Access to preventative care in the United States is a substantial challenge. Preventive care is an essential source of care providing timely screenings and vaccines, early detection of illness and proper treatment of disease. Lack of access to care effects; birth outcomes, prolonged detection of disease, poor disease management, comorbidities and morbidity. Geographic related barriers, limited hours of operation and lack of transportation hinder the ease of utilizing primary care services. As we see a shift in the United States health, with chronic illness at the forefront, primary care is arguably more important than ever in addition to coordinated care across specialties. The implementation of technology based solutions in this day and age is extremely valuable. New technologically based innovations in addition to reverse innovations can aid in overcoming these preventative care access barriers in the United States. In this paper, we will provide a brief overview of the lack of access to preventative care in the United States in conjunction with the utilization of telemedicine to address this issue. We will describe telemedicine, how it works, and how our solution offers a unique approach in utilizing current telemedicine services. This reverse innovation of telemedicine technology will provide better access to necessary preventive care in the United States, particularly to the most vulnerable populations; the aging and rural citizens.
The lack of access to preventative care poses a national challenge, particularly in rural areas in the United States in maintaining optimal health outcomes. Preventative care is a form of care including routine screenings, check-ups and patient counseling to prevent illness and disease, as defined by healthcare.gov, in addition to the management of chronic illness. Preventative care is an essential health service necessary for improving the health of the United States population. The aging and the rural populations are among the most at risk for these unmanaged chronic illnesses due to the lack of access. The CDC reports that more than two-thirds of the United States adult population believe that the health care system should place more emphasis on chronic disease prevention (“Centers,” 2009). There are many barriers affecting an individual’s access to care that provides the resources for disease prevention and management. In response to the demand being made by two-thirds of the United States for more emphasis on preventive care, our team has developed a technologically based innovation which poses a solution to geographic and transportation barriers, specifically in rural areas. Through the use of telemedicine we are aiming to improve disease prevention and chronic illness management for the United States’ most vulnerable populations.
According to a Health Status and Health Care Access report, people living in rural areas of the United States, experience lower access to preventative care which is attributed to proximity issues when compared to urban areas (Jones et. al., 2009). Making the proximity even more burdensome is travel limitations as reported by non-urban households trying to reach primary care providers (Jones et. al., 2009).
While proximity as being a common barrier experienced by the rural population, some residents have no choice but to forego care altogether. HPSA, Health Professional Shortage Areas, are areas that are recognized for lacking health professionals in primary care, dental and mental health providers. The number of full-time healthcare professionals is compared to the populations in addition to high-need indicators such as income in determining which areas lack providers. Commonly, the rural areas of the United States are labeled as HPSA’s. The American Family Physician reports unequal distribution of primary care physicians in rural areas stating that the average primary care physician to patient ratio is 68 physicians per 100,000 persons in rural areas compared to the average 84 primary care physicians per 100,000 persons in urban areas (Peterson, Phillips, Bazemore, Koinis, 2013). As 19.3% of our population make up the rural community it is crucial that we improve access to care and take approaches specific to the barriers this population faces (“NRHA,” 2019).
The United States Census Bureau projects by 2030 there will be 78 million people 65 years or older living in the United States (“US,” 2018). With the predicted increase in the older population an increase in those living with chronic illness is expected. In fact, two-thirds of Medicare beneficiaries live with five or more chronic conditions (“Institute,” 2008). On average, adults 65 and older visit a physician twice as often as those under 65 averaging 7 visits each year totaling around 238 million visits (“Institute,” 2008). Transportation is crucial for these older adults in accessing healthcare services. Much of the older population values their independence and prefers to age-in-place. Transportation barriers correlate with poorer health care access, missed appointments, and poorer health outcomes (MacLeod, Ragland, Prohaska Smith & et. al., 2015). Transportation barriers arguably account for the over utilization of emergency services as well. Older adults use emergency services four times more than younger adults. In 2004, 13 million visits to outpatient hospital facilities were for reasons similar to visits handled by office-based physicians (“Institute,” 2008). Among the main identified barriers, limiting access to healthcare experienced by the older population include; inadequate design and availability of hospital care service and cuts in non-emergent health transportation.
Key Aspect of Problem
Lack of providers in rural areas
During an interview with a fire captain, working in the rural part of Green Valley, the overutilization of emergency services by the older population was discussed. He observed that the older population living on their own tend to call 911 because they cannot wait until their scheduled appointment to manage their illness or they have not done their part in managing their illness; missing appointments and not picking up prescriptions due to transportation issues.
The interview with Vera, who lives in a rural part of Delaware, was the most accurate information on an individual experience delay or lack of access to healthcare. Improving access process could be improved, for instance, through telemedicine coupled with direct access, where Vera could be seen by her primary care physician via telemedicine and then make an appointment to a nearby specialist via direct access. This would have saved her money in travel expenses and time spent driving to her primary care physician in Baltimore, MD.
Distance and Transportation
Individuals living in rural areas and the elderly in particular, face the challenge of travelling longer distances to seek medical care services and/or not having transportation to get them to accessible healthcare.. This burden can be significant in terms of cost, travel time and time away from daily activities of living (“RHI Hub,” 2019). The dependency on public transportation can be an inconvenience since public transportation is often lacking in these remote areas. Moreover, people living in rural areas are most likely the elderly with chronic conditions requiring multiple trips to primary care providers, which makes this a challenge without public or private transportation (“RHI Hub,” 2019). In addition, cut-backs in medical transportation costs is another barrier to medical services experienced by the elderly (“RHI Hub,” 2019).
Benchmark on Existing Products/Organizations
Currently the most common ways telehealth services are delivered are through video conferencing and remote patient monitoring. Primary care services involve an allied health professional in facilitating the consultation between the physician and the patient (“Telehealth,” 2014). The American Medical Association set guidelines for the utilization of telemedicine in its policy report form June 2014.It is required that a valid patient-physician relationship is established through a face-to-face examination before services are offered via telemedicine in most circumstances. Face-to-face could be virtual through real-time video and audio technology. There is also a limitation on the drugs that can be prescribed via telemedicine (“Telehealth,” 2014).
Zoom, the leader in modern enterprise video communications offers Zoom for telehealth which is a consistent, and reliable cloud platform for video and audio-conferencing. Zoom for telehealth is a HIPAA compliant tool that helps expanding patient care and communications and improving patient outcomes by maximizing resources and boosting communications. Zoom with its innovative technology focuses on providing a high-quality video even in low-bandwidth environments. This high-tech tool could be overwhelming to older generations who are mainly the target market for telehealth. In addition, the lack of customization and the personal touch could be another burden on this new technology. Here our telemedicine innovative model offers the ease of use to technologically challenged patient with a touch of personalization which keeps the comfort of the traditional health practice.
U.S. Based Programs
The use of telehealth tackles the geographic and hours of operation barriers, providing healthcare services such as primary care services, chronic disease management, medication management and mental health services on school campus (Moffit, Steffen, 2019). An on-site school nurse acts as the meeting facilitator connecting the student to a physician, using high-definition cameras and special equipment such as stethoscopes and otoscopes. Common addressed health issues include earaches, sore throats, colds, allergies, rashes, physicals and behavioral health services (“Rural,” 2019). Expansion is also limited in areas that have fewer than 1,000 potential people enrolled as it requires 1,000 enrollees to sustain a Health-e-Schools program. The lack of high-speed internet is also an expansion barrier, especially in the rural mountainous ranges of North Carolina which limit the areas Health-e-Schools programs can be utilized (“Telemedicine,” 2018). Political and Insurer support is necessary to fund high speed internet to necessary areas and cover the costs of such technology.
Amazon’s Virtual Assistant
Alexa Smart Speaker – The use of virtual technology opens the possibilities to deliver care at a distance. Alexa Smart Speakers in conjunction with an Alexa-enabled camera facilitates medical and health related tasks such as tracking blood glucose levels, description of signs and symptoms, access post-surgical care instructions and procedures, monitoring home prescriptions, and making same-day appointments (Rae-Dupree, 2019). A virtual assistant can also help physicians diagnose of mental illness, autism, and Parkinson’s disease (Rae-Dupree, 2019). A few number of hospitals, home health providers, clinics and insurers has already experiment with Alexa Smart Speaker technology. For instance, Alexa Smart Speaker technology allows the elderly population to connect with healthcare caregivers to set up reminders about medications, weight and blood pressure levels, and to schedule appointments (Rae-Dupree, 2019). What also makes Alexa Smart Speaker technology practical and unique is that it is HIPAA compliant (Perez, 2019).
Team 3: Telemedicine Innovation
The future of telemedicine, looks very promising as more and more health insurance companies are pushing for it. For instance, this is apparent through newsletters and emails, especially with government employees and with the Veterans Administration as being one of the first institutions to implement online healthcare to its veterans and employees. However, in terms of the actual conduct of telemedicine in for house calls, there is major hope this will replace the current model to a significant degree in the realm of “routine checkups.”
Our telemedicine innovation seeks to provide convenient access to medical experts at a reasonable cost to address access to preventative care challenges, for instance, in rural areas of the United States.
Telemedicine Definition: Basic/Enhanced Remote Coverage
There are various levels of telemedicine: basic remote coverage, enhanced remote coverage and facilitated remote coverage. Telemedicine uses real-time feature in a bi-directional, secure interface initiated by the patient through a video conferencing feature between the patient and facilitator or physician. The telemedicine option of using enhanced remote coverage can be utilized by a facilitator such as a nurse, specialist or other allied health professional, and used for wellness visits.
Team 3’s product
Through the use of telemedicine, the remote diagnosis and treatment of patients by means of telecommunications technology (Oxford, 2019), we will be able to provide in-home care to the at risk populations mentioned above. Our solution to the lack of access to care involved the use of telemedicine technology and a meeting facilitator; registered nurse, making house calls to those facing common access barriers. By having a meeting facilitator the care provided can be tailored to each patient while keeping the care provided as close to the traditional standard of care practiced in the United States. In addition the human interaction allows for a beneficial empathetic interaction format versus the sole use of technology to provide care. This allows for the population who does not consider themselves “digital natives” to feel comfortable using such technologies.
Our Telemedicine design will utilize a basic remote coverage as we are covering home health clientele. Our service includes a licenced facilitator; registered nurse therefore we may resort to a Facilitator Remote Coverage. This coverage is typically used for non-provider visits. Our design will use real-time feature in a bi-directional, secure interface for low acuity services initiated by the patient via video conferencing between patient and facilitator or physician. An enhanced remote coverage, that can be utilized by a facilitator such as a nurse, specialist or other allied health professional, will be used for wellness visits. Peripherals will be used for diagnostics including; stethoscopes, otoscopes and ultrasounds, that allow for the distant physician to clearly assess and guide treatment to the patient.
The University of Minnesota offers continuing professional education for RNs who are interested in effectively facilitating care via telehealth. Continued education programs like such would be required for the nurses facilitating the in-home care for our patients. In addition to learning the technology, nurses taking these courses learn the necessary safety measures that should be taken when using the equipment, the healthcare policies around telehealth and the ethical and legal principles (“Telehealth,” 2014). Current telehealth operations in California require a facilitator to be licensed in the scope of practice (“Telehealth,” 2014).
Technology literacy is also important in patient use especially with telemedicine. Populations that exhibit low technology literacy are from low-income, rural, and minority backgrounds. To give patients full capability and use of telemedicine, we may recruit the use of social workers to be physically present with the patients to give thorough understanding of telemedicine and how to use the service on their own.
Costs related to quality healthcare services continue to increase year by year causing both financial and capacity constraints. The ease of use and affordability of telemedicine can help reduce financial and capacity restraints. For instance, the average estimated cost of an acute care visit is between $136 and $176 versus $40 to $50 for a telemedicine visit. (American Journal of Managed Care, 2013).
Most telehealth services are paid for through the fee-for-service reimbursement method. Due to the recent recognition of telehealth’s benefits both state and national levels are considering financial support changes (“Great,” 2019). However, Medicare currently offers a limited amount of coverage for the utilization of telehealth particularly limiting its use for the rural population only. Although, the fragmented healthcare system results in coverage varying by state. Thankfully, other providers have offered greater coverage for a wider range of telehealth services (“Telehealth,” 2016). Medicaid also covers services, again varying by state. A physician or licenced facilitator may be reimbursed at the “distant site” fee and the facility can file for the “original site” reimbursement. In addition technical support, equipment and transmission charges may be reimbursed based on a fee-for-service reimbursement method or an administrative cost determined by the state (“Telehealht,” 2016).
Facilitators will be HIPAA trained and required to get informed consent from the patient before telehealth technologies are used ensuring that the patient understands the facts and risks involved. Reliance of the EHR will be significant in these consultations therefore our facilitators will connect to the physician through a secured network in addition to using blockchain storage; “read-only” format allowing for no changes to be made after the initial submission to the EHR.
As a team we acknowledged the detrimental effects that lack of access to care has on the United States population’s health. We see this lack of care resulting in poor health for a significant portion of the population. Often proper prevention services and chronic illness management needs are not being met as a result of this limited access.
In efforts to improve access to preventative care telemedicine technology can be utilized during home visits to provide the highest quality care to its patients while diminishing the accessibility barriers such as transportation and lack of available physicians.
What differentiates our innovation from competitors is the ease of use, affordability, and personalization. Telehealth is often seen as a cost-effective method in delivering patient care and increasing access. In 2016, the VA estimated an average annual savings of $6,500 per patient. In 2013, Vermont saved $63,804 per patient through the utilization of home-based telehealth and telemonitoring eliminating time and travel expenses (“Telehealth,” 2016). Our unique approach to providing telemedicine care while having a licenced facilitator allows for easy and accurate use of such technology.
Individuals living in rural areas in the US with a limited access to preventive care. Such care is essential in providing timely screenings, vaccines, early detection of illness and proper treatment of disease. This limitation of access is due to shortages of primary care physicians, locations and transportation-related barriers, lack of health coverage and health illiteracy and language barriers.
Cost focus in our niche market “access to care in rural areas” is the biggest competitive advantage. In general, the rural population makes up at least 15 to 20 percent of the United States population. This population often faces healthcare inequalities resulting in worsening health conditions compared to urban and suburban residents. In the rural areas of the United States, the underprivileged or vulnerable populations often face barriers of access to healthcare services.
According to the United States Census Bureau, in 2016 there were about 27.3 million people in the United States who did not have health insurance. Although our model is targeting a narrow market, the economies of scale needed to compete based on the cost focus would be applicable due to the big segment of individuals living in rural areas in addition to the uninsured and/or underinsured populations.
Telemedicine does have a future. However, it will be limited by the physical technology available to patients, especially in remote areas and aging population who have a difficult time maneuvering the intricate aspects of technology and medical equipment. We currently see the benefit of telemedicine for house calls for preventative care, such as routine check ups with the assistance of an RN facilitator in efforts of eliminating the limitations mentioned above. To avoid network interruption, it is suggested that the basis of the secured network be used by satellite service. Only the facilitator will have access to this network and the network will be hidden from outside users to discouraging them from attempting to connect. PHI is a top priority and will abide respectfully to the Health Information Technology for Economic and Clinical Health Act, “to provide assurance that the EHRs meet basic quality, safety, and efficiency standards (2012).”
Telemedicine does have its limitations as care is not provided in the traditional in-person setting. As a result a remote visit can deprive the physician of the normal cues they could pick up on during an in-person visit. Our solution, through the utilization of a facilitator aims to reduce these effects. There appears to be additional skepticism about the extent to which healthcare delivery can be moved to a virtual environment. We believe some of the challenges that may come with telemedicine for house calls for preventative care are:
● Telemedicine payer contracting restricting billing for insurance
● IT support platform and/or technology that is not stable or compatible
● Lack of internet access, specifically in remote areas
● Restrictions on prescriptions for certain medications to be written
● The necessary “in-person” initial meeting with a physician before a telehealth meeting
In addition to skepticism, laws around the use of telemedicine are always changing and pose limitations on the use of such technologies. Crucial areas to consider include; licensure, accreditation, HIPPA compliance and medication prescriptions. Telehealth law changes frequently so it is recommended that frequent contact with the legal counsel is made (“Telehealth,” 2014).
Population trends in the United States show that the aging populations have a desire to live at home for as long as possible demonstrating a desire of independence. In addition they are shown to live farther distances from their children these days as stated in a 2015 PubMed publication. In efforts to improve caregiver quality at home the use of telemedicine has been implemented. In addition the acceptance from the aging patient population of technical devices at home has increased (Otto, Betternhofer & Tarnutzer, 2015).
Empathy has strong effects on patient outcomes, compliance and satisfaction. Patient-provider relationships are threatened by the implementation of telemedicine. The digitalization of healthcare delivery threatens the traditional form of empathy patients may deiser. Research finds that empathy is strongly associated with positive health outcomes (Terry & Cain, 2016), we believe that a facilitator is vital in the initial transition from a traditional health care delivery to digitalization form of delivery.
Needs: Can serve a broader service based on availability of new diagnostic or exam facilitator. Better preventative care expressed by two-thirds of the population. Improved chronic disease management to cut costs and improve the quality of life for patients lacking adequate care resources.
Fears: Some patients might fear false positives, resulting in unnecessary treatment expenses and physiological disruption. A fear common to both providers and patients is technology breakdown or delays can occur and delay treatment for the patient and increase costs for our company. Less physical contact with provider when not being seen at a facility is another common fear by the older populations as technology innovation is new to them. Along the same lines some lack the confidence to utilize such technologies in fear that they will not be able to work them correctly. Lastly a concern to most everyone is the privacy of their information.
Benefits: Some or the benefits are convenience, more timely access to care, travel cost savings. Increase access for patients, reduced cost for patients and employers, reduce time away from activities or work for individual, increase productivity for employers, additional revenue for employers, increase provider efficiency. The benefit to our solution specifically is the facilitator that takes some of the pressures off of using such advanced technologies enabling patients to feel confident in the care they are receiving. In addition, our facilitators are trained on how to utilize telemedicine technologies effectively.
Features: Remote, portable cart solution with camera that comes with integrated diagnostic equipment. Physicians are able to provide support or a staff such as a registered nurse to assist with patient visit and remote exam. Our software is secure and HIPPA compliant. And our physicians and facilitators are trained and use the most advanced technologies.
Patient/Physician Experience: Experience more timely access to care, less burdensome with travel, convenience. Can be used for consults, medical provider visits, additional tests
Substitutes: Virtual medicine, home health visits, COACH mobile units
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