Quinn reports that the objective was to test whether adding coaching provided via a software application running on a smart phone, coupled with patient/provider web portals to community primary care, to standard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes more than standard management procedures alone.

Research Design and Methods

The University of Maryland School of Medicine “Mobile Diabetes Intervention Study” was a 12-month, cluster-randomized clinical trial. Researchers randomly assigned 26 primary care practices to one of three stepped treatment groups or a control group.

A total of 163 patients were enrolled and included in analysis. The primary outcome was change in glycated hemoglobin levels (HbA1c) over a 1-year treatment period. Secondary outcomes were changes in patient-reported diabetes symptoms, diabetes distress, depression and other clinical (blood pressure) and laboratory (lipid) values. Maximal treatment was a mobile and web-based self–management patient coaching system and provider decision support.

Patients received automated, real–time educational and behavioral messaging in response to individually analyzed blood glucose values, diabetes medications, and lifestyle behaviors communicated by mobile phone. Providers received quarterly reports summarizing patients’ glycemic control, diabetes medication management, lifestyle behaviors, and evidence-based treatment options.

Conclusion

Mobile phone management is efficacious in patients whose glycated hemoglobin levels are above desired levels as well as patients whose glycated hemoglobin levels are less egregiously elevated.

Although there were mean declines across all groups in lipid values and blood pressure readings, Diabetes Distress, Diabetes Symptoms, and PHQ-9 Depression, none of the 12-month changes comparing the UC to any of the active interventions were significantly different (P>.05).

Research Team

Charlene C. Quinn, RN, PhD

Michelle D. Shardell, PhD

Michael L. Terrin, MD, MPH

Erik A. Barr, BA

Shoshana H. Ballew, BA

Ann L. Gruber-Baldini, PhD

“Telemedicine and telehealth have the potential to transform aspects of rural health care, improving accessibility, quality and affordability,” the summary of the paper’s sixth chapter declares. “This working paper discusses the current technological frontiers and likely advances, together with new survey data on current usage of telemedicine by rural and urban doctors, and what they perceive as barriers that need to be overcome.”

Continuing from the synopsis of Chapter 6: “To make full use of telemedicine’s potential, a number of practical changes are now required. These include: building on work by the Federal Communications Commission and others to expand rural broadband capacity (estimated at around 60 percent of rural areas versus 70 percent of urban areas); introducing new public and private payment models for telemedicine, perhaps linked to the move away from traditional fee-for-service reimbursement models; and continued action by the Food and Drug Administration and others to remove outdated regulatory barriers to adoption.”

The complete, 84-page report is available for download from unitedhealthgroup.com/reform. The rest of the Executive Summary contains additional insight into the report’s scope and conclusions.

Three quarters of rural U.S. residents live in the South and Midwest, compared to only one-quarter in the Northeast and West.

Though five million people live in isolated and remote locations, around 31 million people who technically live in rural counties actually live close to an urban area.

Chronic conditions such as cardiovascular disease and diabetes are more prevalent in rural populations than in urban or suburban areas. This is worst in the South, especially among rural minority communities, for whom obesity rates and other risk factors are markedly elevated.

The paper sets out to answer five questions:

1. What are the health challenges confronting rural Americans?
2. How is the care delivery system currently organized to respond?
3. What do we know about the quality of rural health care?
4. What will the expected Medicaid and insurance coverage expansions from 2014 mean for rural areas?
5. Are there practical solutions to these health, access, and quality challenges?

In remote rural areas there are fewer than half the number of primary care physicians per 100,000 population than in urban areas, yet there are slightly more hospital beds per 100,000 residents in rural than urban areas. Nevertheless, about a third of hospitalizations for rural patients occur at urban hospitals.

The paper also includes:

• new empirical research on rural versus urban quality of care
• new projections for rural Medicaid and insurance exchange 2014 coverage expansions
• new state-by-state and county-level analysis of future pressure on primary care capacity
• new models for rural care delivery and care coordination

Outcome quality evidence is mixed

This paper finds new research suggesting that quality scores for urban and suburban areas are higher than those for rural areas in 75 percent of the hospital referral regions (HRRs) for which representative data are available. In a further 20 percent of HRRs there is no statistically significant difference in rural/non-rural measured performance, and in 5 percent of HRRs rural quality scores are higher.

Both rural consumers and rural primary care physicians rate the quality of local care lower than do their urban and suburban counterparts. For example 49 percent of rural consumers rate the quality of local care as ‘very good’ or ‘excellent’, compared to 64 percent of non-rural consumers who do so. Twenty-four percent of rural consumers think their local care is only ‘fair’ or ‘poor’, compared to 12 percent of urban and suburban consumers who believe that.

Healthcare reform

UnitedHealth finds that, by 2019, there could be an increase of around eight million rural residents in Medicaid and state insurance exchange plans, compared with what would have happened without the ACA legislation.

Five million rural residents already live in designated ‘shortage areas,’ defined by the federal government as counties with fewer than 33 primary care physicians per 100,000 residents. Attempting to identify locations where the pressures will be greatest, this paper finds that these areas tend to be in the South, and often have some of the tightest scope-of-practice restrictions on nurse practitioners and other non-physician health professionals.

A range of approaches are discussed that states and the federal government can take to confront the question of how to ensure there are enough high quality health plan choices and rural provider networks to serve rural residents.

These include: recognizing the role that nurses and other suitably qualified health professionals can play in meeting network adequacy standards, alongside mobile and telemedicine-enabled providers where appropriate; taking care in designing insurance market and exchange rules explicitly to recognize the distinctive population and provider characteristics of more rural parts of each state; using the state’s purchasing power to provide incentives to participation by rural providers, as states such as Georgia have done; driving greater transparency on quality; and ensuring new federal initiatives on Medicare reform are tailored for rural communities.

The paper concludes that the next few years will be times of considerable stress on rural health care, but also times of great opportunity. “Across the country there are already impressive examples of innovative new care models providing high quality care, tailored to the distinctive needs of their local community. The challenge for all involved in rural America now is to build on that track record of innovation and self-reliance, so as to ensure that all Americans — wherever they live — can live their lives to the healthiest and fullest extent possible.”

Care Innovations came to life this year as a separate company formed by a joint venture between GE and Intel. Headquartered near Sacramento in Roseville, California, the new company inherited from its parents the “Intel Health Guide,” a tabletop vital sign monitor and two-way telehealth communication device, as its first product. We spoke with Aaron Duerksen, General Manager of Disease Management, to find out what plans Care Innovations has for the product.

He immediately couched the discussion in terms of the industry’s need to prepare for the rise of Accountable Care Organizations (ACO), which have already begun to form in communities around the county in preparation for next year’s demonstration projects.
“We will be moving away from ‘purpose-built’ devices, such as our Intel Health Guide,” he explained, “and toward medical apps.”

Flexibility for providers and patients is the goal of developing software that can run on various devices instead of designing, manufacturing and marketing one proprietary device with medical software embedded. Duerksen calls it piquing and sustaining patient engagement.

The first product will be dubbed simply “The Guide.” Essentially the software currently driving the Intel Health Guide tabletop device, it will run on any Win7 platform, allowing providers to offer devices that best fit each patient’s needs.

“This way, we can empower people to make their own decisions for their own health,” Duerksen told us. “With The Guide, patients move to the center of their own care planning and management, or at least become key players in this new model we’re calling “participatory healthcare,” which is already developing in off-site care service delivery.”

Whereas the Intel Health Guide is a physician-prescribed device, with hospitals, medical practices, home care agencies or even payers installing it in the home and monitoring vital sign data elsewhere, The Guide allows patients to choose the apps that they need — from a menu still under development — as well as select a monitoring service from a range of outsourced entities.

Duersken explained that Care Innovations itself will suggest monitoring service partners to hospitals or other healthcare entities if they do not have or cannot allocate staff of their own to monitor patient data gathered from The Guide. As one example: self-insured employers may contract with an outsource sub-contractor to provide remote patient monitoring and tracking services for employees with chronic conditions.

“Developers of The Guide were able to focus on innovations within the application side instead of on the hardware device side, which is of value to patients or customers in several ways,” Duerksen believes. “Their care, in effect, is more customized when they can install only the apps needed.”

Device independence means providers and patients can move their apps to more advanced devices when these devices become available.
“What we’ve done,” Duerksen continued “is provide obsolescence protection.”

Asked whether the medical app concept would reduce home telehealth costs, now that off-the-shelf computers can replace proprietary devices, Duerksen cautioned that there is one catch. At first glance, it may seem that the concept of device-agnostic medical apps will lower costs to home health care providers of initiating home telehealth services. He clarified, however, that, in order to earn FDA approval, every hardware/software pairing must be certified. The Guide will be the only software running on a dedicated device. In other words, this is not something you can install on the patient’s home PC along with email, browsers and games. The concept, therefore, does provide some flexibility over today’s lineup of proprietary home telehealth devices but some hardware costs still have to be incurred.

A clinical study of use of The Guide is currently underway at the Mayo Clinic, which will report on its effectiveness in reducing hospital readmissions by the end of this year. We will contact Care Innovations in January to report on the results of that study.

“Humana Cares Chronic Condition Management” is in the process of filling 270 new St. Petersburg-based positions to coordinate medical and quality-of-life needs for Humana commercial health plan and Medicare Advantage members suffering with CHF, COPD, coronary artery disease and complex diabetes. The new associates, who will eventually number as many as 780, will include telephonic managers, onsite field care managers and community health educators, according to a Humana statement.

The new program will expand an effort that has already deployed a holistic approach with several thousand plan members to reduce hospital admissions by 36% and emergency room visits by 22%. Humana Cares teams work to help members with these chronic conditions remain independent and safe in their homes by:

• Installing safety items their homes and ensuring their transportation and prescription needs are met
• Providing education on self-care management, especially diabetes education
• Deploying home telehealth systems to monitor vital signs, provide education and identify events, such as escalating blood pressure, before they lead to emergency or inpatient admissions
• Assist members in navigating through a complicated health care system
• Put members in touch with community resources.

Humana Cares opened its doors in February 2009 with a mission to find new ways to reduce hospital utilization and lower overall healthcare costs. “Today, in the United States, 38 percent of Medicare beneficiaries live with three or more chronic health conditions,” said Humana Cares President Jean Bisio. “Our goal is always to keep members independent and…help them manage their health and improve their quality of life.”

Pending regulatory and other customary closing conditions, the joint venture is expected to become operational by the end of the year. Financial terms were not disclosed.

The venture builds on the GE-Intel healthcare alliance announced in April 2009 around patient-centered home telehealth systems to support independent living for persons with and chronic conditions. The common vision is to market home telehealth systems to the consumer rather than to healthcare providers.

“With the dramatic increase of people living with chronic conditions, and a global aging population, there is a need to find new models of healthcare delivery and extend care to the home and other residential settings,” stated a joint news release.

Once formed, the as-yet unnamed company will develop, and globally market, products, services and technologies that promote healthy, independent living at home and in assisted living communities. It will focus on three major segments: chronic disease management, independent living and assistive technologies. GE Healthcare and Intel will contribute assets in remote patient monitoring, independent living concepts and assistive technologies, such as the Intel® Health Guide, Intel® Reader and GE Healthcare’s QuietCare®. (See HCTR’s interview with Intel’s Rhonda Chetney at the May ATA meeting for more information about these products.)

“New models of care delivery are required to address some of the largest issues facing society today, including our aging population, increasing healthcare costs and a large number of people living with chronic conditions,” said Intel President and CEO Paul Otellini. “We must rethink models of care that go beyond hospital and clinic visits, to home and community-based care models that allow for prevention, early detection, behavior change and social support. The creation of this new company is aimed at accelerating just that.”

GE Chairman of the Board and CEO Jeff Immelt said “Controlling healthcare costs while bringing quality care to an increasingly aging population is one of the largest global challenges we face today. We think this joint venture will offer great potential to address these challenges by improving the quality of life for millions while lowering healthcare costs through new technology. This new company is the next step forward in a healthcare partnership that combines the complementary expertise and capabilities of GE and Intel to accelerate the development of innovative home health technology.”

Under terms of the agreement, the company will combine an experienced team, home health assets, technology development, products, sales and marketing from both parents. By combining personnel experience and sharing capital, Immelt believes the new company will be able to speed innovation and delivery of products to market.

The new company will have headquarters in the greater Sacramento, California area. Louis Burns, currently vice president and general manager of Intel’s Digital Health Group, will be CEO of the new company, and Omar Ishrak, senior vice president of GE and president and CEO, GE Healthcare Systems, will be chairman of the board.

www.gehealthcare.com/quietcare

www.intel.com/pressroom

With home care agency telehealth adoption estimated at 17%, perhaps GE and Intel are onto something. Stories of telehealth usage by healthcare consumers have been popping up in the New York Times, Wall Street Journal and other outlets outside the world of healthcare journals, laying the groundwork for planting the idea of remote monitoring into the public consciousness.

Glance at the next few stories, summaries actually, with links to further detail if you want to look into it more deeply, to see if you detect the trend. Telehealth systems developers and device manufacturers need to sell systems in order to thrive. For the most part, home health care is not buying a lot of telehealth systems. Therefore, vendors look to other places to increase sales.

Eventually, remote patient monitoring will not be strongly associated with home health care at all. Instead, the technology will be seen as a commodity to be purchased at Walgreen’s or Ace Hardware —when it is device-related at all — and the public will find it quaint that a few home care agencies also offer the devices along with their monitoring services, just as their hospitals and physicians do.

Systems for adults wanting to monitor parents’ activities

Keeping track of daily activities of an elderly parent living alone is now possible no matter where their adult children live. More and more companies are introducing new technologies that allow remote Internet monitoring of parents’ lives to keep tabs on their health, according to a July 28 story in the Home & Garden section of the New York Times.

The products aim to provide enough supervision for elderly individuals so that they can remain in their homes instead of moving to assisted-living facilities or nursing homes.

One new entry, GrandCare, uses movement sensors, much like those used in security systems, strategically placed throughout a parent’s home. The sensors track the opening of doors, the time at which the parent gets out of bed and movement through certain rooms.
Information is transmitted to the adult children via e-mail, text message and voicemail.

Another program, called MedMinder, functions as a remote monitoring device for medications. The system alerts a patient with flashes and beeps when a pill needs to be taken and alerts relatives via phone or e-mail if medication is not taken at the correct time.

Selling telehealth to the public

Not content with only one human interest story, the New York Times also ran a detailed description of some of the telehealth and other monitoring devices that are becoming available to the consumer. Mentioned were the Philips Medication Dispensing Service and Lifeline PERS, Ideal Life’s wireless CHF and diabetes monitors, the ActiveCare Personal Assistance Link and MobileHelp. The latter two are GPS-enabled cell phone systems for people with chronic conditions who are not homebound.

Not to be outdone, the Wall Street Journal ran a story on July 27 entitled “The Do-It-Yourself House Call,” which opened with, “Technology that aims to keep congestive heart failure patients out of the hospital is gaining traction.”

The story mentioned home telehealth pilot projects by WellPoint’s Anthem unit in California, Humana’s video telehealth program due to start in January, and Aetna’s clinical trial with Intel designed to learn what home care providers already know, whether remote vital sign monitoring can reduce unnecessary hospitalization for heart patients.

What both the Times and WSJ have in common is that the words “home health care” never appear in their articles. Summarizing the importance of telehealth systems, the Journal runs a quote. “The relationship between the consumer and doctor is primary,” said Sam Meckey, chief operating officer for disease solutions at UnitedHealth’s OptumHealth unit.

Systems for insurance companies wanting to pay for preventative care

HIP Health Plan of New York (HIP), an EmblemHealth company, has received state approval to underwrite the cost of providing a Nurse Care Manager to plan members in an effort to “assist frail, elderly and disabled individuals so that they can remain in their homes for as long as possible.”

Once in place, the nurse will be able to assign non-medical caregivers to provide personal care, help with chores, housekeeping and cooking, home and adult-day health care, social day care and delivered meals. The care manager will also be able to install a Personal Emergency Response Systems (PERS) for the insured person.

To be known as the HIP VIP Dual Eligible (HMO) Medicaid Advantage Plus-Managed Long-Term Care (MLTC) plan, the Medicare Advantage produce will be available to
dual eligible Medicare and Medicaid individuals at no additional cost. The MLTC program will be offered in all five boroughs of New York City, as well as Westchester, Nassau and Suffolk Counties.

www.emblemhealth.com

According to The New England Journal of Medicine, avoidable hospital readmissions within 30 days of discharge cost Medicare $17.4 billion per year. CTA’s “Technologies for Improving Post-Acute Care Transitions” (Tech4Impact) grants are designed to encourage creation of new programs through the national system of Aging and Disability Resource Centers (ADRC).

CTA director David Lindeman said, “Use of selected technologies such as remote patient monitoring and medication management technologies is associated with reduced hospitalizations, so it makes sense to focus on expanding their use.”

Tech4Impact grants will complement grantee funding made available through the $60 million AoA and CMS initiative, “Implementing the Affordable Care Act: Making it Easier for Individuals to Navigate their Health and Long-Term Care through Person-Centered Systems of Information, Counseling and Access.”

Complete details are available at: www.aoa.gov/AoARoot/Grants/Funding/index.aspx.

Additional guidelines pertaining to Tech4Impact grants are available at www.techandaging.org

CTA will make Tech4Impact funds available to states that are awarded grants by AoA/CMS for program Option D: ADRCs Evidence-Based Care Transition Programs. (AoA/CMS grant applications are submitted electronically at www.grants.gov.) The CTA application for states will be released by September 30, 2010, and full proposals will be due October 15, 2010. Grants are expected to commence by January 2011.

ADRCs (www.adrc-tae.org) are community-based programs designed to streamline access to long-term care services under the auspice of the Administration on Aging, an arm of the U.S. Department of Health and Human Services.

In addition to this newly announced program, CTA administers grant-funding for projects that seek to expand the use of medication optimization and remote patient monitoring technologies for the care of older Americans. CTA was established with funding from The SCAN Foundation (www.thescanfoundation.org) and is affiliated with the Public Health Institute (www.phi.org) in Oakland, California.

From the CTA web site:

The important work of the Center for Technology and Aging would not be possible without the generous support of The SCAN Foundation, a creation of the Senior Care Action Network not-for-profit health plan. Through an initial grant of $5 million The SCAN Foundation has supported the establishment of the Center to promote the independence and well-being of older adults through the broader diffusion of beneficial technologies. The Center serves as a national resource for providers and policy makers who are engaged in using technology to enhance the lives of older adults.

The Center funds demonstration programs to test strategies to promote the diffusion of technology. We also serve as a trusted and independent expert voice on current technology, providing unbiased analysis and basic facts on technologies that help promote the independence of older adults. In addition, we are a source of information concerning current research, implementation tools, and policy initiatives related to technologies that help older adults maintain their independence.

www.techandaging.org

Chicago, IL and Lynchburg, VA — July 20, 2010

Allscripts (NASDAQ: MDRX) announced last week that Centra, a three-hospital system in Central Virginia, has selected the Allscripts Electronic Health Record (EHR) for its staff physicians and the Allscripts Community Exchange as the platform for electronically connecting the medical community in its region, including Centra’s home health agency.

Centra will initially provide Allscripts’ EHR to over 70 physicians and midlevel practitioners, both employed and affiliated private-practitioners, then extend it to over 250 providers in its service area.

“Our goal is to achieve true community physician integration,” said Ben Clark, Centra’s Chief Information Officer, “to connect the community and extend our electronic health record across our whole sphere of service.”

Allscripts Community Exchange can exchange key clinical data among disparate EHRs, a benefit in a community with at least nine different deployed EHRs.
In addition, Clark pointed out, it will allow Centra to use an Enterprise Master Patient Index, or EMPI, helping ensure that every piece of medical information is associated with the correct patient across the continuum of care.

Allscripts’ Homecare application will enable clinicians to access more information and share that data with other caregivers via an enterprise physician portal.

“Centra has a history of treating the patient for the whole continuum of care, from birth to end of life,” Clark said. “Allscripts Homecare is the perfect fit. We have Allscripts in our emergency department already, and now we are about to deploy their EHR in the ambulatory environment. When we add the Homecare product, we will be using the same platform across a large part of the care continuum. As we continue to expand our connectivity, the Allscripts suite of products will continue to improve the quality of care and show our community the value of a truly integrated health system.”

A custom interface will link Allscripts Homecare to Centra’s enterprise information system, noted Clark. By posting the home health data on the physician portal, he explained, Centra hopes to keep physicians better informed about their patients’ progress, which should lead to reduced readmissions.

“Similarly, the use of Allscripts Community Exchange will ensure proper medication reconciliation during care transitions and will prevent duplication of orders as patients move from one care setting to another,” he continued. “Should a patient present in the ED, the ED physicians will have instant access to all of his or her records, speeding medical decision-making.”

“A connected community enables clinicians to get the maximum value out of health information technology,” said Allscripts CEO Glen Tullman. “By having the right information on the right patient at the right time, physicians and other providers can make better decisions and deliver the appropriate care when it will make the most difference in outcomes. We commend Centra for taking this visionary approach to the deployment of Electronic Health Records and connectivity across the community.”

A Lynchburg-based not-for-profit health system, Centra operates two main hospitals, Lynchburg General and Virginia Baptist. In January 2006, Southside Community Hospital in Farmville joined Centra as an affiliate.

www.allscripts.com

The American Telemedicine Association invites telemedicine and home telehealth practitioners to submit an abstract to be considered for inclusion in the association’s 16th Annual International Meeting and Exposition educational program. Peer-reviewed presentations typically discuss real-world successes achieved through the use of remote patient monitoring.

Proposals will be accepted through September 15, 2010.

The ATA sannual meeting is the largest international meeting and exposition focusing exclusively on telemedicine, telehealth & remote medical technologies. It is the primary opportunity for home telehealth users and those considering remote patient monitoring technologies to listen to and interact with international experts and virtually all of the segment’s vendors.

ATA CEO Jonathan Linkous describes the meeting’s peer-reviewed educational program as one that “sets the standard for continuing medical education on the topics of telemedicine and telehealth.” The 2011 meeting is set for Tampa, Florida, May 1-3. Visit the ATA web site at www.atmeda.org or click here to go directly to the page to submit an abstract.

The “Indiana Cancer Pain and Depression Trial” (INCPAD) included patients in 16 community-based urban and rural cancer practices. Of the 405 participants, 202 patients were assigned to the intervention program and 203 received usual care; 131 had depression only, 96 had pain only, and 178 reported having both depression and pain.

Half of the participating patients received automated home-based symptom monitoring by interactive voice recording or Internet. They were also monitored by a centralized home telecare system managed by a nurse-physician specialist team. The patients were assessed for signs of depression and pain symptoms at the start of the study, and then again at one, three, six and 12 months.

After 12 months, the 137 patients with pain in the intervention group showed greater improvement in pain symptoms than the 137 patients with pain and receiving standard care. The 154 patients with depression in the intervention group had significantly greater improvement in depression severity than the 155 patients with depression in the usual-care group. The report appeared in the July 14 issue of the Journal of the American Medical Association.

Dr. Kurt Kroenke, of the Richard Roudebush VA Medical Center, Indiana University, and Regenstrief Institute in Indianapolis, said the trial demonstrated that it is feasible to provide telephone-based centralized symptom management across multiple, geographically-dispersed, community-based practices in both urban and rural areas by coupling human interactions with technology-assisted patient interactions.

He added that the study’s findings did not appear to be confounded by differential rates of co-interventions or health care use.

“The fact that INCPAD was beneficial for the most common physical and psychological symptoms in cancer patients demonstrates that a collaborative care intervention can cover several conditions, both physical and psychological,” the researchers concluded.

Intrigued, we caught up with Ideal Life president Jason Goldberg at the American Telemedicine Association annual meeting in May. With our cameras running, Goldberg explained how his approach to home telehealth is different from other vendors and how it helped Bayada Nurses address two concerns that had previously kept them from considering remote patient monitoring.

The first concern addressed, of course, is the cost of investing in a home telehealth system without support from government and private payers. The other is the resistence posed by patients who object to having their home so cluttered with medical equipment that it begins to look more like a hospital room than a home.

In this ten-minute conversation, Goldberg explains to HCTR editor Tim Rowan how telehealth can possibly be all three: effective, invisible and affordable.