Think Tank

How Can California Make Most of Telehealth Law?

For the second half of the 20th century, California was a leader on several fronts of health care’s evolution. California innovations and maturations in integrated delivery, managed care, stem cell research and electronic health records often set the agenda for national trends.

Now California is poised to do it again with a 21st century innovation — telehealth.

New state legislation (AB 415) passed this fall has the potential to move two-way audio-visual technology out of the realm of wonky oddity and into the mainstream, according to some industry experts.

Timing for the California Telehealth Advancement Act may be good for a variety of reasons, including:

  • A pervasive shortage of physicians and other health care providers, especially in rural areas, makes telehealth more palatable — even appealing — to formerly skeptical providers and public;
  • Telehealth’s coming of age as major health care reforms take effect may increase the technology’s value in the long run; and
  • Telehealth has the potential to save millions of dollars in health care delivery in both public and private forums. For California — which is struggling with cutbacks in Medicare and Medi-Cal, the state’s Medicaid program — and for the private sector, which is battling rising costs in a floundering economy, new technology may help calm troubled financial waters.

But a new law alone probably will not be enough to move telehealth quickly and efficiently into the medical mainstream.

We asked experts what California policymakers and health care providers can do to make the transition proceed smoothly and effectively.

We got responses from:

Collaborations Pave the Way

Last week, an infant at a clinic in the Northern California town of Redding underwent a lengthy hearing test that was administered by a pediatric audiologist located in Sacramento. It was done via telemedicine as part of the first such program of its kind in the nation. Nearly 40% of newborns in Northern California who are in need of additional testing for potential hearing abnormalities have not been getting screened because of the lack of local pediatric hearing specialists. Now, thanks to this federally funded pilot program, a unique partnership between two separate health-care systems is helping infants and their families receive critical follow-up care without leaving their own community.

This type of specialty care initiative was exactly what the developers of the California Telehealth Advancement Act had in mind.  It represents one of the key building blocks in technology-enabled health care, along with more broadband infrastructure investment and connectivity, as well as more training and education.

To optimize the benefits of telehealth, policies and regulations must continue to evolve. High-tech health-care tools will be fully effective and incorporated into the mainstream only when care is better coordinated between patients, health-care providers, hospitals, pharmacies and others. That said, the array of telehealth partnerships and projects reflects a remarkable transition that is well under way and offers great promise:

New broadband connections: Over the past year, more than 100 clinical sites around the state have been connected to the California Telehealth Network’s high-speed, medical grade broadband system. The new network is providing the crucial infrastructure for collectively addressing some of the challenges that constrain telehealth from becoming part of the medical mainstream.

Workforce Development: For telehealth to become more effective and ubiquitous, California must develop a workforce that has the skills to adopt new technologies and models of care. Such training is already taking place through statewide projects like the U.S. Department of Commerce’s Broadband Opportunities and Training Program, which awarded more than $9 million last year to help advance technology-enabled health care and made it possible for telehealth leaders in the state to leverage an additional $5 million in matching funds.

Creating Long-Term Sustainability: As part of the federal broadband opportunities grant, 15 entities around the state recently were named “Model eHealth Communities” to help further advance technology-enabled health care. These designated communities will become best-practice examples in the use and integration of technology to improve health and health care. The innovative program recognizes that in order to raise California’s literacy levels in areas like telehealth, collaborative efforts must be fostered among the spectrum of organizations that people turn to for health care and health information.

Training the Next Generation: The opening of the California Telehealth Resource Center next summer on UC Davis’ Sacramento campus promises to be another example of an important turning point. The 52,000 square-foot facility, with its capital city location, is designed to help the next generation of physicians, nurses and other health-care professionals more fully embrace telehealth.

California is fortunate to have a favorable policy environment for embracing new technologies. As projects like the pediatric telehealth audiology project illustrate, new collaborations help pave the way for new models of care. Because the full potential of technology-enabled health care has yet to be realized, we must continue working to ensure that regulations and policies align with our new models of care so that tools like telehealth will enable us to truly advance health for all.

Telehealth a Game-Changer in Rural Areas

Sally is an elementary school teacher in a small rural community in a remote part of California. She is surrounded by beautiful forest, pristine lakes, gorgeous vistas and 60 miles of stomach-churning, hair-pin cornered back roads to get to the only health care clinic. Sally has a suspicious new dime-sized dark-colored mole on her shoulder. Her family practice physician, the only doctor in a 600-square mile patch of California, says she is concerned about the growth. Sally is also concerned. Her family has a nasty genetic flaw resulting in a high incidence of melanoma. She is offered two choices. The doctor tells Sally an appointment with a dermatologist would need to be in a city 367 miles away, and the next appointment is three months from today. Her doctor then informs her she can have the growth examined tomorrow with the help of a teledermatologist located at Stanford University, using telehealth.

Telehealth is a health care tool rapidly coming of age in California. It will mean millions of people living in the rural areas of our state will have access to health care that currently is not readily available. It also will mean that small rural hospitals and clinics can provide an even wider array of quality and cost-effective care.

To fully take advantage of telehealth as a health care tool with parity with other health care tools, six things must happen:

  • Rural providers need to become knowledgeable about telehealth. They need to be connected to a medical grade, high-speed and reliable broad band system like the new California Telehealth Network, and they need to be equipped with the equipment that allows them to take advantage of telehealth;
  • Health care specialists need to make themselves knowledgeable about and set up to deliver their side of telehealth, and discoverable by providers in underserved areas of our state;
  • Legislators and regulators need to continue to work with the telehealth network and groups like the California State Rural Health Association, the Center for Connected Health Policy, CTN, the UC-Davis Telehealth Resource Center and similar centers, and the California Telemedicine & eHealth Center to continue to explore and remove unnecessary statutory and regulatory barriers to telehealth in California, like they did with AB 415;
  • Foundations need to continue to provide start-up funds to drive telehealth research, knowledge and implementation to a point where their grant funding is no longer necessary;
  • Medi-Cal, California’s Medicaid program, needs to examine how to incorporate telehealth into its program; and
  • Health plans that have not already embraced telehealth need to enter modern times and include telehealth options and reimbursement into all contracts with health care providers.

Telehealth is one tool that will allow all Californians better access to more timely, quality and cost-efficient health care, but we have some work to do to make this a reality across the state. AB 415 opened the door; now California needs to walk through and take advantage of this opportunity.

Telehealth Can Get Oral Health Care to Underserved

This year, the Institute of Medicine issued two historic reports on oral health: “Advancing Oral Health in America” and “Improving Access to Oral Health Care for Vulnerable and Underserved Populations.” These reports highlight the large number of people in the U.S. who do not have access to oral health services and the resulting profound disparities in oral health experienced by many groups. Among the reports’ recommendations is supporting research and development of new methods and technologies for improving oral health for vulnerable and underserved populations, including new delivery systems and the use of telehealth technologies to bring care to places where these vulnerable populations live and receive general health, social and educational services. A demonstration project is under way in California to do just that.

The Virtual Dental Home is a nine-site demonstration project developed at the Pacific Center for Special Care at the University of the Pacific School of Dentistry. The system uses telehealth technology to allow dentists to collaborate and remotely supervise allied dental personnel who work in Head Start centers, schools, residential facilities for people with disabilities and long-term care facilities for dependent elders. This system allows these allied dental professionals to provide education, triage, case management, preventive procedures and interim therapeutic restorations in community locations. The long-term result will be the ability to reach underserved populations, improve and maintain their oral health and do so using a cost-effective system of care.

Telehealth technology tools now allow us to expand services beyond traditional geographic and physical boundaries. This means that we can provide oral health services and create good oral health for many groups in our society who formerly found good oral health to be out of their reach. AB 415, which reforms California’s telehealth laws, takes an important step toward realizing potential of this new delivery system.

Telehealth's Future in Workers' Hands

The grand promise of telehealth will be realized incrementally. The passage of AB 415 is one of the bigger leaps for California, but this legislation was preceded by decades of pioneer efforts and will be followed by years of hard work to more fully embrace telehealth into our daily lives.

Neither a well-crafted law nor a brilliantly smart technology can achieve the promise alone. Telehealth depends on people — namely, health care professionals and patients — to actually make it happen. California’s health care workers — more than a million individual doctors, nurses, dentists, pharmacists and allied professionals — will make the difference in whether the state will take a lead in integrating information, communication and clinical technologies into routine care.

Perhaps no single word better describes the views and competence of those million health care workers on the issue of telehealth than “mixed.” They vary in their understanding of telehealth, in their training, in their exposure to the different modes, in their views on how and when it should be used, and even in their willingness to try it out. While traditional modes of health care are ubiquitous — who doesn’t know what a stethoscope is for? — the new telehealth modalities are not nearly so common. Levels of comfort and competence vary on everything from handling email messages to remote diagnosis and treatment.

The coming years will be the time to offer telehealth introduction, information and instruction to California’s health care workforce. Some of this can be in the form of continuing education for re-licensing requirements. It can be incorporated into the curricula of all health professional education programs. It can be in the form of public service announcements from the government or charitable foundations. It can come from private sector vendors who have created the hardware and software that are the infrastructure of telehealth. And it can come in the form of mentoring by those who have used it to those who are new to any and all aspects of the technologies.

This is the moment for concerted efforts to introduce the concepts and tools telehealth offers to all health care professionals, to train them in the modalities that suit their practices and patient populations, and to advise them on how to deal with challenges and risks. To more broadly spread and better use high-tech health care, we need to put considerable attention on the people who will be using that technology.

Support Needed for Telehealth To Flourish

Telehealth — the use of information and communication technologies to deliver health care to patients remotely — is an important tool to address some critical issues facing health care. Through the use of telehealth technology, patients who face geographic and/or economic obstacles can have access to the full spectrum of health care services, both primary care and specialty care. Furthermore, fully integrating telehealth services in the health care delivery system has potential for health care cost reduction. 

AB 415 will become effective Jan. 1, 2012. The new law updates California telehealth law and removes administrative and regulatory policy barriers that have become outdated compared to the advancement of telehealth technologies and applications. To make the law effective and increase access to health care services to a greater proportion of the population, health care providers, health plans and policymakers should encourage the expansion of and adequate reimbursement for telehealth services. Some recommendations for consideration follow.

  • Encourage the establishment and development of telehealth services primarily in areas where cost savings can be demonstrated, such as rural and remote communities. There is the potential for savings in reducing the need for transport and timely access to specialty care.
  • Encourage the use of telehealth services where the greatest potential for impact on health care outcomes may be achieved. For instance, home monitoring of patients with certain chronic conditions (e.g., diabetes) has the potential to reduce health care costs.
  • Support organizations whose purpose and mission is to leverage and build upon California’s investments in telehealth, including the California Telehealth Network, the California Telemedicine & eHealth Center and the Center for Connected Health Policy. These organizations offer the resources and expertise to help providers maximize use of telehealth technology.
  • Review and update policies and contracts of all payers to establish adequate reimbursement for telehealth services by the expanded definition of licensed health care providers enacted through AB 415.

With passage of AB 415, California has demonstrated its leadership in the telehealth arena. By moving forward on the steps outlined here, California policymakers and health care providers can ensure that all residents have access to the health care they need.

New Telehealth Law Will Improve Access for Children

California’s lawmakers just made it easier for children to get the health care they need, while building on California’s role as a leader in deploying technology wisely and readying itself for health care reform. AB 415, enacted earlier this year, will enable millions of children and other underserved populations to access needed health and dental care through the use of telehealth.

Telehealth can help overcome the major geographic and economic obstacles that underserved children and families face in getting health care, including provider shortages, transportation costs and lost time from work and school. Through the use of videoconferencing, the electronic exchange of information, Web applications, mobile devices and other technologies, telehealth makes it possible for children and families unable to get needed care today to receive it, including medical, dental, mental, vision, and other primary and specialty care.

While telehealth can increase access to health care for all populations, it holds particular promise for improving the health of children. Nearly 2.4 million children in California live in federally designated shortage areas for health care. Furthermore, children have different needs than adults. Telehealth can help meet those needs by facilitating health and dental screenings, coordinating care and connecting children to pediatric subspecialists.

AB 415 removes many of the restrictions in California law that previously prevented patients and health care providers from using telehealth. For example, AB 415 makes the process of accessing telehealth services more streamlined for patients by eliminating the need for written consent from patients to receive care via telehealth. Furthermore, AB 415 removes unnecessary requirements in Medi-Cal to document a barrier to an in-person visit before one can receive telehealth services. AB 415 also allows Medi-Cal to pay for all store-and-forward applications of telehealth — the transfer of data, such as an X-ray or a digital image from one site to another for review and consultation at a later time — and allows the use of email and telephone to provide health care services.

This policy advancement comes at an opportune time for California. Millions of Californians, including children, will gain health and dental coverage beginning in 2014 due to the implementation of the Patient Protection and Affordable Care Act. California does not have the workforce to provide care to these additional people. Telehealth can play a critical role in alleviating provider shortages in a cost-efficient way. Because telehealth facilitates screenings, consultations, and medical and dental visits, it allows professionals to work at the top of their expertise and training, while ensuring patients get care when and where they need it.

AB 415 is a significant step in advancing telehealth in California. The next step is to ensure that telehealth services are paid for by Medi-Cal and other payers so that California can truly harness technology to ensure its most vulnerable populations get the health care they need.

Telehealth Can Help Solve Workforce Shortage

Virtual technologies are nothing new. We have been watching real-time news feeds from around the globe for years. Historically, the cost has been high and the applications limited, but with the development of an extended infrastructure and equipment at reasonable costs, telecommunications as a means of delivering health care is rapidly becoming ubiquitous.

We know that this technology lends itself to providing care at a distance and often makes care possible in areas where there are not enough medical providers or specialists. We are able to connect remote locations to urban centers of excellence by basically making a phone call. The applications for patient care are expanding.

What may not be so obvious is how we might use this technology in workforce retention. At a time when we have shortages in the health care workforce, we should be doing everything we can to retain skilled and experienced providers. Telehealth can work to bridge our current gaps until we can catch up with the long-term cycle of developing new workforce members by retaining our existing workforce.

For many years, we have anticipated the tidal wave of the baby boom generation reaching retirement age and the implications on health care delivery systems. We need to think of the tremendous resources the boomer generation represents and how to retain these resources. Boomers include an abundance of highly qualified medical providers. Many, if not most, are not interested in instant full-time retirement. Rather, there is a growing appeal to an easing of day-to-day responsibilities, maybe relocating to a calmer environment, while still keeping one’s hand in the game.

Imagine how much health care could be provided if we put telehealth equipment into every willing doctor’s home office. From virtually anywhere in the world, these individuals could easily provide a few half-days a week as they begin semi-retirement. Not only are we retaining the cognitive skills of this highly experienced provider base, it is available virtually anywhere and anytime.

Whether this vast talent pool is used to provide virtual direct care or as consultants, mentors and teachers of the next generation, telehealth technology provides a cost-effective means of retaining a skilled workforce and not wasting the experience of a great generation.

Broadband Needed To Realize Telehealth Potential

Due to legislation (AB 415) signed recently by Gov. Jerry Brown (D), more Californians are set to benefit from increased telehealth initiatives across the state. Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration. It comes as a response to many of California’s challenges and unmet health care needs, with a critical issue being the shortage of physicians and other health care providers in rural areas. Countless benefits can be drawn from the use of telehealth, such as:

  • Remote and rural providers gain access to the consultative services of medical experts at other locations around the state and can participate in educational opportunities and a robust knowledge network to improve their abilities to manage patient care; and
  • Patients get access to medical resources around the state that they otherwise would not have access to.

Through telehealth, Californians benefit from the reduction in travel time; savings of millions of dollars in health care delivery; increased access to health care in underserved communities, etc. However, telehealth is far from being a reality due to the barriers it faces, especially the lack of broadband connectivity in underserved communities.

The need for broadband connectivity is crucial to the quick and efficient induction of telehealth into the medical mainstream. In the San Joaquin Valley, this is being spurred by the designation of the California Partnership for the San Joaquin Valley as the San Joaquin Valley Regional Broadband Consortium, as awarded in a competitive grant process through the California Public Utilities Commission in December of 2011. The consortium is committed to furthering regional deployment, accessibility and adoption of broadband services, and is the next generation and expansion of the Partnership’s Advanced Communications Services work group, the predecessor of the consortium. The consortium is instrumental to developing and implementing telehealth services by creating and implementing the SJV Broadband teleheath deployment plan leveraging off of regional partners, Internet service providers and health care experts.

The deployment of telehealth helps the consortium, and thereby the CPSJV, to reach its goal to enhance the region’s quality of life and economic vitality.

Telehealth for All -- Finally

For many of us who have watched the painfully slow growth of telemedicine over the past decade in the U.S., the passage of the California Telehealth Advancement Act is a welcome breakthrough. It’s hard not to dream — to hope that we will now use this burgeoning cornucopia of tools to solve problems of access, to lend immediacy and personalization to our support for patients facing acute and chronic conditions, and to begin to squeeze the inconvenience, frustration and sheer cost out of our unwieldy health systems.

The technology has been there, but it is much better now. The evolution from fixed, expensive and isolated technologies that couldn’t interface has been remarkable. Today we have supremely mobile, increasingly less-expensive and more user-friendly solutions. And we have a far more technology-friendly installed base of patients and caregivers.

We have all known that culture and reimbursement systems and the fragmentation of care are the real barriers. And now we will get the chance to see what can be achieved when one of these barriers falls. Not only do we have new degrees of freedom in the types of professionals, settings for care, and credentialing of providers — we have the Holy Grail: equivalency in reimbursement.

This sets the stage. Will it be enough? Until now, pushing payers and physicians to adopt telemedicine and telehealth was like pushing the proverbial wet noodle uphill (to mix a metaphor). The hope here is that the larger forces driving new risk arrangements — principally those that encourage providers to assume more risk for the cost and efficacy of care — will create a “pull” phenomenon. If it is true that these new risk arrangements give us a tremendous opportunity to advance telehealth solutions, our most important job will be to raise provider awareness and ensure that the offerings in the market are truly ready for implementation.

That goes to the most important learning of the last half decade for investors and developers in this area. It really isn’t the technology. Because most provider systems know almost nothing about practical implementation strategies for telehealth-enabled care, and don’t have the staff or capabilities to support it, we should encourage the development of fully built services, enabled by technology, rather than offerings of technologies alone.

In Oregon, Telemedicine Improves Care, Reduces Costs

As medical director of the Oregon Health & Science University (OHSU) Telemedicine Network, I’ve seen our program grow into the most comprehensive telehealth program in the region. OHSU first delivered tele-psychiatric care in 2005. Pediatric intensive care consultations came online in 2007. Recognizing the benefits to patients and families, OHSU has rapidly expanded its telemedicine offerings during the past 18 months. Today we offer immediate, around-the-clock access to OHSU’s pediatric intensive care specialists, neonatologists, stroke neurologists, neurosurgeons and trauma surgeons, whose services are not available in many communities around the state. Stroke patients are receiving brain-saving medications more quickly. Children suffering from fast-moving lethal illnesses like meningococcemia are similarly benefiting from early involvement of pediatric intensivists through telemedicine. We have documented improved outcomes for many patients, as well as significant cost savings from averted, unnecessary transports, which would have occurred without the benefit of live interactive video.

While we have realized many of the benefits of telemedicine in the acute care realm, there are still many obstacles to fully utilizing this life- and cost-saving technology. We applaud California’s leadership in this area, especially the recent passage of the Telehealth Advancement Act, which removes some of the historic roadblocks to greater adoption of telemedicine. Moving forward, we hope Oregon can emulate these efforts, especially with regard to the following issues:

  • Simplifying the credentialing and licensing process by adopting statewide and/or federal standards for acute care telemedicine. This would allow one-time credentialing of physicians providing telemedicine consultations, for example, instead of burdening both physicians and hospitals with repeating a variation of this lengthy and expensive process at every health care center receiving telemedicine services;
  • Leveling the playing field for professional fee reimbursement across all payers, with their recognition of the cost savings derived from decreased transports, decreased expenses for families forced to seek care outside their home community (if they are able to access that care it all), and earlier intervention facilitated by improved monitoring of patients with chronic conditions, whether they live in their own home, a rehabilitation center or a nursing facility;
  • Providing funding for equipment and infrastructure needs (including broadband access) that would make telemedicine available to all health systems, especially critical access hospitals that serve smaller rural communities, regardless of the “business model” of the system providing telemedicine consults.

Health care providers, meanwhile, are notoriously slow to adopt new models for care delivery. In order to make the best use of telemedicine, we need to:

  • Better educate providers about the benefits of using telemedicine to achieve the Triple Aim of increasing access to specialty care, improving patient care and reducing costs;
  • Identify ways to change clinician workflows to incorporate telehealth into busy physician practices.  Only through a mindful approach will they gain efficiencies while simultaneously improving the health of their patients and driving down cost;
  • Develop ways to analyze the data generated from in-home monitoring so that physicians can quickly identify patients who need some sort of intervention; and
  • Educate our students and residents who will be practicing in an increasingly connected world.

OHSU has only just begun to tap telemedicine’s potential. There are several hurdles that are vestiges of 20th century health care delivery models and regulations. California has led in improving health care with telemedicine; together we can address these hurdles so people receive the care they need — when they need it and where they need it — for the lowest possible cost.