The Work Comp Virtual

Issue #15: December 2017

Note from the Editor

As 2017 comes to a close, we see telemedicine having gained widespread recognition in the workers’ comp industry as an essential element in the future of work injury response.  The broader term telepresence captures the breadth of uses of this technology: initial triage, on-going care, return to work planning, case management, counseling, investigations, and more.

In this issue of WorkCompVirtual, three news articles report trends and an application that should interest workers’ comp professionals.

– Peter Rousmaniere

What's Happening

Phenomenal Growth since 2014 of Engagement with Telemedicine: Survey

There has yet to be a survey in the workers’ comp industry.  Group health executives have come around in this three years to embrace the technology.

Three-quarters of medical providers currently offer or plan to offer telemedicine services, according to the results of a survey by the law firm Foley & Lardner L.L.P.  The survey included 107 senior executives at hospitals, specialty clinics, ancillary services and related organizations.

In 2014, 87% of survey respondents did not expect most of their patients to be using telemedicine services by 2017.

75% of this year’s respondents currently offer or plan to offer telemedicine services. Also, 53% of those said their programs were growing or expanding, while only 14% said their programs were under consideration or in development. By contrast, 34% of respondents to the 2014 survey said their programs were in the early stages.

Read the survey press release.

Mitchell – Risk & Insurance Survey on Technology in Workers’ Comp

Mitchell International teamed up with Risk & Insurance Magazine to survey 275 workers’ comp professionals on their expectations for technology in the future of the industry.

Forty-five percent of respondents believe telemedicine will have the biggest impact on the industry, followed by artificial intelligence (19 percent), mobile technologies (14 percent), wearable devices (10 percent), and chatbots (one percent). About 10 percent of respondents believe that none of these will significantly impact workers’ compensation.

Eighty-six percent of respondents believe that advanced technologies will most affect medical management and claims management (43 percent each). Similarly, nearly 30 percent of respondents believe advanced technologies will influence improved medical outcomes the most, as well as the direction of care (16 percent), risk mitigation (16 percent), fraud management (17 percent), and claims triage (18 percent).

See the survey results. 

A Case Study on Greatly Reducing Wait Times for Specialists

This case study reveals to workers’ comp claims payers that using telemedicine for specialist exams can cause these exams to happen in days compared to weeks of delay in arranging a face-to-face encounter.  To make this happen, the committed claims payer needs to align with committed clinicians.

A group of community health centers in Massachusetts introduced “teledermatology” to improve access to care.  They selected 22 sites where patients can go for exams.  They joined forces with a telemedicine company that is a spin-off from Yale University, and they negotiated reimbursement with four health plans.

The service is designed as “store and forward,” that is, images are remotely taken, and a dermatologist looks at the images and makes treatment recommendations within 48 hours.  The service uses a handheld scanner to capture three different views of the lesion, and uploads images and patient information for review by a specialist.

As reported by MHealthIntelligence, the traditional way is for a primary care doctor to refer a patient to a face-to-face meeting with a dermatologist, which on average takes 29 days. One study estimated that only 20% of dermatology exams actually require an in-person visit with a specialist.

Archived Issues

Issue #14: November 2017

Note from the Editor

In this issue, we report on how telemedicine has been expanding through some major investments by healthcare providers.

– Peter Rousmaniere

What’s Happening

Mercy Virtual Care

Mercy Virtual Care Center is the first significant launch of a 100% virtual care center in the United States. Initially conceived in 2006 and opened in 2015, it is housed in a four-story, 125,000 square-foot building in suburban St. Louis. To create the Center, Mercy drew upon its patient care experience with 43 hospitals in five states. It is the cornerstone of Mercy’s virtual care program.

Mercy says, “Working in a continuum that is consistent with life, we collaborate with bedside clinicians, primary providers and specialists to maximize patient data in real time. Together, we are now able to diagnose and intervene earlier. And with our teams supplementing the work of local caregivers by providing skillful monitoring and management, we’re closing gaps between incidents.”

Mercy’s business model expects that healthcare will be increasingly moving away from a traditional fee-for-service model and more towards a bundled or capitated model.

Onsite Clinic Demand and Telepresence

The National Business Group on Health surveyed 148 employers with a total of 10 million workers and found 54% had an onsite clinic in 2017 and another 12% expect to open one by 2020. More than half of those clinics offer occupational health services. The Society for Human Resource Management reports that among small businesses, nonprofits and government agencies, 8% have onsite clinics.

Telepresence is a viable alternative to staffed onsite clinic for purposes of health education, brief medical encounters and health monitoring. The “virtual” clinic can be equipped with remote monitoring technology.

Kaiser Telehealth Outpaces In-Person Visits since 2015

Kaiser Permanente logged 110 million patient encounters in 2015. 52% of them occurred through online portals, virtual visits or Kaiser’s apps. Kaiser is seeing more patients online than in person, according to CEO Bernard Tyson. Tyson said, “We are going through a major transformation in healthcare. We have invested billions in our technology platform.”

Issue #13: October 2017

Note from the Editor

Medical clinics are telling us what they want from telemedicine, and several major states are advancing the use of this technology for injured worker treatment.

– Peter Rousmaniere

What’s Happening

What Medical Providers Want

At the center of injured worker medical treatment in the United States is the outpatient clinic, which is the initial point of entry for the vast majority of work incidents requiring medical care. Some 5,000 such clinics market their services to employers and insurers to care for injured workers. About 1,500 of these clinics are fully dedicated as occupational health providers. Consumer Health Connections has met with hundreds of clinic administrators and clinicians and listened to what they see in telemedicine.

These clinics are highly competitive and look for service improvements that are economical and might also solve some operational problems.

Many are looking for after-hours coverage and see telemedicine as a good option for that. They may provide this coverage internally or use a telemedicine network within their state to service their clients.

During normal business hours, many providers also want to connect with their customers, both injured workers and their employers, and see telemedicine’s sight, sound, and recording features as adding new dimensions to service.

Some also view telemedicine as a means of solving staffing problems. When a clinic is backed up due to high demand, it can use this technology to see a patient virtually.

Texas and Colorado Ready for Telemedicine

Texas is now open for telemedicine in workers’ comp. It has been the last state to permit wide use of telemedicine. This summer the Texas Legislature passed a comprehensive bill addressing telemedicine in Texas, specifically removing limitations on its use that had constrained use beyond very limited scenarios.

According to WorkCompWire, the Texas Division of Workers’ Compensation issued an informal ruling in September which expressly authorizes the use of telemedicine for work injuries.

Colorado’s Division of Workers’ Compensation is reaching out to medical providers to encourage them to use telemedicine. On October 25 in Colorado Springs, the Division’s Medical Policy Unit is holding a “Getting Set Up for Telemedicine” workshop.

How New York is Defining the Telemedicine Agenda

According to MHealth Intelligence, New York State is considering legislation to advance telemedicine in workers’ comp. The legislature has defined the need as follows:

“The legislature recognizes due to geographic restrictions, provider shortages, inclement weather, restricted patient mobility and the lack of authorized workers’ compensation medical providers that have familiarity with the language spoken by injured workers, patients face challenges in accessing healthcare providers and healthcare services. It is critically important that injured workers are provided with the ability to receive quality medical care in an efficient and expeditious manner. Telehealth is a valuable tool in improving the continuity, coordination, and efficiency of care for rural and underserved populations.”

Issue #12: September 2017

Note from the Editor

Turning to healthcare systems this month, we find two which have aggressively built capacity to deliver medical services through telepresence.

– Peter Rousmaniere

What’s Happening

University of California Davis’ Telehealth Investment Pays Off

UC Davis built up its telehealth services for adults and children so that “real-time consultation services have been offered in nearly 50 specialties linked to over 200 clinics and hospitals, the majority of which are located in, or provide services to rural area.”

One study of the healthcare system’s pediatric telehealth program for rural emergency department care of children compared telemedicine, telephone, and no consultations between UC Davis clinicians and ED staff. The study found that “medications for patients who received telemedicine consultations had significantly fewer physician-related errors than medications for patients who received telephone consultations or no consultations.” (Pediatrics 2013;132:1090–1097).

Another study looked at the business impact of telemedicine on its operations. “In a competitive healthcare region with more than one children’s hospital, deploying pediatric telemedicine services to referring hospitals resulted in an increased market share and an increased number of transfers, hospital revenue, and professional billing revenue.” (Telemedicine and e-Health July 2013)

Geisinger’s Program

Note how Geisinger, the famous Pennsylvania health system, describes its telehealth program to its clinical partners:

“We are committed to providing your patients with easy access to specialty care within their local community. If you have patients who require specialty care outpatient referrals or need inpatient bedside consults, then Geisinger may be the telemedicine resource for your practice or facility.”

They offer live audio/video consultations to enable patients to see and speak directly to a specialist in real time and “store-and-forward exams” that allow sending photographs, X-rays and other exam information to specialists at other locations for review and interpretation.

Here is how Geisinger summarizes their benefits to patients: “More timely and easier access to high-quality specialty care; earlier diagnosis and decisions on the best care plan; cost savings as a result of not traveling for specialized services; confidentiality, just as if [the patient] were in a specialist’s office; and comfort, by remaining in [the patient’s] community with family support.”

Further Reading

A recent whitepaper written by CHC CEO, Jill Allen, and Work Comp Virtual Editor, Peter Rousmaniere, gives great insight into how CHC clients have used the CHC telepresence platform’s flexibility in a variety of ways. Read The Customer in Charge to learn more about all the different applications CHC clients have found.

Issue #11: August 2017

Note from the Editor

This edition of the Work Comp Virtual compares personal health with workers’ comp, reports on a large employer survey, and shows what day and hour immediate medical response to injury is in most and least demand.

– Peter Rousmaniere

What’s Happening

Telemedicine: Different Paths in Personal Health vs. Workers’ Comp

The clinician–to–patient encounter in an established clinician/patient relationship is the central event for telemedicine in personal healthcare. To enable these encounters, the major payers (Medicare, private health insurers, Medicaid) need to authorize reimbursement. The clinician needs to comply with federal conflict of interest guidelines, such as self-referral.  Ancillary services through telemedicine include health monitoring, but the rationale for using the technology is usually to support two-party encounters between healthcare providers and patients.

For worker’s comp, telemedicine is best viewed as a telepresence platform which supports a broad array of communications and decision-making functions, including but not limited to clinician–to–patient encounters. Scenarios that drive other applications could include:

  • • Initial triage servicers meeting with injured workers and other healthcare providers
  • • Case managers meeting with injured workers
  • • Adjusters meeting with injured workers and worksite personnel
  • • Medical clinic personnel meeting with worksite personnel
  • • Claims management teams conferencing on open claims

Telemedicine technology can thus support diverse tasks in injury management, prevention, and account management. It may evolve into the platform being used as the default venue for joint decision-making in injury risk management.

NBGH Survey Results on Telemedicine: “Surging”

This year’s National Business Group on Health’s (NBGH) survey of 148 large employers conducted in May and June of 2017 reported “telehealth utilization surging.” The survey found that, “Virtually all employers (96%) will make telehealth services available in states where it is allowed next year. More than half (56%) plan to offer telehealth for behavioral health services, more than double the percentage this year. Telehealth utilization is on the rise, with nearly 20% of employers experiencing employee utilization rates of 8% or higher.” Employers are seeking a way to improve employee experience while curbing costs, and telehealth fits the bill.

Demand for Fast Medical Response to Work Injuries – the Greatest and the Least

Looking at all hours in a seven-day week, we have compiled medical response time for work injuries.

The three most busy times for medical response are Monday, 8AM -12PM, Tuesday 8AM-12PM, and Wednesday 8AM -12PM.

The three least busy times for medical response are Sunday, 12AM – 4AM, Saturday 12AM-4AM, and Sunday 8PM – 12PM.

Overall, the busiest day of the week is Monday and the least busy day is Sunday.

Issue #10: July 2017

Note from the Editor

In order to grasp how Telepresence is penetrating the Workers’ Compensation field, we need to consider how people have adapted their lives around the iPhone.

– Peter Rousmaniere

What’s Happening

Telemedicine is like the iPhone

Winding paths

In the late 1990s, I began using a Blackberry. At the time, it was the only widely used device that I could take to a Waffle House in Little Rock, Arkansas at six in the morning to receive and send emails. It was a way for me to stay connected to my home office. Then, I stumbled upon its limited note taking function. Visiting Portland, Maine, I wrote for myself about the shadows of seagulls as they cruised along harbor-side buildings. At the time, the Blackberry was ubiquitous amongst securities traders as a way to keep in touch with their markets as they lunched and commuted. The value was in the application.

Such has been the winding and branching path of adaptation to mobile devices, perhaps the most memorable personal use technology advancement in the past 25 years. And, sometimes with astonishing results: in the developing world, farmers and shop keepers use these devices to leap over the constraints of poor infrastructures of landline phones and banking.

Apple’s iPhone, first introduced in 2007, moved the technology beyond what personal mobile devices had offered at that time. Instead of a limited set of applications, the iPhone was a platform. To use an overused phrase, this changed everything. The applications were, for practical purposes, unlimited and (once the device and the communications provider were paid) extremely cheap.

To my surprise, an object the size of a large oatmeal cookie could let me: phone, dictate, track my walks trough the hills of Vermont, flashlight my way in a darkened garage, and read the news. It was only a matter of time in which I would adapt the platform for a new use; this has taken years and continues today.

The commonly used name of the device sticks to one prominent application, a phone.

Telemedicine is the commonly used term to represent a shared decision making platform that goes far beyond the use by a doctor or nurse to talk with a patient. The value of telemedicine is in the platform. 

Efficiency vs. Breakthrough

The ever-broadening discussion about telemedicine in workers’ compensation reveals a schism in focus, resulting in confusion over what this technology is all about. On the one hand, what we can call the Telepresence platform is construed to be an efficiency tool.

Doctors, patients, nurse case managers, and their injured workers can now engage without worrying about travel, access to encounter rooms in clinics, and so on. This is the efficiency gain—big enough to warrant using the technology.

There is a second gain, which can be called, the breakthrough gain. By radically reducing the cost of group decision making, including both face time and document sharing, Telepresence impacts the core design of how services are delivered, designed, and justified. It affects who is in charge.

Disruption is already underway as medical clinics use the platform to gain occupational medicine market share within a state.  It is giving rise to a new kind of occ med doc, who works solo out of his or her home to do virtual encounters.

With early clients and partners of Consumer Health Connections, we peer into the future. Employers’ Safety and Workers’ Compensation coordinators will greatly enhance their influence through virtual face time with insurance personnel. Insurance brokers will be held more accountable for knowing what their clients and their insurers are up to.

No matter who the consumer is, such as the injured worker, he or she will be able to expect better performance from whomever is providing a service. We are now seeing this future today. This is why CHC’s new white paper is titled The Customer in Charge.

Issue #9: June 2017

Note from the Editor

The transformational power of telemedicine is put on display this week by the acquisition by a telemedicine firm of an expert medical case manager and, Texas, the holdout state for telemedicine, finally removes its objection.

Call it what you will—telemedicine, telehealth, telepresence—interest surges as people begin to explore how the technology solves a number of communication challenges. The technology is not only replacing in-person medical visits, but also enabling high quality encounters of many kinds. Consumer Health Connection’s clients are deciding inventively when to use the platform to their advantage. It’s going to take some time to realize the full value of the technology.

– Peter Rousmaniere

What’s Happening

TeleDoc Acquires Best Doctors

On Monday, June 20, TelaDoc, a major telehealth platform, announced that it entered into a definitive agreement to acquire Best Doctors, a leading expert medical consultation company. Per the press release, “Teladoc is creating a…powerful connected care platform – a single solution for addressing a complete spectrum of medical conditions, from non-critical, episodic needs to chronic, complicated medical conditions.”

Best Doctors, which serves insurers and self-insured employers globally, is known in the United States for expert assessment and consultation on complex medical issues. It has a special strength in finding and advising on remedying misdiagnoses and inappropriate treatment. The company has invested heavily in computer-driven analytics.

Best Doctors services the workers’ compensation community through expert consultation on medically complex claims through its Best Doctors Occupational Health Institute.

Comment: Technology is driving the business model of medical care. A telehealth firm bought a highly respected medical case management firm, not the other way around.

Texas OKs telemedicine

Texas has been the sole holdout state that has severely restricted the use of telemedicine by imposing a number of barriers. Since 2011, the Texas Medical Board and the telemedicine community have been in conflict over restrictive rules of the Board including its demand that prescribing of medications by telemedicine could not take place without a prior in-person meeting. In 2015, TelaDoc sued the Board alleging anti-trust violations.

In 2016, the U.S. Department of Justice and the Federal Trade Commission came down in support of TelaDoc’s legal challenge, saying that they were anticompetitive and not appropriately reviewed.

Senate Bill 1107 was signed by the Governor on May 27. It removes barriers including the requirement of a prior in-person meeting. The text of the bill can be found here.

Insurer Uses Telemedicine Instead of an ER Visit for Non-Urgent Care

Blue Cross Blue Shield of Georgia will soon stop reimbursing for non-urgent emergency room visits, recommending members to use its LiveHealth Online telehealth platform or visit the nearest urgent care or retail clinic instead. “The cost of care’s been going up so much faster than people’s earnings,” explained BCBSGa President Jeff Fusile. “We have got to find a better way to do some of this stuff, taking some of that unnecessary spending out of the system.” Source: MHealth Intelligence, 6/8/17

Issue #8: May 2017

Note from the Editor

What makes an effective clinician in telemedicine? I offer a brief guide in this newsletter. – Peter Rousmaniere

What’s Happening

Choosing the Best Clinical Team for Telemedicine

Telemedicine helps to improve medical care throughout the life of a work injury. The technology works in sharply different ways then in personal health. In fact, telemedicine has more potential with work injuries. Be aware of these differences when you select, train, and support your team of medical providers.

The medical team needs to possess three key personal competencies unique to responding to work injuries:

  • Heightened awareness of the return-to-work and stay-at-work potential as well as limitations for the recovering worker. Many general practitioners and Emergency Department clinicians are not sensitive enough to these issues.
  • Knowing when and how to recommend specialist care. For work injuries, referrals to diagnostic workups and medical specialists are a core aspect of occupational medicine.
  • Keeping the worksite and employer personnel in the loop. Clinicians in occupational health are skilled at including both the injured worker and the employer in the picture while respecting medical privacy.

Besides personal competencies, the medical team needs to fit in well with the informal community of occupational medicine providers throughout the state in which they work.

Why? The doctor, nurse, or other clinician on a telemedicine encounter may engage with an injured worker geographically far removed in that state. The clinician should be aware of what medical resources suitable to work injuries are available in the worker’s region. She or he may even know some of the individual providers by reputation or personally. This knowledge can lead to informed, speedy referrals.

Rapid Growth in Rural Telemedicine

Mental healthcare for rural populations has become dependent on telemedicine over the past ten or so years. A research team studied patterns of rural mental health of Medicare beneficiaries. It reported that between 2004 and 2014 the number of what it called telemental health visits grew on average 45.1% annually. It noted a wide variability among states. “In 2014 nine states had more than twenty-five visits per 100 beneficiaries with serious mental illness, while four states and the District of Columbia had none.”  States with laws more friendly to telemedicine “had significantly higher rates of telemental health use than those that did not.”

Source: Mehrotal A et al. Rapid Growth In Mental Health Telemedicine Use Among Rural Medicare Beneficiaries, Wide Variation Across States. Health Affairs, May 2017.

Issue #7: April 2017

Note from the Editor

Risk & Insurance columnist Roberto Ceniceros recently assessed the potential for telemedicine in workers’ comp and the comments on how new technology enters the workers’ comp industry. So we ask, how is telemedicine to be used? – Peter Rousmaniere

What’s Happening

Using Telemedicine to Better Engage the Injured Worker 

Patterns of actual use in healthcare are a clue. Telemedicine in the United States is increasing the number of medical encounters, evidence that the technology is improving access to care. It may substitute for very expensive physical encounters such as at emergency departments. But its main contribution may be in access to care. For injured workers, this translates into closer engagement with care, and helpful information for the claims team.

The subject was explored in a recent Health Affairs article. The authors wrote, “There were a reported 1.25 million direct-to-consumer telehealth visits in 2015. A recent survey of large employers indicated that 90% of them plan to offer a direct-to-consumer telehealth option to their employees in 2017.”

They studied medical claims data for beneficiaries of the California Public Employees’ Retirement System (CalPERS), a large California public employee benefit organization, which began offering telehealth to selected members in 2012. They compared health encounters with telehealth users and persons not offered telehealth, focusing on medical care for acute respiratory infections.

They found that telehealth encounters were about 50% of the cost of a physician office visit and less than 5% of the cost of an ED visit. About 12% of telehealth encounters substituted for physical encounters; the large majority added to the number of medical encounters.

We may infer that the technology engages the injured worker in his or her speedy recovery. It also avoids some very high cost physical encounters. With lost time compensable injuries costing on average over $50,000, better engagement is indeed valuable.

(Ashwood JS et al. Direct-To-Consumer Telehealth May Increase Access To Care But Does Not Decrease Spending. Health Affairs, March 2017)

Remote Assessment of Concussions is Feasible: study

Medpage reported that neurologists examining college football players via a telemedicine robot made the same decisions as onsite physicians on removal from play and reached similar diagnoses in a pilot study, researchers said. The findings suggest a potential solution to the shortage of immediate neurological care for potentially injured young athletes.

A motorized robot was equipped with a high-resolution camera, microphones, speakers, and wireless internet connectivity. The researchers followed 50 players, with 11 suffering suspected concussions.

Results suggest a telemedicine approach could help a high school sports population that lacks the resources to universally address suspected brain injury immediately. More than half of U.S. high schools did not have sideline medical personnel including athletic trainers.

Issue #6: March 2017

Note from the Editor

Our lead entry includes survey results on how people relate to online healthcare. – Peter Rousmaniere

What’s Happening

The Harris Poll Reports on Online Healthcare

The Harris Poll regularly asks Americans about their healthcare experience and likes and dislikes about medical delivery. Recently it’s been asking people about telemedicine (or as it describes it “virtual health”).  Below are polling results.

Online interaction is growing:

A poll taken in September, 2015, revealed that “Doctors’ offices are clearly enhancing patients’ opportunities to interact with the offices online. Since 2012, the number of patients who say their doctor offers a particular online communication service has increased across the board. Most notably, one quarter (25%, up from 17% in 2012) of patients now indicate they have online access to their medical record, including doctor visits, prescriptions, test results and history. Email access to doctors has grown as well, from just 12% of patients indicating they had access in 2012 to one in five (19%) today.

….and demand for online communication is not being met:

In this 2015 poll, responses revealed large gap between demand and actual delivery:

  • Proactive communications from doctors to schedule preventative care appointments via email or text (16% have the service; 59% believe it’s important to have),
  • Online appointment setting (17% have; 52% important), and
  • Online billing and payments (15% have; 50% important).

The largest gap between access and perceived importance is for an online cost estimator that provides average costs for specific services, which is available to less than one in ten (7%) patients but important to over six in ten (62%).

There’s ample willingness to engage in telehealth:

In a May, 2016 survey Harris conducted for Xerox, “virtual health is gaining acceptance among patients. 61% of consumers surveyed said they are willing to receive non-urgent healthcare advice, exam or counseling in a virtual setting.

“According to the survey, convenience was cited as the top benefit (59%), followed by potential cost savings (40%), the ability to see or communicate with a healthcare professional for minor ailments and to easily receive prescription refills (both 35%) and the ability to see or communicate with a healthcare professional more frequently (26%).”

Concerns remain about telehealth:

The consumers surveyed also cited a number of concerns regarding telehealth and virtual health visits. Consumers cited these as top concerns—my insurance won’t cover (43%), my data and information won’t be secure (37%), I won’t see the same personal relationship with my provider (35%), connection issues (such as internet/Wi-Fi/phone) (34%) and lack of access to regular physicians (30%).

Industry leaders know the challenges:

“This tells me that we’re on the edge of a major expansion in virtual care—when there is this much demand from consumers, the industry must pay attention,” Russ Mulert, innovation office, Xerox Healthcare Business Group, wrote in a blog about the survey results.

“But for healthcare providers, implementing a comprehensive telehealth strategy is easier said than done—otherwise we’d have made more progress in the last two decades. The infrastructure for actually delivering virtual care, and integrating patient and claims data from telehealth visits with mainstream clinical and financial systems, are two significant challenges. And providers also need to be aware of and address patient concerns.”

(Sources: Harris Poll 11/19/14 and Healthcare Informatics 6/8/16)

Big Investments in Telehealth

CHI Franciscan Health operates a telemedicine center in Tacoma, Washington, performing virtual consultations in 11 states. Most common patients are women ages 25 to 55, and the most typical diagnoses are bladder infections, upper respiratory tract infections and pinkeye. Users are prescribed medication about 40 percent of the time. Most visits take place on weekends or between 5 p.m. and 8 a.m. when doctors’ offices are closed. (Source: NY Times)

Mercy Hospital built a $54 million virtual medicine center in Chesterfield, Missouri and opened it for business in 2015. It serves multiple purposes including a telestroke program whereby patients who come to the ER with symptoms of a stroke can be seen immediately by a neurologist via telemedicine. In-home monitoring: Mercy provides continuous monitoring for hundreds of chronically ill patients in their homes after hospitalization. (Source: Mercy Hospital)

Issue #5: February 2017

Note from the Editor

Jill Allen is founder and CEO of Consumer Health Connections. I recently asked her to introduce herself and her outlook on telemedicine. – Peter Rousmaniere

What’s Happening

Interview with Jill Allen, CEO of Consumer Health Connections

PFR: Tell me a little about your background.

JA: I am a Registered Nurse with a BS in Business Management and MS in Health Service Administration. My nursing career started out in acute care, then evolved about 20 plus years ago into helping injured workers recover. I worked side-by-side with medical providers and case managers. At a national case management company in workers’ comp, I rose to lead business development, and eventually assumed ownership of the company. Over these years, I managed case managers, implemented 24/7 triage, placed nurses in-house at insurance carriers, and started on-site clinics at employer locations.

PFR: When did you create CHC?

JA: CHC came into being in March 2015. I had spent a significant amount of time with medical providers, insurers, brokers, and key workers’ comp leaders before then. I wanted to be sure that the venture was likely to succeed, but more importantly, would solve problems.

PFR: What are these problems?

JA: I witnessed first-hand the gaps and challenges that existed within the industry from the provider, carrier and employer perspective. I saw the enormous amount of effort spent trying to recreate the initial event that led to an employee’s injury. And I saw the medical provider shortage becoming more real. And, workers’ comp is often highly negative and adversarial, which erodes trust.

PFR: How does CHC help?

JA: The CHC platform improves accuracy from the onset of injury through the life of the case. Telepresence allows a triage clinician to visually assess an injured employee vs. just talking by phone. And, this higher level of contact continues through recovery. I am a firm believer that quality healthcare needs to be accessible to all employees no matter where they are located. These are significant improvements from where we are now. Removing the uncertainty of a claim while improving engagement is better for all parties.

PFR: What have you seen are main distinctions between telemedicine in group health and in workers’ comp?

JA: I’ve looked at many group health models. There are some good systems out there. But workers’ comp is much different. The telemedicine platform must have workers’ comp requirements in mind. For instance, return to work is critical. Engaging all key stakeholders in the process is critical. Case management is also key in coordinating care. The platform also needs to reflect all the federal and state rules and regulations that apply. These include OSHA recordables and mandatory state forms, such as the first report of injury.

PFR: From your experience, are there any commonalities among claims payers who sign on with CHC?

JA: There’s a lot of interest in the telepresence-recorded intake. The immediacy of connecting an employer, triage nurse, injured employee and provider is of great interest. Also, our clients really like how real-time reporting saves time and money. Lastly, the ease of use is a frequent compliment we hear often.

Issue #4: January 2017

Note from the Editor

We are about to witness many initiatives in telemedicine in 2017. I report here on one from 2016. I show how nurses have prepared for this technology, and I point out how face-to-face encounters are crucial for building trust. – Peter Rousmaniere

What’s Happening

Telemedicine at Missouri Employers Mutual
This leading workers’ comp insurer began using telemedicine in 2016. Nearing year-end, the insurer’s provider network manager, Paul Morizzo, summarized the results. The technology was especially helpful in securing the injured worker’s confidence that his or her injury was handled well. Many injuries that otherwise might have led to an emergency department or outpatient clinic were treated onsite. The physician on the virtual encounter sometimes made quick calls for emergent medical care when it was warranted.

Mr. Morizzo said, “We want workers to get medical care if there is a chance she or he needs it – it’s worth paying $200 or more to be sure. Telemedicine makes sure that injuries are reported quickly and that triaging for medical care is done well.”

The Well-Beaten Path of Nursing to Telemedicine
In workers’ comp, telephone assistance to injured workers by nurses is standard practice. The nurses may be stationed at clinics, in call centers, or working out of their home.  These phone calls have been popular for decades. The nursing profession has been collaborating with state and federal regulators for years to enable telepresence.

Cross-state border permission. Starting in the late 1990s, state boards created a multi-state licensure compact. A nurse in state A can practice in state B. How the compact works is explained here. Twenty-five states participate today in compacts.

Promoting professional practice standards. The American Academy of Ambulatory Care Nursing has been engaged in writing practice standards and training nurses for years. Its annual conference, held this year in May in New Orleans, hosts a half-dozen sessions on telehealth.

Why Face-to-Face is Crucial: Trust
Trust is an important part of successful workers’ comp claims management. As telemedicine grows in workers’ comp, we need to ask, “How can this technology best preserve or restore trust?”

The broker, Lockton, recently reported that, “The average lost-time claim costs 3.5 times more when words such as “fear” and “afraid” are recorded in adjuster conversations. Their report, “Leading with Empathy,” draws upon text analysis of adjuster notes.

“She told me she was SCARED about her future and felt she needed to speak to someone” is an example of these notes. Unanswered concerns “can be overwhelming for an employee who has suffered an injury on the job,” Lockton observes.

Starbucks provides another example of the value of face-to-face meetings. Howard Schultz, the company’s founder, who came out of retirement to take charge again in 2008, credits an extraordinary face-to-face meeting as key element in the company’s turnaround.

Schultz recounted, “I decided—against the advice of many people at the time, because it had a high cost attached to it—to take 10,000 store managers to New Orleans. I knew that if I could remind people of our character and values, we could make a difference. The conference was about galvanizing the entire leadership of the company.”

Trust is built through face-to-face encounters. Schultz aimed to restore trust to engage the entire company in a massive turnaround. He succeeded.

Issue #3: November 2016

Note from the Editor

In this issue, we look at compliance issues in telemedicine. Compliance is a moving target as states and medical boards are trying to catch up with expanding demand for this technology. We also dip into the topic of remote medical monitoring. – Peter Rousmaniere

What’s Happening

Compliance: A Quick Guide
Consumer Health Connections is dedicated to ensuring that its clients who use telemedicine are confident that they are in compliance with standards. CHC pays close attention to the rapidly growing body of formal guidance. It wants to share its knowledge throughout the workers’ compensation field. It is releasing a white paper, “Compliance Issues for Telemedicine in Workers’ Comp” The paper is available here.

When medical providers and insurers begin to grasp onto telemedicine, they seek out answers about compliance. And those who deliver guidance are rushing to catch up. State legislatures, state medical boards and some national societies of physician and nursing specialties are involved.  Overall, formal guidance is becoming more comprehensive and more permissive, though it will take some time to fill in gaps, state by state.

We have identified sixteen topics that can be addressed while planning to use telemedicine. The report contains a checklist to help workers’ comp professionals quickly learn what deserves top attention.

Consumer Health Connections’ compliance personnel can discuss the current and in some instances the prospective situation in each state.

Parity Between In-Person and Telemedicine Encounters
Telemedicine’s expansion is strongly dependent on its use for services covered by health insurers.  Thus a lot of state legislative action focuses on removing impediments to greater use within health plans.

Telemedicine advocates have been inducing states to create a level playing field with in-person care. States have been passing laws banning insurers from refusing to pay for telemedicine encounters. Some states require parity between in-person care and telemedicine for reimbursement to medical providers and for patient co-pays and deductibles. Some prohibit separate telemedicine facility charges.

One case where there is not a level playing field is drug prescribing. Some states prohibit or restrict doctors from prescribing medications unless a prior in-person relationship had occurred.

Read CHC’s white paper on compliance for a broad review of pertinent state legislative topics.

What is Telemonitoring?
Consumer Health Connections uses a broad definition of telemedicine, which includes remote monitoring of patients or persons at risk. Narrower definitions often exclude this use of technology. What is telemonitoring?

Connecticut’s telemedicine law defines it this way:

“Remote patient monitoring” means the personal health and medical data collection from a patient in one location via electronic communication technologies that is then transmitted to a telehealth provider located at a distant site for the purpose of health care monitoring to assist the effective management of the patient’s treatment, care and related support.

Hospital emergency department use and re-admission rates have changed when patients at discharge were suited up with a monitoring device.

A San Diego hospital ran a trial of remote monitoring for patients with chronic obstructive pulmonary disease (COPD) and heart failure.  It found that for COPD patients, there were much fewer emergency department visits within 30 days after discharge but within 180 days the rate of visits showed no change. For heart failure patients, on the other hand, there was a sharp decline in ED visits within 180 days.  (See “Feasibility and Acute Care Utilization Outcomes of a Post-Acute Transitional Telemonitoring Program for Underserved Chronic Disease Patients.”)

A later trial use of remote monitoring of heart failure patients by a hospital in Pennsylvania resulted in lower use of the emergency department.  Interestingly, the devices picked up some medical problems unrelated to heart failure, which triggered some medical encounters.

Issue #2: October 2016

Note from the Editor

In this issue, we look at ODG’s take on telemedicine and report on the emergence of “virtual” medicine under a major integrated health plan. – Peter Rousmaniere

What’s Happening

Kaiser Permanente’s Viewpoint on Virtual Medicine
Kaiser Permanente is an integrated system of doctors, hospitals, and health insurance  which covers ten million lives. Starting in late 2015, Kaiser Permanente Northwest began offering members free video visits for typical urgent care issues, waiving co-pay charges. The attending physician would have the patient’s electronic medical record on hand during the virtual urgent care-like visit. Video visits by telemedicine were also available for dermatology, speech therapy, wound care, mental health and podiatry. Patients can connect through a portable or desktop device.

Kaiser Permanente has long promoted virtual medicine. In 2008, its providers delivered  about one virtual visit (defined as a phone call or email) for every four office visits. In 2013, the ratio narrowed to about one virtual visit to 1.3 office visits. Virtual visits, including video visits, are expected to exceed the number of office visits in 2018.

The organization has been studying for close to a decade how to improve how clinicians and patients engage in virtual space.  It monitors acceptance. In Colorado, nearly 80% of patients who participated in a video visit for dermatology were likely to recommend it to others and two out of three reported not needing an in-person follow up visit because their issue had been resolved.  Focused uses of telemedicine, such as for dermatology, make it easier to evaluate accuracy of diagnosis and other quality measures.

The health plan’s white paper on telemedicine is here.

ODG’s Advice on Telemedicine
ODG 2016, published by Work Loss Data Institute, has a short and generally positive passage on this technology. While mentioning a broad potential, the passage focuses on pain management:

“Current literature supports the use of telehealth in the treatment and education of patients with chronic pain…. Centralized telecare management coupled with automated symptom monitoring can result in improved pain and depression outcomes. Telecare collaborative management can increase the proportion of primary care patients with improved chronic musculoskeletal pain.”

ODG also addresses the question if telemedicine is real medicine. ODG reports on what the American College of Physicians wrote in 2015, that “a valid patient–physician relationship must be established for a professionally responsible telemedicine service to take place.”

The ACP’s statement said, in effect, that telemedicine is real medicine if done right. It said, “A physician using telemedicine who has no direct previous contact or existing relationship with a patient must do the following: a. Take appropriate steps to establish a relationship based on the standard of care required for an in-person visit, or b. Consult with another physician who does have a relationship with the patient and oversees his or her care.”

Worth Noting

Sedgwick on Telemedicine
Sedgwick CMS posted on its website on September 16 an article by its medical director, Theresa Bartlett MD, on telemedicine, “Connecting healthcare quality with telemedicine.” Bartlett crisply lays out what’s required for telemedicine to be effective in treating work injuries.

Issue #1: September 2016

Note from the Editor

American healthcare is rapidly adopting telemedicine technology to overcome doctor shortage, improve quality of care, and reduce cost of care. Telemedicine’s value proposition is even stronger for worker’s compensation. The technology is available today, customized for application in workers’ comp. Most regulatory barriers, where they existed, have been removed.

The Work Comp Virtual seeks to help workers’ compensation professionals stay informed about this technology. Please let us share with you, periodically, insights about trends, opportunities and challenges. – Peter Rousmaniere

What’s Happening

A Risk Manager Sizes up Telemedicine
Ann Schnure began working in risk management at Macy’s, Inc., rising to VP of Risk Management – Claims for the 150,000-employee retailer. She holds several prominent professional designations, including CPCU. She has played a key role in implementing managed care and claims innovations since the mid 1990s. We caught up with her on one of her first days as Chief Operating Officer of Consumer Health Connections, which she joined on September 12.

Q: When you think of major advances in work injury recovery you’ve been involved with, what comes to mind?

Schnure: There have been so many great technology advances in treating injured workers. Fifteen-plus years ago, immediate triage really took off. Another huge advance that still has lots of opportunity is outcomes-based networks. So much work is being done in this area with so many different models.

Q: What got you interested in telemedicine?

Schnure: Healthcare has been doing all kinds of telemedicine for a longtime, and the technology has really taken off in that space. Wearables, smart scales that report in weight, ipads given out to patients, etc. add to the potential. Any time you can handle a patient issue without an in person doctor visit, you can probably get a good ROI.

Q: What specific applications in workers’ comp come to mind?

Schnure: My first thoughts on telemedicine in the workers’ comp space, several years ago, was to address employees who were ready for full duty but who were not attending follow-up visits with the occupational health clinics. They needed these visits for full duty releases. Why not a virtual visit? Then, I saw a huge opportunity for some of the initial visits as well. Telemedicine for low severity injuries that require nothing more than a computer or smartphone is an easy ROI.

(Editor’s note: over one million work injuries needing medical concurrence for return to work occur annually. Another two million do not result in lost time but still need medical oversight.)

The AMA Steps Up
On June 13, 2016 the American Medical Association published a new guidance for ethical practice in telemedicine. The AMA had been working on a formal position for some years. Publishing the document in June signaled that the physician association generally concurs with the increasing use of the technology.

The statement, not yet formally available, said that “the AMA guidelines permit physicians utilizing telehealth and telemedicine technology to exercise discretion in conducting a diagnostic evaluation and prescribing therapy, within certain safeguards.”

Worth Noting

White Papers

The Customer in Charge

White Paper - The Customer in Charge’ CompConsumer Health Connections (CHC) reports on how clients use its virtual meeting platform. Telepresence technology has been employed for work injuries in the past, but in very limited ways. CHC’s launch in 2016 came with a promise that their technology was easy to use and adaptable and would support uses in many arenas such as workers’ compensation, auto and other risk products. This promise was fulfilled in the first year, putting work comp customers in charge!

The Power of Telemedicine in Workers’ Comp

CHC Telehealth White Paper - The Power of Telemedicine in Workers’ CompTelepresence is changing the landscape in healthcare and the benefits of virtual solutions are even greater in workers’ compensation than in commercial healthcare. Telehealth is achieving great success because injured workers, doctors, employers and claims payer are all motivated to use it to save time and money while enhancing the quality of care. Authored by noted expert Peter Rousmaniere, The Power of Telemedicine in Workers’ Comp, elaborates on the gains in compensability review, medical management, and return to work.

Compliance Issues for Telemedicine in Workers’ Comp

Compliance Issues for Telemedicine in Workers’ CompWith today’s rapid expansion of telehealth, there is a rapidly growing body of formal guidance. States are passing laws, and there is a range of statutory guidance from some states passing omnibus laws addressing questions to other states offering little guidance. Authored by noted expert Peter Rousmaniere, Compliance Issues for Telemedicine in Workers’ Comp identifies sixteen key topics organizations should address when planning to use telemedicine for workers’ compensation in a state jurisdiction.

Contact the Editor

About the Virtual

The Work Comp Virtual is a periodic newsletter on advances in workers’ compensation telemedicine and is authored by noted expert Peter Rousmaniere and powered by Consumer Health Connections