NRHA sept2011
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  • “Holding” picture in case needed prior to intro
  • Intro / Title
  • CTeL - Center for Telehealth and e-Health Law, Washington, DCTTAC - Telehealth Technical Assistance Center, Anchorage, AK
  • HTRC is one of 8 regional telehealth resource centers funded by HRSA across the country
  • Covering the Midwest region is the Heartland Telehealth Resource Center (HTRC), a collaborative effort of three of the nation’s earliest, most successful telemedicine programs at the University of Kansas Medical Center, University of Missouri, and University of Oklahoma Health Sciences Center.
  • ARRA – American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT – Computed Tomography scan
  • ARRA – American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT – Computed Tomography scan
  • ARRA – American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT – Computed Tomography scan
  • ARRA – American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT – Computed Tomography scan
  • ARRA – American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT – Computed Tomography scan
  • ARRA – American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT – Computed Tomography scan
  • ARRA – American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT – Computed Tomography scan
  • ARRA – American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)CAT – Computed Tomography scan
  • During the 1970s, it appeared primarily in short-term projects or programs.One such program lasting for two years connected Boston Hospital to a remote site.
  • ARRA - American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)
  • Source: CTeL http://www.ctel.org/expertise/reimbursement/medicare-reimbursement/ New statutory language did not match the practical realities of telehealth practice.Live consultations constitute only about 10% of telehealth servicesA major concern in revising the telehealth reimbursement provisions was the exceedingly high cost (“scoring”) affixed to telehealth reimbursement legislation by the Congressional Budget Office (CBO). In 2000, the Center for Telemedicine Law, with funding from the Office for the Advancement of Telehealth, coordinated a project to use available telehealth reimbursement claims data to develop a more accurate funding projection.
  • ARRA - American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)Limited locations to : Offices of a physician or practitioner, CAHs,RHCs, FQHCs and hospitalsSNF – Skilled Nursing Facilityhttp://www.federalregister.gov/articles/2010/07/13/2010-15900/medicare-program-payment-policies-under-the-physician-fee-schedule-and-other-revisions-to-part-b-for
  • ARRA - American Recovery and Reinvestment Act of 2009 (Division A, Title I and XIII, Sec 13001)SNF – Skilled Nursing Facility
  • I know. HRSA is within HHS, so this is not totally outside agency funding.
  • Universal Service Administrative Company – open to public or non-profit rural health care providers.
  • Telehealth Program vs. NetworkCritical Access Hospitals receive a variety of services from supporting hospitals, including telehealth.Bluestem in WichitaCedar Valley Health Network in Overland ParkNortheast Kansas Healthcare Network in TopekaIn Kansas, telehealth development initially came from KU Medical Center. While not a “Network”, it continues to serve as the major telehealth program in the state.In Kansas, these are the locations that contacted KUMC for clinical, educational or administrative purposes in the year ending June 2010.
  • Missouri Telehealth Network (MTN) - supported by HRSA, private telecommunication companies and each telehealth site.
  • Missouri Telehealth Network (MTN) - supported by HRSA, private telecommunication companies and each telehealth site.
  • Early pioneer in the development, utilization and reimbursement of Store and Forward telemedicine Telemedicine in Oklahoma is not centralized, but offered through distributed and collaborative telemedicine networks and individual providersOklahoma supports telemedicine/telehealth through the state’s high speed intrastate network, OneNet;Oklahoma Universal Service Funds to 165 healthcare provider sites plus 119 Public Health Departments; and Legislation that supports reimbursement of telemedicine services (Medicaid reimbursement comes from OK Healthcare Authority)HTRC/OHA survey 2011 indicates Radiology, Cardiology, Mental Health and Telestroke as the most commonly utilized services via telemedicine
  • 1. The newly formed Council on Physician and Nurse Supply says the United States may lack as many as 200,000 needed physicians (and 800,000 nurses) by 2020. 2. The Bureau of Labor Statistics predicts there will be 212,000 physician openings by 2014 due to growth and net replacement of retiring physicians. That number represents more than 25 percent of the current physician work force. 3. The American Medical Association (AMA) says that as the U.S. population rose 31 percent between 1980 and 2003, its number of medical school graduates remained static.4. The National Ambulatory Healthcare Administration says people aged 66 and older average six physician office visits per year; individuals aged 46 to 65 average 5.4 visits annually; and people 25 to 35 years old average 2.2 visits a year. Increasing numbers of older patients mean heightened healthcare demand. Baby boomers aging bodies require more therapy, treatment, and surgery. 5. Of course, as boomer patients are aging, so are boomer physicians. Many of today’s practicing physicians are retiring, or soon will. The AMA’s data state that “matures” (people over age 61) and baby boomers (people between age 42 and age 60) now make up 67 percent of the existing physician population. Generation Xers (age 27 to age 41) make up only 33 percent of today’s practicing physicians.
  • Oncology – darkened conference room, large monitors, expensive phone lines, telepresenter with headphones assisting
  • Same Oncologist in his own office, software loaded on his desktop computer, standard camera on top of monitor, headphones for stethoscope or clarity, patient on monitor
  • The same set-up on a small laptop computer, note lab tech or physician on screen. Equipment needed: camera, software, Internet
  • Total Exam Camera – GlobalMediaStethoscopesTop – CaretoneRight – MabisBottom - Stethographics
  • Telehealth technology has proven particularly useful for distance education purposes, particularly with reductions in time and budget for travel.
  • Pediatrics, Public health, Nutrition/Weight management, Behavioral health, Counseling2010 Photo, nurse has now gone to desktop ITV
  • Growing in popularity along with personal health management
  • Husband, Coffeyville, KS, resident monitoring vital signs from his home.
  • Wife, Coffeyville, KS, responding to questions on home monitor unit.
  • Devices by WebMDC
  • Devices – PSG Telehealth
  • Total Exam Camera – GlobalMediaStethoscopesTop – CaretoneRight – MabisBottom - Stethographics
  • Tablets – PlaybookWirelessSmart PhonesFlexible, wearable screensNurse walking with RP Xpress
  • Igo in OK working with kidsInTouch Health Robot
  • Provider satisfaction mixed depending on context - Referring Physician or Specialist
  • Staffing – Provide ED coverage for nights/weekends could make up for staff lossGreater access to specialties – increase number of patients
  • Staffing – Provide ED coverage for nights/weekends could make up for staff lossGreater access to specialties – increase number of patients
  • Increasing access to specialty health care, orproviding greater variety of services could result in retaining patients locally
  • RHC – Rural Health ClinicHPSA – Health Professional Shortage Area
  • RHC – Rural Health ClinicHPSA – Health Professional Shortage AreaKDE _ Kidney disease educationDSMT – Diabetes Self-Management Training
  • RHC – Rural Health ClinicHPSA – Health Professional Shortage Area
  • HPSA – Health Professional Shortage Area
  • HPSA – Health Professional Shortage Area
  • DX – Diagnostic
  • KDE – Individual and group MNT – Medical Nutrition TherapyHBAI – Health and Behavior Assessment and Intervention Services
  • Credentialing and PrivilegingLicensureHIPAA
  • Effective July 5, 2011, CMS has new Medicare hospital Conditions of Participation (CoPs) for credentialing and privileging of physicians and practitioners providing telemedicine services at hospitals and Critical Access Hospitals. As stated by CMS: “The removal of unnecessary barriers to the use of telemedicine may enable patients to receive medically necessary interventions in a more timely manner. It may enhance patient follow-up in the management of chronic disease conditions. These revisions will provide more flexibility to small hospitals and CAHs in rural areas and regions with a limited supply of primary care and specialized providers. In certain instances, telemedicine may be a cost-effective alternative to traditional service delivery approaches and, most importantly, may improve patientoutcomes and satisfaction.”
  • All quotes: HHS, CFR Parts 160, 162, 164 Health Insurance Reform: Security Standards; Final RuleFederal Register, Feb 20, 2003 pg 8342
  • All quotes: HHS, CFR Parts 160, 162, 164 Health Insurance Reform: Security Standards; Final RuleFederal Register, Feb 20, 2003 pg 8342
  • I recognize that the FLEX Program (Medicare Rural Hospital Flexibility Program contains explicit expectations and financial incentives to encourage CAHs to undertake collaborative efforts with their communities, but this suggested use of telehealth was not developed in conjunction with anyone from FLEX programs in any state.
  • We all know the strength of hospital collaboration in a variety of areas…
  • a telephone survey of 141 formalized (2 or more) rural hospital networks conducted by the National Rural Health Resource Center and the University of Minnesota Rural Health Research Center between February and October 2009 – 41% had between 11 and 20 membersOrg development – Infrastructure items: contracting, purchasing, other financialEffectiveness – credentialing, education, nurse preceptor training, staffing poolshttp://www.ruralcenter.org/networking/resources/rural-hospital-network-survey-executive-summary
  • WARNING: This example has no outcome data. Too early. Identify with the CAH and what has worked for them – lessons learned
  • High volume of trauma patients due to proximity to Interstate Highway 10, and visitor influx during hunting season Nursing concerns about managing complex patientsMany students in the school district are uninsured, school nurse acts as caregiver
  • Bring in additional partners – grow and expand if desired. May be a solution for additional funding
  • Limited resources at rural hospitals for new project development and securing grant funds.Time demands on rural clinicians already filling multiple roles
  • Innovation – inventing or introducing a new way to get something doneWilling to commit to change for a purposeRe-purpose – changing the reason for which something exists or for which it has been made
  • https://www.cms.gov/CouncilonTechInnov/downloads/qualityroadmap.pdfhttp://www.google.com/search?q=CMS+quality+improvement&rlz=1I7GGLL_en

NRHA sept2011 Presentation Transcript

  • 1. Leveraging Telehealthfor Critical Access Hospital SuccessGordon A. AllowayProject DirectorHeartland Telehealth Resource Center (HTRC)
  • 2. Telehealth Resource Centers (TRCs)• Federally-designated thru HRSA/ORHP• TRC Grant Program established in 2006• Extensive telehealth program implementation experience• 11 Regional centers , plus• CTeL - Legal and Regulatory Assistance• TTAC - Technology Assistance
  • 3. Regional Telehealth Resource Centers • California Telemedicine & eHealth Center (CTEC) CALIFORNIA HEALTH FOUNDATION AND TRUST, SACRAMENTO, CA • Great Plains Telehealth Resource & Assistance Center (GPTRAC) UNIVERSITY OF MINNESOTA, MINNEAPOLIS, MN • Heartland Telehealth Resource Center (HTRC) UNIVERSITY OF KANSAS / UNIVERSITY OF MISSOURI / UNIVERSITY OF OKLAHOMA Primary Service Region: Kansas, Missouri and Oklahoma • Northwest Regional Telehealth Resource Center SAINT VINCENT HEALTHCARE FOUNDATION, BILLINGS, MT New TRCs • Pacific Basin Telehealth Center Coming UNIVERSITY OF HAWAII, HONOLULU, HI Soon • South Central Telehealth Resource Center UNIVERSITY OF ARKANSAS, LITTLE ROCK, AR • Southeastern Telehealth Resource Center GEORGIA PARTNERSHIP FOR TELEHEALTH, WAYCROSS, GA • Southwest Telehealth Resource Center UNIVERSITY OF ARIZONA, TUCSON
  • 4. HTRC SERVICE AREAKANSAS - MISSOURI - OKLAHOMA
  • 5. Telehealth OrTelemedicine?
  • 6. Technology Terms (as defined by CMS)Telehealth - the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.*
  • 7. Technology Terms (as defined by CMS)*Telehealth (or Telehealth Services) includes such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit patient data for monitoring and interpretation.
  • 8. Technology Terms (as defined by CMS)Telemedicine - the use of medical information exchanged from one site to another via electronic communications* to improve a patient‟s health.
  • 9. Technology Terms (as defined by CMS)*Electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site.
  • 10. Two Common Forms of Telemedicine1. Asynchronous or “Store-and-forward”Example: Radiology – Tech takes X-ray image, CAT scan or MRI of patient • With digital equipment • Image can be scanned into digital – Image transmitted electronically to radiologist at different location – Radiologist reads image and responds to PCP/patient
  • 11. Two Common Forms of Telemedicine2. Interactive or “Real Time” – Uses interactive tele-video (ITV) • Face-to-face video conferencingExample: Clinical Consultation – Patient and provider schedule an appointment – Patient goes to clinic, hospital, CAH, etc., and is taken to exam room – An aide remains with patient in exam room • Operates equipment, assists provider – Provider appears on video monitor
  • 12. Technology Terms (as defined by CMS)Originating or “Spoke” Site means the location of the patient at the time the service being furnished via a telecommunications system occurs.Telepresenter – person who may be on-site to facilitate the delivery of this service.
  • 13. Technology Terms (as defined by CMS)Distant or “Hub” Site means the site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.
  • 14. History
  • 15. Telehealth – Feasible for many years.• Telemedicine – appeared in the 1950s• First documented consult – 1959• Brief projects in 1970s – In the American Journal of Psychiatry, Dr. Thomas F. Dwyer, a Massachusetts psychiatrist, said that he has practiced telepsychiatry via video teleconferencing, for five years. Its “adoption by psychiatrists and patients,” he predicted, “will proceed quickly . . ..” (August, 1973)
  • 16. Telemedicine in U.S.• Late 1980s - Current telemedicine movement began – Initial growth came from at least one telemedicine program per state – Many based in university medical centers – Combination of grant and state funding; few are self- sustaining – Research and development focused
  • 17. Telemedicine in U.S.• Late 1990s - Federal support for telehealth began• Key legislation: – The Balanced Budget Act of 1997 (BBA) • Mandated Medicare reimburse telehealth care • Funded telehealth demonstration projects • Limited in scope – Examples: » Provider fee-sharing » Patient had to be present » No originating site reimbursement
  • 18. Telemedicine in U.S. Consolidated Appropriations Act of 2001 (CCA) • Telehealth policies (H.R. 5661, Section 223) - Benefits Improvement and Protection Act of 2000 (BIPA) Objective: to expand rural access Established many of today‟s guidelines– Medicare Improvement to Patients and Providers Act of 2008 (MIPPA) •Included SNF •Added more originating sites
  • 19. Telemedicine in U.S.– American Recovery and Reinvestment Act of 2009 (ARRA) • Significant investments in health technology – Broadband – Health IT – Telehealth and e-health technologies
  • 20. Telemedicine in U.S.– USDA– Rural Development, Farm Bill Loan Program, Broadband Program • http://www.rurdev.usda.gov/utp_farmbill.html– USDA – Rural Development, Distance Learning and Telemedicine Program • http://www.rurdev.usda.gov/UTP_DLT.html– HRSA – Rural Health Grant Programs • http://www.hrsa.gov/ruralhealth/grants/index.html– HRSA – Rural Hosp. Flex Grant Pgm. • Check with your state‟s program
  • 21. Telemedicine in U.S.– USAC – Rural Health Care Support • Will pay for % of Internet access cost – http://wireless.fcc.gov/outreach/index.htm?job=f unding– Dept. of Commerce – National Telecomm. and Information Admin. • Expanding broadband Internet access • http://www.ntia.doc.gov/category/grants
  • 22. HTRC Service AreaKansas/Missouri/Oklahoma
  • 23. Kansas Telemedicine Experience• First implemented in 1991 with one hospital – now over 2,000 clinical consults/yr• Primarily facilitated by ITV• Expanded into hospitals, schools, nursing homes, and clinics• Since 1991, has conducted approx. 24,000 clinical visits across 30 specialties – Including: Cardiology, mental health, oncology, pediatrics
  • 24. Missouri Telemedicine Network (MTN)• Began in 1994 with 10 sites and MU Health Services• One of the first public-private partnerships• Maintains own high-speed intrastate network• Today – Over 200 endpoints – Continued public-private partnership – Nearly 7,000 encounters – 31 medical specialty services
  • 25. MTN County Coverage • 225 Sites • 58 Counties
  • 26. Missouri Telemedicine Network (MTN)• Participants contract with MTN• Contracted services include: – Procurement of equipment and lines – Help with clinical, tech, operational, legal/regulatory aspects of telehealth – Receive clinical services – Support in providing services to own clinics or to others
  • 27. Oklahoma Telemedicine Experience• Began in 1993 – 45 rural hospitals – 15 regional hospitals – OUHSC• Pioneered Store-and-Forward telemedicine• Collaborative networks and individual providers• State provides funding & tech support• Most common services: Radiology, Cardiology, Mental Health, Stroke
  • 28. Intended Benefits of Telemedicine1. Improve health care access2. Reduce patient travel time and cost3. Reduce provider travel time/cost to outreach sites4. Retain patients locally in their home communities5. Addresses physician shortage
  • 29. Past Challenges for Telemedicine1. Limited adoption by providers – Limited Federal/State reimbursement – Private reimbursement not standardized – Seemingly not integrated in clinic flow – Technology concerns • Initial investment of equipment • Ongoing support • Lack of standardization • Inconsistent broadband internet service2. Lack of financial sustainability models
  • 30. Technology
  • 31. Telemedicine in Early 1990’s
  • 32. Telemedicine Today
  • 33. Telemedicine on Smaller Scale
  • 34. Telehealth Peripherals Digital Stethoscopeshttp://www.telehealthtac.org/toolkits/patient-exam-cameras-technology-overview#Patient_Exam_Cameras
  • 35. Technology Specific to Health Care• Peripheral devices – Otoscope – Stethoscope – Dermascope – Ophthalmascope – General exam camera – Handheld retina camera
  • 36. Technical Advances• Smaller, less expensive equipment• From analog to digital• From telephone lines to internet lines• Wireless• Encryption• Integration
  • 37. Applications
  • 38. Group Sessions and Educational Events
  • 39. Specialty Consultation via ITV
  • 40. Telestroke / Physician-to-Physician
  • 41. School-Based Programs
  • 42. Electronic Otoscope for Pediatrics
  • 43. Intra-Oral Scope (Tele-Sleep Study)
  • 44. What Tele-Sleep Presenter Sees
  • 45. Oncology Care (Hospital Exam Room)
  • 46. Home Telehealth / Home Monitoring• Newest, most active segment• Preventive care• Popular with aging population in U.S.• Designed to delay Nursing Facility placement Could reduce Medicaid costs for states• Remote management of chronic illness• Particularly useful for post-acute care management
  • 47. Home Telehealth / Home Monitoring• Can include both wired and wireless monitoring devices• Personal health management – expected to be linked to personal devices iPads Tablets Smartphones
  • 48. Disease Management - Diabetes
  • 49. Disease Management - Diabetes
  • 50. Home Monitoring Devices
  • 51. Home Monitoring Process Central Data Collection “Home” Unit (Web-based)Measuring Device
  • 52. Home Dialysis
  • 53. LatestDevelopments
  • 54. Telehealth Peripherals Total Exam Camera Digital Camera/Camcorders VS Features Digital Advantages Records image Same Features Has own lighting Less expensive HD Easily Availablehttp://www.telehealthtac.org/toolkits/patient-exam-cameras-technology-overview#Patient_Exam_Cameras
  • 55. Technical Advances• Next generation:
  • 56. Robotics
  • 57. Telemedicine Evaluation
  • 58. Feasibility, Satisfaction• Interactive Tele-Video (ITV) model has been tested across numerous specialties and services• Patient satisfaction historically very high, not studied much anymore• Provider satisfaction mixed depending on context
  • 59. CAH Cost-benefit• “Hard Dollar” Benefits – Can depend on context/purpose – Examples: • Patient – Reduced travel costs – Reduced time off from job • Provider - PCP • Educational • Institutional costs • Reduced staffing costs • Greater efficiency for radiology
  • 60. CAH Cost-benefit• Long-term revenue generation(?) – Enables new staffing models • Specialists do not need to be physically located at hospital • Continue patient services while staff physicians on vacation • Reduce recruiting costs • Serve greater number of patients • Staffing for other facilities – Facility fees for originating site – Increased use of Lab, X-Ray/MRI or Pharmacy
  • 61. CAH Cost-benefit• Community economics – Retaining patients locally • Direct – Patient satisfaction = patient retention – Efficient use of employees = Full value of human capital investment – Increased use of local lab, pharmacy • Indirect – Community activity level increases » housing, food, shopping
  • 62. Reimbursement
  • 63. Good News! There Is Reimbursement• Medicare (2001)• Medicaid varies by state, but generally followed Medicare guidelines: – Kansas (2004) – Missouri (2008) – Oklahoma (1998)
  • 64. Medicare Benefit Policy – Telehealth Guidelines• Telecommunications system may substitute for an in-person encounter for: – Consultations (since Oct 2001) – Outpatient visits – Individual psychotherapy – Pharmacologic management – Psych diagnostic interview exam (March 2003) – End stage renal disease (Jan 2005) – Individual med nutrition therapy (Jan 2006) – Neurobehavioral status exam (Jan 2008)
  • 65. Medicare Benefit Policy – Telehealth Guidelines• Telecommunications system may (cont‟d): – Follow-up inpatient consultations (Jan „09) – Initial inpatient consultations (Jan 2010) – Individual (Jan 2010) and Group health and behavior assessment & intervention (Jan 2011) – Group medical nutrition therapy (Jan 2011) – Individual and group KDE (Jan 2011) – Individual and group DSMT (Jan 2011) Source: CMS, Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Sec. 270.2 – List of Medicare Telehealth Services
  • 66. Medicare Benefit Policy – Telehealth Guidelines• Patient location must be: – Physician/Practitioner‟s office – Hospital or CAH – RHC or FQHC – Skilled nursing facilities – In-hospital/CAH dialysis centers – Community mental health center – HPSA county outside metro area
  • 67. Medicare Benefit Policy – Telehealth Guidelines• Physician/Provider location (distant site) – No limitation on location• Who may receive payment – Physician, PA, Nurse practitioner, Nurse midwife, clinical nurse specialist, Clinical Psychologist, Clinical social worker, Registered dietitian / nutrition professional• Telepresenters – Medical professional not required
  • 68. Medicare Benefit Policy – Telehealth Guidelines• Interactive audio and video telecommunication must be used in real-time communication – Patient must be present and participating• Payment is equal to the current fee schedule amount• Telehealth Facility Fee (for originating site)
  • 69. Medicare Telehealth Services & CPT Codes• Consultations (99241-99255)• Office or Outpatient Visits (99201-99215)• Psych therapy and Dx interview (90804-90809; 90801)• Pharmacy management (90862)• End stage renal (G0308, G0309, G0311, G0312, G0314, G0315, G0317, G0318)• Individual medical nutrition therapy (G0270, 97802, 97803)• Neurobehavioral status exam (96116)• Originating site fee (Q3014)
  • 70. Medicare Telehealth Services & CPT Codes (Effective January 3, 2011)• Kidney Disease Education (G0420, G0421)• Diabetes Self-Mgmt Training (G0108, G0109)• Group MNT and HBAI (97804, 96153, 96154)• Subsequent hosp care services – limit one visit every 3 days (99231, 99232, 00233)• Subsequent NF care services – limit one visit every 30 days (99307 – 99310)
  • 71. Telehealth Lawsand Regulations
  • 72. 3 Main Topics• Credentialing and Privileging – 2011 Changes• Licensure – What is required• HIPAA – What does/does not apply
  • 73. Credentialing & Privileging• Where patient is located is place of service• Providers need to be credentialed / privileged/ licensed at each place of service – Effective July 2011 – hospital‟s governing body still responsible for all privileging decisions, but can accept credentials from distant-site Medicare hospital for telemedicine providers. CMS
  • 74. Insurance & Licensure• Standard malpractice insurance covers telehealth• Very low risk service to date – 3-4 known cases (2 were online prescribing) – 2 New Mexico cases bring up telehealth use – If available and not used, there may be liability• No national physician license – A few states require telemedicine license • Supplemental licensing
  • 75. HIPAA Issues• Security Rule does NOT apply to telemedicine events – Not considered electronic Protected Health Information by CMS • Not pre-recorded or stored like PHI (“Not in electronic form before transmission…”)
  • 76. HIPAA Issues• “The standards and specifications of the Security Rule are specific to electronic protected health information (e- PHI). . . E-PHI does not include paper-to-paper faxes or video teleconferencing or messages left on voice mail, because the information being exchanged did not exist in electronic form before the transmission. In contrast, the requirements of the Privacy Rule apply to all forms of PHI, including written and oral.” US Dept. of Health & Human Services http://www.hhs.gov/ocr/privacy/hipaa/faq/securityrule/2010.html
  • 77. HIPAA Issues• Does not require encryption (but most encrypt)• Privacy rule DOES apply • Telemedicine room should be private just like any other clinic room • Use private connections when possible
  • 78. Clinical Models• Level and frequency of telemedicine intervention determined by comfort of provider and specialty needs – TelePsychiatry – completely by telemedicine, no in- person – TeleOncology – hybrid model of some in-person (often 1st appt.) and some telemedicine follow-up – TeleRehabMedicine – more in-person, less telemedicine
  • 79. CAH Opportunities:Meeting Goals through Telehealth
  • 80. What are Your CAH Objectives/Needs?• Increasing access to care • Meet currently unavailable specialty requests • ED after-hours coverage• Improving quality/outcomes • Additional certification training for staff • Improve patient outcomes
  • 81. Collaborative Networks1. Hospital w/ Other Businesses Members of Current Networks Supporting Hospital Local/regional clinics Health Departments2. Community Networks Hospital w/ Others in Rural Community
  • 82. #1 – Collaborative NetworksThe traditional strengths of hospital networks Increased purchasing power Billing administration Cost-sharing Risk-sharing Data-sharing
  • 83. Network Opportunities for CAHs•Look for tie-in/networking opportunities among: •Members of Current Networks •Supporting Hospital •Local/regional clinics •Health Departments
  • 84. #2 - Hospital w/ Community Collaborative Networks
  • 85. Significant Achievementsby Rural Hospital/Community Networks • 31% - Organizational Development • 18% - Improving member effectiveness • 16% - Improving access to care • 15% - Survival/stability • 10% - Administrative development • 5% - Clinical development • 5% - Improving community health Source: 2009 Survey
  • 86. #2 - Hospital w/ Community Collaborative Networks How do I start? What can I accomplish?
  • 87. Basic Telehealth Start Example: Southwest Concho Valley (TX) Telehealth Network• Kimble County Hospital, a fifteen bed CAH in Junction, Texas – Serving nearly 9,000 people – 4,300 square mile service area – 3 counties Tschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, Texas Case Study
  • 88. Rural Texas Health Care Junction, TX Kimble HospitalTschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, TexasCase Study
  • 89. Network Partners– Junction School District • 738 students; 1 county– University of Texas Medical Branch Telehealth Center, Galveston, TX Tschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, Texas Case Study
  • 90. Step One: Establish Relationships1. Initial Contact by Kimble Hospital2. Meetings in Galveston and Junction to discuss organizational goals, needs, potential fit as partners Junction School district UT Medical Branch3. Mutual respect for the skills, knowledge and resources brought by each partnerTschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, TexasCase Study
  • 91. Step Two: Needs Assessment• County has 1 primary care physician, no specialists• Kimble is the only hospital for three counties and the only designated Level IV Trauma Center in a 60-mile radius• ER staffed by mid-level providers• High volume of trauma patients• Nursing concerns managing complex patients• Many school children were uninsured Tschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, Texas Case Study
  • 92. Step Three: Identification of Priority Needs• Top Priority - Telemedicine program to provide back-up consultation for the Emergency Dept.• Clinical services needed from UT Emergency Medicine Department• Telemedicine unit needed at Kimble Hospital Tschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, Texas Case Study
  • 93. Step Four: ImplementationIdentify funding sources for project sustainability Medicare billing for telemedicine consultations Grant funding for equipment and network developmentBring in additional partnersTschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, TexasCase Study
  • 94. Additional Network Partners• Hospital District Home Health Agency• County EMS• Nursing Home• Additional County School DistrictTschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, TexasCase Study
  • 95. Challenges Faced Initial funding for equipment Issues with rural telecommunications infrastructure Limited resources at rural hospitals Time demands on rural cliniciansTschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, TexasCase Study
  • 96. Rural Characteristics Beneficial to Hospital/Community Network Development• Fully engaged communities• Resourcefulness and ingenuity• Willing to commitment to innovation• Academic Health Centers contribute Extensive clinical expertise Grant developmentTschirch, P., Whitson, L., Creating a Model for Rural Telehealth Network Development, TexasCase Study
  • 97. Networks Rewarded Under Current Federal Policies?CMS - strategy to achieve its goal of high-qualitycare: “Work through partnerships to improve performance.”Examples • Surgical Care Improvement Partnership (public-private group) • Alliance for Cardiac Care Excellence • Hospital Quality Alliance (HQA) • Ambulatory Quality Alliance (AQA)
  • 98. How to Locate Opportunities• Check with your Regional TRC
  • 99. AK Telehealth Resource Centers WA St. Lawrence, Franklin, Clinton, MT & Essex ME ND Counties New Northeast VT York OR MN TRC NH MA ID WI SD WY MI RI CT IA Upper NV NE Midwest OH TRC DE IL IN CO WV MD VA KS CA MO KY Mid-Atlantic TRC NC TN AZ OK SC AR NM MS GAHI FL
  • 100. Three New Telehealth Resource Centers! (TRCs) • Northeast Telehealth Resource Center Augusta, Maine New England and New York • Mid-Atlantic Telehealth Resource Center Charlottesville, VA Virginia, D.C., Delaware, Kentucky, Maryland, North Carolina and West Virginia • Upper Midwest Telehealth Resource Center Terre Haute, IN Indiana, Illinois, Ohio and Michigan
  • 101. Who do TRCs serve?• Hospitals and Critical Access Hospitals (CAH)• Rural Clinics• Providers• Health Care Organizations• Health Care Networks• Community Health Systems• and others…
  • 102. How TRCs can help. . .• Telehealthresourcecenters.org Legislation/Regulations Forms & Protocols Toolkits Event Announcements• Staff training Onsite - at your CAH (inc. travel) Telepresenters, Basic Processing• Peer to peer connections Learn from other‟s mistakes Tele-All (Stroke, ICU, etc.) No regional limitations
  • 103. How TRCs can help. . .• Technical Assistance Call or Email - FREE Instant access to > 30 of the most experienced telehealth professionals in the U.S. National and local resources for regulatory matters Solve technology mysteries o What is latest & greatest o What is basic & dependable
  • 104. How TRCs can help. . .• Technical Assistance (cont‟d.) Assessments o Market Conditions o Needs & Prioritization o Organizational Readiness o Technology o Peer Comparison Basic strategic planning o Sources for revenue generation o Expense reductions o Cost Center/Residual benefits o Start Up / Replacement funding
  • 105. How TRCs can help. . .• Technical Assistance (cont‟d.) Business Model Development o Equipment Selection o Program development o Operational support o Education on Insurance o Reimbursement o Quality Assessment
  • 106. How TRCs can help. . .• Technical Assistance (cont‟d.) Advanced business planning (< two hours) o Experienced telehealth consultants available on fee or hourly basis for • Research • Writing • Editing • Presenting • implementation assistance • Evaluation • Quality Improvement
  • 107. The National Telehealth Resource Center Webinar Series Complete Series Coming Soon! www.telehealthresourcecenters.org1. School-Based Telehealth – Dr. Eve-Lynn Nelson Produced by: The Heartland TRC2. Telehealth Legal / Regulatory Review Produced by: The Center for Telehealth & E-Health Law
  • 108. Gordon A. Alloway Rachel MutruxProject Director, HTRC Co-Investigator, HTRCProject Manager, KUCTT Director, MTN Questions@HeartlandTRC.org 1-877-643-HTRC (4872)