Telehealth & Telemedicine in Kansas 12 12-13

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Part of the KDHE Rural Resources Webinar Series, this provides an update on telehealth development, Best Practices and available resources within the State of Kansas through 2013, plus an update of …

Part of the KDHE Rural Resources Webinar Series, this provides an update on telehealth development, Best Practices and available resources within the State of Kansas through 2013, plus an update of Medicare reimbursement codes effective 01/01/14

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  • “Holding” picture in case needed prior to intro
  • Telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve patients' health status. Closely associated with telemedicine is the term "telehealth," which is often used to encompass a broader definition of remote healthcare that does not always involve clinical services. Videoconferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education and nursing call centers are all considered part of telemedicine and telehealth. Telemedicine: exchange of medical informationTelehealth: expanded definition to include remote monitoring of vital signs, continuing medical education, patient education and nursing call centers
  • 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 – Wendy Garrett, Carruthers Elem., KCK
  • Wife, Coffeyville, KS, responding to questions on home monitor unit.
  • This is a picture of our new HDX 7000 Polycom. I feel very fortunate to have administrative supportThe evolution from me and telemedicine to team and telemedicineThe beginning of Mental Health Telemedicine was psychology (behavioral support) in our behavioral school. Psychiatry-many of our students are being treated for ADHD with medications being prescribed by the KUMC provider. These students have an appointment scheduled every month to two months. One Clinic that we have accessed more is the CCHD clinic. Developmental pediatrician and child psychologist.Beginning this year we will have a more formal approach using our multidisciplinary team. For our behavioral students we will have a Functional Behavioral Analysis completed before the telemed consult to assist the KUMC provider. When we access the CCHD (Center for Child Health and Development) Clinic, we with the family are looking for a diagnosis that will help us with the child’s education. The SCK team must have the proper assessments completed prior to the actual consult.If the parent and team are thinking that we may be seeing some autistic behaviors then our autism specialists need to be triggered and a CARS-2 evaluation will be completed. This evaluation is sent to the state Autism Team who depending on the results will possibly travel to the school and evaluate the student. The results of these evaluations are then given to the Doctors who will be evaluating the student over telemedicine. This process is very thorough and is very much respected by the primary providers in our communities. We also have local mental health providers who have asked for evaluations from KUMC Telemed providers. We work in conjunction with the local providers. This process usually involves one telemed consult and if medication is an option then the student’s primary care provider will write the prescription.
  • RHC – Rural Health ClinicHPSA – Health Professional Shortage AreaKDE _ Kidney disease educationDSMT – Diabetes Self-Management Training
  • 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
  • Universal Service Administrative Company – open to public or non-profit rural health care providers.
  • Universal Service Administrative Company – open to public or non-profit rural health care providers.
  • Universal Service Administrative Company – open to public or non-profit rural health care providers.
  • Universal Service Administrative Company – open to public or non-profit rural health care providers.
  • Universal Service Administrative Company – open to public or non-profit rural health care providers.
  • 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
  • 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
  • Total Exam Camera – GlobalMediaStethoscopesTop – CaretoneRight – MabisBottom - Stethographics
  • Tablets – PlaybookWirelessSmart PhonesFlexible, wearable screensNurse walking with RP Xpress

Transcript

  • 1. TELEHEALTH TODAY Successful Applications and Valuable Resources in Kansas
  • 2. This way to Successful Applications and Valuable Resources. . .
  • 3. Gordon Alloway Project Director, HTRC Phone (toll-free): 877- 643 – HTRC(4872) Email: GAlloway@HeartlandTRC.org IP: 169.147.3.125 ext.7010109 WWW: HeartlandTRC.org
  • 4. The Telehealth Resource Center Grant Program Technical assistance for starting or expanding telehealth services. www.telehealthresourcecenter.org
  • 5. What is Telemedicine? Telemedicine:… delivery of health care when distance separates a physician from the patient. What is Telehealth? Telehealth: … broader form of telemedicine that includes additional technologies, providers and health education.
  • 6. How does it work?
  • 7. Telemedicine is NOT a new technique Villemard, 1910 Correspondance Cinéma - Phono Télégraphique Chromolithographie Paris, BNF, Estampes http://expositions.bn f.fr/utopie/grand/3_9 5b2.htm
  • 8. Telemedicine has been around long time. Hugo Gernsback - 1924
  • 9. Now. . . New Forms of Communication = New Delivery Options
  • 10. New Forms of Communication = New Application Opportunities.
  • 11. Telemedicine in the 1990s • • • • Very few telemedicine programs Expensive, bulky equipment Expensive telephone lines Minimal insurance reimbursement (In Kansas, Medicare and Blue Cross/Blue Shield) • Limited research
  • 12. Telemedicine in the 1990’s
  • 13. Telemedicine in Kansas: 1991 Hays AHEC Kansas City
  • 14. Telemedicine in Kansas Clinical Consults: 1993-2001 2001 3000 2000 2500 2000 1998 1500 1997 1000 500 0 1996 1993 1994 1995 1999
  • 15. Telemedicine Today • • • • • • Smaller, less expensive equipment High quality, high definition (HD) technology Less expensive internet connectivity Mobile, wireless capability Improved insurance reimbursement More extensive research
  • 16. Telemedicine Today
  • 17. • In 2013: – KUCTT • Over 60 sites interacted with KUCTT • More than 4,000 clinical visits conducted – Total KS activity unknown
  • 18. Group Sessions and Educational Events
  • 19. Specialty Consultation via ITV
  • 20. Telestroke / Physician-to-Physician
  • 21. School-Based Programs
  • 22. Intra-Oral Scope (Tele-Sleep Study)
  • 23. What Tele-Sleep Presenter Sees
  • 24. Oncology Care (Hospital Exam Room)
  • 25. Disease Management – Home Monitoring
  • 26. Clinical Models • Level and frequency of telemedicine use can vary, based on comfort of provider and specialty needs – TelePsychiatry – completely by telemedicine, no inperson – TeleOncology – hybrid model of some in-person (often 1st appt.) and some telemedicine follow-up – TeleRehabMedicine – more in-person, less telemedicine
  • 27. Kansas Best Practices – Telehealth / Telemedicine
  • 28. Kansas Best Practice - Telehealth / Telemedicine Telemedicine Services at Goodland Regional Medical Center
  • 29. Kansas Best Practice - Telehealth / Telemedicine Hays Daily News By KALEY CONNER 10/25/2013
  • 30. Kansas Best Practice - Telehealth / Telemedicine
  • 31. South Central Kansas Special Education Cooperative School-Based Telemedicine • Behavioral Clinics  Psychology  Psychiatry • Mental Health Clinic  CCHD Autism Diagnostics • Healthy Hawks Clinic  Weight Management Shelly Brensing, RN (With her Polycom HDX 7000)
  • 32. Historical Challenges for Telemedicine 1. Limited adoption by providers – Federal & State reimbursement slow to expand • Medicare - Adding CPT/HCPCS codes annually • Medicaid – Varies by state – Private reimbursement not standardized – Seemingly not integrated in clinic flow – Technology concerns • • • • Initial investment of equipment Ongoing support Lack of standardization Inconsistent broadband internet service 2. Privacy / confidentiality 3. Liability / Licensure
  • 33. Good News! There Is Reimbursement • Medicare (2001) • Medicaid varies by state, but generally follows Medicare guidelines – Kansas (2004) • Reimbursement available from all health insurance providers (no need for KS legislative mandate) • Also, Federal grants & loans available
  • 34. Telehealth Service CPT / HCPCS Codes Emergency department or initial inpatient consultations HCPCS codes G0425 – G0427 Follow-up inpatient consultations (hospitals or SNFs) HCPCS codes G0406 – G0408 Subsequent hospital care services, limitation 1 telehealth visit every 3 days Subsequent nursing facility care services, limitation 1 telehealth visit every 30 days Office or other outpatient visits Individual and group diabetes outpatient selfmanagement training (DSMT) services, with a minimum of 1-hr. of in-person instruction to be furnished in the initial year training period to ensure effective injection training Individual and group Kidney Disease Education (KDE) services End Stage Renal Disease (ESRD) related services Individual and group Medical Nutrition Therapy Individual and group health and behavior assessment and intervention (HBAI) services Psychiatric diagnostic interview examination Individual psychotherapy Pharmacologic management Neurobehavioral Status Exam Smoking cessation services Alcohol and/or substance (other than tobacco) abuse structured assessment and intervention services Annual alcohol misuse screening, 15 minutes Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes Annual depression screening, 15 minutes CPT codes 99231 - 99233 CPT codes 99307 - 99310 CPT codes 99201 -- 99215 HCPCS codes G0108 and G0109 HCPCS codes G0420 and G0421 CPT codes 90951, 90952, 90954, 90955, 90957, 90958, 90960, and 90961 HCPCS code G0270 and CPT codes 97802 -- 97804 CPT codes 96150 - 96154 CPT code 90791 and 90792 CPT codes 90832 -- 90834 and 90836 -- 90838 CPT code 90862 CPT codes 96116 HCPCS codes G0436 and G0437, and CPT codes 99406 and 99407 HCPCS codes G0396 and G0397 HCPCS code G0442 HCPCS code G0443 HCPCS code G0444 High-intensity behavioral counseling to prevent sexually transmitted infection; face-to-face, individual, includes: HCPCS code G0445 education, skills training and guidance on how to change sexual behavior; performed semi-annually, 30 minutes Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes Face-to-face behavioral counseling for obesity, 15 minutes Transitional care management services Telehealth originating site facility fee (short description: “telehealth facility fee”) 2014 Medicare Benefit Policy – Telehealth Services HCPCS code G0446 HCPCS code G0447 CPT code 994951 and 994962 Q03014 Galloway @HeartlandTRC.org
  • 35. Medicare Benefit Policy – Telehealth Services NEW for 2014 (Effective 01/01/14) Transitional care management services CPT code 994951 and 994962 1. Communication with patient and/or caregiver within 2 business days of discharge; face-to-face visit within 14 calendar days of discharge and moderate complexity of medical decision-making during service period 2. Communication with patient and/or caregiver within 2 business days of discharge, face-to-face visit within 7 calendar days of discharge and high complexity of medical decision-making during service period Email: Galloway@HeartlandTRC.org
  • 36. Telehealth Guidelines • Patient location: – – – – – – – – – Physician/Practitioner’s office Hospital (inpatient or outpatient) Critical Access Hospital (CAH) Rural Health Clinic (RHC) Federally Qualified Health Center (FQHC) Skilled Nursing Facility (SNF) Hospital-based or CAH-based Renal Dialysis Centers Community mental health center (CMHC) HPSA county outside metro area
  • 37. Telehealth Guidelines • Physician/Provider location (“distant site”) – No limitation on location – Must be licensed in state where patient is located • Who may receive payment – Physician, PA, Nurse practitioner, Nurse midwife, Clinical nurse specialist, Clinical Psychologist, Clinical social worker, Registered dietitian / nutrition professional • Telepresenters – Not required – Unique to event/specialty
  • 38. 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 Physician Fee Schedule amount • Telehealth Facility Fee (for originating site) – Billable separately under Part B
  • 39. Telemedicine in U.S. Multiple Federal Funding Resources – HRSA – Network Planning and Network Development • Grant assistance for upfront planning and initial development – http://www.grants.gov/web/grants/search-grants.html – USAC – Rural Health Care Support • Will pay for % of Internet access cost – http://wireless.fcc.gov/outreach/index.htm?job=funding – Dept. of Commerce – National Telecomm. and Information Admin. • Expanding broadband Internet access • State Broadband Initiative & Tech Opp. Pgm. • http://www.ntia.doc.gov/grants-combined
  • 40. Telemedicine in U.S. Multiple Federal Funding Resources – USDA – Rural Development (RD) – Grants & Loans • Community Facilities (CF) Program - $70 million Direct Loans / $10 million Grants – Areas/towns up to 20,000 pop. – Construction or renovation of hosp., NF, Clinic (inc. necessary equipment) – Purchase of specific equipment (new CT scanner), technology, software • Application is once a year (end of May/early June) • Announced 60 days in advance of due date • RD staff assistance available for application process • http://www.rurdev.usda.gov
  • 41. Telemedicine in U.S. Federal Funding Support - Kansas USDA – Rural Development (RD) – CF Program Onaga, KS Area: 410 acres Pop: 707 (2012) $5 million CF Direct Loan Bundled variety of needs: • EMR hardware/software in hosp. & clinics • Renovations/enhancements to existing hospital • Purchased diagnostic equipment • Refinanced existing debt USDA Rural Dev HIT Telehealth Program Funding Overview Webinar, April 2013, http://youtu.be/sPXfhyF6lgc
  • 42. Telemedicine in U.S. Federal Funding Support - Kansas USDA – Rural Development (RD) – CF Program WHO: $2.2 million bank loan guarantee $3 million CF Direct Loan Great Plains Health Alliance, Inc. WHAT: 24-Hospital Network WHERE: Phillipsburg, KS Acted as borrower for hospital network: • EHR hardware/software for 22 CAHs • Enabled them to provide telemedicine services, virtual consults, diagnostic exams and imaging, and remote monitoring of patients. USDA Rural Dev HIT Telehealth Program Funding Overview Webinar, April 2013, http://youtu.be/sPXfhyF6lgc
  • 43. Telemedicine in U.S. Multiple Federal Funding Resources – USDA – Rural Development (RD) – Grants & Loans • Distance Learning and Telemedicine (DLT) Program - $15 million – Areas/towns up to 20,000 pop. – 15% matching requirement – Minimum grant award: $50,000; maximum: $500,000 – Purchase of computer hardware/software, computer network components, terminal equip., inside wiring, and inside equip. warranties • Application is once a year (end of May/early June) • Announced 60 days in advance of due date • RD staff assistance available for application process • http://www.rurdev.usda.gov
  • 44. 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
  • 45. 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
  • 46. Privacy/Security Issues • Generally, all current videoconferencing systems include encryption technology. • Security Rule does not require encryption (“Live” events are not ePHI), but technology easily encripts • Privacy rule DOES apply • Telemedicine room should be private just like any other clinic room • Use private connections when possible
  • 47. HIPAA Security Rule • “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
  • 48. Connectivity in Kansas Hospitals* • 66% - Have videoconferencing equipment • 31% - Using telemedicine (2010) – Daily 55% – Weekly 20% • 23% - Receiving reimbursement for telemedicine (25% - Not sure) • 50% used same equipment for education and training * Kan-ed Telemedicine Capacity and Readiness Survey, KS Office of Edu. Innovation & Evaluation / Kan-ed , 2010
  • 49. Connectivity in Kansas • Internet access via Internet Service Provider (ISP) is available throughout Kansas • ISP Internet connectivity is adequate for highquality videoconferencing • Multiple Internet-based videoconferencing services now available via ISP connectivity Source: Kansas Board of Regents: Evaluating the Effects of Eliminating the Kan-ed Program, Legislative Post Audit Committee, Legislative Division of Post Audit, State of Kansas, January 2012.
  • 50. Interactive Tele-Video (ITV) Putting technology concerns into the past. TABLET SMARTPHONE PROVIDER’S OFFICE w/ Desk Top Computer
  • 51. Telemedicine on Smaller Scale
  • 52. Telehealth Peripherals Digital Stethoscopes http://www.telehealthtac.org/toolkits/patient-exam-cameras-technologyoverview#Patient_Exam_Cameras
  • 53. Electronic Otoscope for Pediatrics
  • 54. What the provider or practitioner sees. (Actual otoscope image)
  • 55. Technology Specific to Health Care • Peripheral devices – – – – – – Otoscope Stethoscope Dermascope Ophthalmascope General exam camera Handheld retina camera
  • 56. Telehealth Peripherals Total Exam Camera Digital Camera/Camcorders VS Features Digital Records image Has own lighting HD Advantages Same Features Less expensive Easily Available http://www.telehealthtac.org/toolkits/patient-exam-cameras-technologyoverview#Patient_Exam_Cameras
  • 57. Technical Advances • Smaller, less expensive equipment • From analog to digital • From telephone lines to internet lines • Wireless • Encryption • Integration
  • 58. Technical Advances • Next generation:
  • 59. Telemedicine Today The Wireless World of Hospitals
  • 60. How To Learn More.
  • 61. 1-877-643-HTRC (4872) www.HeartlandTRC.org Questions@HeartlandTRC.org Become a fan: www.facebook.com/HeartlandTRC.org
  • 62. The Telehealth Resource Center Grant Program Technical assistance for starting or expanding telehealth services. www.telehealthresourcecenter.org
  • 63.  Rural Clinics  Federally-Qualified Health Centers (FQHC)  Critical Access Hospitals (CAH)  Community & Urban Hospitals  Primary Care Clinics  Providers  Health Care Organizations  Ambulatory Care Centers  Nursing Homes  and others… http://www.telehealthresourcecenter.org Kimble Hospital Junction, TX Who do the TRCs serve?
  • 64. How TRCs can help. . . • Proven resources Legislation/Regulations Forms & Protocols Toolkits Event Announcements • Staff training Onsite Basic Protocols Telepresenters • Peer-to-peer connections Learn from other’s mistakes Tele-All (Stroke, ICU, etc.) No regional limitations http://www.telehealthresourcecenter.org
  • 65. How TRCs can help. . . • Technical Assistance 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 http://www.telehealthresourcecenter.org
  • 66. 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 http://www.telehealthresourcecenter.org
  • 67. The National Telehealth Resource Center Webinar Series Key telehealth topics from experts! • 3rd Thursday of Every Month • 1:00 PM Central Time www.telehealthresourcecenters.org
  • 68. Gordon Alloway Project Director, HTRC Phone: 1.877.643.HTRC (4872) Email: Questions@HeartlandTRC.org Video IP: 169.147.3.125 ext. 7010109