Remarks to the American Telemedicine Association

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by HRSA Administrator Mary K. Wakefield

June 27, 2013
Washington, D.C.

Thank you for the opportunity to speak with you today about the role that the Health Resources and Services Administration, or HRSA, plays in the deployment and expansion of telehealth technologies to expand access to high-quality health care, particularly for disadvantaged Americans who live in underserved urban areas or rural communities.  

From our perspective, telehealth holds the promise of improved health outcomes far beyond those of rural communities, but rural America in many ways has been a “test bed,” if you will, for telehealth, and I think that so far, it is in rural communities where its impact is still being felt sometimes.  Because even just a small improvement in efficiency and access to care can make a huge difference for people living in the most isolated areas across the country.

And as you may know, rural health challenges resonate with me personally. I’m a native and resident of North Dakota, and I have seen the impact of telehealth in North Dakota, where the realities of geographic isolation and some tough winter weather have made technology and telehealth service delivery a key player in the provision of health care.  I think that when it comes to accessing health care services, what we’ve learned in North Dakota is that necessity is the mother of “innovation,” and that’s driven new technology-based solutions.

When I came to HRSA in 2009, I wanted to capitalize on what we’ve learned from rural telehealth applications, and so I moved the Office for the Advancement of Telehealth back to the Federal Office of Rural Health Policy.  While doing so, I also worked to ensure recognition that telehealth has moved beyond its rural roots, so that employees across HRSA engage in efforts that focus on how this technology can improve care in urban and rural areas.  We see many opportunities to leverage telehealth for partnerships with HRSA’s programs.  These include:

• The national network of health centers, which provide primary and preventive care to about 21 million mostly low-income patients at some 9,000 service sites.  In 2010, 65 percent of health center grantees had adopted Electronic Health Records. By 2012, this number grew to 90 percent.  
• Our 900 Ryan White program grantees deliver health care to more than half a million low-income people with HIV/AIDS. Relevant to our conversation here, the program is working to create an implementation guide that will allow hundreds of grantees to better manage and report patient care through the secure use and sharing of patient health information.
• The Maternal and Child Health Bureau’s block grants to states help tens of millions of mothers and their babies access care and services to ensure healthy births and healthy infant development.  The Bureau funds a number of telehealth projects.

For example, a pilot project in Gallup, New Mexico, is providing pediatric audiology services via telehealth; in West Virginia, a telehealth clinic at St. Joseph’s Hospital is using Mountaineer Doctor Television to provide access to specialty care services; and a project in Arkansas is providing telehealth consultation to physicians and other pediatric providers to triage children with suspected Autism Spectrum Disorder.

The focus on your work is also apparent in other HRSA programs.

• The National Health Service Corps places nearly 10,000 primary care providers in underserved urban and rural areas for at least two years in exchange for scholarships or student loan repayments.  Earlier this year we revised policy to allow NHSC clinicians to provide up to 8 hours a week of telemedicine-based services as direct patient care as part of their clinical practice requirements.
• At the Bureau of Health Professions, many of our Area Health Education Centers Program grantees are integrating tele-learning opportunities for health professions students, preceptors, and health care providers serving in rural and underserved areas.   These online and video technologies allow students and faculty to access up-to-date medical information and distance education training while in remote sites.

So while clinical telehealth delivery is what gets much of the attention, we also know how important it is to use technology to deliver continuing education, grand rounds, distance-based health professional training, and oversight. The use in strengthening personnel is also an important issue for us.

• And of course we have the HHS Office of Rural Health Policy, which advises the Secretary on health issues in rural communities and coordinates activities related to rural health care within the Department.

The continued expansion and innovation we’ve seen in telehealth has implications not only for HRSA’s programs, but for our entire health care system.  That’s why last summer we funded a workshop by the Institute of Medicine to take a fresh look at telehealth issues.  

The workshop addressed a number of questions that you are surely familiar with:  What is the role of telehealth in a health care system predicated on value and improved outcomes?  How do we use this technology to improve care coordination?  What can we do to help clinicians work together in team-based care?  And how can industry and government work together to shape forward-thinking policies that answer these and other questions?

That IOM expert workshop resulted in an important summary that was released this past November.  It’s available at no cost from the IOM website at IOM.edu.

Before last year’s workshop, it had been more than 15 years – or 1996 – since the IOM had focused on telehealth.  So when Sherilyn Pruitt, who heads our telehealth activities in the Office of Rural Health Policy, proposed this idea, I supported it wholeheartedly.  

Given the significant changes under way in the nation’s health care sector, we felt it was time to think more creatively about telehealth.  A major part of that shift is the move from a health care system focused on volume to one that emphasizes value.   

You see that orientation in new models of care such as Accountable Care Organizations and Health Homes, which are more actively focused on outcomes than on quantity of care.  

I think that point is made clear in the IOM summary report from that meeting.  And while there are still policy challenges out there, I think the report shows that there are some exciting things going on in this field that merit attention.  

As you know and as we recognize, we’re seeing exciting new applications, from things like E-ICU and E-emergency to experimental phone apps that provide a glimpse of things to come. At the same time, the cost of the technology associated with telehealth – like the cost of all these types of technologies— is dropping rapidly, while products are becoming easier to use and more widely prevalent in the marketplace.

Related to that, one way that telehealth is playing a key role in finding new efficiencies and driving better outcomes is through awards made by the Center for Medicare and Medicaid Innovation, created by the ACA to support the development and testing of innovative health care payment and service delivery models.  The funds support projects that focus on people enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program.

For example, Emory University, the Philips Company (a tele-ICU contractor), and several medical centers received an award to train critical care nurse practitioners and PAs to use tele-ICU services in underserved and rural hospitals in northern Georgia.  

And the University of Iowa, in partnership with the 11 hospitals comprising its Critical Access Hospital Network, is receiving an award to use telehealth and web-based personal health records to improve care coordination and communication with practitioners in 10 rural Iowa counties.

Beyond telehealth’s role in expanding access to health care services, there is a growing body of evidence showing the potential for telehealth to improve the quality of care.  If used properly to maximize the functionality of electronic health records, registries, and databases, it’s possible to generate quality measures that provide timely, understandable, comprehensive, and clinically valid feedback to safety net providers and their practice teams.

This information is critical for informing a quality improvement strategy, and it’s especially important when health care providers function in a Patient-Centered Medical Home care models or Accountable Care Organizations.    

Within this broad context, we have been making significant investments in telehealth technology in HHS and across government.  

One of the many ways HRSA has been channeling its resources in this arena is through the White House Rural Council, created in July 2011 to enhance the ability of federal programs to serve rural communities through collaboration and coordination across agencies.  

Telehealth is an important area of focus for the Council.  For example, through the Council, we’ve worked closely with the Veterans Administration to identify ways in which we can work together on telehealth issues to improve access to care for veterans, especially those in rural areas.  

Last September, the Council facilitated a memorandum of understanding between HRSA, the Office of the National Coordinator for HIT, and the Veterans Administration.  

As part of that initiative, HRSA refocused $1 million in pilot projects in Alaska, Montana, and Virginia that looked at ways to enhance care for Veterans living in isolated rural areas by leveraging health information exchange and enhanced use of telehealth.  

Another wide-ranging telehealth initiative you may be familiar with is the cross-federal work group on telehealth, or FedTel, which shares knowledge and experience on their own telehealth experiences and identifies collaboration opportunities.  Twenty-six agencies and offices across government with an interest or investment in telehealth are partners in FedTel.

The CMS Innovation Center I mentioned earlier is also funding some unique projects through its State Innovation Model awards to support the development and testing of state-based models to improve health system performance.  

Under this program, Vermont was awarded $45 million for improvements in health system infrastructure that include enhanced telemedicine and home-monitoring capabilities.  Hawaii will examine ways to reimburse telehealth services, and Pennsylvania will examine innovative, advanced telemedicine services, particularly in rural areas.

It’s our hope that projects like these can help inform future policy development, and we’re working to make sure that State Offices of Rural Health are linked into these activities.

We’ve also been working closely with CMS on these projects, and we linked them and the CMS project officers to our Telehealth Resource Centers, which help health care organizations, networks, and providers implement telehealth programs to serve people in rural and underserved areas.  

HRSA currently funds 11 state-wide or regional Resource Centers and cover almost the entire country, from Pennsylvania to the Pacific Basin, with experts that provide technical assistance to HRSA grantees and rural communities that are interested in starting or enhancing a telehealth program.  

We also fund two national Telehealth Resource Centers – one that focuses on policy and one dedicated to telehealth technology.   With the costs of telehealth equipment coming down, we’re seeing the potential for greater deployment of this technology.   And so we now have a national network of TRCs that cover all of the 50 states providing technical assistance at no cost to folks who are seeking assistance.

And as we award a new set of HRSA Telehealth Network Grants this summer, we’re moving toward a stronger focus on how the use of telehealth technology can drive better health outcomes, and quantifying that impact will be an explicit part of our program.  

For those of you not familiar with it, the Telehealth Network Grant Program funds projects that demonstrate the use of telehealth networks to improve healthcare services for rural and frontier communities.

This year we are providing about $5.6 million to support 23 grantees, and we anticipate providing grant funds to support 8 more grantees beginning September 1.  

We’re also seeing some really innovative projects in telehealth through the work of the Beacon programs in the Office of the National Coordinator for HIT.  HRSA has awarded $8.5 million to 85 health centers located in 15 Beacon Communities throughout the country to help them adopt HIT for long-term improvements in quality of care, health outcomes, and cost efficiencies.

For example, one of these grantees, the Colville Nation Community Health Centers, expanded its services to non-native communities in north-central Washington state.  The grantee is successfully using a Remote Patient Monitoring System to improve patient monitoring, allow early interventions, and modify treatment plans, thus reducing the need for emergency room visits.  

And closer to home for ATA members, last year we had the unique opportunity to award a grant to the American Telemedicine Association, which provided information and technical assistance regarding state telehealth policies to Telehealth Resource Centers, HRSA grantees, public officials, and others offering telemedicine services. The grant makes use of your extensive network of contacts in each state and your in-depth knowledge of state telemedicine policies and states with "best practices” in telemedicine, which are extremely useful to everyone in the industry and government.

Related to all this is the issue of licensure portability, seen as a strategy to improve access to care through the deployment of telehealth and other electronic practice services.  But licensure portability goes beyond improving the efficiency and effectiveness of electronic practice services.  

Licensure requirements and barriers to cross-state practice should be seen as part of general considerations around the mobility of health professionals in order to address workforce needs and improve access to care.  

To consider this approach, we established the Licensure Portability Grant Program, which provides support for state professional licensing boards to develop and implement policies that will reduce statutory and regulatory barriers to telemedicine.

As you can see, there are many ways that telehealth can play an important role in our health care system, and HRSA is committed to fully engaging this agenda.  

Looking ahead, new technologies have become a key component of the next and final phase of the ACA.  As you may know, a new Health Insurance Marketplace will open in every state on October 1, giving Americans a whole new way to shop for health insurance.  And both information about new insurance options and enrollment in new health insurance plans will be available electronically.   

The Department is using consumer research and online commercial best practices – including the integration of social media and sharable content – to provide consumers with information.  

For the first time in the history of the private insurance market, consumers will be able to go to one place – the website healthcare.gov – to check out their coverage options, get accurate information in easy-to-understand language, and make apples-to-apples comparisons of plans before they make their decision.  

The website is built with a responsive design so that consumers can access it from desktops, smartphones, and other mobile devices.  Consumers will be able to create accounts, complete online applications, and shop for qualified health plans.  The website is available in English and Spanish, and is also available via an application interface for developers.

As the new Health Insurance Marketplace goes live, the importance of telehealth will continue to grow, as more and more people in rural and isolated areas obtain health insurance coverage and seek health care services.  We will need to find innovative ways of meeting rising demand, and telehealth will be a crucial and determining factor in meeting this challenge.  

In addition, some people will need to learn the basics about how health insurance works, making the challenges we face even greater.  So getting these folks engaged is going to be critical, and this is where I’d ask you to consider helping us in making sure that those who aren’t in the health system get in.  

If you haven’t already, please take a few minutes to go to healthcare.gov and see what’s there.  And I urge you to send patients, family members, colleagues, and neighbors there to help them learn more about health insurance coverage.

In closing, I want to stress that we at HRSA and HHS are proud to be partners with the ATA and all of you in harnessing technology to improve care, and do so as efficiently as possible.  We look forward to working with you.  Thank you.