to be present for his wife’s ultrasound without taking time off work; however, in the middle of the visit, he asked whether the services were going to cost him more.
“We were able to say no,” says Lance. Then the clinicians pointed out that the appointment would be less expensive for the couple because it eliminated travel expenses.
Satisfaction surveys reveal that patients are pleased with the improved access to care. One may think that the experience would be anything but intimate, but patients supported the use of videoconferencing tools, she says. In fact, one nurse practitioner reported that at the end of an appointment, a patient stood to shake the hand of a specialist with whom she was “meeting.”
“You’re that connected and it’s that real to them,” says Lance.
Hometown hospitals and referring physicians have been equally pleased and appreciative of the services, she says. The referring physicians have built relationships with ROC specialists, and they feel comfortable reaching out to them should they need to discuss a patient’s case further.
From credentialing to reimbursement
Lance is responsible for building the relationship between the specialists and local obstetricians. She discusses their needs, describes how the program will work, and credentials ROC clinicians who provide care and make decisions for patients at the remote hospitals. (Credentialing is not necessary if the appointment occurs in a physician’s office or a clinic.)
“The business of healthcare mandates that medical professionals be licensed in the state in which they’re delivering medical care and that they are credentialed and verified with medical centers,” says D’Lorio, adding that telehealth must conform to those rules as well.
On May 26, the Centers for Medicare & Medicaid Services published a proposed rule in the Federal Register—and opened it to public comment—that could simplify this credentialing process for hospitals. The rule states that hospitals, including critical access hospitals (CAH), will soon be able to use credentialing and privileging information about telemedicine providers from the remote location. Previously, CMS allowed hospitals and CAHs to accept credentialing information about telemedicine providers from the distant site, but not privileging information.
Under current CMS regulations, hospitals receiving telemedicine services must privilege each physician or practitioner providing services to their patients as if the practitioners were on-site. This process has been simplified: Hospitals that were accredited by The Joint Commission (formerly JCAHO) were deemed to also have met Medicare’s Conditions of Participation—including credentialing and privileging requirements—under the Commission’s statutory deeming authority.
But with the passage of the Medicare Improvements for Patients and Providers Act of 2008, the statutory recognition of The Joint Commission’s hospital accreditation program is ending effective July 15. With this change, small hospitals and CAHs using telemedicine services could face the burden of privileging specialty physicians that academic medical centers make available to them.
“We’re glad to hear that there is a change because that will help us and many other telemedicine providers,” says Lance. “There used to be reciprocity for different Joint Commission accredited hospitals. Medicare was saying as of July 15 this year, they weren’t going to allow that. They’re sort of putting it back in place for the purpose of telemedicine.”
In terms of reimbursement, the STORC program receives payment for services from all but one carrier, which may be experiencing a paperwork glitch. Lance states that all of the other patient insurers are paying and experiencing no problems.
D’Lorio describes reimbursement as an “emerging issue.” Twelve states currently mandate that private insurers reimburse for telemedicine services, he says. Medicare and Medicaid programs work on a national level, so they create their own reimbursement rules.
Adding services and onboarding others
“We see a lot of programs emerging that really illustrate bringing the right talent to the right place at the right time and the value proposition behind that,” says D’Lorio.
For example, STORC recently added neonatology to its offerings because of the success it has experienced delivering perinatal services. Now, a neonatologist can look at a baby born at a rural hospital and determine whether the hospital needs to transport the baby for care or whether the baby can continue to receive care at the hospital. “Neonatology is one of the medical specialties that might be prevalent in the academic university, but in the rural hospitals and even in the suburban hospitals, it’s a hard specialty to maintain,” says D’Lorio. “Video has become a wonderful mechanism to provide it.”
STORC is also sharing its best practices with other communities interested in developing similar programs in places such as North Carolina and Georgia.
“It’s something that we’re pioneering along with other areas around the country, and we’re certainly willing to help any areas who have questions,” says Lance. “We’re happy to network and share all of the information that we’re learning. It is the way of the future, and it seems to make a difference.”
Future Goals
At the end of the STORC project’s first year, the specialists at the two hub sites had served nearly 150 patients at five remote sites in Cookeville, Tullahoma, McMinnville, Newport, and Winchester, TN. In the first quarter of this year, patient volume increased by 229%. STORC has already set up connections at two more locations in Jellico, TN, and Dalton, GA, and will start providing patient care in those locations soon. The long-term goals of the project are to:
- —Connect 11 rural sites in Tennessee
—Reduce cost of care
—Reduce unnecessary patient transportation
—Reduce unnecessary hospitalizations
—Reduce days of neonatal ICU stays