By Janet Bull, MD, MBA, and Lindsay Bonsignore, PhD

The use of telecommunications technologies in patient care, telemedicine, offers a potential solution to improve access and quality of care for those in rural settings. Telemedicine has grown dramatically over the last decade among many specialties with demonstrated improvements in chronic care management and promising trends in improving access to care in rural areas.^1,2 Only a few programs use telemedicine in palliative care. A home-based palliative care telemedicine program utilizing videoconferencing demonstrated that patients receiving telemedicine had reduced hospitalizations and increased hospice utilization and length of stay compared to usual care.³ In addition, a recent study demonstrated that integration of remote monitoring of symptoms of patients with metastatic cancer was associated with increased quality of life, decreased hospitalizations, and increased survival compared to usual care.⁴ In 2016, Four Seasons Compassion for Life in Western North Carolina (WNC) initiated a pilot telemedicine project as part of the Centers for Medicare & Medicaid Services Healthcare Innovation (CMMI Grant #1C1CMS331331) award utilizing a combined approach of remote patient monitoring (via the TapCloud application) and videoconferencing. A manuscript that presents a descriptive view of the program and demonstrates feasibility, usability, and acceptability of patients/caregivers, and providers of a palliative care telemedicine model is currently under review.

The topic of applying telemedicine in palliative care was presented at the 2017 Palliative and Supportive Care in Oncology Symposium in San Diego, CA. General Session 1: Oncology and Palliative Care Integration – Innovative Models fostered thoughtful discussion and new insights among faculty and attendees, and the following questions were submitted by attendees via the electronic question-and-answer (eQ&A) system.

How is your reimbursement for telemedicine? Are you able to get reimbursed at the same level as a face-to-face visit?

Medicare currently does not reimburse home-based telemedicine, as all reimbursable telemedicine services require an “originating facility” that includes physician offices, clinics, hospitals, and skilled nursing facilities. In addition, the new CMS Advance Care Planning billing code requires direct face-to-face time with the patient/caregiver. The Telehealth Enhancement Act of 2015 (H.R. 2066, section 105) would allow for Medicare reimbursement for home-based telemedicine, however, Congress has not acted on this bill.

Do you provide any telemedicine visits to patients' homes? If so, how you address logistics, such as connectivity, equipment, etc.?

Yes, Four Seasons initiated a pilot telemedicine project in 2016 as part of the Centers for Medicare & Medicaid Services Healthcare Innovation award. The telemedicine program has two components: 1) TapCloud application for remote asynchronous patient monitoring and 2) remote secure videoconferencing to facilitate real time interactions. Using TapCloud, the palliative care team monitors data as patients or caregivers “check-in/tap-in” to inform providers of concerns and well-being. Information is transmitted directly to a dashboard and to the team’s smartphones. When problems are identified, clinicians send secure push messages via the application to the patient/caregiver to attempt to remedy the situation. If unsuccessful, telephone calls and/or videoconferencing are used to further resolve the issue, and if needed a home visit occurs. In addition to TapCloud, the CBPC team uses videoconferencing to further address symptoms, medication management, goals of care, examination of any physical issue, and to facilitate family-focused meetings and counseling. Family members can join the video session from around the country with patient consent.

Patients enrolled in the project either use their personal device or receive a tablet for telemedicine services if they do not have a device or wireless services (about 30% of patients received tablets). Tablets and wireless services were funded as part of the grant project. Patients with limited connectivity are able to use the TapCloud application but not the videoconferencing capabilities, which require a stronger signal. Some patients with limited connectivity are able to use cellular boosters to obtain a high enough signal to participate in telemedicine. In some rural areas, however, connectivity is an issue and precludes some home patients from participating in telemedicine.

What tools/questionnaires are you utilizing to measure patient acceptability and usability of telemedicine? Are these tools validated?

As part of the telemedicine project, in collaboration with Duke University, we conducted qualitative semi-structured interviews to obtain feedback from patients, caregivers, and providers about Four Season’s telemedicine program. Interviews were focused on several aspects of patient/caregiver/clinician experiences with TapCloud/telemedicine: on-boarding and setup, usage, likes/dislikes, and areas for improvement. Patients, caregivers, and providers report overwhelmingly positive experiences with the telemedicine program. Respondents reported three main advantages: access to clinicians, quick responses, and improved efficiency and quality of care. This direct, quick, and improved efficiency and quality of care provided three main benefits in daily care to patients and caregivers: improved efficiency of medication refills, easier symptom checks, and increased comfort and peace of mind. In addition, because of TapCloud’s/telemedicine’s facilitation of direct, efficient contact with patients, clinicians stated that they were able to greatly expand their caseload. This qualitative analysis included a small sample of participants; a larger study is needed to further determine patient acceptability and usability of telemedicine.

How is the acceptability of telemedicine among the older population (patients older than age 65)?

Initially there was concern that using this technology would be burdensome and difficult for elderly patients. However, once coached on using the application, patients readily adopted the technology and often felt a sense of accomplishment in doing so. This is demonstrated by the fact that over a third of the patients in our pilot study were over age 80, and 10% over 90. Success in enrolling an older population is likely due to fact that during the set-up of telemedicine services the palliative care professional engaged the patient/caregiver with the telehealth applications and ensured their confidence and capability with the applications through demonstrated learning.

For the telehealth palliative care services, are these coupled with home-based pallative care also? Is this an option where palliative professionals can see the patients in their home?

Yes, at the initial palliative care visit patients are given the option of participating in the telemedicine program. Part of the telemedicine program includes videoconferencing where palliative care professionals can see the patient to assess health status, symptoms, wounds etc. Patients/caregivers can also take pictures in TapCloud that can be viewed by the palliative care team on the clinical dashboard.

It seems that telemedicine can allow for greater access to specialist palliative care for patients who don't have easy access. Do you believe telemedicine can replace most, if not all, face-to-face visits?

Yes, we believe telemedicine can replace most face-to-face visits. However, in the qualitative interviews, when asked about challenges or limitations to TapCloud/telemedicine, patients, caregivers, and clinicians alike noted that TapCloud/telemedicine is not able to replace the depth of in-person care. There seems to be great value in the initial in-person visit, in developing a trusting relationship and setting up the equipment for ease of use. In addition, telemedicine allows providers to care for more patients, increasing access to palliative care services. Clinicians noted that providing in-person services exclusively brings significant staffing challenges in rural areas because of long travel times, provider burnout, and the inability to care for many patients in a day's timeframe. TapCloud/telemedine has given these providers the ability to care for many more patients than if they focused solely on in-person visits.

How did you integrate the TapCloud telemedicine data into the medical record?

Currently, telemedicine visits by the various palliative care team members are added separately as notes into the patient’s electronic medical record. This gives the palliative care team the ability to review the input of the visit, but does not include specific TapCloud information. To obtain this, the provider logs into TapCloud and can then pull individual patient information.

Dr. Bull is the chief medical officer and head of research and development at Four Seasons Compassion for Life in Western North Carolina. She served as the principal investigator of Four Season’s CMS Healthcare Innovation Grant and is the current president of the American Academy of Hospice and Palliative Medicine (AAHPM).

Dr. Bonsignore is the senior medical and grant writer at Four Seasons Compassion for Life. She played a major role in Four Season’s CMS Healthcare Innovation Grant and pilot telemedicine project.

References

1. Patel K, Darling M, Samuels K, wt al. Transforming rural health care: high-quality sustainable access to specialty care. Health Affairs Blog. Dec 5, 2014. 
2. Bashshur RL, Shannon GW, Smith BR, et al. The empirical foundations of telemedicine interventions for chronic disease management. Telemed J E Health. 2014;20:769-800.
3. Lustbader D, Mudra M, Romano C, et al. The impact of a home-based palliative care program in an accountable care organization. J Palliat Med. 2017;20:23-8.
4. Basch E, Deal AM, Dueck AC, et al. Overall survival results of a trial assessing patient-reported outcomes for symptom monitoring during routine cancer treatment.  JAMA. 2017;318:197-8.