The Department of Veterans Affairs (VA) has long been ahead of the private sector in health IT. Its VistA electronic health record (EHR) system, for example, was in use throughout the VA's hospitals and ambulatory clinics long before non-VA providers began to adopt EHRs en masse in the past few years. And as recent VA figures show, the department has also left the private sector in the dust in the area of telehealth.
Last year, almost half a million veterans received some of their care remotely, either through virtual visits, home monitoring, or a store and forward system, according to Adam Darkins, MD, who leads VA's telehealth program. Included in that total are roughly 148,000 veterans who participated in remote consults with clinicians and 119,000 veterans whose conditions were monitored at home. Remote monitoring enabled 42,000 patients to stay at home rather than be institutionalized.
Following some pilots that started in the late '90s, VA began rolling out its telehealth program in 2003, and it is has now become an integral part of how the system delivers care, Darkins noted. Besides the benefits to patients, which include better outcomes, more independence, reduced travel time, and less time taken off from work, telehealth also saves VA a significant amount of money. A combination of remote patient monitoring and care coordination, for example, reduced hospital bed days by 25% and admissions by 19%, according to a VA study.
Considering these results, it would seem like a no-brainer for the private sector to follow suit. But outside of a few large organizations like Kaiser Permanente, Partners Health Care, and Geisinger, observers say, remote patient monitoring is still in a nascent stage. Virtual visits are catching on more rapidly because some big national health plans are sponsoring remote consultations between members and on-call doctors who are not their personal physicians. Mobile monitoring and consults for patients who have chronic conditions is not yet a factor in the market, mainly because providers are not being paid to view this monitoring data.
The major difference between the VA system and privately delivered healthcare is that the former is a large integrated delivery system in which providers receive salaries, whereas private practitioners are mostly paid on a fee-for-service basis. The VA's goal is to provide high-quality care efficiently in a way that increases access and lowers the costs to the organization. In contrast, the incentive of providers in the private sector is to maximize billing, largely for the face-to-face encounters that are covered by insurance.
This is starting to change in ACOs and other organizations that hold or are moving toward risk contracts of various kinds. These entities recognize that they must manage population health to contain costs and that a key part of this strategy is to provide effective, continuous care between patient encounters. Consequently, many organizations have become interested in remote patient monitoring. However, most of these providers are still working out how they're going to assimilate this data into their clinical workflow.
One of the ways the VA has solved this problem is to integrate telehealth data into its EHR. This makes it easier for physicians and nurses to use the information, because they don't have to leave their workflow to visit a Web portal. Recognizing this advantage, Partners Healthcare recently began to funnel home monitoring data into its EHR. WellDoc, which markets a diabetes management system that includes a mobile app, has also piloted integration of its data with Allscripts' EHR. But most EHR vendors are not yet ready to provide this integration to their customers.
VA is ahead of the curve partly because its patients are older, on average, than people who are commercially insured, Darkins noted, and it had to find a way to increase their access to services, especially in rural areas. But the entire U.S. population is getting older, so other providers also should prepare to offer them services that are easy to access and that help them manage their own health.
Already, Darkins said, many of the private-practice doctors with whom VA contracts receive telehealth training -- most of it Web-based -- and are using these technologies to treat veterans. Medicare should seriously consider offering generic telehealth training to all physicians who participate in its program. It should also begin covering certain kinds of telehealth, and not just in rural areas, instead of waiting for most providers to join ACOs and start taking financial risk. Based on the VA's track record, telehealth in the private sector could save more than it costs.
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