A LeadingAge CAST Report

TELEHEALTH AND REMOTE

PATIENT MONITORING FOR LONG-TERM AND POST-ACUTE CARE

A Primer and Provider Selection Guide

2013

TELEHEALTH AND REMOTE PATIENT MONITORING FOR LONG-TERM AND POST-ACUTE CARE:

A Primer and Provider Selection Guide

2013

A program of LeadingAge

2519 Connecticut Ave., NW Washington, DC 20008-1520

Phone 202-508-9438

Fax 202-783-2255

Website: LeadingAge.org/CAST

© Copyright 2013 LeadingAge

LeadingAge Center for Aging Services Technologies:

The LeadingAge Center for Aging Services Technologies (CAST) is focused on development, evaluation and adoption of emerging technologies that will transform the aging experience. As an international coalition of more than 400 technology companies, aging-services organizations, businesses, research universities and government representatives, CAST works under the auspices of LeadingAge, an association of 6,000 not-for-profit organizations dedicated to expanding the world of possibilities for aging.

For more information, please visit LeadingAge.org/CAST

Table of ConTenTs

1 Purpose of Whitepaper and Executive Summary ...................................................................................... 1

1.1 Purpose of Whitepaper ......................................................................................................................... 1
1.2 Executive Summary ............................................................................................................................... 1
1.3 Disclaimer ............................................................................................................................................... 2

2 Definitions ...................................................................................................................................................... 2

2.1 Information and Communication Technology (ICT) Infrastructure ............................................. 2
2.2 Electronic Documentation Technologies ........................................................................................... 2
2.2.1 Electronic Health Record (EHR)............................................................................................... 2
2.2.2 Electronic Medical Record (EMR) ............................................................................................ 2
2.2.3 Personal Health Records (PHR) ................................................................................................ 2
2.2.4 Health Information Technology (HIT) .................................................................................... 3
2.2.5 Electronic Point of Care (POC)/Point of Service (POS) Documentation Systems ............ 3
2.3 Safety Technologies................................................................................................................................ 3
2.4 Health and Wellness Technologies ...................................................................................................... 4
2.4.1 Telehealth, Remote Patient Monitoring (RPM) and Telemedicine....................................... 4
2.4.2 Telecare/Telemonitoring/Behavioral Monitoring capabilities............................................... 5
2.5 Clinical Decision Support Systems...................................................................................................... 5
2.6 Social Connectedness Technologies .................................................................................................... 6

3 Vision of Technology-Enabled Care and Continuum of Monitoring ......................................................... 6

3.1 Vision for Technology-Enabled Care .................................................................................................. 6
3.2 Continuum of Monitoring Technologies and their Value ................................................................ 9
3.2.1 Safety Monitoring Technologies ................................................................................................ 9
3.2.2 Health and Wellness Monitoring Technologies....................................................................... 9
3.2.3 Scope and Focus .......................................................................................................................... 9

4 Potential Uses of Telehealth and RPM....................................................................................................... 10

4.1 Patient Education and Self-Management ......................................................................................... 10
4.2 Pre- and Post-Acute Management of Chronic Conditions ............................................................ 10
4.3 Post-Acute Patient Stabilization......................................................................................................... 11
4.4 Long-Distance Routine Check-Ups/Treatment ............................................................................... 11
4.5 Specific Teleconsult.............................................................................................................................. 11

5 Benefits of Telehealth and RPM ................................................................................................................. 12

5.1 Health Outcomes/Improved Management....................................................................................... 12
5.2 Reduction in Hospitalizations and Hospital Readmissions ........................................................... 12
5.3 Patient Self-Efficacy, Quality of Life and Satisfaction ..................................................................... 13
5.4 Physician Engagement Key to Success .............................................................................................. 14
5.5 Caregivers’ Workload and Efficiencies .............................................................................................. 15
5.6 Reduced Risk and Liability ................................................................................................................. 15

6 Potential LTPAC Provider Business Models .............................................................................................. 16

6.1 Medicare Coverage .............................................................................................................................. 16
6.1.1 Medicare Reimbursement of Home Telehealth ..................................................................... 16
6.2 Medicaid Coverage .............................................................................................................................. 17
6.3 Private Health Insurance Coverage ................................................................................................... 18
6.4 Medicaid Waiver Coverage ................................................................................................................. 19
6.5 Potential Affordable Care Act (ACA) Related Opportunities........................................................ 19
6.6 Private Pay............................................................................................................................................. 20
6.7 Standard of Care and Other Payment Sources................................................................................. 20
6.8 Return on Investment (ROI) of Telehealth and RPM ..................................................................... 21
6.8.1 ROI to Patients and/or their Families ..................................................................................... 21
6.8.2 ROI to Payers ............................................................................................................................. 21
6.8.3 ROI to Care Provider ................................................................................................................ 22
6.8.4 Online ROI Calculator for RPM.............................................................................................. 23

7 Planning for Telehealth and RPM Solutions ............................................................................................. 24

7.1 Visioning and Strategic Planning ...................................................................................................... 24
7.2 Organizational Readiness Assessment .............................................................................................. 27
7.2.1 Staff Competencies .................................................................................................................... 28
7.2.2 IT Infrastructure ........................................................................................................................ 29
7.2.3 Operating Environment ........................................................................................................... 30
7.3 Operational Planning .......................................................................................................................... 30
7.3.1 Project Team............................................................................................................................... 30
7.3.2 Goal Setting ................................................................................................................................ 30
7.3.3 Program Design ......................................................................................................................... 31
7.4 Technology Review and Selection ..................................................................................................... 32

8 Telehealth and RPM Selection Matrix Components................................................................................. 32

9 Acknowledgement of Contributors............................................................................................................ 36

9.1 Contributing Writers ........................................................................................................................... 36
9.2 Workgroup Members .......................................................................................................................... 36
9.3 Participating Telehealth and RPM Vendors ..................................................................................... 37

10 References and Resources ......................................................................................................................... 38

11 The Telehealth and RPM Selection Matrix ................................................................................................ 42

1

1 PurPose of WhiTePaPer and exeCuTive summary

1.1 Purpose of Whitepaper

The purpose of this paper is to aid LeadingAge and CAST members, long-term and post-acute care (LTPAC) providers, and other aging services orga- nizations in understanding telehealth and remote patient monitoring (RPM) technologies, their uses and their benefits. The paper also includes a Selec- tion Matrix of a number of telehealth and RPM solutions that will help providers select solutions that best fit their requirements.
Case studies were collected highlighting provid- ers’ impacts and benefits of telehealth and RPM on health outcomes (blood pressure, blood glucose, etc.), staff efficiencies, quality of life/satisfaction with care, hospitalizations and hospital readmissions, and/or cost of care and return on investment (ROI) to providers, payers, and/or consumers. These case studies will be published separately approximately one month after the release of this paper.
This whitepaper is available in a PDF format as a living document with links. CAST plans to update the Telehealth and RPM Selection Matrix annually. Finally, the Telehealth and RPM Selection Matrix will be used to create CAST’s online Selection Tool to simplify and facilitate the process of selecting a telehealth and RPM solution for LTPAC providers; the online tool will be updated as needed.
This whitepaper and the companion Telehealth and RPM Selection Matrix, online Selection Tool and case studies, represent a continuation of CAST’s efforts to produce hands-on tools that help LTPAC providers adopt appropriate aging services tech- nologies that enable them to deliver innovative care
delivery models, position them well for strategic partnerships, meet the needs of older adults and prepare them for the future.

1.2 Executive Summary

This paper begins with definitions to help the reader understand the terms used throughout the whitepaper and then delves into the vision of technology-enabled care and the continuum
of monitoring. The whitepaper then provides an explanation of the potential uses of telehealth and RPM including patient education and self-manage- ment, pre- and post-acute management of chronic conditions, post-acute patient stabilization, long- distance routine check-ups/treatment and specific teleconsults.
A review of evidence of the benefits of telehealth
and RPM, including improved health outcomes and reduction in hospitalizations and hospital readmis- sions, is provided in section 5. Potential LTPAC provider business models including Medicare, Medicaid, Medicaid Waiver, and private insurance coverage are explained in section 6. In addition, this section provides an overview of potential Afford- able Care Act (ACA)-related opportunities. Finally, this section concludes with a discussion about
return on investment (ROI) for telehealth and RPM
and provides a link to an online ROI calculator.
Section 7 reviews the planning process for tele- health and RPM solutions to help organizations prepare through visioning and strategic planning, looking at organizational readiness, operational planning, and technology review and selection.
The whitepaper concludes with a description of the components of the Telehealth and RPM Selection

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Matrix, which is included in section 8. Informa- tion from the Telehealth and RPM Selection Matrix will be available as an online Telehealth and RPM Selection Tool to help LTPAC organizations narrow their selections to a manageable list of products that meet their business line, care applicability needs
and essential requirements, based on their answers to key questions.

1.3 Disclaimer

The information included in this paper is meant to assist care providers in the understanding and selection of telehealth and remote patient monitor- ing (RPM) solutions, but cannot possibly include all systems that may be available. Products mentioned in this paper serve as illustrative examples. Infor- mation about the functionalities and capabilities for this effort were provided by participating vendors
of telehealth and RPM solutions. A few telehealth and RPM vendors chose not to participate. Func- tionalities and capabilities of listed telehealth and RPM products have not been verified, tested, in- dependently evaluated or endorsed by LeadingAge or LeadingAge CAST. Please use this as general guidelines in understanding functionalities and examples of current telehealth and RPM systems. The Telehealth and RPM Selection Matrix may help providers identify potential telehealth and RPM solutions that may meet their requirements, and
is intended to help them target vendors to submit a Request for Proposal (RFP). Where appropriate, provider case studies were identified and published separately. However, providers are strongly advised to verify functionalities of the telehealth and RPM solutions prior to final selection through demon- strations, site visits, reference checking and other due diligence steps.

2 definiTions

2.1 Information and Communication

Technology (ICT) Infrastructure

Information and Communication Technology (ICT) Infrastructure includes high-speed Internet connectivity, wired/wireless networks (switches, routers, repeaters), servers, laptop/desktop comput- ers, cloud-based information systems, mobile com- munications device, etc.

2.2 Electronic Documentation

Technologies

Electronic documentation technologies are mainly aimed at health care professionals and professional caregivers such as electronic health records (EHR), point of care (POC), point of services (POS) sys- tems, electronic prescribing (ePrescribing), elec- tronic medication administration records (eMAR), electronic charting and electronic workflow and documentation systems. Some EHR systems offer the individual and/or an authorized family member access to health information on a patient portal or a personal health record (PHR).

2.2.1 Electronic Health Record (EHR)

An EHR is a longitudinal electronic record of pa- tient health information generated by one or more encounters in any care delivery setting. Included
in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician’s workflow. The EHR
has the ability to generate a complete record of a

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clinical patient encounter – as well as supporting other care-related activities directly or indirectly via interface – including evidence-based decision sup- port, quality management, and outcomes report- ing.1

2.2.2 Electronic Medical Record (EMR)

An EMR is an electronic record of health-related information on an individual that can be created, gathered, managed and consulted by authorized clinicians and staff within a single health care orga- nization.2
An EMR is an application environment composed of the clinical data repository, clinical decision sup- port, controlled medical vocabulary, order entry, computerized provider order entry (CPOE), phar- macy, and clinical documentation applications. This environment supports the patient’s EMR across inpatient and outpatient environments, and is used by health care practitioners to document, moni-
tor, and manage health care delivery within a care delivery organization (CDO). The data in the EMR is the legal record of what happened to the patient during their encounter at the CDO and is owned by the CDO.3

2.2.3 Personal Health Records (PHR)

A PHR is a universally accessible, layperson-com- prehensible, lifelong tool for managing relevant health information, promoting health maintenance and assisting with chronic disease management via an interactive, common data set of electronic health information and e-health tools. The PHR is owned, managed, and shared by the individual or his or her legal proxy(s) and must be secure to protect the pri- vacy and confidentiality of the health information
it contains. It is not a legal record unless so defined and is subject to various legal limitations.4 Some EHRs offer patients/consumers the ability to view their records through web portals or the ability to export data to a PHR.

2.2.4 Health Information Technology (HIT)

HIT encompasses a broad array of technologies involved in managing and sharing patient informa- tion electronically, rather than through paper re- cords. HIT performs information processing using both computer hardware and software for the entry, storage, retrieval, sharing, and use of health care information.5 EHR, EMR and PHR are examples of HIT.

2.2.5 Electronic Point of Care (POC)/Point of

Service (POS) Documentation Systems

Electronic point of care (POC)/point of service (POS) documentation systems allow the nurse, phy- sician, aide, or other provider to enter information into an electronic record during or immediately
after visits with clients/residents (e.g., kiosks, tablet computers, hand-held devices, etc.).

2.3 Safety Technologies

Safety technologies include technologies for emergency call and personal emergency response systems (PERS), fall detection and prevention technologies (bed and chair alarms), environmental monitoring (temperature, carbon monoxide, flood, smoke and fire alarms), access control, wander management, unattended stove shut-off systems
and the like.

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2.4 Health and Wellness Technologies

Health and wellness technologies include health promotion technologies, behavioral and health sta- tus monitoring systems, telehealth and telemedicine systems, and medication management technologies, which focus on the physical health and wellness of seniors. In addition, cognitive assessment technolo- gies, reminder systems and cognitive monitoring, and stimulation technologies, which focus on the mental health and wellness of seniors, are also clas- sified under this category. Finally, these technolo- gies include physical exercise and rehabilitation technologies.

2.4.1 Telehealth, Remote Patient Monitoring

(RPM) and Telemedicine

Telehealth, remote patient monitoring (RPM) and telemedicine capabilities are defined as the use of electronic communication and information tech- nologies to allow interaction between providers and patients in different locations (e.g., wound consul- tation by a physician at an offsite location using audiovisual equipment, monitoring blood pressure, etc.).

2.4.1.1 Telehealth

Telehealth can be defined broadly as the use of electronic information and telecommunications technologies to provide access to health assessment, diagnosis, intervention, consultation, supervision information and education across a distance.6, 7
Telehealth technologies include telephones, fac- simile machines, electronic mail systems, video- conferencing, and RPM devices, which are used to collect and transmit data for monitoring and
interpretation. Common applications of telehealth
include both clinical services (e.g., teleradiology in which test results are forwarded to another facil- ity for diagnosis; home monitoring to supplement home visits from nursing professionals) as well as non-clinical services (e.g., continuing professional
education, including presentations by specialists to general practitioners).8
There are two primary modes of delivering tele- health:

2.4.1.1.1 Store-and-Forward (Asynchronous):

In store-and-forward telehealth, clinical informa- tion (e.g., data, images, sound, video) is captured locally, then temporarily stored for transfer at a later time as encrypted e-mail or messages using specially-designed store-and-forward communica- tions modems and software, to a secure web server or EHR, either via phone lines or high-speed inter- net connection (including DSL, ADSL, cable, fiber- optic or cellular modems). The consulting provider then reviews the stored data and makes diagnosis, treatment, and planning recommendations.9

2.4.1.1.2 Real-Time Interactive Systems

(Synchronous):

Real-time telehealth sessions are live and interac- tive, and frequently use videoconferencing tech- nologies. Often, special instruments such as a video otoscope (to examine the ear) or an electronic stethoscope are operated by a nurse or technician
at the consulting provider’s direction to remotely perform a physical examination.9 Or, real-time communication may be a patient and a nurse prac- titioner consulting with a specialist via a live audio/ video link, or a physician and a patient in an exam room communicating through an interpreter who
is connected by phone or webcam.

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2.4.1.2 Remote Patient Monitoring

Remote patient monitoring (RPM) is a type of home telehealth that enables patient monitoring
as well as transfer of patient health data to a health care provider. To capture data, these technolo-
gies use a variety of wired or wireless peripheral measurement devices such as blood pressure cuffs, scales, and pulse oximetry, and they are most often used after a hospital discharge or between routine office visits. Some technologies also permit video interaction/chat between the patient and health care professional in real-time. These systems can
prompt users to enter answers to targeted questions, and then use this information for data interpreta- tion, provision of educational materials, as well as instructions such as scheduling an office visit or going to the nearest emergency room. Similarly, these systems can transmit user-entered data, store the data in secure records systems accessible to clinicians, flag abnormal readings or responses,
and alert clinicians to abnormalities via e-mail or text messages. In response to these alerts, clinicians can log into the system, review data, follow up with patients, or take other appropriate actions. Some systems have the capacity to connect patients with additional resources such as PHR or EMR, targeted educational materials, interactive self-care tools, medication optimization technologies, and health care providers.10 Although applications of RPM technologies are often used in the home setting, these technologies have been pilot-tested in con- gregate settings such as community-based senior centers.11

2.4.1.3 Telemedicine

Formally defined, telemedicine is the “use of medical information exchanged from one site to
another via electronic communications to improve a patient’s clinical health status.” Two-way video, email, smartphones, and wireless tools are examples of a growing variety of telemedicine applications
and services.12 While the terms “telehealth” and “telemedicine” are often used interchangeably, telemedicine can be more narrowly defined to mean the delivery of remote clinical services using technology. Examples of telemedicine include a physician’s review of a patient’s digital images (i.e.
x-rays, CT scans, MRI) via a computer, a physician consult done via a web conference, or telephar- macy whereby pharmacy technicians can prepare prescriptions under the supervision of a qualified pharmacist remotely.

2.4.2 Telecare/Telemonitoring/Behavioral

Monitoring capabilities

Telecare/telemonitoring/behavioral monitoring capabilities technologies include sensors to monitor functional abilities, activities of daily living, behav- iors, sleep patterns etc.

2.5 Clinical Decision Support Systems

Clinical decision support (CDS) systems provide clinicians, staff, patients or other individuals with knowledge and person-specific information, intel- ligently filtered or presented at appropriate times, to enhance health and health care. CDS encompasses
a variety of tools to enhance decision-making in the clinical workflow. These tools include com- puterized alerts and reminders to care providers and patients; clinical guidelines; condition-specific
order sets; focused patient data reports and summa- ries; documentation templates; diagnostic support, and contextually relevant reference information,
among other tools.13 CDS systems offer sophisti-

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cated functions that provide decision support to as a functionality of broader HIT systems including EMRs, EHRs, health information exchange (HIE), and telehealth.

2.6 Social Connectedness Technologies

Social connectedness technologies include spe- cial phones (amplified, large-button, and memory phones) and easy to use/simplified cell phones, which may offer, in addition to basic communica- tion functionality, different communication mo- dalities such as video reminders and multimedia messaging to keep seniors connected with family and friends. Senior-friendly social networking websites, easy to use email systems, e-mail-to-paper communications systems, easy to use video phones and video conferencing systems also fall into this category. Some of the computer-based cognitive and/or physical stimulation technologies may also provide an opportunity to connect with peers par- ticularly in congregate living settings.

3 vision of TeChnology- enabled Care and ConTinuum of moniToring

3.1 Vision for Technology-Enabled Care

The use of information technologies in the care environment is perceived by care professionals to have added value on the levels of administration, integration of services, care quality, and profes- sionalism.14 It can be argued that a new paradigm for technology-enabled geriatric care can emerge with more integrative technologies. For example,
the activities and selected physiological parameters
of an older adult can be monitored in his or her
own living setting through sensors embedded in the environment or other objects, wearable monitoring technologies, telehealth devices, and other tech- nologies. The environment is the place the older adult calls home and it may be the person’s house or apartment in the community, or a residence pro- vided by an aging services provider—a continuing care retirement community, an independent living apartment, assisted living or even a skilled nursing facility. Safety, activity, physiological, health and socialization data can be analyzed, archived and mined to detect indicators of early disease onset, deterioration or improvement in health conditions
at various levels. The care delivery diagram in Fig- ure 1 illustrates the process.

Figure 1. Model for the Technology-Enabled

Geriatric Care Paradigm.

Data analysis results, at various levels, can be made available to all stakeholders in the care process, including the monitored older adults, their profes- sional caregivers, informal caregivers and primary health care providers, and integrated into an EMR or PHR accessible to authorized caregivers when- ever they need them.
The monitored individual can use the analysis results in personal wellness and health maintenance

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(e.g., diet, exercise), or self-management of chronic conditions (e.g., biometric readings, medication management). Informal caregivers will get objec- tive assessment of their loved one’s ability to remain independent and peace of mind when everything is fine. This reassurance will eliminate interrogation, questioning and role reversal between the older adult and their adult children and would increase the social content of their communications. This will improve the quality of life for both parties, as well as reduce unnecessary early institutionaliza- tion of older adults driven by the anxiety of their children.
When the older adult needs assistance in some of
his or her activities of daily living (ADLs)i or instru- mental activities of daily living (IADLs)ii, profes- sional caregivers accessing the reports will have an objective assessment of their actual needs and can determine the appropriate care package. They can coordinate, dispatch and track the delivery of care and services to the monitored older adults via home care agencies (e.g., Meals on Wheels, bathing) if
they live in the community, or on-site direct care workers if they live in a continuum of care facility.
Primary health care providers can perform an educated evaluation of the monitored older adult’s health that is more objective based on trending health data, and more comprehensive than the

i ADLs (Activities of Daily Living) include the ability to move from one place to another, eat, bathe, toilet, and dress in addition to the ability to control the bladder and bowels (Katz S, Ford AB,

Moskowitz RW. Studies of illness in the aged. The index of A.D.L., a standardized measure of biological and psychological function. JAMA; 185:914-919).

ii IADLs (Instrumental Activities of Daily Living) include the ability to use transportation, shop for necessities, prepare meals, and perform house work (Fillenbaum GG. Screening the elderly: A brief instrumental activities of daily living measure. Journal of American Geriatric Society. 33:698-706.).

“snapshot” assessment obtained during an annual physical examination. They may be able to detect the early onset of disease and prescribe appropriate interventions (including preventive interventions), and can monitor the efficacy of these interventions objectively and longitudinally.
Finally, access to the analysis of the same objec- tive data by all authorized stakeholders is expected to improve the communication between them, including the monitored individual (e.g., the aging services provider and the adult child, when decid- ing on the most appropriate care package for the older adult) and enhance coordination.
This paradigm exploits the technical capabilities of embedded sensing, ambient intelligenceiii, interop- erabilityiv and interconnectivity between different devices in the home, as well as other information and communication technologies, in automating continuous assessment, documentation and com- munication. It enables a network of professional and informal caregivers to coordinate and deliver high-touch care when needed. The paradigm is
expected to prolong and enhance the independence of seniors, delay their transition to nursing facilities and thereby reduce the overall cost of care.15

Table 1 summarizes the technical capabilities of the technology and the resulting value utility of this paradigm for seniors, caregivers in their network and payers.

iii A vision of the future where we are surrounded by electronic environments that are sensitive and responsive to people.

iv The ability of two or more systems or components to exchange information and to use the information that has been exchanged.

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Table 1. Technical capabilities and potential value for the technology-enabled care paradigm for seniors and caregivers in their network

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3.2 Continuum of Monitoring

Technologies and their Value

The continuum of technologies that enable this vision of care includes safety monitoring, as well as health and wellness monitoring technologies. The latter covers telehealth, biometric RPM, medication management/monitoring, and telecare/telemonitor- ing/behavioral monitoring.

3.2.1 Safety Monitoring Technologies

Safety monitoring technologies provide an en- hanced sense of security, prolonged independence, improved quality of life and have the potential
for improved health outcomes for seniors. They provide peace of mind and reduce the strains of informal/family caregivers. These technologies also have the potential to improve the quality of care and reduce liability for care providers.
Finally, safety technologies have the potential to improve care quality and reduce health care costs for payers and society in general.

3.2.2 Health and Wellness Monitoring

Technologies

Health and wellness technologies include health monitoring and promotion technologies, behavioral and health status monitoring systems, telehealth, RPM and telemedicine systems, and medication management technologies, which focus on the physi- cal health and wellness of seniors, among others.
The anticipated value propositions these technolo- gies offer may include better health outcomes for seniors and reduced health care bills for payers. These technologies may provide coordination of care, reduced professional caregiver workloads, in-
creased caregiver efficiency, longitudinal data, peace of mind for informal/family caregivers and reduced informal caregiver burdens and strains.

3.2.3 Scope and Focus

This CAST whitepaper focuses on telehealth and biometric RPM only and does not cover safety monitoring, telecare/telemonitoring of activities/ behavioral telemonitoring, or medication manage- ment/monitoring. CAST recognizes the importance of all these technologies and acknowledges that the lines separating these categories of technology are sometimes blurred because some telehealth and RPM technology platforms may integrate with, or offer applications/functionalities, for safety, be- havioral monitoring or medication management. CAST will consider dedicating whitepapers, selec- tion matrices and online selection tools to these other categories of technology based on providers’ interest and demand for such tools. However, the selection matrix of telehealth and RPM products will include information about these products’ abil- ity to interface to or integrate with safety moni- toring, telecare and medication monitoring tech- nologies, as well as EHRs. Finally, the whitepaper and Telehealth and RPM Selection Matrix will be followed with an online Selection Tool that facili- tates and expedites the process of narrowing down
potential solutions and identifying vendors to invite to participate in a Request for Proposal (RFP), as well as a set of provider case studies delineating the benefits they experienced and the lessons learned during the implementation of telehealth and RPM solutions.
This whitepaper and the companion Telehealth and RPM Selection Matrix, online Selection Tool and case studies, represent a continuation of CAST’s

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efforts to produce hands-on tools that help LTPAC providers adopt appropriate aging services tech- nologies that enable them to deliver innovative care delivery models, position them well for strategic partnerships and the future. Telehealth and RPM technologies were the second enabling technology identified in the CAST Strategic Scenario Plan-
ning exercise (please see: A Look into the Future: Evaluating Business Models for Technology-Enabled Long-Term Services and Supports).

4 PoTenTial uses of

TelehealTh and rPm

4.1 Patient Education and Self- Management

Telehealth and RPM can be used as a tool to not only reinforce disease specific education but also help to instill some of the concepts required for self-management, like the importance of taking medications regularly as prescribed and implica-
tions of lifestyle choices, such as smoking, diet and exercise, on the individual’s vital signs and condi- tion in general. The variety of educational materials and delivery options available differ with telehealth solutions. All patient education should consist
of evidence-based care materials, recommended self-management best practices, and incorporate chronic care management principles to assist in providing consistent disease- or condition-specific education that promotes health, wellness, indepen- dence and safety in the home.
In addition, self-management helps individuals with chronic conditions recognize symptoms of exacerbation of their condition and identify what to report to a provider/clinician, and when to report
to it, so that they can make the appropriate inter- ventions in a timely manner. With regular use of telehealth and RPM solutions and the use of data, benchmarks can be established, and individuals can trend and track their readings themselves, noting when they are outside acceptable ranges.
When evaluating technology it is important to keep in mind that what helps people learn most effective- ly differs from one person to another. Some tech- nologies offer visual, audible and video education to help support different learning needs and abilities.

4.2 Pre- and Post-Acute Management of Chronic Conditions

Telehealth and RPM can provide a means for clini- cians to collect vital signs and other data to fol-
low patients between formal interactions with the health care system (physician office and hospital visits). This regular tracking of vitals and daily dis- ease condition monitoring provides clinicians with an opportunity to perform early intervention, such as medication titration, that aim to improve chronic disease management by attending to exacerba-
tions, avoiding the worsening of the condition and preventing the disease from progressing, thereby reducing unnecessary emergency department visits, hospitalizations and associated costs. Similarly, telehealth and RPM can be effective in stabilizing, following and managing individuals with chronic conditions after an acute episode, e.g., emergency department, hospital or physician visit, and can
help shorten hospital stays. Telehealth and RPM can be used after hospital discharge to reinforce the discharge plan instructions with daily monitoring, and provide individuals and their clinicians with op- portunities to take steps to prevent a second exacer-
bation and avoid unnecessary hospital readmissions.

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4.3 Post-Acute Patient Stabilization

To help with post-acute patient stabilization, telehealth and RPM is used for daily monitoring of disease conditions to detect exacerbation. In
theory, telehealth and RPM can keep eyes and ears on patients every day to track conditions; this can be done through biometric data, specific check-in data, and environmental sensors (if/when avail- able).
Telehealth and RPM allow for recognition of key indicators that put the individual at risk for read- mission, including medication non-adherence,
and provides a means for communication with and between multiple care providers (e.g., primary care physician, hospitalist, home and community-based care provider) for follow-up. Care providers can also use telehealth and RPM to provide remind-
ers for treatment and coordinate care with other providers who may provide supportive services to the individual.
Telehealth and RPM have a much larger penetra- tion in post-acute care as compared to ambulatory care patients as the majority of patients are only considered for home monitoring following hospital discharge to prevent readmission. In the U.S., for example, 140,000 post-acute patients were estimat- ed to have been monitored by telehealth in 2012, as compared to 80,000 ambulatory patients.16

4.4 Long-Distance Routine Check-Ups/ Treatment

Telemedicine, telehealth and RPM improve access to health care and benefits individuals who live in rural areas, are home-bound or have obstacles to accessing traditional delivery of health services to
receive routine check-ups and treatment services remotely.17
In addition to improved access, telemedicine, tele- health and RPM offer potential cost reductions for patients, as well as health care professionals (e.g., mileage for home health nurses) because of the ability to target visits as needed; this is especially helpful in rural areas, for home bound patients, or those who don’t have easy access to transportation.

4.5 Specific Teleconsult

The standard face-to-face method for the delivery
of medical care is the preferred means of evaluation and treatment for most health care professionals. Nevertheless, there are times when this type of in- teraction may not be necessary or possible. In these circumstances, “remote consultation” has served as an alternative in recent years.
For the scope of this discussion, the use of the term remote consultation will refer to all methods (not restricted to the use of the Internet, but also to include traditional technologies of information transfer such as mail or facsimile) where:
1. There is an exchange of medical information.
2. A formal report is issued.
3. A fee is charged for the consultative service. There are several reasons that a remote consultation
may be requested. It may be initiated by the patient
(or patient’s family), a clinician in an LTPAC set- ting, a primary care doctor seeking another opinion for their patient, or by a specialist requesting ad- ditional expert assistance. In these select instances, the use of remote consultation is a “win-win-win-

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win” concept for the patient, their primary doctor, the specialist, and the remote consultant. In the setting in which a treating physician is willing to take responsibility to assist in the process, appropri- ate reasons for remote consultation could include:
• The patient lives in a remote region where travel would be difficult.
• The patient is hospitalized, institutionalized or otherwise too ill to travel.
• The history and examination are well- established: there is simply a need for more diagnostic or therapeutic suggestions.
• The diagnosis is known and specific treatment options are requested.

The use of telemedicine technologies like imaging devices for example, can increase the efficacy of the consult. In addition, it can save lives in critical

care and emergency situations allowing clinicians to consult with specialists and more experienced care teams that they would not have access to other- wise.18

pulmonary disease (COPD), asthma and hyperten- sion involve frequent monitoring, coordination among care providers and effective and sustained self-care, all of which can be addressed using tele- health and RPM technologies. Chronic disease is also quite prevalent and very costly in the United States, especially among older adults; they are the primary cause of death in 7 out of 10 deaths and, in
2009, cost an estimated $262 billion in direct health care expenditures. Nearly 92% of older adults have
at least one chronic condition, and 77% have at least two.19

5.1 Health Outcomes/Improved

Management

Effectively managing weight, blood pressure, and cholesterol is critical for individuals with diabe- tes, hypertension and heart disease. Telehealth and RPM can play an important role in assisting patients and care providers in monitoring and tracking these types of vital signs. In fact, several
studies have demonstrated that, compared to usual care, diabetic patients receiving RPM and telehealth
had greater improvements in glucose control, blood

5 benefiTs of

rPm

TelehealTh and

pressure, and cholesterol.20, 21 A review of studies on the effectiveness of blood pressure monitoring among patients with hypertension found that a ma-
jority of the studies showed improvement in both
Improved health outcomes, reduced hospitaliza-
tions and readmissions, better quality of life, and reduced costs for both the payer and care provider are all potential benefits of telehealth and RPM. A review of the research conducted thus far, including several meta-analyses on telehealth and RPM show that its direct benefit may be greatest on chronic disease management. These types of conditions in- cluding diabetes, heart disease, chronic obstructive

systolic and diastolic blood pressures.22

5.2 Reduction in Hospitalizations and

Hospital Readmissions

Perhaps some of the most promising research con- ducted thus far has focused on the benefits of tele- health and RPM in reducing hospitalizations and

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hospital readmissions, especially among patients with heart disease and COPD. For example, one meta-analysis of telehealth studies conducted in
2011 found that, compared to standard care, those patients with heart failure receiving telehealth had a
42% reduction in hospitalizations.23 Another study that focused on the impact of telehealth on hospital readmissions found there was a 60% reduction in hospital readmissions using RPM compared with standard care, and a 50% reduction compared with other disease management programs that did not use RPM. This study concluded that RPM has the potential to prevent between 460,000 and 627,000 heart failure-related hospital readmissions each year.24

The Department of Veterans Affairs (VA) has made a strong commitment to telehealth among its large cohort of veterans by developing a national program called the Care Coordination/ Home Telehealth (CCHT) program. The pur- pose of CCHT is “to coordinate the care of veteran patients with chronic conditions and avoid the unnecessary admission to long-term institutional care.” To that end, the VA has broadly deployed a range of RPM technologies in 50 different health management programs across 18 Veterans Integrat- ed Service Networks and conducted various studies showing improved chronic disease management, cost savings, and reduced hospital admissions and emergency department (ED) visits. Findings from comparative studies conducted on 17,025 patients enrolled in the VA CCHT program in 2006 and

2007 show a 25% reduction in bed days of care, 20% reduction in numbers of admissions, and a mean satisfaction score rating of 86%.25

In addition, two studies focusing on the impact of telehealth and RPM on COPD found promising

results. The first study looked at patients with mod- erate to severe COPD and found that, compared to usual care, case managers’ use of RPM for daily symptom surveillance resulted in a significant decrease in hospital readmission rates as well as a tendency toward fewer hospital days and outpa- tient visits.26 The second study was a retrospective cohort study using the Veterans Health Admin- istration database of COPD patients enrolled in the CCHT program. Results indicated that 71.5% of the CCHT patients had a reduction in the number of ED visits and exacerbations related to COPD requiring hospitalizations after enrollment in the program.27

5.3 Patient Self-Efficacy, Quality of Life and Satisfaction

The use of educational materials and the delivery of disease-specific self-management tips at the appropriate times through telehealth and RPM, can increase the patient’s knowledge, engagement and self-efficacy. In one study, LaFramboise ran- domized 103 patients with heart failure to receive (a) a telehealth intervention that included RPM, clinician assessment, and feedback with advice or
encouragement; (b) the telehealth intervention plus home care; (c) home care alone; or (d) telephone care. Patients using the telehealth intervention had increased self-efficacy, while all groups had equal improvement in health related quality of life, the
6-minute walk test, and depression scores.28 In addition, telehealth and RPM has the potential
to positively impact the patient’s quality of life. A review of home telehealth found that, compared to conventional home care or usual care, home
telehealth improved access to care, patients’ medical
conditions, and quality of life.29

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Finally, active and timely response on the part of health care professionals are important and an expected component of the telehealth intervention. Such active/proactive interventions and timely re- sponses, in turn, lead to higher patient satisfaction rates. For example, one study reported that rapid electronic messaging turnaround and replies by physicians increased patient satisfaction (the aver- age turnaround time was 48 hours in this study).30
In fact, the VA’s telehealth program demonstrated a high, 86%, patient satisfaction score.25

5.4 Physician Engagement Key to

Success

Engaging physicians and health care providers as partners in care beyond the formal interactions with the health care system (office and hospital visits) is vital to improving health outcomes for
patients. Telehealth and RPM technology can play a significant role in increasing such engagement, and consequently, the patient’s and family’s satisfaction with care. However, telehealth and RPM may not deliver the anticipated benefits unless physicians and health care providers are involved. In fact, the most important and consistent finding of a review
of 74 studies that reported the effect of interactive consumer health IT on health outcomes or health care process measures, was that systems were ef- fective when they provided a complete feedback loop. The review revealed that such a feedback loop included (a) monitoring and transmission
of patient status; (b) interpretation of this data by comparison with previously established individual treatment goals or published guidelines; (c) adjust- ment of medications, diet, or information according to patient status; (d) timely communication back
to the patient with tailored recommendations or
advice; and (e) repetition of this cycle at appropriate intervals. These “complete loop” interventions were effective across a wide range of medical conditions, monitoring and communication technologies, geographical areas, and patients’ socioeconomic status.31
Financial incentives for physicians to review data and engage in telehealth interventions may be key to delivering the expected benefits of telehealth
and RPM.11 As discussed above, physician’s respon- siveness and proactive interventions can lead to higher patient satisfaction, and tying physicians’ financial incentives to patient satisfaction through the Consumer Assessment of Healthcare Providers and Systems (CAHPS)32 and similar measures is
one way to ensure physician engagement. The abil- ity of group practice physicians to negotiate with hospitals and insurance companies are becoming intimately tied with CAHPS outcomes. Initial stud- ies seem to suggest that physicians who spend more time with their patients and are able to effectively communicate and answer all patient questions tend to have better CAHPS scores. 33 There may be an opportunity to study how certain technologies can affect physicians’ and health care providers’ CAHPS outcomes.
Additionally, the accountable, person-centered, and quality-driven managed care era is driving health care providers to focus more on patient outcomes and satisfaction. Physician-led Accountable Care Organizations (ACOs) tend to focus their cost-sav- ing efforts on keeping patients out of the hospital
as much as possible. Conversely, hospital-led ACOs often attempt to reduce the costs involved with hospitalizations and hospital readmissions. In both scenarios, telehealth and RPM can play a role in the ACO model. CAHPS is one of the quality measures

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that will be used to evaluate the performance of the Centers for Medicare & Medicaid Services (CMS) Shared Savings ACO program.34

5.5 Caregivers’ Workload and

Efficiencies

Increasing access to health care through telehealth and RPM, especially to patients living in rural areas, has the potential to reduce health care costs and improve efficiencies in a variety of ways includ-
ing decreasing the number of nurse home care visits, reducing the number of patient transports to hospitals and physician offices, and increasing
access to specialists such as wound care experts or pulmonologists. One study, for example, found that a telehealth intervention utilized by a home health agency reduced the number of home visits by
nurses from 8.2 to 5.8 per month.35 Another study found that one out of every four in-person visits can be avoided with telehealth store-and-forward technology. And, one out of every two clinic visits can be avoided with real-time consults.36 Finally, a recent study published in Health Affairs found that telehealth and RPM can increase care provider’s productivity by decreasing home visit travel time and utilizing automated documentation systems.37
Efficiencies can also be found in reducing patient transportation costs and increasing access to spe- cialists via telehealth technologies. Remote visits to patients in skilled nursing facilities for wound
care, for example, can result in avoided transporta- tion costs. In a review of 53 geriatric applications
of telehealth, Jennett and colleagues found that telephone consultations to geriatric patients and video consultations related to chronic wounds can
be cost-saving because they reduce the use of nurs-
ing home services, and limit the need for patients
to be transported.38 Another study by researchers at the University of Virginia Health System found that telehealth interventions in a long-term care com- munity setting replaced patient transport to a local wound care clinic.39 Furthermore, some research in- dicates there may also be a decreased need or desire to travel outside the local community for health
care services in communities where telehealth ser- vices are offered.40
Operational efficiency is another important con- sideration. Many telehealth and RPM solutions operate at very low levels of efficiency because of time consuming set-up and inefficient software solutions. A low level of efficiency is very difficult and costly to scale to large populations. Staffing is often times one of the greatest expenses to an orga- nization and ensuring that the telehealth and RPM solution maximizes operational efficiency while maintaining efficacy is a key area to consider.

5.6 Reduced Risk and Liability

Telehealth and RPM, as well as other monitoring technologies, provide a means for detecting aris- ing health issues that would go undetected without the technology. Hence, they have the potential to reduce risks and providers’ liability as they gener- ate documentation of events, signs, symptoms and interventions. This is especially true when the use of these technologies is coupled with policies and procedures about response protocols and respon- sibilities, clear delineations of responsibilities in
contractual and service agreements, and documen- tation of interventions/actions taken, by whom and when.41

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6 PoTenTial lTPaC Provider

business models

6.1 Medicare Coverage

Under its fee-for-service model, Medicare pays a distant practitioner for a limited number of Part B services that are furnished by a physician or practi- tioner to an eligible beneficiary via a telecommuni- cations system. For eligible telehealth services, the use of a telecommunications system substitutes for an in-person encounter. An originating site is the location of an eligible Medicare beneficiary (pa- tient) at the time the service being furnished via a telecommunications system occurs. Medicare ben- eficiaries are eligible for telehealth services only if they are presented from an originating site located
related to the location or geographic areas. Prac- titioners at the distant site who may furnish and receive payment for covered telehealth services (subject to state law, including inter-state licensure laws) are: physicians; nurse practitioners (NP); physician assistants (PA); nurse midwives; clinical nurse specialists (CNS); clinical psychologists (CP) and clinical social workers (CSW)vi; and registered dietitians or nutrition professionals.
As a condition of payment, an interactive audio
and video telecommunications system that permits real-time communication between the physician or practitioner at the distant site and the beneficiary,
at the originating site, must be used. Asynchronous store-and-forward technology is permitted only in federal telemedicine demonstration programs con-

42

in a rural Health Professional Shortage Area or in
ducted in Alaska or Hawaii.
For a list of Medicare
a county outside of a Metropolitan Statistical Area. Entities that participate in a Federal telemedicine demonstration project approved by (or receiving funding from) the Secretary of the Department of Health and Human Services as of December 31,
2000, qualify as originating sites regardless of geo- graphic location.
The originating sites authorized by law are all medi- cal facilities; these sites include: offices of physicians or practitioners; hospitals; Critical Access Hospi- tals (CAH); Rural Health Clinics (RHC); Federally Qualified Health Centers (FQHC); hospital-based
or CAH-based Renal Dialysis Centers (including satellites)v; skilled nursing facilities (SNF); and Community Mental Health Centers (CMHC). The patient’s home is not an eligible originating site.
Distant sites from which practitioners furnish telehealth services are not subject to restrictions

v Note: Independent Renal Dialysis Facilities are not eligible originating sites.

telehealth services, please see the following fact
sheet: http://www.cms.gov/Outreach-and-Educa- tion/Medicare-Learning-Network-MLN/MLN- Products/downloads/telehealthsrvcsfctsht.pdf.
It is important to note that when telehealth is used with patients in nursing homes, one of the eligible originating sites, the payment goes to the distant physician, clinician or practitioner.

6.1.1 Medicare Reimbursement of Home

Telehealth

Section 1895(e) of the Social Security Act43 states that telehealth services are outside the scope of the Medicare home health benefit and home health Prospective Payment System (PPS). This provision

vi CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive

payment for Current Procedural Terminology (CPT) codes 90792, 90833,

90836, and 90838.

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does not provide coverage or payment for Medicare home health services provided via a telecommuni- cations system (i.e. home telehealth, or RPM are not covered under PPS). The law does not permit the substitution or use of a telecommunications system to provide any covered home health services paid under the home health PPS, or any covered home health service paid outside of the home health PPS. As stated in 42 CFR 409.48(c), a visit is an episode
of personal contact with the beneficiary by staff of the home health agency (HHA), or others under arrangements with the HHA for the purposes of providing a covered service.44
However, this provision clarifies that there is noth- ing to preclude a home health agency from adopt- ing telemedicine or other technologies they believe promote efficiencies, but those technologies will not be specifically recognized or reimbursed by Medi- care under the home health benefit. This provision does not waive the current statutory requirement
for a physician certification of a home health plan of care under current §§1814(a)(2)(C) or 1835(a) (2)(A) of the Act.45 Within its home health agency manual, CMS states that “an HHA may adopt telehealth technologies that it believes promote ef- ficiencies or improve quality of care. Telehomecare encounters do not meet the definition of a visit set forth in regulations at 42 CFR 409.48(c) and the telehealth services may not be counted as Medicare covered home health visits or used as qualifying services for home health eligibility. An HHA may not substitute telehealth services for Medicare cov- ered services ordered by a physician. However, if an HHA has telehealth services available to its clients,
a doctor may take their availability into account when he or she prepares a plan of treatment (i.e. may write requirements for telehealth services into
the POT). Medicare eligibility and payment would
be determined based on the patient’s characteristics and the need for and receipt of the Medicare cov- ered services ordered by the physician. If a physi- cian intends that telehealth services be furnished while a patient is under a home health plan of care, the services should be recorded in the plan of care along with the Medicare covered home health ser- vices to be furnished.”46

6.2 Medicaid Coverage

Medicaid and the Children’s Health Insurance
Program (CHIP) provide health coverage to nearly
60 million Americans, including children, preg- nant women, parents, seniors and individuals with disabilities. In order to participate in Medicaid, federal law requires states to cover certain popula- tion groups (mandatory eligibility groups) and gives them the flexibility to cover other population groups (optional eligibility groups). States set indi- vidual eligibility criteria within federal minimum standards. Medicaid coverage is based on financial and other non-financial eligibility criteria that are
used in determining Medicaid eligibility. In order to be eligible for Medicaid, individuals need to satisfy federal and state requirements regarding residency, immigration status, and documentation of U.S. citizenship; these criteria vary by state.47
The Center for Telehealth and e-Health Law
(CTeL) completed a 50 state survey which reviewed each state’s telehealth reimbursement policies. CTeL’s research found that 45 states have some
type of reimbursement for services provided via telehealth. There are many factors that states use to determine the scope of coverage for telehealth
applications, such as the quality of equipment, type of services to be provided, and location of providers

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(e.g., remote rural sites).
CMS requires that reimbursement for Medicaid- covered services, including those with telehealth applications, must also satisfy federal requirements of efficiency, economy, and quality of care. With this in mind, states are encouraged to use the flex- ibility inherent in federal law to create innovative payment methodologies for services that incorpo- rate telehealth technology.
For example, states covering medical services utiliz- ing telehealth may reimburse both the provider at the distant site from which the services are pro- vided for the consultation as well as the provider at the originating site where the patient received the telehealth services for the office visit. States also
have the flexibility to reimburse any additional cost
(i.e. technical support, line-charges, depreciation on equipment, etc.) associated with the delivery of
a covered service by electronic means as long as the payment is consistent with the requirements of ef- ficiency, economy, and quality of care. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state. If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service.48 For specific information about Medicaid coverage of telehealth in each state, please see: http://ctel.org/expertise/reimbursement/medic- aid-reimbursement/.

6.3 Private Health Insurance Coverage

There is no single widely-accepted standard for pri- vate insurance coverage of telehealth services. Some insurance companies value the benefits of tele- health and will reimburse a wide variety of services. Others have yet to develop comprehensive reim-
bursement policies, so payment for telehealth may require prior approval. Likewise, different states have various standards by which their Medicaid programs will reimburse for telehealth expenses. As with Medicaid, regulations for telehealth reim-
bursement by private insurers are set by the states.49
Nineteen states have enacted parity laws requiring that services provided via telehealth must be re- imbursed if the same service would be reimbursed when provided in person. These states include: Arizona, California, Colorado, Georgia, Hawaii, Kentucky, Louisiana, Maine, Maryland, Michigan, Mississippi, Missouri, Montana, New Hampshire, Oklahoma, Oregon, Texas, Vermont and Virginia.50
Some insurance programs cover specific telehealth services, e.g., behavioral health. Even in the absence of a definitive policy, some insurers and Medicaid agencies will reimburse for telehealth services as long as the rationale for using telehealth is justified to the agency’s satisfaction. State waivers or spe-
cial programs offering remote diagnostics, remote monitoring for specific disease entities or for particular populations, allow for additional cover- age of telehealth services. A few states simply pay claims regardless of whether the encounter was in person or via telehealth. The introduction of man- aged care, within Medicaid and the private sector, has complicated telehealth reimbursement policies since a number of state programs acknowledge us- ing telehealth within managed care but do not keep specific telehealth utilization data. In many cases, state Medicaid managed care and fee-for-service are separate programs with separate guidelines.

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6.4 Medicaid Waiver Coverage

Medicaid waivers are vehicles states can use to test new or existing ways to deliver and pay for health care services in Medicaid and CHIP. There are
four primary types of waivers and demonstration projects:
• Section 1115 Research & Demonstration Projects: States can apply for program flexibility to test new or existing approaches to financing and delivering Medicaid and CHIP.
• Section 1915(b) Managed Care Waivers: States can apply for waivers to provide services through managed care delivery systems or otherwise limit people’s choice of providers.
• Section 1915(c) Home and Community-Based
Services Waivers: States can apply for waivers
to provide long-term care services in home and community settings rather than institutional settings.
• Concurrent Section 1915(b) and 1915(c) Waivers: States can apply to simultaneously implement two types of waivers to provide
a continuum of services to the elderly and people with disabilities, as long as all federal requirements for both programs are met.51
ing and personal emergency response systems (PERS). New York, South Carolina, and South Dakota also have exemplary telehealth and RPM reimbursement programs.52 Rates and requirements vary. For more details about the coverage of tele- health and other aging services technology services in these states, please see: http://www.leadingage. org/uploadedFiles/Content/About/CAST/CAST_ State_Paymen_%20Analysis.pdf.

6.5 Potential Affordable Care Act (ACA) Related Opportunities

The Affordable Care Act (ACA) is shifting the health care system in the U.S. away from the tra- ditional fee-for-services to a pay-for-performance system. Moreover, CMS is moving to reimburse Medicare Certified Home Health based on a value- based purchasing model instead of a Prospective Payment Model. This is starting to eliminate the misalignment of incentives inherent in traditional Medicare, Medicaid and private insurance pro- grams. There are many provisions and models in the ACA that would benefit from, provide oppor- tunities to cover, and consequently encourage the adoption of telehealth and RPM technologies and services.53 The act created the Center for Medicare
and Medicaid Innovations (CMMI), which is tasked with exploring new care delivery and payment

54

According to a CAST Analysis of Medicaid Waiver
models and initiatives
that:
Programs, seven states, including Kansas, New York, Pennsylvania, South Carolina, South Dakota and Texas reimburses for home telehealth under sections 1915(b) and/or 1915(c). The analysis showed that Pennsylvania has the most comprehen- sive coverage for aging services technologies in its telecare program, which includes home telehealth, activity/wellness monitoring, medication dispens-
• Use more holistic, patient-centered and team-based approaches to chronic disease management and transitional care.
• Improve communication and care coordination between/among care providers.

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• Improve care quality and population health while reducing growth in expenditures.
The act puts explicit emphasis on the use of health information technology (HIT), including telehealth and RPM, in Health Homes for Enrollees with Chronic Conditions, the Independence at Home Demonstration and the Use of Technology in New State Options for Long-Term Services and Sup- ports.55
These initiatives include:
• Hospital Readmission Reduction Program
(HRRP)56
• ACOs57
• Bundling of Payments models, of which the following two are relevant to LTPAC providers:
• Retrospective Acute Hospital Stay plus
Post-Acute Services58
• Retrospective Post-Acute Care Only59
LTPAC providers bring a significant value for hos- pitals, physician groups, payers and ACO partners, by providing the following services:
• Rehabilitation and skilled nursing facilities provide post-discharge/post-acute patient rehabilitation.
• Skilled nursing facilities, assisted living facilities, continuing care retirement communities, housing with services, and home health agencies provide post-acute patient stabilization and sub-acute chronic disease management.
• LTPAC provides holistic person-centered care, including support services.
• LTPAC offers lower cost care settings than hospitals.
These new care delivery and payment models will provide LTPAC providers utilizing technologies, like telehealth and RPM technologies, with oppor- tunities to derive revenue sources from strategic partners. The following whitepaper offers some key questions LTPAC providers should discuss with their acute care partners: http://www.leadingage. org/uploadedFiles/Content/About/CAST/Re- sources/The_importance_of_home_and_commu- nity_March_2013.pdf.

6.6 Private Pay

Another payment source for telehealth and RPM services may be private payers or out of pocket. As mentioned above, home health services under the prospective payment system may use telehealth to enhance the efficiency and effectiveness of home visits during the 30-60 days of post-acute services. When the Medicare coverage period expires, these agencies usually offer an extension of telehealth and RPM services, with home visits as needed, to
clients if they would benefit from such a program as private duty services covered out of the patient’s or family’s pocket.

6.7 Standard of Care and Other

Payment Sources

LTPAC and community health providers, special population agencies, self-pay and self-insured orga- nizations and others, especially not-for-profits, may offer/cover an array of telehealth and RPM services.

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These services may be covered by grants, or offered as standard of care with the cost absorbed by the organization and covered from different revenue sources, including charitable contributions.

6.8 Return on Investment (ROI) of

Telehealth and RPM

Return on investment (ROI) represents the ratio of the net gains relative to the initial investment over
a certain period of time. Subsequently, ROI can be expressed in the following equation:

ROI = Net Gains ⁄ Investment

As discussed above, telehealth and RPM delivers various benefits, including potential financial sav- ings to different stakeholders, including patients and/or their families, payers, care providers, etc.
However, the financial savings and ROI, depend on a number of factors including the care delivery model, the payment/reimbursement model, the technology, and of course costs. The first and most important step in calculating ROI is to consider the different stakeholders, identify the investors, and calculate the gains and savings netted/accrued to each investing stakeholder under each particular care delivery and payment model. When calculat- ing ROI, one should only include the gains that accrued to that particular stakeholder minus all expenses, relative to that stakeholder’s own invest- ment/cost. Often the reduction of hospital days is erroneously included in the providers’ ROI, which
is not true under the traditional fee-for-service reimbursement model and can be misleading; such a reduction usually accrues to the payer.

6.8.1 ROI to Patients and/or their Families

ROI to patients and/or their families can be calcu- lated as:

ROI Patient or Family = Net Gains Patient or

Family ⁄ Investment Patient or Family

For private pay patients and their families, for example, the financial gains of home telehealth and RPM lie in prolonging independence by avoiding deterioration in health that may lead to disability and avoiding the need to move into assisted living
or skilled nursing facilities, which is significant. The gains may also include savings in co-pays for recur- ring hospital visits, and of course a higher quality
of life, which is difficult to quantify. The patient’s/ family’s expenses/investment are the monthly out of pocket cost of private home telehealth services, and any co-pay for the occasional physician office visit, lab tests, and prescriptions.

6.8.2 ROI to Payers

ROI Payer = Net Gains Payer ⁄ Investment Payer

For dual Medicare and Medicaid eligible patients who are nursing home eligible, for example, the financial gains of home telehealth and RPM under a Medicaid Waiver program that accrue to Medicaid, which would otherwise be liable for the costs of nursing home room and board costs, lie in remain- ing in their own home with home health, home
care and other supportive services. Medicaid’s investment is the monthly rate of home telehealth services and additional supportive services aimed at keeping the individual independent.
In this particular example there may be additional savings, like reductions in hospitalization and hospital readmission costs that accrue to Medicare,

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which is liable for and covers health care costs. Consequently, such savings or gains should not be included in calculating Medicaid’s ROI, which is investing in the home telehealth and supportive services in this case.

6.8.3 ROI to Care Provider

ROI to care providers can be calculated as:

ROI Care Provider = Net Gains Care Provider ⁄ Investment Care Provider

For the care provider who makes investments in information and communications technology infrastructure, the telehealth technology, as well as the clinical and care services, benefits may include: lower costs in delivering the same services includ- ing staff efficiencies, staff travel costs (if the payer covers the remote services, rather than just the
in-person visit), and higher reimbursements/pay- ment from the payer or strategic partner in terms
of incentive payments for avoiding more costly care settings, procedures, events, or penalties.
For example an LTPAC provider partnering with a physician group ACO to manage a chronically ill patient population can potentially get a percentage of the incentives or shared savings payments the ACO receives from the payer for reducing hospi- talizations and hospital readmissions, which can be significant for certain populations. The LTPAC pro- vider’s net gain is the sum of all gains accruing to the LTPAC provider in staff efficiencies, increased referrals from the ACO, traditional fee-for-service payments, and additional incentive payments received from the ACO, minus the costs of leasing the home telehealth equipment and actual costs of services delivered. The physician group ACO’s ROI is the portion of the payer’s incentive payment that
they get to keep plus any additional fee-for-service payments due to more frequent office-based ser- vices minus the actual costs of services they deliver (for example in medication reconciliation or care coordination), relative to the portion of incentives they pass through to the LTPAC provider.
In contrast, a partnership between an LTPAC pro- vider and hospital under the traditional fee-for-ser- vice model, for example, the LTPAC provider may help their hospital partners reduce 30-day readmis- sion rates for pneumonia, congestive heart failure and acute myocardial infarction (heart attack) pa- tients, hence helping the hospital avoid Medicare’s payment penalties under the HRRP. The hospital may contract with and pay the LTPAC provider a percentage of the penalties saved for delivering tele- health that lead to reducing 30-day readmissions
for patients discharged from the hospital after being admitted for one of the above mentioned three conditions. The LTPAC’s net gain is again the sum
of all gains accruing to the LTPAC provider in staff efficiencies, increased referrals from the hospital, traditional fee-for-service payments, and additional payments received from the hospital, minus the costs of leasing the home telehealth equipment and actual costs of services delivered. The hospital’s
ROI is the portion of avoided penalties they get to keep plus any additional fee-for-service payments they gain for more referrals due to improved qual- ity ratings minus the actual costs of services they deliver, relative to the portion of avoided penalties they passed through to the LTPAC provider plus any additional costs incurred for staff time in care coordination, medication reconciliation, or health information exchange, for example.

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6.8.4 Online ROI Calculator for RPM

Once individual investors have been clearly identi- fied, an estimate of the ROI to the different stake- holders can be calculated. The Center for Technolo- gy and Aging and the Center for Connected Health jointly developed an online tool to facilitate calcu- lating ROI for a RPM program for the management of chronic conditions, like Congestive Heart Failure (CHF). The tool was funded by the California Healthcare Foundation60.
The online ROI calculator asks users to enter data in 5 areas:
1. Patient Enrollment: Users specify the size of patient enrollment in the RPM program in year
1 and project what enrollment will be in year 5.
2. Technology: Users estimate their investments in HIT. These estimates include 1-time invest- ments in medical devices and infrastructure; if applicable, an amortization period for purchas- es/expenditures can be specified. The tool also asks for recurring costs like hardware rental, data costs and server hosting.
3. Staffing: Users enter the RPM program’s staffing requirements. This includes fixed man- agement costs, as well as clinical and support staff costs that will change with the number of patients enrolled.
4. Other Costs: Users can enter other RPM- related costs, including costs for services, subscriptions, travel, administration, patient materials and external monitoring services.
5. Outcomes: The final step helps users estimate their potential savings from the RPM program.
The tool bases its calculation of savings on whether patients change their health care utilization as a result of the program. One of the advantages of the tool is that it allows users to identify the stakeholder that will bear the
financial risks or enjoy the financial gains when service utilization changes. It is important to precede any anticipated increase in utilization (home visits, for example) with a minus (-) sign to have the correct results, as the calculator as- sumes savings, i.e. decrease in utilization.
Once users answer the ROI Calculator’s 5 questions, the tool provides 4 reports:
1. A Cost Summary gives users a quick overview of the RPM program’s total cost by year and total cost per patient per year.
2. A Savings Summary charts the potential cost savings to the stakeholders identified in ques- tion 5.
3. An ROI Evaluation compares the RPM pro- gram’s financial gains to its financial costs.
The tool provides a score indicating the extent to which the RPM intervention will generate enough savings to cover the cost of the pro- gram.
4. A Sensitivity Analysis allows users to see how the ROI at year 5 would change if patient en- rollment and costs changed.
Please see the ROI Calculator tool at: http://www. telemedroi.com/#home

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7 Planning for TelehealTh and

rPm soluTions

Telehealth and RPM technologies help manage and monitor health conditions to improve the care of chronically ill patients and people who have trouble accessing care. Initiating, expanding or integrating telehealth as a service is complex and begins with understanding organizational strategic goals and vi- sion for a telehealth program in order to strategical- ly plan for this initiative. The next step is evaluating operational readiness and conducting operational planning, followed by due diligence in selecting a vendor partner with experience in strategic plan- ning, program design and ongoing program devel- opment to support unique organizational goals and needs to help ensure success.

7.1 Visioning and Strategic Planning

Visioning and strategic planning is a key founda- tional step to the success of a telehealth program. Telehealth should be viewed as a tool to achieve specific organizational goals and part of a well- founded overall organizational strategy. Getting true value from telehealth comes from the orga- nization’s ability to align the telehealth and RPM initiatives with the organizational strategic goals, understand their operational needs, set operational goals, engage all stakeholders, including strategic care partners (e.g., hospitals and physician groups), and plan for such an initiative ensuring that the plan is realistic in terms of timeline and resources. Then selecting and implementing one or more of the numerous types of telehealth and RPM tech- nologies and solutions.
The following areas should be considered as part of an organization’s initial vision and strategic plan- ning:
• Care Setting and Business Goals
Visioning and planning process starts with understanding the care settings in which the organization is considering implementing telehealth and RPM vis-à-vis the strategic and business goals of the organization. The setting will have implications on the availability
of professional caregivers, the technologies that fit the setting and operational needs, the characteristics of the patient/user population, and operational, care and business model for the telehealth initiatives. For example, the organization’s strategic goals may be making their skilled nursing facility a strategic partner and a preferred discharge destination to
the local hospital, or offering cost-effective home health services into the broader local community.
• Target Population
Have a vision for the population that will be impacted by telehealth program. Different targeted patient populations should have different telehealth solutions, care delivery and support services. When it comes to telehealth, one size does not fit all and having the flexibility to match proper technology
to the targeted patient population is a key factor to success. It is important to stratify the population, based on health condition, acuity, risk, utilization of health care services, etc.61
Examples of target patient populations that should receive different types of technology
may include patients who are high-risk, with

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specific conditions, post-acute, rural, facility- based, those that require video-based visits,
or those that require additional activity and/ or safety monitoring. Many organizations will have a need to address several different types of patient populations so it is critical to select
a vendor partner that can match the telehealth solution that will meet the organization’s needs.
• Technology Review
Learn about the types of telehealth and RPM technologies, how they functionally operate and what network infrastructure and connectivity they require. For example, some technologies are designed to help
individuals with chronic care management and post-acute care management by identifying disease exacerbation risks and alerting health care professionals with a goal to help avoid unnecessary hospitalization, provide chronic condition education, and promote self- management. Others are designed for health care professionals to connect with more specialized or experienced clinicians to seek guidance, advice, or interventions. In addition it is important to understand the technology transmission requirements and what alternatives are available should the technology not be able to be utilized in some specific patient environments.
• Software Considerations
Software considerations should not only include the user’s experience but also the operational efficiency it may provide. Different telehealth software products will actually allow organizations to manage many more patients because of operational efficiencies built into
the software products and will result in lower telehealth program operating costs.
Be sure to understand internet and mobile access requirements, interfacing opportunities with current EHR systems, potential customization requests, reporting options, inventory management systems and any other systems-specific factors that will potentially assist in the organization’s successful implementation of a telehealth program.
• Access Requirements
Understand how the organization and provider partners will access the telehealth information, who will need to access the information
and what unique types of information each recipient will need to access. It is important
to understand not only whether the telehealth solution meets the unique organizational needs, but also the requirements of any care partners (e.g., a partner physician practice) and the lead time should needs change from the initiation of the program. Since telehealth requires broad data sharing, organizations should ensure that such data sharing is done in compliance with all the applicable Health Insurance Portability and Accountability
Act (HIPAA) Privacy and Security Rule requirements. Under the new HIPAA Omnibus Rule, which became effective in March 2013, business associates of covered entities (including telehealth vendors) are now directly liable for compliance with certain
of the HIPAA Privacy and Security Rules’ requirements. These measures include “a mechanism to authenticate,” “a mechanism to encrypt and decrypt electronic protected
health information (EPHI),” and “policies and

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procedures to protect EPHI from improper alteration or destruction.”
• Program Support
Program Support includes the internal requirements to set-up, operate and maintain the support of the telehealth program within organizations as well as the ongoing support provided by the vendor selected. Not only is it critical for organizations to understand their infrastructure options and requirements but it is important to understand the level of clinical expertise needed to operate the program, availability of such expertise internally or
from care partners and any clinical support services offered by the vendor (if applicable). It is also critical to understand the burden of support that will be expected by any internal IT support staff or development resources to support the ongoing program.
Another key consideration regarding support is the level of support the vendor provides to the customer, including technical support. Keep organizational operating hours and
access in mind. For example, if an organization operates seven days a week it is important
to match those operating hours with vendor support availability.
• Budget Considerations
There are many items to think about when creating a budget for telehealth including per- unit cost, software and user-licensure cost, ongoing maintenance and repairs, staffing, and training to name a few. One additional budget issue rarely planned up front is the changes
to work flow that impact staff training and
accountabilities. Organizations often overlook
the fact that existing staff with current job assignments often do not appreciate how their work will change (for example, how staff will input new data, how messages will be shared with the health care team, how much new data will be incoming, etc.).
There are several different models of agreements and fee requirements available from vendors, including purchase or lease of hardware and software. Consider the long-term and short-term advantages and disadvantages of these different options when considering purchase versus lease
options. Technology changes very rapidly and understanding the opportunities included
in upgrades and replacements are critical to future success. Keep an eye out for hidden costs not only with the telehealth unit,
but other items such as additional staffing requirements because of lack of operational efficiencies in the software, maintenance, repair, lost units, fees associated with ordering new units and any training fees for additional or replacement staff.
• Remember the Future
Be a visionary when it comes to telehealth in general and in particular within your organization. Telehealth programs evolve over time due to the changing landscape of health care, market and technology; it is critical to select a vendor partner that can support, grow and change with your organization’s needs.

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7.2 Organizational Readiness

Assessment

Determining organizational readiness to initiate and operate or expand a telehealth program is a basic step towards ensuring success. Planning and developing a comprehensive telehealth program takes time, resources and dedication. Many ven- dor partners offer turnkey solutions with program materials available for telehealth policy and pro- cedures, staffing models, patient population selec- tion and eligibility criteria, participant enrollment process, evaluation methods, outcome measures, data sources, and analysis plan. Even with all of the supporting materials, it is important to understand that there is still a need for leadership engagement and a significant time commitment required in both planning and ongoing program support.
Designating individuals that are accountable, qualified and available for the required areas of responsibilities is a first step in evaluating the state of an organization’s preparedness for telehealth. Review staffing resources and determine if there are significant staff shortages or excessive staff turnover that may influence whether to initiate or expand a telehealth program. Some key roles to consider are:
• Leadership – the engagement of a senior- level leader that articulates the organization’s strategic visions and goals as well as ensuring staff accountability will be key to the success of a telehealth initiative. A leader will help the organization influence the adoption of the telehealth program to help achieve its goals
for telehealth. The telehealth program may be led by the chief executive officer (CEO), chief operations officer (COO), chief medical officer
(CMO), or a senior/executive vice president.
• Patient Management Registered Nurse – have a clear plan for who will be responsible for receiving and monitoring the telehealth and RPM information. Consider items such as 24-hour coverage, business days-only coverage, seven days a week coverage, or
holiday coverage and always ensure that there is backup staff fully trained to take over at
any time. There are a few vendor partners that offer patient management as a service
to help meet organizational needs. Consider what interventions the clinical team will implement and who will be responsible for implementing them; keep in mind that there are very few vendors who provide clinician or clinical support services. In addition, consider the full scope of clinical interventions the
team plans to deliver, as some intervention plans may require partnerships, or at least coordination, with other health care providers and professionals, such as physicians,
hospitals, pharmacies, etc. In these cases, make sure those other providers are on board with and would be willing to work, coordinate and collaborate with the team.
• Inventory Control – consider utilizing administrative staff for equipment control to help reduce operational costs. This is especially important for individual home telehealth
as well as wearable telehealth/mobile health (mHealth) units, contrasted with telehealth kiosks.
• Marketing and Business Development – involve business development teams early in the planning process to help ensure engagement, marketing support, ongoing

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growth and ultimately success of the telehealth program.

7.2.1 Staff Competencies

Competency-based training programs to demon- strate the ability to perform the above roles is an- other element to success. The individual designated initially may not always be the right person to help ensure success. What makes people learn most ef- fectively differs from one person to another. Ensure that there are multiple options offered for training to guarantee competencies, which may include
self-learning modules, video-based training mod- ules, webinar training modules, and live training. Competency-based training is an avenue to achieve a highly knowledgeable and skilled telehealth team which will contribute to the goals of a telehealth
program.

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7.2.2 IT Infrastructure

Selecting the appropriate telehealth solution will depend on an organization’s IT infrastructure and needs. Typical options include purchasing and locally hosting the telehealth software onsite at the organization’s data center, purchasing the software and having a 3rd party host it in their data center, or the vendor host- ing and offering their own Software as a Service (SaaS). Each has pros and cons depending on the size of an organization and its current IT infrastructure.
Some things to consider when evaluating these options are:

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7.2.3 Operating Environment

The type of software solution will most likely be di- rectly influenced by the type of operating environ- ment required to meet your business needs. Under- standing and defining organizational, provider and family access will help determine the most effective operating environment. Items to consider include:
• Required access to the system remotely from any web-enabled device.
• Provider access, including partner providers.
• Family portal access.
• Storing all information securely behind firewall protection.
It is important to consider unique organizational needs and applications to ensure selection and setup of the appropriate operating environment.

7.3 Operational Planning

7.3.1 Project Team

Successful implementation of telehealth relies on a wide array of stakeholders on the project. The most successful telehealth programs incorporate the program into the day-to-day operations of the or- ganization and provide all staff with some involve- ment with and exposure to the telehealth program. Since telehealth is enabling a new care delivery model, most staff will need to be involved, includ- ing executive leadership, clinical teams, technical representatives, DME/logistics, finance, operations and marketing/business development. Getting all
of these groups on board with a clear set of goals,
timelines, resource requirements, and deliverables will lead to success.

7.3.2 Goal Setting

Defining goals of the telehealth program is critical to measure success. Each organization will have different ideas of what success looks like based on internal operations. Before starting a telehealth program, the organization should set a clear series of goals and metrics.
Keep in mind that goals should be measurable



and routinely reported on within your operations. The fundamentals to setting goals are to ensure that they are SMART goals (specific, measurable, attainable, realistic and track-able). Setting both short-term and long-term goals for the telehealth program is highly recommended. Telehealth programs will naturally change and progress over
time. Organizational goals set at the initiation of the program will likely be different six to twelve months post implementation. Telehealth program goals should continuously be evaluated and updated as programs change. It is also important to understand that a new program will have the ability to achieve several major goals during the initial adoption of
the program.
Goals for each organization should be unique and may incorporate ideas from the following categories:

Clinical Outcomes

• Improved control of chronic conditions.
• Improved integration/coordination of care.
• Reduction of hospitalizations.
• Hospital readmission reduction.

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• Increased chronic condition education.
• Improved self-management skills.

Satisfaction Outcomes

• Improved patient satisfaction scores.
• Improved provider satisfaction scores.
• Employee satisfaction and retention.
• Increased trust from the patient.
• Provide security in the home environment.

Operational Outcomes

• Increased staff productivity/efficiencies.
• Focused intervention and needs.
• Attracting new talents.
• Positioning and market advantage.

Financial Outcomes

• Readmission reductions.
• Increased productivity.
• Decreased travel time.
• Increased market share/referrals.
• Increased occupancy.
• Opportunity for new lines of business.
Be sure to define outcome measures that will help in evaluating the success of the program in the short- and long-term. After program goals have been determined, ensure that baseline data has been captured and discussed during telehealth planning sessions. These goals and metrics should be periodically reviewed and updated throughout the planning and implementation process.

7.3.3 Program Design

Telehealth programs should be designed with the organizations’ short- and long-term goals in mind to help ensure success. In addition to the orga- nization’s goals, care coordination, collaboration and communication to enhance patient care and outcomes with other care providers along the con- tinuum of care should also influence the program design. The design of each program should always consider how to align objectives, strategies, and technical plans with care partners by using tele- health and the EHR, as a source of information and
a facilitator of communications. Be sure to share ex- periences from other similar organizations to assist in strategies to build a telehealth program within
the organization or strengthen an already existing telehealth program (please see the companion case studies that CAST is collecting).

7.3.3.1 Operating Model, Workflow, and

Change Management

When a new telehealth program is implemented, it does not just mean adding technology into an existing care model; on the contrary, care models themselves change because the delivery of patient care is being done via telehealth technology. This is particularly significant for the clinical care model. Before starting any program, make sure that the

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new model of care is clearly defined and that staff have been prepared with training and support plans. To gain the most benefit out of telehealth, ensure it is used as a tool for changing care delivery and workflows, both inside the organization and with outside partners, and not simply an add-on. Adding telehealth, or any other technology for that
matter, without assessing and redesigning processes and workflows to take advantage of the technolo- gies’ capabilities and efficiencies, will likely fail to produce the anticipated benefits.

7.3.3.2 Patient Population

Identifying the patient population an organization wants to reach with telehealth-enabled care should be done at the earliest stages of planning. As part
of this process, ensure that there is a process for patient identification, enrollment and gathering of their consents. Demonstrating the value of tele- health and making sure that patients understand their care will be improved, not diminished, is at the heart of the consent process.

7.3.3.3 Business Model: Expenses and Revenue

Sources

Consider the care deliver and payment model(s) being proposed for the telehealth program. Identify all expenses including technology infrastructure, connectivity, telehealth system expenses, installa- tion, troubleshooting, maintenance and support, change management, training, clinical services and support. Identify all the revenue sources (private pay, payer, strategic partner), and carefully calculate the organization’s ROI, as well as the other stake- holders’ (please see section 6.8).

7.4 Technology Review and Selection

Once an organization has completed the visioning and strategic planning exercise, assessed organi- zational readiness, assembled the project team, set the project’s goals and designed the program, then the team needs to develop a set of requirements to use as criteria to review and select the appropriate telehealth technology solution that can help achieve desired program’s goals and meets an organization’s needs. When reviewing possible telehealth technol- ogy options, it is important to know what type of telehealth technology embodiment fits within an organization’s care setting and planned care delivery model, etc. In the CAST Telehealth and RPM Selec- tion Matrix that follows, we outline options that
will help narrow down the selection to a limited number of vendors that can be invited to submit request for proposals.

8 TelehealTh and rPm seleCTion maTrix ComPonenTs

CAST’s Telehealth Workgroup, consisting of pro- viders, vendors and consultants, compiled a list of telehealth and RPM products that serve the LT- PAC market, as well as a list of functionalities and capabilities that would help providers choose the telehealth and RPM product that fits their business line and functional requirements best. Each of the telehealth and RPM vendors was then provided
the opportunity to complete a self-review of the workgroup’s pre-determined questions. Some of these vendors chose not to participate. Those who did participate were then offered the opportunity to nominate a case study from a provider’s perspective
on the use of the vendor’s telehealth/RPM product.

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Some telehealth and RPM vendors have multiple embodiments of their products (Single-User/Pa- tient Home Base Unit, Single-User/Patient Mobile/ Wearable Unit, Staff-Operated Multi-User Mobile Unit, and/or Multi-User Unit/Kiosk). In this case, the vendor was asked to provide information on each product separately.
The Telehealth and RPM Selection Matrix includes the following sections:

Business Line/Care Applicability lists all the various business lines to which the telehealth/RPM solu- tion is applicable, including Physicians’ Offices, Emergency Department, Hospitals, Housing with Services, Home Health/Home Care, Hospice, Adult Day Care/Senior Centers, Assisted Living Facili- ties, Acute Rehab Facilities, Long-term Acute Care Hospitals, Long-term Care Rehab Facilities, Skilled Nursing Facilities, Intermediate Care Facilities, Intellectual Disabilities/Mental Retardation/Devel- opmental Disabilities (ID/MR/DD) Facilities, Con- tinuing Care Retirement Communities (CCRC), Program of All-Inclusive Care for the Elderly (PACE), Accountable Care Organizations (ACOs), and Multiple Site Integration.

System Type defines the basic function of the solu- tion and includes Store-and-Forward: Interactive Voice Response System (IVR), Store-and-Forward: Biometric Remote Patient Monitoring, Other

Store-and-Forward Systems: Other than IVR & Biometrics (e.g., Imaging, Consultation Notes, etc.), Real-Time Biometric Remote Patient Monitoring (exists with Store-and-Forward as well) and Real- Time Interactive Two-Way Video Conferencing
with Clinician.

Embodiment provides information about the physical system and includes the options of Single-

User/Patient Home Base Unit, Single-User/Patient Mobile/Wearable Unit, Staff-Operated Multi-User Mobile Unit, and/or Multi-User Unit/Kiosk.

Program Development & Support Offered includes Program Development (Planning, Business Model Templates, etc.), Telehealth/RPM Nurse Services, Other Store-and-Forward Clinician Services, Real- Time Interactive Video Conferencing with Physi- cian/Clinician Services, Physician Engagement Services, Patient Education, Patient Engagement, and Family Engagement.

Available Ancillary Sensors/Devices covers Sensor Types (Stethoscope, Temperature Probe, Blood Pressure Cuff, Weight Scale, Heart Rate, Peak Flow, Glucometer, Pulse Oximeter, Pulse Waveform, Spi- rometer, EKG/ECG, High-Definition Still Camera, High-Definition Video Camera, Other Sensors listed, and Notes on Specialty Sensors Offered),

and Sensor Connectivity (Wired, Wireless, and/or
Others).

Front-End Hardware Unit User/Patient Interface & Communications identifies the unit’s functionalities, user interface capabilities, and communications modalities with the user/patient including Touch Screen, Audible Prompts, Visual Prompts, Standard Disease-Specific Questionnaires, Customizable Questionnaires, Biometric Thresholds are Custom- izable, and Branching Logic Based on Biometric Data and User’s/Patient’s Responses. Additionally, the various Communications Modality options are listed as Plain Old Telephone System (POTS) Line, DSL Internet Connectivity, High-Speed Internet Connectivity, Wi-Fi Connectivity, Cellular Connec- tivity, and Minimum Internet Connectivity Speed Required.

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Hardware and Software Requirements - Front End lists the required Desktop/Laptop specifications for Software-Only Solutions including requirements

for Minimum Processor, Minimum Processor Speed, Minimum RAM, Minimum Hard Disk Stor- age, Operating System (OS) - Windows, Operating System (OS) -Apple, and/or Operating System (OS)
- Unix/Linux. Other features compared include Network Specifications, Wireless Specifications, Browser Based Requirements, Minimum Internet/ Bandwidth Specifications, Miscellaneous Software/ Applets Needed (i.e. Citrix), Miscellaneous Report- ing Specifications (i.e. Crystal Reports), Scalability, Local Model, Hosted Model, Software as a Service Model (SaaS), Remote Access, Off-Line Functional- ity Support, Ability to Store/Handle Attachments (Insurance card, Historical Notes, etc.), Available
for Purchase, and Available for Lease. Last, Mobile options are listed as Cellular Carriers that Support Solution, Mobile OS - Android, Mobile OS - Black- berry, Mobile OS - iOS, Mobile OS - Unix/Linux, and/or Mobile OS - Windows.

Front-End Unit Support lists materials delivered through the front-end unit, including On-Screen Educational Self-Management Material, Self- Management Educational Audios, and/or Self- Management Educational Videos. Front-End Unit Multi-Language Support section lists the available languages. The final options here include Remote Updates and/or Remote Configuration Capability.

Report and Personal Health Record (PHR)/EHR examines options to provide Customizable Reports or Ability to Schedule Automatic Reports, and to whom Health Record/Report Access is provided (Client/Patient’s Physician, Client/Patient’s Nurse/ Other Licensed Clinician, Client/Patient/User/Self, Care Manager/Professional Caregiver, Family and/

or Other).

Alerts and Chronic Disease Management Deci- sion Support includes to whom Alerts can be sent (Client/Patient’s Physician, Client/Patient’s Nurse/ Other Licensed Clinician, Client/Patient/User/Self, Care Manager/Professional Caregiver, Family, and/ or Other) and the Alert Sending Modality, which includes options for Pager, E-Mail, Text Message, and/or Other.

Single Condition Clinical Decision Support System has options for Congestive Heart Failure (CHF), Myocardial Infarction, Pneumonia, Chronic Ob- structive Pulmonary Disease (COPD), Diabetes, Hypertension, Asthma, Arrhythmia, Stroke, Pres- sure Ulcers/Wound Care, End-Stage Renal Disease, Depression or Other.

Customizable Pathways and Clinical Decision Sup- port Systems for Multiple Chronic Conditions and Comorbidities builds upon the previous section and lists all comorbidities. Vendors were instructed to only check comorbidity options that can be handled simultaneously. Options included Congestive Heart Failure (CHF), Myocardial Infarction, Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Diabetes, Hypertension, Asthma, Arrhythmia, Stroke, Pressure Ulcers/Wound Care, End-Stage Renal Disease, Depression or Other.

Interfacing, Integration and Add-Ons looks into the telehealth/RPM solution with Electronic Health Records (EHRs), Medication Adherence Monitor- ing Dispensers, Safety Monitoring Systems (e.g., Personal Emergency Response Systems (PERS)), Wellness, Behavior and Activity Monitoring Sys- tems, or Others.

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Interoperability, Interoperability Standards and Certification begins with Type of Interoperability Supported (None, Export Data Only, Import Data Only, or Bi-Directional data import and export), Supported Interoperability Standards: HL7 Personal Health Monitoring Report and/or Other, Back-End EHR/PHR Certification in the form of ONC-ATCB, Comprehensive CCHIT-LTPAC: Home Health and/ or Comprehensive CCHIT-LTPAC: Nursing Home. The section ends with information on Front-End System Certification, namely the Continua Health Alliance Certification.

Program Support Services includes options for Equipment Delivery/Pick Up, Site/Home Instal- lation, IT/Network Troubleshooting & Support, Front-End System Set-up, Front-End System Customization, Back-End System Set-up, Back- End System Customization, Onsite Staff Training,

Online Staff Training, Onsite User/Patient Training, Online User/Patient Training, Equipment Cleaning, Equipment Refurbishing and/or Other.

Clinical Supportability includes options for 24-Hour

Support-Phone, Limited Hours Support – Phone,
24-Hour Support – Web, Limited Hours Support – Web, E-Mail Support, Listserv and/or Usergroup, Online Training, Onsite Training, and/or Other.

Technical Supportability and Warranty Information includes technical support options for 24-Hour Support-Phone, Limited Hours Support – Phone,

24-Hour Support – Web, Limited Hours Support – Web, E-Mail Support, Listserv and/or Usergroup, Online Training, Onsite Training, and/or Other,
as well as warranty options that include Length of Product Warranty and goes onto share what is cov- ered under warranty: Parts, Parts & Labor, or Parts,
and In-Field/On-Site Labor.

Legal/Regulatory/Cyberliability touches on FDA Ap- proval (Approved, Cleared, Pending, Listed, None), FDA Classification (Class I, Class II, etc.), HI- TECH, HIPAA, Security - List HIPAA & HITECH Act Requirements Met, List Applicable Regulatory Requirements Met, Provide a Link to Company’s Cyberliability Policy, and List Any Other Legal Requirements, as well as an option to Provide a link to Sample Contract.

Hardware and Software Requirements - Back End provides required specifications for Desktop/Lap- top systems including requirements for Minimum Processor, Minimum Processor Speed, Minimum RAM, Minimum Hard Disk Storage, Operating System (OS) - Windows, Operating System (OS)

-Apple, and/or Operating System (OS) - Unix/ Linux. Other features compared include Network Specifications, Wireless Specifications, Browser Based Requirements, Minimum Internet/Band- width Specifications, Miscellaneous Software/Ap- plets Needed (i.e. Citrix), Miscellaneous Reporting Specifications (i.e. Crystal Reports), Scalability, Local Model, Hosted Model, Software as a Service Model (SaaS), Remote Access, Off-Line Functional- ity Support, Ability to Store/Handle Attachments (Insurance card, Historical Notes, etc.), Available
for Purchase, and Available for Lease. Last, Mobile options are listed as Cellular Carriers that Support Solution, Mobile OS - Android, Mobile OS - Black- berry, Mobile OS - iOS, Mobile OS - Unix/Linux, and/or Mobile OS - Windows.

Company’s Experience and Viability includes Num- ber of Years in Business, Release Date of Current Version, Number of Patients served, Core Customer Base, Focus of Line of Business, as well as Links to Additional Case Studies.

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The last section of the matrix is dedicated for Strengths, Areas for Improvement, Ongoing Devel- opment and References.

9 aCknoWledgemenT of

ConTribuTors

9.1 Contributing Writers Majd Alwan, LeadingAge CAST Jennifer Bravinder, Cardiocom Paul Burnstein, LeadingAge CAST Eric Eiting, GrandCare Systems David Loveland, WoundRounds

Shannon McIntyre Hooper, Intel-GE Care Innova- tions
Laura Mitchell, GrandCare Systems
Linda Spokane, LeadingAge New York

9.2 Workgroup Members Majd Alwan, LeadingAge CAST Harry Bailes, Family Health Network Andrea Bellis, HoneyWell HomMed Jennifer Bravinder, Cardiocom

Paul Burnstein, LeadingAge CAST
David Dring, Selfhelp Community Services
Eric Eiting, GrandCare Systems
Jen Farrell, Cardiocom
Scott Flacks, Ideal Life, Inc.
Stacey Force, HoneyWell HomMed
Cory Fosco, WoundRounds
Bryan Fuhr, Healthsense
Lynette Ladenburg, LeadingAge Washington
Pete Larson, HealthInterlink
Ben Laub, Sholom
David Loveland, WoundRounds
Shannon McIntyre Hooper, Intel-GE Care Innova- tions
Regina Melly, Jewish Home Lifecare Laura Mitchell, GrandCare Systems Brian Robbins, Westminster
John Ryan, Philips Medical Systems
Andy Schoonover, Monitoring Care
John Schumacher, Biosign Technologies Inc. Linda Spokane, LeadingAge New York

9.3 Participating Telehealth and RPM Vendors

Ambio Health, Kevin Jones
Biosign - Healthanywhere, Michelle Violette, John
Schumacher
Cardiocom, Jennifer Bravinder, Jen Farrell, Chris
Taylor
CJPS Medical Systems, LLC, Christophe Sevrain

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Family Health Network, Harry Bailes GrandCare Systems, Laura Mitchell, Eric Eiting HealthInterlink (Beacon), Pete Larson Healthsense, Bryan Fuhr
HoneyWell HomMed, Andrea Bellis, Stacey Force Ideal Life, Scott Flacks, Julianne Wassong Independa, Becky Wheeler
Intel-GE Care Innovations, Shannon McIntyre
Hooper
Philips Medical Systems, John Ryan
Tunstall America, Christina Coons, Brian Verban
VRI, Andy Schoonover
WoundRounds, David Loveland, Cory Fosco

Telehealth and Remote Patient Monitoring for Long-Term and Post-Acute Care:

A Primer and Provider Selection Guide 2013

38

10 referenCes and resourCes

Endnotes

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Telehealth and Remote Patient Monitoring for Long-Term and Post-Acute Care:

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11 Telehealth and RPM Selection Matrix 42

Telehealth and Remote Patient Monitoring

(RPM) Selection Matrix

Disclaimer

The information included in this paper is meant to assist care providers in the understanding and selection of telehealth and remote patient monitoring (RPM) solutions, but cannot possibly include all systems that may be available. Products mentioned in this paper serve as illustrative examples. Information about the functionalities and capabilities for this effort were provided by participating vendors of telehealth and RPM solutions. A few telehealth and RPM vendors chose not to participate. Functionalities and capabilities of listed telehealth and RPM products

have not been verified, tested, independently evaluated or endorsed by LeadingAge or LeadingAge CAST. Please use this as general guidelines in understanding functionalities and examples of current telehealth and RPM systems. The Telehealth and RPM

Selection Matrix may help providers identify potential telehealth and RPM solutions that may meet their requirements, and is intended to help them target vendors to submit a Request for Proposal (RFP). Where appropriate, provider case studies were identified and published separately. However, providers are strongly advised to verify functionalities of the telehealth and RPM solutions prior to final selection through demonstrations, site visits, reference checking and other due diligence steps.

Business Line/Care Applicability

Business Line/Care Applicability

Business Line/Care Applicability

Business Line/Care Applicability

System Type

System Type

Embodiment

Embodiment Single-User/Patient Home Unit Single-User/Patient Mobile/wearable Unit Staff-Operated Multi-User Mobile Unit Multi-User Unit/Kiosk

Healthsense, Inc.

www.healthsense.com Yes Yes Yes Yes

Honeywell HomMed - Genesis DM

www.hommed.com Yes No No Yes

Honeywell HomMed - Genesis Touch

www.hommed.com Yes No No No

Ideal Life, Inc.

www.ideallifeonline.com Yes Yes No Yes

Independa

www.independa.com Yes Yes Yes Yes

Intel-GE Care Innovations™ Guide

www.careinnovations.com Yes No No No

Philips

telehealth.philips.com Yes Yes No No

Tunstall - Contact Center Services/IVR

americas.tunstall.com/Contact-Center Yes Yes No No

Tunstall - Telehealth

americas.tunstall.com/Telehealth Yes Yes Yes Yes

VRI TeleHealth

www.monitoringcare.com Yes Yes No Yes

WoundRounds (Telemedicine Solutions)

www.woundrounds.com No No Yes No

Program Development & Support

Offered

Program Development & Support

Offered

Healthsense, Inc.

www.healthsense.com Yes Yes No No No No Yes Yes N/A

Honeywell HomMed - Genesis DM

www.hommed.com Yes Yes No Yes Yes Yes Yes Yes

Channel Marketing Support Program, Online training and resources

Honeywell HomMed - Genesis Touch

www.hommed.com Yes Yes No Yes Yes Yes Yes Yes

Channel Marketing Support Program, Online training and resources

Ideal Life, Inc.

www.ideallifeonline.com Yes Yes No No No Yes Yes Yes N/A

Independa

www.independa.com Yes No No Yes Yes Yes Yes Yes Social engagement

Intel-GE Care Innovations™ Guide

www.careinnovations.com Yes Yes No Yes Yes Yes Yes No

Additional optional professional services, including: logistics, hardware recommissioning, managed wireless service as a connectivity option

Philips

telehealth.philips.com Yes Yes No No Yes Yes Yes Yes Transitional care services

Tunstall - Contact Center Services/IVR

americas.tunstall.com/Contact-Center Yes Yes Yes No Yes Yes Yes Yes

Augment & extend telehealthcare services i.e. appointment scheduling & reminders, referral processing, patient & provider surveys

Tunstall - Telehealth

americas.tunstall.com/Telehealth Yes Yes Yes No Yes Yes Yes Yes

Complete spectrum of programs, health interviews, and client customization

VRI TeleHealth

www.monitoringcare.com Yes Yes Yes No Yes Yes Yes Yes N/A

WoundRounds (Telemedicine Solutions)

www.woundrounds.com No No Yes No No No No No N/A

Available Ancillary Sensors/ Devices

Available Ancillary Sensors/ Devices

Communications Modality (R=Required, P=Preferred, A=Available, N/A= Not Available/ Adequate)

Front-End Hardware Unit User/Patient

Interface & Communications

Ambio Health

www.ambiohealth.com No Yes Yes Yes Yes Yes No N/A A A A N/A 1 Mbs

Beacon® by HealthInterlink

www.healthinterlink.com Yes Yes Yes Yes Yes Yes No A A A P A 1 Mbs

Biosign - Healthanywhere

www.biosign.com Yes Yes Yes Yes Yes Yes No A A A A A

28.8 Kbps (minimum) and 1 Mbs for video streaming

Cardiocom - Commander FLEX

www.cardiocom.com No Yes Yes Yes Yes Yes Yes A A A A A POTS

Cardiocom - Link View

www.cardiocom.com Yes Yes Yes Yes Yes Yes Yes N/A A A A A

Recommend 1.5 Mb/s+ when using video capabilities

Cardiocom - TeleResponse

www.cardiocom.com No Yes No Yes Yes Yes Yes A A A A A POTS

Cardiocom - NetResponse

www.cardiocom.com Yes No Yes Yes Yes Yes Yes N/A A A A A 1 Mbs

Cardiocom - Attentiv

www.cardiocom.com No Yes Yes Yes Yes Yes Yes A A A A A POTS

Cardiocom - Telescale

www.cardiocom.com No Yes Yes Yes Yes Yes Yes R N/A N/A N/A N/A N/A

CJPS Medical Systems (VitalPoint HOME)

www.cjps-medicalsystems.com Yes Yes Yes Yes Yes Yes Yes A A A A A POTS

Family Health Network Connected for Life

www.familyhealthnetwork.com Yes Yes Yes Yes Yes Yes Yes N/A A A A A 2 Mbs

GrandCare Systems

www.grandcare.com Yes Yes Yes Yes Yes Yes No N/A A P A A 1 Mbs

Hardware and Software

Requirements - Front End

Hardware and Software

Requirements - Front End

Front-End Unit Support

Front-End Unit Support

Alerts can be sent to the Following External Parties Alert Sending Modality

Alerts and Chronic Disease

Management Decision Support

Single Condition Clinical

Decision Support System

Single Condition Clinical

Decision Support System

Customizable Pathways and Clinical Decision Support Systems for Multiple Chronic Conditions and Comorbidities*

*Important Note: Selection includes all comorbidities that can be handled simultaneously.

Customizable Pathways and Clinical Decision Support Systems for Multiple Chronic Conditions and Comorbidities*

*Important Note: Selection includes all comorbidities that can be handled simultaneously.

Interfacing, Integration and

Add-Ons

Interfacing, Integration and

Add-Ons

Type of Interoperability Supported (N=None, E= Export Data Only, I= Import Data Only, or B=Bi-Directional data import and export)

Supported Interoperability

Standards Back-End EHR/PHR Certification

Front-End System

Certification

Interoperability, Interoperability

Standards and Certification

Interoperability Supported (N=None, E= Export Data Only, I= Import Data Only, or B=Bi-Directional data import and export)

Ambio Health

www.ambiohealth.com E Yes HL7, CCD No No No No

Beacon® by HealthInterlink

www.healthinterlink.com B No HL7, CCD No No No No

Biosign - Healthanywhere

www.biosign.com E No N/A No No No No

Cardiocom - Commander FLEX

www.cardiocom.com B Yes HL7, CCD No No No No

Cardiocom - Link View

www.cardiocom.com B Yes HL7, CCD No No No No

Cardiocom - TeleResponse

www.cardiocom.com B Yes HL7, CCD No No No No

Cardiocom - NetResponse

www.cardiocom.com B Yes HL7, CCD No No No No

Cardiocom - Attentiv

www.cardiocom.com B Yes HL7, CCD No No No No

Cardiocom - Telescale

www.cardiocom.com B Yes HL7, CCD No No No No

CJPS Medical Systems (VitalPoint HOME)

www.cjps-medicalsystems.com B Yes N/A No No No No

Family Health Network Connected for Life

www.familyhealthnetwork.com B Yes HL7, CCD No No No No

GrandCare Systems

www.grandcare.com B No N/A No No No No

Healthsense, Inc.

www.healthsense.com E No N/A No No No No

Honeywell HomMed - Genesis DM

www.hommed.com
Honeywell HomMed - Genesis Touch www.hommed.com
Ideal Life, Inc. www.ideallifeonline.com
Independa www.independa.com
Intel-GE Care Innovations™ Guide www.careinnovations.com

Philips telehealth.philips.com

Type of Interoperability Supported (N=None, E= Export Data Only, I= Import Data Only, or B=Bi-Directional data import and export)

Supported Interoperability

Standards Back-End EHR/PHR Certification

Front-End System

Certification

Interoperability, Interoperability

Standards and Certification

Interoperability Supported (N=None, E= Export Data Only, I= Import Data Only, or B=Bi-Directional data import and export)

Tunstall - Contact Center Services/IVR

americas.tunstall.com/Contact-Center B No N/A No No No No

Tunstall - Telehealth

americas.tunstall.com/Telehealth E No N/A No No No Yes

VRI TeleHealth

www.monitoringcare.com B Yes N/A No No No No

WoundRounds (Telemedicine Solutions)

www.woundrounds.com I No N/A http://ldng.ag/11hxHft No No No

Program Support Services

Program Support Services

Clinical Supportability

Ambio Health

www.ambiohealth.com No Yes Yes No Yes No Yes Yes N/A

Beacon® by HealthInterlink

www.healthinterlink.com No No No No No No No No 3rd party partner options for some of these services

Biosign - Healthanywhere

www.biosign.com No Yes Yes No Yes No Yes Yes N/A

Cardiocom - Commander FLEX

www.cardiocom.com Yes No Yes No Yes No Yes Yes Patient management and monitoring services

Cardiocom - Link View

www.cardiocom.com Yes No Yes No Yes No Yes Yes Patient management and monitoring services

Cardiocom - TeleResponse

www.cardiocom.com Yes No Yes No Yes No Yes Yes Patient management and monitoring services

Cardiocom - NetResponse

www.cardiocom.com Yes No Yes No Yes No Yes Yes Patient management and monitoring services

Cardiocom - Attentiv

www.cardiocom.com Yes No Yes No Yes No Yes Yes Patient management and monitoring services

Cardiocom - Telescale

www.cardiocom.com Yes No Yes No Yes No Yes Yes Patient management and monitoring services

CJPS Medical Systems (VitalPoint HOME)

www.cjps-medicalsystems.com Yes No No Yes Yes No Yes Yes Web-based audio/video conferencing and videos

Family Health Network Connected for Life

www.familyhealthnetwork.com Yes No Yes No Yes Yes Yes Yes N/A

GrandCare Systems

www.grandcare.com No Yes Yes No Yes Yes Yes Yes

24/7 support, in-home caregiving & real time monitoring. Online help videos & user guides.

Healthsense, Inc.

www.healthsense.com Yes No Yes No Yes Yes Yes Yes

Established a membership organization of customers that provides best practices for implementing technology-enabled care.

Honeywell HomMed - Genesis DM

www.hommed.com Yes No Yes No Yes No Yes Yes N/A

Honeywell HomMed - Genesis Touch

www.hommed.com Yes No Yes No Yes No Yes Yes N/A

Ideal Life, Inc.

www.ideallifeonline.com No Yes No No Yes No Yes Yes N/A

Independa

www.independa.com No Yes Yes No Yes Yes Yes Yes N/A

Intel-GE Care Innovations™ Guide

www.careinnovations.com No Yes No No Yes No Yes Yes Clinical services monitoring available

Philips

telehealth.philips.com No Yes No Yes Yes No Yes Yes N/A

Clinical Supportability

Legal/Regulatory/ Cyberliability

Legal/Regulatory/ Cyberliability

Hardware and Software

Requirements - Back End

Hardware and Software

Requirements - Back End

Company’s Experience and Viability

Ambio Health

Number of Years in Business Release Date of Current Version Number of Patients (Regardless of setting)

Core Customer Base, Focus of Line of Business Link/s to Additional Case Study/ies

ACO/IDNs, Assisted Living, Chronic Disease Management,

www.ambiohealth.com 2 December 2012 Available on Request

Home Health, Person Centered Medical Homes, Post-

Acute Care

None

Beacon® by HealthInterlink

www.healthinterlink.com 3 August 2013 Available on Request

ACO/IDNs, CCRCs, Health Plans, Home Health, Hospital,

PACE, Person Centered Medical Homes None

Biosign - Healthanywhere

www.biosign.com 10 January 2012 Available on Request

Chronic Disease Management, Home Care, Post-Acute

Care, Independent Living, Skilled Nursing Facilities

http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3192601/ http://www.biosign.com/ media/1777/Thompson-Telemedicine-and- eHealth-2011.pdf

Cardiocom - Commander FLEX

www.cardiocom.com 15 February 2011 1,000,000 Patient Months of Service ACO/IDNs, Health Plans, Home Care, Special Needs Plans http://www.cardiocom.com/video.asp

Cardiocom - Link View

www.cardiocom.com 15 June 2013 1,000,000 Patient Months of Service ACO/IDNs, Health Plans, Home Care, Special Needs Plans http://www.cardiocom.com/video.asp

Cardiocom - TeleResponse

www.cardiocom.com 15 November 2011 1,000,000 Patient Months of Service ACO/IDNs, Health Plans, Home Care, Special Needs Plans http://www.cardiocom.com/video.asp

Cardiocom - NetResponse

www.cardiocom.com 15 November 2012 1,000,000 Patient Months of Service ACO/IDNs, Health Plans, Home Care, Special Needs Plans http://www.cardiocom.com/video.asp

Cardiocom - Attentiv

www.cardiocom.com 15 June 2013 1,000,000 Patient Months of Service ACO/IDNs, Health Plans, Home Care, Special Needs Plans http://www.cardiocom.com/video.asp

Cardiocom - Telescale

www.cardiocom.com 15 January 2005 1,000,000 Patient Months of Service ACO/IDNs, Health Plans, Home Care, Special Needs Plans http://www.cardiocom.com/video.asp

CJPS Medical Systems (VitalPoint HOME)

www.cjps-medicalsystems.com Device/Software = 9 years; Entity = 6 years February 2013 Not Disclosed

Home Care, Hospice, Hospitals, Independent Living,

Physicians' Offices, Skilled Nursing Facilities None

Family Health Network Connected for Life

www.familyhealthnetwork.com 4 May 2013 Available on Request

ACO/IDNs, Health Care Systems, Home Health, Person

Centered Medical Homes, Skilled Nursing Facilities None

GrandCare Systems

www.grandcare.com 8 April 2013 Not Disclosed

Assisted Living, CCRCs, Health Care Providers, Home Care,

Home Health, Hospital Transitions, Independent Living http://www.grandcare.com/testimonials/

Company’s Experience and Viability

Strengths, Areas for Improvement, Ongoing Development and References

Strengths, Areas for Improvement, Ongoing Development and References