BY: WILL SNYDER and DOUGAL HEWITT
Over the centuries, the Catholic health ministry has been at the forefront of advances in compassionate care or "high touch": Florence Nightingale wrote of how much she owed to the example of the Sisters of Mercy she met working amid the carnage of the Crimean War. The Daughters of Charity and the Sisters of Bon Secours began some of the very first home visiting and child care programs. But we aren't always seen as being high tech.
Yet Catholic health care organizations once again are at the forefront of a momentous shift — a move from taking care of people when they are sick to supporting people in staying well. A key part of this change is telehealth.
By its nature of small iterations and incremental improvements, telehealth may not feel so sudden or dramatic. Don't be fooled: By its ability to improve outcomes, reduce costs and increase patient engagement, telehealth is revolutionizing health care and spreading expertise across wide geographies. Machines and technology also are presenting the Catholic health ministry with the opportunity to bring compassion and healing to more people than ever before, and to support them in staying well.
As the largest Catholic health system based in Illinois, with more than 150 locations around the state, Presence Health uses the power of telehealth to provide remote access to experts, critical care and loved ones in geographies as varied as urban Chicago and rural Danville. With 12 hospitals, 27 long-term care and senior living facilities, dozens of physician offices and health centers, home care, hospice, behavioral health services and more, Presence Health provides health care access to more than 4.5 million individuals. And as one of the largest Medicaid providers in the state, Presence Health is finding telehealth to be an effective avenue for engaging at-risk individuals throughout the care continuum.
There is a growing understanding of the ways in which telehealth can reduce costs and complications and keep people out of emergency departments. But what excites telehealth advocates is the opportunity it brings for greater access and ongoing engagement.
"We are moving to a world of interconnected devices, so your scale and treadmill will be feeding information right into your electronic health record, which is available to both you and your doctor through iPhones," said Sandra Bruce, president and CEO of Presence Health in Chicago.
Though health care is not all the way there yet, it is heading that way quickly. The possibilities are dazzling, if we in the ministry think about technology as an imaginative solution. For example:
- Can we help at-risk mothers make and keep their health care appointments by placing a shared calendar — a calendar they can see and we can see — on their smartphones?
- Could we give elderly patients an iPad loaded with games and puzzles to help them with mental acuity while also giving us the ability to monitor their progress?
- Could we sync a pedometer to a fitness regimen that a primary care physician has set for a patient?
Two of the most effective tools for conveying telehealth's impact are data and personal stories. Here's one of each:
Since Presence Health began using telestroke programs, the time from a patient entering the hospital door to a drug being administered has been cut by 50 percent. Such a drastic reduction in time is the result of on-call neurologists being able to respond via a tablet and phone loaded with the telestroke software. The clinician can access the system, see EMRs and scans and set up a video conference with the unit staff, as well.
"One of our neurologists could be at the park with her family on call, and step away from the picnic for a few minutes and decide on the best course of treatment," Laura Messineo, system manager of eICU Operations at Presence Health, said. "Telestroke totally changes the meaning of 'call.'"
That's the data; now, the story: A 37-year-old patient in Chicago suffered a stroke while walking out of a local coffee shop. The type of stroke was rare; it has a survival rate below 20 percent. When the patient arrived in the emergency department, he was able to be evaluated by video hookup with a neurologist and received a clot-busting drug within five minutes. When it became apparent that surgery was needed, the patient was quickly transferred to a hub facility for a procedure to retrieve the clot. Just three months later, he was walking, talking and back at work.
While telehealth often is touted for the access it provides in rural areas, it's also extremely effective in navigating urban settings where distances might be shorter, but travel times can be much longer. With three hospitals in Chicago and another five in the nearby suburbs, Presence has found telehealth extremely effective in navigating urban settings. In an environment like Chicago, waiting for a clinician to arrive at the hospital, especially during rush-hour traffic, could be the deciding factor in an emergency. In the stroke patient's case, telestroke was the difference between life and death
"The technology was also what preserved his quality of life," says Dhruvil Pandya, MD, a neurologist with Presence Health who treated the patient remotely.
Telehealth systems in the ICU have existed for some years now. Like the evolution of other technology, eICUs have improved from one-way video to two-way (think Skype or FaceTime). Critical care nurses are able to monitor patients for subtle changes and can counsel and help patient families who might be in the room. Also, having access to a remote team lessens the burden on smaller hospitals while keeping patients local.
"With the extra level of support we offer through the teleICU, we can reduce transfers, providing stability in a time of uncertainty to a patient and family," said Messineo.
In 2013, Presence Health piloted the TeleSitter program at Covenant Medical Center in Urbana, Ill. Designed for use with elderly patients at risk of falls, agitation or confusion, the program uses audio/video technology to connect virtual "sitters" with patients in their hospital rooms in order to respond to a bed alarm, view the patient, and give gentle reminders for things like not getting out of bed alone.
Because the telesitters are able to contact nursing stations immediately with a code, the response time in the case of a fall is just seconds. And because a nurse can't be bedside at all times, the telesitter can help soothe the patient if he or she becomes agitated, while at the same time dispatch someone from the nursing station.
The program seeks to reduce falls by 10 percent in its pilot phase. Not only will that create large savings in care costs, it provides a better quality of life and a far superior patient experience. But in practice, the TeleSitter program has offered more than fall prevention or calming someone down. In the first week of the pilot, a patient in her 80s quickly figured out how to use the technology her own way.
"She reached over to the screen and tapped it. When the telesitter responded, the woman asked if she could have a glass of water," said Messineo. "It's a reminder that while we might design something to work in one way, our patients are often finding additional, helpful uses too."
Assuming a successful pilot program, the telesitter technology will be deployed across Presence Health's 27 extended care facilities, with the broader goals of both increased safety and compassion.
NICHES
Working remotely, at a fast pace and in a variety of medical situations, means telehealth has created a workforce niche. The primary requirement, from nurses to pharmacists to clinicians, is experience. People are not coming right off residency to practice via telehealth. Most of Presence Health's nurses have at least 15 years of experience. It takes a special person with ample experience because the work relies on so many trusting partnerships.To paraphrase author and surgeon Atul Gawande, MD, there are no cowboys in telehealth. It's a pit crew.
To be sure, caregivers generally don't enter the health care profession because they want to work remotely, but making a shift to telehealth brings advantages, observed David DiLoreto, MD, chief clinical, quality and innovation officer for Presence Health.
"Telehealth has the potential to extend the careers of caregivers, both specialists and primary care physicians," he said.
William Gibson, a science fiction writer, famously quipped, "The future is already here, it's just not evenly distributed yet." In the last decade, smartphones have permeated every aspect of everyday life — and made it easier. Think about restaurant reservations, plane tickets, car services. Or consider how easy it is to email with a distant friend or video chat with a relative. All of these services could be transferred to functions in care delivery. You should be able to use a mobile application to quickly book an appointment, pay a bill and chat or email with your clinician.
So one of the questions that comes up in any telehealth discussion is, "Why can't you do those things yet?" In other words, why hasn't the future been distributed to doctors and health systems?
Part of that is a loaded question: In banking, you can do almost everything you need to without interacting with a live person. In health care, you can't. For example, technology can't handle your labs remotely (yet). But health care technology needs to be better integrated with technologies other sectors use.
"Health care providers must deploy new ideas, learn from them, make improvements and redeploy quickly," said DiLoreto. "It's a new way for many of them to operate."
Doctors draw on creative thinking in infectious disease and trauma situations, but not as much on day-to-day care. Software developers, on the other hand, test and retest new ideas in software on a rapid timeline.
The future versions of telehealth also can bridge the distribution gap Gibson references. Smartphone penetration in the Chicago area's Medicaid population is around 70 percent. Nationally, the largest age group to use tablets such as iPads is over 50 years old. So, as Gibson said, the future is here. By building on such access, telehealth can start eliminating the barriers to equity in care, especially with younger generations and the elderly.
Changing consumer behavior is no easy task, but there are opportunities to target who uses what, as well as to manage certain lower-cost populations. With youth, for example, the focus is on regular checkups and developing strong wellness behaviors.
Gamification is technology's way of using dessert to get someone to eat their leafy greens. It works by taking mundane tasks like tracking weight or taking blood sugar measurements and turns the process into one of challenges and rewards. Gamification has been very effective with younger generations, but it also is being tested with the elderly and homebound, thus expanding access.
At Presence Health, "We are deploying an app called Zest," DiLoreto said. "Every action a consumer takes feeds information into the network. Those actions are then turned into points which can purchase things through an online marketplace."
With young populations in lower-income urban settings, telehealth is creating access from touchpoints beyond normal care settings. A promising opportunity is tele-mental health for children. Many mental health school services have been cut across the country due to budget strains. To address this situation, the Illinois Department of Public Health identified several organizations ranging from a nonprofit gang intervention group to a childhood education agency and is working with them on demonstration projects on tele-mental health for children.
"Health systems like Presence can then provide professional staff while these coordinating agencies can handle scheduling, on-site monitoring and follow-up," said DiLoreto. This can help to reduce costs while expanding care through non-traditional avenues.
Fostering healthy lifestyles with children could have a major impact on the long-term cost of health care in this country, but major, current consumers of health care frequently are elderly. And those with chronic disease can have very high expenses. (It's the classic case of 5 percent costing the system 50 percent.) There are significant opportunities to leverage telehealth to give a patient's family better information. Home monitoring and engaging loved ones to participate in caregiving through remote access will help caregivers see problems before they progress too far and result in an ED visit.
Telehealth is proving effective with additional initiatives around women's services. Women with high-risk pregnancies in underserved communities in the Chicago area can get access through local clinics with telemedicine machines equipped with "plug and play" features like ultrasound. An OB who specializes in high-risk pregnancies is then able to expand reach into more at-risk communities.
One Illinois domestic abuse shelter uses technology to save social workers having to travel to numerous sites in a day for assessments. By staying central and treating or assessing women across a network, social service agencies are able to do so much more with what seem like perpetually challenged budgets. These are all ways that technology is helping to remove barriers to health care that was previously far more costly to provide, while furthering Presence Health's mission to serve the vulnerable.
MINISTRY OPPORTUNITIES
While sites like Amazon have streamlined electronic commerce and created access to seemingly every product made, you're still only interacting with a website and not a person.
"Telehealth is a revolution in health care delivery," said Bruce, "but we don't want to lose the human touch, the care and the compassion, and become just a place to get medical treatment."
Fortunately, technology and the personal connection are not mutually exclusive. "Through the video conferencing capabilities of telehealth, Catholic health care has the opportunity to deepen and strengthen the spiritual element of care," Bruce said. "While telehealth is often thought of as providing medical advice on demand, why couldn't we offer our chaplain services in the same way?"
Telehealth has plenty of attributes for patient care and monitoring, reduction of costs and for access, but it's also proving helpful for family members.
"When physicians are rounding, it might not coincide with visiting hours. Now when a family is visiting, they can push a button, the TV comes on, and if they have a question it can be answered," Messineo said.
Much of the anxiety that comes from caring for a loved one in intensive care is not knowing what's happening. Such anxiety can be mediated with a video consult with a nurse, clinician or chaplain.
CHALLENGES
Telehealth offers clear advantages to improving all aspects of care. The Advisory Board Company, a health-care think tank based in Washington, D.C., noted, "Using telehealth increases data accuracy and optimizes care coordinator time. Remote patient monitoring systems save time for patients and clinicians by avoiding superfluous — and expensive — care management." And telehealth "can help curb the impact of physician shortages by extending remote access to physicians."1
But there are challenges.
Think of a speed limit. While the highway might look and feel the same, when you cross a state line, the speed limit could suddenly shift from 65 mph to 55 mph. Such shifts in regulation also impact how clinicians can deliver care. It might be the same fiber-optic cable running between Illinois and Wisconsin, but the licensing changes between the two. (Being licensed in all 50 states costs more than $28,000.)
With Medicare, reimbursement remains a challenge. Medicare will pay for telehealth but only in health care shortage areas, which are defined by states. As a result, health systems don't have an incentive to use telehealth in population centers. Still, payment models are driving change. Capitated payment encourages a faster adoption rate of telehealth so a practice or system can handle the volume. Much like banks would steer clients to tellers, now the reverse is true. Banks will penalize customers for using tellers before trying to handle their issues online or with an ATM. And it's possible the model could flip similarly in health care.
THE NOW SOCIETY
Where do we go from here? Smaller, faster and in-the-moment is the short answer. And that's good for the Catholic health ministry and its mission to bring healing and hope, and especially to care for the underserved.
It's likely we'll see telehealth services move into the regular toolbox of the primary care physician. And when elderly patients need help with chronic disease, much of that will occur in the home through connected devices. With cheaper technology and wider reach, all populations can be empowered to pursue wellness in real time.
"We live in a 'now' society that is so fast-paced. Even the thought of driving to [an urgent care clinic] feels outdated and too slow," Messineo says. "We want to open an app on our phone and be connected to our local caregiver."
The good news is that telehealth can be immediate and intimate, giving our ministries the opportunity to be both high tech and high touch for our communities.
DOUGAL HEWITT is the chief officer for mission and external affairs at Presence Health, Chicago.
WILL SNYDER is the system director, community engagement, at Presence Health, Chicago.
NOTE
- Caitlin Stuhan, "The Real ROI for Telehealth," The Advisory Board Company, www.advisory.com/research/marketing-and-planning-leadership-council/the-growth-channel/2014/09/the-real-roi-for-telehealth (accessed Dec. 8, 2014).