Event ID: 1167663
Event Started: 11/20/2008 12:52:14 PM ET
Please stand by for realtime captioning.
We're broadcast now.Please stand by for realtime captioning.
The captioning code for the Caption Colorado website?
Yes.
111167663.
1167663.
Yes.
Sorry, what was that code for? This is Peter Thomas.
Peter, that code is a code that you need if you want to access the
captioning through the alternate site, directly on the Caption Colorado
website.
You don't need the code, Peter.
Okay. I just got back on. I am still not on the URL and having trouble but I am working with my office staff to get it on.
Okay.
Hello, people around the world. This is Kate Seelman. Welcome to the
State of the Science virtual telerehabilitation conference, and I want
to welcome you on behalf of our directors and Dr. David to my immediate
right and Dr. Michael McCue to my far right. Dave, do you want to kick
off a little bit?
Yes, thank you, Kate. Let me add my welcome
to everyone. Before I start, I would just like to get a sense as to how
many of you are returning from one of our previous days? This is the
fourth and final day of our conference, so actually if you would put up
a poll, if you in the audience would respond to this to give me an idea
who is new, who is returning, and I can guide my comments based on
this. Looks like most of you, all but two of you in fact are returning,
so I will be brief and try not to dwell too much on this material. Let
me just add, though, and say that this is a very important opportunity
that we have today. We have 250 people registered from 14 countries and
37 states in the United States. As we all know, professionals and
consumers around the globe recognize the need for accessible, available
and affordable quality rehabilitation services. Because the percentage
of the population that is disabled increases with age, the number of
persons needing healthcare services projected to increase dramatically.
The society adopts innovative technologies to curb costs, highteddenned
demand for health service threatens to increase healthcare spending to
unsustainable levels. This brings us to several fundamental questions
which we like to address through our deliberations today at our
conference. First, does telerehabilitation provide essentially cost
effective and efficacious alternatives to face-to-face services?
Second, what are the research problems and training needs, and finally,
third, how can we more fully integrate participation of consumers of
rehabilitation? These questions have guided the objectives of our
conference. What we will strive to achieve today is to first present
the state of the art in telerehabilitation that is present the
evidence, and then to explore current issues in technology, clinical
service delivery, end-user usability and acceptance and public policy.
As you know, today the focus is on public policy on this fourth day. We
would also like to identify deficiencies in the use of
telerehabilitation technology products. We've discussed this
extensively over the past three days, and finally to identify and
prioritize future research and training needs and dissemination
strategies, and I am sure that today's conference will contribute to
that achieving that objective. I would just like to tell you that the
process of preparing for this conference began over a year ago when we
assigned people within our center the task of drafting white papers on
specific topics. Throughout the year we have added outside perspectives
by adding authors to those white papers and successive drafts. The
draft date most of you received in e-mail and that we made available on
our website is that the second full draft of the white papers. These
white papers will evolve over the next six months based on the
conference today, the discussions that we have on the blog site that we
will create for continued discussion after the conference, and finally
the papers will be produced in final form in the premier issue of the
International Journal on Telerehabilitation, an on line journal we're
producing here at the University of Pittsburgh. I would also like to
tell you that today's conference is being recorded and the archived on
our website and made available to you for viewing after the conference
ends, and that archive will be available within 24 hours after the end
of the conference. In addition to the video feed, we will also make the
transcript available for you to have as well.
Actually, what was the final tally of the poll?
93% of respondents were returning.
How many new people?
3%.
I will give you just a very, very brief overview of the layout. What
you have in front of you is a layout that's created in the Adobe
connect software, and it allows us to create pods with different
functionality. We have approximately three layouts that we'll be using
over the course of the day. The arrangement of the components will be
slightly different, but they will be largely the same, only changing in
size and location. If you look to the upper left of your screen, you
see the video feed. We will have the video feed in all of our layouts.
To the right of the video feed is a pod which contains these slides
that will be presented periodically throughout the conference.
Underneath the PowerPoint or the slide pod are two pods on the right
beneath the slides is the chat window. Through this chat window we
would like you to submit comments and questions. I will be monitoring
that chat window over the course of the conference, and relaying
important questions and comments as they come up to the presenters when
I get a chance to do that.
To the left of the chat window is a document window. There is a list of
documents here that are available for you to download to your computer
and use as you -- on your own time and have it for your own use:. Knees
documents you see here are the evaluation forms and the post test form,
both of which you will need to receive continuing education credits for
this event.
Finally, in the lower left of the screen is the captioning window, and
that window will contain the text derived from the audio stream.
Before I relin qish control here, I would like to acknowledge a big
group of people who have made this conference possible. First our
sponsors, the National Institute on disability and research and the
U.S. Department of Education NIDR and the sponsor of our center and is
funding this conference. I would also like to acknowledge the group of
advisors that we have for our center, our scientific advisory board,
dedicated group of professionals and consumers who have been actively
involved in the planning of this event.
Here in our room we have a team of technical assistance people, people
in our school and in our center who are doing everything it takes to
make our event go smoothly today, and those are Kipp ( indiscernible ),
Joe Roughing and Eric Port. Thank you, guys. Everything is going very
smoothly. I also want to add this is our fourth day now, and we're
starting to get the hang of this, but we're still I would consider
ourselves to be novices, so I am not guaranteeing that we will be free
of glitches today as many of you have seen over the prior days that we
have had a few glitches.
One thing that has been happening on and off, and sometimes it is a
local event happening on your end, and sometimes it is due to something
happening on our end, but the audio will drop out periodically, and
when this happens, if you first look to the captioning window, you may
find that you can follow what's going on by just seeing the text. The
captioner has a feed from the telephone line. The telephone line is
being used by our presenters and panelists, and the captioning service.
That audio is being then bridged over and streamed out over the
internet, so the captioner has our telephone feed, and may have access
to audio when you do not. The people most important 20 this whole
process are Casey ule man and Ashley ( indiscernible ). They have been
spear heading this effort from the beginning and working tirelessly to
make this a success, and it is turning out to be a great success.Mike,
I would like to turn it over to you now.
Before I do that I
would like to say a word about the fact that we want this conference to
be as interactive as possible, so while we haven't been able to open
this up audio wise to everybody in a two-way, you do have the ability
to communicate with us and we ask you to take the opportunity. We would
like your questions. We would like your comments, and we would like
your feedback. to bolster what we're trying to communicate today and
also to credibility to thoughts and ideas, so we fully encourage you to
do that. If you should happen to think of some ideas or this should
stimulate some thoughts down the road, please visit our blog site.
There is a URL on your screen now for our blog site, and we encourage
you to communicate with us and interact have via that blog site. We'll
be monitoring that, and we would love to see your comments and
thoughts, both today and through our chat window as well as
subsequently using our blog or our e-mail. Today as paper, the last of
four, deals with telerehabilitation, policy issues and research tools.
We have two white paper authors, Catherine Seelman is the associate
dean of disability programs and professor of rehabilitation science and
technology here at the University of Pittsburgh. She is one of two from
the United States serving on the world health organization's
nine-member international panel guiding development of the first world
report on disability. Dr. Seelman is co-science director of the
national science foundation support quality of life technology
engineering research center here collaborating between Carnegie Mellon
University and the University of Pittsburgh. Kate has served as the
direct why are of the national institute on disability and
rehabilitation research under President Clinton. She is widely
published and recipient of many awards.
Our second author is Linda Hartman currently a reference librarian at
the University of Pittsburgh and the library's liaison to our school,
school of health and republican sciences. Linda is working with the
quality of life technology center, the national science foundations
engineering research center, whose mission is to transform the lives of
people with reduced functional capacities due to either aging or
disability, to build a knowledge base on quality of life technology
information. With that, I will turn this over to the speakers. We'll be
about 30 seconds getting organized, and then we'll be back with you.
Enjoy the conference.
Thank you, gentlemen.We're on line
again, and this is Kate Seelman, and to my right is my colleague and
co-white paper writer, Linda hartd man who as Dr. McCue indicated is a
resident librarian at the University of Pitts Pittsburgh and serves as
an in-dispense I believe resource for our school of health and
rehabilitation science. I will do a short introduction also to for our
panelists, and we have five superb panelists, and I will try to
introduce them in the order in which they will make their comments
around 2:15 obviously our time. Deena puskin is the director of the
federal office for the advancement of telehealth in the health
resources and services administration in the United States Department
of Health and human services. The second panelists is Al drar
Understanders, an OTR occupational therapist and a senior research
associated and policy analyst at the research and training center on
disability in rural communities at the University of Montana. Our third
panelists is Cynthia waddell who is a lawyer and serves as an executive
director in law, policy, and technology subject matter expert of the
international center for disability resources on the internet. And
after we hear from Cynthia, we will hear from Dr. Lawrence Welchleer,
professional of newer rolling and neurological surgery at the
University of Pittsburgh School of Medicine. He is the director of the
stroke institute, and he serves as the Vice President of the
telemedicine in the physician services decision at University of
Pittsburgh Medical Center. Finally, but not least, is a Washington
lawyer, Peter Thomas, who focuses on disability law and disability
practice or health law in Washington, and we'll look forward to his
remarks. He is among those in the panelists that really has an indepth
understanding of one of the key policy issues which is reimbursement of
course.
Before we turn to the presentation, my eye caught a recently released
study by the California -- support by the California Healthcare
Foundation quoting New York Times columnist Thomas Friedman who says
and observes that the world is flat now because in emerging
technologies, and the concept is as true in healthcare as it is in
business and social politics. We may think it is flat, but certainly
we'll have to question that. Part of what is making it flat according
to this study called right here right now ten telehealth pioneer
sincerely broadband technology which is getting cheaper and ubiquitous.
Telephones have emerged as a use. Healthcare delivery tool for
providers and consumers. Reimbursement for on line care is more
available. Providers are beginning to embrace remote care. We hope they
are. Consumers are benefiting more, and then home can be the center of
healthcare, so these were very interesting study or papers developed
after we developed ours, but certainly thoughtful observations.
I am now going to turn to the PowerPoint itself, and begin presenting
the slides, and I hope everybody can see it up there. First we have the
objectives. We hope that the participants will have an enhanced
understanding of the following: policy related advantages of
telerehabilitation over in-person face-to-face delivery of rehab
services; policy related disadvantages of telerehabilitation;
methodology used to conduct policy studies, which includes economic
studies, their strengths and weaknesses and need for further research;
and U.S. government programs supporting telerehabilitation research.
Next slide gives us the presentation sequence and agenda for today. So
at 1:15 and beyond we will do the PowerPoint presentation slides 1
through 18, and then do a little audience polling to keep you awake out
there, and then back to the slides, back to the polling, a short break,
and then we'll bring in and invite our expert panelists, so that's what
we hope will happen today. Then we'll have of course you participating
and has been said regularly every day, it is the interaction and the
dialog here in the United States and around the world that really
enriches this process, so it makes it very exciting.
The next slide, and we see the slide telerehabilitation which is
abbreviated TR, public policy and research tools: significance and
need. Almost every day we've been talking about the significance to
some extent, to affect health and technology, public policy objectives
of access, availability, and affordability within the continuum of
care, and our part, rehabilitation part of the continuum of care
sometimes is not emphasized as much as say acute care is. Especially
for under served populations and those in remote areas. Complement and
support technical, clinical, and operational components of TR. The
literature really does show that when you have a complementary policy
framework it is very supportive of the technical and the clinical.
Next slide, please. To continue with the TR policy and research
significance, deliver rehabilitation services to people with
disabilities who have been identified as under served populations. Now,
by healthy people 2010 which is really the national health report and
objectives for the United States, and within the last healthy people
2010 we included the disability population as an under served
population. It certainly is not the only under served health
population. To relieve increasing demand for and costs of
rehabilitation generated by aging, demographics, and providing
potentially less expensive supply of rehabilitation.
This of course is an objective that to which we are all very interested
and committed. Various panelistses in earlier days have picked up on
definitions, and in this white paper we used the term telehealth as the
broadest term to refer to telemedicine, telepractices, and telerehab.
We picked the definition out of U.S. government agency definitions in
this case Department of Health and human welfare and again hi.IRSA. --
HIRSA. The background definitions definitions for telemedicine was also
taken out of American telemedicine association and in this case refers
to the use of telecommunications to help deliver healthcare services as
patient care such as patient care and telemonitorring. Finally, the
telerehabilitation which is surely definition purely operational at
this point, we use our own in this particular paper to refer to remote
delivery of rehab and home healthcare services. Next slide, please.
The next slide looks at background and telecommunications applications.
Under applied to services we have consultations. We talked about them,
home care, monitoring, therapy, and direct care, and while some of
these are in the most undeveloped states, perhaps, there is some
literature that discusses any one of these applications or service
applications. Now, the applied populations, I was very interested in
someone who called in who talked about concerns I think was around
counseling about remote delivery of services versus face-to-face, and
are we losing human connection here, and certainly there is literature
discussing it, and there is considerable concern, and so we know that
rehabilitation is closely associated with face-to-face hands-on
traditions, and that has a great deal to do with the professional
acceptance rated, it impacts on the professional acceptance rate so the
literature shows. However, the traditional physical rehabilitation
population is not the only population that for TR applications, and
people with communications swallowing and hearing disorders are also
included in the population, and we certainly have telepractice
literature, and certainly people with psychiatric disorders. Ncht let's
go to the next one. Background and telerehabilitation in the continuum
of care. Optimizing the advantage hereof optimizing the timing,
intensity and sequencing at intervention and the length of care which
we can do remotely or we have shown to be able to do remotely. Another
opportunity is to receive rehabilitation in end-users social and
vocational environments, and we found at least one study that tried to
cost out the savings of providing rehabilitation in the vocational
environment rather than just having to continue to have the patient
client go to a clinical setting, and whether there would be workdays
saved.
There are a great many complexities related to the delivery of
telehealth and many of these complexities have very little to do or
under the control of policy makers, telehealth is delivered to a wide
variety of populations by condition, for example. And by location, by
organizational model, and I hope Dr. Welchleer mate might say something
about that a little bit later. He serves here at the University of
Pittsburgh Medical Center, by clinical protocols, by evaluation
frameworks, and we do not have a standardized evaluation framework.
We're challenged by degree of physical contact required in rehab
therapy and patient characteristics, and we require assessment and
treatment tools that can replicate face-to-face practice, and these are
challenges that are with us now and will probably be with us for quite
some time. Next slide.
The United States has a rich history
of using using telemedicine, and it goes all the way back to Alexander
Graham Bell and the telephone. I have always been a great lover of the
history of technology, so it seems that the doctors are, too, because
somewhere around the 1880s our physicians began to use the telephone at
least for consultation, but perhaps the most impressive applications in
telerehabilitation in particular and in home care come from the
veterans administration. The first recorded use that I could find was
in 1957, and now the telemedicine is incorporated by the VAinto care
coordination to augment community-based outpatient clinics and vet
centers -- center programs with so much coordination in the veteran's
administration, and provide consultations, referrals, direct services,
and home and remote telemonitorring, and certainly there is a great
deal that the nonmilitary community can learn from the VA experience.
Is the civilian side and in the Department of Health and human
services, we have programs that have mainly supported rural areas. Now,
here in our telerehabilitation center we have discussed whether or not
it if only the rural person who is older, an older adult or person with
disability who is isolated or under served, and certainly there is some
indication that we should be serving urban audiences as well or urban
clients as well, so we have the program supported by the office for the
advancement of telehealth he it U.S. Department of Health and human
services, and we are very lucky to have Dr. Dean Pushkin on the panel
and she is going to kick off the remarks today, so we all look forward
to hearing from her. She has been a good colleague to much of us over a
number of years. We have also in the U.S. government office of rural
health policy we have rural development, distance learning and
telemedicine loan and grant programs at the U.S. department of
agriculture. So again you see somewhat of a bias that perhaps an
important bias and an appropriate bias to rural populations and remote
populations in the United States, and this may be true and some of you
not in the United States may want to talk about the distribution of
your telemedicine, telerehabilitation resources, resources, geographic.
The national institute disability research and U.S. Department of
Education support the first rehabilitation engineering research center
in 1998, and we are a successor, and we learn from our predecessors,
and so that has been very useful, and that -- this RERC has tried to
integrate itself into the larger telemedicine and telehealth community
in the United States, so now with this I can get a glass of water and
turn the slides over for a moment to our librarian. We were pretty
meticulous in trying to do a well-founded literature search, and to do
that we were lucky enough to have a very good librarian, Linda Hartman,
so, Linda, will you take it from here, please.
Thank you, Dr.
Seelman. As librarians know and one of our things that we like to do is
searching, and looking at the literature, and looking at several
different databases, and there is a number of reasons for that. The
literature sin decked or covered by different organizations who put out
the indexes and the databases. Sometimes things just slip through the
cracks and aren't always in the databases that you expect them to be,
so it is good to look at more than one, and so we did look at different
r several different databases. Also, the trick is sometimes finding the
terms in discovering the ones that you should be using, and we'll talk
a little bit more about that, and then of course once we conducted the
search and then organizing the results. Anybody that's done a search
knows that it doesn't take much to sort of start to feel overwhelmed
and a little disorganized, so hopefully we can help you with those
areas as well. As I said there is a number of different database that
is cover this area. There is an interdisciplinary area that covers a
lot of different types of information, medical, policy, social
information, and so I did start with the medical literature, and using
med line which is the premier medical database that is used, and then I
took a look at some of the others such as the allied health literature
and the psychiatric and social literature, and then also just kind of
looking to see, well, what do we miss? What else is out there, where
else are things covered, and I looked at some of the telemedicine and
telerehab journals to see where are they being indexed, indexed, what
databases are they found in, and when I did that, I foined that most of
the ones that before -- the four that I looked at were primarily in med
line, scopist, which is a science and social sciences database, and
then also some more general databases, the academic databases such as
academic search, and of course policy file which is a rather specific
database, so by doing a search with our University of Pittsburgh has a
system where we can search several databases at one time. I was able to
incorporate the searches for academic search and policy file in those
searches. Of course we talked to experts to see what are the areas.
They look for their information, where do they start their search, what
is the vocabulary they use. That's often the trickiest part is just
figuring out what are the right terms to put into the database, and so
helping talking to them helped us to get some of the information there.
Also the databases a lot of them have controlled vocabulary or tool
that is will help us find the correct terms to use, steer us in the
same direction, and so I used those tools such as mesh, the medical
subject headings or SINOL and some of the others that have controlled
vow kak vocabulary, typing in terms and seeing where did they direct
the search, and then of course any time you have a term that you're
looking at, there is also the possibility that there are more Broadways
of -- broadways of talking about the discipline, and soy looked at
those, sometimes back the our search up a little bit and did a broader
search, and as well as just narrowing it, if you had something specific
or specific issue that we wanted to take a look at, we would use those
terms. Some of the databases have what we call the scope notes which
are helpful. They're basically helping us find out what do they mean by
a particular topic, what do they mean by telemedicine, the same thing I
am thinking of, and that can be very helpful, so I looked at those when
they were available, and often the scope notes also include other terms
to use such as the related terms. It will say try looking at this, it
is a similar term, sort of same as that you use in the library
searching, and then also terms are continuously added to the databases
and made into subject headings, so it helps to know what was the former
terminology that was used, and a lot of times the dated abase or the
scope noted will tell us that, what was the older terminology, and then
we can type those terms in, and then also just using key words, and the
common useage for terms can also be helpful to gather some of the extra
article that is we didn't find otherwise. And then of course looking to
see where the authors that we know of and who are the experts in the
field where they were publishing, what journals, databases, so we would
do author searches, what institutions they were associated with or what
institutions were doing a lot of the research in the areas of which we
were interested, again, leads us to other areas that we might not have
gotten to, and by looking then at the subject headings, the terms that
were used to categorize those articles, we often found other terms to
do our searches, and so we would go back and do that. Then again
sometimes you just have to do a keyword search. You just have it type
in the term. It is not going to be a subject heading, so we just put
those in as well as the entry terms and other terms that were not
controlled vocabulary.
I always start with my databases that do have controlled vocabulary. I
find they help leave me to those secondary terms that I hadn't thought
of, that I always start there, and again that's what I did, and then
just try to stay organized like I said once you start to search more
than one database, sometimes things can get a little out of control, I
put them into a Word document and tried to keep track of all of the
different terms used for the different type of terms, so I kind of
broke them into the policy terms, the telerehab, telemedicine,
whatever, same thing with populations. I had a list of populations,
people with disables, disabled people, those types of things, hearing
impaired persons, et cetera, so just to kind of keep them altogether, I
put them together in a Word document.
All right. I think it is time for us to do some polling. So if you
could give us the first couple polling questions, Ashley. All right.
Research shows as the working -- the population ages, the nabbed for
rehabilitation -- demand for rehabilitation will increase the most in
most countries, but meeting demand may be prohibitively expensive. We
regard telerehabilitation as a potentially cost effective and
efficacious alternative to face-to-face service. So, yes or no.
Majority are saying yes so far, it is potentially cost effected active.
Okay. We're all of like mind. That's good. Our second question.Should
telerehabilitation research should focus more on which of the
following? Home care applications, consultations, telemonitorring,
patient care delivery, all of the above, or other? It is sort of
changing a little bit.Started with all of the above but looks like
others are gaining.It does look like all of the above is going to be
the one that comes out in front. That will be important for us to
remember when we're looking at the research down the road and
performing the research. All right. Thank you, Ashley.
So how do we organize that search strategy? I used -- one of the things
I I did, the paper file, but I kept everything labeled, making sure I
knew where it came from and also using the some of the tools we have
available to us, bib low graphic citation software that does help us
keep track of citations we found, also helpful sometimes to write the
paper you can put your citations in, change them around, they will then
also put in whatever style that you need, whenever you're going to
write the paper, so bib low graphic citation management software has
become very popular. We used end note. I did create a separately
brother for each search that I did. I am one that wants to be able to
kind of go back and follow the trail, so I tend to kind of keep track
of -- keep copies of everything, and then I did combine all of the
searches that I found perhaps for all the med line searches or all of
the scopist searches, I would put those altogether and send them off to
Dr. Seelman who then would make her selections, and then I would keep
track of those as well, and that helped later on down the road when we
were putting together the big log graff and the reference list.Some
other things in keep in mind were criteria, and public policy, and
other terms were similar, if it said anything about license sure or
payment structures, particularly reimbursement, that was something we
were very interested in, and then anything to do with law and
legislation or regulation, and of course any of the providers of
Medicare, Medicaid, and different agencies, we included that as well.
We didn't look at so much -- we kind of didn't include the engineering
and technology and medical information. We were more interested in the
policy end and the reimbursement, so we stuck with those, and anybody
under the age of 65 unless they had a disability, the article had those
as a population we did not choose those. We read only the English
language literature, and most of the things came from 1996 to the
present.
Our initial searching gave us about 1,000 citations, but after we did
those initial search through of looking for the policy terms, the
reimbursement terms, he hes, et cetera, brought us down to about 325
that I sent over to Dr. Seelman and then of course looking at the
titles and the ab abstracts and sometimes taking a peek at the articles
to see if they were something what we were targeting on we would use
those which brought us down to the 70 or so articles actually reviewed
for the paper. Well, as with any study there is always limitations, and
some of the things that we found with our paper was that the federated
searching, that's kind of doing a search over multiple databases at one
time, can be a limiting factor because you're not doing a keyword
search -- I am sorry, you're not doing a subject search. If there are
subjects available for each data database because if you're trying to
search more than one at a time the system doesn't know who is
controlled vocabulary do I pay attention to, so it just defaults to a
keyword search, so we may have missed some things there, but doing a
keyword search really is a broad search, so we weren't too worried
about that. In the search also for telerehab and policy publications I
mostly was looking at it from the telerehab point of view, and again I
tend to look at more of the medical and scientific literature because
of my background, and to go forward I would probably look at some of
the other more social science literature and definitely putting the
emphasis on the policy side of the search. Do you want to do the
findings or me?
I will do it.
Okay.
Okay.
Thank you very much, Linda. I look forward to working with you (
indiscernible ). We're now going to the results of the literature
search, and general findings. The literature on telehealth and
telerehabilitation originates from locations all around the world,
particularly in resource rich countries such as the United States,
Canada, Australia, Singapore, and those countries in Europe, and of
course this has the implications for the less developed or low resource
countries, lower resource countries, and perhaps as we join the
discussion later, not only with the expert panelists but with you we
can get into some discussion of the implications of accessing these
kinds of services when you live in a low resource area. The literature
span is also interesting in terms of jurisdictions. There were
interjurisdictional levels including a global level, institutional
health systems, and indeed we have a representative on the expert panel
from University of Pittsburgh, medical center, regional country and
local. I say this because there is great concern as many of you know
about standardizing protocols across countries in terms of quality of
care, interoperability, and so on and so forth. So we need to move
towards developing and supporting a more international leadership not
only the world health organization but professional organizations and
also VPOs, that is disability people's organizations on the
international level, and we see some of that coming as a result of the
adoption by the United Nations of the convention on the rights of
people, the human rights of people with disabilities, but that
hopefully will come a little later, too, the next slide, please.
Another general finding from here in the United States is that the
Center for Telemedicine and E-health and the American Telemedicine
Association are among the leaders in the United States in generating
literature, addressing research, and especially practical perspectives
on telehealth and you see then moving not only at the federal
government level but at the state government level, and they've been
very useful in perspectives and educating professionals and other
interest groups.
The TR, telerehabilitation public policy and research tools and the
results of that literature, the general findings, there is a modest
body of telerehabilitation policy and research literature and a much
larger telehealth literature policy, policy literature. Policy issues
were generally assumed in sections within articles that address other
topics. So sort of at the end you would have an author, especially
clinicians who are very thoughtful and realized they're bumping into an
inadequate policy framework which is not complement -- does not
complement their own objectives in delivering services remotely, but
looking for reimbursement, for example, being the major but not only
problem, they're not finding it. Nonetheless, these sections are
usually not imperically based and are not themselves constitute
research as such, merely descriptive sections stating the problem.
Continuing with TR policy and research tools, results of literature
search, general findings, the authors across the board identified as
important policy issues costs unsurprisingly, and reimbursement
unsurprisingly. However, there are a number of other issues that they
named, and one of them as you well know is license sure, and is it
portable, and at the moment of course port portability across the
states and the United States are a big problem, and across national
borders is also a problem because countries want and regulatory
agencies want to feel secure that the credentials of the individuals
providing services outside the United States are complementary to the
quality of care and standard of quality of care that we have here, and
I am sure this is not solely a concern of the United States but
certainly other governments and regulatory agencies and professional
groups groups. That of course was the next point, the quality of care,
and equivalency of care across borders.
There has been some statement about regulation of privacy. Strangely
enough I don't think informed consent has been mentioned in the last
three days, so we will mention it today. And we all know that not all
countries have IRBs, and informed consent regulations, so privacy
within and across borders is a public policy concern. Systems security,
what in the world does that mean? At the policy ( indiscernible ) and
not a technologist, I really had to think about that, and of course
we're dealing with very, very complex technical systems. I think of it
as a plumbing pipe and somewhere where they come together and go, you
wonder about the security of the next system, so the system security
problem comeses out very, very clearly in the literature, and I am sure
across borders. Another is the interoperability of technologies and
that I leave to the technologists.
Again, continuation of findings, and now we're going to talk a little
bit about the client related issues, and they are indeed public policy
issues, and they are not only public policy issues because I know that
not only the disability community but the clinical community and the
provider community are very concerned with these issues. There is very
large study in Canada that shows and emphasizes that we shouldn't only
be focusing on cost and reimbursement, that there are issues such as
social isolation and life stress and poverty that need to be considered
in delivering telecommunications services.
There was a concern shown in the literature related to the
vulnerability of older adults and the vulnerability of people with
disabilities as research subjects, and this is not so new for most of
us, this is a concern we share. A concern was shown in shifting the
service location to the home, and what is the implication, social and
other implications of shifting to the home? What is the impact on the
family? Especially on the caregiver? If the caregiver is not now
medical but is much more mother, maybe father, probably mother,
grandmother, and so on and so forth. There is also concern about
reporting. I use the word reportage, but reporting about the technical
reliability and usability. There is great concern that we're not
getting feedback or there is concern that we're not getting teedback
when the technology itself has a negative impact, medical or otherwise,
on the individual end-user. Are we receiving and asking for again
report on the impact of telerehabilitation on function and quality of
life? Quality of life and function are areas that are emphasized
needless to say in the rehabilitation literature.
The literature also shows a real concern about cost related issues both
for policy makers and for providers. The studies lack imperical
background about the costs and benefits included in the studies, and we
do not have standardized evaluation tools or framework, so this was the
American telemedicine association supported an expert panel, and I
believe Dr. Puskin was on that panel, and some of the the findings
including the cost related issues finding is something that was
reported outside that panel. The cost related issues for policy makers
and providers include rigorous comparisons between face it face visits
and telehealth visits and this is just simply something that I have
passed with common sense now to the research community. You heard
before about the problem of insufficient rigorous outcome studies
showing or not showing improvement in patient medical conditions and
functioning. We need to know so that when policy makers are making
decisions or providers are making decisions, especially on
reimbursement of course, that they have the evidence at their finger
tips. The studies show that evidence for cost savings the number of
face-to-face visits avoided is important, showing reductions in
rehospitalization, reductions in follow-up consultations, and
elimination of redundant lab tests worded by multiple providers. You
can imagine how that happens if you have one provider requesting one
set of tests and another provider or clinician ordering another set of
tests, you certainly can get duplication. In the psychiatric area the
cost reduction evidence would involve showing improved continuity of
care for rural consumers, showing increase in family and consumer
involvement in treatment, and showing reduction in length of stays and
readmission rates. These are all indicators of cost savings. The
reimbursement related issues for policy makers and providers and these
providers of course are supported by Medicare and Medicaid in the
United States, private payer, fee for service, and we know throughout
the world we're dealing with very different health systems, but here in
the United States for the premier gold standard reimbursement is
Medicare. And so providers are clinicians are wanting to have their
sites eligible, and Medicare issues involve eligible sites, they
involve geographic coverage, and facility fees, co-payments, and home
health durable medical equipment. Other reimbursement issues for
Medicare and I am sure there are many out there that have been involved
with these reimbursement issues are the CTT codes and their
applications within telemedicine and telerehab, the Medicare home bound
rule which more or less requires, for example, with durable medical
equipment that will be used at home which for those of us who have been
very involved with civil rights seems to be a direct contradiction to
the Americans with disabilities act, and then Of course for Medicare
and Medicaid the medical necessity standards which is rather strict.
For promising areas for telemedicine, the literature shows home health
settings as being a promising area, and specialties where care can be
delivered via impact is videoconferencing such as psychiatry and
neurology, therefore vocational rehabilitation, and in looking at the
lited sure and really looking for as I would a person with a policy
background any studies in traditional areas of political science or
policy found very little, but we did find one reasonably good focus on
interest groups that showed that factors on the state level that would
be supportive of telerehabilitation include state legislative
professionalism, obviously availability of government resources, and
severity of need. In this study nursing was positively related to
telehealth implementation, and physician networks were negatively
associated, so it suggests that we need to do some education with our
clinicians, and something interesting to both of us again in the policy
area, procedural policy, that is regulatory policy does not usually
attract influence or interest groups, and in this case it does attract
interest groups such as the clinical organizations, the nursing
organizations, the OTs, the PTs, and they don't mind diving in at all
into these ar Kain regulatory agencies and areas and processes on the
state level, so we should be sensitive to training education and policy
support related to them.
In relation to research tools, findings indicate that there was an
inconsistent quality of literature that ranged from anecdotal to
randomized political trials. We need quantitative and qualitative
research. We have a lack of economic analysis, many of the articles and
indicated that clinical trials were very expensive, and often
inappropriate when the scope of the problem was as broad as health
service research. We immediate to develop measures of care, end-user
acceptance and outcomes, costs, and access.
Rehabilitation is playinged of course with the problem of small
samples, so some of our authors and the articles that we reviewed
recommended various solutions to that such as quasi experimental
designs, case control studies or indeed linking qualitative and
quantitative analyses. The large picture clearly in terms of costs
includes technology, goes to ergonomics, goes to clinical outcome
studies, then at that point we can do economic studies which might have
implications for the centers for Medicare and Medicaid for Social
Security that are interested in these economic studies, but they have
to include these other factors, the costs related to technologies, the
costs related to clinical protocols, and so on and so forth.
So recommendations to address issues and problems and I am sure we'll
hear more from the panelists, use utilization and outcomes data from
centers for Medicare and Medicaid databases, ( indiscernible ) will
give us a larger bases for study, population studies, fund large scale
experimental telemedicine programs and I am sure we would all welcome
that, use theoretical try ang lags that integrates results from qawn
take active and qualitative designs and then someone has suggested that
creating a nationwide database looking for a clinical efficacy
criteria.
So in conclusions, we want to see rigorous studies of costs,
utilization, outcomes, and acceptance and traditional -- and
traditional policy areas such as legislative process, agencies, and
organizational decision making and interest groups. This is absented
from the literature now, so we don't know very much about it. Develop
outcome assessment measurement tools. This is nothing new to
rehabilitation, and we must take it on for telerehabilitation, and
standardized evaluation framework. Target for study promising
applications such as home care, and Medicare reimbursed facilities and
practices such as telepsychiatric.
Integrate TR into the larger telehealth field through jointed studies,
professional cooperation, and client education and participation. That
ends the PowerPoint which we based on the white paper, and I believe we
have a couple more polling questions out for you out there in the
audience, and then we'll take a short break, and we'll move into our
expert panel.
We have some questions.
We do?
From the audience. Perhaps we can handle those after the polling questions.
Okay.
Next polling question is in the absence -- is the absence of rigorous
cost studies a major barrier to adoption of telerehab by healthcare
delivery services? Yes or no? Looks like we have a resounding yes so
far.We have close to 90% saying yes. All right. If we could have the
next one, please. Telerehabilitation like rehabilitation is limited by
severe restrictions on reimbursement of services throughout the world
including U.S. med care, Medicaid, and other public and private payers.
Should TR invest its research resources in outcome studies that may
provide evidence of cost saving and therefore justify reimbursement?
Again, we have 90 some percent saying yes. I think we have one more
question.
Do youDo you regard functional assessment and
quality of life measures as necessary factors in telerehabilitation
outcome studies? We have a couple saying no. One person says no. The
majority are saying yes. All right. Thank you.
Thank you very much. Okay.
Let me relay some of the questions we've gotten from the audience.I
will copy the questions to the chat window so you can see them. The
first one is from Sue. Excuse me while I type here. Sue asks given the
emerging evidence that disability care coordination can save money,
advance progress towards healthy people 2010 goals, and improve quality
of life, it would be helpful to do a lit review of telecare
coordination. Any comments on that?
That's a statement, and
we agree. It may have been done, we have to look -- do a lit review to
find out whether we have done it. What do you think?
Right.
That was one area I didn't search was the telecare coordination, so
that would be an interesting portion to add and to see if it has been
done.
We may need some clarification on the next question,
but I will relay it anyway. When you ask if it can be considered
COLARIS effective, it depends -- cost effective, it depends on if it
gets reimbursed. Do you think we have an answer to this in the field of
seating and ability yet?
I think that with that one, Alexandria,.
Yes?
Did you hear the question?
I have a different take on this one. Maybe we can talk about that during the panel.
Okay. We're then going to bait until we -- wait until we go to the panel to discuss that question. Okay? Let's take one more.
Cost effectiveness really needs to be looked at broadly, but maybe more
broadly than it is currently being looked at, so we'll discuss that
later.
Thanks, Alexandria. ThatTake one more, David.
Okay. This is from Eric. Eric asks speak to the usefulness of distance
technologies for group therapies, counseling, and staffing with
multi-point connections, for example, vocational and psychological
counseling, bringing participants together in a room for group
interaction?
Is that a question?
I think it is a
comment asking for -- I am not sure, Eric, actually what are you asking
there. If you get a chance, Eric, maybe you can clarify that and we'll
get back to that.
I think also, Eric, that since we have
yesterday had a panel that focused more on counseling and that kind of
service that we may also share your question with the vocational
counseling experts in our engineering research center, so we do have
those experts.
Put it on the blog.
Yeah. We'll put it on the blog. Can we do that, Dr. Brienza?
Certainly.
What was that I think we're almost at a time when we can move to the
expert panelists, and I do want to give them a good deal of time to
present, so the first thing I wanted to do is brag about them a little
bit more. So Alexandria end Enders analytic focus is on infrastructure
issues such as transportation and telecommunications which determine
the availability, accessibility and usability of the vehicles of modern
participation. For more than 30 years she has been involved with
service delivery systems and networks, public policy, funding, and
quality assurance issues, program development and training activity,
and so you will be hearing from her in just a minute. Deena Puskin has
served in addition to her current role at the Office for the
Advancement of Telehealth as director has served as acting director and
deputy director of the Office of Rural Health Policy, and senior
analyst for Congress' prospective pain and assessment commission. That
probably is full of stories, Deena, I haven't heard, and would like to.
Senior legislative analysts blue cross blue shield association,
research director of finger health system, system, move to Cynthia and
brag about her a little bit. In addition to her work as intekEexecutive
director at the International Center for Disability Resources on the
Internet, she has also served as the information communication
technology accessibility and government service expert for the United
Nations global initiative for inclusive information and communications
technology, and I have to say having been involved with that myself,
that that is an extraordinarily important initiative not only for every
country throughout the world, so anyway that's some of Cynthia's
background. To turn to Dr. Lawrence Wechsler, in addition to his
professor activities here and his director ship of the stroke
institute, and Vice President si of telemedicine, his interests of
course are in acute stroke therapy, imaging and telemedicine. He has
participated in many clinical trials and treatments for stroke as an
investigator or a member of the steering committee. Peter Thomas has a
federal administrative law legislative and regulatory practice in the
areas of healthcare and disability policy, Medicare coverage, and
reimbursement and medical rehabilitation services, devices and
research. Peter Thomas has been engaged in representation of rehab
related clients since 1991 including the AMRPA consumer and clinical
affairs task force, the American Association of PMR, and related
organizations. He has serve odd a number of government advisory
committees, and he has served as co-chair of the health task force for
the consortium for citizens with disabilities which really is an
important con shore consortium in Washington, D.C. for the disability
community here in the United States, so with that I am now going to
invite our expert panel to make presentations, and I will invite Dr.
Puskin to step up first. Are you there?
Yes, I am. I am here.
Very good. We look foward to hearing your observations.
I will try to sort of stick to your questions that you sent us ahead of
time, but also you asked me to talk a little bit about the programs
that we fund because I think that was one of our objectives. What I am
going to first do is tell you a little bit about what we do here at
HIRSA for about two minutes, and then I am going to get into the
questions because my answers are going to be dependent on our
experience, and in the health resources and services administration we
have been funding and telehealth projects since 1988. We are basically
the start of what I call this iteration of telehealth or telemedicine
depending on how you want to look at it. There have been as you
suggested by the history there is a long history behind it, but
actually not much success until the late 80s and into the 90s, and part
of that was limitation in the technology, at least as we're trying to
introduce visualization, and the revolution in both telecommunications
and computer technologies has made possible today what was impossible
before, so given that we started out and we learned a lot of lessons,
actually the hard way, and we are now funding three programs, and why I
think it is important for you to know about them for those of you who
may be interested in funding, at least one of them will be competed
this year, and one of them is the telehealth resource -- the telehealth
network grant program which is basically funding networks of healthcare
providers to deliver telehealth services, and among the programs we're
funding there are three home care -- home monitoring programs looking
at the cost effectiveness as home monitoring and rural settings. These
programs have been historically rural although given Congress'
legislation they actually could be urban and rural, but a certain
threshold has to be reached in terms of dollars before it to move into
the urban. I would share your belief that this is not a rural issue,
especially now as we're aging population, and but there are some
lessons to be learned from the rural experience. In terms of license
sure portability, a question that has come up on the screen, we are
funding a program called the license sure portability grant program,
and that program is basically looking at how we can overcome cross
state barriers to license sure, and as I get into some questions and
answers I would be more than happy to talk about it, but we are funding
the federation of state medical boards and the national council of
state bortsdz of nursing to develop and essentially enhance models for
license sure portability. Both those two organizations and the state
boards are looking at what we call mutual recognition models. That's
nursing compact as well as some of the work that the federation is
doing is to basically work on how do we get states to recognize one
another's license, and the third program is telehealth resource center
grant program which funds resource centers around the country to help
folks step off the curb. With that being said, we have had a lot of
experience in both evaluating telehealth technologies as well as in
trying to fund innovative applications.
So in your first question you're asking about basically do we regard
telerehabilitation as a cost effective and efficacious alternative to
face-to-face? Now, you've all heard, and I think you're well aware of
the many, many applications, so in a way it is a meaningless question,
and I say that because it depends on which application you're looking
at. At this point in time, we can basically say that we can demonstrate
it to be efficacious. Whether it is cost effective is another question,
and that gets to many of the research questions that we're going to
discuss down below because in my opinion cost effectiveness is much
harder to show than showing that something may be clinically
efficacious. Also is it clinically optimal which is often what people
are asking. I don't think that's the right question because it is
always compared to what? If you're out there in a rural community with
no physical therapists, no psychiatrists, no psychologists, and you are
using technology to at least get care that you would not have gotten
before, the question really is are you getting more care and more
appropriate care and does it do no harm, and I think we have lots of
evidence to say that in the settings that we have funded it does no
harm, and in fact actually does good.
Is it well documented and rigorously studied and rigorous cost studies?
The answer is not really. I think the closest to some of the work done
at the VA and at the military for efficaciousness, cost effectiveness,
is very much harder to show. Now, is the lack of rigorous cost studies
a major barrier to the adoption of telerehabilitation by healthcare
delivery services? I would say that it is a barrier. I think it gendz
on what we're looking at. I think there is not been enough study or
discussion on the part of what value-added does it provide. It is very
interesting that cisser permanent in developing many of its telehealth
services I would say did not have rigorous cost studies. What they had
were very good targeted studies to answer specific questions they had
as a system of care as to whether it made a difference. Did it save
money for them, did it result in more efficiencies for their providers,
et cetera. Were they rigorous from the sense of when I put my doctor
Puskin hat on? Some of them were not. Are they a barrier, essentially
the lack of it ultimately would we benefit from the field from better
studies? We need better studies, but what we need is studies that
answer the questions that people are asking, and very, very targeted
studies, and often I think we have general studies that are not
specific enough to the questions that payers are asking and that
systems are asking that will demonstrate value added from their
perspective. Should telehealth research focus on home care applications
more than applications. There is a lot of studies on home care
applications. I think there is tremendous benefit as healthcare is
moving into the home, but I do not think we should be funding -- we
should be looking at one over the other because I think actually in all
arenas telerehabilitation has a role and the only issue would be a
discussion of priorities of where do you think sustainability will come
first? I think that is a question that we can talk about because that
does get to who is interested and who is willing to pay? On the fourth
question, telerehabilitation is limited by severe restrictions on
reimbursement by Medicare. Again, when we're looking at this, certain
services are and certain services aren't. As you're going to hear later
on, stroke, and I would have loved to have talked about it, but since
you're going to have an expert, I would say to you that in some a
reason as, there is payment, but in almost every arena there are
limitations. Medicare does pay for physician consultations. The issue
for stroke often is making decisions about TPA, and some of the details
in the re reimbursement that make it sometimes less than an effective
payment mechanism, but one of the issues with telerehabilitation is our
therapists don't get paid under Medicare and under Medicaid, so when we
talk about telerehabilitation, if many of the major providers are not
covered, is that an issue, yes. Do we need for evidence to justify it,
yes, but do we also need to get evidence that improves the acceptance
of the technology by the very providers that are seeking re
reimbursement. There is often two sides to it. Money honey, yes, does
money matter, form follows function and function follows funding. Sure
it matters. Often the money and the reimbursement follows when it is an
accepted standard of practice, so in fact I think there needs to be
much more work within the profession as well as getting it acceptable
as a practice. Functional assessment and quality of life measures as
necessary factors, absolutely. If you can show that those also relate
to higher functioning level and reductions in costs, you have got a
winner.
Finally, to identify and prioritize telehealth -- telerehabilitation
future needs. There is no question that the research model cannot be I
believe in this field the randomized control trial. We may be lucky to
get a few, but what we need to do is more with a we call collaborative
research efforts which we're doing for instance in the home care where
people collect data the same way, use existing data sources, as we are
doing for Oasis for telemonitorring and roll it up and essentially in
answering very specific questions and essentially in a tight rigorous
model quasi experimental designs. I can only point to you, and I don't
have enough time to talk about the huge randomized control trial that
we fund odd diabetes in New York for over $60 million. That has
actually come out with very limited results because of the limitations
in randomized control trials needing long time periods and the impact
of rapidly changing technologies on being able to make judgments at
all. In terms of training, we need to incorporate intercurriculum
telerehabilitation in every curriculum. If this is ultimately going to
become normal parts of how people practice. And fortunately that
doesn't exist. In order to do that, however, the accrediting bodies
that approve curriculum also need to be brought along or we will never
get this routinely incorporated. With that I think I have taken enough
time to give you an overview of very I had sin accurate I can views on
this particular topic. Thank you so much.
Thank you very
much. Maybe after if we have time and after Dr. Wechsler makes his
presentation maybe we will have a little opportunity for interaction
among and between the panelists, so thank you very much for leading off
and for those comments which are very thoughtful and provocative.
Alexandria Enders, would you come on next?
Great. Thank you. Are the screens up?
Can you see me?
Yes.
I couldn't see Deena.
Alexandria, you will have to turn on your camera from your end.
My camera is turned on.
It is turned on.
You mean from the screen? The screen shot here?
Right.
We're getting you.
Okay.
You need to turn off your Mike microphone. Do you see the top button? There you go.
Okay. You're emerging.
I amy Americaning?
There you are. You have emerged.
Thank you. We're split screening. I want so start by saying I think
that telerehabilitation we need to think of as a delivery truck which
is a different model maybe than we're thinking of, but if you think of
it as a delivery truck, as something that moves a service from one
place to another, I think it points out many of the directions we need
it go in research, many of the problems problems happening, and let me
go through these. When you think of it as a delivery truck, you get
into the huge policy problem of cost shifting. Traditionally in
healthcare, medicine, rehab, the consumer bears the costs related to
travel and that part of the cost has been in-visible or irrelevant to
the provider. Of the challenge in telerehab is shifting the travel and
shipping costs to the provider's side. Policy is going to need to
acknowledge and address that. My question would be is the U.S. system
really willing to a dament to this shift? -- adapt to this shift? Other
countries may be more or less willing since they don't have the same
healthcare rehab infrastructure and investment reimbursement schemes
that exist in the U.S., but I think it is a big question about where do
the shipping costs lie, and in some ways I think that this policy
review move been very frustrating to do because it doesn't bring in
some of the things that aren't called telerehabilitation, but in fact I
think we could probably identify them as such. The literature does
describe descriptions of factors that increase -- that influence the
shipping costs, all of these things that Dana just talked about about
license sure and reimbursement and costs, all of those things are part
of the shipping cost issues. A lot of those issues have been and are
being as the policy review looked at are being incrementally addressed
in short-term policy fixes and demonstrations. I think that policy as
can you are not currently exists probably inhibits the development of
new models by forcing what could bey Americaning new models, new
products, into old trucks and boxes. I think one of the big question
from the policy research side is where are the incentives to change? I
think one of the major questions, and this is market forces, who and
what drives demand. I think that the slides yesterday from the
Department of Defense and VA both show that they developed really good
systems of care. Of course both our single pair. Both already include
the travel or shipping costs, and their coste equations. They know how
much, and they account for how much it costs to move soldier, how much
it costs to move professionals, and to a certain extent even the travel
costs for veterans. So they've incorporated that, so there is no system
disincentive to the transportation costs of the trucks.
Market demand I think raises lots of issues. It is like telerehab like
an iPod, you know, an answer to a need we didn't know we had because
the technology can do it? Now we can't live without it? I am not too
sure. Mr. ( indiscernible ) yesterday point out many of the telerehab
problems are embedded in the ongoing rehab issues, and rehab is not
something we have learned yet to live without. I don't think it is the
iPod model at all. Telerehab research has typically looked at post
acute events. I am glad there is discussion on stroke. It is the pinnal
cord injury, the TBI, the amputation, but in the arena of long-term
chronic conditions where no identified acute stage, you got to ask the
question as Deena was asking, cost effective as measured against
what?If had he this suffered through loss of function, it is cost
effective I suppose to never introduce the rehab service. Or never to
introduce the array of products that could improve function, safety,
dignity, quality of life and Dan ( indiscernible ) nothing. I don't
think we have addressed the moral questions in face-to-face rehab, and
I think we need to address them together because it is not just an
issue of telerehab.The telerehab trucks make much more possible in many
ways than face-to-face in person services. Again, the question about
the absence of rigorous cost studies, I was one of the people who said
no, I think, Deana, you must have been another. I think we need to
reframe the question. How much is the U.S. health care reimbursement
system influencing the use of telehealth and telerehab service?
Separate out the utility of the telerehab approach frtd inhibiting
factors we usually focus on. Other countries may have different
barriers. We'll have different barriers, at least looking at the things
jointly with Dan da, UK, various folks in the EU, Australia, might help
correct for the effective reimbursement policy on the actual inherent
capacity of distance delivered services support. I think most countries
are interested in cost saving element of these, otherwise why not
condition with business as usual? Each country will have different
assumptions from different social models, and different perspectives
and I think they'll offer valuable answers. I would bet that there is
very little of that in the literature review, and again must have been
particularly frustrating to not see it there.
Sometimes I think the American -- we're such a big gorilla, that we
forget that things work differently in other countries. Americans need
to remember that not all countries drive on the right side of the road.
Might be an auto industry issue there. I think that when we start
looking at studies, we need to measure the right thing and the right
comparative timeframes. The papers in the review talked about reduction
in follow-up consulted taigs, but they also talked about continuity of
care. I kept wondering should cost effectiveness be equated with a goal
of never seeing the person again? That doesn't fit with continuity of
care. This is a some of the scaling up that I think Mr. PRUMULKA
brought up. Approaches that increase involvement of consumers with
disabilities and their own wellness management may not call themselves
telerehab. They add currently on reimbursed players to the continuity
of care models, he mentioned centers for I understand independent
living yesterday, the Arlington training center has the model living
well with disability which has an on line and component, and I know Peg
nose ake and Rosemary on this meeting today. They're doing a project in
Second Life funded by NIDR on I hope they will add more information on
the blog. They wouldn't call it telerehab, but it is certainly is in a
broughter sense. We aren't getting that in the literature yet. I am
sure nose and Hughes will publish on this. We aren't getting those yet
because the technology is emerging so quickly it will take a couple of
years for them to do the project and a couple more years to get it
published. By then we'll be onto other things. The literature review
didn't include things like that. I think we need to find ways if we're
going to get stuff in the literature and get a cross index to have
these community-based kind of approaches incorporated into how we look
and view telerehab, adding especially the players that currently aren't
usually at the table. I think one of the issues with looking at the
measuring the right things and the right comparative frameworks,
especially when you start looking although more chronic conditions and
some of the more interesting interventions possible possible, when you
first increase awareness and involvement, of people like as we did with
the living will stuff, there may actually be an increase in
iewtdization, costs need to be viewed longer term. Look at the employee
wellness programs, initial screening they show long-term neglect, for
example, diabetes, smoking cessation, once it is stabilized you should
crowEunder crow control, then the cost changes. Costs really need to be
properly accounted for and placed in context whiches is I think part of
the answer to this cost effectiveness issue, and again Dena's point,
the cost effectiveness of doing nothing is like I mean that to be
provocative. She probably did, too, but is something better than
nothing? Where should the line go between quantity and quality? One of
the questions I had about the literature review was since outcome
studies are often the focus of these existing publications, why aren't
the results already translating into improved reimbursement? I think
that actually needs to be considered. It is like are they asking the
right questions, if it is not changing as much as we like to see of the
one of the other issue that is came up is a lack of a standardized
evaluation framework. This stuff needs to be compared longitudinally
but also needs to be measured against technology capacity, both the
hardware and the network access pots and pans, you know, plain old
telephone service versus pretty amazing stuff, the hull bling
experience only a few weeks ago about only being able to connect on a
24K connection which we will be testing all of our stuff on slower
connections like that. I had for gotten that anything could run that
slow.
I think we really need to be measuring in standardized evaluation
formats against community resource availability and using an ICF frame
Bork from WH. WHO to really period of time the person environment into
the equation, and of course comparing cross boundaries, international
boundaries, to free the analysis from the art facts of any one
country's reimbursement policy.
I think that some of the ethical questions about when is something that
is nothing really need to be addressed. Looking at the less developed
countries, some of which are going wireless and can support the
infrastructure, they have fewer elf pros, uncovers many of the issues
we in the U.S. seem reluctant to acknowledge and much less address. We
don't like to say we are 15th in broadband penetration in the world
right now. There is lots of interesting issues around that nugget, but
I think to identify and prioritize future telerehab research and
training needs from a policy perspective I think we need to start
rewriting they equations, rethinking distribution acts and equity. The
research needs to be able to support that. We need clear goals as Mr.
PRAMUKA said and we need to rethink the product dis. it really need to
look and feel like traditional services in order to qualify for
reimbursement like we need to know what can be done incrementally and
what are the limits of existing policy systems, what would take a real
paradigm shift? I am increasingly believing that face-to-face versus on
line telerehab is not the right did I ked my. I don't think we have
even -- a lot of this stuff I don't think we frame the questions
appropriately. In some ways this really is not an alternative delivery
system of trucks delivering the same old cargo. It may actually be a
whole different service, especially when looking at the informed
consumer and self management models.
Alexandria, you have about maybe a minute.
Okay. Can telerehab be more than a delivery truck? When horses change
to autos, the technology changed the -- what you could deliver changed
differently. I don't think telerehab should be just following trends,
it should be helping to set them, especially in self managed care, we
need to ask questions about when do you really have to replicate
face-to-face practice, and when would an alternative more integrated
approach be better. This telerehab has the potential to look at the
person environment interaction, the broader context that ICS brings to
us much more effectively, when rehab it done at a distance, have you to
learn how to utilize community resources to exercise, for example, for
exercise protocols, so you have to go out and access local fitness
centers, even small rural communities have a curves place. You could
use telerehab as a vehicle for increasing community environmental
access, and the civil and human rights laws could assist in getting
that access. I will end there.
That's very good. We're
putting into the chatted room a couple of comments, but we're not going
to get interactive at the moment because we want to move on with our
expert panel, but I will read the comments. Telerehab must be
financially sustainable without including the cost of transportation.
If private sector insurers are not paying for transportation now,
they're not going to do so in the future. Workers comp and Medicaid
programs that pay for taxi services have some financial incentives for
telecare. That was one comment.
There is no question that telerehab will improve access to rehab. This
is why insurers including Medicare are afraid of this. They can't
quantify the unmet needs, and they're afraid of the potential for fraud
and abuse, especially store and forward. We'll just leave that at the
moment, and thanks to the people that sent in those comments, and I
wanted to share them with everyone.
Okay. Our next -- Alexandria, thank you very much. Our next speaker is Cynthia Waddell. Cynthia, are you ready?
I am ready.
I thought you would be. Okay.
Over to you. Are you on cam are?
I am on camera.
We'll try to find you.
Okay.
There I am.
( laughter ).
Hello there.
For the rest of the audience, last I talked to Dr. Seelman I had my
monitor hiding my video cam, so you could not see me, so I think she is
seeing me now in the first time for a number of years, isn't that
right? I wanted to thank you very much for inviting me to participate.
I will be speaking strictly from a public policy perspective, and on
the use of technology and its a accessibility or include ziff design.
There are just too many issues here to discuss. I will not be able to
discuss all of them, and can everyone hear me?
I can say, Cynthia.
Yes.
As another hard of hearing person, I can hear you.
Great. I am going to turn off my captioning window which I very much
appreciate having. So what I decided to do briefly for this short
period is to focus from the international perspective especially on the
United Nations treaty or conventional rights of persons with
disabilities and how that might be expected to have a significant
impact on research, so I would like to point to some of those treaty
provisions and drivers that may address some of the cost issues being
raised as well as some of the delivery truck versions that have been
discussed.
First of all, for those of you who may not know much about the treaty,
it was adopted by general assembly of the United Nations in 2006, and
2007 opened for signature and became the first human rights treaty of
this millennium with historic number of CIGNA to to signatures. We now
are up to 136 countries, I believe that have signed this treaty, and
what is significant about it is many of the provisions in the treatedy
address technology and equal access and equal participation for people
with disabilities in society, and that equal access will include access
to medical, health, and teleservices, so first of all, with the
countries having signed the treaties, they now will be lining laws and
policies to address them. I understand President-elect Obama here in
the U.S. has indicated that he will be signing the treaty, and we
cannot at this point go into discussion on the GAAP analysis, and we
can talk about that later with we actually do have some GAAP in U.S.
laws in meeting these treaty provisions: provisions. The main thing I
would like to point out is article 4 of the convention speaks about the
general obligations of each of these countries that they have for
patients and health professionals and ake dem a with respect to this. I
would like to suggest that in this general obligation there is a
provision here that may address some of the research needs that we have
here. For example, it is now a general obligation of treaty signatures
to undertake or promote research and development of universal design
goods and services and equipment, and that would mep the delivery mode
of telerehab must be designed to be accessible, and I am not just
talking about connectivity and internet penetration in the sense of
telecommunications delivery, but that the delivery itself for the
end-user enables the end-user regardless of disability or functional
limitation that they can fully use and receive that delivery of
services. The other piece of general obligation of the treaty is that
it requires that the minimum possible adaption for the individual as
well as with the least cost meets the specific needs, so we get an
issue of costs not in terms of who is going to payor reimbursement
policy, but actually the actual technology costs in promoting and
making this universal design of delivery accessible.
Another obligation of the treaty is to undertake and promote research
in development of the availability of new technologies which would
include telerehabilitation. That would be suiteddable for thriferry to
them, group people with disabilities, and giving priority to
technologies at an affordable cost. Now, in the context of the general
obligation, I should say before I go to more research issues, do want
to say that the article 25 and 26 of the convention address health and
rehabilitation, but when we get to articles further on regarding
collaborative research, I want you to know that articles 31 addresses
the statistics and data collection. I understand in your literature
survey you took a look at what we always do, our databases, and one of
the main issues that have arisen now and as technology has evolved and
our use of assistive technology, even by researches with disabilities
is the problem that many proprietary databases are not assess I
believe, that is people using assistive computer technology cannot use
and manipulate search screens in databases, so one of the things that
the treaty calls for, it calls for statistics and data collection using
accessible design of databases but one of the things that I have
encountered in my work with the international telecommunications union
we were looking at factors, statistics and factors for fact gathering,
and worldwide, and we were looking at penetration of the internet and
use of technologies, and telephones, and one of the glaring absences of
data that we had was on the use of technology, use of the internet, use
of telecommunications by persons with disabilities.
So this is now being surveyed and addressed at the international level
for informing our research as to what is is the population out there of
persons with disabilities that are using internet and receiving
telerehabilitation services?The other piece that is important to inform
you in your area is article 32 has a significant provision dealing with
collaboration. Now, I agree that collaborative research, especially
pooling of resources, sharing of approaches, are important, and so
article 32 addresses international cooperation and its importance for
undertaking effective measures including the supporting of capacity
building, of research programs, facilitating cooperation in research
and access to scientific and technical knowledge and providing
technical and economic assistance including facilitating access and the
sharing of accessible and assistive technologies and through the
transfer of technologies.
Now, the transfer of technologies for some as you know many persons
with disabilities, let's say the majority of perches with disabilities
live in developing countries, and it is the developing countries that
the call came out of the requirements of the need for a human rights
treaty on rights to persons with disabilities. The investments of
technology in the developing countries it is now critical that the
investment is made that it be designed to be accessible. So that is one
of the reasons why there is a provision specifically in there regarding
the transfer technologies that it be accessible.
I talked briefly about databases, successful design, how we want to be
sure a person with disables, whether they be providers or not, be able
to access that information. I have talked a little bit about the
collaborative research, but one of the aspects that struck me as I went
through this list of questions, let's look at the first one, research
shows that as populations ages, the demand for rehabilitation will
increase, but meeting demand, the demand may be prohibitively
expensive. My opinion is it had be expensive if we do not address
universal design, if we do not decide what those accessible features
are, and delivering accessible rehabilitation services, then we will
increase the costs, and in fact in our research if we do not have a
starreddized evaluation framework that measures accessible design in
that delivery, how are we going to match that with the last question
here on functional assessment and quality of measures if we can't even
deliver it in a meaningful and accessible manner?
Question number 2, in the absence of rigorous cost studies, is it a
major barrier, and if so what research strategies should be addressed?
I think that it is a barrier, but as has been point out, money and
reimbursements start with an acceptable practice. We have a practice
that is accessible design. We use a research strategy involving
collaborative research, and assessing the accessible delivery of
telerehabilitation, then we will be able to manage the costs.
I can't tell you the examples I have seen where people have thought
they were trying to uses a technology to solve a problem, and because
they did not understand the accessible design issues, they made it more
expensive than they needed to, and so part of the piece problem -- part
of the puzzle here is one of the things that the treaty calls for is
outreach, education and training of professionals on accessible design,
and that would -- and the rierms of the treaty, but even so here in the
U.S. we have an ongoing issue on the section 508 implementation which
is the successful design of electronic information and technology that
is procured by the federal government, so still outreach education
training, just regarding our technologists technologists who are
developing the technology we use, so that continues to be an issue.
Number 3. Should TR research focus more on home care applications than
on consultations, telemonitorring, and patient care delivery? Last
month I was at the State of the Science conference speaking for the
Corwin institute at the University of Colorado at Boulder, very
impressed with presentations regarding telemonitorring, patient care
delivery, issues, that they were going to address, and there were some
privacy questions raised by the way. Whether or not we should focus on
home care applications as opposed to all of these others, I don't have
an opinion. I think we need all of this, and of course my focus is of
course that whatever we do we use accessible design of technology. [
captioner transition ]]Should TR invest in research resources to
outcomes study, that may provide evidence to show savings therefore
satisfied investment.
I think there is a disconnect. Between
what the ADA requires and the patchwork - that came about as a means of
- and we need to do another take another assessment of what is
happening with our blog and how it is driving or not driving
reimbursement. Maybe we need a new paradigm shift on that. It is not
where it should be yet. Did it - - quality life measures, in PR outcome
setting, I certainly do. And number six, identify prioritize future
research and training needs. I think the training needs of four hour on
fields, on what it means to have I delivery - delivery of successful
technology that some of you may not know by what I mean by that and I
don't have time to pull explain that and, on the other hand, the
research that I would like to reiterate that I think that in any
project that we are looking at, it is true that if you have measured
timeframe and technology changing through that, we are not going to end
up with a very good result. It is interesting hearing about the
diabetes case study example. So I think that again, I am looking at,
wondering about the technology changes, the conversion of technology
now where we have voiced audio, which is audio text and video could
conversion in single platform, we have efforts internationally, for
example, international - - and standardization protocol, total
conversation, waste to enable ways been able access delivery to single
platform.
Centra, you are running out of time.
Thank
you. Dr., at this is about I wanted to point out to, the treaty
provision, how it might impact the research and how important it is
that we take a look at and include the design of the delivery in
telerehab.
Thank you very much. If only the convention had a budget coming up with it we would be in fine shape.
And that is quite interesting to watch.
A little later, we are going to take a two minute break, everybody
stand up and do press - - so you will not need rehab, stretch and we
will be back on that in two minutes.
And then we will start
with Dr. Lawrence - - who will bring us down to the ground again. And
then an actual pinnacle program. So we will be with you in about a
minute and a half.
[ On break for 2 minutes ]
We are back. Everyone I hope stretched and in good form. And now we have Dr. Lawrence Wechsler, Larry, are you there?
Okay.
Thank you very much. I don't know whether my video is coming through. I
do not see it on the screen there. If not, then I will just go with the
voice. Thank you very much for including me in this discussion. I am
honored to be included in this distinguished panel. I am coming into
this from a slightly different perspective. I want to make a few
comments on the questions, that were have been mentioned. I think many
of the points that I was going to make have been made by the other
panelists so I would like to start by talking of that about the tele
stroke in general about what it is and where it comes from and why I
believe it has been successful. And then talk about the you PNC tele
medicine program in general. Because I think there are a lot of lessons
to be applied. The first is really why the 10 stroke has been
successful. It has been successful from a number of different points of
view. The major reason that it has been successful to date is that it
fills a very critical need. Let me describe what that need is to you,
but that is the first take away point for me about tele medicine and
tele help in general. The most successful things are things that needed
in the clinical world and that leads directly to their success. And we
have been talking mostly about we have but now I am going to get in the
area of the stroke treatment. That is one of my main interest. As many
of you know, we have an approved treatment for stroke, mainly TPA. That
has been around since 1996, the penetration of the treatment in terms
of number of the stroke patients being treated is appallingly low.
About two or 3% nationwide. One of the reasons has been that there it
is not the expertise out there in a small community hospitals with 24 -
seven coverage, it is to emerge and we evaluate patients and whether
they are good candidates for TPA. So telemedicine has provided what
seems to be a good solution to that problem. But we noted years ago was
that what was happening was when a patient came to a small community
hospital they would call as, the stroke team at the you PNC and say
they have a patient that might bid candidate and they describe it and
should we give him to be a? And we are limited to the description over
the telephone and what we could gather on the telephone phone
conversation and make the decision because the patient cannot wait to
come down it would take along. Quite often we found that in retrospect,
once the patients arrive, they were not good candidates. The number of
protocol violations was quite high. And that was concerning. So
telemedicine we adopted to try and solve this problem, that is to get
the expertise of the stroke specialist to the small hospital and to
avoid the complications of time to evaluate patients over the phone.
And this is a by no means the first of many tell the stroke network
across the country. And rapidly clock draw growing weight should acute
care it with that expertise is not available.
What has been
shown in tele stroke, and a couple things, the increase of the number
of patients treated, and it does so with a quite a good results. With a
complication rate that is comparable to patients were treated in person
and outcome that are comparable to patients treated in person. So I
think all of that is quite encouraging. There is also have been a
recent random control trial or random trial, I should not say control.
Testing telephone versus telemedicine for acute stroke evaluation.
Which for the first time in the randomized, first - showed that the
addition of the telemedicine did improve the decision-making capability
for treating patients with acute stroke with TPA. That is quite
encouraging. Again, I would come back to the point that we have a clear
and clinical need and there is a lack of expertise at small hospitals
across the country and this is a way of delivering that and because it
does so effectively and in a way that is comparable to the patient
being evaluated in person, it has been successful. And we are starting
to see improvements in the reimbursement as well. I will talk about
that when we get to the questions.
From this experience, and
from another us a number of the other fledging effort that's developing
telemedicine, at the PNC - - UPMC, a more organized efforts in
telemedicine in general at the nine. If you're not familiar, it is a
very large health care delivery organization. It involves 20 hospitals,
$6 billion your badge budget, and involves of all facets of medical
care. I think this organization is beginning to realize that for
physician services and medical services in general, that telemedicine
has tremendous potential to change what we do and very important ways.
Recognition of that, we started something called the Center for tele
help at the nine and the goal of this is to, but it to the additional
models, the goal of this is to centralize the function and developing
telemedicine applications and to share the knowledge base that comes
from developing individual applications so that an additional
application is begun, that it does not start from scratch and reinvent
the wheel and learn Hebert think again. So there are various aspects
that we have discussed. Such as licensing and legal aspects and
contractual relationship and business issues and reimbursement that are
common to many of the telemedicine application. And that with the prior
knowledge have already been through this, can you individuals or groups
that are developing telemedicine application can take advantage of the
knowledge and be further ahead and get things done quickly and
efficiently than without the central organization.
Also from
an organizational viewpoint, there are a number of issues that with
regard to privilege and licensing protection and the institution and
physicians and the service providers, that can be centralized through
this organization. Sorg that I think it has been useful already and
that I think it will be growing concern here at the nine and something
that we will develop and other places as well. And also a lot of
interest in provider's side, the physician side in telemedicine. And I
think that gets to the second point I want to make that has to do with
questions. We are talking a lot about cost and cost effectiveness. And
to me, the goals of using telemedicine go beyond that. And the other
issues that I think telemedicine should deal with and are important for
it include number 1, improving access to care. And I think that has
been mentioned and I think that is self evident. But perhaps something
that we have not emphasized enough. That one of the really important
achievement in telemedicine is that many individuals who otherwise
cannot access care are now able to access it through telemedicine. Or
put another way perhaps individuals who would not access certain types
of care because of the travel distance, and certainly being in
Pittsburgh and Oakland, we know this because patients tell us all the
time that they don't want to come down because of traffic, congestion
and not that they don't want doctors, but you cannot park your car. So
people who would not access this care can access it through
telemedicine. That is an important point. The other is, the second goal
of telemedicine is to increase efficiency.
Both for patients
and for providers from the decision site, you have very busy physicians
who are in one location and have to trouble travel to multiple other
locations to see their patients. And that is inefficient. If they can
be in one place and see patients and go back to the operating room or
go back to what ever they are doing, or laboratories and continue
Research, it would save them time. When we get the cost, that has to be
figured into the cost analysis. The time-saving both in the side of the
patient and the side of the physician. Because the physician may be
able to do it efficient and other things that they otherwise could not
do if they can reduce the travel time. Travel time is critical to the
patient. Here at UPMC, we often have patients who travel to or three
hours to get to a clinic here to visit a specialist in some cases. It
is to were three hours here and back. To save them the period of time,
is based an important savings and increases access to care, and
satisfaction for the patient paid and saves in terms of efficiency.
Having said that we want to improve access, and efficiency, that is
absolutely true. Obviously we wanted - we want to save money as well
for the system. No question that healthcare is it already expensive and
we do not want to add to the cost of health care if anything, we want
to decrease it. There is every indication that while telemedicine does
these other things it also has the potential of decrease costs. And
that needs to be demonstrated.
So let me describe for you a
few other non stroke things that we're doing here. In terms of
telemedicine. That also seem to be quite successful. Tele consultation
is a growing area. There are many specialists that are using
telemedicine to see initially your follow-up with patients. We have a
neurologist in our department who is a movement this order, Parkinson's
disease for example, who has an arrangement with an eight neurologists
in Franklin P. a. So the patient with Parkinson's who obviously quite
difficult travel long distances can be seen by the specialist by
telemedicine. She has a regular clinic once a month by telemedicine
which she evaluates five - four or five patience. We have a surgeon,
and colleges that operates cancer, and draws from many different areas
in the northern parts of the state by I80. Can now does that surgical
call-up by telemedicine. Able to see in discussed problems. And take a
good look at the Oakland And prescribe anything for one care. Many
other specialists are going to start taking advantage of that. There
are other acute-care - - liked. Acute surgery, the row surgery. Even
now, application that we call tele mentoring. Where a surgeon in an
operating room can communicate directly with a specialist like a
neurosurgeon here who has special expertise and procedures and a
community hospital my only do this infrequently and may not have this
experience, but he can get real-time advice and help by a more
experienced surgeon. That is a sampling when we get to the forward
things like dermatology and proctology and radiology, there is a
growing portfolio of these telemedicine application. Let me take a few
minutes and give you my reaction quickly to these questions. Many of
the comments I was going to make work already made. Maybe reemphasize
some few things.
First of all, I question number one, it is
tell their rehab pay specifically here, cost-effective and efficacious
alternative to face-to-face - - I think that's I think, has been
commented on this, on a case-by-case issue. That needs to be shown for
each specific telemedicine application. As I mentioned offered tele
stroke for example there is now evidence that it is efficacious,
whether it is cost-effective is a little bit more difficult to pin
down. When we talk about cost effectiveness, we have to take a broad
view of cost. That is one of the difficulties with the whole approach
to cost and telemedicine, it is a that you have to look at the entire
epic of care in order to assess cost. For example, coming back to
stroke, when we treat patients by telemedicine, and we get them better,
we not only safe hospital costs, not only we have cost, we also save
money in terms of the patient returning to work and save money it in
terms of potential caregiver who now does not have to take off work, to
care for someone with a stroke, there are many aspects of this that has
to be included. When you really look at cost effectiveness. But who is
asking the question about cost effectiveness is also critical. If you
are a hospital, that is asking what is tele stroke it cost-effective?
You don't care about some much if we are part of it, about the return
to work, about the cost of caregiver because that does not affect the
bottom line a hospital. If you are an insurer, again, there are aspects
that you care about, and some that you don't. So a health care system
when we talk about cost effectiveness, I think we have to include all
of this in the analysis and that is the proper way to do it. When we go
to a specific payers, to support the telemedicine application they may
have a different idea of what cost effectiveness is actually
constitutes.
With regard to question number two, are rigorous
cost studies a barrier? No question that they are. Should they be? I
don't pixel. Unfortunately, they are. Again that gets back to the issue
of reimbursement. One of the comments that was made reimbursement will
follow a standard of care. And I think that is true to some degree it
that is happening in some places. But it is hard to establish
telemedicine application as standard of care without reimbursement. It
is a very difficult to get it going and generalize to a point that it
is considered a standard if there is no reimbursement a bit of give and
take their. That is difficult and clearly, that the lack of
reimbursement is impeding the development of many of these telemedicine
applications. And with Piper. Cost studies, they could be done that
could drive reimbursement and and improve the spread in the application
of these telemedicine efforts.
The issue of Home care
applications, I think that is absolutely critical. If you looked at the
spectrum of Pele health by far what will have the greatest impact in
the system is home care. Tele stroke, tele rehab, tele dermatologic,
there are great things and important, but in terms of the overall
impact of the health-care system, and the help of the us - health of
the people in the United States and the world, the home kill
application is ready cash option is. I do believe that relate to
concentrate on that. I would ignore these other things but in this
world of financial collapse and limited resources, if we have to make
toys, I would certainly push toward home care. Question number four, I
think foreign five kind of go together. Should we be investing in
outcome studies?
Again, I think we have to because it is
outcome that is going to drive reimbursement. Personally, I don't
believe that is the only measure a move the benefits of telehealth or
telemedicine application. To me, if you can show that what you're doing
with telemedicine is the equivalent of face-to-face, that should be
good enough to drive reimbursement. If I am a dermatologist, and I can
go to Mercy Hospital and see a patient and get paid for that, but I am
providing that absolute services remotely via telemedicine, frankly I
don't see any reason why that should not be reimbursed exactly the
same. But the payers have said, will it cannot be just as him, you have
to show us how it saves money. And that is where the outcome study
become important. That is how we are going to demonstrate the cost
effectiveness. To me equivalence should be the bar and unfortunately it
is not. And the other point of outcomes, ultimately, as healthcare
providers, we want to know the what we're doing has an impact on
outcome and that is the gold standard for any new treatment in medicine
is that patients get better because of it. So certainly from that point
of view that is important.
Larry, give us a quick answer to the last question on research and then we have to turn to our final person.
Let me mention a couple of thoughts I have about the last question. I
think one of the things we need to know is not only what we can to by
telemedicine but what we cannot do by telemedicine. I don't think
everything can be done remotely, not everything is [ INDISCERNIBLE ] to
that and I think that needs to be studied as well. But is and what is
not possible by telemedicine. I think we have to be looking at how
telemedicine fits into the spectrum of care. And pick the rehab example
there are many examples to rehab, where does this fit in? Is this
something that is a small place or large please, does it replace things
or enhance things. And I think what we should be looking for is to
enhance existing care not to replace it. And finally I would say that I
think this point was made earlier, there may be some things that
telemedicine can do that we cannot do in face-to-face. I think we have
to be thinking about this as well because they are undoubtedly and AM -
- aspects to telemedicine that go above and beyond what we can do with
the patient face-to-face. This are my comments. Again I thank you for
including me. And I look forward to the discussion.
Thank you
very much. Mary and I found it fascinating what you're saying about
cost and maybe it is necessary and it is too bad. Let's move on to
Peter who I think, you are in San Diego right now and? IM.
But you're feeder - feet are usually charting the street in Washington.
In the.
Will you give us the benefit of thinking about your questions the question and certainly reimbursement.
I would be happy to. I think what I will do because previous speakers
have gone through each one of those questions, so meticulous the, what
I would do it is tickled bit more of a 30,000 put look at these issues
and see which I could provide my thoughts. In more summary format.
First, taking a look at the will health care system and seeing where
telemedicine and telerehab in. They do what all. I would suggest that
it is a pretty exciting time for telemedicine and telerehab. When you
have health care system that is widely viewed as being unsustainable,
when you've got policy trends that are moving more and more toward
home-based care, and breaking the institution based bias and getting
people back served in their homes and communities. When you have
Medicare generally time to focus on chronic illness and the long-term
need population, under Medicare. Where you have the situation where it
is brought relatively small benefit beneficiaries that consumed the
large resources and a lot of policy makers focusing on that and trying
to figure out ways to address that issue. And where you got general -
that's where we need to find solution not only to improving care and
increasing access to care as just mentioned. But also to reducing
costs. I think telemedicine is foursquare part of the toolbox that can
address these very pressing and very difficult set of factors that we
as a nation case and probably to some extent the world faces, but
certainly we as a nation case.
There are a number of pieces
of legislation that are pending and are being debated in Congress right
now. We are just about to enter into a very significant debate on
health care reap reform. The Medicare physician fees schedule will
decrease by 21% January 1 of 2010 and so Medicare is going to be looked
at again next year and children's health plan and programs will be
looked at, Medicaid will get a close look in terms of regulations.
Virtually the entire complement of major health care programs including
private sector is on the table next year. It strikes me that if you can
demonstrate efficacy and some degree of cost effectiveness, I know not
about all about cost effectiveness, but they are looking for ways like
never before to save money and if you can figure out a way to do that,
in terms of raw political power, it is : to be a whole lot easier sell
to get anything included and passed into law if it saves money.
And Medicare, you got the medical home concept that many people are
talking about as a way to move forward in healthcare. You have the
independence of home act that will basically provide a benefit to
manage people with chronic illnesses much closer than they're
currently. It have snacks, which are special needs plans that are
addressing people with chronic illness and high-cost conditions. That
is under Medicaid, you have the community to is adequate which really
bricks the constitutional bias and allows people to step services and
their home and community. There is an awful lot taking place including
the whole rural and urban set of challenges of providing quality care
and make sure making sure that people have access to care. And again in
a way that telemedicine and Telerehabilitation can be very significant
answer. I want to say about the importance of home care. Example. When
you've got a chronic illness and disability population, my personal
view is that the access to care piece as was mentioned, is critical.
There's a lot of people that whose disabilities or chronic illnesses
themselves present them prevent them from getting out of the house and
getting to a health-care provider to get the kind of care they need and
they may be in pain, in a particular position where that is not
something that they are not capable of doing or it is does not get
them. The access issue is extremely important for the disability
population.
The bottom line all of that is in my view,
reimbursement drives practice. Right now, reimbursement for telehealth
health and Telerehabilitation is very challenging. In part, it is
because some of the studies and necessary evidence based is under
development and has not been bought off by policymakers and health
plans and Medicare and Medicaid officials. And there have been attempts
and there are some funding sources available for these kinds of things.
There are public programs like the Percy programs that are trying to
develop some in for cash and frustration. But there are, it strikes me
there is a couple of different important factors, first, doctors and
therapists and the like don't really get reimbursed under Medicare at
least for email correspondence or phone calls. The bottom line is you
need to go in and see and have an office visit with a position in order
for the position to get paid under Medicare. Until we have some kind of
like benefit the permits greater access to telehealth,
Telerehabilitation, where reimbursement is able to be a factor, much
greater factor than it is today. It is never going to take off. In my
mind. I think you have a lot of different kinds of types of
rehabilitation and some of what I am about to say may not make sense in
the context of providing various types of telehealth. There are often
capital cost, if you're talking about home care situation, and the have
some kind of capacity to monitor a patient from their home. There are
often times capital cost in establishing that that technology. And of
course you have the ongoing reimbursement for the services that would
be necessary if you're going to be providing on an ongoing basis. The
capital costs are very significant problem. Who pays for that? Everyone
can wrap their arms around the Medicare program for instance, agreeing
to cover an ongoing service that is tell Web-based. But when you talk
about the couple cost, such as a system that is much more difficult.
When I say there are a lot of different kinds of telehealth, I remember
in the mid-90s, working in the Medicaid waiver where one of the real
ground breaking aspects of that waiter waiver was to provide a phone in
each person's home if they did not have one. Simply so that the mother
or father for that child under Medicaid could call the nurse
practitioner or the plan itself. In the case of an emergency court any
kind of need. The instructor and be instructed where to go rather than
showing up in the emergency room. That is a form of rudimentary
telehealth. That may quickly go into what Medicare doesn't recognize. A
number of demonstration projects taking place at CMS and the
telemedicine area. There is currently a benefit under the Medicare
program for telemedicine, but there are a number of barriers to it. It
is simply has not caught on as people had hoped as many people had
hoped I suppose. The benefit was past five or six years ago. It is
permanent but the provider that wants to bill Medicare for our
telehealth services must apply. Physically apply for the right to do
that. And demonstrate to CMS that it will be providing one of two
categories of services. One would be in the general category of office
visit and consultation and the other would be other services that would
be approved by Medicare part telehealth would not interfere with the
service. In other words, the provision of service through telehealth
mechanism would not undermine or undercut the quality of the service.
It is only also available and rural areas so it is not benefit that
would be widespread across the urban centers. It is rule-based benefit.
I don't get this sense that Medicare officials and working on this
issue and speaking with some of my partners working on this issue, I
don't get the sense that Medicare officials are all that excited and
interested frankly in pushing this forward and picturing this as the
next wave of Medicine. And next wave of innovative way to approach a
lot of the problem. In our health system. Again, they are there are
plenty of studies that demonstrate the efficacy of telehealth, there
are some icy use telehealth, projects that have done very well, and
demonstrated some. Positive results, but CM's seems to be a bit stuck
in the past of the traditional medical model and it is not very
motivated or appears not to be motivated to move forward to this in a
very significant way. So I guess, the telehealth, the area of Medicine
in Medicare at least, my sense is that it could be a real solution but
at the current time, it is lost it has lost some momentum that it has
several years back. One of the critical elements to the program under
Medicare it is it at there has to be a health professional at each end
of the care being delivered. That takes away a lot of the potential for
telemedicine especially being provided in the home. ~ monitoring,
public consultation. Where you have to have the health-care provider in
that home where in order for you to build Medicare for the service. You
are basically sending out healthcare professional to see the patient
anyway. And the question is are you really getting as much out of the
system and its you could. If you did not require the health care
professional being in the room of the same time of the other end.
Between both ends of the communication. There are August problems with
reimbursement I think a large part of that is cost-benefit analysis and
if you could work out a situation where you have proposals that have
provided [ INDISCERNIBLE ] to develop and incentive the - - the
telehealth and telerehab programs and simply Congress could do that
relatively quickly and easily. And frankly I think that those systems
would be included in the important components of a lot of the earlier
versions of legislation that I talked about, medical home, independence
and Community Toys Act. You could see a significant increase in
Reliance and telehealth of the next several years. And any kind of cost
effectiveness studies that would demonstrate cost savings would make
that legislative push a lot easier.
I will stop there.
I think that your presentation would generate about another week of
conferences. Thank you very much. We will take a couple questions maybe
even one, [ INDISCERNIBLE ] is asking what is the policy position of
that a am a telemedicine and how it affected policy development? Who
would like to take that one on the panel?
Larry, do you know?
The question about the American Medical Association? I have not seen
policy statement from the AMA. It think that is an interesting
question, as far as I know, they have not taken any kind of official
position. I am not sure that that has reached awareness of the AMA, but
it probably should.
Peter, of you know - have you noticed any
activities? No, I don't. I know there are a number of Dr.
Organizations, in particular some of the home care doctors, that are
very interested in being reimbursed for the kind of the things I was
talking about, email communications and other kinds of telehealth
related things. I think they find it just as frustrating as anyone else
cut that in order to receive payments from Medicare for consulting,
they have to have the patient physically in their office, during an
office visit in order to do it. I don't think it would be erode black
necessarily to the benefit or new form of we in reinvestment print for
this kind of care.
The biggest drivers with this that I know
of this comes from the medical association. They have been very active
lobbying CMS and state governments and I do now that the American
Academy of neurology, is preparing a number of and if statements that
will pump from the society regarding the value of telemedicine and
reimbursement issues. I think it is certainly from a professional
organizational point of view, and - -
Kate, can pick this up?
This is Deena.
A couple of things, that a and a weight in on cross state licensure and
continues to weigh in that issue which has implications, but it is in a
sub specialty that you see it. For example, the American dermatological
Association develop standards for telemedicine. What you're seeing is
increasingly the family practice folks have gotten into it. What you're
seeing is increasingly by some specialty more higher-level of activity
than by the AMA. Can I take the opportunity to ask Peter a question?
Will quit, Peter, both of you quick.
Peter, I it right and in first - - I deal with day-to-day for Medicare
and Medicaid. And he said - not sure I understood. They have to be
clinician at both ends, and that is not true for Medicare payment, for
consultation, were you referring to specific applications?
As
I understand, under the Medicare benefits for telehealth, there are two
different categories that I spoke of, when you are talking about health
care and delivered in the home care setting, through telehealth, my
understanding their needs to be a professional in both ends of the
communication.
I want to make sure that we were talking strictly about home care. Because other applications, that is not true.
That is correct. I think I limited my statement to home care. And
talking about the chronic disability population in the home setting.
Okay.
Peter, are you out there at the academic [ INDISCERNIBLE ] meeting? Academy of physical - -
Are you seeing any interest at that meeting at all in telemedicine come rehab?
There are some presentations, three or four day meeting, I am only here
for one day or two. There are, I am not going to be able to attend. In
the area of rehabilitation, I think telemedicine offer a tremendous
amount and again, in part because of the nature of the disability that
largely being treated with the chronic illness being treated. Many of
the people who can benefit from this technology especially when they
are in the home and community-based setting, they don't have to go to
the person delivering care. In many instances. I don't think that can
be under recognized when you are sitting there with an extraordinarily
painful back or you have an artificial limb or spinal cord injury or
rehab and as an having a clear up, you're getting yourself together out
of the house down the road many miles and into a doctor's office can be
insurmountable. And the access issue cannot be overstated what how
important it is for those population.
One last question for
Larry. When you have a stroke victim at home, and in need of a fairly
long time long term tell the monitoring of some kind of PT, do you see
telerehab possibility there with your patient?
Absolutely.
I think that that would be tremendously valuable application of this
technology. The same thing that Peter is talking about applies here. It
is very difficult to how any follow-up done on patients who are
disabled from the stroke 28 do come to see as, they do so infrequently
because of all the effort to get them there. And oftentimes, the decree
of follow-up is inadequate for the problem. Yes, I think the biggest
issue there is how to get to live monitoring or telling services into
the house. And some of the companies like Intel or Microsoft are it
coming up with home based devices for this kind of monitoring that will
be a big market.
I think the home care agencies as well are
getting more sophisticated. It comes the time when, think use are
appropriate and I have to say that one of the people that called in,
was one of the people whose Article we would use and I would rather "
was she said, she said, this is an extraordinarily interesting and
informed panel. And also a great conference. I will say that the
directors out there that special thanks to Deena, Alexander and Cindy,
Larry and Peter. Thank you so much I hope that we will all be
continuing to dialogue on these questions in the future. Thank you.
Thank you.
[ Event Concluded]] can I make another comment? I think that whole
system is broke. Peter said there are opportunities in the next, to
look at some of these. I think it is really important especially with
the [ INDISCERNIBLE ] invoke rehab beyond the health care system and
what would increase market demand. The more things you can have out
there showing that this stuff works, not necessarily in typical
traditional health care and I think one of the biggest issues is
focusing what so much on the elderly and the boomers coming up and it
is a real mistake to design only four elderly folks my age. The
different expectation, we need segmented business models going on. What
really appeals to younger people who are - Do this 24, seven. Some of
us may have different payment models. But getting more focused, not
just so tightly focused, than just health care, it is going to be
critical for making this work. That is where we are going to develop
the pressure and incentives and motivation for change. More markets
coming up than just us old folks.
Thank you very much. I
never considered you old, Alexander. I still don't. No matter how old
you are. Because of the creative mind. Again, thank you very much to
the panelists, which will now turn to the slides for a couple more
slides. The slides are actually reminders slides. The first slide is a
reminder. Continuing education, please complete and return the session
evaluation. The post test forms in order to the writ to receive the CPU
or CRC see. And you have out there it in the download, and the website
location. Also to remind you that we will pick up and questions and
comments from, if you simply submit them to the conference blog, which
is http//rerc--
We will also have as zero s are cuts, posted - -
If you have additional questions, these latter conference brought
blocks in the archives, they will see - - and the next slide, please.
I think, that in all the languages of all the countries that have
joined as over the four days, we want to say thank you and we will
test, also concentrate on one particular Thank you. Which is directed
at the person is the producer the FOS teleconference and her name is
Ashley Molly narrow and she is the person who we do not see that you
can see her hand and her head. We want to thank you, but we want to
also think the team here. All of you, students, faculty and staff and
the audience with the interaction that we had today. Again, thank you,
everybody and I think it is almost good night here in Pittsburgh. Maybe
morning for some of you. Anyway, thank you.
[ Event Concluded ]