With the recent Supreme Court decision affirming provisions of the Affordable Care Act, it is again time to consider strategies for healthcare organizations (HCOs) to thrive in this difficult and evolving landscape. We believe one key strategy involves connected health and telehealth, essentially the use of technology to extend evidence-based best practices beyond the walls of the clinic to improve outcomes, operating efficiency and financial performance.
As Chilmark Research, the leading healthcare IT industry analyst, points out, “For as long as health IT has been around, Connected Health has been the promise of the future. As industry veterans are quick to point out however, the promise has always come with one caveat or another: reimbursement by insurers is a few years away, evidence of any ROI remains limited to closed systems like Kaiser or the VA, data remains proprietary and disconnected, and so on and so forth.” While this is certainly true, there are opportunities today where Connected Health can achieve the “Triple Aim” of: improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care. At least as important and despite the difficulties listed by Chilmark, there are opportunities where there is a compelling business case for connected health and where the Triple Aim can be achieved while improving sustainability and even increasing profitability for HCOs.
In this and the next several posts, I’ll present a few opportunities where Connected Health may improve outcomes and sustainability today. In each instance, the evidence appears to be clear. Nonetheless, I hope these posts foster a discussion of the merit of each, in order that we might all find the best early opportunities to improve healthcare.
Connected Health vs Telehealth
“Connected health is a model for healthcare delivery that uses technology to provide healthcare remotely. Connected health aims to maximize healthcare resources and provide increased, flexible opportunities for consumers to engage with clinicians and better self-manage their care.” This aligns very well with the definition “telehealth.” The Health Resources Services Administration (HRSA) defines telehealth as “the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration.” For this discussion, we will refer to connected health as the model of healthcare delivery and telehealth as the technologies that enable the Connected Health delivery model.
From a technology perspective, telehealth encompasses the following:
Live Video Encounters. This is exactly what most people think of when they hear “telehealth” with a clinician in one location viewing and speaking with a patient in another. It may also include online group meetings among patients and providers, including support groups. It can also include provider to provider encounters for consultation or education.
Community Coordination and Patient Engagement. This is an emerging area where online and mobile applications are used to extend evidence-based best practices beyond the four walls of the clinic. Sometimes this is referred to as “store and forward” technology. A good example is Centerstone of Indiana’s “electronic Recovery Oriented System of Care (e-ROSC)”. E-ROSC is an electronic extension of established evidence-based practice for the treatment of substance use disorder. E-ROSC has been shown to improve recovery capital (a measure of internal and external resources necessary for an individual to achieve and maintain recovery) and lower the rate of relapse while improving operating efficiency and financial stability for HCOs. Another example is MyPlasticBrain, a set of online and mobile apps designed to help people who suffer from brain injury. These applications use technology to influence behavior by extending and improving access to established evidence-based therapies.
Devices and Remote Monitoring. This includes the emerging set of devices ranging from home motion sensors to glucometers and activity trackers. These have generally developed as standalone devices with limited reporting or analytics. They have been available for several years sold primarily to consumers. The recent shift towards telehealth includes data from these devices integrated with EHR and other telehealth solutions.
Electronic Health Records and Practice Management. While not traditionally thought of as a part of telehealth per se, it is clear that to achieve true connected health, telehealth technologies must be integrated into the broader universe of EHR and practice management systems. This is particularly important as telehealth becomes a standard part of care.
Here is a link to Chilmark’s excellent post on the state of telehealth, referring to the present state of telehealth as the “First Wave”, with limited use cases and functionality, which will transition to the “Second Wave” over the next several years.
While we agree with Chilmark’s overall evaluation of the market, we believe there are specific sets of health conditions, which we call “Care Units,” where the conditions are ripe today for true connected health success based on telehealth technologies.
Criteria for Connected Health success
- A defined set of health interests or Care Unit. This is simply the notion that one-size does not fit all. People facing breast cancer have different goals, needs and barriers from people with diabetes, or substance use disorder, or… Defining the limits and characteristics of a specific Care Unit is the first step to determine the right configuration of telehealth technologies. The corollary is to identify frequently co-occurring Care Units. After all, not many people have just one condition or health interest. (See my blog post “I am a TAB” in the About section.) The patterns are clear.
- The Care Unit must be sufficiently common and consistent among patients. In order to maximize the value from telehealth technologies, particularly at this early stage, it is appropriate to focus on those Care Units where the condition is common to a large population and is fairly consistent in its manifestation among patients.
- Treatment must be reasonably consistent among providers and clearly supported by evidence-based practices. Telehealth is first and foremost an extension of evidence-based practice. While telehealth may add new value, the starting point has to be a common evidence-based protocol that can be expressed through the telehealth solution.
- Demand for clinical service exceeds supply. If demand for clinical service and the supply of clinical services providers are in balance, there is little incentive for either consumers or HCOs to change behavior. On the other hand, where the demand for care cannot be met by the present supply, where providers feel over stretched and consumers feel neglected and underserved, and where payers understand that increasing access can lower total cost, then HCOs may be more willing to look at telehealth and connected health as a means to solve their operating challenges.
- Telehealth must bring clear and compelling value to evidence-based practice. For most Care Units, this means evidence-based practice that focuses on patient/consumer behavior. At core, telehealth uses technology to increase levels of engagement with evidence-based protocols and improve the communication between the patient, the clinicians, caregivers and the social community for the purpose of improving healthy behaviors. Care Units and therapies that are not focused on ongoing behavior are less likely to benefit from connected health.
- Lest we forget, there must be a revenue model for healthcare providers that supports telehealth technologies and work flow. This, as they say, is where the rubber meets the road. If nobody is willing to pay for it, it isn’t going to be used. A few years ago, funding for telehealth solutions was just about non-existent. While still nascent, today there are payment models with Medicare, Medicaid and insurance that make it worthwhile for providers to adopt Connected Health.
Early Candidates for Connected Health Success
Following these criteria, we have identified six Care Units where, at least in some states, the conditions are right to embrace Connected Health. These aren’t the only ones, but these are a starting point. They are:
- Substance Use Disorder. We can’t pick up the (virtual) newspaper without reading about the epidemic in addiction and the cost to society. Yet it is estimated that only 1 in 10 people receive treatment for addiction. Relapse rates are unacceptably high. And when we look at the demographic and geographic distribution of access to care and the disparities that result, it is clear this an opportunity where Connected Health may improve outcomes, lower cost and strengthen financial sustainability.
- Criminal Justice Re-entry. With the change in eligibility requirements for Medicaid in 30 states under the Affordable Care Act, and with the huge increase in incarceration and now recent initiatives to reduce prison populations, a large percentage of new Medicaid enrollees are people are involved with the criminal justice system. Along with disproportionately high rates of chronic conditions, new models of re-entry therapy, focusing on needs/risks/responsivity, are showing tremendous success. It is hard to imagine a bigger value proposition than one that not only improves healthcare but also reduces the rate of recidivism and perhaps even the crime rate.
- eHealth Coach. This is at the heart of integrated health. It only makes sense. If we are not dealing with a person’s mental or behavioral health issues, then we’re not likely to have success dealing with his/her diabetes or COPD or Hep c or… Thus an integrated approach to managing the full range of behavioral, physical and social conditions is the emerging trend. These models leverage work by the CDC, along with readiness for change and stages of change theories to promote true coordinated care through Connected Health.
- Brain Injury. Adapting new evidence-based models based on “neuroplasticity,” the brain’s ability to reorganize itself by forming new neural connections, technology for people with brain injury can improve cognitive function. It can improve care coordination while providing support not only for the patient but for caregivers. In this instance, technology can truly extend and expand evidence-based practices beyond what is available through traditional models of care.
- Palliative Health. Palliative care involves the care of patients with chronic or advanced illness, and includes not only the physical management of the patient, but also the emotional and spiritual aspects of care. The Palliative Health Care Unit focuses on providing patients with relief from the symptoms, pain, side effects and stress of a serious illness—whatever the diagnosis. Palliative health is also the fastest growing area of healthcare service, with demand far exceeding capacity. The potential for improved health and operating efficiency is hard to overstate.
- Pain Management. Rather than simply a symptom of other conditions, pain has come to be thought of as a chronic condition with its own complex and unique diagnosis and treatment. Informed by “Relieving Pain in America,” a major report published in 2012 by the Institute of Medicine that makes recommendations for the diagnosis and treatment of chronic pain, connected health can bring together physical and behavioral health to support a truly integrated care experience to improve health related quality of life for people living with chronic pain.
In the next few posts, we will drill into each of these Care Units, to consider the goals, barriers, stakeholders, requirements and metrics that will allow us collectively to determine whether the time is now for Connected Health, at least with respect to these Care Units.