September 19, 2005
Bridging the gap | Maine Telemedicine Services uses videoconferencing to connect doctors and patients in rural Maine. But can the technology pay for itself?
By Jennifer Hazard
When Ron Emerson thinks about the benefits of telemedicine, he recalls a severely wounded, elderly islander whose home was 25 miles away from his doctor's office on the mainland. The patient was in no condition to travel, and his condition was worsening. But with the help of a basic videoconferencing unit ˆ a small video camera attached to a television screen ˆ an island nurse was able to not only describe the symptoms, but also send live images of the patient's wound to the doctor. Moments later, the patient's doctor was able to view the injury, diagnose it and recommend a course of treatment ˆ all without ever setting foot on the island.
The story demonstrates precisely what Emerson, the executive director of Maine Telemedicine Services, says is the benefit of telemedicine: It allows patients access to care no matter where they live. Introduced in Maine in 1997, the technology has been growing steadily; MTS has helped its partners develop approximately 280 videoconferencing sites statewide. That means, according to Emerson, that 300-500 patients across Maine are using telemedicine on a monthly basis to communicate with doctors, psychiatrists and social workers. Emerson attributes the growth at least in part to Maine's rural nature. "Medical access is an issue and geographical barriers can often be broken down using telemedicine," he says. "The system allows for greater access and continuity of care."
Organizations such as MTS, which is a division of the Healthways/Regional Medical Care Center at Lubec, hope telemedicine use will continue to spread. However, the ability to sustain grants and funding for telemedicine has proved difficult over the years. In order to make telemedicine programs financially viable, Emerson is actively exploring new ways to use the technology, including a brand-new telepharmacy system for which MTS received funding this month.
While residents in rural areas have been receptive to telemedicine, Emerson says that the program is still in its early stages. To get the most out of the technology, as well as a return on their investment, organizations need to use the teleconferencing system in a multipurpose fashion, he says. "Telemedicine doesn't have to be used solely for clinical purposes. Many have used it successfully to provide educational programs and social services as well."
Expanding the ways in which telemedicine is used has been a hallmark of MTS' operations. In 2002, the organization was awarded a $250,000 grant from the Office for the Advancement of Telehealth in Washington, D.C. to bring the technology to rural nursing homes. While the system has benefited elderly patients from a clinical and educational standpoint over the past three years, Emerson has concerns about the program's sustainability. "Medicare won't pay for telemedicine when a patient is in a nursing home," he says. "We're trying to get the data together to show that telemedicine is cost effective. When the grant money runs out, we'll need Medicare's support to continue the program."
Emerson is not alone in facing this challenge; sustaining funding for telemedicine programs is an ongoing challenge for many nonprofit health care organizations in Maine. Gary DeLong, executive director of the Maine Seacoast Mission ˆ a Bar Harbor nonprofit that provides telemedicine to Frenchboro, Matinicus, Isle au Haut and Swans islands through its Sunbeam Island Health Services program ˆ says his organization has been able to sustain its telemedicine program using its own operating revenues and donor support. While the program has successfully connected patients and providers, DeLong says the mission will need to become more formally engaged in the health care system if it chooses to expand its program.
DeLong explains that hospitals, for example, are reimbursed for telemedicine services, but that the rate barely covers their costs. For this reason, he says, Maine Seacoast Mission has never asked for its share of reimbursement. DeLong says the nonprofit would have to apply to become a Federally Qualified Healthcare Clinic to receive a reimbursement rate that's higher than what is currently offered. While this seems a plausible solution, DeLong worries that becoming a FQHC could require patients to change their current providers. "We'd only move forward if the end result would be a positive one for islanders," he says. (For more on MSM, see "On the high seas," this page.)
A rural solution
While the ability to sustain telemedicine services remains an uphill battle, MTS and its members are determined to find ways to increase access to health care in rural areas. For now, Emerson says his challenge is to make organizations aware of what telemedicine can offer in order to expand their mission cost-effectively.
MTS has its roots in the Down East Telemedicine Network, for which it was in 1997 awarded $1.1 million from the Office for Advancement of Telehealth, a division of the U.S. Department of Health and Human Services, to connect Downeast health care centers via teleconferencing to hospitals in Maine's larger towns and cities. Since then, MTS' network has grown to include nearly 100 members throughout the state.
One of those members is Kno-Wal-Lin Home Care and Hospice in Rockland, which serves patients in Knox, Waldo and Lincoln counties. According to Bambi Kay, the organization's clinical services manager, KWL is the first home care agency in the midcoast to use telemedicine, having launched the service in June. She says the agency decided to try using videoconferencing units to improve case management of chronic care patients. "We believed the units would allow patients to get in the mode of caring for themselves," she says.
To get the program started, KWL needed to find funding for 10 videoconferencing units, each costing $4,000-$6,000. According to Kay, the units were paid for through a loan from the agency's affiliate hospital, the Penobscot Bay Medical Center in Rockport, which she says regarded the program as a sound investment in the community.
At the start, Kay and her colleagues decided to target cardiac and congestive heart failure patients, as studies showed these patients had the highest hospital readmission rate. "Hospitals don't receive reimbursement from Medicare for second admissions, and we believed offering care and learning through videoconferencing would be in the best interest of the patient," she says.
Once a patient signs up to participate in the program, a nurse will visit to be sure the patient or her caregivers are able to manage the equipment, which consists of a computer monitor and camera that connects to a patient's telephone line. The nurse downloads all of the patient's medical information to a data chip that is placed inside the monitor. This way, the agency can connect to the patient's records at any time. Kay says everything connected to the unit is individualized to meet the patient's needs, so a blood pressure cuff, thermometer, scale or glucose monitor may be added if necessary. The unit also provides daily reminders to patients to self-monitor, whether it's their heartbeat or weight. The patients send their daily results to the agency's server after each reminder.
Kay says the advantage of the unit is that it teaches patients and their families what to monitor and what signs to look for before calling a physician. "After they get over the learning curve, patients don't want to let it go," she says. "The downside is that after a 60-day period, we don't get reimbursed by Medicare or private insurance."
Still, Kay maintains that the program's benefits far outweigh the insurance problems. "Not only are the units a great teaching tool, but they also help to improve our market share," she says, adding that the addition of telemedicine makes her agency stand out among its competitors. In fact, KWL has decided to purchase 25 more units in the fall. Kay says the agency applied for a Federal Rural Health Grant last spring to fund the purchase, and hopes to receive approval this month.
Strength in diversity
Once organizations like KWL receive a grant, it's important that they look for a variety of ways to use the unit, says Emerson. He cites the Bath-based Pine Tree Society, a nonprofit that provides service programs to people with disabilities, as a partner that has done just that.
When the Pine Tree Society started its telemedicine program in February 2002, it used the technology to provide hospitalized deaf patients with around-the-clock interpretive services. The organization first used the system solely for situations in which patients required immediate medical attention. "When we began, people thought it would only be used for emergency purposes, but many rural hospitals may not have interpretive services at all," says Doug Newton, who runs the interpreting services program at PTS' branch office in Scarborough.
In its pilot year, 12 state hospitals signed up to participate in the program, which was funded by a three-year Technology Opportunities Program grant for $579,000 from the U.S. Department of Commerce. (Additional financial assistance was provided by the Maine Health Access Foundation in Augusta.)
Along the way, the Pine Tree Society received feedback from interpreters, medical staff and focus groups in the deaf community. Newton says these comments helped PTS expand its program, adding state agencies, medical centers and social service organizations to its list of partners. The Pine Tree Society provided the organizations with training and access to the units, so that interpretive services could be provided for medical, educational or psychiatric care. And in all cases, a deaf patient ˆ or his or her provider ˆ is able to connect to an on-call interpreter at PTS via the unit at any time.
In the future, Newton hopes hospitals will consider adding videoconferencing units to every patient's room, although he says doing so would require high-speed digital telephone lines throughout the facility. "That's where the challenge comes into play," he says. "There's only so much money people can spend on technology, but for programs like these to succeed, we have to be careful not to eliminate the possibilities."
It's forward thinking like Newton's that Ron Emerson hopes will positively affect telemedicine's sustainability ˆ and growth ˆ in Maine. In fact, he believes the technology has the ability to go even further. This month, MTS and the Regional Medical Center at Lubec were awarded a two-year, $200,000 grant from MeHAF to pursue the first telepharmacy program in the state, which would allow drugs to be prescribed and distributed to patients in rural areas who don't have convenient access to a pharmacy.
According to Emerson, the telepharmacy unit is similar to a vending machine for candy, although in this case, it utilizes a high-speed phone line to connect to a participating pharmacy. The machine itself, which Emerson says costs approximately $55,000, is stocked with pre-poured medicines, such as antibiotics or anti-inflammatories for acute illnesses, prepared by the pharmacist. The first unit will be located in RMCL' s health clinic. Once a patient is prescribed a medication through his or doctor, the prescription is faxed to the pharmacist, who connects to the unit at RMCL via computer. The unit prints out a bar code for verification and dispenses the prescription. And if the patient has questions, he or she is able to talk to the pharmacist by means of videoconferencing.
While the idea of a vending machine distributing medicine may seem risky, Emerson says the well-regulated system has been used with great success in Washington, D.C. area hospitals. And if all goes well with this pilot program, MTS and RMCL hope to add other telepharmacy sites throughout the state.
As for the issue of sustaining funding, the nonprofit remains confident. Carol Carew, CEO of RMCL, has been involved in Maine Telemedicine Services' efforts from its beginning. She says MTS has always been successful in receiving funding for their projects. "Money is always tight and grants are competitive," she says. "But we believe this is a worthwhile project and hope others will see that, too."
The story demonstrates precisely what Emerson, the executive director of Maine Telemedicine Services, says is the benefit of telemedicine: It allows patients access to care no matter where they live. Introduced in Maine in 1997, the technology has been growing steadily; MTS has helped its partners develop approximately 280 videoconferencing sites statewide. That means, according to Emerson, that 300-500 patients across Maine are using telemedicine on a monthly basis to communicate with doctors, psychiatrists and social workers. Emerson attributes the growth at least in part to Maine's rural nature. "Medical access is an issue and geographical barriers can often be broken down using telemedicine," he says. "The system allows for greater access and continuity of care."
Organizations such as MTS, which is a division of the Healthways/Regional Medical Care Center at Lubec, hope telemedicine use will continue to spread. However, the ability to sustain grants and funding for telemedicine has proved difficult over the years. In order to make telemedicine programs financially viable, Emerson is actively exploring new ways to use the technology, including a brand-new telepharmacy system for which MTS received funding this month.
While residents in rural areas have been receptive to telemedicine, Emerson says that the program is still in its early stages. To get the most out of the technology, as well as a return on their investment, organizations need to use the teleconferencing system in a multipurpose fashion, he says. "Telemedicine doesn't have to be used solely for clinical purposes. Many have used it successfully to provide educational programs and social services as well."
Expanding the ways in which telemedicine is used has been a hallmark of MTS' operations. In 2002, the organization was awarded a $250,000 grant from the Office for the Advancement of Telehealth in Washington, D.C. to bring the technology to rural nursing homes. While the system has benefited elderly patients from a clinical and educational standpoint over the past three years, Emerson has concerns about the program's sustainability. "Medicare won't pay for telemedicine when a patient is in a nursing home," he says. "We're trying to get the data together to show that telemedicine is cost effective. When the grant money runs out, we'll need Medicare's support to continue the program."
Emerson is not alone in facing this challenge; sustaining funding for telemedicine programs is an ongoing challenge for many nonprofit health care organizations in Maine. Gary DeLong, executive director of the Maine Seacoast Mission ˆ a Bar Harbor nonprofit that provides telemedicine to Frenchboro, Matinicus, Isle au Haut and Swans islands through its Sunbeam Island Health Services program ˆ says his organization has been able to sustain its telemedicine program using its own operating revenues and donor support. While the program has successfully connected patients and providers, DeLong says the mission will need to become more formally engaged in the health care system if it chooses to expand its program.
DeLong explains that hospitals, for example, are reimbursed for telemedicine services, but that the rate barely covers their costs. For this reason, he says, Maine Seacoast Mission has never asked for its share of reimbursement. DeLong says the nonprofit would have to apply to become a Federally Qualified Healthcare Clinic to receive a reimbursement rate that's higher than what is currently offered. While this seems a plausible solution, DeLong worries that becoming a FQHC could require patients to change their current providers. "We'd only move forward if the end result would be a positive one for islanders," he says. (For more on MSM, see "On the high seas," this page.)
A rural solution
While the ability to sustain telemedicine services remains an uphill battle, MTS and its members are determined to find ways to increase access to health care in rural areas. For now, Emerson says his challenge is to make organizations aware of what telemedicine can offer in order to expand their mission cost-effectively.
MTS has its roots in the Down East Telemedicine Network, for which it was in 1997 awarded $1.1 million from the Office for Advancement of Telehealth, a division of the U.S. Department of Health and Human Services, to connect Downeast health care centers via teleconferencing to hospitals in Maine's larger towns and cities. Since then, MTS' network has grown to include nearly 100 members throughout the state.
One of those members is Kno-Wal-Lin Home Care and Hospice in Rockland, which serves patients in Knox, Waldo and Lincoln counties. According to Bambi Kay, the organization's clinical services manager, KWL is the first home care agency in the midcoast to use telemedicine, having launched the service in June. She says the agency decided to try using videoconferencing units to improve case management of chronic care patients. "We believed the units would allow patients to get in the mode of caring for themselves," she says.
To get the program started, KWL needed to find funding for 10 videoconferencing units, each costing $4,000-$6,000. According to Kay, the units were paid for through a loan from the agency's affiliate hospital, the Penobscot Bay Medical Center in Rockport, which she says regarded the program as a sound investment in the community.
At the start, Kay and her colleagues decided to target cardiac and congestive heart failure patients, as studies showed these patients had the highest hospital readmission rate. "Hospitals don't receive reimbursement from Medicare for second admissions, and we believed offering care and learning through videoconferencing would be in the best interest of the patient," she says.
Once a patient signs up to participate in the program, a nurse will visit to be sure the patient or her caregivers are able to manage the equipment, which consists of a computer monitor and camera that connects to a patient's telephone line. The nurse downloads all of the patient's medical information to a data chip that is placed inside the monitor. This way, the agency can connect to the patient's records at any time. Kay says everything connected to the unit is individualized to meet the patient's needs, so a blood pressure cuff, thermometer, scale or glucose monitor may be added if necessary. The unit also provides daily reminders to patients to self-monitor, whether it's their heartbeat or weight. The patients send their daily results to the agency's server after each reminder.
Kay says the advantage of the unit is that it teaches patients and their families what to monitor and what signs to look for before calling a physician. "After they get over the learning curve, patients don't want to let it go," she says. "The downside is that after a 60-day period, we don't get reimbursed by Medicare or private insurance."
Still, Kay maintains that the program's benefits far outweigh the insurance problems. "Not only are the units a great teaching tool, but they also help to improve our market share," she says, adding that the addition of telemedicine makes her agency stand out among its competitors. In fact, KWL has decided to purchase 25 more units in the fall. Kay says the agency applied for a Federal Rural Health Grant last spring to fund the purchase, and hopes to receive approval this month.
Strength in diversity
Once organizations like KWL receive a grant, it's important that they look for a variety of ways to use the unit, says Emerson. He cites the Bath-based Pine Tree Society, a nonprofit that provides service programs to people with disabilities, as a partner that has done just that.
When the Pine Tree Society started its telemedicine program in February 2002, it used the technology to provide hospitalized deaf patients with around-the-clock interpretive services. The organization first used the system solely for situations in which patients required immediate medical attention. "When we began, people thought it would only be used for emergency purposes, but many rural hospitals may not have interpretive services at all," says Doug Newton, who runs the interpreting services program at PTS' branch office in Scarborough.
In its pilot year, 12 state hospitals signed up to participate in the program, which was funded by a three-year Technology Opportunities Program grant for $579,000 from the U.S. Department of Commerce. (Additional financial assistance was provided by the Maine Health Access Foundation in Augusta.)
Along the way, the Pine Tree Society received feedback from interpreters, medical staff and focus groups in the deaf community. Newton says these comments helped PTS expand its program, adding state agencies, medical centers and social service organizations to its list of partners. The Pine Tree Society provided the organizations with training and access to the units, so that interpretive services could be provided for medical, educational or psychiatric care. And in all cases, a deaf patient ˆ or his or her provider ˆ is able to connect to an on-call interpreter at PTS via the unit at any time.
In the future, Newton hopes hospitals will consider adding videoconferencing units to every patient's room, although he says doing so would require high-speed digital telephone lines throughout the facility. "That's where the challenge comes into play," he says. "There's only so much money people can spend on technology, but for programs like these to succeed, we have to be careful not to eliminate the possibilities."
It's forward thinking like Newton's that Ron Emerson hopes will positively affect telemedicine's sustainability ˆ and growth ˆ in Maine. In fact, he believes the technology has the ability to go even further. This month, MTS and the Regional Medical Center at Lubec were awarded a two-year, $200,000 grant from MeHAF to pursue the first telepharmacy program in the state, which would allow drugs to be prescribed and distributed to patients in rural areas who don't have convenient access to a pharmacy.
According to Emerson, the telepharmacy unit is similar to a vending machine for candy, although in this case, it utilizes a high-speed phone line to connect to a participating pharmacy. The machine itself, which Emerson says costs approximately $55,000, is stocked with pre-poured medicines, such as antibiotics or anti-inflammatories for acute illnesses, prepared by the pharmacist. The first unit will be located in RMCL' s health clinic. Once a patient is prescribed a medication through his or doctor, the prescription is faxed to the pharmacist, who connects to the unit at RMCL via computer. The unit prints out a bar code for verification and dispenses the prescription. And if the patient has questions, he or she is able to talk to the pharmacist by means of videoconferencing.
While the idea of a vending machine distributing medicine may seem risky, Emerson says the well-regulated system has been used with great success in Washington, D.C. area hospitals. And if all goes well with this pilot program, MTS and RMCL hope to add other telepharmacy sites throughout the state.
As for the issue of sustaining funding, the nonprofit remains confident. Carol Carew, CEO of RMCL, has been involved in Maine Telemedicine Services' efforts from its beginning. She says MTS has always been successful in receiving funding for their projects. "Money is always tight and grants are competitive," she says. "But we believe this is a worthwhile project and hope others will see that, too."
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