VA Telehealth Lauded As Model Healthcare Program

As U.K. report praises U.S. veterans' home health monitoring, it begs the question why telehealth hasn't gained traction across U.S. healthcare system.
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The United Kingdom's National Health Service (NHS), which plans to roll out a telemonitoring service for 3 million patients, could learn a lot from the U.S. Veterans Health Administration (VHA) home telehealth program, according to a new report from U.K. research firm From an American perspective, the report raises the question of why telehealth hasn't gained more traction in this country, considering the VHA's success with it.

The VHA program, which served 50,000 veterans in 2011, is the largest telehealth project in the world, the report said. Patients enrolled in the program--most of whom have chronic conditions such as heart failure, COPD, hypertension, diabetes, and post-traumatic stress disorder--receive free telemonitoring equipment and attention from care coordinators who teach them how to manage their own care.

The VHA began exploring telehealth in the late 1990s, and it rolled out its current program, called Care Coordination/Home Telehealth (CCHT), between 2003 and 2007. According to a 2008 study cited in the U.K. report, the program reduced hospital bed days by 25% and hospital admissions by 19% for a cohort of 17,000 participating patients. A full 87% percent of the patients said they liked the program.

Extrapolating from these results to the patients who are expected to enroll in the NHS telehealth program, the researchers predicted that the initiative could reduce the NHS' utilization of healthcare resources by 20% to 56%, depending on patients' health conditions. Results of a recent U.K. telehealth pilot showed reductions of 15% in emergency department visits and 14% in admissions and bed days. Mortality rates dropped a whopping 45%.

[ With strong outcomes data like this, a major barrier to telemedicine adoption will drop: Telehealth Reimbursement Will Grow, Health Leaders Say. ]

One key to VHA's success with the CCHT, the report said, has been the integration of telehealth data with its electronic health record (EHR) system, and the availability of EHR data to all providers in the VHA system. "This allows all validated telehealth data to be accessed through the patient record," the report said. "Whilst this is a large amount of data, physicians find the information immediate and useful for determining patient treatment."

The nurse case managers, the report added, provide summary notes at least monthly, and these are also available in the EHR.

Without the care coordinators' summaries and alerts, physicians would never be able to deal with the home monitoring data, observed Kenneth Kizer, MD, a former undersecretary for health in the U.S. Department of Veterans Affairs (VA), in an interview with InformationWeek Healthcare. "If we're going to get individual practitioners to adopt telehealth, we'll have to make the burden of data management as easy as possible," said Kizer, who launched the VHA's telehealth program in the late '90s and is now director of the Institute for Population Health Improvement at the UC Davis Health System in Sacramento, Calif.

But the challenge of data management is not the main reason why the U.S. healthcare system has not widely adopted telehealth, despite its proven ability to cut costs and improve the quality of care. Speaking of telehealth, as well as technologies such as EHRs and mobile health apps, Kizer said, "The barrier is that the payment [method] doesn't support these alternative ways of providing care."

Salaried VHA physicians, the U.K. report noted, have largely accepted telehealth because it benefits patients and doesn't cost them anything. In contrast, Kizer pointed out, private U.S. practitioners don't have the resources to provide their patients with home telemonitoring--and would lose money if they did so.

"If you're making money off of a visit, or a face-to-face encounter, telehealth loses its attractiveness," he stated. "A major barrier to telehealth having the widespread uptake in the U.S. that it could and should have is simply our payment models."

Even in the VHA system, Kizer said, the telehealth program is not an unalloyed success. "The VA is a very big system, and there's better penetration of telehealth in some places than others. But it's still not universally a routine part of care. It's still in many places an add-on, and that's one of the biggest barriers to telehealth everywhere."

The U.K. report recommended 10 steps to maximize the impact of the NHS' telehealth program. These include leadership commitment, long-term investment, changes in infrastructure, incremental adoption, the use of risk stratification in patient selection, the use of dedicated care coordinators, clinician engagement, a strong emphasis on training, and integration of monitoring data with EHRs.

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