Telemedicine Barriers Associated with Regional Quality Measures

Abstract

Telemedicine practitioners are familiar with multiple barriers to delivering care at a distance. Licensing and reimbursement barriers are well known and are being addressed at national and state levels by the American Telemedicine Association. Another telemedicine barrier comes in the form of quality measures for diabetes. Minnesota medical practices are currently being compared on the proportion of their patients with diabetes who have attained goals for blood pressure, low-density lipoprotein cholesterol, and hemoglobin A1C. The quality measure for blood pressure specifically excludes measurements taken by the patient, thus precluding blood pressure telemonitoring as a way to meet the blood pressure goal. To counter this barrier, advocacy in telemedicine is needed so that telemonitoring as a data collection tool is included in quality measures.

Introduction

In the United States, implementation of telemedicine faces several barriers. There are ongoing initiatives by the American Telemedicine Association (ATA) to overcome state legislative barriers to practicing telemedicine across state borders and to promote telemedicine reimbursement. These efforts are coming to fruition and are visible on the ATA Web site.^1
–3

The Minnesota 2008 Health Reform Law directed the Commissioner of Health to establish a standardized set of quality measures for healthcare providers across the state.⁴ Clinics and hospitals have been required to submit data on those measures since 2010, and these measures are publicly reported on the Minnesota Community Measurement Web site (MNCommunity Measurement© at www.mncm.org). There are currently measures to assess care for diabetes, vascular disease, asthma, and depression. The Minnesota HealthScores Web site (www.mnhealthscores.org) rates practices based on how well measure goals have been attained. An emerging barrier to telemedicine is the lack of acceptance of patient-reported data to meet the quality measures. State-required quality measures stipulate face-to-face visits and require physiologic measurements that are attainable by telemonitoring but are not allowed by measure specifications.

Quality Measures and Telemedicine

Minnesota Community Measurement has focused on diabetes, vascular disease, asthma, and depression for its ambulatory medicine quality measures (Table 1). For diabetes measures, practices are required to submit patient data on blood pressure readings, hemoglobin A1C, low-density lipoprotein cholesterol, tobacco use, and aspirin use. Clinic ratings for diabetes care are based on the percentage of patients with blood pressure under 140/90 mm Hg, hemoglobin A1C under 8%, and low-density lipoprotein cholesterol under 100 mg/dL. Vascular disease measures and goals are similar (Table 1). These are all measures that could be collected from patients without requiring face-to-face visits. Currently, several technologies can facilitate transmission of blood pressure readings from patient to clinic. Real-time telemonitoring can directly send patient blood pressures to the clinic by telephone line, wireless, or Internet. Blood pressures can also be taken by automated cuffs and uploaded by the patient into a secure message on a patient portal, or called or faxed to the clinic. Telemonitoring trials using automated blood pressure monitors have demonstrated improved blood pressure control whether by real-time telemonitoring, telephone, or fax.^5,6 In addition, home monitoring of blood pressure has been shown to be unaffected by the white-coat effect or other factors in the office and is more predictive of risk.⁷ Home blood pressure monitoring is now endorsed by the American Heart Association and the American Society of Hypertension and is recommended specifically for evaluating antihypertensive response and for patients with diabetes.⁷

Table 1.

PATIENT GROUP MEASURED	INCLUSION CRITERIA (THOSE WITH RELEVANCE TO TELEMEDICINE)	QUALITY MEASURES (CLINIC RATINGS BASED ON PROPORTIONS OF PATIENTS MEETING THESE GOALS)	MEASUREMENT SPECIFICATIONS (THOSE WITH RELEVANCE TO TELEMEDICINE)
Diabetes¹⁰	Face-to-face visits at least 2 times during last 2 years (with ICD-9 diabetes code) AND at least 1 face-to-face visit during last 12 months (not restricted to ICD-9 diabetes code)	BP <140/90 mm Hg; LDL <100 mg/dL; hemoglobin A1C <8%; non-tobacco user	“Do NOT enter BP reported or taken by the patient” “Nurse-only BP checks in the clinic may be used”
Vascular disease¹¹	Face-to-face visits at least 2 times during last 2 years (with ICD-9 ischemic vascular disease code) AND at least 1 face-to-face visit during last 12 months (not restricted to ICD-9 ischemic vascular disease code)	BP <140/90 mm Hg; LDL <100 mm Hg; non-tobacco user; daily aspirin or antiplatelet medication or contraindication to aspirin	“Do NOT enter BP reported or taken by the patient” “Nurse-only BP checks in the clinic may be used”
Asthma¹²	Face-to-face visits at least 2 times during last 2 years (with ICD-9 asthma code) AND at least 1 face-to-face visit during last 12 months (not restricted to ICD-9 asthma code)	Asthma Control Test (ACT) ≥20 OR Childhood Asthma Control Test (C-ACT) ≥20 OR Asthma Control Questionnaire (ACQ) ≤0.75 OR Asthma Therapy Assessment Questionnaire (ATAQ)=0; patient-reported number of ED visits and hospitalizations from asthma<2; asthma management plan created or reviewed and revised with patient within measurement period	Specifications allow contact by visit, telephone call, e-visit, or other contact during which the asthma control test was administered (e.g., a test administered to the patient via phone). No statement specifically requiring review of asthma management plan face-to-face
Depression¹³	Patient had visit or contact with provider in measurement period (July 1, 2011–June 30, 2012)	6- or 12-month follow-up Patient Health Questionnaire 9 (PHQ-9) score reduction ≥50% from baseline (response); PHQ-9<5 (remission)	Specifications allow contact by visit, telephone call, e-visit, or other contact

BP, blood pressure; ED, emergency department; LDL, low-density lipoprotein.

Unfortunately, Minnesota Community Measurement does not accept self-reported blood pressure readings (Table 1). This data collection restriction excludes real-time blood pressure telemonitoring and portal telemonitoring (patients using a patient portal to report their blood pressures). Self-reported blood pressure by telephone or fax is also disallowed.

Minnesota Community Measurement also requires face-to-face visits (Table 1). Although the requirement for face-to-face visits may have good intentions, it does impose limits on clinics that could attain excellent quality measures with virtual visits and telemonitoring. To be in the measurement group, one face-to-face visit within the previous year and two face-to-face visits in the previous 2 years are required. This criterion applies to diabetes, vascular disease, and asthma. There are no stated exceptions for virtual visits. Only the inclusion criteria for depression have no explicit face-to-face visit requirements.

Impact of Telemonitoring Barriers

There are monetary and access costs associated with restrictive data collection requirements. Requiring face-to-face visits and disallowing patient-reported measures increase the cost of care⁸ and may limit access for other patients. At the Mayo Clinic, our primary care diabetes registry has over 7,700 patients, with over 30% of those patients registered to a portal account. The Mayo Clinic portal can be used to electronically push blood pressure data collection forms to patients' portal accounts. Because many of our patients with diabetes have automated blood pressure monitors, they can send their blood pressure readings back via the portal, and providers can remotely manage their antihypertensive medication without the need for a face-to-face visit. This saves patients the cost of a face-to-face visit and allows the practice to open up appointments for other patients. For those currently without portal accounts, care managers can use the telephone, fax, or real-time telemonitoring to monitor patient blood pressure readings. Provider treatment recommendations can be sent back by telephone or directly to their monitoring device.

The total number of visits in our primary care practice in 2011 was 264,294. If only one yearly face-to-face visit of each of the 7,700 diabetes patients was circumvented by portal, real-time, or telephonic telemonitoring, 3% of all office visits could be reclaimed for other patients more in need of a face-to-face visit. Indirect cost savings would also accrue to patients from less time away from work and decreased transportation expense to and from the clinic.

Advocacy Alert

Despite the great successes of advocacy groups such as the ATA, there are still barriers to telemedicine that need our attention. Current regional quality measures stifle the use of telemonitoring in treating hypertension associated with diabetes and vascular disease. The rejection of data collection by virtual technologies is not based on evidence that telemonitoring is inferior to face-to-face care; telemonitoring of blood pressure results in outcomes at least equal to those of face-to-face care.^5,6 The criterion for face-to-face visits also discounts the potential of virtual visits.

Minnesota is currently one of the national leaders in rating practices by quality measures, and the National Quality Forum has endorsed Minnesota's diabetes and vascular care measures.⁹ Telemedicine options need to be actively placed on the table in future discussions about quality measures. Telemedicine has the potential to reduce costs, increase access, and deliver high-quality outcomes. Rather than creating new barriers to the use of telemedicine, quality measures should be designed to incorporate the potential value that telemedicine options bring to our healthcare delivery system.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

American Telemedicine Association. American Telemedicine Association public policy and advocacy. Available at www.americantelemed.org/get-involved/public-policy-advocacy/policy-issues (last accessed October 21, 2013 ).

American Telemedicine Association. 2013 state telemedicine legislation tracking. Available at www.americantelemed.org/docs/default-source/policy/state-telemedicine-legislation-matrix.pdf (last accessed October 21, 2013 ).

American Telemedicine Association. State legislation for telehealth-provided covered services. Available at www.americantelemed.org/get-involved/public-policy-advocacy/state-telemedicine-policy (last accessed October 21, 2013 ).

Minnesota Department of Health. Health care quality measures adopted rule— November 13, 2012. Available at www.health.state.mn.us/healthreform/measurement/adoptedrule/index.html (last accessed October 21, 2013 ).

Bosworth

, Powers

, Olsen

, et al. Home blood pressure management and improved blood pressure control: Results from a randomized controlled trial. Arch Intern Med, 2011; 171:1173–1180.

Canzanello

, Jensen

, Schwartz

, et al. Improved blood pressure control with a physician-nurse team and home blood pressure measurement. Mayo Clin Proc, 2005; 80:31–36.

Pickering

, Miller

, Ogedegbe

, et al. Call to action on use and reimbursement for home blood pressure monitoring: Executive summary. A joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. J Clin Hypertens, 2008; 10:467–476.

Funahashi

, Ohkubo

, Fukunaga

, et al. The economic impact of the introduction of home blood pressure measurement for the diagnosis and treatment of hypertension. Blood Press Monit, 2006; 11:257–267.

National Quality Forum. Quality positioning tool: Measures search diabetes (Optimum Diabetes Care). Available at www.qualityforum.org/QPS/ (last accessed October 21, 2013 ).

10.

MNCommunity Measurement. Data collection guide direct data submission optimal diabetes care 2013. Available at http://mncm.org/wp-content/uploads/2013/04/Optimal_Diabetes_Care_2013_FINAL_11_27_2012.pdf (last accessed October 21, 2013 ).

11.

MNCommunity Measurement. Data collection guide direct data submission optimal vascular care 2013. Available at http://mncm.org/wp-content/uploads/2013/04/Optimal_Vascular_Care_DDS_2013_FINAL_11_27_2012.pdf (last accessed October 21, 2013 ).

12.

MNCommunity Measurement. Data collection guide direct data submission optimal asthma care 2012. Available at http://mncm.org/wp-content/uploads/2013/04/Optimal_Asthma_Care_2012_DDS_Final.pdf (last accessed October 21, 2013 ).

13.

MNCommunity Measurement. Data collection guide direct data submission depression care measures 2013. Available at http://mncm.org/wp-content/uploads/2013/04/Depression_Care_Measures_DDS_2013_Final_11_29_2012.pdf (last accessed October 21, 2013 ).