CDC now estimates the prevalence of Autism Spectrum Disorders (ASD) to be 1 in 110, up from 1 in 150 just 3 years ago. While the causes of ASD are unknown, effective treatment is available and there are now more resources through public funds and private insurance to meet the need than ever before. It is clear that access to physicians and other diagnosticians is critical to helping families deal with ASD and by using telehealth technologies it can be an effective strategy.
That is why support from a “Real Choice Systems Transformation” five year grant funded by CMS, made it possible for the state of Missouri to help children with ASD. The funding for the grant “The Use of Telehealth for Service Provision to Children with ASD” helped the state use a number of strategies to improve access to community-based services with telehealth as one of the key strategies.
At this point, a small pilot study with 5 patients was conducted by Dr John Mantovani, M.D. Medical Director, St. John’s Mercy Children’s Hospital. The pilot focused on children between 2 and 4 years of age that had been referred for possible ASD issues by primary care physicians for diagnosis. According to the project completion document, telehealth technologies were used to evaluate the children and it was found that using telehealth for diagnosis depends on:
• Appropriate qualified professionals including state licensed physicians, psychologists, or other health or mental health professionals. They should have advanced training and clinical experience in the diagnosis and treatment of ASD and other neurodevelopmental disorders
• Reliable, secure, and confidential video access along with adequate support from the information technology staff available on both ends of the connection
• Availability of completed pre-evaluation information in the form of parental questionnaires and information on prior testing plus observational information from relevant care takers and professionals
• A range of age appropriate toys and other items to facilitate the evaluation
• Parents who can understand the examiner and can work with their child under the direction of the examiner
The pilot concluded that if two examiners instead of just one examiner observes and interacts with the child and family either simultaneously or in tandem, similar reliable results will occur. This approach is currently being used by Dr. Matt Reese and colleagues at the Kansas University Center for Child Health and Development where a physician and psychologist work side-by-side during telemedicine evaluations.
It was found that diagnostic reliability appears to be directly related to the severity of the symptoms when using telehealth to evaluate the child. It was felt that although a considerable number of young children can be diagnosed via telehealth there will still be children with more severe problems that can’t be adequately diagnosed by just using distance technology.
One of the issues that arose during the telemedicine examinations was not being able to have the child visible at all times. Sometimes a child may run around the room and be too far from the video screen or completely out of view. The thinking is that perhaps some type of barrier or small wall could be used to form a corral to contain the child.
It was also felt that the ability to interact with the child via the equipment could be improved by lowering the video-screen in the room to either eye-level with the mother’s seated position or the child’s eye level to enable the child to get as close to the screen as possible to enhance interaction with the examiner.
The report also points out that some of the barriers to using telehealth concerns the availability of networks and/or the ability to create new networks. Although many hospitals and medical centers have the capacity for telehealth connections, most often telehealth in these locations is used for distance learning, lectures, and conferences rather than for clinical activities. The MTN system operates many sites in the state, but these sites are limited to the University of Missouri Health System providers.
In the state, reimbursement is a key issue and needs to be dealt with locally and regionally since third party payers vary significantly with regard to coverage for professional services. So far, the Missouri HealthNet Program has been reimbursing telehealth services provided by physicians, nurse practitioners, and psychologists since 2008. An additional modifier code (GT) was added to the usual CPT code for the provider with reimbursement the same as for an office consultation.
Missouri continues to be active in the autism field. A bill signed into law in 2008, established a Governor-appointed Commission for Autism Spectrum Disorders plus an Office for Autism within the Division of Developmental Disabilities. Today, a home and community-based Medicaid waiver for children with ASD was approved by CMS and currently serves 150 children.
In addition, legislation to become effective this year requires private insurance to cover applied behavioral analysis for children through age 18 and establishes standards for professionals providing services to autistic children.
The report stresses that there is a need for a more comprehensive ASD project to continue to evaluate the use of telehealth to diagnose and manage children with ASD, but for another project to take place more grant funding is needed. The report looks for possible future financial grant support from HRSA especially in their rural health program, the Missouri Foundation for Health, Autism Speaks, and the Thompson Foundation.
To view the complete report, go to http://dmh.mo.gov/docs/dd/Mantovani.pdf. For more information, contact the Missouri Department of Mental Health at www.dmh.mo.gov or call (573) 751-4122.
