Among the predictions for 2015, one that has received a lot of attention is the growth of telehealth. In a 2015 posting on Forbes titled "Why Telemedicine's Time Has Finally Come," Fleshman, an asset manager, attributes today's dramatic increase in teleheath to people's desire for convenience. Hall (2015b) identified four key drivers for what I would call connected health, a broader concept than telemedicine:

* Faster Internet connections and better software provide a better video chat experience than in the past.

* With mobile devices, people can consult a doctor from anywhere.

* The adoption of electronic health records makes it easier for doctors to access patient records.

* Patients are comfortable with asynchronous messaging, which can be more time-efficient for doctors.

In the Forbes posting, Fleshman noted a prediction (by the associate dean at the Center for Connected Care at the Mayo Clinic) that the "60-plus crowd" will be the fastest growing population for connected health. These are individuals who "are not technology-averse [and] have the greatest mobility challenge in terms of getting to a doctor."

Fleshman also noted that the Carolinas HealthCare System "rolled out a virtual visit program that allows any of their 1 million eligible patients to access a provider at any time for a flat fee. The provider on the virtual consultation can see the patient's medical record, and their notes can be accessed by the primary care doctor and care team." Other hospitals are following this trend. Thomas Jefferson University Hospital is creating "a video visits program that would enable the hospital to help patients while keeping them out of their physical facility" (Tozzi, 2015). The CEO of Thomas Jefferson believes that keeping people out of the hospital is one of the best ways to save money. Video visits will be for emergency room (ER) and urgent care visits.

A recent report (Accenture, 2014, 2015) on 25 State Health Innovation Plans funded by the Centers for Medicare & Medicaid Services provides additional support for the growth of telehealth. It identifies five top investment areas by states currently in the program. These are considered health care reforms as they provide accessible care at lower costs by integrating health care and human services:

* Patient-centered medical homes. All 25 states are investing in medical homes to strengthen primary care integration with specialists and community health workers. Most will also integrate physical and behavioral care.

* Lower-cost labor models. All 25 states are targeting investment in community health workers to shift labor costs to more appropriate caregivers. Some states are mobilizing human services "navigators" as liaisons between primary care coordinators and social service programs. Others are mobilizing cross-sector partners (e.g., business and community organizations) for health and wellness initiatives.

* Telehealth. Of the 25 states, 19 are expanding use of virtual care technology (e.g., telehealth and remote monitoring) to treat more patients without adding health care workers and facilities. Some are also focusing on improving reporting and evaluation of health data (e.g., geographic information systems to match resources to hotspots of chronic disease).

* Self-service tools. Fifteen states are offering patient portals and other digital tools to reduce administrative costs while improving self-care, expanding access to electronic health records and information on value-based health choices and access to care delivery options.

* All-payer claims databases. Fourteen states are pursuing statewide data aggregation and analytics to reduce redundancy, improve insights into population health, and foster integration of health data with human services data, with a goal of designing more effective intervention and wellness programs to reduce long-term costs.

RECENT STUDIES

The VA

Now let's look at some recent studies that are further fueling virtual visits. The Veterans Administration (VA) reported in October 2014 that more that 690,000 veterans participated in more than 2 million virtual visits. The VA currently offers three types of virtual visits: traditional store and forward (image sent to specialist for review), clinical video visits (two-way live visit between a patient and a provider), and home monitoring.

Vesely (2014) reported that VA video visits increased by 22 percent over the year with a 34 percent reduction in readmissions for home telehealth patients and 42 percent reduction in bed days for telehealth patients. She also reported that clinical video visits had a 94 percent satisfaction rating. (An overview of telehealth statistics at the VA is online at http://c.ymcdn.com/sites/www.hisa.org.au/resource/resmgr/telehealth2014/Adam-Dar.) A recent randomized clinical trial at the VA (Fortney et al., 2015) found that a telemedicine collaborative care approach improved PTSD outcomes for rural veterans who were able to participate more often in cognitive processing therapy sessions.

Other Surveys

In 2014, MDLive (a telehealth service provider) hired the Harris Poll to conduct a Mobile Health Index Survey of adults 18 to 34 years old. The results are not surprising given that the population surveyed was not only tech-savvy but somewhat care-averse with regard to seeking health care. The results demonstrated that "young invincibles" (ages 18-34) are more likely (54 percent) to postpone or cancel (72 percent) a visit to a health care provider because of inconvenience, for example, the need to take off from work, high costs, or a long wait for an appointment. Eighty-two percent said that consultation over a mobile device would be the best option for them.

More interesting are the results of the Telehealth American Survey 2015 conducted by the Harris Poll for American Well (2015), another telehealth service provider. Consumers were asked about the types of health care they would consider via online communication and what would make them more comfortable with virtual visits. Sixty-four percent said they would do a virtual visit with a health care provider because of convenience, not having to drive, avoiding germs, and shorter wait times. Others would not do video visits because they did not understand how a physician would examine them.

When asked what they would do if they were sick in the middle of the night, 41 percent said they would go to the ER, 21 percent would do a video visit, and 17 percent would call a 24-hour nurse line. Close to 70 percent would do video visits to obtain a prescription refill and prescriptions for birth control, antibiotics, and chronic care conditions. Of the 60 percent of the sample who believed that virtual visits were effective, 69 percent preferred visits on their smart phones. You can download the report and also watch a video about the survey (American Well, 2015).

Financial Implications

A recent survey by Software Advice (Leventhal, 2015) stated that 75 percent of patients not currently using telehealth visits would be interested in virtual visits for minor health conditions. A similar percentage said they would use a virtual visit in favor of an ER visit for a minor ailment. The posting notes that according to a study by the National Institutes of Health in 2013, "the average ER visit [horizontal ellipsis] costs $2,168 - vastly more than the average telemedical visit, at $40 to $50."

Speaking of costs, a study by Yamamoto (2014) assessed the feasibility and cost of substituting one in-person patient visit with a virtual visit within Medicare. Data were collected from service providers, and details are given on how costs were calculated. The study also assessed types of health issues and redistribution of care by service (ER, urgent care, physician office, other clinics, or do nothing). The bottom line finding is: an average telehealth visit costs between $40 and $50 compared with $136 to $176 for an in-person care acute care visit.

Now let's look at what is always a showstopper: how to cover the costs of connected health. Interestingly, with the movement from a fee-for-service model to a value-based care model, it is possible for institutions to view connected health as a cost savings. A January 2015 announcement from the US Department of Health & Human Services (DHHS) about a shift from volume to value for Medicare reimbursements is certainly a step in the right direction. The Better, Smarter, Healthier announcement tells of a goal to tie "30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018" (DHHS, 2015). This shift can certainly facilitate the development of digital connected health models as alternative care delivery systems.

The Centers for Medicare & Medicaid Services (CMS) has also proposed changes that will greatly expand reimbursements for virtual visits. CMS proposes that telehealth care be used to provide four services to Health Provider Shortage Area Medicare beneficiaries: annual wellness visits, psychotherapy, psychoanalysis, and prolonged evaluation and management services (Bowman, 2014). To read more about the CMS codes and support for telehealth, you can go to http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html.

The American Telemedicine Association (ATA, 2014) noted that "CMS added a new Current Procedural Terminology (CPT) service code, 99490 for chronic care patient management. This is not a telehealth code and does not require the patient to be present so it is available to be used for any patient, regardless of location." A small but important victory for reimbursement models.

Another step forward was the recent signing of legislation in New York to require commercial insurers to cover telemedicine and telehealth services. New York becomes the 22nd state to require parity in reimbursements (Hall, 2015a), meaning that insurers must not allow deductibles, co-insurance, or other coverage conditions for telemedicine to differ from those allowable for in-person services. In Colorado, we are awaiting a decision on legislation that would prevent health care plans from requiring an in-person visit and allow for care delivered via a computer, smart phone, or other device. Although there is currently a restriction in this legislation for patients residing in counties with 150,000 residents or fewer, this may be lifted over time if approved (http://www.denverpost.com/news/ci_27374271/colorado-lawmakers-advance-bill-sprea).

The ATA has created an accreditation program for online patient consultations. It will give a seal of approval to organizations providing online, real-time patient health services that comply with standards specified by the organization. The program promotes patient safety, transparency of operations, and adherence to all relevant laws and regulations (http://www.americantelemed.org/accreditation/online-patient-consultations/progra).

The ATA is also developing a guide for consumers who use online telemedicine or virtual health visits. Read about SafeOnline for Consumers at http://www.americantelemed.org/safeonlinehealth/safeonlinehealth-org#.VNaA2nbZ4Y. A new organization, Center for Connected Health Policy (http://cchpca.org), also provides essential and useful information regarding policy and how to maximize telehealth benefits.

WHAT IS NEEDED NOW?

Given these developments, what is needed to push forward with connected health? Asked by Healthcare IT News what can be done to accelerate the rate of adoption of telehealth, Kvedar (2015) offered five accelerants:

* Increase value-based reimbursement for providers.

* Create more mechanisms for provider reimbursements for nonface-to-face care, such as the new CPT codes.

* Accelerate consumer choice in the marketplace as well as consumer-driven health care (e.g., high deductible plans, health savings accounts).

* Make consumer-facing technology truly frictionless.

* Create universal privacy/security technology and make it a public good.

I would add a sixth accelerant: begin to educate health care professionals to use these digital technologies and to become comfortable in providing care in a connected health era. This means we need to include this preparation in our nursing curricula. At our university, we have instituted a telehealth pilot in our nurse practitioner program, and I am sure we are not alone in offering these learning opportunities.

Are you addressing this in your curriculum? Are you providing your students with telehealth experiences? If so, please send me an email (mailto:[email protected]) with a short description and I will mention it in my next column.

REFERENCES