Case Studies in Telehealth Adoption
January 2013
Scaling Telehealth Programs:
Lessons from Early Adopters
Andrew Broderick and David Lindeman
ABSTRACT: Remote patient monitoring (RPM)—like home teleheath and telemonitor-
Fund is to promote a high performance
ing—can help improve coordination, improve patients’ experience of care, and reduce hos-
health care system. The Fund carries
pital admissions and costs. Such technologies remotely collect, track, and transmit health
out this mandate by supporting
data from a patient’s home to a health care provider and can facilitate communication and
independent research on health care
issues and making grants to improve
help engage patients in the management of their own care. This synthesis brief offers find-
health care practice and policy. Support
ings from case studies of three early RPM adopters: the Veterans Health Administration,
for this research was provided by
Partners HealthCare, and Centura Health at Home. Each of the programs started as a pilot
The Commonwealth Fund. The views
with the support of a small group of advocates who believed in the technology’s poten-
presented here are those of the authors
tial for offering improved care for a targeted population. Early lessons include promoting
and not necessarily those of The
a culture of openness and preparedness; using a multidisciplinary team-based approach;
Commonwealth Fund or its directors,
officers, or staff.
establishing leadership support; minimizing barriers to patient enrollment, like cost; and
including nonstandard measures, like patient experience and staff satisfaction, in program
evaluations.
For more information about this study,
OVERVIEW
please contact:
A lack of systematic care coordination contributes to a high prevalence of pre-
Andrew Broderick, M.A., M.B.A.
ventable rehospitalizations in the Medicare population. As the U.S. health care
Codirector, Center for Innovation
and Technology in Public Health
system looks to achieve the goals of the Institute for Healthcare Improvement’s
Public Health Institute
Triple Aim—improving patients’ experience of care, improving the health of popu-
lations, and reducing the cost of health care—providers increasingly acknowledge
that patient-centered technologies can contribute toward the realization of those
goals. However, providers for the most part have little experience with such
technologies.
To learn more about new publications
when they become available, visit the
Health care reforms provide an opportunity to replace current fragmented
and poorly coordinated care delivery practices with a more integrated model of
care, supported by the use of technology-enabled innovations. While their imple-
Commonwealth Fund pub. 1654
Vol. 1
mentation into care practices can be disruptive to workflow and result in process
2
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changes in the basic delivery of care, experience
Each of the programs described in this series
indicates that their diffusion can lead to significant
of case studies started as a pilot with the support and
improvements in the quality and cost of care and trans-
promotion of a small group of advocates who believed
form the performance of care delivery on key outcome
in the technology’s potential and capacity for offering
measures such as preventable readmissions.
improved care for a targeted population. Evidence of
each program’s positive impact reinforced that belief
Using Remote Patient Monitoring to
and strengthened the case for expansion throughout the
Improve Patients’ Outcomes and
organizations. While each organization’s approach to
Experiences
the design and implementation has varied, their collective
This brief offers a synthesis of findings from case stud-
experience offers other organizations best practices for
ies of three early adopter organizations that use remote
implementing telehealth-enabled care programs at scale.
patient monitoring (RPM). RPM—also referred to as
home telehealth, telehomecare, and telemonitoring—
Early Lessons from Teleheath Adopters
can help resolve critical challenges in care coordina-
The experiences of the three organizations offer con-
tion. RPM technologies can remotely collect, track,
siderations for organizations planning to design, imple-
and transmit patient health data from a patient’s home
ment, and scale telehealth programs for target popula-
(or other care setting) to a health care provider or case
tions within their health systems:
manager in a different location. RPM can facilitate
•
Telehealth-enabled programs disrupt the status
interaction and communication between the patient and
quo. Telehealth requires a different mind-set to
caregiver and can help to activate and engage patients
achieve desired changes in practice and targeted
in the management of their own care.
outcomes. An organization’s ability to promote a
Specific outcomes of RPM include reduc-
culture of openness, preparedness, and adaptive-
ing hospitalizations and health care costs; improving
ness to technology-led change will increase the
patient knowledge, satisfaction, and clinical outcomes;
likelihood that the implementation will succeed.
and activating patients to better manage their own
•
Program development involves a multidis-
health and care. However, despite the potential broad-
ciplinary, team-based approach. Telehealth
based benefits, their use is still in the early stages of
requires the integration of technical, clinical,
adoption for most providers.
and business processes into a standard program.
The three organizations studied in this series—
Telehealth programs tend to specialize in providing
the Veterans Health Administration (VHA), Partners
the technology expertise, wraparound support and
HealthCare, and Centura Health at Home—have suc-
training, and equipment installation, while home
cessfully implemented telehealth programs for target
care and other care partners provide the clinical
populations within their systems. The telehealth-
expertise for successfully designing and imple-
enabled interventions deployed by these organizations
menting the technology for use in care.
rely at their core on the use of remote monitoring
devices in the homes of patients to capture and trans-
•
Technology implementation is a social process.
mit biometric data and communicate health status to
Technology-enabled solutions in health care are
a remote care team who continuously review the data
very much social in nature. Establishing leadership
and coordinate care accordingly. These programs can
support and identifying program champions are the
help realize improved financial and clinical outcomes
core foundations for a successful program, while
by facilitating behavior change and by staging timely,
patient activation and engagement have been key
interactive care interventions to prevent unnecessary
to successful program outcomes.
hospital admissions or emergency department visits.
Scaling Telehealth Programs: Lessons from Early Adopters
3
•
Barriers to patient participation need to be low.
and improvement in care quality and reduced cost or
To minimize any potential barriers to maximizing
responses to health care and payment reforms.
enrollment, patient participation should be at no
Each program has sought to enhance patient
or little financial cost and enrollment should be
activation and engagement in care, as well as the
automatic for all eligible patients. The VHA has
remote monitoring of data for the early detection of
recently announced that it will waive copayments
complications. These shared program features are
for patients receiving its telehealth services.
fundamental to facilitating behavior change and ensur-
ing timely, interactive care interventions that prevent
•
Telehealth data can empower all stakehold-
unnecessary hospitalizations. In all organizations,
ers. Telehealth data can have a positive impact on
organizational culture, human factors, and social pro-
patient care when placed in the hands of motivated
cesses that promote support from executive leadership,
clinicians and patients. The real-time transmission
clinical staff, and patients and their families have been
of monitoring data, for example, allows nurses to
key elements to ensure the realization of successful
provide patients with just-in-time care and educa-
program outcomes.
tion. The use of personal health data can help edu-
cate and motivate patients to make necessary life-
Veterans Health Administration: Taking
style changes and realize better clinical outcomes.
Home Telehealth to Scale Nationally
•
Program evaluations need to incorporate non-
standard measures. Program evaluations need to
notable example of a home telehealth service taken
recognize the importance of nonstandard measures
to scale. The VHA piloted, evaluated, and deployed
and the role they contribute to improved clinical
home telehealth in a continuing process of learning
and financial outcomes. These may include patient
and improvement, and found that an enterprise-wide
experience and staff satisfaction, for instance.
implementation can be achieved and can lead to cost-
•
Successful programs can take time to scale suc-
effective, quality outcomes for chronic care patients.
cessfully. It takes time to integrate technology into
The organization’s Care Coordination/Home Telehealth
care delivery and to allow staff to adapt. Structure,
(CCHT) program uses Group Health’s Chronic Care
coordination, planning, and setting goals and
Model as a framework, with the patient’s home the pre-
expectations are critical. Aligning program goals
ferred site of care wherever possible and appropriate.
with broader organizational strategic initiatives to
Promoting patient activation and self-management has
improve performance and deliver more account-
been key to CCHT’s success in preventing unnecessary
able care can facilitate progress.
hospital admissions or emergency department visits.
First introduced in 2003, CCHT is now a
LEARNING FROM THE VETERANS HEALTH
routine service that uses home telehealth and disease
ADMINISTRATION, PARTNERS HEALTHCARE,
management technologies in the remote care manage-
AND CENTURA HEALTH AT HOME
ment of chronically ill patients at risk for long-term
Each organization has established practices for scal-
institutional care. CCHT has demonstrated successful
ing telehealth based on its needs and objectives. The
outcomes including patient satisfaction and reduc-
strategic objectives used by these organizations to
tions in bed days of care and hospital admissions.
guide the introduction of telehealth programs into
Through the end of fiscal year 2010, veterans reported
practice are often in alignment with larger strategic
patient satisfaction levels greater than 85 percent for
initiatives. These may include performance improve-
home telehealth services offered through CCHT, and
ment initiatives that seek to achieve clinical excellence
reductions in bed days of care in excess of 40 percent
on preenrollment figures for the CCHT population
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receiving home telehealth. The reduction in health care
on an enterprise scale. With more than 70,000 patients
resource utilization (defined as hospital days of stay)
receiving telehealth-supported care management in
from 2004 to 2007 is significant across eight primary
2012, the VHA’s experience demonstrates that imple-
conditions for patients monitored for either single or
mentation at scale is possible and can yield substantial
multiple diagnoses (Exhibit 1).
returns. Some of the VHA’s keys to success include:
The VHA’s national telehealth program has
•
Aligning telehealth strategy with organizational
been developed through strong leadership support,
vision and mission. The VHA’s success with
articulation of a strategic vision and compelling
telehealth is evidence of the organization’s ability
business case, and an underlying health information
to connect vision, strategy, and technology in the
technology infrastructure. Coupled with a strong com-
delivery of continuous, coordinated chronic care
mitment to standardized work processes, policies, and
for targeted populations at risk for long-term insti-
training, the program has transformed care coordina-
tutional care. The experience serves as a strategic
tion to successfully meet the chronic care needs of an
and operational blueprint for other organizations
aging veteran population while reducing their utiliza-
looking to implement telehealth at scale.
tion of and costs associated with institutional care.
•
Leveraging underlying human and social pro-
Other integrated delivery networks or government-
cesses. The VHA has instilled an organizational
sponsored systems can benefit most from VHA’s
culture and capacity for technology-led change.
lessons learned. From the perspective of patient care
This has resulted in the telehealth program being
coordination, the lessons may be most applicable to the
embraced by the national and local leadership, as
Medicare-Medicaid dual-eligible population.
well as by the population it is designed to serve.
The VHA attributes the rapidity and robustness
The staff that originally started the program has
of its CCHT implementation to the systems approach
since advanced to more senior positions through-
taken to integrate the clinical, technology, and business
out the organization, effectively becoming champi-
elements of the program based on experience gained
ons for the program.
from piloting. For example, CCHT incorporated exist-
ing business processes wherever possible to reduce
•
Generating systematic evidence of targeted out-
the program’s overhead costs and increase efficiency
comes. Targeted outcomes have been maintained
Exhibit 1. VHA Care Coordination/Home Telehealth Program Outcomes, 2004-07
Percent decrease
Condition
Number of patients
in utilization
Diabetes
8,954
20.4%
Hypertension
7,447
30.3
Congestive heart failure
4,089
25.9
Chronic obstructive pulmonary disease
1,963
20.7
Post-traumatic stress disorder
129
45.1
Depression
337
56.4
Other mental health
653
40.9
Single condition
10,885
24.8
Multiple conditions
6,140
26.0
Source: A. Darkins, P. Ryan, R. Kobb et al., “Care Coordination/Home Telehealth: The Sytematic Implementation of Health Informatics, Home Telehealth, and Disease
Management to Support the Care of Veteran Patients with Chronic Conditions,” Telemedicine and e-Health, Dec. 2008 14(10):1118-26.
Scaling Telehealth Programs: Lessons from Early Adopters
5
as the program has been taken to scale. As the
Partners HealthCare: Connecting Heart
program has grown, the evidence has reinforced
Failure Patients Through RPM
the benefits to patients and has made a strong clini-
cal and business case that facilitates buy-in from
in Boston. Partners’ programs in home telehealth
clinicians and managers. The dissemination of
have been driven in large part by the Center for
findings broadly throughout the system has rein-
Connected Health (CCH), Partners’ research center
forced the continuous cycle of learning within the
for the development, testing, and implementation of
organization.
patient-centered technology solutions for health care
delivery. Being one of only a handful of research cen-
•
Standardizing core program elements. With
ters of its type in the world, CCH plays a unique role
systemized clinical, technology, and business pro-
in the integrated delivery system’s development of
cesses, as well as national policies and operational
technology-enabled approaches to delivering quality,
procedures for contracting with vendors and a ded-
cost-effective, patient-centered care. The Connected
icated program office and training center, CCHT
Cardiac Care Program (CCCP), which provides home
care is consistent across time and place throughout
telemonitoring and education for heart failure patients,
the VHA system.
is among a number of CCH programs that have been
•
Balancing system with local needs. Successful
successfully piloted at Partners and scaled across the
implementation of the program has relied on the
network.
VHA’s ability to balance top-down guidance on
A 2006 pilot study of CCCP with 150 heart
standardizing approaches to clinical protocols,
failure patients showed reductions in heart failure-
workforce training, and business processes with
related and all-cause readmissions as well as in emer-
bottom-up innovation to meet the needs of patients
gency room visits. While these results were not statisti-
at the local level.
cally significant, they provided evidence to Partners’
•
Investing in an enabling technology infrastruc-
leadership that led to its support for the expansion of
ture. The enterprise-wide health information
CCCP. Additional benefits included a reduction in the
technology infrastructure and use of algorithms to
need for nurse visits for patients receiving skilled nurs-
match patients with appropriate telehealth tech-
ing care from a home care provider, and participants’
nology have contributed to the consistency in the
high satisfaction levels and greater confidence to self-
systemwide implementation of home telehealth.
manage diseases. To date, more than 1,200 patients
Although beneficial to the program, they are
have been enrolled in CCCP. The program has consis-
not necessarily required for a program to work
tently experienced an approximate 50 percent reduction
successfully.
in heart failure-related readmission rates for enrolled
patients. Non-heart failure readmissions have declined
•
Dedicating resources to staff training and devel-
by 44 percent. CCH’s in-house analysis estimates that
opment. Establishing a national training center to
the program has generated total cost savings of more
deliver online training programs has ensured a tele-
than $10 million since 2006 for the more than 1,200
health-competent workforce to deliver efficient and
enrolled patients (Exhibit 2).
effective care at scale. Program staff and graduates
In Partners’ experience, the role of human
of the training program have been critical in help-
factors and social processes in supporting technology
ing solve programmatic issues at the local level
deployment has been as important as the technology
and in serving as ambassadors for promoting the
itself in ensuring the successful introduction of con-
program throughout the organization.
nected health solutions into workflow and patient
care. The impact that the technology has on patient
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Exhibit 2. Partners HealthCare’s Connected Cardiac Care Program and
Reducing Preventable Readmissions
CCCP outcomes
•
51% reduction in heart failure hospital readmissions*
•
44% reduction in non-heart failure hospital readmissions*
• Improved patient understanding of heart failure and self-management skills
• High levels of clinician and patient acceptability and satisfaction
Savings**
A case study prepared by CCH reports the following cost savings to date from CCCP:
• Cost of CCCP: $1,500 per patient
• Total savings from reduction in hospitalizations: $9,655 per patient
• Total net savings: $8,155 per patient
• Total savings: $10,316,075 for 1,265 monitored patients since 2006
* N=332
** This program targeted reductions in unplanned heart failure and non-heart failure related admissions. The savings achieved factor in the cost of running the program,
including marketing, referral management, telemonitoring nurse support, and technology.
Source: CCH analysis provided to the author.
activation and engagement in self-care and the subse-
process, patients who have been identified as eligi-
quent role it plays in demonstrating evidence to provid-
ble for participation are automatically enrolled and
ers has been key to Partners’ success. These outcomes
clinicians are now responsible for notifying CCCP
are critical evidence in demonstrating to providers that
if a patient wishes to not be enrolled. This has
such programs can support behavior changes that lead
resulted in an increase in the number of enrollees
to improved health and quality of care.
in CCCP. Satisfaction levels among doctors have
Strategic initiatives aligning the Partners orga-
increased as benefits in patient care have become
nization with external forces that are shaping the future
evident.
of health care organization, financing, and delivery
•
Activating and engaging patients in self-care
have served as important levers for more widespread
through technology. Technology has a positive
use of connected health solutions in patient care.
impact on patient engagement and motivation once
Factors that have been critical to Partners’ success in
it is placed in patients’ hands. The evidence that the
implementing CCCP at scale include: the importance
program can and does support behavior changes
of leadership support for and the championing of the
that lead to improved care and quality outcomes
telehealth program, the integration of patient data
has contributed to the program’s overall success.
into workflow to enable providers to more effectively
Through technology, patients have felt more con-
assess patient status and provide just-in-time care
nected to their care team.
and education, and the use of personal health data to
•
Using data to motivate and empower clinicians
help educate and motivate patients to make necessary
and patients. Teaching patients self-management
lifestyle changes and realize better clinical outcomes.
skills can help drive a reduction in readmissions.
Additional success factors include:
Participants receive constant feedback about how
•
Enrolling patients on an opt-out basis. The initial
lifestyle factors affect health outcomes, as well as
enrollment approach required that clinicians refer
just-in-time care in which remote monitoring and
patients to the program. This resulted in low lev-
intervention by nurses sends strong messages to
els of clinician engagement. Through the opt-out
patients that they are accountable.
Scaling Telehealth Programs: Lessons from Early Adopters
7
Centura Health at Home: Making Home
and case loads of nursing staff, and cost savings of
Telehealth the Standard of Care
between $1,000 and $1,500 of total costs per patient.
Centura’s experience indicates that restructuring
Centura Health, the largest integrated health care
home service coordination and educating clinical call
system in Colorado. CHAH expands the reach and
center nurses on chronic disease management are key
impact of telehealth-enabled home health care services
elements to the program’s success. The scaling of the
through the integration of two independent, success-
program led to a decision to switch telehealth vendors
ful home health services: a clinical call center and
to more cost-effectively support the program while
remote monitoring telehealth program. The integrated
meeting the broader patient population’s needs. The
program combines RPM efforts that started in 2004
program’s success has led to telehealth becoming the
with a clinical call center-based program that has
standard of care at CHAH. The results of the program
been in existence for more than 20 years. The merged
supported the sustainability of the intervention and
clinical call center-telehealth program extends the
led to plans to expand the telehealth program within
reach of telehealth to include all patients in the target
CHAH and to senior living communities with the goal
populations who are preparing for hospital discharge.
of reaching 1,000 patients by 2012 and 2,000 patients
The merged program also broadens the clinical call
by 2013.
center’s capabilities to include telehealth assistance
Centura’s experience indicates that the use
and coordination of care for patients by using remote
of RPM combined with a 24/7 telehealth clinical call
patient monitoring on a 24/7 basis, while adapting the
center benefited older adults’ health while making
clinical call center’s traditional business marketing
more effective use of existing health care resources and
model to a clinical business model to support a more
extending the reach of nursing staff. Key elements of
robust telehealth program. The new program expands
the program’s success included: restructuring discharge
service coverage to patients not previously meeting the
planning to introduce patients to the telehealth program
Medicare homebound benefit by offering a telephonic
while still in the hospital, having clinicians introduce
telehealth-only treatment group.
the program to patients to increase the likelihood of
A one-year pilot of the integrated program in
their enrollment, educating call center nurses on the
2010-2011 demonstrated successful outcomes in terms
clinical management of chronic diseases, and providing
of reducing 30-day hospital readmissions and home
real-time education to patients to improve their self-
nursing visits, while improving quality of life and
management capabilities. Additional success factors
patient self-management and education. The specific
for bringing the program to scale include:
goal of the pilot was to decrease the 30-day readmis-
•
Engaging staff through evidence-based outreach
sion rates across the Centura system by an additional
and promotion. Programs need to communicate to
2 percent for patients with congestive heart failure,
home care nurses and clinicians the value of tele-
chronic obstructive pulmonary disease, and/or diabetes,
health for patients, nurses, and physicians to reduce
as well as measurably increase participants’ quality
the likelihood of resistance and ensure high levels
of life. Over the course of the year-long pilot, 30-day
of staff engagement. Forums may include an open
readmission rates across the three targeted conditions
house for clinicians to interact with the technology
were reduced by 62 percent. Emergency department
and ask questions. Key discussion points focus on
use decreased from 283 visits in the prior year to 21
outcomes, patient-to-staff ratios, and rehospitaliza-
visits after one year, and the frequency of home visits
tion rates, as well as patient satisfaction data.
was reduced to an average of three visits over a 60-day
period from an average of two or three visits per week
•
Restructuring discharge planning and home
prior to the implementation of the intervention (Exhibit 3).
service coordination. The discharge planning
This led to improved efficiency, extending the capacity
process and home service coordination were
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Exhibit 3. The Impact of Integrated Telehealth on 30-Day Readmission Rates at
Centura Health at Home
Pre-project
Post-intervention readmission
Facility and condition:
readmission rates
rates achieved*
St. Anthony’s Central
• Congestive heart failure
13.8%
4.2%
• Chronic obstructive pulmonary disease
14.1%
6.7%
• Diabetes
14.7%
0.0%
Porter Adventist Hospital
• Congestive heart failure
17.7%
9.5%
• Chronic obstructive pulmonary disease
12.5%
2.7%
• Diabetes
9.5%
0.0%
* About one-quarter of the 200 patients used telephonic telehealth, while the majority used remote patient monitoring and had access to the clinical call center.
Source: Data provided by Centura Health at Home, reporting outcomes to the Center for Technology and Aging.
restructured in the hospital to incorporate tele-
during their hospital stay required additional train-
health-based care. Case managers have been
ing for effective communication techniques to
trained to identify patient eligibility and enrollment
emphasize the value of the program to patients.
criteria for patients being discharged without home
Clinical call center nurses also benefited from
care. Introduction to the telehealth intervention
effective communication training as well as disease
takes place before discharge. Within 48 hours of
management education to bolster confidence in
patient discharge, a personalized telehealth algo-
clinical decision-making processes to actively man-
rithm is created for RPM patients, and telehealth
age patients in response to issues raised during calls.
technicians install and train patients to use the
•
Selecting technology that scales with the pro-
device within their homes.
gram and its needs. As a result of increasing the
•
Introducing patients to the program through a
volume of patients served through the integrated
trusted clinician. Introducing the program during
telehealth program, CHAH made a decision to
the hospital stay by a home care nurse or physician
change vendors to support more cost-effective
or by a primary care physician during a scheduled
scaling of the program while meeting the broader
office visit after discharge increased the likelihood
patient population’s needs. The new platform
that a patient would enroll in the telehealth program.
offers the ability to monitor only those patients
who fall outside established parameters, thereby
•
Providing staff training on effective commu-
placing the emphasis on those patients needing
nication techniques. Home service coordination
immediate attention.
nurses who introduced patients to the program
The organizations profiled in our Case Studies in Telehealth Adoption series include the Veterans Health
Care Program, and Centura Health’s
Centura Health at Home program. To read the profiles, visit our website at
Scaling Telehealth Programs: Lessons from Early Adopters
9
About the Authors
Andrew Broderick, M.A., M.B.A., is codirector, Center for Innovation and Technology in Public Health, at the
Public Health Institute. Mr. Broderick’s research focuses on the adoption and appropriate use of technology to
address vital and pressing challenges in public health, including efforts to enhance linkages between the public
health and health care delivery systems. Mr. Broderick previously managed research activity at HealthTech, including
work in cardiovascular disease, remote health services, and technologies for independent living. Mr. Broderick
holds a master of arts in economics and geography from Trinity College, in Dublin, Ireland, and a master of
business administration from San Francisco State University. He can be emailed at abroderick@phi.org .
David Lindeman, Ph.D., is director, Center for Aging and Technology, and codirector, Center for Innovation and
Technology in Public Health, at the Public Health Institute. He has worked in the field of aging and long-term
care for more than 30 years as a health services researcher and administrator, focusing on health care technology,
dementia, community-based and residential services, safety-net populations, and long-term care public policy.
He previously served as the founder and director of the Mather LifeWays Institute on Aging; associate profes-
sor of Health Policy at the Rush Institute for Healthy Aging, Rush University Medical Center; and codirector of
the University of California, Davis, Northern California Alzheimer’s Disease Center. Dr. Lindeman received his
Ph.D. and M.S.W. from the University of California, Berkeley.
Editorial support was provided by Deborah Lorber.
These case studies were based on publicly available information and self-reported data provided by the case study institutions. The
Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case study
series is not an endorsement by the Fund for receipt of health care from the institution.
