Telehealth Needs Assessment in the Southern Finger Lakes Final Report

October 2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes (Steuben, Schuyler and Chemung Counties)



Final Report



Prepared for the: Submitted by:



Finger Lakes Health Systems Agency



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Acknowledgements



The Community Health Foundation of Western and Central New York (CHFWCNY) is a not-for profit organization dedicated to improving the health and health care of the people and communities of western and central New York. The CHFWCNY identified the importance of examining the Needs Assessment for Telehealth Applications in the Southern Finger Lakes, specifically Steuben, Schuyler and Chemung Counties. James X. Kennedy has served ably as the Program Officer on this project.



The CHFWCNY engaged the Finger Lakes Health Systems Agency (FLHSA) to conduct this needs assessment. The FLHSA engaged a consultant, Kathryn Votava, PhD, RN of GOODCARE.com to collaborate with them. The FLHSA and GOODCARE.com formed a team (Table 1) to conduct the needs assessment for telehealth applications in the southern Finger Lakes region. The richness of the team’s mix of background, skill and experience in health planning significantly contributed to the successful completion of this project.



Table 1. FLHSA needs assessment for telehealth applications in the southern Finger Lakes project team



Name Arthur Streeter, MHA Kathryn Votava, PhD, RN Michael Yates Cymantha Campbell Ann Marie Rotter, RN, CCM



Title Senior Planner and Director of Review; FLHSA Research Consultant- President GOODCARE.com Research Librarian; FLHSA Research Assistant-Operations Manager GOODCARE.com Research Assistant – Consultant GOODCARE.com



|2 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Table of Contents Report Sections Acknowledgments Section 1 Section 2 Section 3 Section 4 Section 5 Epilogue List of Appendixes Appendix A Appendix B Appendix C Appendix D Appendix E List of Tables Table 1. Table 2 Table 3 Table 4 List of Figures Figure 1 Figure 2 Figure 3 Figure 4 List of Charts Chart 1 Chart 2 Electronic survey process flowchart Broadband access by zip code in the southern Finger Lakes 12 22 Telehealth applications currently in use Planned telehealth expansion How could telehealth improve healthcare Obstacles to successful organizational telehealth utilization 17 18 19 20 FLHSA needs assessment for telehealth applications in the southern Finger Lakes project team Telehealth need assessment organizations surveyed by type and response Telehealth need assessment survey respondents by county Selected regional cable and DSL Internet access 2 16 17 21 Electronic Survey Results Electronic Survey Methods Telehealth Focus Group Invitation Detailed Results of Expert Interviews and Focus Groups Survey Process Experience 29 40 56 58 65 Executive Summary Background Needs Assessment Methods Needs Assessment Results Implications and Recommendations Needs Assessment Report Dissemination Plan Page 2 4 6 9 13 23 28



|3 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Section 1 Executive Summary Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Objective: To assess and document the need for telehealth applications in the southern Finger Lakes. The project will not seek to actually develop any telehealth applications or infrastructure supportive of such applications. The project commenced May 1, 2009 and was completed October 31, 2009. Project Description This project assessed the need and demand for telehealth applications in the southern Finger Lakes. It included an assessment of the readiness and barriers to utilize telehealth applications in the region. Interest in telehealth was gauged by conducting interviews with experts in the field of telehealth, a survey of and focus groups with healthcare providers and community organizations, in Chemung, Schuyler and Steuben counties. Findings Thirty-two participants, representing 29 organizations, completed electronic needs assessment surveys. A substantial proportion of survey participants, 35%, were already using telehealth and an even larger proportion, 44%, were planning to add telehealth applications. Of those using telehealth applications, the most common applications were electronic health records, teleconferencing, remote patient monitoring, and e-mail communications with patients or clients. Of those who were planning to expand telehealth, the plans were most commonly for telehealth nursing, remote patient monitoring and telepsychiatry. Focus groups discussed advantages of and obstacles to using telehealth services in their service areas. Implications and Recommendations There was broad support among advisory groups, survey respondents and focus group members for the development of telehealth services in the southern Finger Lakes (Chemung, Schuyler and Steuben Counties in New York). Respondents anticipated a range of advantages that telehealth solutions could bring to rural areas, including improvement of care in community settings to patients with chronic illnesses, reduction of transportation barriers, improved access to specialty care and enhanced efficiency of service delivery.



|4 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Through electronic survey, focus groups and interviews with interested parties, this study found, however, that there are obstacles which are constraining the development of telehealth in the study area. Those obstacles centered around cost and reimbursement issues, technical concerns including operational issues such as data security, and learning curve and practitioner resistance issues. The Community Health Foundation of Central and Western New York (CHFCWNY) can play a vital role in resolution of these obstacles by supporting advocacy for improved third-party reimbursement of telehealth and by supporting one or more technical assistance centers to stimulate regional players in their telehealth development. Critical to development of telehealth services is appropriate third-party reimbursement, both from regional insurers and especially from NYS Medicaid. In concert with others, CHFCWNY can advocate for establishment of such reimbursement. An important first step is support of a literature review to compile the information to support the business case for telehealth applications. There is substantial state and especially federal funding available to support development of telehealth services, especially through capital equipment acquisition. However, much of that grant funding requires consortia of providers to be eligible to apply; through CHFCWNY’s own actions and those of technical assistance center(s), such consortia can be stimulated. Finally, this study found a number of situations where providers or agencies in the southern Finger Lakes were eager to initiate particular applications, but lacked certain resources such as modest funds for needed equipment. CHFCWNY should consider funding for such situations to provide “early wins” in development of telehealth services in the southern Finger Lakes.



|5 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Section 2 Background Organizational Descriptions Finger Lakes Health Systems Agency (FLHSA) is the state-designated regional health care planning organization for the 9-county Finger Lakes, NY region. For 33 years, FLHSA has been an independent, community based and community oriented health planning entity providing a neutral table to which all segments of the community can come to address the health and health care needs of the community. It provides a trusted and objective source of health data, including populationbased studies. Agency areas of focus include elimination of health care disparities experienced by racial, ethnic, geographic and economic sub-populations, access to care, and health systems capacity analysis. The Needs Assessment for Telehealth Applications in the Southern Finger Lakes counties of Steuben, Schuyler and Chemung project is in line with the FLHSA’s goal of bringing together community stakeholders to assess and define health care services needs by provision of relevant data and analysis, and seeking mechanisms to meet those needs. FLHSA has a focus on planning activities seeking means to provide health care close to one’s residence for rural counties, without the need for unnecessary travel to more urban centers. GOODCARE.com is a private consultancy that provides research, consulting and training in the areas of healthcare services, healthcare economics and outcomes. GOODCARE.com is based in Rochester, NY and Washington, DC and has extensive expertise in telehealth and health services research. GOODCARE.com is collaborating with FLHSA in conducting the study. Significance The potential applications of telehealth, especially in rural communities in the Southern Finger Lakes (Chemung, Schuyler and Steuben Counties), are great. For instance, provision of primary care can be extended into sites staffed by mid-level practitioners, Nurse Practitioners, Emergency Medical Technicians and trained aides and would permit care to be more widely distributed geographically. This is an important consideration for families, for whom transportation to urban centers is costly in terms of time and money, therefore currently limiting their access to the most effective and efficient health services. Extension of specialty health care into areas which otherwise would not easily support such specialty care would facilitate provision of care in place.



|6 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Provision of telehealth care services in organized residential settings such as homes for adults, assisted living facilities, senior housing sites, and nursing homes, could permit residents to avoid travel or need for more intensive institutional care. Many population groups could be aided by telehealth services including elderly persons, especially frail elderly with more limited mobility, who could be supported in or near their residence. Children could receive specialty consultations close to home and school. Telehealth services can be provided by an interactive network of “source” and “recipient” organizations. Some examples of these pairs of organizations include: • Secondary or tertiary level hospital to primary hospital • Primary or secondary level hospital to extension clinics, nursing homes, congregate living sites, emergency medical systems, etc • Peer-to-peer clinician interactions, including specialist to primary care clinicians • Remote monitoring systems provided by home care agencies, facilitating improvement of care of frail, chronically ill or isolated populations and supporting the patient’s remaining in the home setting. • Support services for caregivers such as counselling with mental health providers, or information and extended care management through community agencies could enhance caregivers’ capacity and facilitate patients staying in home and home like settings. Telehealth modalities include a wide range of applications. There are two broad categories of telehealth: • Real Time Telehealth is the concurrent transmission and receipt of information between parties for the purpose of providing healthcare services. Examples: o Teleconferencing type systems that are used for patient – provider encounters. Some of these systems also have enhanced capabilities such as physiologic monitoring. o Patient/provider telephone encounters Store and Forward Telehealth is the collection of information at one point that is stored by one system and forwarded to another system for action. Examples: o Home telehealth and remote patient monitoring systems with physiologic monitoring in home and community based settings that transmit data to a central location for action. o Remote ICU monitoring.



•



Electronic health records (EHRs), at the broadest level, is a type of telehealth as well. Depending on the system, EHRs have features of both real time and store and forward technologies. EHRs can provide an exchange of health record information between providers and other telehealth applications and were included in the survey. However, New York State and the federal

|7 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



government are supporting organizations, such as Regional Health Information Organizations (RHIOs), specifically to encourage EHRs and EHR connectivity; such activity is not in the scope of this study. Project Objectives This grant project may help regional stakeholders to better define the needs of the region that might be met by telehealth, gauge both the opportunities and barriers to establishing telehealth applications as well as provide information that may potentiate consortia formation of organizations interested in moving forward with telehealth services in the southern Finger Lakes region. The project served to define need for and ability to provide telehealth services from the users’ perspectives, and also to stimulate interest, gauge capacity and identify barriers on the part of organizations. The project included an educational component in order to help with both the definition of needs, the stimulation of interest and reduction of barriers objectives. The Frequently Asked Questions included basic messaging about telehealth services. The content of the surveys may have broadened participant’s perspectives on the available variety of telehealth modalities. The final report is being made available in two forms: full report text version and a webinar. The reports will be distributed to those participants who asked for a copy via email delivery. They will also be posted on the following websites: www.chfwcny.org for the Community Health Foundation of Western and Central New York, www.flhsa.org/telehealth.html for the Finger Lakes Health Systems Agency and www.GOODCARE.com for GOODCARE.com.



|8 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Section 3 Needs Assessment Methods This needs assessment used qualitative and quantitative methods. These methods were designed to collect experiential data and measure the telehealth applications needed or in use in the area, obstacles to implementing telehealth services in the area, and issues of telehealth reimbursement. It also provided experiences in conducting community needs assessment using electronic surveys. Qualitative methods included: • • • Meetings with healthcare organizational advisory groups in the rural areas being examined in this study. Interviews with experts in the field of telehealth, reimbursement and healthcare delivery in the region. Focus groups with healthcare providers in the region



Quantitative method was an electronic survey accessed via email or website that collected detailed information about telehealth services, needs, obstacles and readiness in the region. The survey method and questions were developed based upon a review of the literature from studies in California 1, 2 Central New York State 3 and in Binghamton, NY 4. Input from advisory groups and industry leaders were incorporated as well. The survey included 16 questions (Appendix B) with forced choices, and skip logic. Constant Contact was the survey software employed. In addition to the above qualitative and quantitative methods, an interactive webpage was developed at http://goodcare.com/news/index.php. That page included the study purpose, scope, frequently asked questions (FAQs), and links to FLHSA and CHFWCNY. It was an informational resource over the course of the study for recruiting prospective participants.



1



California Telemedicine and eHealth Center. (2009). Optimizing Telehealth in California: An Agenda for Today and Tomorrow. Sacramento, CA: California Telemedicine and eHealth Center. 2 California Telemedicine and eHealth Center. (2009). Assessing Organizational Readiness. Sacramento, CA: California Telemedicine and eHealth Center. 3 Community Health Foundation of Western and Central New York. (2008). Provider Assessment of Community Health Needs. Syracuse, NY: Community Health Foundation of Western and Central New York. 4 Kerr, C. B. (2003). Strategic Planning for Children’s Medical Homes through Telemedicine: A Regional Plan. Funded by Community Access to Child Health Planning Funds through the American Academy of Pediatrics.



|9 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Advisory Group and Individual Meetings Art Streeter and Kathryn Votava met with an advisory group at the outset of the project as part of a data gathering process about regional needs and capacity. The Rural Health Network advisory group meeting was held on May 12, 2009 in Bath, NY. The participants of that meeting were very interested in the project and expressed opinions that increasing access to telehealth modalities would address many of the issues in rural areas including care coordination, complications that arise due to limited transportation and specialty care needs. Mr. Streeter and Dr. Votava also met with Dr. Kenneth Oakley at the Western New York Rural Health Education Center, in Warsaw, NY on June 6, 2009 to seek his input on the regional needs and capacity issues. Dr. Oakley’s organization has a rich history of involvement in telehealth services and his input echoed some of the issues discussed with the Rural Health Network in terms of rural access to services. Jackie Palcik 5 was interviewed by Dr. Votava to get advice on electronic surveys. Ms. Palcik conducted a research project for the Community Health Foundation of Western and Central New York that employed electronic surveys and noted in her report that they had had a poor response rate to those surveys. That matter of poor response rates to electronic surveys of health care providers and organizations was discussed at length. Ms. Palcik reported the difficulties in accessing accurate email address, the heavy amount of follow-up that was required to obtain that information and the reluctance of many healthcare organizations to participate in surveys due to lack of time and organizational policies. During the course of the study, Dr. Votava interviewed four health and telehealth experts concerning telehealth issues; summaries of those interviews are provided in Section 4, with detailed interview reports provided in Appendix D. Focus Groups Focus groups were conducted to enrich and inform the results of the survey data, have discussion of those findings and discuss implications within organizations and the communities they serve. Prospective focus groups participants received an email inviting them to participate in one of two focus group sessions. (Appendix C) Each focus group was 1 hour in length and conducted via toll free conference call. Participants were provided with an agenda in advance. That invitation was distributed via email to all prospective survey participants in the Telehealth Survey data base with



.5 Community Health Foundation of Western and Central New York. (2008). Provider Assessment of Community Health

Needs. Syracuse, NY: Community Health Foundation of Western and Central New York



| 10 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



email addresses on Monday, September 28, 2009, and focus groups occurred on October 6 and 7. Detailed reports on the focus groups are found in Appendix D. Electronic Survey Method An electronic survey method was selected for this study. A benefit of using an electronic survey is to get an initial impression of participants’ access to and basic use of email and Internet technology which are foundational in many telehealth modalities. The survey included 16 questions (Appendix A) with forced choices, and skip logic. Constant Contact was the survey software employed. The project team put together a contact list of potential organizational participants including: • • • • • • • • • • • • •



Hospitals Veterans Administration facilities Nursing Homes Public Health Departments Home Health Agencies Licensed Agencies Assisted Living Facilities Senior Living Centers Emergency Medical Systems Insurers Community Health Centers Major Physician groups Other organizations in health related fields.



The process for survey distribution, generally speaking, was to send an initial postal mailing (Appendix C) to survey participants to inform them of the project, heighten their awareness of telehealth with educational messaging and offer them the option of completing the survey directly on the web as well as correcting or providing an email address in order for a survey to be directly emailed to them. The electronic survey process flow chart (Chart 1) depicts the progression from the initial postal mailed packets, to email contact through to survey completion. A more thorough discussion of this process is presented in Appendix E.



| 11 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Chart 1. Electronic survey process flowchart



83 postal packets mailed



68 email contacts



10 web based surveys



13 email contacts not usable



31 email contacts unresponsive to postal, email and telephone



2 abandoned web based surveys



24 completed email surveys



8 completed web based surveys



| 12 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Section 4 Needs Assessment Results Expert Interviews Dr. Votava interviewed clinicians, healthcare mangers and telehealth technical experts for this project. Following here is a synopsis of those interviews. More detailed information is contained in Appendix D. Those experts were: • • • • Dr. Cheryl Kerr, physician and owner of a telehealth company Thomas Remein, RN, BSN, Rural Clinical Program Coordinator for the Monroe Plan Sandeep Krishan, telehealth technical expert Cynthia Gordon, RN, BSN, Rochester General Hospital Telehealth Program Manager



Dr. Cheryl Kerr, a physician expert 6 who has developed telehealth software operates a medical collaboration software company called www.clickcare.com located in Binghamton, New York. Dr. Kerr’s software is used primarily for physician specialty consultation. Dr. Kerr was very interested in the development of telehealth capabilities in the Southern Tier region and in follow up with interested parties that may be an outgrowth of this needs assessment. The Monroe Plan, a health management company, provides Medicaid managed care programs in the three county study region. Thomas Remein, Rural Clinical Program Coordinator for the Monroe Plan, was interviewed by Dr. Votava to discuss the Monroe Plan’s perspective on paying for and supporting telehealth services in the region. Currently, the Monroe Plan does not cover telehealth services. Family Health Plus and the Child Health Plus have no health insurance benefit for telehealth services In spite of that, Mr. Remein did think that the Monroe Plan would be supportive of telehealth services for several reasons; i.e., if telehealth improved the timeliness of information, if the information was secure, and of great interest to the Plan, would be the possibility of decreasing barriers to those needing care in the rural areas. Mr. Remein noted that within a fee for service system there may be limited incentives for telehealth. Those incentives might broaden in a population based reimbursement business model.



6



Kerr, C. B. (2003). Strategic Planning for Children’s Medical Homes through Telemedicine: A Regional Plan. Funded by Community Access to Child Health Planning Funds through the American Academy of Pediatrics.



| 13 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Sandeep Krishan is an IT expert and has been involved in several telehealth projects in the western New York region including the Area Health Education Center (AHEC) as well as the Finger Lakes Migrant and Community Health Program. Mr. Krishan’s observation was that it was difficult for hospitals and large health care organizations to cover the capital expense for equipment and to determine how telehealth works in their business models and their corporate missions. Mr. Krishan also expressed concerns about dealing with regulations through the New York State government. His perspective was that cogent telehealth public policy should drive grant funding but that was not always the case in practice. An improved focus on merging the two would enhance effective implementation of telehealth programs throughout New York State. Cynthia Gordon RN, BSN, is the Telehealth Program Manager with Rochester General Health System who oversees operations in the rural telehealth specialty consultation service at Newark Wayne Hospital as well as other sites. This interview focused on telehealth reimbursement issues. Ms. Gordon reported that specialty telehealth consultation service is typically reimbursed by private insurance. Medicare allows some coverage for this service if the patient is in a rural area as determined by a Medicare “rurality” score. Medicare beneficiaries are eligible for telehealth services only if they are presented from an originating site located in a rural health professional shortage area or in a county outside of a Metropolitan Statistical Area 7. Ms. Gordon’s opinion was that some of the areas in the southern Finger Lakes would be classified as “rural” by Medicare and some would not. Medicaid has yet to reimburse this type of service. Focus Groups The focus group participants were: • • • Edward Linsler, Administrator, Elcor Health Services, Horseheads, New York Patty Baroody, Coordinator, NY Connects, Steuben County. Pamela Paine, Program Coordinator of the Child and Family Services Program, Steuben County Department of Community Mental Health.



A major theme that emerged from the focus groups was that each one of the organizations was interested in or using telehealth application. The participants expressed a great deal of interest in seeing telehealth move forward in their organizations. The advantages reported were: increased ability to provide follow-up care on an ongoing basis, the ability to overcome transportation



Centers for Medicare and Medicaid. Services. (June 2009).Telehealth Services Fact Sheet ICN 901705. Department of Health and Human Services.



7



| 14 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



obstacles to accessing care and the capability to effectively use staff resources in the midst of staffing shortages. Several obstacles to telehealth use were identified during the focus group discussions. Cost and reimbursement was overwhelmingly viewed as the major obstacle to using telehealth applications. Organizations had limited or no access to capital for equipment, software or ongoing operations. They reported limited access to revenue streams and reimbursement for telehealth applications. Technical concerns about implementing telehealth services were discussed. All participants reported significant challenges related to data security and HIPAA implications. Focus group participants also discussed learning curve issues and practitioner resistance to adapting to new technology and processes. And yet, interestingly, learning curve and practitioner resistance were not insurmountable obstacles. Organizations reported relying on early adopters to lead the way. They also experienced success with methodical and incremental roll outs of telehealth applications. In fact, organizations found that once staff members became accustomed to the technology, staff were happy with their own increased effectiveness. This phenomenon led to increased demand for telehealth deployment, thereby turning the corner on this obstacle.



| 15 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Survey Results Summary Survey results are included in full in Appendix A. What follows here is a summary of the key findings of the electronic e-mail survey. A total of 29 healthcare organizations participated in the survey (Table 2). Some organizations had more than one participant which resulted in total of 32 surveys from 29 organizations. Table 2. Telehealth need assessment organizations surveyed by type and response Provider Type Adult Care Facility Community Agency Community Health Center Emergency Medical Systems Government Agency Home Health Agency Hospice Hospital Mental Health Center Physician Group Public Health Department Skilled Nursing Facility Other Total # Potential Organizations 14 6 3 5 1 12 1 6 1 3 3 12c 17 84 # of Contacts with email address a 2 6 2 4 1 4 1 6 2 1b 3 10c 17 59 # Completed Surveys 3 3 1 2 1 5 1 7 2 0 3 7c

(includes 5 hospitalbased SNFs)



2 32



Notes: a The number of organizations with full contact information including email addresses. b One physician group provided email contact information but did not complete the survey. No physician groups completed the web version of the study. c Five nursing homes are hospital based. Those survey respondent organizations are also counted in the hospital category. They are Arnot Ogden Medical Services, Ira Davenport Memorial Hospital, St. James Mercy Hospital, St. Joseph’s Hospital and Schuyler County Hospital.



| 16 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



The distribution of survey respondents by county is displayed in Table 3 Table 3 Telehealth needs assessment survey respondents by county County Chemung Schuyler Steuben Total # Respondents 12 4 16 32



Most survey participants, 21 of the 32 (65%); do not currently use telehealth applications. The following section presents key finding from the survey. N= 32 survey respondents. The results are reported in terms of duplicated counts as respondents were instructed to select all that applied. Of those using telehealth applications, the most common were electronic health records, teleconferencing, remote patient monitoring, and e-mail communications with patients or clients (Figure 1). Figure 1.



Telehealth applications currently in use

4% 8% 28% 16% Electronic health records Teleconferencing Remote patient monitoring E-mail communications with patients/clients Real-time remote/provider contact via video or computer 20% 24% Radiological imaging



N = 11 respondents with 25 applications



| 17 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Interestingly, only one respondent indicated it was using teleradiology applications. In other parts of the Finger Lakes region, such applications are ubiquitous, and represent one of the applications where efficiency of care delivery far exceeds the cost of the application. For instance, radiology groups or departments can share call to provide real-time interpretation of images during off-hours periods, periods when smaller institutions may not otherwise have radiologist coverage. While the majority of respondents, 18, were not aware of any plans to expand telehealth in their organization in the future, 14 organizations did indicate such plans. Of those who are planning to expand telehealth, the plans were most commonly for telehealth nursing, remote patient monitoring, telepsychiatry, and then quite a range of distribution of other applications (Figure 2).



Figure 2.



Planned telehealth expansion

4% 4% 19% Telehealth Nursing Remote patient monitoring Telepsychiatry Teleradiology EMS preparedness Pediatric Telehealth 8% 19% 8% 11% 11% Teledermatology Community Health Services Medication Management Ocular Telehealth Patient Portal



4% 4% 8%



N = 14 respondents with 28 applications



| 18 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



When asked about how telehealth could improve healthcare, the most common responses were that telehealth could make healthcare more accessible, patient or caregiver centered, collaborative among professionals, or coordinated (Figure 3). Figure 3.



How could telehealth improve health care?

1% 5% 21% 16% Accessible Patient/caregiver centered Collaborative among professionals Coordinated Comprehensive Culturally Accessible Other 19%



19%



19%



N = 114 improvements suggested



| 19 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



The most commonly mentioned obstacles to successful utilization of telehealth in the organization were cost factors, practitioner resistance, infrastructure or technology, lack of training or expertise, and less face-to-face contact (Figure 4). When organizations were asked about what factors would “make or break” the ability to maximize the real value of telehealth, the top answers were cost, usefulness to clients or constituents, ease in integration with current practices, and usefulness to staff. The factors considered to be uppermost when implementing telehealth were adequate financial support, benefits to clients, benefits to staff, and development of a leadership team. Figure 4.



Obstacles to successful organizational telehealth utilization

Cost factors Practitioner resistance 19% Infrastructure: technology Lack of training or expertise 9% Less face-to-face contact 12% 9% Infrastructure: policy procedure 12% 12% Other legal, regulatory stipulations Competitive interests Other HIPAA regulations



5% 5%



5%



12%



N = 113 obstacles cited



| 20 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Regional Internet Access Internet access is an important aspect of telehealth services. In order for consumers and providers to use many telehealth modalities, access to the Internet is required. The survey found that the vast majority of organizations were using high speed Internet with 25 (78%) responding yes, and yet 3 organizations did not know what type of Internet service they used and dial-up Internet service was in use at 3 organizations. Dedicated or institutional high speed lines were reported in use by 18 (56%) of the respondents. The majority, 20, reported wireless Internet access. Most organizations, 27, were using cell phones. The most common conduits to access the Internet are cable, DSL, and wireless cell phone modems. As a part of the needs assessment, access to these types of conduits was also evaluated. Cell phone service is generally available in the area. Generally speaking, most areas of all three counties, Chemung, Schuyler and Steuben, have cable or DSL access. Table 4 displays availability in selected zip codes in the project region. Chart 2 exhibits broadband availability in the tri county locale. Table 4. Selected regional cable and DSL Internet access Zip Town Verizon DSL Frontier DSL Time Warner Cable X X X X X X X X X X X X X X X X X X X X X X X X X X X X Empire Telephone DSL



14801 14809 14810 14814 14830 14839 14843 14845 14865 14869 14870 14891 14901 14904 14905



Addison Avoca Bath Big Flats Corning Wayland Hornell Horseheads Montour Falls Odessa Painted Post Watkins Glen Elmira Elmira Elmira X X X X X X



| 21 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Chart 2.



Broadband Access by Zip Code in the Southern Finger Lakes

Broadband Access

14512 14512 14512 14512 14512 14512



Has broadband Does not have broadband



14437 14437 14437 14437 14437 14437



14572 14572 14572 14572 14572 14572 14808 14808 14808 14808 14808 14808



14874 14874 14874 14874 14873 14873 14873 14873 14873 14873 14826 14826 14826 14826 14826 14826 14840 14840 14840 14840 14840 14840 14807 14807 14807 14807 14807 14807 14809 14809 14809 14809 14809 14809 14837 14837 14837 14837 14837 14837 14878 14878 14878 14878 14878 14878



14841 14841 14841 14841 14841 14841 14886 14886 14886 14886



14818 14818 14818 14818 14818 14818



SCHUYLER

14815 14815 14815 14815 14815 14815 14810 14810 14810 14810 14810 14810 14891 14891 14891 14891 14891 14891 14865 14865 14865 14865 14879 14879 14879 14879 14879 14879 14812 14812 14812 14812 14812 14812 14864 14864 14864 14864 14864 14864 14821 14821 14821 14821 14821 14821 14872 14872 14872 14872 14872 14872 14824 14824 14824 14824 14824 14869 14869 14869 14869 14869 14869 14805 14805 14805 14805 14805 14805



14843 14843 14843 14843 14843 14843



STEUBEN



14823 14823 14823 14823 14823 14823 14819 14819 14819 14819 14819 14819 14820 14820 14820 14820 14820 14820 14806 14806 14806 14806 14806 14806 14839 14839 14839 14839 14839 14839 14855 14855 14855 14855 14855 14855



14870 14870 14870 14870 14870 14870



14845 14845 14845 14845 14845 14845



14889 14889 14889 14889 14889 14889 14816 14816 14816 14816 14816 14816 14838 14838 14838 14838 14838 14838



14814 14814 14814 14814



CHEMUNG

14903 14903 14903 14903 14905 14905 14905 14905 14905 14905



14830 14830 14830 14830 14801 14801 14801 14801 14801 14801



14901 14901 14901 14901 14901 14901



14859 14859 14859 14859 14859 14859



14877 14877 14877 14877 14897 14897 14897 14897 14897 14897 14885 14885 14885 14885 14885 14885



14898 14898 14898 14898 14898 14898 14871 14871 14871 14871 14871 14871 14858 14858 14858 14858 14858 14858



14904 14904 14904 14904 14904 14904



14861 14861 14861 14861 14861 14861



14825 14825 14825 14825 14825 14825



14892 14892 14892 14892



14894 14894 14894 14894



| 22 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Section 5 Implications and Recommendations Wide spread interest was expressed concerning utilization of telehealth applications. Convergence emerged on a range of advantages telehealth solutions could bring to rural areas in the southern Finger Lakes. A substantial proportion of survey participants, 35%, were already using telehealth and an even larger proportion, 44%, were planning to add telehealth applications. However, a wide range of concerns affecting telehealth in rural areas were explored in this Needs Assessment for Telehealth Applications in the Southern Finger Lakes. The major themes that emerged from this project were: • • • Cost and reimbursement Technical concerns about implementation with a particular focus on data security and HIPAA implications Learning curve issues and practitioner resistance related to adapting to new technology and processes



The combination of these themes, no doubt, contributes heavily to the fact that the majority of organizations are not yet using nor planning to add telehealth applications. Cost and Reimbursement The most frequently expressed obstacles to implementing telehealth were cost and reimbursement factors. Concerns about cost and reimbursement were a consistent theme in the electronic survey, focus groups and expert interviews. Cost was the number one problem indicator selected in the electronic survey in every single category where it was asked. Cost and reimbursement concerns fell into the following categories: • • Capital costs of procuring equipment and software Ongoing operations costs for: o Human capital o Ongoing service fee costs • Limited access to revenue streams and reimbursement for telehealth applications



| 23 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Given that there currently is limited reimbursement for and revenue stream generation from telehealth applications, organizations do not perceive incentives to devote resources to implementing telehealth programs into their operations. While this is the case, there is mounting evidence that utilization of telehealth modalities can improve efficiency and effectiveness of healthcare services. These gains, in and of themselves, can generate a return on investment for some or all of the cost of the technology. In fact, efficiency gains and increased access to care might generate positive margins for operational budgets. Therefore organizations find themselves in the predicament of how and where to get started. Technical Concerns and HIPAA Implications Technical concerns about implementing telehealth programs and services converged on equipment acquisition and connectivity related to data security and HIPAA implications. All focus group participants discussed obstacles they have experienced in implementing telehealth applications between and among organizations. While some of the technologies such as email and transmitting laboratory results are, in and of themselves, relatively simple, the obstacles to having interorganizational communication due to HIPAA concerns and data security walls were large. As one participant said “you wouldn’t think that it would be this hard.” Learning Curve Issues and Practitioner Resistance Learning curve and practitioner resistance issues were complicating factors for organizations. Specifically, adapting to new technology and processes were identified as obstacles. Those findings were consistent in both the surveys and focus groups. Across the board, focus group participants expressed that for them as well as their organizations “this is a whole new world.” Differences in generational adaptive patterns between those who grew up in the digital age and those who did not emerged as a theme. The pattern was that individuals who use digital communication technologies in their day to day lives were clamouring for access to those technologies in the work place. At the other end of the spectrum are those who do not use or are new to using digital technology on an everyday basis. Currently most organizations have more workers in the latter category than the former. And yet, interestingly, learning curve and practitioner resistance were not insurmountable obstacles. Organizations reported relying on early adopters to lead the way. They also experienced success with methodical and incremental roll outs of telehealth applications. In fact, organizations found that once staff members became accustomed to the technology, staff was happy with their own increased effectiveness. This phenomenon led to increased demand for telehealth deployment, thereby turning the corner on this obstacle.



| 24 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Recommendations The Community Health Foundation of Western and Central New York (CHFWCNY) recently published a policy white paper entitled Rural Health Investment Strategy that included a framework with four broad categories to use as an investment policy for rural health: • • • • Health disparities and socio-economic challenges System and capacity deficits Measurability of outcomes Future public policy



Opportunities exist within each of these rural health investment policy areas for targeted telehealth application deployment to make a positive impact and improve healthcare service effectiveness. The intersection between these categories, the capabilities of telehealth applications and the results of this needs assessment lead to two major recommendations: • Telehealth finance public policy advocacy for: o Grant funding of consortia to stimulate sustainable telehealth service development and expansion o Advocacy for third party reimbursement with a major focus on New York State Medicaid and regional private insurance • Telehealth Development Center: o Technical assistance, standards and education o Regional convener of telehealth consortia Telehealth Finance Public Policy Advocacy Given that the most frequently expressed obstacle to implementing telehealth was cost and reimbursement factors, it is imperative that effort be applied to improving telehealth financing. For the CHFWCNY those efforts could focus in two paths. The first would be seed funding for regional consortia to stimulate sustainable telehealth service development and expansion. The second would be public policy advocacy for third party reimbursement of telehealth services. Seed funding for regional consortia would facilitate parties from multiple organizations in the region to work together on sustainable telehealth service program development. Many of the federal level grants that are and will soon be available require groups of providers to work together to form



| 25 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



networks of services. Seed funding would enhance these community groups’ abilities to develop pilot projects and fundable proposals. Third party reimbursement is critical to the sustainability of telehealth services. Even in the circumstance of grant funding for capital equipment acquisition, program development and long term sustainability is only feasible when the services work within business models. New York State Medicaid has very limited telehealth reimbursement, thereby excluding it from those who might benefit most. Studies in other states8 have shown that telehealth access for Medicaid beneficiaries increases access to care, patient participation in care, more effective use of resources and decrease in care costs. In New York State, healthcare providers can seldom access it for Medicaid patients. The Rochester General Health System telehealth program has shown that it is possible to negotiate private insurance coverage of telehealth services; advocacy could make such reimbursement more widely available to the region’s telehealth providers Telehealth Development Center Technical concerns about implementing telehealth programs and services converged on concerns related to data security and HIPAA implications. Learning curve and practitioner resistance issues were also complicating factors for organizations. Both of these obstacles could be reduced if organizations have access to a telehealth development center in the region. A Telehealth Development Center could provide technical assistance, standards and education for potential users. It could also serve as one possible convener of regional telehealth consortia. The demand for technical assistance, clarification of data security and HIPAA standards as well as telehealth start up education and training were prominent themes in the needs assessment results. As a focus group participant said “please don’t make us reinvent the wheel.” A Telehealth Development Center could fulfill this role making it easier, less costly and more efficient for organizations to roll out and expand telehealth services. The Telehealth Development Center could also serve as a convener of regional telehealth consortia. Telehealth services by their very nature have the capability to include many different organizations and constituents. As mentioned previously, many of the federal level grants that are and will soon be available require groups of providers to work together to form networks of services.



Applegate, W. K. (2009). A New Paradigm for Chronic Care Management: Medicaid Demonstration. Journal of Telemedicine and e-Health. 15, Supple 1, p S27. ATA International Meeting & Exposition 2009.



888



| 26 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Selected Investments In order to promote public policy discussions in the areas of cost and reimbursement a white paper focused on return on investment (ROI) for telehealth applications would be beneficial. The output from that white paper could support organizations’ efforts in accessing reimbursement sources, grant sources and realizing economic efficiency gains within their operations. Finally, this study found a number of situations where providers or agencies in the southern Finger Lakes were eager to initiate particular applications, but lacked certain resources such as modest funds for needed equipment. CHFCWNY should consider funding for such situations to provide “early wins” in development of telehealth services in the southern Finger Lakes. A project to consider funding could include capital equipment for two way telepsychiatry specialty consultation services for the Steuben County Department of Community Mental Health. The Steuben County Department of Community Mental Health has successfully implemented most aspects of an electronic health record. They have identified a need for as well as interest in using telepsychiatry specialty consultation services but lack the two way video conferencing equipment that is required. While funding may eventually come from New York State Office of Mental Health, OMH budget constraints and priorities suggest a long wait. Another project that may well generate an early win could be a replication of the Chronic Care Management Medicaid Demonstration from Iowa that has demonstrated a 61% decrease in emergency department visits and a 65% decrease in acute hospital das for heart failure patients. This study employed a relatively simple telephone promoting method to remotely monitor heart failure patients. A Medicaid managed care program, such as the Monroe Plan, might be a partner in this type of replication. 9



9



Applegate, W. K. (2009). A New Paradigm for Chronic Care Management: Medicaid Demonstration. Journal of Telemedicine and e-Health. 15, Supple 1, p S27. ATA International Meeting & Exposition 2009.



| 27 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Epilogue Needs Assessment Report Dissemination Plan Findings from this need assessment will be available in two forms: • • Final report PDF version Final report webinar.



The final report PDF version will be distributed to all participants who requested one. In addition, the report will be offered to prospective participants who did not participate in the study. Both forms of the report will be available on the following websites: • • • www.chfwcny.org - Community Health Foundation of Western and Central New York www.flhsa.org/telehealth.html Finger Lakes Health Systems Agency www.goodcare.com/news/index.php - GOODCARE.com.



| 28 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix A Electronic Survey Results



| 29 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix A Electronic Survey Results Number of surveys sent Number of completed surveys Response rate Number of email surveys Number of web based surveys Number of surveys completed on the phone 66 32 48% 24 8 1



The following is a compilation of the survey results presented in terms of counts. Type and number of organizations that responded to the survey Hospital Home Health Agency Adult Care Facilities Community Agencies Public Health Mental Health Emergency Medical Service Providers Skilled Nursing Homes Community Health Hospice Private Industry Physician Groups Other Total 7 5 3 3 3 2 2 2 2 1 1 0 0 31

| 30 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



1. How many survey participants currently use telehealth applications: Yes 11 No Total 2. What telehealth applications are being used? Electronic Health Records Teleconferencing Remote patient monitoring E-mail communications with patients/clients Real-time remote/provider contact via video or computer Radiological imaging Total Comments: • 7 6 5 4 21 32



2 1 25a 2



Since we are in the Network, we do not have telehealth ourselves. Schuyler Public Health, one of our partners, uses telemonitoring. If community health care providers, the physicians and the hospitals had telehealth capabilities, it would seem that much better patient care could occur in home care. Community Health



| 31 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



3. Are you aware of plans to develop or expand telehealth in your organization? Yes No Total 14 18 32



4. Areas that will apply development or expansion in telehealth Telehealth Nursing Remote patient monitoring Telepsychiatry Teleradiology EMS preparedness Pediatric Telehealth Teledermatology Telemental Health Community Health Services Medication Management Ocular Telehealth Patient Portal Total Comments: • There is no concrete plan; however, this possibility has been raised at various planning meeting for enhancing Long Term Care in Steuben County. – Community Agency Not clear on what the question is for this area. Is it to mean the area where there is currently use, or is it what is being planned, as the previous question indicates? - Community Agency 5 5 3 3 2 2 2 2 1 1 1 1 28a



•



| 32 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



• • •



We currently use all the applications in our agency. - Hospital Will be working with New York State Office of Mental Health to develop Telepsychiatry access. –Community Agency Patient Portal – Hospital



5: Are cell phones being used at your workplace? Yes No Unknown Total 27 3 2 32



6: Is Dial-up Internet services being used at your workplace? Yes No Unknown Total 3* 29 0 32



* Continuing Care Retirement Community, Home Care Agency, Hospital



7: Is High-speed Internet service being used at your workplace? Yes No Unknown Total 25 4 3 32



| 33 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



8: Is a dedicated or institutional broadband (i.e., T1) being used at your workplace? Yes No Unknown Total 18 8 6 32



9: Does your workplace have wireless internet access? Yes No Unknown Total 20 11 1 32



10: Are online lab results (i.e., EKG, virtual radiology, other) being used at your workplace? Yes No Unknown Total 10 19 3 32



11: Do you think telehealth can improve health care by making it more? Accessible Patient/caregiver centered Collaborative among professionals Coordinated Comprehensive Culturally Accessible Other Total 24 22 21 22 18 6 1 114a



| 34 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Note: a Denotes duplicated counts as respondents could choose as many as applied.

Comments:



•

• •



We are inundated with issues related to the pandemic H1N1 flu and feel unable to comment further. Public Health No. Emergency Medical Service I think it’s a great concept. Public Health Dept.



12: What do you see as obstacles to successful utilization of telehealth in your organization? Cost factors Practitioner resistance Infrastructure: technology Lack of training or expertise Less face-to-face contact HIPAA regulations Infrastructure: policy procedure Other legal, regulatory stipulations Competitive interests Other Total 21 14 14 14 13 10 10 6 5 6 113a



Note: a Denotes duplicated counts as respondents could choose as many as applied. Comments: • • Not sure how telehealth fits in for us. – Office for the Aging Both federal and state authorities present a double edged sword when it comes to technology....on one hand, they encourage its use as a means for increasing quality and reducing cost, but on the other, the threat of lawsuits and fines from breaches of electronic records, as well as the general lag in



| 35 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



regulations that can impede the use of technology, creates disincentives to move forward. Hospital • I don't believe that it fits in most instances with what we do as an Office for the Aging, but then I would need to learn a lot more about it to be sure. Office for the Aging Another issue that might be a barrier is compatibility with our patient software system. Hospice The lack of known established, effective hospice telehealth systems- Hospice As technology & capabilities of our out-sourced services and the related vendors increase, we will investigate the addition of telehealth to our Total Health Programs such as disease management for diabetes and cardiac disease. Private Industry



• • •



13: From your organization’s viewpoint, what factors would “make or break” the ability to maximize the real value of telehealth for your institution? Cost Usefulness to our clients/constituents Ease of integration with current practices Usefulness to staff Relevance to our organization Time required for implementation Other Total 23 19 16 13 11 9 2 93a



Note: a Denotes duplicated counts as respondents could choose as many as applied. Comments: • • • Safety of communication/confidentiality. County Mental Health Agency Ability to see or at least hear about a system operating in a hospice. Hospice Physicians and hospital having this as well. Community Health Agency

| 36 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



14: In terms of planning for telehealth in your region, what factors should be uppermost in the group who leads the implementation? Adequate financial support Benefit to clients Benefit to staff Development of leadership team Training responsibility Non-financial support from government and sponsoring institutions Other Total 27 25 20 19 18 8 0 117a



Note: a Denotes duplicated counts as respondents could choose as many as applied. Comments: • I think there will need to be awareness of operating systems and how these systems have benefited patients and staff. The planning needs to include a strong training component. I think the financial support issues will be present, but will be more of an issue in implementation with specific providers. Hospice

We would rely on an external vendor to implement this as part of our current program. We would expect that the implementation did not increase issues and calls back to the employer. Private Industry



•



15: Please describe other thoughts about this topic that have been stimulated as you completed this survey, for example, people or other resources that may be known to you, or specific opportunities/challenges that have not been mentioned. Comments: • I believe that for rural healthcare to survive and continue to support the needs of their local clients, telehealth will need to be used to supplement the services that are offered within the organization. Hospital

| 37 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



•



To promote support for public financing of systems, patients (the public) will have to be educated on the benefits to THEM in use of portable health data. The benefits can be safety and quality of care as well as cost and access. Competition among health providers and institutions is fierce! That will be a deterrent to development. Community Agency I think that technology has greatly improved healthcare, but while there is interest, there appears to be a lack of good systems to show the benefits - particularly in relation to cost. Hospice I don't see a great deal of literature indicating that telehealth actually improves outcomes for patients (in the aggregate). The costs for set-up, training and continued operations are significant. Hospital One of the key obstacles to the use of telehealth, and sharing information between providers, is patient identification, and resolving patient ID's, because there is no national patient identifier. This is an obstacle in itself, as providers seek to avoid potential legal liability. Hospital In Steuben, the VA is the only organization that I am aware of that has utilized telehealth practices thus far. Collaboration/ communication with all stakeholders are keys to success. NY CONNECTS is extremely relevant in this effort. Community Agency Alere appears to be one of the leading companies in this area. We use them for other services currently and are looking at their telehealth & technology advances to better understand them. Private Industry



•



•



•



•



•



16: Would you like us to e-mail you a copy of the survey results in November 2009? Yes No No response Total 25 7 0 32



| 38 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Survey Responding Organization Arnot Ogden Medical Services Bath VA Medical Center: Elmira Outpatient Clinic Bethany Village Bethany Village Community Home Health Care Chemung County Department of Health Chemung County Emergency Medical Services Chemung Valley Rural Health Network Corning Hospital Corning Inc. Elcor Health Services Founders Pavilion, Inc. Gentiva Ira Davenport Memorial Hospital Home and Health Care Inc. NY Connects: Steuben County's Choice for LTC Pro-Action of Yates & Steuben, Inc. Regional Health Network Schuyler County Community Services Schuyler Hospital Schuyler County Mental Health Schuyler County Office for the Aging Southern Tier Hospice St. James Mercy Hospital St. Joseph's Hospital St. Joseph's Hospital Nursing Facility Steuben County Department of Community Services Steuben County Office for the Aging Steuben County Health Care Facility The New Falls Home



| 39 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix B Electronic Survey Methods



| 40 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix B Electronic Survey Methods



Electronic Survey

GOODCARE.com in conjunction with the Finger Lakes Health Systems Agency (FLHSA) is conducting a telehealth needs assessment in Chemung, Schuyler and Steuben counties. The Community Health Foundation of Western and Central New York is funding this study. We want to assure you that we are not selling any goods or services but would very much like your input on this community planning effort. The purpose of this survey is to assess the current capabilities of organizations in the Southern Tier to operate telehealth services and to find out the barriers local agencies perceive or are experiencing as they consider developing telehealth care. If you have any questions please call toll free @ 866-696-6543 This survey should take only a few minutes to complete. We know that you have many demands on your time and want to thank you for your participation in this important survey!



Are telehealth applications being used in your organization? (skip logic, a “no” response skips to next yes/no question)

Yes No



| 41 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



If you are using telehealth applications, please check all that apply.

Electronic health or medical records Remote patient monitoring Teleconferencing Real-time remote patient/provider contacts via video or computers Email communications with patients/clients



Other

Comments:



Are you aware of plans to develop or expand telehealth in your organization? (Skip logic, a “no” response skips to next yes/no question)

Yes No



Please check all that apply.



| 42 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



EMS and emergency preparedness Pediatric telehealth Ocular telehealth Teledermatology Telemental health Telepsychiatry Teleradiology Telerehabilitation Telehealth nursing Remote patient monitoring Community services coordination



Other

Comments:



Are you using the following telecommunications tools at your workplace?



| 43 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Cell phone

Yes No Unknown



Dial-up internet service

Yes No Unknown



High-speed internet service (i.e., broadband or DSL )

Yes No Unknown



Dedicated private or institutional broadband (i.e., T1)

Yes No



Unknown Wireless internet access

Yes No Unknown



| 44 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Online lab results (i.e., EKG, virtual radiology, other )

Yes No Unknown



Do you think telehealth can improve health care by making it more: (check all that apply)

Patient/caregiver centered (e.g., increased access, better care) Collaborative among professionals Accessible Comprehensive Coordinated Culturally accessible



Other

Comments:



What do you see as obstacles to successful utilization of telehealth in your organization? (check all that apply)



| 45 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



HIPPA regulations Other legal, regulatory stipulations Practitioner resistance Less face-to-face contact Infrastructure: policy, Infrastructure: technology Lack of training or expertise Competitive interests Cost factors



Other

Comments:



From your organization's viewpoint, what factors would "make or break" the ability to maximize the real value of telehealth for your institution? (check all that apply)

Cost



| 46 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Relevance to our organization Time required for implementation Usefulness to our clients/constituents Usefulness to staff Ease of integration with current practices



Other

Comments:



In terms of planning for telehealth in your region, what factors should be uppermost in the group who leads the implementation? (check all that apply)

Adequate financial support Development of leadership team Benefit to clients Benefit to staff Training responsibility



| 47 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Non-financial support from government & sponsoring institutions



Other

Comments:



There may be other thoughts about this topic that have been stimulated as you completed this survey, for example, interested people or other resources that may be known to you, or specific opportunities/challenges that have not been mentioned. Please describe those, if any.

Comments:



Thank you for your time and effort in completing this survey. Your response will be reported only in the aggregate. We hope that your interest has been heightened by participating in this survey. Our report will be ready for distribution in November 2009.



| 48 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Would you like us to email you a copy?

YES



NO



Is there anyone else you would like to recommend we send this survey to?

First Name:



Last Name:



Job Title:



Company Name:



Email Address: emailaddress@xyz.com City: State/Province (US/Canada):



-- Select a state --



| 49 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Initial Mailing to Survey Participants • Telehealth Needs Assessment Cover Letter: o For those with an email address o For those without an email address • • • Telehealth Needs Assessment Frequently Asked Questions Insert Telehealth Needs Assessment Response Form Insert

Self addressed stamped envelope with return address



o



GOODCARE.com 50 Office Parkway Pittsford, NY 14534



| 50 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Dear ___________________ We are writing to ask for your help with a very important project that will have an impact on your organization and others in the Southern Finger Lakes region. The Finger Lakes Health Systems Agency (FLHSA), www.flhsa.org, is conducting a telehealth needs assessment in Chemung, Schuyler and Steuben counties. Telehealth includes a wide variety of up and coming techniques that are working to aide healthcare providers take better care of more people in a more cost effective way. Attached is brief overview of the types of telehealth. The purpose of this study is to assess the need for, the barriers to and the readiness for telehealth applications to be put to work and expanded in the Southern Finger Lakes. The Community Health Foundation of Western and Central New York has engaged us, to conduct this study. Our plan is to talk with healthcare leaders, like you, in the tri-county region to get your input on these important topics. During this process, we plan to conduct a survey, via email and the internet, as well as conduct focus groups. Dr. Kathryn Votava, of GOODCARE.com, is working with us on this study and will be conducting the surveys and focus groups. We will be conducting this study over the next couple of months and expect to make the results available to you in early November 2009. You may be aware that recent federal stimulus funding has over 500 million dollars specifically targeted for health information technology and telehealth, with a particular emphasis on rural health. Additionally funding is designated for telecommunications infrastructure which will allow greater access to telehealth for healthcare providers and your patients. This study will generate valuable data and information that you and others in the community can use to generate proposals for that funding. The greater the number of providers who participate, the richer the results will be. We appreciate your response to our brief electronic survey that we will send to your email address ____________________. If your email address is incorrect, has changed or if you feel that another member of your team would be more suited to complete our brief survey, please let us know. To give us updated information please either: • • Go to www.flhsa.org/telehealth.html to complete the survey. Or, Complete the enclosed form with the information and return it to us in the SASE.



We welcome your questions so please call me @ 585-461-3520 ext. 108 or Dr. Kathryn Votava toll free @ 866-696-6543. We know that you have many demands on your time and want to thank-you for your participation in this important study! Most sincerely,



Arthur Streeter Senior Health Planner



| 51 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Dear ___________________ We are writing to ask for your help with a very important project that will have an impact on your organization and others in the Southern Finger Lakes region. The Finger Lakes Health Systems Agency (FLHSA), www.flhsa.org, is conducting a telehealth needs assessment in Chemung, Schuyler and Steuben counties. Telehealth includes a wide variety of up and coming techniques that are working to aide healthcare providers take better care of more people in a more cost effective way. Attached is brief overview of the types of telehealth. The purpose of this study is to assess the need for, the barriers to and the readiness for telehealth applications to be put to work and expanded in the Southern Finger Lakes. The Community Health Foundation of Western and Central New York has engaged us, to conduct this study. Our plan is to talk with healthcare leaders, like you, in the tri-county region to get your input on these important topics. During this process, we plan to conduct a survey, via email and the internet, as well as conduct focus groups. Dr. Kathryn Votava, of GOODCARE.com, is working with us on this study and will be conducting the surveys and focus groups. We will be conducting this study over the next couple of months and expect to make the results available to you in early November 2009. You may be aware that recent federal stimulus funding has over 500 million dollars specifically targeted for health information technology and telehealth, with a particular emphasis on rural health. Additionally funding is designated for telecommunications infrastructure which will allow greater access to telehealth for healthcare providers and your patients. This study will generate valuable data and information that you and others in the community can use to generate proposals for that funding. The greater the number of providers who participate, the richer the results will be. The survey is available on-line for you to take in one of two ways. You can either: • • Go to www.flhsa.org/telehealth.html to complete the survey now. Or, Provide us with you email address by completing the enclosed form and returning it to us in the SASE. We will email the survey link to you after we receive your email address.



We welcome your questions so please call me @ 585-461-3520 ext. 108 or Dr. Kathryn Votava toll free @ 866-696-6543. We know that you have many demands on your time and want to thank-you for your participation in this important study! Most sincerely,



Arthur Streeter Senior Health Planner



| 52 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Frequently Asked Questions About the Telehealth Community Needs Assessment

Q: Why is the study being conducted? A: This study is being conducted to determine the current capabilities of organizations in the Southern Tier to operate telehealth services and to find out the barriers local agencies perceive or are experiencing as they consider developing telehealth care. A side benefit of the study may be to stimulate interest in the field and to educate individuals and organizations to the possibilities of telehealth. Q: Who is doing the study? A: Community Health Foundation of Western and Central New York (CHFWCNY) is a notfor profit organization dedicated to improving the health and health care of the people and communities of western and central New York. The Foundation is funding the study. Finger Lakes Health Systems Agency is a not-for-profit organization that is a leader in community based health planning and works to promote the health of the Finger Lakes region's population by providing a "community table" where all stakeholders meet; conducting outreach to community groups as well as retaining extensive data on the region's health and health care. FLHSA is conducting the study. Art Streeter, Senior Planner & Director of Review, can be contacted at 585-461-3520 ext. 108. GOODCARE.com is a private consultancy that provides research, consulting and training in the areas of healthcare services and outcomes. GOODCARE.com has extensive expertise in telehealth and health services research. GOODCARE.com is collaborating with FLHSA in conducting the study. Dr. Katy Votava, President, can be contacted at 866-659-6543. Q: Are you selling anything? A: No, this is not a commercial endeavor. We are not selling any products or services. Q: What is telehealth? A: Telehealth is the use of telecommunications to provide health care services. Telehealth has been used for generations, typically through the use of telephones and now the field has expanded greatly in the past few years to encompass the use of a wide variety of techniques and devices to give care to patients, their families and improve collaboration among health care professionals. Telehealth is used by many specialty services i.e., EMS and emergency preparedness telehealth, pediatric telehealth, ocular telehealth, teledermatology, telemental health, telepsychiatry, teleradiology, telerehabilitation, telehealth nursing.



| 53 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



There are two broad categories of telehealth: • Real Time Telehealth is the concurrent transmission and receipt of information between parties for the purpose of providing healthcare services. Examples: o Teleconferencing type systems that are used for patient – provider encounters. Some of these systems also have enhanced capabilities such as physiologic monitoring. o Patient/provider telephone encounters Store and Forward Telehealth is the collection of information at one point that is stored by one system and forwarded to another system for action. Examples: o Home telehealth and remote patient monitoring systems with physiologic monitoring in home and community based settings that transmit data to a central location for action. o Remote ICU monitoring. o Telephone call systems.



•



Q: Why should my organization participate in this study? A: Whether you are currently a user of telehealth services or not, there are several reasons you should participate: • There is a great deal of federal funding that will become available in the next year or so for telehealth. There will also be state funding. You will receive a copy of the study results that you can use to strengthen your proposals for funding. The greater the number of participants the more robust the results will be. This study will generate a list of organizations in your area that you might want to partner with in your telehealth endeavors.



•



Q: What will happen with the results of the study? A: The study results will be: • • • Sent via email to all study participants. Posted on the www.CHFWCNY.org website. A free webinar highlighting the study results will be made available to participant organizations.



Q: How do we get involved? A: Go to WWW.FLHSA.ORG/TELEHEALTH.html to complete the survey and let us know of others whom you think might be interested in participating. Thank-you!



| 54 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Telehealth Community Needs Assessment in Chemung, Schuyler and Steuben Counties Check one:  Updated contact information  New contact information Name: _____________________________________________ Organization: ________________________________________ Email Address: _______________________________________ Phone Number: ______________________________________ Note: We ask for your phone number in case we have difficulty with the email address. If you are recommending someone, other than yourself to complete this survey, please let us know: Your Name: ___________________________________________ Your Organization: ______________________________________ Please return this in the enclosed self addressed stamped envelope or fax to 800551-1859. Thank-you for your time and effort in helping with this process! Art Streeter Dr. Katy Votava



| 55 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix C Telehealth Focus Group Invitation



| 56 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix C Telehealth Focus Group Invitation

Subject: You're Invited to a Telehealth Focus Group



You're invited to a Telehealth Focus Group

Dear __________, GOODCARE.com in conjunction with the Finger Lakes Health Systems Agency (FLHSA) is conducting a telehealth needs assessment of health care providers in Chemung, Schuyler and Steuben counties. In addition to the survey, we are now conducting telephone conference call focus groups on: • •



Tuesday, October 6th @ 11:00AM-12:00Noon Wednesday, October 7th @ 3:00-4:00PM



Our goal is to gain more information and create comprehensive documentation about the need for, the barriers to and the readiness for telehealth applications to be put to work and expanded in the Southern Finger Lakes counties of Steuben, Schuyler and Chemung. We hope you are willing to join the conversation and share your opinions, experience, and thoughts about telehealth.



If you would like to participate, please email Cymantha Campbell by Tuesday, September 29th. We will then email you an agenda and details about calling in to the focus group. Please let us know which date works the best for you. Each focus group is limited to six participants.

Please call if you have any questions toll free @ 866-696-6543. Click this link for more information about the Telehealth Needs Assessment .



We know that you have many demands on your time and would greatly appreciate your participation! Take GOODCARE,



Dr.Katy Votava President, GOODCARE.com

Email Marketing by



Forward email kathryn.votava@goodcare.com.



This email was sent to kathryn.votava@goodcare.com by



Update Profile/Email Address | Instant removal with SafeUnsubscribe™ | Privacy Policy. GOODCARE.com | Tobey Village Office Park | 50 Office Park Way | Pittsford | NY | 14534



| 57 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix D Detailed Results of Expert Interviews and Focus Groups



| 58 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix D Detailed Results of Expert Interviews and Focus Groups



Expert Interviews On May 18, 2009 Dr. Votava interviewed Jackie Palcik who had performed a research project for the Community Health Foundation of Western and Central New York. As part of the method for that study Ms. Palcik used electronic surveys and had noted in her report that they had poor response rate to those surveys. That particular matter was discussed at length. Ms. Palcik reported that it was "tough to get updated email addresses." She also noted that many people would not release their email address or that many of the contacts had incomplete lists of key information elements. As a matter of follow up when phone calls were made she did determine that there were many typographical errors in their lists, that there had been turnover in staffing, and that some of the key individuals did not have email addresses including executives who were using their own personal email addresses rather than a company email address. Ms. Palcik also noted that it was easy for people to delete emails, particularly if they were "of my generation" referring to folks who did not grow up using email technology. Ms. Palcik reported receiving a great deal of feedback from individuals working in healthcare organizations that they were functioning in “crisis mode” and that they had no time to participate as well. She also determined that individuals were leery of the actual survey software that was used called Survey Monkey as being perceived as unprofessional. She experienced that physician groups were the most difficult to get to participate in the study. Ms. Palcik was also told by some groups in health care organizations that they "do not do surveys" unless they are required by the Department of Health. Dr. Votava interviewed Dr. Cheryl Kerr, a physician expert who has developed telehealth software May 27, 2009. Dr. Kerr runs a medical collaboration software company called www.clickcare.com. This company is located in Binghamton, New York. It is used primarily for specialty consultation for such issues as pathology, gastroenterology, dentistry, occupational health, orthopedics, pediatrics, school based health centers, genetics, medical education and wound care. Dr. Kerr conducted initial studies for the use of this software package through the American Academy of Pediatrics as this product was initially developed for pediatrics and Dr. Kerr herself is a pediatrician. The product is used in home care settings particularly related to wound care. Dr. Kerr was very interested in the

| 59 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



development of telehealth capabilities in the Southern Tier region and is interested in follow up with interested parties that may be an outgrowth of this needs assessment. Dr. Votava interviewed Sandeep Krishan, IT expert, June 4, 2009. Mr. Krishan has been involved in several telehealth projects in the western New York region including the AHEC and the Finger Lakes Migrant and Community Health Program. It was Mr. Krishan's observation that it is difficult for hospitals and large health care organizations to cover the capital expense for the equipment and to see how it fits into their business models and their corporate missions. Mr. Krishan also expressed concerns about dealing with regulations through the New York State government. His perspective was that policies and grants didn't necessarily go together and were not always heading in the right direction for effective implementation of telehealth programs throughout New York State. Dr. Votava interviewed Thomas Remein, Rural Clinical Program Coordinator for the Monroe Plan, to discuss the health management company’s perspective on paying for and supporting telehealth services through its Medicaid managed care programs. One difficulty that Mr. Remein acknowledged was that the insurance company was not in a position to “subsidize” telehealth, and that physicians don’t get paid for it. He did think that the Monroe Plan would be supportive of telehealth services for several reasons, i.e., if telehealth improved the timeliness of information, if telehealth information was secure, and if barriers to care in the rural areas could be decreased. In spite of that, the Monroe Plan is not directly involved in promoting telemedicine. While the Monroe Plan does not pay for telehealth services, it provides some practice support to key primary care practice offices in Monroe County. That support places Monroe Plan staff at those practice sites to enhance the site’s ability to help them implement electronic medical records. Mr. Remein reports that the Monroe plan is currently trying to determine how to extend that type of assistance to satellite areas. Another limitation that Mr. Remein mentioned is that the Family Health Plus and the Child Health Plus have no health insurance benefit for telehealth services. Mr. Remein reported that the Monroe Plan does see a particular need for specialty consultations that currently are not available in rural areas. It has been their observation that primary care practitioners in the rural areas take on more clinically complex cases than they’re technically able to handle. They have seen some problems where patient situation needed a specialty consultation sooner that was feasible in the rural current primary care practice. Mr. Remein acknowledged that there is limited reimbursement for telehealth within current fee for service business models and reimbursement systems. He noted that primary and outpatient care is not population management based but that telehealth might fit as part of the business model if population based finance models were used. Mr. Remein mentioned that his office based in Geneva, NY oversees some Monroe Plan clients in Schuyler and Steuben counties. The Chemung,

| 60 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Steuben and Schuyler counties are also covered in his company by a Donna Crain in the Binghamton office. He was going to pass this information and effort along to his colleague, Ms. Crain, to solicit her input. Mr. Remein was very interested in some of the promising telehealth research and the results that are coming out and asked to be kept informed. Focus Groups Table ___ Focus group session outline Content Participants Time Allotted 5 min.



Welcome and introductions. Telehealth Survey results overview: • Telehealth application use • Types of telehealth applications • Planning for telehealth applications Telehealth survey results: • Perceived opportunities • Perceived obstacles Solicit feedback and discussion from participants re: obstacles and opportunities in their organizations and in their service areas. Solicit updated information about telehealth utilization in the region Provide information of plan to provide report via webinar and published report. Thank-you’s. Total Focus Group Time



Dr. Katy Votava



Interactive section with Dr. Katy Votava to presenting high lights from results and solicit feedback from focus group participants.



37 min.



Group discussion, some of this may flow with the portion above. Dr. Katy Votava



10 min. 3 min.



55 min.b



The first teleconference focus group was held on October 6th. In attendance were Arthur Streeter, Kathryn Votava, Edward Linsler Administrator from Elcor Health Services, which provides skilled nursing facility care, inpatient and outpatient rehabilitation and medical adult day care in Horseheads, New York, and Patty Baroody, Coordinator for NY Connects in Steuben County. An overview of study results to date was discussed. The majority of the focus group time was devoted to discussing experiences, perceptions and feedback from the organizations represented. A benefit



| 61 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



of telehealth noted by both industry representatives was that transportation for rural patients to health and specialty services is very cumbersome, and that having telehealth resources could eliminate that obstacle for many, many patients. The Elcor representative, Mr. Linsler, said that they had no electronic medical records with the exception of what comes to them through other sources. Elcor is going through a sale of the entire facility, and that may be completed by late spring 2010 or early summer 2010; they would not consider investing in equipment and processes until after that time. Elcor does employ its own physicians and nurse practitioners. Elcor Nursing Home noted that patient monitoring after short term rehabilitation stays would be very well welcomed through remote patient monitoring, even though they do not have the capability at this current time. Many of the patients are discharged to home and may be somewhat unstable medically; otherwise, they are also discharged to adult homes and other settings. Mr. Linsler was not concerned as much about capital costs to invest in the equipment as much as the ongoing operations and staffing cost. The Elcor representative did also note that there are generational differences for those who will use telehealth and those who will not. Younger physicians are very technology oriented, and are “pushing the envelope,” and are “barking” at us to be able to check their labs and other values for their residents. Semi-retired physicians on their staff want nothing to do with telehealth and electronic medical record. The NY Connects representative, Ms Baroody, reported that medication management is the number one issue in addition to work force issues which are "huge," and yet she felt they are “spinning their wheels” and not moving forward. Ms. Baroody noted that no agency will take on long term medication management, and that this is a real problem. NY Connects is working on a pilot electronic medication system that will be connected to the PERS system and is looking for a funding agency to move forward. They're working on this project with Lifeline through the St. James Mercy Hospital. NY Connects has no budget to cover any type of telehealth services at this point. They do see the opportunity to work closely with discharge planners who are highly motivated to prevent readmission to hospital. In terms of practitioner resistance, the NY Connects program thought that you had to nurture the masses and find the middle ground that can work on these types of systems and “let the bottom section go.” Younger people are not as stressed by adapting to this technology because they are used to it. The “knitting it together” issue in terms of integrating telehealth into their organizations was discussed. Mr. Linsler reported while it seems simple to knit these systems together that, in fact, has not been the case at Elcor. They have encountered many stumbling blocks dealing with the HIPAA

| 62 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



issues and getting the Elcor electronic system to consistently “talk to” the Arnot for laboratory reports. Elcor has noted a benefit to the physicians when technologies, such as on line laboratory results systems are functioning. Elcor physicians, who use the technology, have found benefits such as increased ease of dealing with their client’s needs and more time off. Therefore, these types of benefits need to be promoted amongst the physician community to get their buy in. The possibility of having a technology center available to support multiple organizations was discussed. Both the Elcor and the NY Connects representatives said that they would have an interest in a technology center. A technology center would be helpful to their IT departments because currently both organizations are hesitant to open up systems to the outside world. Having a technology center would help them such that they “don’t have to reinvent the wheel.” A further concern about HIPAA was expressed because with telehealth there is “a whole new rule book” and that people need to have the tools in terms of rules and regulations and a resource center would be a very good contact point. Both representatives thought that organizations were not going to take this on individually. They recommend advocacy for funding to staff programs and to reorganize systems. The second telehealth focus group was held on October 7th. In attendance were Arthur Streeter, Kathryn Votava, and Pamela Paine, Program Coordinator of the Child and Family Services Program at the Steuben County Department of Community Mental Health. Ms. Paine had a very in-depth discussion about psychiatric mental health telehealth services in her area. Steuben County was already using electronic medical records, and they’re phasing in the process of using the treatment planning program as a part of their electronic medical records. They made a big investment overall, but are very happy in terms of staff who are now becoming accustomed to using the system. When Steuben County started with their electronic medical record they started with just having patient progress notes and then added other pieces over time such as billing, intake, and crisis forms. They are just moving to the process of being able to do the quarterly treatment planning review, and they will be doing training this winter to implement that. The start up phase went better than expected even though people were initially concerned. They did have an issue with some folks not having adequate typing skills, making it difficult for them to use the electronic medical record system. They felt that they were successful in introducing pieces over time, beginning with the progress note that people were most familiar with doing anyway and that implemented quite well. Then they graduated to the other aspects of the system and found the “early adapters” were the people who could use this system most effectively and then other people seemed to pick it up over time. Steuben County Community Mental Health used a one month training period and then six months for use of each new section as they rolled it out. Now many clinicians are scheduling their own



| 63 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



appointments online. Psychiatric notes are still dictated into the system. They do not yet use voice recognition software. They are trying voice recognition software currently, and that may be used in the future. The system has been helpful for them to run routine reports. The Steuben County mental health system has three primary clinics, seven satellite clinics in schools, and they are using the Internet connections with the schools. If equipment was available, people would actually like to use it more now that they have become accustomed to it. They would particularly like to be able to use real time two way video psychiatric specialty consultations. They have no budget for new sophisticated video two-way conferencing equipment. The cost of equipment is approximately $15,000 to start up as well as monthly fees. Steuben County is eligible for funding from the New York State Office of Mental for this type of equipment, but the funds have not been appropriated yet. They have an option of going to the Elmira Psychiatric Center but that is one county away. When asked if there might be a problem with less face-to-face contact in a specialty consultation, Ms. Paine did not think that would be an issue. She thought that families and mental health providers would welcome it. Ms. Paine also noted that transportation is a problem that limits access for mental health services and consultation in the rural area she serves. They are currently doing telephone psychiatric specialty consults that are paid for through a New York State Medicaid waiver. The one limitation is that only one fee can be charged for the visit, resulting in one party on one end not being reimbursed for the care. Ms. Paine did think it would be helpful to have access to a technology support. She reported a technical support center might assist the Steuben County IT department and privacy office with HIPAA and data access concerns. The Steuben County mental health system has not had any experience with privately billing for telehealth Services. They do not currently send information via e-mail, only via Intranet within the county. They don’t have plans yet to communicate directly with their clients via e-mail.



| 64 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix E Electronic Survey Process Experience



| 65 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



Appendix E Electronic Survey Process Experience The team worked on identifying not only the organizations and individuals within the organization but also building accurate electronic mailing lists with accurate email addresses. At the close of the study the contact list had 59 organizations and individuals with full contact information, including email and postal mailing address. The list also has 11 additional potential participants for whom no email address had yet been identified. The list contains 51 other organizations for which no contact person’s name has yet been identified. The process for survey distribution, generally speaking, was to send an initial postal mailing to survey participants to inform them of the project, heighten their awareness of telehealth with educational messaging and offer them the option of completing the survey directly on the web as well as correcting or providing an email address in order for a survey to be directly email to them. Appendix C contains the contents of that postal mailing packet including: • Telehealth Needs Assessment Cover Letter: o For those with an email address o For those without an email address • Telehealth Needs Assessment Frequently Asked Questions Insert • Telehealth Needs Assessment Response Form Insert • Self addressed stamped envelope with return address After the initial mailing on June 29, 2009, this mailing was distributed sequentially to new prospective participants as their contact information became available. Forty three introductory postal mail packets were distributed. Seventeen additional email contacts were identified through this process. One week after the postal mailing was distributed, an email with a web ink to the survey was sent to prospective participants. Second and third email reminders were distributed if there was no response. There are a small number of the contacts that did not receive the postal mailed packet mentioned above. This occurred in the instance where only a contact name and email address was available. In these cases an email was sent to the prospective participant in lieu of the postal mailing. Then the email survey was distributed. The experience was that 25 – 35% of potential participants open the survey email. Of those who open the email, 75-100% complete the survey. Clearly, those who open the email have a high likelihood to complete the survey. The question remained as to why others did not open the email



| 66 11/12/2009



Needs Assessment for Telehealth Applications in the Southern Finger Lakes



at all. Possibly, the survey email arrived in recipient’s “junk” folder versus the “inbox.” While the Constant Contact survey method is designed to minimize that possibility it might have occurred. Also, given the volume of email that people receive, they may not open an email that appears unknown or unimportant to them. To determine if the response rate could be increased by offering a participant incentive, a token incentive method was trialed. One half of the participants received a slightly different email with a mention in the email subject line of receiving a $5 Dunkin Donuts coupon as a token for their participation. There were 24 contacts in each group. Response rates did not improve with the token method. In fact, only 1 recipient who received the incentive opportunity opened the email as opposed to 4 of those who received the email without the incentive. This suggests that either the incentive was not adequate enough or that recipients were more skeptical of the email with the incentive. In addition, there were many challenges throughout this process. Many survey emails “bounced” back to the team. These emails bounced for several reasons: typographical errors on original source documents, spam filters on the receiving end, recipient mail boxes that were full and would not accept any further emails, or the identified individual was no longer associated with the organization In order to deal with the above issues, the project team made a concerted effort via a heavy volume of follow-up phone calls and internet searching to resolve bounced emails, identify other contacts and collect missing contact informant information and provided follow-up instruction to potential respondents who were unfamiliar with email survey processes.



| 67 11/12/2009