by VISIONS staff
As we enter a new political era, uncertainty is the only sure thing, and when it comes to the healthcare sector, this is doubly true. The Affordable Care Act (ACA) is almost certain to be repealed and the nature of its replacement, if and when a replacement is enacted, is anybody’s guess. A new and philosophically different Secretary of Health and Human Services (HHS) is likely to “shake up” healthcare in many ways. Yet there is some certainty amid this era of change: technology continues to advance at a rapid rate, promising to transform healthcare delivery in many ways.
THE PROMISE OF TELEMEDICINE
High on the emerging healthcare technology list is telemedicine, also known as telehealth. Such patient communication and coordination technology was initially coverage-oriented––as a tool for providing better service access to distant underserved populations. But the rationale for telehealth has evolved to also serve as a tool for ensuring quality patient care, and patient satisfaction, facilitating group coordination and reviews, and managing costs more effectively.
Akin to other primary care areas, occupational health practitioners are using telemedicine to examine patients with work-related injuries directly at their worksites and to conduct screening examinations remotely.
Some of the advantages conferred by the various telemedicine software applications include:
1. A decrease in employee lost time from work and absenteeism
2. Applications are mobile so practitioners can use them on the go
3. A convenient approach to wellness education at both the individual and group levels
4. Seamless and longitudinal med management
5. The availability of core occupational health services at on-site clinics
6. An avenue to enhance ACA compliance
7. The ability to monitor physical therapy remotely
8. A decrease in physical injuries incurred traveling to and from a clinic
Telemedicine can also serve as a teaching tool through which practitioners can observe, show, and instruct practitioners in another location with more effective or faster examination techniques. In addition, telehealth breaks down geographic barriers and can serve the community in a more efficient way.
Kelly Duncan, operations director for Georgia-based Salus Telehealth (http://salustelehealth.com/), spoke on “Innovations in Telemedicine” at RYAN Associates’ 30th Annual National Conference last October in Boston. “Telemedicine provides our clients with access to both urgent and specialty care. It enhances consistency and helps boost client company profits by reducing unnecessary costs.” Like many telemedicine products, Salus possesses its own EMR.
Ms. Duncan noted that telemedicine offers images that are often clearer than real-time face-to-face visuals. Further, you can take screenshots. “We have noticed spikes in patient satisfaction when telemedicine is used,” noted Ms. Duncan.
In addition, telemedicine service providers note that the technology is invaluable when it comes to coordinating associated community physicians, said Ms. Duncan.
Ms. Andrea Comporato, vice president of sales and strategic solutions at American Well, a national telehealth technology company, (www.americanwell.com/) noted that telehealth can decrease lost-time claims and expedite the return to work process through more timely access to in-network care throughout the life of a claim. Telehealth can be deployed to examine initial workplace injuries using high-definition video consultations, to assess and triage care in a timely manner. In addition, Ms. Comporato noted that “telehealth supports operational efficiency through load-balancing, allowing clinical staff at a single location to be projected to multiple locations, improving access to care for employees in rural areas and expanding service hours to 24/7 with no or limited additional overhead.”
TELEHEALTH APPLICATIONS IN OCCUPATIONAL HEALTH
Core occupational health services can include virtual clinics based in an office building where there is a large concentration of employees; mobile applications used by workers facilitate 24/7 access to physicians, health coaching, physical examinations, health histories, triage, and follow-up care, as well as urgent care. Mobile apps are or will be available for wellness management, psychiatry, and addiction issues.
There is a role for behavioral health as well. Jeff Kesler, Ph.D., president of Salus Telemedicine, said that telepsychology can be an important component of an overall occupational health strategy.
Ms. Comporato noted that telehealth can help with the management of chronic diseases like diabetes and asthma. “For example, a patient can walk around their home with a smartphone and show a registered dietician what’s in their refrigerator or pantry and develop a care plan.”
David Kobrinetz, national director of Telemedicine for U.S. HealthWorks (www.ushealthworks.com/), emphasized the crucial role of patient satisfaction. “You need to always be asking ‘How does this work for the patient?’ The patient experience guides everything else.”
GETTING STARTED
Salus Telehealth’s Dr. Kesler feels that the appropriate starting place for an employer is to ensure unfettered organizational commitment at the senior management level. When committing to a telemedicine initiative, step one should be to identify the user organization’s goals. Dr. Kesler believes companies need to be aggressive and committed to reaching out to their workforce, whether it is through fliers, health fairs, or other avenues used for frequent communication.
The degree to which an occupational health program invests in telemedicine hardware, software, and training will vary depending on the size and opportunity within their market and the nature and complexity of their goals.
Hardware and software required for telemedicine can run anywhere from $10,000 to the six-figure range. A basic telemedicine equipment cart can cost $40,000 to $50,000 per cart, although much can be done on a simple laptop. In some cases, smaller medical groups can start with a subscription rate (e.g., $500 per month per physician) or their own branded enterprise system with full flexibility to configure as desired for $300,000 or more.
Turn-key training typically takes one to two hours and involves some type of on-site demonstration. For example, individual patients/employees may view a mock physical exam to better understand what telemedicine can do for them. Train the trainer and group training sessions are also common. Dr. Kesler noted that “depending on goals, messaging will vary.”
—Andrea Comporato
—David Kobrinetz
Out-of-pocket costs for individual workers are usually modest. Such telemedicine services are usually either covered by an individual’s health plan or delivered on a highly affordable cash basis––less than it would cost the employee to see a physician.
Occupational health programs are encouraged to consider:
- Policies, protocols, and standards to ensure consistency of care
- HIPAA security and a HIPAA-compliant environment
- EMR capability
- Defining and then setting up a platform with technical support
Some training considerations seem simple and yet are critical, according to America Well’s Comporato. “For example, lighting issues or where and when a provider looks at the camera are important.”
SUCCESS FACTORS
Telemedicine experts cited several keys to success, including:
- A well planned implementation strategy
- The establishment of target goals such as fewer sick days, fewer urgent care visits, various wellness issues, early detection and management of chronic diseases such as diabetes, or a reduction of hands-on physicals
- Pre-defined metrics such as a reduction in a company’s healthcare costs
- The quality of facility and physician onboarding (a process to welcome and educate new physicians to an organization) and training.
- An organizational commitment to “own” telehealth at the executive level
- A project manager who can bring together a team that will bring occupational health–related telehealth to the community, including care staff, IT liaisons, and relevant sales/ marketing personnel
- A social media presence is largely dependent on available assets such as a partnership with a payer organization
- Workforce management including proper logistics and hours of service
U.S. HealthWorks’ Kobrinetz noted that “The necessary resources may be available but execution is much harder. It is not just the financial support and technology, but the human resources required to make sure care works.”
MINEFIELDS
Professionals interviewed for this story were asked what the most common snafus and hitches their clients have encountered are; that is, what is likely to go awry?
Dr. Kesler emphasized two potential hitches: follow-through and messaging. “It is easy to think that it is simple, but you don’t just purchase the equipment and assume utilization. You can’t just give people an app and assume they will use it. Frequent positive messaging to the employee base, provider commitment, and an understanding of the technology are the keys.”
Concerns about receptivity from employees are unfounded. All parties interviewed for this story noted that the vast majority of employees working with the technology love it.
For her part, Ms. Comporato felt the most significant issues were marketing, driving engagement with consumers, and integrating telehealth into a physician’s daily workflow. “It is a virtual practice. Physicians should have their provider mobile app in their pocket all of the time.”
Mr. Kobrinetz believes that the challenges are roughly the same as with other clinical activities. “The same kind of barriers that affect us in our clinics…balancing clinical and operational strengths to ensure we deliver quality above all else.”
FUTURE VISIONS
A key to long-term success in most fields is the ability to visualize the future and be an early adapter to that vision.
Dr. Kesler identified a compelling future. “Cars with sensors in the steering wheel will allow for the continuous monitoring of pulse, blood pressure, oxygen saturation level and blood glucose; workers will all be continuously assessed 24/7. Of course, within the next 20 years many will have chips imbedded in their body that will, among other things, facilitate the early detection of potential diabetes and heart disease.”
EXPERT ADVICE
What do N.A.O.H.P. members need to know in order to embrace the brave new world of telehealth?
Ms. Comporato: “Don’t let others bypass you. Take advantage of the incredible technology available to extend critical services into the community.”
Dr. Kesler: “Every company ought to be providing telehealth services to their employees. It is just a matter of time; telemedicine will change the way healthcare is delivered.”
Mr. Kobrinetz: “Go all in. Your organization needs to be financially and operationally committed to a new service.”
Dr. Warner Hudson, medical director of occupational health at UCLA noted that “Amazingly, patients I have been studying actually prefer this to seeing doctors in person. It’s because they have their doctors’ undivided attention; the doctors weren’t distracted by the myriad things in the exam rooms.” 1
Dr. Molly Coye, chief innovation officer for the UCLA Healthcare System said “Imagine two or three years from now, when all hospitals and clinics in California are connected by broadband and we have the opportunity to offer services to places throughout California, the country and the world. This will reconfigure the way our professionals provide care. It will reconfigure our financial arrangements, how we make money, and who we serve, and it will completely rearrange the way patients receive care.”
Steve Jobs once said, “I have a great respect for incremental improvement, but I’ve always been attracted to the more revolutionary changes. Because they’re harder. They’re much more stressful emotionally. And you usually go through a period where everybody tells you that you’ve completely failed.”
Change in healthcare, while inevitable, can often be a long, laborious and uncertain process. Special interests reign, territorialism abounds and the next new thing often strangles the last new thing in its infancy. Given a new national administration committed to change, change is likely to proceed at an unprecedented pace and in ways we can’t predict.
So it has been with occupational health during the past several decades. There are invariably new visions, and often there is only short-term progress associated with these visions before the trail turns cold.
One of eleven courses at RYAN Associates’ 30th annual conference in Boston addressed the future of occupational health. Four sessions offered uncommon insight into where we have been, where we are, and where we are going. Course faculty cited in this story include:
- Dr. Tom Winters, Occupational Health Chief and President, the Occupational and Environmental Health Network in Marlborough, MA
- Dr. Karen Huyck, Assistant Professor, Dartmouth Hitchcock Medical Center and Dartmouth Medical School in Lebanon, NH
- Dr. Madelynn Azar-Cavanaugh, Medical Director of AllOne Health, a Massachusetts-based company with more than 70,000 clinicians that provides a wide array of occupational health, wellness, and population health services to employers.
- A “visionary panel” including Barry Eisenberg (Executive Director of ACOEM), Dr. Barry Magnus (regional medical director at Concentra), John Garbarino (former C.E.O. of Occupational Health + Rehabilitation) and RYAN Associates’ founder and former President, Frank Leone.
Panel members were asked to reflect on what prominent change forecast during recent decades turned out to be less impactful than originally projected and why.
Dr. Magnus zeroed in on the less-than-desirable impact of wellness programs on worker health when included in the occupational health umbrella. He noted that there is a “chronic inability to provide current and prospective wellness employer clients with a meaningful ROI projection.” Dr. Magnus added “The proper evaluation of corporate wellness programs is based largely on long-term effects which become virtually impossible to measure given the short-term mobility of so many employees.”
For his part, Dr. Winters noted the inordinate power and entrenched position of insurers in effecting change. But, at the same time, he added “The insurance industry is fragmented, thus creating somewhat of a stalemate in terms of progress.”
At a more macro level, Mr. Leone said that current occupational health professionals should “‘beware of the ‘next big thing.’ At various times managed care, workers’ compensation reform, PPMs, PPOs, MCOs, ACOs, and Patient-Centered Medical Home Models (PCMHs) were hailed as the new face of healthcare. Yet in our special interest world, it is difficult to jump on any new bandwagon.”
Panelists cited a variety of other stalled concepts:
- Insufficient progress on service integration
- Fewer for-profit occupational health system/healthcare system joint ventures than initially thought
- An inability of the workers’ compensation system to merge into the larger healthcare system
Given the slow pace of change, it may be time for a reset and a short pause before we identify the next wave of changes.
THE NEXT WAVE
Dr. Winters associated our industry’s likely evolution with significant changes and innovations that are already underway.
“We need to adapt to a changing work environment. There are new job types, emerging markets, more women in the workplace, a proliferation of nanotechnology, and, within five to ten years, the 30 hour work week.”
Dr. Winters continued, “Climate change, for example, is certain to have an increasingly profound effect on workplace health. For example, the effect of climate change can trigger a greater prevalence of asthma, new, more debilitating allergies, and more infectious diseases, and accentuate numerous mental health issues. As a result of climate change, these are likely to all move up on the (occupational health) agenda.”
Dr. Winters cited the obesity epidemic as a foreboding trigger. “It (obesity) alters ergonomic approaches and stimulates a greater prevalence of cardiovascular disease and diabetes. Sitting down issues are stealth and likely to get worse, resulting in more degenerative disk diseases and other related conditions.”
The new occupational health paradigm is likely to move further than these issues. Dr. Winters forecast a wide range of additional changes:
- Circadian disorders borne by shift workers affect mental health and need to be addressed.
- The worker mix is changing: there are more contingent workers and non-employees, resulting in more workers with partial or no health coverage.
- The emergence of autonomous vehicles will decrease the prevalence of DOT physicals. • Data overload, as a result of more cameras and sensors, can vastly increase stress-related conditions.
- The treatment of many mental health conditions will change as our society uses fewer pharmaceuticals such as anti-depressants and as pharmaceutical solutions are replaced by more functional jobs and supportive managers.
According to Dr. Winters, the workplace setting of many occupational health professionals will also change. “There is likely to be a decrease in corporate-based occupational medicine professionals and a proliferation of more highly specialized consultants.”
Dartmouth-Hitchcock’s Dr. Karen Huyck emphasized the need to use occupational health to “ignite” a transformation of American healthcare from a “sick-care” system to a “healthcare” system. Dr. Huyck noted that there is an inexorable link between occupational medicine and an organization’s ability to develop functional Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs). For example, a classic ACO is based on physicians and other practitioners coming together to provide care that increases value and enhances quality while minimizing costs. Such a structure is at the core of occupational health practice.
For their part, PCMHs stress a whole-person approach to providing care which should be the heart and soul of every occupational medicine practitioner’s mission. “You will need the connection to an employer base for ACOs and PCMHs to be successful,” stressed Dr. Huyck.
“Work affects health and health affects work,” said Dr. Huyck. Workers need to come to work healthy and a central role of an occupational medicine physician is to enhance the health status of both individuals and populations.” Dr. Huyck appears bullish on occupational health, “The potential leverage available to a single occupational medicine physician can affect the well-being of tens of thousands of individuals.”
Dr. Huyck also emphasized the “psychological health of the workplace.” She noted ten primary health risk factors that can and should be addressed at the workplace that are associated with an increase in chronic disease: back/neck issues, depression, fatigue, chronic pain, sleep problems, high cholesterol, arthritis, hypertension, obesity, and anxiety. Dr. Huyck noted that these risks are inherently interrelated; that is, the incidence of one condition stimulates the development of others, yet many practitioners tend to view them in isolation if at all.
HOW WE NEED TO CHANGE
What, then, do we need to do to manage change as we move forward?
Mr. Eisenberg, executive director of ACOEM, noted the “need to better tie occupational medicine to workplace safety. Traditionally there is little to no linkage of the two while considerable new evidence has emerged that a healthy worker is a safer worker. We need to associate both work-related and non-work-related incidents with a worker’s ability to work effectively.” Dr. Eisenberg cited the oft-stated notion that someone who reports to work on Monday after incurring a softball injury over the weekend may still be unfit for duty.
The lack of certified practitioners is a significant impediment to keeping occupational medicine out of the mainstream.
“Few realize that only 4,043 physicians have been certified since 1949. We gain about 90 new board-certified occupational health physicians a year while losing about 200-300 a year due to retirement and other factors. Given that our nation still incurs about 4.5 million injuries per year, we can conclude that occupational medicine is still a supply-dominated specialty.”
What will it take to bring more certified occupational health physicians (and other practitioners) into the fold?
OneCall’s Dr. Azar-Cavanaugh stressed the need to generate greater specialty awareness at the basic level. “During grand rounds, I learned that half [of physicians] have not heard of the specialty, and only a few knew occupational medicine was a specialty. We need to come together to at least get occupational medicine on medical school curriculum.” Others noted that occupational medicine was often not even on the list that would-be residents could match up to.
“If occupational medicine continues as it is currently defined, it is destined to languish, if not perish.”
Frank Leone noted, “If occupational medicine continues as it is currently defined, it is destined to languish, if not perish.” The specialty needs to redefine itself by actually renaming it. There is a precedent, noted Mr. Leone, “ACOEM was once labeled “ACOM” until the specialty realized that “Environmental’ should be included in the title. A redefinition/ renaming needs to pull together a new vision of occupational medicine that integrates multiple specialties.”
The dream will endure. In the words of beloved Civil War-era abolitionist Harriet Tubman, “Every great dream begins with a dreamer. Always remember, you have within you the strength, the patience, and the passion to reach for the stars to change the world.”
The pieces for a new and considerably more impactful world of occupational health are within our grasp. We need to think big, learn from the past, and advance a powerful vision of occupational health as an integral part of the new healthcare dynamic.
